NUR 265 Nursing Concepts Test # 3/Adv Med Srg #3 STUDY GUIDE

NUR 265 Nursing Concepts Test # 3
Care of Critically Ill Patients with Neurologic Problems / Chapter 47 (25
questions)

Traumatic Brain Injury
Your text here 1
1. Contrecoup injury
 Coup is an impact to the frontal lobe; countrecoup is the impact to the
occipital area from the brain bouncing backwards.
2. Contusion
 Bruising of the brain tissue; structural damage
3. Concussion
 Shaky movement of the brain; may lose consciousness; retrograde amnesia;
NO structural damage.
 Client teaching: have pt. woken every 3-4hrs to assess LOC; EXPECT
headache, nausea and dizziness for 24hrs, if gets worse or does not subside,
go back to hospital; no alcohol, sedatives or sleeping pills, give Tylenol prn
every 4hrs; GO BACK TO HOSPITAL IF THESE SYMPTOMS OCCUR: blurred
vision, rhinorrhea or ottorrhea, weakness, slurred speech, progressive
sleepiness, vomiting, unequal pupil size, and worsening headache.
4. Basilar skull fracture (unique fracture)*
 Fracture at base of skull; causes CSF leakage of the nose (rhinorrhea) and
the ears (ottorrhea);
 Risk for INFECTION r/t direct access to subarachnoid space.
 Potential for hemorrhage: Raccoon eyes (bleeding around orbits of eyes) and
Battle Sign (bruising behind ears)

Hemorrhage (Brain)
*All hematomas are potentially life-threatening because they act as space-occupying lesions
and are surrounded by edema, thus increasing ICP.

1. Epidural hematoma
 Located above dura; primarily an arterial bleed.
2. Subdural hematoma
 Located below dura and above arachnoid; primarily a venous bleed.
 Slow bleed; acute stage happens within 48hrs. after impact; high mortality rate;
usually goes unrecognized.
 Earliest sign is a change in personality; Ask pt. if they fell or hit their
headhowcheck headput on gloves and palpate.

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, 3. Intracerebral hemorrhage
 Can be both venous and an arterial bleed; usually results from a blown
aneurysm; causes increased ICP.

Increased Intracranial Pressure

**Normal ICP: 10-15 mmHg
1. Earliest change:
 Change in LOC r/t pressure on frontal lobe, best indicator!!!!
 Other early s/s: headache and projectile N/V
2. Cushing’s triad-:
 classic, late sign: severe hypertension with widened pulse pressure and
bradycardia
3. Pupillary changes :
 ovoid pupil: midstage between a normal pupil and a dilated pupil
 pupils that are dilated and fixed (‘blown’) r/t pressure exerted onto III cranial
nerve. Cranial nerve III directly affects pupils.
4. EOMs diminished- CN III, IV, and VI
 EOM: Extra Ocular Eye Movement
 These nerves regulate eye muscle movement
 Diminished cranial nerves r/t increased pressure on brain stem (where these
nerves are located); since pressure moves downward from frontal lobe to
brainstem, once pressure gets to this point, it means increased ICP is severe.
 Pinpoint and nonresponsive pupils are indicative of brainstem dysfunction at
the level of the pons.
5. Papilledema
 Choked disk (edema and hyperemia; increased blood flow of optic disk; only
seen with an ophthalmoscope)
6. Decorticate and decerebrate posturing
 Decorticate: Upper extremeties are flexed inwards at core
 Decerebrate: upper extremeties/wrists are tensed outwards at sides; this is
more severe than decorticate, indicates more damage to brain.
7. CSF leak- “halo” sign
 CSF contains glucose and protein
 To assess for CSF leak, obtain gauze to absorb fluid, fluid will scatter outwards
forming a “yellowish halo”.
8. Glasgow Coma Scale
 Three major areas assessed on scale: Eye opening, motor response and verbal
response
 Graded from 3-15; 3 being the worst, 15 the best.
9. Brain Herniation – death
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