Head injury ranges from a mild bump or bruises up to a traumatic brain injury. Institute measures to prevent increased ICP or other neurovascular compromise. Administer medication as a prescription to decrease increased intracranial pressure (ICP) and pain. A client with a high cervical spine injury, A client with a herniated nucleus pulposus. TBI can be characterized as mild, moderate, or severe, and the differing severity levels cause predictably different impairments .Mild TBI is known to cause poor physical functioning, including fatigue and emotional distress, which may resolve in a few weeks .Although mild TBI has higher incidence rates compared to moderate-to-severe TBI , a large portion of care … It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage. Cerebrospinal fluid leakage at ears and nose, which may indicate skull fracture. Pediatric Mild Traumatic Brain Injury and Population Health: An Introduction for Nursing Care Providers Crit Care Nurs Clin North Am . Skull and cervical spine X-ray identify fracture and displacement. Somatropin or growth hormone, not vasopressin is used to treat growth failure. When given through an IV catheter hand, dilantin may cause purple glove syndrome. Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. Currently she is working as a Registered Nurse at Apollo Hospitals Dhaka, Bangladesh. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? Have to check for different symptoms of diabetes insipidus (High urine output, low urine specific gravity) to maintain hydration. How should the first-responder open the client’s airway for rescue breathing? TRAUMATIC BRAIN INJURY GUIDELINE Ver. Immediate nursing actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious stimulus. Nursing vigilance is required to maintain a Which of the following conditions can cause autonomic dysreflexia? Changes in LOC, such as restlessness and irritability, may be subtle. Any items you have not completed will be marked incorrect. Describe nursing a patient with a severe head injury in a case study. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. Maria Katun Mona is a Nursing and Midwifery Expert. 2017 Jun;29(2):157-165. doi: 10.1016/j.cnc.2017.01.003. Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. Have to monitor and record major symptoms and intake and output, increased intracranial pressure, hemodynamic variables, cerebral perfusion pressure, specific gravity, laboratory studies, and pulse oximetry to detect early signs of compromise. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used forsupratentorial craniotomies. The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. You have not finished your quiz. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client’s neurological status deteriorates quickly. The nurse is caring for the client in the ER following a head injury. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury. A slight headache may last for several days after concussion; severe or worsening headaches should be reported. Cerebrospinal fluid (CSF) leak could leave the patient at risk for infection. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia. Administer an antihypertensive medication. The other options are incorrect. A client comes into the ER after hitting his head in an MVA. Significant; the client has alveolar hypoventilation. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Monitoring vital signs before and during position changes, Using vasopressor medications as prescribed. Which of the following assessments would take priority? Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. Deterioration and pressure produce irregular respiratory patterns. Check deep tendon reflexes to determine the best motor response, Count the rate to be sure the ventilations are deep enough to be sufficient. A traumatic brain injury is a type of acquired brain injury that occurs following an impact to the head, causing damage to the brain tissue. Which nursing intervention protects the client without increasing her ICP? Observe for the sign of increasing increased intracranial pressure (ICP) to avoid treatment delay and prevent neurologic compromise. Good luck! To replace antidiuretic hormone (ADH) normally secreted by the pituitary. After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Nitroglycerin is given to reduce chest pain and reduce preload; it isn’t used for hypertension or dysreflexia. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Mail her at. The client has signs and symptoms of autonomic dysreflexia. Complete blood count, coagulation profile, electrolyte levels, serum osmolarity, arterial blood gases, and other laboratory tests monitor for complications. Doctors usually need to assess the situation quickly. There is no indication that the client needs a chest x-ray. Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. People or provider (e.g., nosocomial agents, staffing patterns, cognitive, affective and p… Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Traumatic brain injury (TBI) affects people of all ages, is expensive, has varying levels of severity, and contributes to disability. Etiology And Pathophysiology Types of Traumatic Brain Injury Concussion – transient interruption in brain activity; … The airway doesn’t need to be opened since the client appears alert and not in respiratory distress. Biological (e.g., immunization level of community, microorganism) 2. A traumatic brain injury nursing care plan is a comprehensive document outlining a patient’s medical diagnosis, personal information, recommended nursing interventions, explanations and justifications for the recommended nursing interventions, and the patient’s response to previous nursing interventions. Which of the following conditions would most likely be suspected? Nurses should take an Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The nurse also would check for a fecal impaction and disimpact if necessary. The nurse is planning care for the client in spinal shock. Our hottest nursing game is out now in the App Store. After checking the client’s vital signs, list in order of priority, the nurse’s actions (Number A being the first priority and letter E being the last priority). Their interventions address the prevention of secondary brain injury and complications and provide significant support and guidance for the family members. Injuries below L2 cause paraplegia and loss of bowel and bladder control. Stroke and Brain Injury Care. A client is at risk for increased ICP. Apply firm pressure over puncture site for subdural trap, and observe for drainage and dressing. Is the disruption of normal brain function due to trauma-related injury resulting in compromised neurologic function resulting in focal or diffuse symptoms. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. She has great passion in writing different articles on Nursing and Midwifery. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. Traumatic brain injury (TBI) is a major source of death and severe disability worldwide. 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