Brain Injuries

52 flashcards

What are the two types of injury that can cause a TBI?

Direct Injury (a blow to the head) and Indirect Injury (force applied to another body part causing a rebound effect).

What are the 2 types of indirect TBI injuries?

Acceleration Injury: external force contacting the head, suddenly placing the head in motion Deceleration Injury: a moving head is suddenly stopped or hits a stationary object

What is the difference between a focal and diffuse TBI?

Focal TBI is confined to a specific area of the brain, causing localized damage detectable by CT scan or MRI. Diffuse TBI results in damage throughout many areas of the brain, often beginning at a microscopic level. - Not detectable by CT and only by MRI w/ necrosis

What is the difference between an open and closed TBI?

Open TBI occurs when the skull is fractured or pierced, violating the integrity of the brain and dura. Closed TBI occurs when the integrity of the skull is intact, but damage to the brain tissue occurs due to increased intracranial pressure (ICP).

What are the main symptoms associated with all TBIs?

Confusion, disorientation, dizziness, headache, N/V, light & noise sensitivity, sleep disturbances, emotional changes All brain injuries affect the body's autoregulation ’ hypo OR hypertension with weak OR strong pulses

What characterizes a mild TBI?

GCS 13-15. Consists of at least ⅓ of these conditions: 1. Possible loss of consciousness for up to 30 minutes 2. Loss of memory for events immediately before or after the accident 3. Focal neurologic deficit(s) that may or may not be transient No evidence of brain damage with imaging

What characterizes a moderate and severe TBI?

Moderate TBIs are characterized by a period of loss of consciousness for 30 minutes to 6 hours and a GCS score of 9 to 12. Severe TBIs are characterized by a GCS score of 3 to 8 and loss of consciousness for longer than 6 hours. - Results in permanent neurological damage that can produce lifelong deficits to varying degrees

What is a concussion?

Temporary loss of neurologic function with no apparent structural damage, lasting a few seconds to minutes.

What is a contusion?

A more severe injury where the brain is bruised with possible surface hemorrhage, lasting more than a few seconds.

What is usually the first sign of deterioration in TBI?

Any change in LOC is usually the first sign of deterioration and the earliest sign of increased ICP.

What are the 2 main components in a neurological exam?

Arousal (alertness): Patient's ability to respond to stimuli in an appropriate manner Content (awareness): Patient's orientation to person, place, and time

If a patient is suspected of having suffered a brain injury, what is the first nurse assessment?

Assess neurological status through the pupils - GCS is useful, but focus on the eyes as it's quick & easy Any abnormalities in PERRLA indicate ICP and should be notified to the provider.

What does the Glasgow Coma Scale (GCS) assess for?

Neurological status through eye response, verbal response, and motor response

What are the initial interventions for a TBI patient?

1. Immobilize until cervical spine X-ray clears possible fracture 2. Get a baseline assessment of the patient's motor and sensory function 3. Complete history, including the mechanism of injury 4. Basic labs & CT scan

What are all the assessment components for TBI patients?

1. GCS 2. Neurological Assessment 3. Bilateral Motor Assessment ’ posturing, flaccidity, ROM 4. Daily labs 5. ICP 6. Diagnostic Imaging ’ same as stroke, but looking for damage, not bleeding/clotting 7. ABGs

Why should nurses monitor ABGs, and what component should nurses be looking out for?

TBI patients might be intubated & ventilated or have respiratory distress The body will try to retain as much CO2 as possible to vasodilate cerebral vessels for perfusion, but this increases ICP in return - CO2 is a natural vasodilator

Why is temperature regulation important in brain injuries?

Normothermia ’ want to maintain normal temperature for brain rest & healing Shivering w/ hypothermia ’ ‘ metabolic demands ’ ‘ brain activity Fever ’ inflammation ’ ‘ O2 demands ’ ‘ brain activity

What is trauma-informed care, and how can nurses promote it?

Trauma-informed care ’ promote understanding, acceptance, and support for victims of trauma through positive adaptation and healing. Educate that most patients are discharged with varied long-term physical and cognitive disabilities. - Encourage PT, OT, & SLP to maintain remaining abilities - Changes in personality and behavior are very common.

What is the opioid of choice for TBI?

Fentanyl is the opioid of choice as it doesn't affect BP & HR like morphine - Can also be used with sedation for analgesia

What medications are used in both strokes, TBIs, and ICP?

Mannitol reduces ICP by crossing the BBB and drawing fluid out of the brain tissue Hypertonic IV fluid draws fluid from cells into the vasculature and is then removed from the body with a diuretic (furosemide) Phenytoin is used to prevent seizures that can worsen ICP - Phenobarbital aids in sedation and seizure management to stabilize patients with increased ICP.

What are the main causes or risk factors for strokes?

Non-modifiable 1. Age, risk doubles each decade after 55. 2. Gender, more common in men, but more women die 3. Higher incidence in African Americans 4. Heredity/family history Modifiable 1. HTN, HLD, atherosclerosis, heart disease 2. Smoking, excess alcohol consumption, and drug abuse 3. Obesity and/or lack of physical exercise, sedentary lifestyle 4. Sleep apnea 5. Metabolic syndrome, poor diet

What is a stroke or cerebrovascular accident (CVA)?

Medical emergency during which any portion of the brain has an interrupted or reduced blood supply/flow Leads to brain damage depending on how long the brain is deprived of O2

What does BE FAST stand for in stroke assessment?

1. Balance: Sudden loss of balance or coordination. 2. Eyes: Trouble seeing out of one or both eyes. - More towards blurry vision, not blindness 3. Face: Facial drooping or uneven smile. 4. Arms: Weakness or numbness in one arm. 5. Speech: Slurred speech or difficulty speaking. 6. Time: Emergency! Call an ambulance

What diagnostic imaging test is used for strokes?

CT or MRI - Indicate the size and location of the lesion - Differentiate between ischemic and hemorrhagic stroke Noncontrast is used first to diagnose hemorrhagic stroke, while contrast is needed to diagnose ischemic stroke

What is a Transient Ischemic Attack (TIA), and what can it progress into?

Transient episode of neurologic dysfunction caused by focal (localized brain damage), spinal cord, or retinal ischemia, but without acute blood supply obstruction (infarction) of the brain - Symptoms only last < 1 hour compared to an actual stroke Associated with an increased risk of strokes - ⅓ of patients progress into ischemic stroke

What is an Ischemic Stroke, and what can it progress into?

A blood vessel becomes blocked, and the blood supply to that part of your brain is blocked - Can be thrombotic or embolic 30% of ischemic strokes progress into a hemorrhagic stroke as the blockage and increased pressure will cause the vessel to burst and bleed

What is the difference between a thrombotic ischemic stroke and an embolic ischemic stroke?

Thrombotic Stroke - Clot gets formed (thrombosis) in an already narrowed blood vessel Embolic Stroke - A blood clot (embolus) travels through the body and lodges in a blood vessel for blockage

What is a Hemorrhagic Stroke?

A stroke caused by a ruptured blood vessel in or around the brain, leading to bleeding.

How is motor function impaired with stroke?

1. Loss of skilled voluntary movement ’ akinesia 2. Alterations in muscle tone - An initial period of flaccidity then spasticity of the muscles 3. Alterations in reflexes - Can be hyporeflexia or hyperreflexia

What are the 3 main communication impairments with stroke?

Aphasia, dysphagia, and dysarthria

What are all the types of aphasia or dysphagia?

Aphasia and dysphagia are used interchangeably 1. Expressive Aphasia: unable to speak 2. Global Aphasia: total inability to communicate 3. Receptive Aphasia: cannot understand verbal/written words - Still able to talk but unable to enunciate words, and has no meaning ’ word salad 4. Non-fluent Aphasia: minimal speech activity with slow speech 5. Fluent Aphasia: speech is present but contains little meaningful communication

What is the role of Mannitol in TBI management?

It reduces ICP by crossing the blood-brain barrier and drawing fluid out of brain tissue.

What is the purpose of hypertonic IV fluids in TBI treatment?

They draw fluid from cells into the vasculature and are then removed from the body with a diuretic like fureosemide

What are the differing symptoms between a left-side stroke vs a right-side stroke?

Right-Sided - Paralyzed on the LEFT SIDE of the body - Special perceptual deficits - Denies body parts or illness - Poor depth perception and direction perception - Quick, impulsive behavioral style Left-Sided - Paralyzed on the RIGHT SIDE of the body - Speech-language deficits (articulation, stuttering, fluency, struggle to follow directions) ’ aphasia - Slow, cautious behavioral style

What is agnosia and apraxia?

Both are special perceptual deficits common in right-sided strokes Agnosia ’ unable to recognize object by touch/sight/hearing Apraxia ’ unable to carry out learned sequential movements on command

What is dysarthria?

Disturbance in the muscular control of speech, affecting pronunciation, articulation, and phonation.

What is the medical treatment for ischemic stroke(s)?

1. Thrombolytic Therapy - IV alteplase is given within 3 to 4.5 hours to restore blood flow - Aspirin: given within 24-48 hours unless alteplase was given 2. Antiplatelet and anticoagulant medications help prevent further clot formation after initial treatment 3. Monitor for bleeding and assess neurological status frequently during stroke treatment - Permissive HTN within the first 24 hours, SBP 220-185/110-120

What is the permissive BP limit for ischemic strokes, and why do we want to leave BP this high?

Permissive hypertension within the first 24 hours - SBP 220 - 185/ 110 - 120 HTN is recommended to stay high to compensate for the blockage and maintain brain perfusion

What is the medical treatment for hemorrhagic stroke(s)?

1. Anticoagulants and platelet inhibitors are contraindicated. 2. Management of hypertension is the main focus. - Oral and IV agents are used to maintain BP within a normal to high-normal range ’ not as high as ischemic stroke (goal < 140) 3. Seizure prophylaxis is situation-specific 4. Surgery might be needed to stop the bleeding - Resection, clipping of an aneurysm, evacuation of hematomas, and coiling

What is the initial treatment for a stroke alert?

1. Neurological assessment focusing on the eyes and PERRLA ’ BE FAST, Glasgow Coma Scale, and NIHSS 2. Obtain V/S with emphasis on BP ’ maintain under 185/120 - 220/110 3. Noncontrast CT or MRI to look for bleeding ’ doesn't need an IV 4. Start IV access for contrast CT (angiogram) to look for perfusion if noncontrast CT shows no bleeding ’ looking for ischemic stroke 5. Be prepared to start TPA alteplase or obtain consent for thrombotomy

How should stroke patients be positioned?

ROM exercises and positioning ’ the paralyzed or weak side needs special attention when positioned - Weak or paralyzed side for only 30 mins Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop Hand splints to reduce spasticity

Depending on the side of the stroke and their respective deficits, how should nurses communicate with those patients?

Right-Sided - Impulsive, impatient, and denies problems related to stroke - Respond best to directions given verbally Left-Sided - Slower in organization and performance of tasks - Fearful, anxious response to stroke ’ responds well to nonverbal cues

What are the values for ICP?

Normal is 10 to 15 mmHg. - Periodic increases in pressure occur with straining during defecation, coughing, or sneezing, but do not harm the uninjured brain. Sustained ICP > 20 is detrimental to the brain ’ neurons begin to die

What are early and moderate signs of ICP?

Early - Altered consciousness, irritability, restlessness, sleepiness, and flat affect Moderate - Constant headache and sudden vomiting require urgent attention to prevent deterioration

What are late and deadly signs of ICP?

1. Irregular breathing, stiff neck, fixed dilated pupils, and abnormal posturing indicate severe brain stem pressure 2. Cushing's Triad Indicators

What are the 2 late and deadly posturing signs of ICP?

Decorticate - CORE for the center of the body - Flexion of the arms, while the elbows bend and fold their arms up towards their chest Decerebrate - E for extensors - Limbs extend away from their head, with the arms at the sides of the body - Worse than decorticate due to less brain functioning

Why should nurses educate patients to call for an ambulance, especially for strokes?

Ambulances can start an IV and alert the hospital for early preparation ’ better patient outcome

What is Cushing's Triad?

Hypertension, bradycardia, and irregular respirations.

How can nurses manage patients with ICP?

1. Elevate the HOB to 30 degrees and maintain neck alignment to reduce ICP and prevent neurological damage. 2. Prevent activities like coughing (e.g., unnecessary suctioning in a vented patient) or straining that increase intrathoracic pressure and worsen ICP. 3. Regularly assess neurological status with the Glasgow Coma Scale and monitor temperature to prevent hyperthermia. 4. Ongoing monitoring and accurate documentation help detect changes early and enable timely intervention

What is cerebral perfusion pressure (CPP)?

Pressure gradient necessary to supply adequate amounts of blood to the brain - How much pressure you need to supply blood to the brain

What is the normal range for Cerebral Perfusion Pressure (CPP)?

80 - 100 mmHg. - Acceptable: 60-160 - Must be > 60 mmHg for adequate cerebral perfusion

How do you calculate CPP?

CPP = MAP - ICP Ex. Patient's BP is 120/80; ICP is 10 MAP = [120+2(80)]/3 = 93 CPP = MAP - ICP CPP = 93 - 10 = 83