NURS 443 Lecture Notes - Lecture 14: Depressant, Tracheal Intubation, Lurasidone
Cognition
Book Notes
A. Brain Trauma
a. Traumatic Brain injury
i. Cause: Motor vehicle collisions, falls, firearms, assaults, sports-related trauma,
recreational injuries, and war-related injuries.
ii. Risks:
1. substance abuse, not wearing seatbelt or helmet, accidental injuries, violence
iii. Classifications- determined by GCS
1. Primary- occurs immediately on impact of mechanical force
a. Daage to rai or vasulature is doe ad a’t e reversed.
b. EX. Contusion, penetration, hematoma, Intracerebral hematoma
2. Secondary- evolves over next hours or days (swelling of brain)
a. Result of inadequate nutrients and oxygen to brain cells
b. Decreased perfusion, hypoxia, infection, electrolyte imbalance contribute
to secondary
iv. Types:
1. Scalp laceration- easily recognized, major complication is bleeding and infection
a. Manifestation: profuse bleeding
2. Skull fractures – linear or depressed, simple, comminuted or compound, and
closed or open
a. Manifestations: location determines the manifestations. Battle’s sign
(behind the ear ecchymosis) and periorbital ecchymosis (raccoon eyes)
Rhinorrhea (CSF leakage from nose) otorrhea (CSF leakage from ear)
b.
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c. Complication: intracranial infection (meningitis), hematoma, meningeal
and brain tissue damage.
d. S&S:
i. Mild injury
1. Loss of consciousness for a few seconds to a few minutes, no
loss of consciousness (but is dazed and confused), memory/
concentration problems, headache, dizzy/ loss of balance, N/V,
ringing in ears, sensitive to light, mood change, depressed,
fatigue, difficulty sleeping, sleep more than usual
ii. Moderate injury
1. Loss of conscious for several hours, profound confused,
agitation/ combative, unable to awaken from sleep, slurred
speech, weak or numb fingers/toes, persistent headache,
repeated vomiting, dilation of one or both pupils in eyes, clear
fluid draining from nose or ears
iii. Children
1. Change in eating/ nursing habit, persistent crying, unusual
irritability, change in ability to pay attention, change in sleeping
habits, sad/depressed mood, loss of interest
e. Diagnostic:
i. GCS, CAT scan, MRI, SPECT scan, PET scan, Ranchos Los Amigos scale,
evaluation from physicians
f. Testing: determine whether the fluid leaking from nose or ear.
i. Test fluid with Dextrostix or Tes-Tape strip to determine whether
glucose is present. CSF give a positive reading in glucose
ii. If blood present in the fluid than test is not reliable. Allow the leaking
fluid to drip onto a gauze pad and observe the drainage. Blood should
coalesce in the center and yellowish ring encircles the blood if CSF if
present also known as Halo/Target sign.
g. Treatment
h. Interventions
i. Primary Prevention: educating about safety and disease prevention.
Wear helmets and seatbelts
ii. Secondary prevention: screening and diagnosis of injury.
1. Keep pt. oxygenated and allow for perfusion
2. Stay talking to patient for neuro assessment throughout shift
3. Keep patient on fall risk
iii. Tertiary prevention: occupation therapy or rehabilitation to bring
patient back to best state of health
b. Head trauma (pg 1372 Table 57-9 show interventions)
i. Types:
1. Diffuse injury (Generalized)
a. Concussion: sudden transient mechanical head injury with disruption of
neural activity and a change in LOC
i. Cause: rapid acceleration-deceleration or sharp blow to head
ii. S&S: altered LOC, amnesia regarding then even, and headache. May
lose conscious or not loss conscious and typically short lived.
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Document Summary
Battle"s sign (behind the ear ecchymosis) and periorbital ecchymosis (raccoon eyes) Csf give a positive reading in glucose: if blood present in the fluid than test is not reliable. Allow the leaking fluid to drip onto a gauze pad and observe the drainage. Blood should coalesce in the center and yellowish ring encircles the blood if csf if present also known as halo/target sign: treatment. Interventions: primary prevention: educating about safety and disease prevention. Consist of lacerations, contusions, hematomas, and cranial nerve injuries: lacerations: actual tearing of the brain tissue, s&s: if severe hemorrhage, hematoma formation, seizures, and cerebral edema. Unconsciousness, hemiplegia on contralateral side, and dilated pupil on ipsilateral side: treatment: antibiotics until meningitis is ruled out, contusion: bruising of brain tissue within a focal area, s&s: may have hemorrhage, infarction, necrosis, and edema. 1374: no: drinking, driving, use of fire arms, working w/ hazardous machinery, unsupervised smoking, post surgical, flat or slight elevate (10-15o) for post op phase.
