Trauma and the Nursing Process for the patient with a neurological disorder

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Questions and Answers

What is the first action the nurse should take when a resident with a head injury is attempting to leave the facility?

Instruct a UAP to perform one-to-one observation.

Allow him to wander around but keep an eye on him.

Speak calmly and redirect him to another activity. (correct)

Obtain a prescription for an antianxiety medication.

In a patient with a spinal cord injury who shows symptoms of diaphoretic, restless behavior and a high blood pressure, what should the nurse prioritize doing first?

Recheck the blood pressure.

Put the patient in a sitting position. (correct)

Check the bladder for distention.

Check the rectum for impaction.

Which patient is most likely to achieve independent ambulation after a spinal cord injury?

Patient has a level of injury at L4 sustained in a motorcycle accident.

Patient has a level of injury at C8 sustained in a diving accident.

Patient has a level of injury at L1 secondary to a gunshot wound.

Patient has a level of injury at T12 related to an occupational incident. (correct)

What level of spinal cord injury is typically associated with the ability to ambulate with long leg braces?

L1-2 Signup and view all the answers

Which evaluative measure should be used to assess if a patient is free of infection?

Assess for any signs of infection such as increased temperature. Signup and view all the answers

What is the primary distinction of head trauma?

It involves an alteration in consciousness. Signup and view all the answers

Which age group has the highest incidence of traumatic brain injury (TBI)?

Children younger than 4 years and persons aged 15 to 19. Signup and view all the answers

Which factors influence the seriousness of a head injury?

Emergency treatment and management of injuries. Signup and view all the answers

What are the typical causes of head injuries in the United States?

Motor vehicle collisions and sports-related trauma. Signup and view all the answers

What is the term used to describe craniocerebral trauma?

Head injury. Signup and view all the answers

What type of trauma results in acceleration-deceleration injury?

Indirect trauma. Signup and view all the answers

Which of the following can occur as a result of severe head injury?

Cerebral edema. Signup and view all the answers

Which factors determine the severity of an open head injury?

The velocity, mass, shape, and direction of the impact. Signup and view all the answers

What is a key difference between epidural and subdural hematomas?

Epidural hematomas are located above the dura mater. Signup and view all the answers

Which of the following symptoms would raise suspicion for a subdural hematoma?

Loss of consciousness after a period of being alert Signup and view all the answers

What is the primary concern for managing a patient with a head injury in the emergency setting?

Ensuring a patent airway and adequate oxygenation Signup and view all the answers

In assessing a patient with a head injury, which of the following is NOT considered an objective data point?

History of loss of consciousness Signup and view all the answers

What indicates that the meninges may be torn in a patient with a head injury?

Observations of blood and serous drainage from ears or nose Signup and view all the answers

Which medication is commonly used to reduce cerebral edema in head injury patients?

Dexamethasone Signup and view all the answers

What is a likely complication when cerebrospinal fluid (CSF) drains from a head injury?

Meningitis Signup and view all the answers

Which sign is typically associated with a fracture of the lower skull?

Battle's sign Signup and view all the answers

How should drainage from the nose be handled if CSF is suspected?

Redirect their attention to avoid coughing or sneezing Signup and view all the answers

The prognosis for a patient with a head injury is generally considered to be:

Often unpredictable with varying outcomes Signup and view all the answers

What characterizes a complete spinal cord injury?

Complete loss of spinal cord function below the level of injury Signup and view all the answers

What is the initial period following a spinal cord injury often characterized by?

Flaccid paralysis and loss of reflexes Signup and view all the answers

Which of the following symptoms is associated with autonomic dysreflexia?

Severe hypertension and diaphoresis Signup and view all the answers

Which diagnostic test is commonly performed first to assess cervical vertebral fractures?

Radiographs Signup and view all the answers

What type of nursing intervention is crucial for patients with spinal cord injuries to prevent complications?

Ensuring skin integrity and preventing contractures Signup and view all the answers

Which statement is true regarding tetraplegic patients?

They have injuries to the cervical segments of the spinal cord Signup and view all the answers

What is areflexia, also known as spinal shock?

Loss of systemic sympathetic vasomotor tone Signup and view all the answers

What is an important consideration regarding bladder management in spinal cord injury patients?

Bladder training should be initiated as soon as possible Signup and view all the answers

What is a common complication for men following a spinal cord injury?

Impotence and decreased sensation Signup and view all the answers

What is one of the major goals outlined for bowel management after spinal cord injury?

To eliminate the need for suppositories Signup and view all the answers

What is the initial position recommended for a patient experiencing autonomic dysreflexia?

Sitting position Signup and view all the answers

Which intervention is NOT appropriate for a patient with autonomic dysreflexia?

Restrict the patient from moving Signup and view all the answers

What is a common teaching point for patients with spinal cord injuries?

Educate about autonomic dysreflexia Signup and view all the answers

Which prognosis is associated with complete spinal cord injury?

Almost no chance of return of function Signup and view all the answers

What should nursing assessment focus on when caring for a patient with neurologic deficits?

Observing for subtle changes in neurologic status Signup and view all the answers

Which of the following is a potential patient problem related to neurologic disorders?

Compromised swallowing ability Signup and view all the answers

What is a key goal when planning care for patients with neurologic deficiencies?

To maintain cerebral perfusion Signup and view all the answers

What is one of the first signs of complications in neurologic assessment?

Subtle changes in neurologic status Signup and view all the answers

Which nursing intervention helps prevent complications in neurologic patients?

Monitoring skin to prevent breakdown Signup and view all the answers

What criteria should be considered when developing care plans for patients with neurologic conditions?

Patient's preferences and mental status Signup and view all the answers

What has been identified as the leading cause of trauma-related deaths among individuals younger than 45 years of age?

Traumatic brain injury (TBI) Signup and view all the answers

Which of these factors does NOT influence the seriousness of an open head injury?

Gender of the patient Signup and view all the answers

What is a significant risk associated with indirect trauma to the head?

Acceleration-deceleration injury Signup and view all the answers

What type of head injuries result from skull fractures or penetrating wounds?

Open head injuries Signup and view all the answers

Which age group shows the highest incidence of traumatic brain injury (TBI)?

Children younger than 4 years Signup and view all the answers

Study Notes

Head Injury: Etiology and Pathophysiology

Head trauma primarily refers to craniocerebral trauma, marked by altered consciousness, including brief changes.
It ranks as the second most common cause of neurologic injuries, being the leading cause of death for individuals aged 1 to 35.
Historical causes include motor vehicle collisions and falls, but firearm-related deaths from head injuries have increased.
Traumatic brain injury (TBI) is widespread and the leading cause of trauma-related fatalities in individuals under 45 years.
Highest TBI incidences are in children under 4 and individuals aged 15 to 19; timely treatment influences survival.

Craniocerebral Trauma

Can involve injuries to the scalp, skull, and brain tissues, ranging from minor wounds to severe concussions and fractures.
Seriousness of head injury does not always correlate with visible damage; severe injuries can result in cerebral edema, sensory/motor deficits, and increased intracranial pressure (ICP).
Injuries may result from direct trauma (impact to head) or indirect trauma (tension strains).
Acceleration-deceleration injuries lead to bruising or contusions in key brain areas like the occipital and frontal lobes.

Clinical Manifestations of Head Injuries

Head injuries can be open (due to skull fractures) or closed (concussions, contusions, lacerations).
Open head injuries’ severity depends on the impact’s velocity, mass, shape, and direction.
Closed head injuries may result in significant bleeding, especially with scalp lacerations.
Hemorrhages can occur in various areas, such as scalp, epidural, subdural, intracerebral, and intraventricular locations.
Epidural hematomas from arterial bleeding require immediate attention if lethargy or unconsciousness develops after regaining consciousness.
Subdural hematomas form more slowly and can develop in patients who were previously alert.

Assessment of Head Injuries

Subjective data: patient’s understanding of the injury, headaches, nausea, loss of consciousness, and bleeding history.
Objective data: level of consciousness, respiratory status, pupil size/reaction, orientation, and vital signs monitoring.
Presence of Battle’s sign indicates a possible skull fracture.

Diagnostic Tests and Medical Management

Key diagnostic tools: CT, MRI, and PET scans for soft tissue evaluation.
Immediate care focuses on life-support measures and maintaining normal body functions.
Important interventions include maintaining a patent airway, ensuring oxygenation, and handling cervical spine injuries.
Medications include mannitol and dexamethasone for managing cerebral edema and ICP, alongside anticonvulsants if necessary.

Nursing Interventions

Monitor for signs of cerebrospinal fluid (CSF) leakage from ears/nose; do not attempt to clean or blow the nose if drainage occurs.
Educate patients about complications to watch for post-injury like increased drowsiness or behavioral changes.
Memory aids can facilitate patient orientation during recovery.

Prognosis for Head Injuries

Outcomes can be unpredictable; damage extent does not always correlate with surgical or CT findings.
Minor injuries may lead to lasting issues, including personality changes and increased susceptibility to further injury.

Spinal Cord Trauma: Etiology and Pathophysiology

Spinal cord injuries, commonly from accidents, lead to serious disabilities or death.
The vertebral column protects the spinal cord; injuries can involve fractures, compression, or dislocation.
Complete cord injuries result in total loss of movement below the injury site; incomplete injuries vary in symptoms.
Tetraplegia affects cervical segments, while paraplegia is confined to thoracic, lumbar, or sacral areas.

Clinical Manifestations of Spinal Cord Injuries

Initial flaccid paralysis and loss of reflexes below the injury level occur; systemic functions may also be impaired.
Complications, like autonomic dysreflexia, manifest in patients with injuries at the sixth thoracic vertebra or higher, characterized by high blood pressure and other symptoms.
Dyspnea, unusual sensations, pain, and loss of consciousness should be assessed.

Diagnostic Tests and Medical Management for Spinal Cord Injuries

Radiographs detect vertebral fractures; spinal taps or myelograms assess cord integrity.
Immediate care focuses on realigning the vertebral column, potentially using immobilization, traction, or surgical decompression.
High-dose methylprednisolone may be administered within 8 hours of the injury.

Nursing Interventions for Spinal Cord Injuries

Care aims to restore structural integrity and prevent complications, including skin issues and contractures.
It is crucial to maintain skin integrity, mobilize patients early, and implement bladder/bowel training to minimize infection risk.
Monitor and educate patients about autonomic dysreflexia and sexual health post-injury.

Prognosis for Spinal Cord Injuries

Complete spinal cord injuries lead to minimal chances of functional recovery, while incomplete injuries may allow for adaptations enabling satisfying lives despite limitations.### Assessment and Evaluation in Nervous System Disorders
Disorders of the nervous system can lead to physical and cognitive challenges requiring tailored care.
Continuous assessment of the patient’s learning readiness is crucial in providing effective care.

Evaluation Process

Success of interventions should be evaluated both during and after care to adapt to the patient's changing condition.
Care plans must be flexible; modifications are necessary when new symptoms, like confusion, arise post-operation.
Ongoing evaluation aims to determine if specific outcomes have been achieved, aligned with pre-established goals.

Evaluation Goals and Measures

Goal 1: Infection-Free Status
- Evaluative Measures: Monitor for increased temperature, urinary frequency, erythema at incision sites, elevated white blood cell counts, or confusion.
Goal 2: Alertness and Orientation
- Evaluative Measures: Engage the patient with orientation questions and observe their participation in conversations and care tasks.

NCLEX Type Questions and Answers

A safety scenario involving a young man with a head injury emphasizes redirection as the first action to manage potential aggressive behavior. Medication is secondary and less preferred initially.
In another case with a spinal cord injury patient presenting with high blood pressure and associated symptoms, placing the patient in a sitting position is prioritized to lower blood pressure.
For rehabilitation potential in spinal cord injury patients, identifying the level of injury is important. The patient with a level of injury at L4 has the greatest chance for independent ambulation with aids.
Ambulation with long leg braces during rehab is linked to injuries at levels L1-2, indicating a moderate recovery potential.

Case Scenarios for Nursing Action

A calm redirection can effectively manage agitation in a resident with a history of poor judgment resulting from a head injury, rather than immediate medication or increased observation.
Properly addressing hypotension in spinal cord injury patients involves quick assessment for bladder distention or impaction and appropriate positioning. Following emergency protocols is critical for unstable cases.