Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide

Signs and symptoms of brain injuries: • Vertigo/dizziness • Odd behaviors/hyperactivity • Loss of consciousness • Confusion/disoriented • Visual disturbance • Memory loss • Headache

• • Fixed pupils/uneven pupils Seizures • Weakness/decreased motor function • Posturing • Incontinence • Wide pulse pressure • High temperature (hyperthermia)

Nursing assessment for head injury: • Assess GCS, responsiveness, and pupil response first on all head injuries; if abnormal, the physician should be alerted immediately because this shows increased ICP • Assess respiratory function • Full neurological assessment; take note that hand grips may be positive due toreflexes • Vital signs: temperature, pulse, respiration, and blood pressure; watch for wide pulse pressure • Take a thorough history on nature of injury: how it happened, force, and where blowoccurred • Note any visible signs of trauma: bruising, lacerations, and leakage of CSF/clear fluid from ears or nose • Review radiology and laboratory reports: o CT scan: This test is done to check for swelling inside the skull. It can help to provide an actual location of the injury and aid in diagnosis of brain injuries, bleeding, and cerebral edema. o MRI/MRA: These tests go one step further than a CT scan and can identify injuries or compression of vessels inside the brain. o X-ray: Can check the bones in the skull for actual fracture or penetrating injury. o CSF testing: Litmus paper (detrastix) can be used to check for glucose in the clear fluid. If that is found there is most likely CSF leakage. This test will not be accurate if blood is present since blood contains glucose and the test strips are very sensitive. o Arterial blood gases: Checks for signs of hypoxia in brain injuries. o Electrolytes: Head injury can alter the regulation of needed electrolytes. o Ammonia levels: Even without a blow to the head, head injuries can be caused by a high ammonia level as seen in patients with liver failure. o CBC: Can check for internal bleeding or signs of infection.

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