Acute Intracranial Problems - Modified SG Flashcards
Calculate CPP
CPP = MAP - ICP CPP = Flow x Resistance MAP = ((SBP-DBP)1/3) + DBP
Clinical Manifestations of Increased ICP
Changes in LOC - most reliable
Cushing’s Triad
Changes in Pupils
Decrease in Motor Functions
Nocturnal Headache or Morning headache that’s worsened with straining, agitation, and movement
Projectile vomiting or Vomiting with no nausea
Cushing’s Triad
MEDICAL EMERGENCY
Systolic HTN with widening pulse pressure
Bradycardia with bounding pulses
Irregular respirations
How does Compression of cranial Nerve III look like?
Dilated pupils on same side as mass lesion (ipsilateral)
Sluggish or no response to light
Inability to move eye upward and adduct
Ptosis (eye drooping)
Neurologic emergency for eyes
Fixed, unilateral, dilated pupil
Clinical Manifestations of CN II (optic), CN IV (trochlear,), CN VI (abducens) damage
Blurred vision
Diplopia
Changes in extraocular eye movements
Clinical Manifestations Central Herniation
Sluggish but equal pupil response
Clinical Manifestations Uncal Herniation
Dilated unilateral pupil
Clinical Manifestations Papilledema
Edematous optic disc on retinal examination
Nonspecific signs but always with increased ICP
Decrease in Motor functions
Contralateral hemiparesis or hemiplegia
Decorticate posture
Decerebrate posture
Decorticate posture
Internal rotation and adduction of the arms with flexion of elbows, wrist and fingers.
Extension, internal rotation and plantar flexion of lower extremities
Decerebrate posture
Arms are stiffly extended, adducted and hyperpronated.
Hyperextension of the legs with plantar flexion of the feet.
Important Nursing Assessment of increased ICP (and Head Injury)
Glasgow Coma Scale Neuro Assessment: Comparing pupils with one another Test pupils with light reaction Assess eye movements Test motor strength for awake and cooperative pts. Assess for motor response with unconscious or unresponsive pts. Record v/s
GCS
Lowest score: 3, Highest score: 15 Eyes Open (4 total) Verbal Response (5 total) Motor Response (6 total) If any category is unstable, they get a U
GCS Eyes Open
Eyes Open (4 total) Spontaneous response- 4 Opening eyes to name or command - 3 Lack of eye opening to previous stimuli but opens to pain - 2 Does not open eyes to any stimulus - 1
GCS Verbal Response
Verbal Response (5 total)
AOx 4 and appropriate conversation- 5
Confused, conversant but disoriented in 1 or more spheres - 4
Inappropriate or disorganized word choices or lack of sustained conversation - 3
Incomprehensible words or sounds - 2
Lack of sound with painful stimuli - 1
GCS Motor Response
Motor Response (6 total)
Obedience of command - 6
Localization of pain, lack of obedience but presence of attempts to remove offending stimulus - 5
Flexion withdrawal, Arms flexed with pain but not abnormally - 4
Abnormal flexion, making a fist, flexing of arm at elbow and pronation - 3
Abnormal extension, extension of arm at elbow usually with adduction and internal rotation of arm at shoulder - 2
Lack of response - 1
Nursing Management of increased ICP
Maintain ABCs, esp, respiratory function Sedate pt to deal with pain Monitor fluid and electrolyte balance Monitor ICP Maintain proper body position Protect pt from injury with surroundings Assess psychologic considerations
How do you promote respiratory function?
Maintain airway patency
Monitor breathing patterns - Snoring sounds indicate obstruction and need immediate intervention
Intubate PRN,
Suctioning should only be done when necessary because it can increase ICP
Monitor and evaluate ABGs
NG tube to prevent abd distention but not with facial or skull fractures
Opioids
Fast response with minimal effect on CBF and O2 metabolism
Propofol (Diprivan)
Opioid used to manage anxiety and agitation
Dexmedetomidine (Precedex)
Alpha2- adrenergic agonist used for continuous IV sedation of intubated and mechanically ventilated pts in ICU for 24 hours
Hypotension - lowers CPP
Nondepolorizing neuromuscular blocking agents
Used for complete ventilatory control in treatment of refractory intracranial HTN.
Benzodiazepine
Avoided due to hypotensive effect and long half-life
How do you monitor fluid and electrolyte balance in pts with increased ICP?
Record I&O and daily weights
Monitor serum electrolytes
Monitor urine output for DI and SIADH
DI- increased urine output and hypernatremia
SIADH- decreased urine output and dilutional hyponatremia
What should the pt with increased ICP should avoid doing?
Coughing, sneezing and Valsalva maneuver.
Proper positioning in pts with increased ICP
Head-up position with head in midline position.
Elevate HOB to promote drainage from head
Turn the pts with slow, gentle movements
Avoid extreme hip flexion
How do you protect pt with increased ICP from injury?
Quiet, nonstimulating environment with calm, reassuring approach.
Use restraints PRN
Antisz precautions
Types of Head Injuries
Scalp Lacerations
Skull fractures
Head trauma
Scalp Lacerations
External head trauma with profuse bleeding
Skull fractures
Linear or depressed
Simple, comminuted or compound
Closed or opening
Rhinorrhea and Otorrhea
CSF Leakage from nose and ear, respectively
Both indicate high risk of meningitis
Give anti-bx as preventative measure
How to test for CSF leak?
Dextrostix and Tes-Tape for present glucose
If blood is present, look for yellowish halo ring in a gauze pad.
Diffuse Injury
Damage to the brain not localized in one area.
Focal Injury
Damage is localized to specific brain area.
Concussion
Sudden, transient mechanical head injury with disruption of neural activity and change in LOC.
Benign and solves spontaneously
Discharge if no loss of consciousness or if loss of consciousness = <5 min.
Notify HCP if behavioral changes or symptoms persist
Postconcussion Syndrome
Develops 2 weeks to 2 months after injury.
Affects pt’s ADLs
Diffuse Axonal Injury (DAI)
widespread axonal damage occurring after mild, moderate or severe TBI.
Takes 12-24 hrs to develop and may persist longer
Monitor for increased ICP
Lacerations
Tearing of the brain tissue
Antibiotics and preventing secondary injury = main goal of treatment
Contusion
Bruising of brain tissue within a focal area.
Associated with close head injury and occurs at fracture site.
Coup-contrecoup injury
CT scan shows bleeding or “blossom”
Traumatic Brain Injury (TBI)
Severe form of head trauma
Complications of Head Trauma
Epidural hematoma
Subdural Hematoma
Intracerebral Hematoma
Epidural Hematoma
NEUROLOGIC EMERGENCY
Bleeding between dura and inner surface of the skull.
Classic Signs: Initial period of unconsciousness at scene, lucid interval followed by decreased LOC.
Subdural Hematoma
Bleeding from between the dura mater and arachnoid layer of the meninges
Manifests within 24 to 48 hours
Signs and Symptoms: Decreased LOC and Headache
Subacute Subdural Hematoma
Occurs within 2-14 days of the injury.
Chronic Subdural Hematoma
Develops over weeks or months after seemingly minor head injury.
Intracerebral Hematoma
Occurs from bleeding within the brain tissue.
Diagnostic Studies and Interprofessional Care
CT scan - best diagnostic test to evaluate for head trauma
MRI scan - detects small lesion
Transcranial Doppler Studies - measures cerebral blood flow (CBF) velocity.
Cervical Spine X-ray
Craniotomy
Elevate the depressed bone and remove the free fragments.
Visualizes and allow control of bleeding vessel
Craniectomy
Removal of bone
Burr-hole openings
Used in extreme emergency for rapid decompression after craniotomy.
Drain will be placed to prevent blood accumulation.
Major Causes of TBI or head injuries
Falls
Motor Vehicular Crashes
Emergency Management of Head Trauma
Assess and Maintain ABCs
Assume neck injury and stabilize cervical spine
Apply O2
Establish IV access
Intubate if GCS <8 or no gag reflex
Control external bleeding with sterile pressure dressing
Remove pt’s clothes
Maintain normothermia using blankets, warm IV fluids
Monitor v/s, LOC, pupil size and reactivity, GCS score
Assess for rhinorrhea, otorrhea and scalp wounds
Give fluids cautiously to prevent fluid overload and increase ICP
Nursing Management of Head Trauma
Monitor for changes in neurologic status - LOC, GCS, Behavior, Pupil reaction, etc.
Loss of corneal reflex needs eye drops or taping eyes shut
Avoid fever with goal temperature 96.8-98.6F
Inform HCP of rhinorrhea and otorrhea - no sneezing or blowing nose, no NG tubes and no nasotracheal suctioning
Burrhole or Craniectomy for severe cases or pt deteriorates.
Seizures may occur and need to be treated with anti-seizure medication.
Mental and Emotional consequences - not realized they have brain injury, loss of memory, mood swings, lack of awareness, etc.
Provide appropriate guidance and referrals.
Follow No policies
No Policies
No drinking alcoholic beverages No driving No use of firearms No working with hazardous machinery No unsupervised smoking
Meningitis
Inflammation of the meningeal tissues surrounding brain and spinal cord
Can be Bacterial or Viral
Bacterial Meningitis
MEDICAL EMERGENCY
Streptococcus pneumoniae and Neisseria meningitidis = leading cause
Enters through respiratory tract or bloodstream and can spread to other areas of the brain.
Bacterial Meningitis Clinical Manifestations
High Fever Severe Headache N/V Nuchal rigidity Possible skin rash - Petechiae
Bacterial Meningitis Complications
Increased ICP
Residual Neurologic Dysfunction
Hydrocephalus
Waterhouse-Friderichsen syndrome
Waterhouse-Friderichsen syndrome
Petechiae
DIC
Adrenal hemorrhage
Circulatory collapse
Nursing Assessment of Bacterial Meningitis
v/s - High Fever Neurologic assessment - Severe headache Fluid I&O Evaluation of lungs and skin Vaccine History - Meningococcal Vaccines
Nursing Care of Bacterial Meningitis
Respiratory Isolation Give Antibiotics Give antipyretics GIve pain medication PRN Slightly elevated HOB Darkened Room with cool cloth over eyes Provide fluids adequately High protein, High calorie in small frequent feedings Promote ROM and warm baths
Meningitis Diagnostic Assessment
History and Physical Examination
Analysis of CSF - protein, WBC and glucose, culture
CBC, Coagulation profile, electrolyte levels, platelet count,
CT scan. MRI, PET scan,
Skull x-ray studies
Viral Meningitis Clinical Manifestation
Moderate to High Fever
Headache
Photophobia
Stiff Neck
Viral Meningitis Diagnostic Test
Xpert EV test to test for enterovirus
Polymerase chain reaction (PCR)
Encephalitis
Acute inflammation of the brain
Caused by different viruses
Spread by ticks and mosquitoes
Encephalitis Clinical Manifestation
Nonspecific that appears within 2-3 days
Fever
Headache
N/v
Encephalitis Diagnosis
Brain images - CT, MRI, and PET
PCR - HSV and West Nile encephalitis
Blood tests that detect viral RNA - West Nile virus
Nursing Care for Encephalitis
Mosquito Control
Symptomatic and supportive treatment
Acyclovir (Zovirax) - treatment for HSV infection.
