Cerebral Flashcards
Cranium composition
80% brain
10% CSF
10% blood
Major causes of Head injurys
Falls Motor vehicle injury Bicycle/motor bike Sports related injury Child abuse Assault
TBI
Leads to severe brain damage or death if not recognized and treated appropriately
Causes of ICP
Head injury Subdural/Epidural hematoma IVH (intraventricular hemorrhage) Fractures Meningitis/Encephalitis Hydrocephalus Status Epilepticus Reyes Syndrome Cerebral edema
Concussion:
Most common injury
Concussion: Hallmark signs and symptoms
Confusion, amnesia, altered neurological or cognitive function with or without loss of consciousness
Occurs immediately after injury
Signs of ICP
Concussion: Treatment
Resolves between 7-10 days but can take up to several months depending on severity
Rest!!!
Contusion
Visible bruising and tearing of cerebral tissue
Small petechiae or little bleeds in brain tissue
Degree of brain damage in the contused areas varies according to the extent of vascular injury
Epidural Hemorrhage/Hematoma:
Bleeding the dura mater and the skull to form a hematoma, dura is peeled off the skull, and its arterial blood that lying underneath
Not as common as subdural hematomas
Usually occurs in younger adults
Epidural Hemorrhage/Hematoma: S/S
Brief loss of consciousness followed by a period of awareness that may last several hours before the brain function deteriorates sometimes leaving the patient in acoma
Very serious if not treated immediately the patient can die
Epidural Hemorrhage/Hematoma: Treatment
Neurosurgeon will go in and evacuate the hematoma
Patients usually have a good outcome if its recognized immediately
Subdural Hemorrhage
Bleeding between the dura mater and the arachnoid membrane, usually due to stretching and tearing of veins on the brain’s surface
Traumatic, acute subdural hematoma is the most lethal of all head injuries
More common than epidural hematomas. most often infancy as a result of birth trauma, falls, child abuse, or violent shaking
CSF analysis: Glucose content-viral
Normal
Penetrating trauma
Gun shot wounds or objects that break the barrier of the skull
Fractures: Linear
Most common type of skull fracture
break in the bone but it doesn’t move the bone
May be observed for a brief time
No interventions needed
Fractures: Depressed
Seen with and without a cut in the scalp
Part of the skull is actually sunken in from the trauma
May require surgical intervention, depending on the severity, to help correct the deformity
Fractures: Diastatic
Widen the sutures of the skull and usually affect children under 3
The normal suture lines are widened
More often seen in newborns and older infants
Fractures: Comminuted
Fracture in which the bone has broken into several pieces
Fractures: Basilar
Most serious type of skull fracture, and involves a break in the bone at the base of the skull
Frequently have bruises behind the ears (battle signs) and around the eyes (raccoon eyes)
Clear fluid draining from their nose or ears due to a tear in part of the covering of the brain
Usually require close observation in the hospital
Classic raccoon eyes, bleeding around the nose, ear, and ethmoid sinus
Minor head injury symptoms
May or may not lose consciousness HA Confusion, amnesia Listlessness Pallor Vomiting, generally projectile Irritability Seizures
Severe head injury symptoms
Decreased LOC/GCS Changes in VS Bulging fontanels Retinal hemorrhage Unsteady gait Hemiparesis, numbness on one side Quadriplegia, numbness on all 4 extremities Elevated temperature
Warning signs after head injury (first 24hr)
Change in LOC Increased drowsiness, confusion, difficult to arouse Seizures Bleeding or water drainage from nose and ears Pupils slow to react or unequal Visual problems Loss of sensation to any extremity Slurred speech Projectile vomiting
Diagnostics for head injury
H&P Baseline VS SpO2 LOC/GCS ABG Alcohol level Drug screen CBC Xray CT scan MRI
Secondary complications from head injury
Changes in LOC (Pay attention to changes) Coma Increased ICP Infection -open penetrating wound Cerebral edema Hemorrhage Seizures Hypoxic brain damage Brain herniation Brain death
Nursing management of head injury
ABC Cervical spinal cord stabilization (neck brace has to stay in place until cervical spine injury has been ruled out) Elevate HOB and Midline Thorough PE (log roll patient) VS (look for widening pulse pressure and low pulse- sign of Cushing's triad) SpO2 GCS Pain Drainage (eyes, ears, nose) NPO IV fluids Strict I & O Monitor labs closely (Na, serum osmolality, urine output, DI, SIADH) Seizure precautions Monitor S/S of ICP (complaining of HA, pupillary changes, vomiting, behavioral changes) Quiet, dark room, Cluster care Support family and educate
Glascow coma scale: Eye opening
4: Spontaneously
3: To voice
2: To pain
1: None
Glascow coma scale: Verbal response
5: Normal conversation
4: Disoriented conversation
3: Words, not coherent
2: No words, only sounds
1: None
Glascow coma scale: Motor response
6: Normal
5: Localized to pain
4: Withdraws to pain
3: Decorticate
2: Decerebrate
1: None
GCS classifications
Mild: 13-14
Moderate: 9-12
Severe: 3-8
Leaking of CSF
Halo sign on the sheets
There is blood at the center surrounded by clear liquid leaking and a visible ring surrounding
Use a chemical strip and dip it for glucose
Positive: its CSF
Increased intracranial pressure (ICP)
Increase in volume of the cranium leads to increases intracranial pressure
Infants can compensate when sutures are still open
Changes in LOC is the first sign of ICP
Changes in vital signs follow: Cushing triad (late sign)
Causes of Increased ICP
Head injury Subdural/Epidural hematoma IVH (intraventricular hemorrhage) Fractures Meningitis/Encephalitis Hydrocephalus Status Epilepticus Reyes Syndrome Cerebral edema
Signs of Increased ICP: Infants
Tense bulging fontanel Separated cranial sutures Increased FOC Irritability Restlessness Drowsiness Increased sleeping Poor feeding High pitch cry
Signs of Increased ICP: Children
HA N/V Diplopia Blurred vision Seizures Drowsiness Lethargy Increased sleeping
Severe/ Late signs of Increased ICP: Changes in LOC
Decreased response to painful stimuli
Decreased consciousness
Coma
Seizures
Severe/ Late signs of Increased ICP: Eyes
Changes are considered a medical emergency (notify MD immediately)
Papilledema (bulging or swelling behind optic disc that is caused by increased ICP, usually bilaterally and can occur occur a period of hours to weeks)
Alterations in/unequal pupil size and reactivity to light (fixed or dilated pupil)
Impaired eye movement
Severe/ Late signs of Increased ICP: Posturing
Decerebrate
Decorticate
Flaccid
Decerebrate
Arms are extended outward, indicative of severe brain stem injury
Worst posturing
Decorticate
Abnormal posturing where person is stiff with arms bent, clenching fist with legs pointed out straight
Mummy pose
Severe brain damage
Severe/ Late signs of Increased ICP: Change in vitals
Cushing’s triad
Cheynes-stokes respirations (increased RR, then slow RR, then a period of apnea)
Decreased motor response to command
Management of Increased ICP
Neurosurgery consult Emergency craniotomy Mechanical ventilation Central line/Arterial line CPP (cerebral perfusion pressure)=MAP (represents the pressure gradient driving cerebral blood flow and hence O2 and metabolite delivery) NGT/DHT Foley ICP monitoring (EVD, Bolt, Normal pressure ranges from 3-5, sneeze goes up to 10-15) High ICP must be treated immediately
Nursing management of Increased ICP
Monitoring Strict bed rest NPO/IV fluids Strict I&O Pain control Elevate HOB Head midline Decrease stimuli Cluster care Suctioning Restraints Elimination Safety Nutrition Seizure precautions Coping
Diabetes insipidus
High urinary output Low level of ADH HyperNa Dehydrated Lose too much fluid Excessive thirst
SIADH
Low urinary output High ADH HypoNa Overhydrated Retain too much fluid Excessive thirst
Pharmacological management of Increased ICP
Mannitol (cerebral edema) Hypertonic saline solution (preferred) Corticosteroids Analgesics Sedatives Paralytics Anticonvulsants (prophylactic) Antibiotics
Reportable S/S of Increased ICP
Change in: V/S, labs, LOC, GCS, Behavior, Pupils, Pain, Posturing
Confirmation of brain death
Fixed and dilated pupils
Absent corneal reflexes (rub q-tip across cornea)
Absent gag reflex
Apnea test (turn off ventilator for 30 sec and see if the patient breaths)
Cold caloric test (put water in the patient’s ear- causes nausea, nystagmus)
EEG (cerebral silence)
Cerebral blood flow exam/No flow to the brain
Prevention of head injury
Never leave infant unattended on bed, couch, chairs
Always have infant/child secure in high chair
Always have infant/child in appropriate size car seat, secure seatbelt
Place car seat in appropriate position in regards to age/wt/manufactures recommendations
Firearm security and safety
Make sure helmets are worn during bike ride/horseback riding/skating/skateboarding/sports
Monitor child’s play on playgrounds and around roads/stairs/steps
Never shake a child
Cushing’s triad
HTN
Bradycardia
Apnea
Intracranial infections
Meningitis (inflammation of the meninges lining the brain and the spinal cord)
Encephalitis (inflammation affecting the brain)
Meningitis: Viral or Aseptic: Caused by
Viral illnesses (mumps, measles, herpes, CMV, adenovirus, HIV)
Meningitis: Viral or Aseptic
Short lived, self limiting, complete recovery
Occurs most often in very young children <2mo
Meningitis: Viral or Aseptic: Manifestations
Generalized rash but wont have a purpuric or petechial rash that you see in bacterial meningitis
Meningitis: Viral or Aseptic: Treatment
Give Tylenol or Ibuprofen if they complain of HA or body aches and to control their temp
Keep comfortable, the virus has to run its course
Meningitis: Bacterial or Septic: Caused by
Pus forming bacteria
Group B Strep, E. coli, L. monocytogenes: <2mo old
S.pneumoniae, N. meningitidis: >2 mo old
Meningococcal meningitis: School age, adolescents, college students
Vaccines that have lead to a decline in meningitis
H. influenzae type B (Hib)- 2,4,6 months and between 12-18 months
Pneumococcal conjugate vaccine- 2,4,6 months and between 12-18 months
Meningococcal conjugate vaccine- given between 11-18 years with a booster 5 years later
Bacterial Meningitis: Symptoms in Neonates
Refusing feedings or poor sucklig ablility
Vomiting or Diarrhea
Poor or weak muscle tone and lack of movement
Weak cry
Full/tense bulging fontanel
Bacterial Meningitis: Symptoms in infants and young children
Bulging fontanelle High pitch cry Vomiting Refusing food Stiff or rigid neck Fast shallow breathing Skin rash Very irritable Extreme shivering Floppy limbs Cold hands and feet Seizures High or low temp Lethargic Photophobia
Bacterial Meningitis: Symptoms in children and adolescents
Usually abrupt onset Fever Chills HA Vomiting Seizures Agitation Nuchal rigidity May develop: photophobia, delirium, stupor, hallucinations, drowsiness, coma
Nuchal rigidity
Resistance to neck flexion due to meningeal irritation
Positive Kernig and Brudzinski sign
Kernig sign
Patient supine, with hip flexed 90 degrees, knee cannot be fully extended
Brudzinski sign
Neck rigidity
Passive flexion of neck causes both flexion of both legs and thighs
Meningitis: Diagnostics
Physical assessment; Head to toe Lumbar puncture (definitive) CT scan (rule out other abnormalities) Blood culture (rule out infections)
Lumbar puncture
Patient is bent over to open spaces between. vertebrae
Explain to the patient and family what to expect after
Use Elma cream on L4-5 or L3-6, and let it stay on for 30 minutes
Lie still for several hours after procedure to prevent HA or a CSF leak
CSF analysis: WBC count: bacterial
Elevated, increased polymorphonuclear leukocytes
CSF analysis: WBC count: Viral
Slightly elevated, increased lymphs
CSF analysis: Protein count: Bacterial
Elevated
CSF analysis: Protein count: Viral
Normal or slightly increased
CSF analysis: Glucose content: Bacterial
Decreased
CSF analysis: Glucose content: Viral
Normal
CSF analysis: Gram stain: Bacterial
Postive
CSF analysis: Gram stain: Viral
Negative
CSF analysis: Color: Bacterial
Cloudy
CSF analysis: Color: viral
Clear
Meningitis: Nursing Alert
Major priority with a child suspected of having meningitis
1. Initiate contact and respiratory isolation precautions immediately
2. Initiate antibiotics as soon as they are prescribed by physician. Child is places on respiratory isolation for at least 24 hr after initiation of antibiotics and C&S results are confirmed
Need to give antibiotics with in 30 minutes
Bacterial Meningitis: Management
Isolation precautions Initiation of antibiotics with in 20 minutes of patients arrival, suspecting meningitis Restrict hydration initially Maintenance of ventilation - ABCs Reduction of increased ICP Management of systemic shock Control seizures Control temp
Bacterial Meningitis: Nursing management
ABCs Cardiopulmonary monitoring IV placement (long term- big veins) ABX at least 7-10 days so possible PICC line placement Strict I&Os Quiet room Cluster care Elevate HOB Pain control
Bacterial Meningitis: Education
Exposed family need to take Rifampin
Long term antibiotics needed for at least 10 days
Hearing loss is common due to ototoxicity from high dose of antibiotics and from having meningitis itself
Auditory evaluation 6 months after the illness has resolved
Seizures
Result of uncontrolled electrical discharge from nerve cells to the cerebral cortex
Seizures: characterized by
Sudden brief attacks of altered consciousness, motor activity, and sensory phenomena
Seizures: Associated with
Variety of verbal and systemic disorders such as a focal or generalized disturbance of cortical function
Seizures: Sensory symptoms
Arise in the parietal lobe
Seizures: Motor symptoms
Arise in the frontal lobe
Seizures: Risk factors
Genetics Feve Head trauma Infections Noncompliance with medications Stress Tumor Withdrawal Fluid and electrolyte imbalance Flashing lights or video games Toxin or chemical exposure
Febrile seizures
Most common neurological condition of childhood
Affects children between the ages of 6mo-5 yr
Occurs with a fever above 38.0C
Use tylenol or ibuprofen to make child more comfortable
Recurrence is common
Febrile seizures: Parental reassurance
It will stop on its own, does not cause any other health problems, place the child on their side or stomach
Time seizure, if it last longer than 10 minutes take them to the ER
Once seizure has ended take child to provider to check the source of the fever, this is urgent if the child is showing signs of stiff neck, extremely lethargic, continued vomiting- signs of meningitis
Febrile seizures: Signs
Jerky movement Convulsions Shaking Twitching Moaning May become unconscious
Seizure: Treatment options
Antiepileptic drugs
Ketogenic diet
Vagus nerve stimulation
Surgical management
Seizure: Antiepileptic drugs
Fosphenytoin Phenytoin Diazepam Lorazepam Gabapentin Cerebyx Tegretol
Seizure: Ketogenic Diet
Hight fat, low CHO and adequate protein that puts them in a state of ketosis and studies have shown that as many as 50% of children on this diet will have a decrease in seizures
Seizure: Vagus nerve stimulation
Performed under general anesthesia, where a device is implanted into left chest wall and is connected to an electrode placed at left vagus nerve
Its programed to administer intermittent vagal nerve stimulation by holding a magnet over the implanted device at the onset of seizure activity. This will either abort the seizure or lessen its severity
Seizure: Surgical management
In certain situations it may be needed, like a corpus colostomy, or depending on severity of seizures, how often they are having them…
Seizure: Nursing management
Side rails up Bed in the lowest position Padded side rails Call light within reach Waterproof mattress O2 and suction at bedside Medical ID bracelet for seizure and fall precautions
What to do when pt is having seizure
Remain calm Time the seizure Position the child for safety (side laying) Prepare to suction any oral secretions Maintain airway Loosen clothing Never restrain Never attempt to open their jaw or insert an airway during seizure activity Place pillow under head Ensure safe environment Stay with the child and reassure until fully awake Notify MD Document S/S
What to do after seizure
Stay with them until they are fully awake
CHeck VS
Keep them in side lying to prevent aspiration and facilitate drainage of oral secretions
Assess for any injuries and perform neurological checks
Allow the child to rest, they will be sleepy in the postictal state
Reorient them and calm them
Encourage them to describe the period before, during and after seizure activity, experience aura? trigger?
Document s/s, onset, duration, apnea, cyanosis, LOC, incontinent
Seizure: When to call for Dr./RR
Evidence of injury after seizure Pt has DM Pt is pregnant Seizure last >5 min Pupils are not equal after seizure Child vomits continuously 30 min after the end of seizure Seizure occurred in water Pt first seizure Status epilepticus occurs
Seizure: Call code/start CPR
Patient is unresponsive, stops breathing, barely breathing, gasping with <10 breaths/min
Patients heart stops beating or less than 60 beats/min with signs of poor perfusion
Seizure: Care management
Nurses are responsible for observing the seizure episode and accurately document the events, not diagnosing the type
Only describe what happened
Note the duration with a start and stop time
Seizure: Goals of Care
Control the seizures or reduce their frequency and severity
Discover and correct the cause when possible
Help the child live as normal as possible
If child has a history, ask them if they have an aura before an episode. This will let you/them know what to look for so you can protect them for harm/implement precautions
Status Epilepticus
Continuous seizure lasting more than 30 min, or 2 or more seizures without full recovery of consciousness between any of them
Requires immediate treatment to prevent loss of brain function, which may become permanent, because the brain isn’t getting the blood/O2 flow it needs
Status Epilepticus: Nursing management
ABCs Monitor VS Continuously monitor SpO2 and ABGs Administer O2 Obtain IV, preferably a central line because many antiepileptic drugs can be caustic to the vein Perform a stat EEG Intubation Sedation Give loading dose of Lorazepam or Diazepam followed by continuous infusion of Phenytoin
Hydrocephalus
Imbalance in the production and absorption of CSF in the ventricular system
Ventricles become dilated and compress the brain against the cranium, causing an increased ICP
Hydrocephalus: Causes
Tumor Hemorrhage Infection Congenital malformations Trauma
Hydrocephalus: Clinical manifestations: Infants
Large head Widened sutures Rapidly increasing FOC Full and bulging fontanels Irritability Vomiting High pitched cry Poor feeding Sun-setting sign Sluggish pupils
Sun-setting sign
Sclera showing at top eyelid, eyes depressed and rotated downward due to the increased pressure in the brain
Hydrocephalus: Diagnostics
FOC- crosses the 1% line on the FOC chart with in 2-4 weeks 🚩
CT scan
MRI
Any clinical manifestations
Hydrocephalus: Therapeutic management
Placement of a VP or a VA shunt in the ventricle and threading it into either the right atrium of the heart or the peritoneal cavity of the abdomen
Hydrocephalus: Post-op nursing care
Positioning: initially supine for the first 12 hr, can also be placed on their side if that's comfortable, make sure its t the uncooperative side. Slowly start elevating the HOB Pain management Monitor VS GCS Skin integrity at insertion site, in their heart/chest area (if catheter is threaded to their abdomen: assess that area for signs of redness, swelling, drainage, tenderness, and distention) Signs of infection Signs of malfunction Educate/prepare for DC
Hydrocephalus: Signs of Shunt malfunction
Signs of increased ICP because the valve gets kinked, then drainage is backing up in the brain
Hydrocephalus: Complications: Shunt infection
Greatest risk is 4-8wk after placement
Meningitis
Ventriculitis (inflammation of the ventricles where the shunt was placed)
Remove shunt: get culture to know how to treat
Antibiotics: 7-10 days (PICC line preferred)
Hydrocephalus: Complications: Shunt malfunction
Kinking Plugging Separation or migration of tubing Mechanical obstruction Remove shunt Replace shunt
Hydrocephalus: External ventricular device (EVD)
If patient does have to have their shunt removed, they may have had an EVD to drain the fluid until the shunt is replaced.
This allows you to obtain cultures from the CSF
You can regulate the amount of drainage you’re getting from the patient
Pay attention to patients position because if they move, you have to adjust your EVD, because it impacts the amount of drainage coming out
Hydrocephalus: EVD: Nursing management
Must be knowledgeable about the equipment Assist MD in insertion Set up and replace equipment Maintain placement level Draw samples from port Interpret and monitor readings Document assessment findings Notify MD of changes/problems
Hydrocephalus: EVD: Notify MD if..
Change in color, amount of CSF drainage
Behavioral changes
Signs of infection at EVD insertion site
Reyes syndrome
Extremely rare but serious illness that can affect the brain and liver
Most commonly in children recovering from viral infection
Occurs more in winter months when there’s been an outbreak of chickenpox or influenza B
Duration of illness depends on the severity of the disease
5 Stages (mild and self limiting-rarely death within hours)
Early recognition and treatment are imperative
Treat as medical emergency
Reyes syndrome: Etiology
Still not well understood, and there’s no cure for it.
Just has to run its course
Treatment is systemic depending on the stage
Linked to aspirin/salicylates or aspirin containing medication during viral disease as a factor in development
Reyes syndrome: Diagnosis
No specific test
Screening starts with blood, urine tests, testing fatty acid oxidation disorders and other metabolic disorders
More invasive diagnostic tests are needed to evaluate other possible causes of liver problems and to investigate any neurological abnormalities (spinal tap, liver biopsy, CT scan, MRI, Skin biopsy may be done for FA oxidation or metabolic disorders)
Reyes syndrome: Signs and Symptoms
Frequent vomiting Lethargy, sleepiness Irritability or aggressive behavior Infants: Diarrhea, rapid breathing Changes in vision Difficulty hearing Abnormal speech Alteration in LOC Fatty liver changes Hepatomegaly Severe muscle weakness Seizures Loss of consciousness
Reyes syndrome: Management
Supportive or symptomatic depending on the stage- NO cure
ABCs
Prepare patient and family for diagnostic tests
Monitor VS (continuous cardio-pulmonary)
Strict I&Os
Monitor for signs of /Control ICP (at risk for increased ICP want to give osmotic diuretic)
Implement seizure precautions (at risk for seizure: put on prophylactic medication)
Monitor lab studies (put them on vit. K, might also receive plasma and platelets due to bleeding from the live abnormalities, so pay close attention to PT, aPTT, INR)
Nutrition support
Monitor fluid and electrolyte and liver function tests
Reyes syndrome: Stage 1
Vomiting Lab evidence of liver dysfunction lethargic Sleepy (Mild-moderate)
Reyes syndrome: Stage 2
Deeply lethargic Restlessness Confused Delirious Combative Hyperventilation Hyperreflexia (Mild-moderate)
Reyes syndrome: Stage 3
Obtunded or in a light coma
Decorticate rigidity
(Mild-moderate)
Reyes syndrome: Stage 4
Deepening coma Seizures Decerebrate rigidity Fixed pupils Loss of oculovestibular reflexes (severe)
Reyes syndrome: Stage 5
Seizures Deep coma Flaccid paralysis Absent deep tendon reflexes Respiratory arrest Fixed and dilated pupils (Severe)
Reyes syndrome: Family support and education
Many OTC medications contain Salicylates
Aspirin should not be used for kids or teenagers except on the advice of the Dr for certain conditions because it can cause severe brain and liver damage
NO ASPIRIN OR ASPIRIN CONTAINING MEDICATIONS TO CHILDREN OR ADOLESCENTS!!
