CVA and ICP Flashcards
Causes of ICP
- Head injury: depends where. It’s the bleeding and swelling that cause the problem
- Infxn
- Subarachnoid hermorahage
- Subdural/epidural hematoma (causes pressure)
- Tumor
- Stroke
eary Signs and symptoms of ICP
- Dec. LOC
- headache, seizures
- anxiety, irratibility, restless, confusion
- inc. BP
- Dec. pulse
- change in resp.
- change in temp (hot, fevers)
- nausea, vomitting
- slurred speech
- not able to follow what you’re saying
- Pupils fixed and dilated d/t dec blood supply to eyes
Assessments for ICP:
Glasgow coma scale
- The lower the number the worse.
- 15 is best
Why are neurological infxn hard to treat?
blood brain barrier
Causes of neuro infxn?
-meningitis
signs and symptoms of neuro infxn
- changes in mental status
S & S for meningitis
- severe headache
- rigid neck
- difficulty extending legs at knee
Assessment for meningitis
- Monitor ICP
Intracranial hemorrhage causes
- any bleeding in brain
when would you not give TPA
- when someone has a bleed
Hydrocephalous?
- increase fluid
Causes of stroke (CVA)
- blocked (ischemic) or burst (hemorrhagic) blood vessel
what are ppl with Hydrocephalous are at risk for?
- infxn
Who is at risk for CVA (stroke)?
non-modifiable: age, male, ethnicity
modifiable: HTN, A-fibb, hyperlipidemia, obesity, smoking, diabetes, periodeontal disease, asymptomatic carotid stenosis, excessive ETOH consumption
cushings triad (ICP)?
- inc BP
- dec. pulse
- change in resp
Ischemic stroke
- blood clot or blockage of blood flow to brain tissue
Types of ischemic stroke
- large artery thrombotic
- small “ “
- cardiogenic embolic
- crypt
late Signs and symptoms of ICP
- positive babinkski reflec
- fixed dilated pupuo;s
- absent reflexes
- abnormal posturing (decerebrate, decorticate)
- flacidity
What are the causes of the symptoms in ICP
- decrease cerebral perfusion = further inc. swelling and shifts brain tissue
- herniation through openings in the dura mater
What is coning?
- herniation through openings in the dura mater
Causes of hemorrhagic stroke?
- aneurysm
AVM?
arterial venous malformation - disrupted flow beteen arterial and venous system so as BP inc. as pt gets older, veins and arteries rupture
disgnostics for ICP
- CT
- MRI
- ICP monitoring
- PET (positive emission tomogrpahy)
- EEG (electroencephalography
disgnostics for ICP
- CT
- MRI
- ICP monitoring
- PET (positive emission tomogrpahy)
- EEG (electroencephalography)
- xray
ICP
- insertion of external ventricular crain (EVD)
- monitor ICP
- dec ICP
medical interventions for ICP
- Craniotomy: blood removed
Pharmacology for ICP
- mannitol
- vasodilator
- AntiBx
- opioid analgesis
- andrenergic blockers
- corticosteroids
- hypertonic saline
- sedation
- skeletl muscle relfexants
- anti-parkinsons
- anti-convulsants
- calcium channel blocker
- diuretic
- stool softeners ( straining)
Osmitrol (Manitol) for ICP
- hypertonic solution for hen they have inc. intracranial pressure = pulls fluid off brain
- blocks reaborption of fluids
= excrete water pot. chloride, Mg, an PO4 - monitor for electrolyte balance
- may have to replace electrolytes
- only given IV
- dose: weight based
- do not give to renal pt, or intracranial bleeding
- VItals
- electrolytes imbalances
- headaches, CHF
- renal fxn (GFR)
Contraindicated:
- pulmonary edema
Nursing diagnoses for ICP
- Ineffective airway clearance R/T diminished protective reflexes (cough/gag)
- Ineffective breathing patterns R/T neurologic dysfunction (brain stem compression, structural displacement)
- Ineffective cerebral tissue perfusion R/T the effects of increased ICP
- Risk of hemodynamic disturbance R/T increased ICP
- Risk for imbalanced body temperature R/T neurologic dysfuntion
- Deficient fluid volume R/T fluid restriction
- Risk for fluid overload R/T increased ICP
- Risk for electrolyte imbalance R/T increased ICP
- Risk for infection R/T ICP monitoring system
Nursing plan/outcome for pt with ICP
Maintenance of a patent airway Normalization of respiration Adequate cerebral tissue perfusion through reduction in ICP Restoration of fluid balance Absence of infection Absence of complication
Nursing interventions for ICP
- Monitor for changes in LOC and changes in Neuro vital
signs, regular Neuro vital signs - Monitor for changes in BP, HR, pulse pressure increase,
Temp, RR, O2 sats - Airway patency and lung fields assessed regularly,
Sx with care – coughing discouraged - Monitor breathing patterns
- Head midline, HOB 30-45 degrees (avoid extreme
rotation of neck and flexion) - Avoid extreme hip flexion
- Administer stool softeners, high fiber diet
- Administer Pain medications PRN
- Provide a calm environment
- Maintain fluid balance (fluid restriction, diuretic, fluid
resuscitation) - Monitor for electrolyte imbalances
- renal f
Rule for remembering S&S of ICP and Schock
ICP: cushings triad Inc BP Dec pulse Dec resp
*shock is the opposite
Assessments for ICP
- complete head to toe
- Glasgow coma scale
- fluid balance = excess fluid output
- electrolytes
TIA
Transient ischemic attack - brief neurological dysfxn d/t loss of blood flow (ischemia) to brain, spinal cord or retina without tissue death (infarction).
S&S of TIA
- same as stroke..
- paralysis
- weakness
- numbness on one side of body
- dizzy
- mumble words
motor symptoms of stroke
- hemiplegia - half-sided paralysis
- hemoparesis - half-sided weakness
- ataxia - unsteady gait
- dysphagia - difficulty swallowing
communication symptoms of stroke
- dysarthia - weakness/paralysis of muscle used to speak
- dysphasia - difficulty speaking
- Aphasia - inability form speech or language
- Apraxia - difficulty performing tasks
communication symptoms of stroke
Visual perception dysfxn d/t problem with sensory pathways between eye and visual cortex
Homonymous hemianopsia: can only see either left or right
sensory symptoms of stroke
- touch impairment
- difficulty interpreting stimuli
cognitive impairment symptoms of stroke
- o Frontal lobe damage can affect learning capacity, memory, and other higher intellectual functions o Limited attention span o Comprehension difficulty o Forgetfulness o Apathy o Headache
emotional deficits of stroke
o Loss of self-control o Emotional liability o Depression o Withdrawal o Fear, hostility, anger o Feelings of isolation
Stroke assessment
FAST face arm speech time - 911
diagnostics for stroke
Ct scan: bleeding CT angiography Carotid U/S: narrowing of artery MRI: bleeding Phenytoin level and albumin PTT, PT-INR(baseline), Hgb, Na and K, renal fxn test
Pharmacological for stroke
TPA (Tissue plasmin activator): thromboltic. Cannot give if unsure of when stroke happened
Antihypertensive (ACE inhib, beta blocker, Ca blocker): HTN risk factor for developing stroke
Anticoags (aspirin)
Platelet-inhibiting meds: Plavix, coumadin
Anticonvulsants: if at risk for dev. seizures
