MedSurg Mod 6: CNS Disorders Flashcards
How are head injury, Increased ICP, intracranial surgery, seizure and other complications all interrelated?
Head Injury –> ICP, Seizures and Complications, Surgery
Intracranial Surgery Increased ICP and Seizures and other Complications
Increased ICP Seizures and Other complications
What is the one thing independent from most other CNS injury relationships
Spinal Cord Injury
Head Injury
involves trauma to the scalp, skull, and brain
It results in anything from a mild concussion to coma to even death
TBI
Traumatic brain injury
What is the most common cause of TBI
falls (any age)
Open TBI
Skull opened
Closed TBI
skull is still closed
Diffuse TBI
widespread damage
Focal TBI
localized damage to one brain area
TBI damage and what you see is dependent on ___ and ___
location and severity
Epidural Hematoma (Hemorrhage)
Above the dura and under the skull
a medical emergency that is usually due to a rupture of a middle meningeal Artery
can cause brain herniation leading to loss of consciousness and focal neuro deficits like pupil dilation and paralysis of an extremity
Subdural Hematoma (Hemorrhage)
Below the dura, Between the Dur and Brain
usually venous in origin - bleeding not as dramatic but this can be both good and bad
may be acute, subacute, chronic (elderly, people on anti coagulants)
Intracerebral Hematoma (Hemorrhage)
withIN the brain tissue
result of focused injury or system issues (focal rather than systemic)
Major risk factor is HTN –> CVA
Concussion
Global and Microscopic
Widespread homogenous impairment of brain cells (cells under perform)
No visible bleeding occurs
Confusion, irritability, Disorientation, and HA occur
harder to measure and no real fix just cures itself over time
Contusion
Localized and macroscopic
structural damage to cells (cells die)
effects peak 18-36 hours post injury
coup contrecoup injuries cause this
can increase ICP d/t bleeding
blurred vision, disorientation, unsteady gait, vomiting, slurred speech, and coma can occur
Just because evidence of damage is easier to see with a contusion does not mean…
it will tell what type of injury occurred like hypoxia, impact, foreign body etc - it just tells us there is cellular damage
Can a concussion and contusion occur simultaneously
yes
Damage at the brain cell level is not dependent on…
actual injury
Coup-Contrecoup injury
2 injuries from one impact - a rebound effect
a focal injury
commonly associated with a contusion occurring
Diagnosis for Head Injuries
CT or MRI - identifying and evaluating injuries to brain tissue
Skull X Rays - look at penetrating injuries to the skull and if skull is damaged
Angiography
What is the number1 concern of head injuries
bleeding and increased ICP
Medical care for Head Injuries
1 - Control ICP
- Reduce cellular demands
- Surgical intervention
- Minimize secondary injury
Intracranial Bolt (ICB)
Bolt put in brain tissue that can monitor ICP
Why may mechanical ventilation and a respiratory be used on a head injury patient
- To aid if respiratory centers are damaged or at risk and prevent hypoxemia: Lactic Acidosis increased –> increased vasodilation occurs to compensate –> increased ICP will occur!
- to prevent hypoxemia and hypercapnia as a result of cerebral vessel vasodilation causing increased ICP
Why do head injury patients sometimes undergo medically induced comas?
to decreased CNS activity and reduce too much work in the brain in order to reduce cellular demands
What is the secondary injury to watch for with head trauma that can skyrocket ICP
edema
Goals of Nursing Care of Head Injuryu
- Address acute issues like respiratory, cerebral circulation, safety
- Prevent and treat secondary complications like infection, pneumonia, skin integrity, safety, and positioning
- Prevent treat and minimize consequences via behavior, physical rehab like OT and PT, and education
What to do first for nursing care of head injuries
Assess all systems for direct impact (PRIMARY COMPRIOMISE):
a. Patent Airway and Optimal Breathing pattern –> Monitor O2 sat, respiratory rate, lung sounds, VS
b. Optimal Cerebral tissue perfusion –> monitor mentation
c. Appropriate fluid balance –> monitor labs for H&H and lytes
What to do second for nursing care of head injuries
Assess all symptoms for secondary impact (secondary compromise):
a. s/s of infection
b. complications
c. consequences
What is an important issue to teach patient and family about?
Post concussion syndrome
how difficult it is to measure concussion
when to monitor and notify MD
how changes depend on location and severity
What are the s/s of post concussion syndrome
HA
Dizziness
Lethargy
irritability
emotional lability
fatigue
poor concentration
decreased attention span
memory difficulties
intellectual dysfunction
How long does post concussion syndrome last
may last 1 week or 1 year even
When to monitor and notify an MD regarding head injuries post care?
Difficulty in awakening or speaking
confusion
severe HA
vomiting
unilateral weakness
Functions of Frontal Lobe
behavior
intelligence
memory
movement
Functions of Temporal Lobe
behavior
hearing
memory
speech
vision
Function of Parietal Lobe
intelligence
language
reading
sensation
Functions of Occipital lobe
vision
Functions of Brain Stem
Blood pressure
breathing
consciousness
heartbeat
swallowing
Function of Cerebellum
balance
coordination
Reasons Intracranial Surgery is Done
- Reduce elevated ICP
- remove tumor/foreign body
- evacuate a blood clot
- control hemorrhage
Ectomy
removal
Plasty
repair
Craniectomy
removal of part of skull to allow room for swelling
it gives access to brain tissue like an epidural hematoma or allow some brain swelling to occur
the skull pieceis either frozen or put in the peritoneum
Cranioplasty
Repair of the skull using a metal or plastic plate
Approaches for Intracranial Surgery
Supratentorial (above the tentorium fibrous tissue)
Infratentorial (below)
Medical Interventions to do Pre Operatively for Intracranial Surgery
Define diagnosis/surgical approach
general pre and post op considerations
medications - anti seizure, corticosteroids for edema, hyperosmotic agent (mannitol), diuretics, antibiotics, anti anxiety
Nursing interventions to do pre operatively for intracranial surgery
document baseline neurological status
routine pre operative care and education
continue with established care - diet, activity, medications, etc
Why give corticosteroids for intracranial surgery
to reduce cerebral edem
Why give hyperosmotic agents like mannitol for intracranial surgery
it pulls water into the bloodstreaam thus pulling fluid out of swollen brain tissue
Medical interventions to do post operatively for intracranial surgery
reduction of cerebral edema via mannitol and Decadron (a corticosteroid)
relive pain with narcotic analgesics
prevent seizure with Dilantin and valium
monitor intracranial pressure with an implanted ICP monitor
Nursing interventions to do post operatively for intracranial surgery
assess every hour the neurologic status via Glasgow coma scale or FOUR score, repsiratory status, ABGs, labs, VS, intracranial pressure readings (read ICP but not put monitor in)
proper positioning depending on surgical approach
routine post op care such as C-DB, I&O checks including tubes and ventilation, and dressings and drainage
Why must we check with the MD first regarding C-DB after intracranial surgery
it can increase the pressure in the chest and above into the head
ETT
endotracheal tube
breathing tube from ventilator
Glasgow Coma Scale
The most widely used method for evaluation of coma
simple
has a number of shortcomings such as limited utility in intubated patients and inability to assess brainstem reflexes
FOUR Scale (Full Outline of UnResponsiveness)
a more in depth assessment tool used on neuro unites
provides further neurological details (gives a full status)
better predictor of outcome
useful for intubated patients and assessing reflexes
What sort of score is better on the GCS
a higher score
What sort of things does the FOUR scale look at
more detailed things like eyes, motor response, brainstem response, and respiration
allows for checking someone who is not fully awake but to monitor best motor response they need to be awake
may be useful for someone comatose post op
Potential intracranial surgery post op complications
bleeding and hypovolemic shock
fluid and electrolyte disturbances
infection
increased ICP
seizures
Diabetes insipidus
SIADH
What are the 4 specific complications arising from surgery to the head
- Increased ICP
- Seizures
- Diabetes Insipidus (d/t damage)
- SIADH (d/t damage)
What is intracranial pressure
balance of brain tissue, blood and CSF
normal ICP level
7-15 mmHgh
Monroe Kellie Doctrine
increase in any compartment –> compensatory changes in others
Increases in ICP could be due to what things
injury
brain tumors
subarachnoid hemorrhage
toxic or viral encephalopathies
Early (S/S) Human responses to increased ICP
change in LOC
pupillary changes
impaired ocular movements
weakness in one side or extremity
headache that is constant and is increasing in intensity while aggravated by movement and straining
Late (S/S) Human Responses to increased ICP
further deterioration of LOC
respiratory pattern alterations
loss of brainstem reflexes like pupillary, gag, swallowing, corneal
Cushing’s triad
hemiplegia or flaccidity
posturing
What are the 3 things in Cushing’s Triad
- HTN/Widening Pulse Pressure
- bradycardia
- Bradypnea
What is one of the most negative findings of increased ICP
Decorticate or Decerebrate Posturing
I.C.P. acronym for human responses to increased ICP
I - increasing pulse pressure
C - Changes in loc, respiratory, speech, heart rate
P - pupils, puking, pain, posturing
Decorticate Posturing
Sign of severe damage to the brain at the cOrticOspinal tract
Arms are adducted and flexed, hands clenched, may be unilateral or bilateral to the core
serious but mOre favOrable than decerebrate
may progress to decerebrate posture of the 2 can alternate
Decerebrate Posturing
indicates severe damage to the brain at the Brainstem level
Arms are adducted, extended, and pronated with wrists flexed, head and neck arched Backwards, and muscles tightened and held rigidly
is Badder than decorticate
Diagnostics for Increased ICP
presenting s/s
H&P
MRI and CT scan to show underlying cause like tumor or hematoma
spinal tap (if there is no concern for increased ICP)
direct monitoring
Why can a spinal tap only be done if there is no concern for increased ICP
because a hole in the lumbar region can cause herniation of the brain into the spinal canal
Direct Monitoring or ICP
done via catheters and equipment in the skull and brains
done in the ICU and can see pressure changes early and measure the degree of them to initiate appropriate treatment
also gives access to CSF for sampling and evaluation to treatment response(s)
It is important to know what about nursing interventions for increased ICP
not all of them are always done all the time, critical thinking will let you choose to most appropriate one for the specific patient manifesting a specific human response at a specific time
Nursing Interventions for cerebral perfusion
elevate HOB 30-45 degrees and put head in neutral position with cervical collar if needed
position to avoid extreme hip flexion (can increase pressure in head and chest)
note abdominal distension
avoid Valsalva maneuver
avoid enemas and suppositories’ (can increase pressure d/t position)
avoid isometric exercises increasing SBP
pre oxygenate and hyperventilate prior to suctioning since it can take O2 away
avoid high levels of PEEP (positive end expiratory pressure)
space nursing interventions
assess level of cognition, orientation, and ability to follow commands
avoid emotional distress and frequent arousal from sleep
AVOID INCREASING PRESSURE
Nursing Interventions for airway clearance
elevate HOB
auscultate lung fields
O2 as needed
monitor pulse oximetry
suction as needed
hyperoxygenation for suctioning - suctioning of nares is a no no
note nasal drainage
Why should you never suction the nose
because if there is head injury damage in this area could lead to suctioning brain
Nursing interventions for fluid balance/imbalance
monitor VS
monitor I&O
monitor skin turgor, mucous membranes, serum and urine osmolality
monitor IVF carefully
observe for CHF and pulmonary edema if giving mannitol - dont wanna give so much fluid we cause CHF
good oral hygiene - non drying mouth rinse and lip lubrication
Nursing interventions for bowel and bladder function
monitor UO every 2-4 hours
test urine for specific gravity and glucose
monitor bowel sounds
monitor for abdominal distension
test stools for occult blood
Nursing interventions for infection
aseptic technique when managing the intra ventricular catheter/direct ICP monitoring
observe character of the CSF drainage - report cloudiness and blood
monitor for s/s of meningitis - fever, chills, nuchal rigidity, increasing and persistent headache
monitor temp, labs, urine, and lungs
Nursing Interventions to control ICP
Lots of MEDS:
Mannitol
corticosteroids
Dilantin
antibiotics
anti-anxiety
Mannitol
osmotic diuretic
Purpose of corticosteroids for ICP
reduce cerebral edema
Dilantin
prophylaxis for seizure activity
What complications should be monitored for with increased ICP
brain stem herniation
respiratory distress or failure
pneumonia
aspiration
pressure ulcer
DVT
contractures and positioning
seizures
Diabetes insipidus
SIADH
What are some miscellaneous nursing interventions for increased ICP
Keep CO2 down in the 25-30 mmHg by hyperventilating the patient
prevent hyper or hypothermia with temperature control
BP control - high enough to perfuse the brain but not so high that is increases ICP and causes damage
Sedation
Seizure - Pathology
uncontrolled abnormal recurring electrical discharges in the brain
Causes of Seizures
- idiopathic
- acquired - via CV disease, hypoxemia, fever, head injury and surgery, HTN, CNS infection, metabolic and toxic conditions (renal failure and hypoglycemia), brain tumor, drug and ETOH withdrawal, allergies
Classifications of Seizure
Generalized
Partial
Generalized Seizures
involves the whole brain
Partial Seizure
focal seizures beginning in one part of the brain
can be simple or complex
Simple Partial Seizure
partial seizure where consciousness remains intact
Complex Partial Seizure
partial seizure where there is impairment but no loss of consciousness
Manifestations of Seizure
Not all seizures cause all of these things
Loss of consciousness
Excessive movement - not all cause convulsions though
Loss of muscle tone (drop attacks)
disturbances of behavior, mood, sensation, perception
Status Epilepticus
Emergency
seizure lasting longer than 5 minutes
seizure activity occurs without waking occurring in between
with something like a tonic clonic seizure a lot of energy and O2 is needed for all that activity so the brain may not be perfused
Things to Assess about a Seizure
precipitating factors
presence of an aura
initial presentation
types of movements
areas of the body involved
eyes: size of pupils, open or closed, any deviations
incontinence
duration
periods of unconsciousness
paralysis or weakness after the seizure
inability to speak
movement at the end of the seizure
post-ictal period
cognitive status after the seizure
What may be the first thing indicating an impending seizure
an aura
Post-ictal period
period after seizure ends where the person may be confused and embarrassed and not 100% again
What to do if someone is having a seizure
Maintain and protect airway - turn sideways, suction available, intubation potentially
Limit seizure duration with medications like valium, Ativan, and Dilantin
prevent patient and personal injury
observe the seizure activity - monitor neuro/cardio/pulmonary
documentation
What to do after someone has had a seizure
reorient patient when awake
provide comfort and reassurance
treat any injury from seizure activity
maintain seizure precautions
anti seizure medications if ordered
education of medication, triggers, at home and school care
have crowds leave so not everyone is staring and make sure everyone knows what to do fi the person has a seizure
What to do if someone has a hx of status epilepticus
limit seizure duration with medications like IV valium, Ativan, and Dilantin
establish and protect the airway - turn sideways and intubate potentially
neuro/cartdio/pulmonary monitoring
maintain safety
documentation
Diabetes Insipidus (DI)
deficiency of ADH secretion
fluid Drains out
Result of DI
polydipsia and polyuria
low urine specific gravity
dehydration
Causes for DI
increased ICP
surgical ablation or irradiation of the pituitary
infections of CNS
Syndrome of Inappropriate ADH (SIADH)
Excess ADH secretion
fluid Stays in
Result of SIADH
fluid retention, no edema = dilutional hyponatremia
Causes of SIADH
increased ICP
bronchogenic carcinoma (paraneoplastic syndrome: ADH secreted by tumor cells)
severe pneumonia
hemothorax
The important goal of managing DI and SIADH is…
identify and treat/eliminate underlying causes
Medical management of DI
replace fluids - hourly IV fluid volume dependent on UO
replace ADH with vasopressin
Complications of DI
dehydration
electrolyte imbalance
unintentional weight loss
Medical management of SIADH
restrict fluid intake - 1200 to 1800 mL/day to increase serum sodium
replace sodium with a hypertonic saline
Complications of SIADH
water overload
electrolyte imbalances
fluid shifts
Vasopressin
an external form of ADH given to DI patients
Risk factors for spinal cord injuries
youth
male
drug and alcohol use
Causes for Spinal Cord INjuries
non traumatic things like tumors
traumatic things like MVA, GSW, sports injuries
What areas of the spines are more likely to have injuries occur and why?
C5 to C7 and T12 to L1 (cervical and thoracic region)
this is because these areas are more mobile and no protected by things like the ribcage
What can the damages be like in spinal cord injuries
ranges from full recovery to complete cord transection with paralysis below the injury level
Primary Spinal cord injury
the permanent effect
Secondary Spinal cord injury
potentially reversible effect of injury that can be reversed if treated within 4 hours of injury
What areas may be effected by C5 to C7 damage
Tetraplegia - same as quadriplegia:
Deltoids
biceps
wrist extender
triceps
hand
chest muscles
abdominal muscles
leg muscles
bowel
bladder
sexual function
`What areas may be effected by T12 to L1 damage
Paraplegia: (it is lower)
leg muscles
bowel
bladder
sexual function
How may a cervical, thoracic, lumbar, and sacral lesion impact mobility?
Cervical - wheelchair bound unable to move arms too - quadriplegia
Thoracic - wheelchair bound but able to move arms - paraplegia
Lumbar - need assistance with crutches and supports due to leg paresis and maybe monoplegia of a single leg
Sacral Lesion - crutches due to monoplegia or paresis of legs
What are the acute complications of spinal cord injuries? (at time of injury)
impaired spontaneous respirations and gas exchange
hypotension related to vasodilation and loss of reflexes
FIRST CONCERN IS BREATHING ESPECIALLT WITH CERVICAL INJURIES
Interventions for the acute phase of spinal cord injuries
chest PT
mechanical ventilation
possible tracheostomy placement
elevation of feet
IV fluid resuscitation or vasopressor agents
What is the goal for HR and SBP during acute spinal cord injury
HR >60
SBP > 90
Medical Care for a Spinal Injury patient
Prevent further injury by keeping immobilized until diagnosis
maintain airway
administer methylprednisolone
stabilize spine with reference to actual injury
ASIA impairment scale
Methylprednisolone
decreases inflammation near injury which appears to reduce damage to nerve cells
decreases edema and inflammation and stabilized the nerve cells in that region
American Spinal Injury Association (ASIA) Impairment Scale
a scale that can determine extent of injury and where it may lead rehabilitation wise
evaluates level and completeness of injury
determines treatment and rehabilitation plan
Pharmaceutical therapies for spinal cord injuries
glucocorticoids
vasopressors like dopamine
plasma expanders like dextran
atropine
muscle relaxants and anti spasmodic
histamine 2 receptor antagonists
anticoagulants
stool softeners
vasodilators
anti seizure medications
Why give glucocorticoids to SCI patients
to suppress the immune response
Why give vasopressors like dopamine to SCI patients
to help stop hypotension via vasoconstriction
Why give plasma expanders like dextran to SCI patients
to maintain volume and treat shock
Why give atropine to SCI patients
it can fight bradycardia by speeding up HR
Why give histamine 2 receptor antagonists to SCI patients
to prevent GI ulcers by decreasing acid production
Why give anticoagulants to SCI patients
to prevent DVT
why give vasodilators to SCI patients
used if blood pressure got too high after vasopressors - to bring HTN down
Recovery Concerns (possibly for rest of life) for SCI patients
aspiration risk if injury was high on the spine
ineffective thermoregulation
spinal shock (temporary)
ineffective airway clearance
impaired physical mobility
DVT
imbalanced nutrition
urinary incontinence
bowel incontinence and/or constipation
impaired skin integrity
ineffective coping
anticipatory grieving (of things lost)
sexual dysfunction
Autonomic Dysreflexia
reaction of the autonomic (involuntary) nervous system to overstimulation and generally occurs with injuries above T6
it is the sudden onset of HTN
Thinks “auTonomic” - there are 6 letters after T so T6 + injuries
What area of the spine commonly has autonomic dysreflexia issues
anywhere T6 and above
What s/s occur with sudden onset of autonomic dysreflexia
severe HTN
severe throbbing HA
profuse diaphoresis and flushing
nasal stuffiness
blurred vision
nausea
bradycardia
Interventions for Autonomic Dysreflexia
elevate HOB to sitting position
check BP
check remove and treat possible causes !!! like a kinked catheter or distended bladder and bowel
administer anti hypertensive meds prn
monitor every 3-4 hours after symptoms subside
What exactly occurs in autonomic dysreflexia?
some afferent stimulus makes the body have a massive sympathetic response causing vasoconstriction, but the brain cannot control below the injury so it slows heart rate to try and stop vasoconstriction
the sympathetic response below the injury from the stimulus and the brain knowing this is happening but cannot reach down that low so it impacts and controls the heart leading to both BRADYCARDIA AND HTN simultaneously
Halo traction
External fixation device to stabilize the CERVICAL spine
immobilizes cervical spine fractures and is a form of skeletal traction with pins going into the skull and a metal ring connecting them - this cannot be removed as it is skeletal traction - and the ring is attached to a jacket by rods
What does halo traction allow for
early mobilization and rehabilitation
Can halo traction be removed
it is skeletal traction and skeletal traction is not removed
What is a big risk with Halo traction
fall risk since there is more weight on the head allowing for easy tripping and falling
Nursing care for person in halo traction
wrench taped to front at all times for emergency access
fall risk
NEVER grasp the rods to assist the patient in repositioning
pin care
skin assessment of areas under the jacket which does not come off but can (usually) be released for skin assessment
Nursing Care for SCI
suction set up at bedside
supplemental O2 therapy
encourage coughing
turning and positioning
Chest PT
core temp every 4 hours during the first 72 hours after injury
control environmental temperature
monitor for abdominal and bladder distension
bladder training
check post void residual via bladder scan and catheterize only if necessary
baseline weight
presence and absence of bowel sounds determines nutrition route
education on calorie activity relationship
AE stockings and SCDs
subcutaneous heparin or lovenox
education on s/s of DVT
encourage independence in ADLs
use adaptive equipment in bed and for transfers
prevent contractures - wrist drop, foot drop - with ROM
safety - assist with transfers and ambulation’s
use of braces and wheelchairs
GOOD SKIN CARE
Why use AE hose on a SCI patient
there may be vasodilation so this helps with venous return
Why is it so important to teach an SCI patient about DVT signs
they may not necessarily be able to feel pain
What are some ways to go about good skin care for a SCI patient
wheelchair pressure reduction seating cushions
teach strategies for frequent position changes - with the commercials, after every radio song, etc
teach skin inspection with a mirror
What sort of skin ulcers are common in SCI patients
ischial ulcers are common d/t lack of sensation
