Neuro day 2 Flashcards
Surgery: Burr Holes
- Hole drilled in the skull
- Used to assess presence of brain swelling, or removal of a hematoma or abscess, making a bone flap, shunting procedure or placement of a drain
Surgery: Decompressive craniectomy
- For refractory brain swelling
- Removal of part of skull so the brain can expand
- Complications include, infection and potential for brain injury because the brain is largely unprotected
- Bone flap is replaced once the brain swelling is resolved
Surgery:Craniotomy
- Opening skull to access brain
- Skull cut to crete a bone flap, bone flap temp removed to access brain
Surgery: Cranioplasty
Removal of cranial defect with autologous bone, plastic or metal plate
Supratentorial Craniotomy
Craniotomy above the tentorium
* Positioning post op:
* Avoid head rotation
* Pt on back or side, avoid surgical side down if there was a large lesion removed
* 1 Pillow
* HOB 30 degrees
Turn every 2 hours with skin care
Infratentorial craniotomy
Craniotomy by the Posterior fossa
* Pt positioning post op
* Pt kept flat on one side, off the back
* Small firm pillow used to keep neck neutral
* Turn body as an entire unit (Log roll), to avoid strain on incision
* Can elevate the bed slowly as tolerated
Turn every 2 hours with skin care
Transsphenoidal Craniotomy
- Through the mouth and nasal sinuses to reach the nasal sinus
- Used to resect tumors, usually at the base of the skull
- Approach allows direct access to sella turcica
- Minimal risk of trauma or hemorrhage
Surgery: Awake Craniotomy
- Used for cortical mapping (Poking area of the brain and seeing if the patient is affected) used to determine language and sensorimotor function when resecting brain tissue/tumor
- Pt is put to sleep while skull is opened and then woken up to map, after mapping the patient is put to sleep again
- Area of the brain is stimulated with a probe and then assess patient response
- Sensorimotor mapping
- can see abnormal involuntary movements of face, arm and leg
- Pt asked to report abnormal sensations such as numbness/ tingling
- Language mapping: Pt is asked to count numbers, name objects ect. used to determine aphasia
- Visual mapping: Patient reports any visual phenomena, field cut, abnormal vision
Surgery: Intraoperative MRI
- Guides the brain resection in real time
- Able to identify residual tumor after tumor resected to guide further surgery
Tentorium
- An extension of the dura mater that separates the cerebellum from inferior cerebrum and occipital lobes
- Essentially its the line between the cerebrum and cerebellum
Supratentorial and infratentorial surgery: Medications
- Anticonvulsant (Phenytoin, Levetiracetam, fosphenytoin)
- Corticosteroids (Dexamethasone), only if pt has a tumor
- Diuretics: Mannitol, Furosemide (fluid retention)
- Antibiotics, on call or to or
- Benzo, anxiety
Supratentorial and infratentorial surgery: Nursing actions Preop
- Neuro assessment for baseline to compare post op
- Pt shower and wash hair before surgery
- Hair shaved with electric clippers
- Foley cath placed in the OR
- Art line placed in OR
- Establish communications alternatives prior to surgery (picture cars, writing board)
- Reassurance and support: What to expect post op (Dressing, ICP monitor, swelling, bruising, intubated)
Supratentorial and infratentorial surgery Post op: Reducing cerebral edema
- Mannitol
- Dexamethasone IV, change to oral asap, taper dose 5-7 days, may need extended taper
Supratentorial and infratentorial surgery: Post op, Relieve pain and prevent seizures
- Acetaminophen for temp and mild pain
- Opiate for postop pain if needed
- Anticonvulsant prophylactic following supratentorial craniotomy, Increased risk for seizure
Supratentorial and infratentorial surgery: Post op mgmt
- Reduce cerebral edema
- Relieve pain and prevent seizures
- Monitor ICP
- Monitor for infection
- Neuro checks
- Vital sings
- Resp function
Post op mgmt, cranial surgery: Neuro checks
- Frequently, initially 15-60 min to detect increased ICP, edema, bleeding
- Maintain cerebral perfusion (CPP: 60-70)
- Monitor for hypoxia, hypercarbia
- ETT until pt starts to awaken, has spontaneous respiration
- Edema peaks 24-36 hours postop, monitor for decreased LOC
- Proper positioning: based on type of surgery
Post op mgmt, cranial surgery: Monitor vitals
- Document fluctuations and signs of increased ICP
- HR, RR, SBP
Post op mgmt, cranial surgery: Resp function
- Avoid hypoxia which cna increase cerebral ischemia
- ABG, Rate and pattern
- Risk of impaired gas exchange, atelectasis and pul function
- Reposition every 2 hours to mobilize secretions and prevent stasis
- Suction if needed, cautiously and short periods (Can increase ICP)
- Humidity in O2 to thin secretions
- Once alert, deep breathing, yawning , sighing, incentive spirometer, coughing , chest PT
Post op mgmt, cranial surgery: Monitor Temp
- May be hypothermic initially after surgery, slowly rewarm avoid shivering (Increases ICP)
- Assess for hyperthermia and treat fever (remove blankets, place ice packs, antipyretics)
- Aseptic technique if handling intraventricular drainage device, central lines, art line
Post op mgmt, cranial surgery: Check surgical dressing
- Surgeon always does the first dressing change
- Check for bleeding or CSF drainage
Post op mgmt, cranial surgery: Sensory deprivation
- Periorbital edema from surgery, blood drains into the orbits, swells eyes shut
- Elevate HOB unless contraindicated
- Apply cold compress
- Announce when you enter the room to avoid startling the pt
- Extubate Asap
- Bulky head dressings can affect hearing, blocking hearing
Post op monitoring of complications, skull surgery: Increased ICP and bleeding
- Hematoma, extradural, subdural, intracerebral
- pt does not wake up
- New post op neuro deficits (Dilated pupils, restless, confusion)
- Return to OR for evacuation of clot
Post op monitoring of complications, skull surgery: Infection
- CHeck surgical site for redness, drainage, tenderness, bulging, seperation, foul odor, pus
- Aseptic technique with all lines, catheters, dressing changes per protocol
- Reinforce dressing until surgeon assesses and or removes
- Cultures if needed
- Antibiotics
Post op monitoring of complications, skull surgery: CSF leak
- Monitor for clear thin drainage from suboccipital incision (Infratentorial surgery is more common)
- Pt cant cough blow nose or sneeze
- Risk for meningitis
Post op monitoring of complications, skull surgery: Monitor for seizure activity
Prevention is best treatment and it is essential to avoid cerebral edema, hypoxia
Post op monitoring of complications, skull surgery: monitor fluids and lytes
- Serum and urine electrolytes, BUN, creatinine, glucose
- Daily weight strict I+O
- Fluid restriction if possible
- NPO then ice chips and advance as tolerated
- Monitor for N+V, (Vomiting increases ICP)
- Monitor for hyperglycemia, especially if on corticosteroids, fingersticks
- Gastric ulcer prophylaxis: PPI or H2
Post op teaching and discharge planning post craniotomy
- Meds: Especially anti seizure meds, if you suddenly stop taking them you can have a rebound seizure
- Showering: Discression per surgeon, no baths or submerging in water generally especially in lakes or rivers
- Protective helmet; if skull defect
- Post hospital care depending on diagnosis and deficits: Home care vs rehab vs long term care
- Case mgmt; social work hospice oncology referral, radiation referral
- Pt/OT: weakness mobility self care deficits
- Speach therapy
- Cognitive therapy
- Psych eval
Complications of transsphenoidal surgery
- Transient DI
- CSF leakage
- Post Op meningitis
- Pneumocephalus
- SIADH
- Sinusitis
- Visual changes (bilateral field cuts, diplopia due to closeness of optic chiasm)
HIgh risk of complications due to puncture of dura mater
Preop Transsphenoidal surgery:
- Endocrine labs, ENT eval, imaging , fundoscopic exam and visual fields (Baseline) nasopharyngeal cultures, contraindication if sinus infection
- Corticosteroids before and after surgery especially if pituitary is removed
- ACTH no longer secreted, can develop adrenal insufficiency
- Antibio can be given or not
Preop Transsphenoidal surgery: Nursing actions
- Teach, deep breathing and incentive spirometer
- Teach: Need to avoid coughing, blowing nose, sucking through a straw or sneezing (All can increase ICP
Post-op Transsphenoidal surgery:
- Surgical approach disrupts the oral and nasal mucous membranes
- Goal: Prevent infection and promote healing
- Nasal packing: During initial post op period, its uncomfy and anxiety inducing
- CSF leak: different methods available to close surgical defect and minimize a leak
- Sella floor filled with gel foam pase, dura replaced, mucosal flaps placed over dura and fixed with surgical cellulose and fibrin glue
- May have fat packing or tissue graft into sella to prevent CSF leak
- Antibiotics until packing is removed
- COrticosteroids for swelling
- Analgesics, for pain
- Foley cath; strict I+O
- Monitor and treat DI or SIADH, super common after
Transsphenoidal Surgery: Nursing actions
- Vitals, hemodynamics and cardiac and vent
- Visual acuity and visual fields assessed frequently, (Optic chiasm), if decreasing possible hematoma in sella
- HOB raised to decrease pressure in brain and promote normal drainage (Avoid straining, use stool softeners), increases in ICP is bad, (Promote drainage and prevent leak)
- I+O, daily weights
- FE balance, monitor for DI
- Advance diet as tolerated
- Nasal packing, check for blood or CSF
- Oral care, thirst dry mouth, mouth breathing
- No teeth brushing until incision is removed
- Warm saline mouth rinses
- Cool mist humidifier
- Lubricant to lips Clean around the nose with prescribed solution after packing is removed
Transsphenoidal surgery, Discharge instructions
- Humidifier
- HOB 30 degrees 2wks
- No nose blowing and avoid sneezing
- Call for S+S infection or fever
Syndrome of inappropriate Anti diuretic hormone (SIADH)
- Water retention
- Hyponatremias as a result of hypervolemia
- Low serum osmolality
SIADH mgmt
- Fluid restriction
- Replace lytes
- Self limited
- Conivaptan (caprisol), inhibits adh, want to avoid critical levels of this however
Diabetes Insipidus (DI)
- Excessive Urinary output
- Elevated serum osmolality (High is dry)
- Decreased urine osmolarity (So much fluid its dilute and clear)
- Hypernatremia (Dehydration)
- Low urine specific gravity
DI mgmt
- Replace fluids to compensate for UOP
- Monitor K level (Can be low)
- DDAVP (synthetic adh)
3% hypertonic Saline
- Hyperosmolar agent used for severe hyponatremia due to cerebral edema
- Can cause irritation to vessel walls, give centrally if possible
- Use largest peripheral vein with good flow, peripherally upper extremity if possible
- 20-24 gauge to avoid trauma to vein
- Monitor for redness, swelling , tenderness, extravasation
- Monitor for pulmonary edema, neuro changes, strict I+O
- Goal is to SLOWLY increase serum sodium by 5 mmol/L to acutely decrease brain swelling and reverse neuro symptoms
DDAVP, Vasopressin
- Used to reduce renal excretion of water in DI
- Given IV, oral , nasal
- Acts on distal tubule and collecting ducts in the kidney
- Side Effects are hyponatremia (Seizure, confusion, HA) arrhythmias, fluid retention, rapid weight gain
Conivaptan (vaprisol)
- ADH inhibitor (Makes you pee)
- Used to treat hyponatremia caused by SIADH (FVE)
- Works at renal collecting ducts causing excretion of free water (Increased up, decreased urine osm)
- Loading dose day 1 then continuous infusion for up to 4 days
- Also used in CHF
- Side effects; hypotension, thirst
Seizure:
Abrupt uncontrolled burst of electrical activity in the brain
* Many neurons firing at the same time, faster than normal
* Can cause involuntary movements, sensations, emotions and behaviors
* May have loss of awareness due to abnormally firing neurons
Epilepsy
- Chronic recurrent abnormal brain activity
- Has multiple different causes and types of seizures
- Diagnosed when person has 2 or more unprovoked seizures separated by at least 24 hours
Provoked seizures
- Caused by a specific precipitating factor
- Fever, CNS infections, TBI, fluctuations in blood glucose or lytes
Risk factors for seizures
- Genetic predisposition–absence seizures common in children, tend to occur in families; SCN1A gene mutation (affects sodium ion channels)
- Acute febrile state–usually children under 2 years (systemic infection)
- TBI—early or late onset
- Cerebral edema—especially if acute, risk decreases once edema resolved
- Abrupt cessation of anti-epileptic drugs (AEDs)—seizure threshold is low and have rebound seizures; AEDs MUST be tapered
- Infection—intracranial infection with increased ICP (meningitis, encephalitis)
- Metabolic disorder—hypoglycemia, hyponatremia
- Toxins—pesticides, carbon monoxide poisoning, lead poisoning
- Stroke—within first 24 hours due to increased ICP
- Heart disease—common cause of new onset seizures in older adults
- Brain Tumor– due to increased bulk of tumor and increased volume in cranial vault. If associated with temporal lobe, increased risk.
- Hypoxia—decreased O2 to brain can lead to seizures
- Acute substance withdrawal or alcoholism
- Fluid and Electrolyte imbalances—abnormal level of nutrients for neuronal function, hypervolemic state (decreased sodium)
Triggers for seizures
- Excessive fatigue, sleep deprivation
- Increased physical activity and dehydration
- Stress
- Hormonal changes/ menstrual cycle
- Hyperventilation
- Acute alcohol ingestion or withdrawal
- Excessive caffeine intake
- Flashing lights
- Substances: coke and other drugs
Generalized Seizures:
- Involves both hemispheres
- May begin with an aura, Smell visual, hearing, emotion
- Types
- Tonic Clonic
- Tonic
- Clonic
- Myoclonic
- Atonic
- Absence
Generalized Seizures: Tonic-Clonic
Also called gran mal
* Starts with muscle stiffening (Tonic phase), pt may cry out and loss of consciousness, Then clonic movements begin (Jerking of extremities)
* Breathing can stop during tonic phase and be irregular during clonic phase
* Can become cyanotic, bite tongue or cheek, or become incontinent
* Postictal phase: confused then sleepy
Generalized Seizures: Tonic
- Only involves tensing
- Sudden loss of consciousness, increased muscle tone, generally in back arms and legs
- Can have arrythmias, apnea, vomiting, incontinence salivation
- Can last 30 seconds ish
Turn them to their side so they dont aspirate
Generalized Seizures: Clonic
- Only the clonic phase
- Last several min (Longer than tonic)
- Muscles contract then relax, repeated jerks or twitches of muscles on both sides of body
Generalized Seizures:Myoclonic
- Brief jerking or stiffening of the extremities, symmetrical or asymmetrical
- Only last a few seconds
Generalized Seizures: Atonic
- Loss of muscle tone for a few seconds
- Pts will drop to floor
- Confusion for a period of time after
Generalized Seizures:Absence
- Pt looks like they’re staring off into space. with or without slight twitching of muscles
- Typically children
- Momentary lapse in consciousness
Partial seizures: Focal seizures
- Only involve one hemisphere and one are of the brain
- Types
- Complex Partial/focal
- Simple partial/focal
- Secondary generalized
Partial seizures: Complex partial/focal
- Dazed or confused
- Unable to respond to questions or directions for several min (Black out)
- May have automatisms (Lip smacking, picking at clothes without their awareness)
- Amnesia prior and after seizure
Partial seizures: Simple partial/focal
- Can cause twitching or change in sensation, strange taste or smell, deja vu, flushing, HR increased, unilateral extremity movements, pain sensation
- Consciousness maintained
Partial seizures: Secondary generalized
- Begins in one part of the brain and spreads to both sides
- Starts as focal but becomes generalized
Test: seizures
- Tox screen: Alc and other drugs
- CMP, CBC with diff, colag studies, cultures if fever, lead levels
- Screen for CNS infection (HIV infection, Meningitis, encephalitis)
- Consider referral for genetic counseling if child
- CT, MRI, PET determine potential cause of seizure
- EEG records the electrical activity and can identify origin of seizure
Seizure assessment
- Detailed medical history:
- Symptoms and duration of seizures
- Past illnesses fevers other symptoms
- Family history of seizures
- Determine if provoked or unprovoked
- Prior seizures or is this the first
- Neuro consult
Anti-epileptic drugs
- Goal is to control seizure activity
- Monotherapy is usually good, if not effective change to another drug
- Do not abruptly discontinue
- Pt should take at same time each day
- Monitor for therapeutic levels of drugs
- Monitor for side effects
- Be aware of adverse effects and interactions with foods and other meds
- Routine dental and oral care, some can cause gingival hyperplasia
- Can develop tolerance, which can increase incidence of seizures, will need more frequent blood levels check with increase in dose
Vagus nerve stim
- Helps to manage partial seizures refractory to meds and refractory depression
- Implanted in left chest wall and an electrode placed on the left vagus nerve
- Programmed to give intermittent electrical impulses to the vagus nerve which then send signals to the brainstem then on to your brain
- with the onset of a seizure a person can hold a magnet over the implanted device which will increase electrical charge, aborting the seizure
- Does not cure seizures but can decrease the amount
- Avoid MRI, microwaves, shortwave radios
- Not sure how they work but hypothesis
- Increasing blood flow to key brain areas
- Raising levels of neurotransmitters important to control seizures
- Changes EEG patterns during seizures
Seizure mgmt: Surgical mgmt
- Used in partial or generalized seizures
- AED discontinued and EEG is done to determine area of seizure
- Conventional surgery: Take the area out that is causing the seizure if its not a vital area
- Wada test, neuropsych testing, Awake craniotomy
- Partial corpus callosotomy: Cuts the corpus callosum preventing electrical signal between left and right brain, decreasing frequency and severity of seizures
- Complications are going to be neuro deficits, infection and lack of success
Wada test
Intracarotid amobarbital administered to see if language or memory will be affected, used in surgical mgmt of seizure
Status epilepticus
More than one, in a 30 min time frame or one lasting longer than 5 min
* Complications: Hypoxia, inability of brain to return to normal function
* Acute condition and requires immediate attention to prevent perm loss of brain function or death
* Causes: Substance withdrawal, sudden withdrawal from AED, head injury, cerebral edema, infection, metabolic abnormalities
* Nursing: Maintain/ protect airway, provide O2 , establish IV access, ECG monitoring, pulse ox, ABG
* Administer diazepam or Lorazepam IV followed by Phenytoin or fosphenytoin
Nursing care during a seizure
- Maintain patient privacy and protect pt from injury (Pillow under head)
- Position pt to provide patent airway (sidelaying)
- Suction oral secretions
- Turn pt to side to decrease risk of aspiration
- Loosen restrictive clothing
- Do not restrain the pt
- Do not attempt to open the jaw or insert an oral airway
- do not use a padded tongue blade
- DOCUMENT: onset, duration, associated findings (LOC, apnea, Cyanosis , motor activity, incontinence) prior during and after the seizure (like a code)
Nursing care after seizure: Postictal
- Maintain patient in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions
- Check vital signs
- Assess for injuries
- Perform neurological checks
- Allow patient to rest
- Reorient and calm the patient who may be agitated or confused
- Determine if the patient experienced an aura
- Try to determine a possible trigger
After Postictal
* Obtain a medical alert bracelet
* Med instructions
* State driving laws
