Neuro ICU Flashcards
what are 9 challenges of acute neuro PT management
level of acuity/medical instability
level of arousal
cog changes
behaviors
language and communication
visual disturbances
multiple medical monitoring devices
precautions and comorbidities
physical environment
what are common cognitive changes that are challenges in acute neuro pt management
unable to process auditory info
irrational thoughts
confusion
hallucinating
memory problems/amnesia
what is the focus of care in a neuro ICU
preserving life
protecting neural tissue
prevent secondary consequences of prolonged immobility (ie pressure ulcers, DVT, pneumonia)
how is a neuro step down unit different from neuro ICU (4)
more medically stable
less medical monitoring
higher nursing ratio
focus shifts to recovery, dc planning
focus of care in neuro step down unit
shift to recovery, dc planning
nursing ratio in neuro ICU vs neuro step down unit
in ICU - 1:1
step down - 1:6 nurse to pt
what is ICP
intracranial pressure
pressure exerted by CSF w/i ventricles
what is CPP
cerebral perfusion pressure
measure of how much O2 is getting to brain tissue
how is CPP calculated
MAP - ICP
relationship of CPP to ICP
CPP dec w inc of ICP
what is the normal range for ICP
0-15mmHg
how is the structure of the skull a factor in CPP’s inverse relationship to ICP
skull is tightly fused
- not forgiving or able to easily adapt if change in ICP d/t edema, swelling, inc in BP, extracellular fluid
so if ICP inc, limited space that will cause CPP to dec
what MD orders might be placed if they are monitoring ICP levels
HOB > 30deg
activity
acceptable ICP ranges for interventions
why is it important to check MD orders for ICP monitoring
no strict guidelines for what activity is acceptable w different ranges of ICP
- up to MD
what are examples of ICP monitors
ICP bolt
intraventricular catheter
epidural sensor
what is a consideration for PT when using a ICP monitor
keep transducer at level of external auditory meatus always for accurate reading
what is a specific benefit to intraventricular catheters over other ICP monitors
get readings right from ventricle
also drain CSF if acute inc
what type of patient is an intraventricular catheter appropriate for
high ICP or at risk of spike
- can drain CSF quickly
what is a contraindication for PT with regard to ICP
if active CSF drainage present
- external ventricular drain must be clamped for mobility
what is a general guidance for ICP level during exercise
<25mmHg
- not standard or fixed precaution
- coordinate w team
what is the normal CPP range
70-100mmHg
what value should CPP be above at all times and why? what are the PT implications?
40mmHg
- if less than 40, ischemia and infarction can occur w/i minutes (no longer adequate O2 delivery to brain structures)
if <40 during treatment, go to nurse and defer treatment
what is the risk of elevated ICP and why
brain and/or brainstem herniation (often fatal)
closed pressure system and only place to go is down into foramen magnum
what are 8 signs of inc ICP
change in LOC - lethargy, coma
pupils dilated or fixed
blurred or double vision
paresis/ms weakness
HA
sz (EEG feedback, tonic clonic)
n/v
HTN, bradycardia, RR change
what are 3 s/sx of infection
nuchal rigidity
- resistance in moving head, flexing neck
inc body temp (diaphoresis)
other neuro changes
why is infection a common complication
wound from accident
indwelling devices
how does the ICP waveform correspond to the cardiac and respiratory cycles
corresponds w cardiac
between respiratory waves
what are 6 techniques for medical management of inc ICP
- anti-HTN meds
- osmotic diuretic
- mechanical vent to maximize O2 delivery
- ventriculostomy to drain CSF
- craniectomy
- sedation
why is mechanical ventilation used to manage inc ICP
short term set to hyperventilate
- lower CO2 levels (CO2 dilates cerebral blood vessels and inc ICP) and induce alkalosis
-> constrict vessels -> dec ICP
why are anti-HTN meds and osmotic diuretics prescribed for inc ICP
dec pressure in system
why is sedation or pharmacological coma used to manage inc ICP
dec level of agitation and metabolic demands on system
what are 2 things we have control over for medically managing inc ICP
positioning: HOB >30deg
dec environmental stim/limit agitation
why do you want to dec environmental stim when there is inc ICP and what is the challenge with doing this in a neuro ICU setting
dec sensory inputs -> calmer and dec agitation -> dec metabolic demands and blood flow -> dec ICP
hard to dec environmental stim in ICU w all the machines and people
what does the literature say about mild to mod hypothermia in managing inc ICP
lowers metabolic demands and overall calms system down
not well supported in literature
- studies in acute SCI, less in TBIs
what is a common secondary complication that pts are on prophylactics for in a neuro ICU
seizures
what is the danger of having a sz on top of a brain injury
sz on top of already damaged neural structures can amplify damage
what is the immediate action for someone having a sz
lie them on their side
remove tight clothing
remove sharp objects
place soft flat object under head
if something was in person’s mouth, try to remove to prevent aspiration
call for nurse and/or MD
what are lab values to monitor acutely
CBC (WBC, Hgb, Hct, Plt)
ESR
Chem-7
coagulation profiles
- PT/PTT/INR
why is ESR monitored
indirect measure of inflammation
what are the 2 most important lab values to look at when treating a pt in a neuro ICU
ESR
coag profile
what information does a clotting profile give you (3)
determine ability to initiate clotting sequence
dx clotting disorders
monitor effects of coag therapy
what does it mean if someone is a “therapeutic level” when it comes to coagulation
blood has been sufficiently anticoagulated
what is the therapeutic range for INR
2-3
PT implications of INR > 3.5
risk for bleeding
modify activity
PT implications of INR >5
may need bed rest
*no activity** - mobilization or bronchopulm hygiene
- can cause bleeding and bleeding into joints (hemarthrosis)
PT implications of INR < 2
risk for developing blood clot
PROM
compression boots donned for longer periods
monitor skin for s/sx of DVT (redness, pain, swelling)
what might be the team’s medical management if the pt’s INR > 5
vit K injections or change of anti-coag med rx to get INR into therapeutic range
what are the activity guidelines based on INR >/= 4
no resistive exercise
only light exercise
- RPE </= 11
- close supervision if fall risk
what are the activity guidelines based on INR > 5
exercise contraindicated
assess safety
prevent falls
what are 3 common precautions in the neuro ICU
craniectomy/bone flap
spine precautions
aspiration precautions
what are craniectomy/bone flap precautions
helmet when OOB
no pressure/contact on site
what are spine precautions
vary but typically no bending, lifting >10lb, twisting
logrolling to roll, get in/out of bed
may require c-collar, TLSO, jewett brace
what is the purpose of spine precautions
keep spine straight
why are craniectomy precautions a thing
soft/gelatinous brain tissue is exposed w/o skull protection
what are aspiration precautions
check status of swallowing prior to giving any PO’s
keep HOB elevated at all times
what are the 2 main pt goals when in the neuro ICU
preserve life and viability of neural structures
prevent secondary complications (ie ROM)
why is it important to be vigilant when working in a neuro ICU
modify POC based on emerging conditions
prepare for events such as:
PE
sz
inc in ICP
respiratory distress
acute change in neuro status
paroxysmal sympathetic hyperactivity (“storming”)
what are secondary complications to prevent/limit
contractures
pneumonia
ms length
pressure ulcers
what is storming
sudden onset of tachycardia, tachypnea at rest d/t autonomic dysfunction and triggered by a random stimuli (not always noxious - ie could be d/t to PT)
can be dangerous if prolonged
why should you check w the nurse always before entering a room
can be acute change since last documented
what are 2 PT goals acutely in the neuro ICU
promote safety w functional activities
prioritize and select exam procedures that align w goals
what does it mean to prioritize/select exam procedures that align w goals for PT in acute neuro ICU setting
more important to examine gross functional mobility first
- might not be able to address impairments all at once
what are components to consider with early mobility
close monitoring
MD orders
IP team coordination
environmental set-up
what are the benefits to early mobility
dec LOS
inc home dc rate
dec cost
dec nosocomial infections
dec secondary complications
what is the common progression with early mobility
PROM -> AAROM -> AROM -> rolling -> sit EOB -> bed to chair transfers -> standing -> amb
considerations of skilled vs non-skilled therapy in hospital
think about if what we are doing is skilled or if we could train others (ie family, nurses) to do
- ex: positioning
why is there such a heavy focus on preserving neural tissue acutely
more neural tissue saved and viable (limited ischemic core), more potential for neuroplasticity in rehab later
what is the biggest risk with early mobility
dislodging line or tube
what are the 4 main secondary consequences that we try to prevent and how
- contractures (d/t adaptive ms shortening, joint immobility)
- use of positioning, splints - pressure ulcers (d/t sedation won’t be moving spontaneously)
- have to be repositioned q2hr - DVT
- prophylaxis - pneumonia
- pulmonary hygiene
why does brainstem herniation from inc ICP lead to death
won’t be able to breath or have neurocentral functions
what is the implication of a dec CPP
not enough bloodflow, oxygenation, metabolism to brain tissue
what might cause ICP to spike when the pt is already in the neuro ICU
bronchopulm hygiene and suctioning
positioning
pain
what are cons of intra-ventricular catheters
invasive
sacrifices some brain tissue
once ICP >25 what is the risk
death
what is an equivalent of CPP hitting 40
SpO2 <88
