Neuro ICU Flashcards by Jenn Cantilli

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

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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

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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)

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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

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focus of care in neuro step down unit

shift to recovery, dc planning

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nursing ratio in neuro ICU vs neuro step down unit

in ICU - 1:1
step down - 1:6 nurse to pt

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what is ICP

intracranial pressure
pressure exerted by CSF w/i ventricles

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what is CPP

cerebral perfusion pressure

measure of how much O2 is getting to brain tissue

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how is CPP calculated

MAP - ICP

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relationship of CPP to ICP

CPP dec w inc of ICP

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what is the normal range for ICP

0-15mmHg

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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

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what MD orders might be placed if they are monitoring ICP levels

HOB > 30deg
activity
acceptable ICP ranges for interventions

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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

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what are examples of ICP monitors

ICP bolt
intraventricular catheter
epidural sensor

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what is a consideration for PT when using a ICP monitor

keep transducer at level of external auditory meatus always for accurate reading

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what is a specific benefit to intraventricular catheters over other ICP monitors

get readings right from ventricle
also drain CSF if acute inc

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what type of patient is an intraventricular catheter appropriate for

high ICP or at risk of spike
- can drain CSF quickly

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what is a contraindication for PT with regard to ICP

if active CSF drainage present
- external ventricular drain must be clamped for mobility

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what is a general guidance for ICP level during exercise

<25mmHg
- not standard or fixed precaution
- coordinate w team

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what is the normal CPP range

70-100mmHg

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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

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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

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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

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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

1. anti-HTN meds 2. osmotic diuretic 3. mechanical vent to maximize O2 delivery 4. ventriculostomy to drain CSF 5. craniectomy 6. 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

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

1. contractures (d/t adaptive ms shortening, joint immobility) - use of positioning, splints 2. pressure ulcers (d/t sedation won't be moving spontaneously) - have to be repositioned q2hr 3. DVT - prophylaxis 4. 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