Neurological Illness

Question 1

What are the three components and the significance of the monro-kellie doctrine of fixed intracranial volume?

Answer 1

Parenchyma
CSF
blood

These things help self-regulate the intracranial volume/pressure, if one increases, one of the others must decrease.

Question 2

What happens when the compensatory mechanisms for increase ICP fail?

Answer 2

Even the smallest increase in volume significantly effects ICP.

Question 3

what is a very important thing that is effected by ICP?

Answer 3

cerebral blood flow

Question 4

What is the normal ICP range?

Answer 4

0-15 mmHg

Question 5

Does the brain autoregulate its pressures based on what the MAP of the body is to maintain a constant blood flow in response to continuosly changing blood pressures?

Answer 5

YES

Question 6

How do you measure cerebral bloof flow?

Answer 6

CPP (cerebral perfusion pressure)

Question 7

What needs to be present for autoregulation to be effective?

Answer 7

CPP >60
MAP <160
systolic bp of 60-140 mmhg
ICP less than 30

Question 8

what are some things that can vasodilate the brain? vasoconstrict?

Answer 8

acidosis, hypercapnia, hypoxia

alkalosis, decreased PaCO2

Question 9

What are some things that can increase BP in brain if autoregulation is absent?

Answer 9

coughing, suctioning, restlessness, ect..

Question 10

How do you measure CPP?

Answer 10

CPP = MAP - ICP

Question 11

What is the normal range for CPP?

Answer 11

60-100 mmHg

Question 12

What are some causes of cerebral edema?

Answer 12

brain trauma

CNS infections

tumors

strokes

Question 13

What are some signs of cerebral edema?

Answer 13

GCS <8

abnormal CT

signs of increased ICP - cushings triad

Question 14

What are the three signs of cushings triad?

Answer 14

Increased pulse pressure (HTN)

decreased pulse

change in respiratory (bradypnea) pattern with pupillary changes

LATE SIGN OF INCREASED ICP

Question 15

What are some other signs of increased ICP?

Answer 15

decreased LOC

diminished reflexes

papilledema (usually effects eyes bilaterally)

decorticate and decerebrate posturing

unequal pupils

projectile vomiting

altered breathing

HA

Question 16

what is the primary goal of treating cerebral edema?

Answer 16

keep plasma osmolarity up to 320 mOsm/L

Question 17

How do you monitor ICP? are there advantages? disadvantages?

Answer 17

intraventricular monitoring is the most common - can allow for CSF drainage.

allows drainage of CSF

difficult to insert, high rates of infection

Question 18

What are some nursing management techniques for increased ICP treatment?

Answer 18

Position - HOB up 30-45 to decrease ICP 15-30 degrees, straight head, no trendelenburg. However - position the patient to help decrease ICP - whatever works!

Nursing Activities - limit suctionning, avoid valsalva, no PEEP, sedation

Hyperventilation - permissive hypocapnia, keep paCO2 35

Temp - vasodilation - hyperthermia, vasoconstrction - hypothermia

Blood pressure -maybe all it takes is sedation - if not, antihypertensives are used to keep CPP 60 - 100

Seizures -increased metabolic demand, causes ischemia

All interventions are directed toward decreasing volume of one of the 3 components

Lidocaine - through ET decreases ICP with suctionning
Table 34-5 page 791

Bowel – stool softeners, enemes, prevent constipation and valsalva!
Environment – limit stimuli, monitor conversations, gentle touch, dimming lights, back/hand rubs

Question 19

What are some medical management therapies for increased ICP?

Answer 19

Neuromuscular Blockade – monitoring
Barbiturate Coma – suppress seizures
Blood Pressure Management - monitor the MAP!
Avoid hyper and hypotension
Seizure prophylaxis – drug of choice for acute seizures
Normothermia – decrease metabolic demand
Craniectomy

Question 20

What are some warning signs of an aneurysm?

Answer 20

warning signs : headaches, lethargy, neckpain, optic, oculomotor cranial nerve dysfunctions

Question 21

What are some aneurysm precautions?

Answer 21

Anuerysm precuations - quiet environment, prevention of valsvalva, stool softeners, limit visitors, low lighting,, sedation

Question 22

What might a ruptured aneurysm look like?

Answer 22

once ruptured - will complains of worse headache in life, may have decreased LOC< visual disturbances, hemiparesis, vomiting, signs of ICP

Question 23

How can you surgically treat an aneurysm?

Answer 23

Clipping - within 48 hours, across neck of aneurysm - preferred
craniotomy is performed

Coiling - blocks aneurysm from circulation

AVM - remove AVM very high risk!

Question 24

What are some signs and symptoms of cerebral vasospams? What is triple H therapy? What medication can help decrease vasospasms completely?

Answer 24

Signs and symptoms - new focal deficit, hemiparesis, visual disturbances, decreasing LOC
Vasospasm – 4-14 days after rupture, peak at 7-10 days

3 days to 2 week after SAH, can last up to 3-4 weeks!

Hypertensions - vasopressors - get SBP between 150-160 - decreases spams

Hypervolemia - colloid and crystalloid solutions, volume expanders - watch for heart fialure!!!

Hemodilution - decrease viscocity and increase oxygen trasnport

nimodipine - calcium channel blocker can help prevent vasospasms

Question 25

what is the window to administer TPA for a stroke? other inclusion criteria?

Answer 25

4.5 hours

older than 38
diagnosis of ischemic stroke with measurable deficit on NIHSS scale
CT: no high density lesion, no significant mass effect or midline shift, no parenchymal hypodensity, no effacement of cerebral sulci in more than 33% of MCA territory

Question 26

What does hyperglycemia do in regards to stroke?

Answer 26

Increases infarction size

Question 27

What are the different types of ischemic stroke?

Answer 27

embolic

thrombolic

Question 28

Where can bleeds happen to cause hemorrhagic stroke?

Answer 28

subarachnoid

intracerebral