Week 4 - Neuro ~ IICP Flashcards
Intracranial Pressure
Normal ICP: _____________ (hydrostatic force) exerted by the combined volume of brain tissue, blood, and CSF within the skull
Normal ICP: total pressure (hydrostatic force) exerted by the combined volume of brain tissue, blood, and CSF within the skull
Normal ICP ranges from______ mmHg
A sustained pressure of greater than ___ mmHg = Intracranial HTN (IICP)
Normal ICP ranges from 5 to 15 mmHg
A sustained pressure of greater than 20 mmHg = Intracranial HTN (IICP)
Normal Compensatory Adaptations - Monro-Kellie Doctrine
The skull is a rigid compartment filled with 3 components at relatively constant volumes
____________, _________, ________
____ / ___ / ____
Brain tissue, blood and CSF
80/10/10
Autoregulation of Cerebral Blood Flow
PRESSURE _______________: Brain regulates it own blood flow in response to its metabolic needs regardless of changes in systemic arterial pressure
Mechanism: Automatic changes in diameter of cerebral blood vessels in response to changes in systemic arterial pressure
If BP increases > cerebral vessels _______
If BP decreases > cerebral vessels _______
GOAL: maintain constant CBF to meet metabolic needs of brain tissue & ensure cerebral perfusion pressure WNL
PRESSURE AUTOREGULATION: Brain regulates it own blood flow in response to its metabolic needs regardless of changes in systemic arterial pressure
Mechanism: Automatic changes in diameter of cerebral blood vessels in response to changes in systemic arterial pressure
If BP increases > cerebral vessels constrict
If BP decreases > cerebral vessels dilate
GOAL: maintain constant CBF to meet metabolic needs of brain tissue & ensure cerebral perfusion pressure WNL
Pressure Autoregulation Parameters
Limits to Effective Autoregulation: Mean arterial pressure (MAP) needs to be
between ______ mmHg
MAP < 70 mmHg = CBF decreases > cerebral ischemia
MAP > 150 mmHg = cerebral vessels maximally constrict > further vasoconstrictor
response lost
70 - 150
Cerebral Perfusion Pressure
CPP: Pressure needed to _____________ to brain
CPP = MAP – ICP
Normal CPP: 60-100 mmHg
60 mmHg needed for brain to receive minimal blood flow
Less than 50 mmHg = ischemia & neuron death
Less than 30 mmHg = ischemia & incompatible with life
ensure blood flow
Chemical Metabolic Regulation of Cerebral Blood Flow
Cerebral blood vessels respond to changes in _____________
-Increased cerebral CO2 (PaCO2): potent vasodilator of cerebral blood vessels
-Decreased cerebral O2 (PaO2): vasodilate cerebral blood vessels
-Acidic environment (Lactic acid and elevated H+): vasodilate cerebral blood vessels
PaCO2 & PaO2:
Causes of Increased Intracranial Pressure (IICP)
______ Injury
Vascular Insult
Mass lesions
Encephalopathies
Cerebral ________
Head Injury
Vascular Insult
Mass lesions
Encephalopathies
Cerebral Infections
IICP Pathophysiology
Primary injury: cerebral insult causing ___________
Secondary injury: cerebral _______
Focus our treatment on this
If untreated: IICP, herniation, and death
Primary injury: cerebral insult causing tissue damage
Secondary injury: cerebral edema
Focus our treatment
If untreated: IICP, herniation, and death
Cerebral Edema
Cerebral edema (accumulation of fluid in the intracellular and/or extracellular spaces of the brain)
Vasogenic
Disruption in the BBB allowing leakage of large molecules into the ___________ space
(shift intravascular to extravascular)
Cytotoxic
Disruption in cell membranes allowing fluid to seep into the _____ and out of ECF (cells
swell and lose function)
Cerebral edema (accumulation of fluid in the intracellular and/or extracellular spaces of the brain)
Vasogenic
Disruption in the BBB allowing leakage of large molecules into the extracellular space
(shift intravascular to extravascular)
Cytotoxic
Disruption in cell membranes allowing fluid to seep into the cells and out of ECF (cells
swell and lose function)
IICP Pathophysiology
Primary injury—lack of ______ to area— ______ environment—increase membrane __________ — _______ —causes increased ICP
Monroe-Kellie hypothesis
Decrease in blood flow (tissue hypoxia)
Ischemia—vasodilation—increases blood volume—increases ICP
Compensation fails: lose autoregulation
Any small increase in volume—herniation—death
Primary injury—lack of blood flow to area— acidotic environment—increase membrane permeability—edema—causes increased ICP
Monroe-Kellie hypothesis
Decrease in blood flow (tissue hypoxia)
Ischemia—vasodilation—increases blood volume—increases ICP
Compensation fails: lose autoregulation
Any small increase in volume—herniation—death
IICP Diagnostic Studies/Tests
SKULL ______ : Skull fracture, subdural hematomas
___ Scan: intracranial masses, hemorrhages, brain edema, infarction, atrophy
Best for hospital use, not as sensitive as MRI
MRI/MRA: more sensitive
–Hemorrhage, tumors or cerebral edema
____ : seizures, brain death
SKULL X-RAY: Skull fracture, subdural hematomas
CT Scan: intracranial masses, hemorrhages, brain edema, infarction, atrophy
Best for hospital use, not as sensitive as MRI
MRI/MRA: more sensitive
–Hemorrhage, tumors or cerebral edema
EEG: seizures, brain death
IICP Early Findings
_______________: first sign of IICP
Early signs
Alert (conscious and awake)
Drowsy/lethargic
_________
Level of Consciousness: first sign of IICP
Early signs
Alert (conscious and awake)
Drowsy/lethargic
Confused
IICP Early Findings - Level of Consciousness
Provide least amount of stimuli possible to obtain ______
Verbal: orientation person, place and time
Tactile
_____: fingernail pressure
Provide least amount of stimuli possible to obtain response
Verbal: orientation person, place and time
Tactile
Pain: fingernail pressure
Glascow Coma Scale
Eye ______ (1 – 4)
Best ______ Response (1 – 5)
Best ______ Response (1 – 6)
Eye Opening (1 – 4)
Best Verbal Response (1 – 5)
Best Motor Response (1 – 6)
IICP Early Findings - Pupil Changes
Pressure on CN ___ (Oculomotor)
Note size, shape, position, reaction
Look for changes in pupils ipsilateral (same side) to edema/lesion
Early IICP: _______ response (to light)
Pressure on CN III (Oculomotor)
Note size, shape, position, reaction
Look for changes in pupils ipsilateral (same side) to edema/lesion
Early IICP: sluggish response
IICP Early Findings - Motor changes
Motor ______: hand grips, foot strength
___________ to command: observe spontaneous movements
Contralateral Hemiplegia
Motor strength: hand grips, foot strength
Unresponsive to command: observe spontaneous movements
Contralateral Hemiplegia
IICP Early Findings - Vital signs
Fairly stable in early stages of IICP
__________ most sensitive
Look for change in pattern, rate
Fairly stable in early stages of IICP
Respirations most sensitive
Look for change in pattern, rate
IICP - Summary of Early Findings
____ - Confusion, lethargy, respond to verbal or tactile
______ - Sluggish
_______ - Decreased strength and response
Vital Signs - Minor change in ____________
LOC - Confusion, lethargy, respond to verbal or tactile
Pupils - Sluggish
Motor - Decreased strength and response
Vital Signs - Minor change in respirations
IICP: ______ Findings
LOC: continued deterioration-
Inattentive
Stuporous
Vegetative state
Comatose
IICP: Later Findings
LOC: continued deterioration-
Inattentive
Stuporous
Vegetative state
Comatose
IICP: Later Findings - Pupils
__________ pupils sign of impending herniation which compresses brainstem
Dilated and fixed either unilaterally or bilaterally: _____________
Dilating pupils sign of impending herniation which compresses brainstem
Dilated and fixed either unilaterally or bilaterally: notify HCP stat
IICP: Later Findings - Changes in Motor Function
Posturing
Decorticate: brainstem intact at diencephalon level
Decerebrate: brainstem not intact at pons level related to increasing pressure on brain stem
Mixed: variance in blood flow to areas, diffuse ischemic damage
Bilaterally flaccid: terminal stage
Posturing
Decorticate: brainstem intact at diencephalon level
Decerebrate: brainstem not intact at pons level related to increasing pressure on brain stem
Mixed: variance in blood flow to areas, diffuse ischemic damage
Bilaterally flaccid: terminal stage
IICP: Later Findings - Vital Signs
Temperature _______ [Pressure on hypothalamus]
Ability to control body’s temperature lost
Respirations - As ICP increases: become __________ with periods of apnea then ceases
Temperature Increases [Pressure on hypothalamus]
Ability to control body’s temperature lost
Respirations - As ICP increases: become irregular with periods of apnea then ceases
IICP: Later Findings
Cushing’s Response/Triad (__________ Response)
Activated in attempt to provide adequate CBF and CPP in presence of rising ICP
Signs:
_____cardia
_______ Systolic Pressure/Widened Pulse Pressure
__________ Respiratory Patterns
Cushing’s Response/Triad (Compensatory Response)
Activated in attempt to provide adequate CBF and CPP in presence of rising ICP
Signs:
Bradycardia
Rising Systolic Pressure/Widened Pulse Pressure
Irregular Respiratory Patterns
IICP: Later Findings - Cerebral Herniation
Increased ICP that continues to develop will result in cerebral herniation
Brain tissue pushed __________ thru tentorial notch > herniates (________) thru it >
Results: severe consequences or death if not treated aggressively
Increased ICP that continues to develop will result in cerebral herniation
Brain tissue pushed downward thru tentorial notch > herniates (protrudes) thru it >
Results: severe consequences or death if not treated aggressively
IICP: Later Findings - Loss of Brain Stem Reflexes
Babinski’s Reflex:
Stroke lateral aspect of sole from heel to across ball of foot:
Normally plantar flexion when stimuli applied
Babinski’s reflex: dorsiflexion of great toe with fanning (separation) of other toe
Adult should not have Babinki’s reflex
IICP: Later Findings - Corneal reflex
CN V (Trigeminal) and VII (Facial)
How do you test this?
Do they blink when an eye drop/cotton is near eye
If not, cranial nerves not intact
IICP: Later Findings - Gag and Swallow Reflexes
CN IX (Glossopharyngeal) and X (Vagus)
Reflex center in medulla
Intubated patient: slightly moving ETT - should stimulate gag response if intact
How do you test on a non-intubated patient? - use a tongue blade for ______
gag reflex
IICP: Later Findings - Oculocephalic Reflex (Doll’s Eyes)
Quickly turn head horizontally from side to side (CN III, VI) or vertically up and down (CN III) while holding eyelids open
Doll’s eyes present = intact brainstem; eyes lag behind movement of head
Doll’s eyes absent = brainstem not intact; eyes move passively with head
Quickly turn head horizontally from side to side (CN III, VI) or vertically up and down (CN III) while holding eyelids open
Doll’s eyes present = intact brainstem; eyes lag behind movement of head
Doll’s eyes absent = brainstem not intact; eyes move passively with head
IICP: Later Findings - Oculovestibular Reflex (Cold Caloric Testing)
More sensitive test of brainstem function
Comatose patient only
Results: slow eye _________ toward irrigated ear if brainstem intact
Procedure
Raise patient’s HOB 30 degrees
Irrigate one ear at time with 30-50 ml _____ cold water over 30 seconds
Wait > 5 minutes before irrigate other ear
IICP: Later Findings - Oculovestibular Reflex (Cold Caloric Testing)
More sensitive test of brainstem function
Comatose patient only
Results: slow eye deviation toward irrigated ear if brainstem intact
Procedure
Raise patient’s HOB 30 degrees
Irrigate one ear at time with 30-50 ml iced cold water over 30 seconds
Wait > 5 minutes before irrigate other ear
IICP: Later Findings
Apnea test - turn off mechanical ventilator and see ___________ ; check ABGs
if pt breathes
Summary of Late Signs of IICP
LOC
Pupils
Motor
Cushing’s Triad
Herniation
Reflexes
Cranial Nerves
LOC
Pupils
Motor
Cushing’s Triad
Herniation
Reflexes
Cranial Nerves
Goals: Prevent/Minimize IICP
Positioning:
Elevate HOB __ degrees
Body alignment
Avoid _____ position
Positioning:
Elevate HOB 30 degrees
Body alignment
Avoid prone position
Goals: Prevent/Minimize IICP
Decrease activities that result in IICP:
Avoid valsalva maneuver
Avoid arousal from sleep, especially REM sleep
Avoid noxious stimuli
Avoid coughing
Limit suctioning
Try to space activities
Decrease activities that result in IICP:
Avoid valsalva maneuver
Avoid arousal from sleep, especially REM sleep
Avoid noxious stimuli
Avoid coughing
Limit suctioning
Try to space activities
Goals: Prevent/Minimize IICP
Management of patent airway and optimum ventilation:
Maintain PaO2 - ____ mm Hg
Maintain PaCO2 _____ mm Hg
Management of patent airway and optimum ventilation:
Maintain PaO2 - 100 mm Hg
Maintain PaCO2 35-45 mm Hg
Goals: Prevent/Minimize IICP - Blood pressure management
Maintain MAP that will keep CPP > __ mmHg
Avoid severe hypotension and hypertension
Maintain systolic B/P < 150 mmHg*
Maintain MAP >90 mmHg
Maintain CPP > 70 mmHg
Critical to monitor ICP and MAP together to maintain CPP
Tolerate a higher SBP
70
Goals: Prevent/Minimize IICP
__________: (If MAP too high)
Nipride (Nitroprusside) IV
Decreases preload & afterload > decreased B/P, CBF, ICP
_________ : (If MAP too low)
Dopamine Increases myocardial contractility, CO, thus B/P
5-10 mcg/kg/min
Vasodilators: (If MAP too high)
Nipride (Nitroprusside) IV
Decreases preload & afterload > decreased B/P, CBF, ICP
Vasopressors: (If MAP too low)
Dopamine Increases myocardial contractility, CO, thus B/P
5-10 mcg/kg/min
Goals: Prevent/Minimize IICP - Maintain fluid/electrolyte balance
Fluid administration
Usually NS
Hypertonic Solutions (3% NS)
Intake and Output
Consider insensible losses & daily weights
Fluid administration
Usually NS
Hypertonic Solutions (3% NS)
Intake and Output
Consider insensible losses & daily weights
Goals: Prevent/Minimize IICP - Diuretics
Osmotic diuretic
_________ (Osmitrol) IV
Creates osmotic gradient between brain & plasma; fluid moves from tissues into vascular system > diuresis > decreased ICP
Loop diuretic ~ Lasix (furosemide), Bumex
Mannitol
Goals: Prevent/Minimize IICP - Prevent Infection and Maintain Normothermia
Every degree of Temp increase > increases ___ demands and CBF > increases ICP
Monitor and prevent infections (WBC’s, fever)
Culture, ATB’s, Tylenol
Cooling blanket
Prevent ________
Every degree of Temp increase > increases O2 demands and CBF > increases ICP
Monitor and prevent infections (WBC’s, fever)
Culture, ATB’s, Tylenol
Cooling blanket
Prevent shivering
Goals: Prevent/Minimize IICP - Reduce _________ demands
Relieve pain, fear, anxiety: can increase HR, B/P, BMR which lead to an ↑ CBF > ↑ ICP
Pain relief
Opioids: _________ Sulfate
Control of anxiety/agitation
Anesthetic sedative: IV Diprivan
(propofol): rapid onset, short half life; able to assess neuro status after turning off
infusion
__________ (Diazepam, Lorazepam)
Goals: Prevent/Minimize IICP - Reduce metabolic demands
Relieve pain, fear, anxiety: can increase HR, B/P, BMR which lead to an ↑ CBF > ↑ ICP
Pain relief
Opioids: Morphine Sulfate
Control of anxiety/agitation
Anesthetic sedative: IV Diprivan
(propofol): rapid onset, short half life; able to assess neuro status after turning off
infusion
Benzodiazepines (Diazepam, Lorazepam)
Goals: Prevent/Minimize IICP - Reduce Metabolic Demands cont.
Refractory intracranial hypertension
Neuromuscular blockade (NMBA’s): Vecuronium, Pancuronium
Barbiturate Coma: Pentobarbital, thiopental
Both v metabolism > v metabolic demands> v CBF v ICP
Refractory intracranial hypertension
Neuromuscular blockade (NMBA’s): Vecuronium, Pancuronium
Barbiturate Coma: Pentobarbital, thiopental
Both v metabolism > v metabolic demands> v CBF v ICP
Goals: Prevent/Minimize IICP - Maintain nutritional balance
Hypermetabolic, hypercatabolic state: need glucose for metabolism
Prevent __________
Early feeding following brain injury improves outcomes
Enteral feedings, TPN
Hypermetabolic, hypercatabolic state: need glucose for metabolism
Prevent hypoglycemia
Early feeding following brain injury improves outcomes
Enteral feedings, TPN
Goals: Prevent/Minimize IICP - Prevent Injury
Agitated
Seizures
→ increase CBF → ↑ICP
Use restraints only if absolute necessary:
↑ agitation → ↑ CBF → IICP
Ativan, Haldol, Dilantin
Padded side rails, suction
Agitated
Seizures
→ increase CBF → ↑ICP
Use restraints only if absolute necessary:
↑ agitation → ↑ CBF → IICP
Ativan, Haldol, Dilantin
Padded side rails, suction
Other Considerations [IICP]
Monitor for _________________: pressure on hypothalamus interferes with ADH synthesis/release > decreased ADH > uncontrolled UO
UO > 200 ml/hr x 2 hr
24 hrs > 4000 ml
Decreased specific gravity < 1.005
Treatment: vasopressin (Pitressin) or desmopressin acetate (DDAVP)
diabetes insipidus (DI)
IICP - Surgical Therapies
Burr hole
Craniotomy/Craniectomy
Ventriculostomy
Burr hole
Craniotomy/Craniectomy
Ventriculostomy
Intracranial Pressure Monitoring - ___________:
Gold standard for monitoring ____
Intraventricular space: most accurate
Directly measures pressure within ventricles
Can remove CSF, decreasing ICP
Obtain samples of CSF
Intracranial Pressure Monitoring - Ventriculostomy:
Gold standard for monitoring ICP
Intraventricular space: most accurate
Directly measures pressure within ventricles
Can remove CSF, decreasing ICP
Obtain samples of CSF
IICP - Acute Rehabilitation
Reentry into Community
Chronic problems r/t motor/sensory/memory deficits, communication, intellectual functioning
Mental/emotional issues
Personality changes, loss of concentration, mood swings
Lack of awareness of seriousness of injury
Loss of social restraint, judgment, tact, emotional control
Reentry into Community
Chronic problems r/t motor/sensory/memory deficits, communication, intellectual functioning
Mental/emotional issues
Personality changes, loss of concentration, mood swings
Lack of awareness of seriousness of injury
Loss of social restraint, judgment, tact, emotional control
IICP - Acute Rehabilitation - Teaching regarding:
Risk factors
Symptoms
DI
Seizures
Medications
Activity
Restrictions
May need psychological & family support
Referral for specific services: speech therapy, physical therapy
Risk factors
Symptoms
DI
Seizures
Medications
Activity
Restrictions
May need psychological & family support
Referral for specific services: speech therapy, physical therapy
A patient with intracranial pressure monitoring has a pressure of 12 mmHg. The nurse understands that this pressure reflects:
A. a severe decrease in CPP
B. an alteration in the production of cerebrospinal fluid
C. the loss of regulatory control of intracranial pressure
D. a normal balance between brain tissue, blood, and cerebrospinal fluid
D. a normal balance between brain tissue, blood, and cerebrospinal fluid
During admission of a patient with a severe head injury to the ED, the nurse places the highest priority on assessment for:
A. patency of airway
B. presence of a neck injury
C. neurologic status with the GCS
D. cerebrospinal fluid leakage from the ears or nose
A. patency of airway
The nurse is assigned four patients. Which patient should the nurse see first?
A. patient with a skull fracture whose nose is bleeding
B. an elderly patient with a stroke who is confused and whose daughter is present
C. a patient with meningitis who is suddenly agitated and reporting a HA of 10 on a scale of 0-10
D. a patient who had a craniotomy who is 3 days post op and is having frequent emesis
C. a patient with meningitis who is suddenly agitated and reporting a HA of 10 on a scale of 0-10
The Skull’s Essential Components
_________
the central nervous system and controls all functions of the body.
_____
vessels that supply oxygenated blood and essential nutrients to the brain tissue.
___________
cushions and protects the brain and
spinal cord from trauma and provides nutrients
Brain Tissue
The skull contains the brain tissue, which is the central nervous system and controls all functions of the body.
Blood
The skull houses the blood vessels that supply oxygenated blood and essential nutrients to the brain tissue.
Cerebrospinal Fluid (CSF)
The skull contains the cerebrospinal fluid, which cushions and protects the brain and
spinal cord from trauma and provides nutrients
Understanding the three essential components of the skull - brain tissue, blood, and cerebrospinal fluid - is crucial for recognizing and managing any injuries or conditions affecting the ______ and its contents.
Understanding the three essential components of the skull - brain tissue, blood, and cerebrospinal fluid - is crucial for recognizing and managing any injuries or conditions affecting the skull and its contents.
Intracranial Pressure - Factors that influence ICP
◦ _______ pressure
◦ _______ pressure
◦ Intraabdominal and intrathoracic pressure
◦ _________
◦ Temperature
◦ Blood gases (____ levels)
◦ Arterial pressure
◦ Venous pressure
◦ Intraabdominal and intrathoracic pressure
◦ Posture
◦ Temperature
◦ Blood gases (CO2 levels)
Normal ICP ________ mm Hg
5 to 15
__________ doctrine
States that the 3 components of the brain must stay at a relatively constant volume
within the closed skull
If the volume of 1 component increases, the volume of another is displaced to maintain ICP
Only applicable if skull is ______
Normal ICP 5 to 15 mm Hg
A sustained pressure > 20 mm Hg is abnormal
Monro-Kellie
-closed
Cerebral Blood Flow
Amount of _______ in mL passing through 100 g of ________ in 1 minute
Global CBF is about 50 mL/min/100 g of brain tissue
The brain uses ___% of the body’s O2 and ___ of its glucose
Amount of blood in mL passing through 100 g of brain tissue in 1 minute
Global CBF is about 50 mL/min/100 g of brain tissue
The brain uses 20% of the body’s O2 and 25% of its glucose
Cerebral Blood Flow - Autoregulation
◦ Automatic adjustment in _______ of cerebral blood _______
◦ Ensures consistent CBF to provide for ________ needs of brain
◦ Only effective if mean arterial pressure (MAP) ___________ mm Hg
◦ Automatic adjustment in diameter of cerebral blood vessels
◦ Ensures consistent CBF to provide for metabolic needs of brain
◦ Only effective if mean arterial pressure (MAP) 70 to 150 mm Hg
Cerebral perfusion pressure (CPP)
- CPP = MAP - ICP
- Normal is 60 to 100 mm Hg
- < 50 mm Hg is associated with ischemia and neuronal death
- CPP < 30 mm Hg incompatible with life
Effect of cerebral vascular resistance
CPP= flow x resistance
- CPP = MAP - ICP
- Normal is 60 to 100 mm Hg
- < 50 mm Hg is associated with ischemia and neuronal death
- CPP < 30 mm Hg incompatible with life
Effect of cerebral vascular resistance
CPP= flow x resistance
Stages of Increased ICP
- Stage 1: Total _________
The body’s initial response to increased ICP, with mechanisms in place to maintain normal ICP and cerebral perfusion pressure (CPP). - Stage 2: ________ Compensation
Compensatory mechanisms become inadequate, leading to a rise in ICP and a risk of further increases. - Stage 3: ________ Compensation
Clinical manifestations of increased ICP appear, such as Cushing’s triad (hypertension, bradycardia, and irregular respirations). - Stage 4: __________ Imminent
Unchecked ICP rise leads to brain herniation, which is life-threatening and requires immediate intervention to prevent death
- Stage 1: Total Compensation
The body’s initial response to increased ICP, with mechanisms in place to maintain normal ICP and cerebral perfusion pressure (CPP). - Stage 2: Decreased Compensation
Compensatory mechanisms become inadequate, leading to a rise in ICP and a risk of further increases. - Stage 3: Failing Compensation
Clinical manifestations of increased ICP appear, such as Cushing’s triad (hypertension, bradycardia, and irregular respirations). - Stage 4: Herniation Imminent
Unchecked ICP rise leads to brain herniation, which is life-threatening and requires immediate intervention to prevent death
Cerebral Blood Flow
Factors affecting cerebral blood vessel tone
◦ CO2
◦ O2
◦ Hydrogen ion concentration
CBF can be affected by
◦ Cardiac or respiratory arrest
◦ Systemic bleeding
◦ Other pathophysiologic states
Factors affecting cerebral blood vessel tone
◦ CO2
◦ O2
◦ Hydrogen ion concentration
CBF can be affected by
◦ Cardiac or respiratory arrest
◦ Systemic bleeding
◦ Other pathophysiologic states
Cerebral Edema
Increased __________ fluid in brain
Variety of causes
3 types of cerebral edema
Vasogenic
Cytotoxic
Interstitial
Increased extravascular fluid in brain
Variety of causes
3 types of cerebral edema
Vasogenic
Cytotoxic
Interstitial
Vasogenic cerebral edema
◦ Most ________ type
◦ Occurs mainly in white matter
◦ Results from disruption of blood-brain _______
◦ Fluid leaks from intravascular to extravascular space
◦ Exposes brain cells to _____ products from the blood
◦ Causes fluid to flow from intravascular to extravascular space
◦ Variety of causes
◦ Edema produces continuum of symptoms → coma
Vasogenic cerebral edema
◦ Most common type
◦ Occurs mainly in white matter
◦ Results from disruption of blood-brain barrier
◦ Fluid leaks from intravascular to extravascular space
◦ Exposes brain cells to toxic products from the blood
◦ Causes fluid to flow from intravascular to extravascular space
◦ Variety of causes
◦ Edema produces continuum of symptoms → coma
Cytotoxic cerebral edema
◦ Disruption of _________________
◦ From destructive lesions or trauma to brain tissue
◦ Results in cerebral hypoxia or anoxia and SIADH secretion
◦ Cerebral edema occurs
◦ Fluid and protein shifts from extracellular to intracellular
◦ Subsequent ________ and loss of cellular _________
◦ Disruption of cell membrane integrity
◦ From destructive lesions or trauma to brain tissue
◦ Results in cerebral hypoxia or anoxia and SIADH secretion
◦ Cerebral edema occurs
◦ Fluid and protein shifts from extracellular to intracellular
◦ Subsequent swelling and loss of cellular function
Interstitial cerebral edema
◦ Usually result of _________
◦ Manifested by ventricular _________
◦ Excess CSF production, obstruction of flow, or inability to reabsorb CSF
◦ Treat with ventriculostomy or ______
◦ Usually result of hydrocephalus
◦ Manifested by ventricular enlargement
◦ Excess CSF production, obstruction of flow, or inability to reabsorb CSF
◦ Treat with ventriculostomy or shunt
Increased ICP can take many forms
Depends on cause, location, and rate of increase
Change in level of consciousness
Flattening of affect to coma
Change in vital signs
Cushing’s triad
* Systolic hypertension with
* widened pulse pressure, bradycardia, irregular respirations)
Change in body temperature
Increased ICP can take many forms
Depends on cause, location, and rate of increase
Change in level of consciousness
Flattening of affect to coma
Change in vital signs
Cushing’s triad
* Systolic hypertension with
* widened pulse pressure, bradycardia, irregular respirations)
Change in body temperature
Clinical Manifestations - Compression of cranial nerve (CN) III oculomotor nerve
◦ Ipsilateral pupil _______
◦ Sluggish or no pupil response to ______
◦ Inability to move eye _______, adduct
◦ Eyelid ptosis
◦ Fixed, unilateral, dilated pupil is considered a neurologic emergency
◦ Indicates brain ________
◦ Ipsilateral pupil dilation
◦ Sluggish or no pupil response to light
◦ Inability to move eye upward, adduct
◦ Eyelid ptosis
◦ Fixed, unilateral, dilated pupil is considered a neurologic emergency
◦ Indicates brain herniation
Clinical Manifestations
Other cranial nerves
◦ Optic (CN II), trochlear (CN IV), and abducens (CN VI) nerves
◦ Diplopia, blurred vision, EOM changes
◦ Central herniation- sluggish but equal pupil response
◦ Uncal herniation- dilated unilateral pupil
◦ Papilledema- edematous optic disc on retinal exam
Just know damage to cranal nerves >
pupillary changes
Clinical Manifestations [IICP]
- Headache
Severe, continuous headache that is often worse in the _________ - Vomiting
Sudden, _________ vomiting that is not preceded by nausea - Altered Motor Function
Contralateral hemiparesis or hemiplegia, decerebrate or decorticate posturing, indicating more serious damage
Decorticate and Decerebrate Posturing
For any of these, notify Dr.
- Headache
Severe, continuous headache that is often worse in the morning - Vomiting
Sudden, projectile vomiting that is not preceded by nausea - Altered Motor Function
Contralateral hemiparesis or hemiplegia, decerebrate or decorticate posturing, indicating more serious damage
Decorticate and Decerebrate Posturing
For any of these, notify Dr.
Complications of Increased ICP
- Inadequate Cerebral ________
Decreased blood flow to the brain can lead to tissue ischemia and damage. - Cerebral ________
The brain can become displaced and compressed as intracranial pressure rises, leading to life-threatening complications. - Tentorial ________
The brain can herniate downward, pushing through the tentorial opening and causing compression of the brainstem. - Uncal ________
Lateral and downward displacement of the brain, often caused by a mass lesion, can lead to compression of the midbrain and brainstem. - Cingulate ________
Lateral displacement of brain tissue beneath the falx cerebri can cause further intracranial crowding and injury.
- Inadequate Cerebral Perfusion
Decreased blood flow to the brain can lead to tissue ischemia and damage. - Cerebral Herniation
The brain can become displaced and compressed as intracranial pressure rises, leading to life-threatening complications. - Tentorial Herniation
The brain can herniate downward, pushing through the tentorial opening and causing compression of the brainstem. - Uncal Herniation
Lateral and downward displacement of the brain, often caused by a mass lesion, can lead to compression of the midbrain and brainstem. - Cingulate Herniation
Lateral displacement of brain tissue beneath the falx cerebri can cause further intracranial crowding and injury.
IICP - Acute Care Interventions
Maintain Cerebral Oxygenation and Perfusion
Prevent Secondary Cerebral Ischemia
Monitor for Changes in Neurologic Status
Provide Patient and Family Teaching
Maintain Cerebral Oxygenation and Perfusion
Prevent Secondary Cerebral Ischemia
Monitor for Changes in Neurologic Status
Provide Patient and Family Teaching
IICP Nursing Implementation
Observe and Record _________
Prevent injury and administer antiseizure drugs as ordered.
Vigorously Manage _________
Fever increases cerebral edema and risk of seizures. Prevent neurologic damage
from high, prolonged fever.
Maintain Cerebral Oxygenation and _________
Prevent secondary cerebral ischemia and monitor for changes in neurologic status.
Minimize Environmental _________
Provide a calm, soothing environment to avoid delirium and hallucinations.
Prevent _________
Implement measures to maintain normal cerebral perfusion pressure, achieve maximal cognitive/ motor/ sensory function, and prevent infection or fever.
Observe and Record Seizures
Prevent injury and administer antiseizure drugs as ordered.
Vigorously Manage Fever
Fever increases cerebral edema and risk of seizures. Prevent neurologic damage
from high, prolonged fever.
Maintain Cerebral Oxygenation and Perfusion
Prevent secondary cerebral ischemia and monitor for changes in neurologic status.
Minimize Environmental Stimuli
Provide a calm, soothing environment to avoid delirium and hallucinations.
Prevent Complications
Implement measures to maintain normal cerebral perfusion pressure, achieve maximal cognitive/ motor/ sensory function, and prevent infection or fever.
IICP Diagnostic Studies
◦ CT scan / MRI / PET
◦ EEG
◦ Cerebral angiography
◦ ICP and brain tissue oxygenation measurement (LICOX catheter)
◦ Transcranial doppler and evoked potential studies
◦ NO ______ puncture
◦ CT scan / MRI / PET
◦ EEG
◦ Cerebral angiography
◦ ICP and brain tissue oxygenation measurement (LICOX catheter)
◦ Transcranial doppler and evoked potential studies
◦ NO lumbar puncture
Monitor any type of _____ with IICP !
fever
Measurement of ICP
Ventriculostomy
◦ Gold standard for monitoring ICP
◦ Catheter inserted into lateral _________
◦ Coupled to an external transducer
◦ Directly measures _________ within the ventricles
◦ Facilitates removal and/or sampling of _____
◦ Allows for intraventricular _____ administration
Ventriculostomy
◦ Gold standard for monitoring ICP
◦ Catheter inserted into lateral ventricle
◦ Coupled to an external transducer
◦ Directly measures pressure within the ventricles
◦ Facilitates removal and/or sampling of CSF
◦ Allows for intraventricular drug administration
IICP Interprofessional Care
Goals are to
◦ Identify and treat ______________ of increased ICP
◦ Support brain _________
Adequate oxygenation
◦ PaO2 greater than or equal to 100 mm Hg
◦ PaCO2 of 35 to 45 mm Hg
◦ Mechanical ventilation
Surgical removal of mass or lesion
Goals are to
◦ Identify and treat underlying cause of increased ICP
◦ Support brain function
Adequate oxygenation
◦ PaO2 greater than or equal to 100 mm Hg
◦ PaCO2 of 35 to 45 mm Hg
◦ Mechanical ventilation
Surgical removal of mass or lesion
IICP Drug therapy
◦ ________ (Osmitrol)
◦ Plasma expansion
◦ Creates vascular osmotic gradient
◦ Monitor fluid and electrolyte status
◦ __________ saline solution
◦ Moves water out of cells and into blood
◦ Monitor BP and serum sodium levels
______________
◦ Used to treat vasogenic edema
◦ Improve neurogenic function
◦ Monitor fluid intake, serum sodium and glucose levels
◦ Concurrent antacids, H2 receptor blockers, proton pump inhibitors
◦ Antiseizure medications
◦ Antipyretics
◦ Sedatives
◦ Barbiturates
◦ IV 0.9% NaCl preferred over D5W or 0.45% NaCl
◦ Mannitol (Osmitrol)
◦ Plasma expansion
◦ Creates vascular osmotic gradient
◦ Monitor fluid and electrolyte status
◦ Hypertonic saline solution
◦ Moves water out of cells and into blood
◦ Monitor BP and serum sodium levels
Corticosteroids
◦ Used to treat vasogenic edema
◦ Improve neurogenic function
◦ Monitor fluid intake, serum sodium and glucose levels
◦ Concurrent antacids, H2 receptor blockers, proton pump inhibitors
◦ Antiseizure medications
◦ Antipyretics
◦ Sedatives
◦ Barbiturates
◦ IV 0.9% NaCl preferred over D5W or 0.45% NaCl
IICP Nutrition therapy
◦ Hypermetabolic and hypercatabolic state increases the need for ________
◦ Enteral or parenteral nutrition
◦ Early feeding (meet caloric needs by at least 5 days after injury)
◦ Keep patient euvolemic
◦ Hypermetabolic and hypercatabolic state increases the need for glucose
◦ Enteral or parenteral nutrition
◦ Early feeding (meet caloric needs by at least 5 days after injury)
◦ Keep patient euvolemic
IICP assessment - Subjective data
Level of consciousness (LOC)
Glasgow Coma Scale
◦ Opening the eyes
◦ Best verbal response
◦ Best motor response
Level of consciousness (LOC)
Glasgow Coma Scale
◦ Opening the eyes
◦ Best verbal response
◦ Best motor response
IICP Cranial nerves
◦ Eye movements
◦ Corneal reflex
◦ Oculocephalic reflex (doll’s eye reflex)
◦ Oculovestibular (cold caloric reflex)
◦ Eye movements
◦ Corneal reflex
◦ Oculocephalic reflex (doll’s eye reflex)
◦ Oculovestibular (cold caloric reflex)
IICP assessment cont.
Pupillary Check for Size and Response
Motor strength
* Squeeze hands
* Pronator drift test
* Raise foot off bed or bend knees
Motor response
* Spontaneous or to pain
Vital signs
Pupillary Check for Size and Response
Motor strength
* Squeeze hands
* Pronator drift test
* Raise foot off bed or bend knees
Motor response
* Spontaneous or to pain
Vital signs
Clinical Problems
INCREASED INTRACRANIAL PRESSURE
INADEQUATE TISSUE ___________
RISK FOR ________
INCREASED INTRACRANIAL PRESSURE
INADEQUATE TISSUE PERFUSION
RISK FOR INJURY
IICP Overall goals
◦ Maintain a patent airway
◦ ICP within normal limits
◦ Normal fluid, electrolyte, and nutritional balance
◦ Prevent complications from immobility and decreased LOC
◦ Maintain a patent airway
◦ ICP within normal limits
◦ Normal fluid, electrolyte, and nutritional balance
◦ Prevent complications from immobility and decreased LOC
IICP Acute Care - Respiratory function
◦ Maintain patent airway
◦ Elevate head of bed 30 degrees
◦ Suction as needed
◦ Prevent abdominal distention
◦ Monitor ABGs
◦ Maintain effective ventilation
◦ Maintain patent airway
◦ Elevate head of bed 30 degrees
◦ Suction as needed
◦ Prevent abdominal distention
◦ Monitor ABGs
◦ Maintain effective ventilation
IICP Pain and Anxiety Management
- ________
Potent analgesics that can be used to manage severe pain associated with increased intracranial pressure - ________(Diprivan)
A sedative-hypnotic agent that can be used to induce and maintain sedation, reducing anxiety and agitation - _____________(Precedex)
A selective alpha-2 agonist that provides sedation and analgesia without respiratory depression, useful in managing agitated patients - Nondepolarizing neuromuscular
blocking agents Used to provide neuromuscular blockade, facilitating mechanical ventilation and reducing muscle tone that can contribute to increased ICP - ______________
Anxiolytic and sedative medications that can be used to manage anxiety and agitation in patients with acute intracranial problems
- Opioids
Potent analgesics that can be used to manage severe pain associated with increased intracranial pressure - Propofol (Diprivan)
A sedative-hypnotic agent that can be used to induce and maintain sedation, reducing anxiety and agitation - Dexmedetomidine (Precedex)
A selective alpha-2 agonist that provides sedation and analgesia without respiratory depression, useful in managing agitated patients - Nondepolarizing neuromuscular
blocking agents Used to provide neuromuscular blockade, facilitating mechanical ventilation and reducing muscle tone that can contribute to increased ICP - Benzodiazepines
Anxiolytic and sedative medications that can be used to manage anxiety and agitation in patients with acute intracranial problems
IICP Acute Care - Interventions to optimize ICP & CPP
◦ HOB elevated, head midline
◦ Avoid extreme neck flexion
◦ Turn slowly
◦ Prevent pain or discomfort
◦ Avoid hip flexion
◦ HOB elevated, head midline
◦ Avoid extreme neck flexion
◦ Turn slowly
◦ Prevent pain or discomfort
◦ Avoid hip flexion
Cont. IICP Acute Care
Minimize complications of _________
Protection from self-injury
Judicious use of restraints; sedatives
_________ precautions
Quiet, _________ _________
Psychologic considerations
Minimize complications of immobility
Protection from self-injury
Judicious use of restraints; sedatives
Seizure precautions
Quiet, nonstimulating environment
Psychologic considerations
Evaluation and Expected Outcomes
Maintain ICP and CPP within normal limits
Ensure the patient’s intracranial pressure (ICP) and cerebral perfusion pressure (CPP) remain within the acceptable range to support proper brain function and perfusion.
Prevent serious increases in ICP
Closely monitor the patient’s ICP and quickly intervene to address any significant increases that could lead to further complications.
Avoid complications of immobility
Implement strategies to prevent issues like pressure ulcers, deep vein thrombosis, and muscle atrophy that can arise from the patient’s decreased mobility.
By maintaining ICP and CPP within normal parameters, preventing serious increases in ICP, and avoiding complications of immobility, the nurse can help ensure the best possible outcomes for the patient with a head injury.
Maintain ICP and CPP within normal limits
Ensure the patient’s intracranial pressure (ICP) and cerebral perfusion pressure (CPP) remain within the acceptable range to support proper brain function and perfusion.
Prevent serious increases in ICP
Closely monitor the patient’s ICP and quickly intervene to address any significant increases that could lead to further complications.
Avoid complications of immobility
Implement strategies to prevent issues like pressure ulcers, deep vein thrombosis, and muscle atrophy that can arise from the patient’s decreased mobility.
By maintaining ICP and CPP within normal parameters, preventing serious increases in ICP, and avoiding complications of immobility, the nurse can help ensure the best possible outcomes for the patient with a head injury.
Types of Head Injuries
- Scalp Lacerations
Tears in the highly vascular scalp tissue, which can cause profuse bleeding and potential complications like infection. - Skull Fractures
Breaks in the skull bone, which can be linear, depressed, or compound, and require specific management based on the type and location. - Concussion
A sudden, transient mechanical injury to the brain, resulting in a brief disruption of consciousness, retrograde amnesia, and potential post-concussion syndrome. - Contusion
Bruising of the brain tissue, associated with closed head injuries, which may result in areas of hemorrhage, infarction, necrosis, and edema. - Intracerebral Hematoma
Bleeding within the brain tissue, which typically occurs in the frontal and temporal lobes, and can significantly impact patient outcome based on the size and location. - Cerebral Edema
Increased fluid accumulation in the brain, which can be vasogenic (disruption of the blood-brain barrier), cytotoxic (cell membrane disruption), or interstitial, and requires specific management strategies.
- Scalp Lacerations
Tears in the highly vascular scalp tissue, which can cause profuse bleeding and potential complications like infection. - Skull Fractures
Breaks in the skull bone, which can be linear, depressed, or compound, and require specific management based on the type and location. - Concussion
A sudden, transient mechanical injury to the brain, resulting in a brief disruption of consciousness, retrograde amnesia, and potential post-concussion syndrome. - Contusion
Bruising of the brain tissue, associated with closed head injuries, which may result in areas of hemorrhage, infarction, necrosis, and edema. - Intracerebral Hematoma
Bleeding within the brain tissue, which typically occurs in the frontal and temporal lobes, and can significantly impact patient outcome based on the size and location. - Cerebral Edema
Increased fluid accumulation in the brain, which can be vasogenic (disruption of the blood-brain barrier), cytotoxic (cell membrane disruption), or interstitial, and requires specific management strategies.
Raccoon Eyes and Battle’s Sign
Battle sign is prominent when there is a fracture of the petrous temporal bone. It may also be associated with rhinorrhea and bruising over the eyes
Head injury
Most common causes
_______
________________
Other causes
* Firearms
* Assaults
* Sports-related trauma
* Recreational injuries
* War-related injuries
Head injury
Most common causes
* Falls
* Motor vehicle accidents
Other causes
* Firearms
* Assaults
* Sports-related trauma
* Recreational injuries
* War-related injuries
Head injury
TBI are twice as common in ______
High potential for poor outcome
Deaths occur at 3 points after injury
* ____________ after the injury
* Within ________ after injury
* About ________ after injury
Head injury
TBI are twice as common in males
High potential for poor outcome
Deaths occur at 3 points after injury
* Immediately after the injury
* Within 2 hours after injury
* About 3 weeks after injury
Lacerations [type of head injury]
◦ Tearing of brain tissue
◦ With depressed and open fractures and penetrating injuries
◦ Intracerebral hemorrhage
◦ Subarachnoid hemorrhage
◦ Intraventricular hemorrhage
◦ Management
◦ Antibiotics
◦ Preventing secondary injury
◦ Tearing of brain tissue
◦ With depressed and open fractures and penetrating injuries
◦ Intracerebral hemorrhage
◦ Subarachnoid hemorrhage
◦ Intraventricular hemorrhage
◦ Management
◦ Antibiotics
◦ Preventing secondary injury
Contusion [type of head injury]
◦ May continue to bleed or rebleed
◦ Focal and generalized manifestations
◦ Monitor for seizures
◦ Potential for increased hemorrhage if on anticoagulants
◦ May continue to bleed or rebleed
◦ Focal and generalized manifestations
◦ Monitor for seizures
◦ Potential for increased hemorrhage if on anticoagulants
Complications - Epidural hematoma
◦ Initial period of ___________
◦ Brief lucid interval followed by decrease in LOC
◦ Headache, nausea, vomiting
◦ Focal findings
◦ Requires rapid evacuation
◦ Initial period of unconsciousness
◦ Brief lucid interval followed by decrease in LOC
◦ Headache, nausea, vomiting
◦ Focal findings
◦ Requires rapid evacuation
Complication - Types of Subdural Hematomas
◦ _______ subdural hematoma
◦ _______ subdural hematoma
◦ _______ subdural hematoma
◦ Acute subdural hematoma
◦ Subacute subdural hematoma
◦ Chronic subdural hematoma
Subdural hematoma
◦ Bleeding between dura mater and arachnoid
◦ Most common source
◦ Veins that drain brain surface into sagittal sinus
◦ Can also be arterial—develops more rapidly
◦ Bleeding between dura mater and arachnoid
◦ Most common source
◦ Veins that drain brain surface into sagittal sinus
◦ Can also be arterial—develops more rapidly
Acute subdural hematoma
◦ Within __________ of injury
◦ Symptoms related to increased ICP
◦ Decreased LOC, headache
◦ Ipsilateral pupil dilated and fixed if severe
◦ Within 24 to 48 hours of injury
◦ Symptoms related to increased ICP
◦ Decreased LOC, headache
◦ Ipsilateral pupil dilated and fixed if severe
Subacute subdural hematoma
◦ Within ___________ of the injury
◦ May appear to enlarge over time
◦ Breakdown products of blood draw fluid into subdural space
◦ Within 2 to 14 days of the injury
◦ May appear to enlarge over time
◦ Breakdown products of blood draw fluid into subdural space
Chronic subdural hematoma
◦ __________ after seemingly minor head injury
◦ More common in older adults
◦ Presents as focal symptoms
◦ Increased risk for misdiagnosis
◦ Weeks or months after seemingly minor head injury
◦ More common in older adults
◦ Presents as focal symptoms
◦ Increased risk for misdiagnosis
Intracerebral Hematoma
Bleeding within ___________
Occurs in about 16% of head injuries
Usually happens within frontal and temporal lobes
Size and location of hematoma are key in determining patient outcome
Bleeding within brain tissue
Occurs in about 16% of head injuries
Usually happens within frontal and temporal lobes
Size and location of hematoma are key in determining patient outcome
Acute care - Measures for patients leaking CSF
◦ Head of bed _______
◦ Loose collection pad under nose/over ear
◦ No _______ or blowing nose
◦ No NG tube
◦ No nasotracheal suctioning
◦ Head of bed raised
◦ Loose collection pad under nose/over ear
◦ No sneezing or blowing nose
◦ No NG tube
◦ No nasotracheal suctioning
Diagnostics [head injury?]
______
* Best test to evaluate for head trauma
* Allows for rapid diagnosis and interventions
MRI, PET, evoked potential studies
Transcranial doppler studies
Cervical spine x-ray
CT scan
Emergency Treatment [head injury]
Circulation, airway, breathing
Stabilize cervical spine
Oxygen
IV access
Intubate if GCS less than 8
Control external bleeding
Remove patient’s clothing
Circulation, airway, breathing
Stabilize cervical spine
Oxygen
IV access
Intubate if GCS less than 8
Control external bleeding
Remove patient’s clothing
Emergency Treatment [head injury]
Maintain ____________
Ongoing monitoring
Intubation if _________ impaired or absent
Give fluids cautiously
Maintain normothermia
Ongoing monitoring
Intubation if gag reflex impaired or absent
Give fluids cautiously
cranial nerves - mnemonics
Ooh, ooh, ooh to touch and feel very good velvet
Some say marry money but my brother says big brains matter most
Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?
A. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
B. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min
C. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min
D. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
A. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately lifethreatening process.
When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?
A. Flexion withdrawal
B. Localization of pain
C. Decorticate posturing
D. Decerebrate posturing
C. Decorticate posturing
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
The nurse has administered prescribed IV mannitol (Osmitrol) to an
unconscious patient. Which parameter should the nurse monitor to
determine the medication’s effectiveness?
A. Blood pressure
B. Oxygen saturation
C. Intracranial pressure
D. Hemoglobin and hematocrit
C. Intracranial pressure
Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration.
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
A. Encourage coughing and deep breathing.
B. Position the patient with knees and hips flexed.
C. Keep the head of the bed elevated to 30 degrees.
D. Cluster nursing interventions to provide rest periods.
C. Keep the head of the bed elevated to 30 degrees.
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
A. Have the patient gently blow the nose.
B. Check the drainage for glucose content.
C. Teach the patient that rhinorrhea is expected after a head injury.
D. Obtain a specimen of the fluid to send for culture and sensitivity.
B. Check the drainage for glucose content.
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient’s nose. Which admission order should the nurse question?
A. Keep the head of bed elevated.
B. Insert nasogastric tube to low suction.
C. Turn patient side to side every 2 hours.
D. Apply cold packs intermittently to face.
B. Insert nasogastric tube to low suction.
Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.
When assessing a patient who has a right frontal lobe tumor, what finding should the nurse expect?
A. Expressive aphasia
B. Impaired judgment
C. Right-sided weakness
D. Difficulty swallowing
B. Impaired judgment
The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.
A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
A. Document the BP and ICP in the patient’s record.
B. Report the BP and ICP to the health care provider.
C. Elevate the head of the patient’s bed to 60 degrees.
D. Continue to monitor the patient’s vital signs and ICP.
B. Report the BP and ICP to the health care provider.
Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] – ICP). MAP = DBP + 1/3 (Systolic Blood pressure[SBP] -Diastolic blood pressure [DBP]). Therefore, the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient’s therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.
A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?
A. Check oxygen saturation.
B. Palpate the head for injuries.
C. Assess pupil reaction to light.
D. Verify Glasgow Coma Scale (GCS) score
A. Check oxygen saturation.
Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.
The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse?
A. The patient reports a headache.
B. The apical pulse is slightly irregular.
C. The patient is more difficult to arouse.
D. The blood pressure increases to 140/62 mm Hg.
C. The patient is more difficult to arouse.
The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not
unusual in a patient after a head injury.
With decorticate posturing, the patient exhibits _______ rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate, mixed decorticate and decerebrate posturing, and opisthotonic posturing.
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