WEEK 9 Flashcards
neuro: traumatic brain injury, brain tumor
indications of head injury : what is it ?
scalp wound
fracture
swelling, bruising
loss of conciousness
nasal discharge
stiff neck
head injury : emergency management interventions
initial scene
what would you do ?
calm gentle approach, get info from patient or others with the pt - what happened ? ( did the person lose conciousness )
head injury : emerg management interventions
what is the number one thing that is very important in this case ( aside from conciousness )
patent airway, stabilize cervical spine until x-ray
head injury : emergency management interventions : initial at scene : what would you do if a pt walks in with an external bleeding ?
apply pressure to external bleeding, warm blankets
Head injury : emerg management interventions : initial at scene what would you assess for ?
rhinorrhea/ ottorrhea / scalp wounds
head injury : emergency management interventions
once have access to hospital
02 via NP or re breath mask
establish 2 large bore IVs ( large gauge cannula )
true or false. do we give iv fluid cautiously, give drugs to decrease icp and increase cpp , control pain, seizures when the pt has an access to hospital. ( we are talking about a head injury : emerge management interventions )
yes this is true
is it important for the patient to be warm once have access to hospital ?
yes it is important especially for a patient who had a head injury : emerg management interventions this is something that we would do
what are the type of monitoring we are doing for our head injury pts as an emerg management interventions ?
frequent VS neuro checks ( monitor for change in LOC )
true or false ongoing monitoring of VS, 02 SATS, cardiac rhythym , GCS pupils and limb strength is something we need to utilize once the patient has an access to the hospital when they had a head injury ?
yes this is true
what do we need to ask the patient ( if they have a head injury : emerg management interventions and have an access to the hospital ) ?
ask for pt health hx, allergies, meds: provide support for patient and family
what type of health history are we going to ask the patient ?
diabetes
hypertension ( think abt allergies and medications )
what could we do physically to access the pt?
cns fluid flowing out their ears ( look for blood and clean their hair ) looking for wounds
usually anticobital - this gives fluid
what duration of ays is typically intense for a traumatic brain injury ?
first 5 days is intense ( and monitoring should be happening during these 5 days )
what is the severity range for traumatic brain injury :
severity range : mild ( concussion) , moderate, or severe ( traumatic brain injury TBI )
who are working on traumatic brain injury ? and what can it lead to ?
typically neurosurgery is an intervention/ working with physician/team
this could lead to impairment in cognition, mobility, sensory perception, psychosocial function- temporary or permanent
traumatic brain injury ; presentation depends on what ?
severity of the injury - speed and force
location :
- frontal, occipital, parietal , basilar
- focal or diffuse , open or closed
surgery - may depend on locstion of injury
what is the diagnoses for traumatic brain injury
CT head - repeat CT scan and compare
true or false. Make sure infection doesn’t become significant.
true
what is consider different level of injury ?
fell in the head or hitting a bat ( different level of injury )
what is basilar?
is at the base of the skull
what does focal or diffuse mean or open or closed ?
focal or diffuse means in a certain spot ( diffuse mean all through the brain )
open means skull fracture and been broken
close means the skull hasn’t been fracture and all intact
what does a mil concussion look like ?
may not feel great but the next day feel good, and then doing sports/work
what does frontal lobe affect ?
intellect
what does temporal lobe?
hearing, smell , taste
memory ( short term )
reading
occipital lobe what does it do ?
visual reception
writing
eyes to opposite side body awareness
whar does parietal lobe control ?
sensory discrimination
what alters the presentation of clinical manifestations ?
the location of skull fracture
what are examples of basal skull fracture
battles sign ( post auricular ecchymois )
what are the raccoon eyes ( bilateral periorbital ecchymois ) what does this under go to
have bilateral black eyes or shadow underneath
this undergoes basal skull fracture
what are some complications of facial and skull fractures
dural tear is common ( csf leak )
recall that a complication of facial and skull fractures
is dural tear and this is common known as a csf leak which can cause meningitis
explain how
infection can get into csf fluid ( circulating in your spine and brain )
if you were to hit or injured hard enough to fracture the skull very likely for dura mater will be torn - this is a huge risk for meningitis
abx is a big deal
True or false.the safety of ng tube insertion is important.
bonus : why would this be important ?
this is important as head injury may have facial fractures safety ! ng insertion`
how do we make sure ng insertion is not causing head injury ( fracture )
make sure the ct
fracture and eye orbital shown in the pic ( slide 7 )
if u have that fracture very likely they have fractured their nose
with nasal drainage it is important to know if it is what ? what sign are you looking for ?
mucus or csf leak
looking for a halo sign
if we see a nasal drainage - is it mucous ? what is a quick way to find out ?
is to get a drop of the mucous 2 by 2
but 2 by 2 to catch those drops
not putting just to know for sure there are no facial fractures
the halo effecting of leaking : typically what does this look like ?
serosanguinous in the centre
cerebrospinal fluid around
what does the halo effect of leaking indicae?
this is a major head injury
look at his ears ( a bunch of blood and in the sheet )
focal head injury
depends on how ?
on how the person was hit
focal finding - the person was hit in the front ( which will mainly affects in the brain or overall increased in ICP )
focal head injury: contusion
bruising of brain tissue within the focal area
focal findings but can lead to overall IICP
what are common in focal head injury contusion
seizures are common
what does the prognosis depends on in focal head injury
prognosis depends on severity of contusion and whether it continues to evolve
focal head injury : contusion what coup contre coup injury lead to ?
multiple contusions ( direct impact site and opposite side )
direct impact ( getting hit by a bat in the middle of the head )
diffuse axonal injury ( DAI )
What does this mean ?
widespread axonal damage
90% with severe DAI remain in a vegetative state
how long can diffuse axonal injury take after initial TBI to occur?
12-24 hours
diffuse axonal injury ( DAI )
what does this result in ?
results in global cerebral edema and IICP
diffuse axonal injury is shaken ?
shaken like a bowl of jello
—searing of neurons - overall
—-diffuse nerve axon injury
what is the complication of head injury
hemorrhage
complications of head injury : hemorrhage
emergency ( if its an artery ) blood filling in the space and the pressure in that head
arterial bleeds and these people need emergency surgery quickly
what are the two complications of head injury : hemorrhage
epidural hematoma and subdural hematoma
what is epidural hematoma ( know that this is emergent ) what is the location?
between dura and skull
what is this describing : usually arterial - bleeds fast, pressure in skull ( ICP ) increases fast
epidural hematoma ( emergent )
nsg care for IICP : is needed for ?
epidural hematoma
what requires an immediate surgery to remove bleed?
epidural hematoma which is emergent
what is the location for subdural hematoma
between dura and arachnoid space
usually venous
what is needed for subdural hematoma?
surgery is needed to remove the bleed
nsg care for iicp
subdural hematoma what is it typically ?
usually venous
- acute
- subacute
- chronic
define what she said in the video : for subdural hematoma
also serious but this is venous the blood collecting is going slower and not as urgent
what would they do for subdural hematoma
they’ll do a ct scan surgery to remove collection of blood
true or false. our job as a nurse is treating the increased intracranial pressure for subdural hematoma ?
yes this is true
head injury : nursing management
what is our overall goals
maintain adequate cerebral perfusion
remain normothermic, might cool the pt
be free from pain discomfort and infection
true or false. attain maximal cognitive motor and sensory function is important when it comes to managing a head injury
true
as nurses what is important to look at for a head injury ?
lets give them time, lets look at the LOC and neuro status
what is the key nursing assessments for head injury and nursing management
nursing assessment record
- monitor changes in LOC and neurological status
CSF leak is identified as a key nursing assesments ?
yes this is seen as a csf leak
-doing a halo test is beneficial
what is important to treat for a head injury ?
treat iicp
what does the brain need?
oxygenated blood and not have damage, we want to make sure normothermic- meaning normal body temperature
if they have icp - icu we cool the patient (cooling blanket ) - rectal thermometer and try to lower down the temp0
treat IICP
vessels in the brain starts shutting down
treatment is quite similar
what is the classification for brain tumors
benign
malignant
metastatic
what does benign
malignant
metastatic identify as in the brain tumor ?
benign is not cancerous
malignant is cancer
metastatic - this is cancer somewhere else in the body and now travelled to their brain
if brain tumor is not cancerous why is this stills serious?
if you have something taking place , you are going to get cerebral edema and high icp
true or false. Eventually all brain tumours unless they have some treatment can lead to death ?
yes this si true
depending on where the brain tumour is - sometimes we cannot remove it
why do they not do brain surgery sometimes ?
the risk is too high – remove tumour for example L will be blind not able to move legs or stop breathing
what is a classic sign or symptom of brain tumour ?
dull headache is a classic sign and symptom ( but this depends on the location )
the person has hormones that arent normal and this could also be a sign, however what is one thing that would never go away when u have a brain tumour
dull headache , this is constant and always there
recall that headache is constantly there when someone has a brain tumour- when does it usually get worst
it gets worst at night ( the person is lying down - more swelling there )
the headache is so bad it wakes the person up
recall that headache is a number one constant thing with brain tumor what else?
seizure
nausea and vomiting from increase of intra cranial pressure
cognitive dysfunction ( not thinking clearly )
memory problems
all depends on where it is
brain tumours - collaborative care
what decreases the inflammation?
corticosteroids
- dexamethasone ( this works ery quickly and decreases
inflammation – brain tumour often times is started off with this ) it reduces cerebral edema and can help decrease symptoms
what is important to manage in brain tumours as we doing a collaborative care
recall we use corticosteroids ( dexamethasone to decrease inflammation )
build up of csf fluid in the brain, they can pout a shunt in ( commonly done in children when they have this as a problem )
goes from ventricle of brain all the way down to the side of neck and then peritoneal cavity
true or false. csf should be sterile
true this should be sterile
brain tumors - collaborative care
surgery to remove or debulk mass
go more in depth abt these interventions
craniotomy
stereotactic radio surgery ( high dose radiation precisely delivered )
brain tumours - collaborative care
recall it is important for surgery to remove or debulk mass ( craniotomy and stereotactic radiosurgery ( high dose radiation precisely delievered )
what else is important ?
radiation ( internal, external )
chemotheraphy
nsg care for IICP
pts level of conciousness should be assessed ( this is important )
caused this can indicate decline if it has changed
this is true
surgery options : craniotomy
recall this is one of our surgery options what is this doing
remove bone flap ( safety )
remove clot or tumour or fix problem
establish a drain
—- re- attach bone flap ( later time, not urgent )
if the brain is swollen what is initially happening to the brain ?
squeezing i no matter what were doing if it is swelling/give them room
go to the or and cut the bone out and remove it
what used to be a practice before but now is not practice for craniotomy
they use to put them in jars and save them but the practice now is make a small incision in the bone and close it up – why do they do this ?
by having no bone that means that brain is having a little bit more space to given ( swell up more and doesnt get squish )
yes this is true
establish drain what are we initially utilizing ?
jackson pratt ( after these pts - these surgery is their bone flap it is important as nurses, we are not turning them on that side ) brain is pushing on that skin
post op care for craniotomy
where are the patients located ?
ICU or stepdown for close monitoring
what do u have to make sure during post op care craniotomy
make sure their ICP is in the normal stage, their cpp is also important ( how much blood flow and perfusion pressure naturally dips down- very swollen brain
what can poor perfusion lead to ?
it can lead to more brain problems ( not just injury and the fall ( taking care of that patient ) gets icp as normal as possible
what is important for post op care craniotomy
monitor/treat for IICP, while maintaining CPP
post op care craniotomy : what is there to see ?
periorbital edema and ecchymois
post op care craniotomy :
prevent, assess, tx any complications such as
pneumonia, stress gastric ulcer, DVT/PE , constipation , fluid and electrolyte balance
infection prevention / care of drsg to head is important when it comes to post op care craniotomy , what should be practiced ?
sutures/staples in for 7-10 days
pain, nausea control, anti-seizure med is important ?
yes it is important
what is potential determined once cerebral edema and iicp subside ?
rehab is potential determined, referrals to speciliasts , long process, personality
be careful with incision , what is a possibility that could happen with an irritated brain ?
seizure or epilepsy
what is another surgical options?
burr hole
describe burr hole
often used for subdrual hematoma
what is often used for subdural hematoma
burr hole
how many holes are drilled thru the skull ?
1 or 2 holes
hematoma is evacuated
can leave drain in for a few days
what is stereotactic methods
stereotactic radiosurgery
radiation used to destroy brain tumour
how is the patients head positioned in stereostatic radio surgery
patients head is held still by a stereotactic frame
gamma knife ( high dose of radiation is delivered )
stereotactic bx/surgery ( is not heavily sedated )
used for brain biopsies, small tumours, abscesses etc
apparatus and computer used to find precise area of brain
surgeon enters with fine instruments
what is this describing ::?
stereotactic bx/surgery
S&S of IICP brain tries to compensate
is important to pay attention to this
what is the early signs : ( your compensatory mechanisms are still intact )
altered LOC ( confusion, restlessness )
- unilateral pupil change in size, equality, and/or reactivity )
altered resp pattern ( bradypnea or irregular pattern )
true or false. what is the variable signs : for early signs
focal findings ( eg speech, difficulty , visual disturbances )
- papilledema
-vomiting
-headache
-seizures
what are the late signs of S&S of IICP brain tries to compensate
compensatory mechanisms failing
decrease in LOC ( stupor )
- unilateral or bilateral pupillary changes : size, equality, and/or reactivity
late signs is seen as your compensatory mechanisms are failing , how is the breathing pattern ?
ineffective breathing pattern ( cheyne stokes respirations )
abnormal motor response ( decorticate or decebrate posturing )
what are the variable signs for late signs ( compensatory mechanisms failing )
HTN with widened pulse pressure
bradycardia
hyperthermia
terminal signs ( decompensation )
coma
- bilaterally fixed and dilated pupils
-respiratory arrest
- absence of motor response ( flaccid )
what are variable signs for terminal signs
HTN with widened pulse pressure
bradycardia
hyperthermia
what stage is this describing : this is too late to really do anything to treat them ( this pt will pass away )
terminal signs of s and s of iicp brain tries to compensate
the physicians and family will meet the criteria and they will consider organ donations ( if they are brain dead )
icp & cerebral perfusion pressure
what do u need to see a pt’s ICP and CPP in stepdown or ICU?
u need an icp monitor
icp and cerebral perfusion pressure
these patients would be on bedrest.
yes this is true they would be in bedrest
what is normal ICP ?
<15 mmHg
GCS<8 ‘coma ‘
if ICP > 20 ( there are problems )
relation between BP and CPP
normal CPP
may need to use meds to increase BP ( SBP goal ordered, ex: keep SBP 160 with meds )
the relation between BP and CPP, what do we need to understand.
we need to understand that it is because we need to know that perfusion has to keep up to the brain and keep them alive
IICP causes the brain tissue to receive inadequate perfusion, what do we do ?
want iCP at a level so that CPP is good and can perfuse brain tissues, Dr write medical order stating our goals.
what is a normal CPP ?
60-70 mmHg ( our goal is to keep it at 70 )
what is a prognosis for good recovery ? ICP and cerebral perfusion pressure
worst prognosis : longer patient is unconscious are high ICP
worst prognosis - likely never be tha same as before or ancient
how do we monitor neuro status?
icp and cpp
gcs ( eye opening, best verbal response, best motor response )/15 /how awake they are
recall that in our neuro assesment we are checking for the icp and cpp along with gcs ( eye opening, best verbal response, best motor response )/15 /how awake they are
what else?
clinical assessment - pupil size and reaction to light using pen light
true or false. Ct head/brain results - compare to previous CT what are we looking for ?
this is true and the bonus question is looking for that tightness
it is indeed true that recovery from a neuro injury takes time, what does this mean ?
recovery takes time ( process of waking up from a trauma )
they may be restless moving their arms and legs, eyes are starting to open
** key finding is if the pt can follow demands
( the doctor would like to know abt these findings )
What would cause a pt to have issues with IICP?
anything that can increase/cause cerebral edema
what would a patient who has issues with IICP ct scan look like?
brain looks tight and a shift ventricles looks collapsed
true or false. this could be an example of a pt who has issues with IICP : looks like the right or left side has shifted
of they may say ventricles have collapsed ( pressure pushing down to the ventricles )
this si true
recall that anything that can increase/cause cerebral edema can cause issues with IICP, what else?
- Head injury
- Assault/accident
- Subarachnoid hemorrhage (SAH) – spontaneous or fr an injury
- Meningitis (infection)
- Stroke (anoxic/ischemic problem)
- Brain surgery
what undergoes head injury that can cause increase in intracranial pressure ?
assault/accident - diffuse axonal injury
skull fracture
cerebral hematoma
contusion
moderate or severe brain injury
What are some things that cause or worsen IICP ?
A re bleed
seizure
pain/irritating issue
fever
coughing,straining ( valsalva maneuver )
true or false. increase in cerebral edema would require a repeated ct- and if the results come out that the brain looks tight and ventricles have collapsed , this can cause worsen IICP
this is true
If a pt has an icp monitor , what type of position are they on?
they are on bedrest, and still needs to be turned/repositioned q2-3 hours
IICP - nursing care, tx
what are we monitoring closely
vs, neuro,( pupils size, rx ) gcs, cpp, icp, 02 and c02 levels
posturing, any seizures
ICCP nursing care :
true or false. obtain parameters for BP from physician ( goal is SBP, gaol CPP induce HTN )
this is true
why we do give meds as a nursing care for IICP to induce HTN ?
we have to give meds to induce htn to make it higher in purpose to ensure blood flow getting to the brain cells
what type of environment do we want the pts in when they have iicp
we want them to have a quiet and dark environment - calm voice
when it comes to a pt who has an iicp what do we want them to have in terms if they are in an icu sedation
heavily sedated, meds to sedate them normal or low we want their oxygen to be high
do we want to prevent c02 from rising when they have iicp ?
yes we do, and we do this by intubating or putting them into a ventilator
what is the positioning like for a pt who has an iicp?
we want them to be atleast in a 30 degrees, neutral position
true or false. when it comes to repositioning a pt who happens to have iicp sometimes they may have central lines, or picc or monitor to drilled to the skull, ng cathether, typically it invovles 3 people or 4 when turning a pt which is usually done in the ICU.
true
monitor intracranial number - and also drain csf fluid from ventriclur into the brain
what is important is nursing care with high icp - guide out nrsing care these ppl can only hjave maybe small things done ( mouth care )
or pre medically for fentanyl or rest before we turn them ( breakuo our care ) not doing too much at the sae time ( may go up ) .
true
why is nutrition important for people who have iicp ?
nutrition is important , these people are hyper metbaollic * under alot of ftress , getting rid of calories )
what is the supportive care for pts who have iicp
tube feeds, prevent gastric ulcers, prevent problems that come with immobility ( constipation, pressure ulcers, pneumonia )
recall that it is important to maintain head in neutral position
and if wearing as aspen collar - ensure it is not too tight
what is the care for this ?
remove collar to wash
underneath and checking under skin around collar ( no pressure ulcers )
how do we want the neck to be if they have iicp
have the neck straight alignment ( venous drainage in the head, can see neck is not turned off to the side or too tight )
depending on the things to drain and normal range we want
IICP - nursing care, TX
airway/resp
oral airway
position side lying to prevent tongue from obstructing if in coma
true or false. it is important for db and c or suctioning as a airway/resp in iicp nursing care what else?
limit suctioning- 2 passes <10 sec each
02 before and after
a person who has iicp may have ng tube why ?
to relieve pressure on diaphragm
true or false. intubation and mechanical ventilation is also seen as intervetion for airway/resp on a pt who has iicp
yes this is true
IICP : NURSING CARE, TX
airway/resp
pre oxygenate these people suction their tracheostomy ( two passes and les than ten seconds each )
have nasogastric to drain and prevent vomiting ( drain whatever is in the stomach )
if bowel sounds is active , what do u do ?
icu , urgent time is done, nasal prongs, or tracheostomy and sent off to the unit
this is all true
for the question you: drainage to tube feeds
IICP - nursing care , tx
fluid and electrolyte balance
it is important to monitor amount of fluids accurately, why?
too much fluid can increase ICP
it is important to monitor electrolytes when it comes to fluid and electrolytes balance
diuretics and iv fluid can affect
recall that monitor amount of fluids accurately and monitor electrlytes is important what else is important when it comes to fluid and elctrolytes balance ?
monitor urinary output
- di
- siadh
cerebral salt washing
what does cerebral salt washing mean in terms of iicp ?
associated with cerebral injury
excessive renal sodium excretion
what electrolytes do we have to monitor closely ?
glucose, sodium , potassium , osmolality is the once we have to monitor closely ( iv fluids and diuretic safe to give ) to make sure pt is in safe level
true or false. manitol is an osmotic diuretic given IV ( decrease their iCP ) bonus how does this work ?
does it by expanding the plasma and osmotic diuretic, move fluid tissue to blood vessels
true or false. pts with high icp ( monitor serum osmolality ) having impact on their fluid balance .
true
true or false. pt have to give them salt tablets , bonus where do we give it through?
yes this is true, give them through ng , watch na , checking sodium level is important
what is typically given as meds?
iv fluids, vasopressin, or ddabp ( Desmopressin) is what is given
what does siadh produce.
result in hyponatremia, then proceeds into cerebral edma 0 checking possibilities, such as checking urine output, serum osmolality, and thinking abt dilation
IICP - Nursing care TC
nutritional therapy
what is going on here ?
IICP is an increased hyper metabolic and catabolic state (Burn lots of calories)
what route do we typically give the calorie to ?
typically a tube feed and if a ptient who has icp is quite metabollic , if its long term probably would have a peg
true or false. will require feedings to provide optimal nutrition
in terms of nutrition theraphy
true
who will be involve in this case, when it comes to nutrition therapy
dietician will be invovled
true or false. PT loc may mean they cannot eat, need feeding tube
true
is it true they cannot take pills, why is that in terms of nutrition theraphy
because their LOC means they cant swallow, or they don’t have control to protect their airway means and nutrition through a tube
true or false. Early feeding after brain injuries improve outcomes.
true
Supportive therpahy is important in terms of IICP
why is that
reduce metabolic demands as much as possible to prevent further increase in ICP
in terms of supportive theraphy what could we do ?
mouth care, and repositioning them and giving them full baths
visiting - they can visit ( do not talk loudly or music because disturb the brain ) sit their quietly
as supportive therpahy it is important to what ?
control fever, monitor for seizures
manage pain
decrease stimuli
dilatin sometimes would be administed we give narcotics like fentanyl dilantin or morphine
if they are conscious complaint of headaches and narcotic or tylenol 3
decrease stimuli - environment dark and quiet
true
recall that a fever could indicate an infection
why would we give them tylenol regularly?
to reduce fever, and potential cooling blanket if a pt has high temp and makes the brian work harder = high icp which we do not want
IICP - NURSING care, tx
body positioning
what is the HOB like ? what do we want to prevent ?
hob 30 degrees
prevent neck flexion
within the body positioning of iicp - nursing care how often do we turn them ?
turn 2 q with slow gentle movements (prevent agitation)
prevent ______ and intra-thoracic pressure ( keep body midline , NG if necessary to drain )
abdominal pressure
what do we have to decrease in terms of body positioning
decrease stimuli
in terms of iicp what do we do in terms of ICP ?
allow ICP to return to baseline in between
- necessary nursing activities
true or false. In essence the patient needs rest
true
true or false. Watch ICP tells us what do we do , soemthing for a pat or let them rest.
true
True or false keeping the HOB 30 degrees and higher is the general rule.
true
what do we want to do during body positioining ?
turning to the side , whole body ( we do not want agitation or icp )
we want to train the stomach
it is important to protect the pt from injury what do we do in terms of that ?
(confusion , agitation, seizures)
couple of weeks or so, icp monitor is taken out of their brain often times they are confused
are patients going to be heavily sedated or light sedated ( nursing care iicp )
light sedation, icu they have heavy sedation
true or false. body is waking up and trying to figure out what is happening , generally we used less restraints or soft restraints.
true
is it true that a pt is on pad side rails because we want them to be protected from injury.
yes it is true
what is the psychological care ( patients and families )
anxiety over diagnosis
competent assureed manner
short simple explanations
allow family participation in care when possible
IICP - things to AVOID
overstimulation
- noise, interventions in a short time ( bath, turning, changing sheets on bed , mouth care, suctioning ) bright lights
IICP things to avoid
flexing hips, having head turned , keeping bed flat , not treating fever, or pain
recall that : * Overstimulation –
* noise, ++interventions in a short time (bath, turning, changing sheets on bed,
mouth care, suctioning), bright lights * Flexing hips, having head turned
* Keeping bed ‘flat’
* Not treating a fever
* Not treating pain
we should avoid
what else ?
an increase in cerebral metabolism ( shivering, pain, seizures, fever ) we should avoid
IICP - treatment medications used
narcotics
edatives
in icu may use hig dose barbituate or paralytics and sedatives
what else are we going to used as treatment if they have iic
tylenol ( antipyretic )
nimodipine ( for vasospasm )
steroid ( decadron ) if has a brain tumor
why are we going to use :
* Mannitol
* Anticonvulsant
* Hypertonic saline (3%)
* Stool softener
* Antibiotics
(osmotic diuretic) – dec blood viscosity, dec cerebral edema
(dilantin) to prevent seizure
- Antibiotics – ICP monitor use strict aseptic techniques
to decrease cerebral edema we want their brain to relax
we want to give pain control and sedation
thats when they are intubated
yes this is true
vessels in the brain
because what they do is decrease inflammation - steroids only used for brain tumour not effective for other reasons that increase ICP
this is true
true or false. not uncommon for them to have insulin even if thy didnt have diabetes before steroids increase chance of bleed, hyponateremia, infection watch or those things happening
true
manitol is given through an iv what should we watch out for ?
watch out for sodium, and osmolality level when mannitol is effective urine output increases and cerebral edema can decrease , we want to make sure sodium is still safe
why is hypetonic saline given ?
draw water out of the brain tissue - improve cerebral blood flow- serum sodium level and blood pressure ( watch for fluid overload )
true or false. going right into the brain or ventricles so watch out for that .
true
Signs of ICP is increasing and the pt condition deteriorating
what is a number one sign ?
iicp is increasing and cpp is decreasing ( look at the trends )
Signs of ICP is increasing and the pt condition deteriorating
Pt is less awake , not as responsive
- loc decreasing ( change in LOC is a sensitive, early indicator )
waht does changes in LOC mean in terms of a result in signs of icp is increaisng and the pt condition is deteriorating?
changes in LOC are a result of impaired of cerebral blood flow
eyes arent opening is an early indictor of what ?
gcs is decreasing
recal that pt is less awake and not as response is a sign of icp increasing and the pt condition could be deteriorating what else?
decrease in motor function
- posturing of the patient ( decorticate, decerebrate )
pupil size increases, rx is more slow
headache, vomiting ( without nausea before ) is what ?
sign of icp increasing and pt condition deteriorating
true or false. seizure and change body temp could indicate a sign of icp and pt condition deteriorating
yes this is true
change in vs - cushings triad is a sign of icp is increasing and the pt condition deteriorating
yes this is true
signs of icp is increasing and the pt condition deteriorating ( hint talk abt vs )
Increase SBP, wide pulse pressure, bradycardia with full bounding pulse, irreg resp pattern
true or false. change in body temp - pressure puts on the brain
true
measure and compare pupil size and reaction, which nerve ?
cranial nerve III
posturing and what it means : what is decerebrate and decorticate postures
decorticate is less serious than decerebrate
what is this describing : means damages to upper brains stem
this is the most serious one
decerebrate
craniotomy - bone flap removal
safety - turning and helmut
you can see where the scar is
ng tube placeed in and concave part
cerebral edema has decreased now
during the craniotomy bone flap is removed , what does this mean
has been removed, goes many weeks to decrease and let the patient recover safety is the biggest thing here
true or false. do we turn our craniotomy patients?
nah bruh
we should have them laying in bed ( working on physio assessment make sure they will not hurt the brain several weeks or so go back to the to the or back into the skull
true
what is a complication of uncontrolled IICP
inadequate cerebral perfusion ( low cpp )
cerebral herniation - brain is so tight and squeezed that it displaces moves where it shouldnt
recall that : Complication of Uncontrolled, IICP
* Inadequate cerebral perfusion (low CPP)
* Cerebral herniation – brain is so “tight” and squeezed that it displaces
– moves where it shouldn’t
what else ?
see cushing triad - terminal
* if brain pushes/herniates lateral & downward – thru foramen magnum
* this compresses medulla, often fatal
brain death criteria
coma
absense of brian stem reflexes
apnea
these pts are potential organ donors
brain dead is very diff than vegetative state
1) the pt is not breathing , what is causing this ?
2) it is irreversibly destroyed
potential organ doners
waht happens here
drug overdsoe - hypoxci for a long time
lead to sustain life or potential organ donors
3) brian dead is vegetaiv e- brain dad in icu on life support making diagnosis is done by two doctors
secpfic criteria that needs to be met
4) apnea coma no brain stems activiteis
usualyl these tests are done y the bedisde with no family presetn
who are not organ donors - care facilities or usually wheelchairs , very different outcome but both hard for patients famly
hgiher aprt of the brain for volutnary movment ( is not working anymore )
is because of a sefvere head injury
what is increased intracranial pressure ( IICP ) ?
brain is in a closed box ( skull )
true or false. if brain size increases from inflammation, infeciton, or bleeding there is very limited space for welling, causing IICP
bonus what do we refer to this
this is true
we refer to it as cerebral edema
what is a primary injury ?
what is a secondary injury ?
primary injury happens at the time of the injury
secondary injury happens several hrs to days after injury
IICP is generally an issue that needs to be treated for how long ? maybe even ?
for several days, maybe even 2 weeks
brain is in a closed box ( skull ) increased in intracranial pressure
may induce what ?
may induce coma in patient ( coma is GCS <8)
what is a normal ICP ?
<15 , higher than 20 mmHg increase the risk of ischemia and infraction resulting in brain damage
normal CPP is what ?
60-80 mmHg
what is the major complications of uncontrolled IICP ?
inadequate cerebral perfusion ( low CPP )
cerebral herniation
what is a cerebral perfusion ?
blood flow to and into the brain( if inadequate causes brain damage )
what is cerebral herniation
this is where the brain is squeezed so hard - pushes into the brain steam
what does the brain steam deals with ?
deals with resp, motor, cardiac function of the body
our issue is trying to control that edema
with these pts that have major head injuries usually treated with _____ or ____ and hospitals for several days to weeks to icu
surgical icu is where they would go ( icu doctors and neurology or neur surgery doctors )
surgery or meds
true or false.if icp is really high is induced a coma in a pat ( gcs is less than 8 ) might give them drugs to be unconciousness - wants to relax their brain
true
phenomenon that happens in the brain
brain is a closed block and if that brain tissues increases , why does it causes problem ?
( it really causes problem , no room for swelling )
squeezing that brain
causes cerebral edema - iicp is increased
when we are caring for patients who have major complications of uncontrolled iicp such as inadequate cerebral perfusion and cerebral herniation what is our goal of care?
iicp and cpp and even blood pressure
mantain icp less than 20 or less than 22 meaning that our goal as nurses is to admin med to get it to that goal
true or false.we have to time the perio for the pt to rest ( giving bath, oral care, physio, those thing can raise icp ) we do not want that icp and cpp are important.
true
recall that the body tries to compensate for iicp but can only manage for so long
what are the 3 major components try to compensate
brain tissue
blood
csf
what undergoes brain tissue
and blood when trying to compensate
brain tissue - distention of dura and compression of tissue
blood - vasoconstriction of cerebral vessels. this leads to a decrease in perfusion thru the brain ( decrease in cerebral perfusion pressure CPP)
what undergoes csf as ur body tries to compensate for iicp
csf
- production slows down
-displaced to spinal column
monitoring icp, cpp ( constantly shown on the monitor ) and doing neuro checks ourselves on the pt
as nurses what are we thinking abt when it comes to the body trying to compensate for iicp but can only manage for so long
the whole time we are thinking of the brain getting compressed the body not being able to compensate
we worry about the brain damage
brain damage when the blood is getting constricted ( constriction for cerebral vessels not getting perfusion again ) lead to brain damage
circulation in brain
what does the brain need ?
brain needs alot of oxygenated blood ( alot of arteries )
alot of vessels that can burst if there is a stroke of increase in icp
if someone has an aneurysm and stoke - a couple of test is what exact artery is causing a problem document and have direct care. is this true or false
this is true
recall that when someone has a head injury or stroke, it can impact their body and life
motor activity that why stroke or cerebral palsy have problems with what ?
moving, parietal , discriminatory, areas of smell and senses or memory
other factors that increase icp
certain things cause the cerebral vessels to dilate so avoid these
increased paco2
decreased in pa02 ( <50)
elevated H+ concentration ( lactic acid released from low Pa02 causing anaerobic metabolism )
what must nurse monitor ? when it comes to other factors that increase icp
nurse must monitor c02 levels and oxygen levels
ABGs
what is key ?
respiratory assessment is key because of the large impact the 02 and c02 have on the brain
- constant 02 sat monitoring or often
asses rr and depth of breaths and keep Pac02 normal, keep Pac02 normal or slightly decreaed
this is important when it comes to toehr factors that increase icp resp assesment is key
true
there is also things that can cause cerebral vessels to dilate, which is very clearly linked to where?
very clearly linked to resp system , looking at the assesments for resp is important
sats, oxy, is important ( certain things cuases dialte vessels , which can increase icp )
true or false. we want to make sure oxy sats, resp rate, oxygen level normal and not hypoxic.
true
true or false. CO2 must be normal or slightly decrease
true
note that their breathing problems are well ( they can start developing what ? )
snoring patterns, tongue falling back, decrease oxygen levels, increase c02 level icp is even increased )
lactic acid levels lead to what?
anaerobic organism
neurological assessment record
cranial nerves
Olfactory
Optic
Oculumotor
Trochealr
Trigimenal
Facial
Abducens
Glossopharync
Vagus
Accesory
Hypoglossal
what are the neurological assesment record
cranial nerves table
loc- glasglow coma scale
3 areas of focus :
1) eye opening
2) best verbal response
3) best motor response
pupils
- perl ( pupil. equal, reactive to light)
VS ( cushing triad ) could also be seen as a neurological assesment record
widening pulse pressure, bradycardia, irreg resps
limb movement is a part of neurological assessment record
measure strength in limbs
is it equal right vs left
note if a pt posturing decorticate or decorate
we are doing it in detailed
lookin at LOC
GCS scale this stuff is important this is where we are assesing the pupil ( ocular motor never or cranial nerve III )
non reactive or sluggish - not normal
is this true or false.
true
it means med emergency that indicated brain stem is being compressed ( no way of saving ) see these things
(Cushing triad )
body temp- Cushing triad is actually pushing on hypothalamus in which is impacts body temperature
yes this is true
with us on the hispital - icu or step down
if there is a step down unit - go about every ___ hours
neuro unit - stable enough to do it every ___ to ___ hours
how often are we checking their pupils
4
4 to 5 hours
limb assesment, when we are doing neuro assesment
looking at strength and libs and equal are they able to move this is crucial
yes this is crucial
which positioning is the worst ?
decorticate or decerebrate
decerebrate is the worst icp is high and pressure on the brain stem
dialted pupil indicates what ?
compressed cranial nerve III
bilateral dilated fixed pupils is what ?
ominious sign
this is important : what is the size of them benzos or sedatives ( dilated of pupil is very bad sign, what could happen dialted pupil could be dead and not rectice to light )
both piupuils are large ( sign )
no reactions to liught if dialted
yes this is important
diagnostic tests - common in neuro
what undergoes xray
ct/brain/head
cerebral angiogram
xray - skull or facial bone fractures
ct brain/head- done initially and then repeated in 24-48 hours and again if further pt decline ( clinical findings such as decreased loc or increased in icp )
are these typically diagnostic tests common in neuro
cerebral angiogram
eeg-brain waves
lp
yes
cerebral angiogram - clot-anerurysm , perfusion to brain
eeg-brain waves seiure
lp-obtain csf ( infection/blood )
transcranial doppler - vasospasm
skull and facial xray
head injury may have facial fractures safety ! ng insertion:
a crap in their skull ( safety aspect ) — we do not stop and think could us doing this could do harm
this is a pt who had a ng tube inserted ( shouldnt have ng insrted ) they had facila structure
incteas of turning around wen ip to their brain
think abt pts who had serious head injuries, other injuries in their bdy, nose fractures, cheekbones can be seen with nerious head injury ( assault etc )
yes
think abt status of their airway , airway clear, safe to put it on ng
any tohe fracture in their face
may do this in operating room or under endoscopy
yes this is true
ct scan
brain tumor
whole brain will shift over
we need to go to the oeprating room and get some pressure off
ct of right and left side should be equal
what does epidural hematoma look like in a ct scan ?
epidural hematoma here is being squeezed and push over - high icp
are common in pts like these
could give good look in their brain
diagnose of what has happened repeated fter surgery has been done
if pt didnt needs surgery ( redo ct san from 24 hours ) is edema worst or better?
any tye of bleeding o hemtaoma allows us to see how cereblra edem is occuring
epidural hematoma and subdural hematoma
true
cerebral angiogram
looking at the vessels in the brain, tells us about aneurysm and strokes
is this clotted off or spontaneous bleed or prominent injury
cerebral angiogram some questions u should ask urself
stop perfusion in the brain , what it does is help perufisonm, and very bagiue of the idea m
what defecients they would have ?
eeg- brain waves, bran activity - identify seizure
eeg - non invasive looking at brain waves or brain injury
head injury is a high risk of seizure
they can have this in pt to have subclinical ( not twitching or moving caution )
cap and electordes monitoring that and seinding monitor
yes for brain waves. eeg
interesting with ppl with ehad inkuries ( iritaed of the bed ) epilepsy but brain is irritiated now the can have them
smetmes we give prhatically from seizure happening
could be brain damage afterwards abt the seizure
yes this si true
why do we do a lumbar puncture
they get a sample look for sample and see if there is any blood of it
type of meningitis
colourless and contain only a free cell
should not have any blood in the sample ( more investigatio should be done ) position them on their sde and curl over there bef and lead over bedisde table this helpscurl voer their back seprate vertebrae at the back
yes this si true
lumbar puncture :
l3 to l4 get a csf and tell the patient any shotting or tingiling apain
this si quite upsetting so may requrie anagexsic medication
afte needle is removed put pressure and bandaid strip[
bed rest adn remain flat would not be up going home or up ing eneral
csf leak let the dr know if they get a headache give tylenol and if the analgesic doesnt improve afte tylenol could indicste a leak call the doctor
check the dressing and if itd doesnt stay dry - asses for headache
yes this si true
what is transcranial doppler
vasospasm of intracerebral arteries
velocity of blood flow
what is transcranial doppler
( what are the assesments )
decrease gcs, increse icp, not as awake as before
whre is transcranial doopler done ?
done at the bedside
non invasive and cheap
usually done by repeated every other day or daily lookking at it
look at the peed of blood flow through extra cerrebral arteries ( byt eh forehead )
we do that because major head injuries or stroke can be at risk fo vasospams ( iriiated , has blood where there shouldnt be )
true
whe cerebral whe n a cerebrla pefusion shunt - spasm is an intesne closing of teh large
conducting arteries in subarchnoid spcar 9 where the clot is ) brain trissues is not getting perufsed and can get brain damage
intracranial regulation what are the common meds
what is the purpose
decrease cerebral edema, slow brain metabolism, prophylactically treat anything that can further increase ICP
recall that common meds :decrease cerebral edema, slow brain metabolism, prophylactically treat anything that can further increase ICP
prevent complications from immobility, supportive care (protein powder, tube feed)
common meds in intracranial regulation
- Opioids – fentanyl p920
- Sedatives – versed, propofol p920
- Anticonvulsant/antiseizure Box 39.2
- Antipyretic
- Corticosteroids (brain tumors only, not for diffuse cerebral edema) p923
common meds since :
recall : Opioids – fentanyl p920
* Sedatives – versed, propofol p920
*Anticonvulsant/antiseizure Box 39.2
* Antipyretic
* Corticosteroids (brain tumors only, not for diffuse cerebral edema) p923
what else :
- Hi-dose barbiturates, paralytics (in ICU only, severe IICP)
- Mannitol – osmotic diuretic p919
- Hypertonic saline (3%)
- H2-receptor blocker, PPI (prevent gastric ulcer/bleeding)
- Stool softeners
coma is immobile 0 pressure ulcer weh a. pat is in a coma blood clots, penumonia
neuro is a lot of meds we can give and give a huge affect on pt and help them
variety reasons can slow down metabolsima dn chill out
yes this is true
what are exemplars of peds neuro
seizure disorders- concept of intracranial regulation
cerebral palsy- concept mobility
seizure disorders
this is caused by
caused by excessive and disorderly neuronal discharges in the brain
seizure disorders are determined by what ?
site of origin
seizure what is the msot common
treatable neurological disorder in children
seizure disorders occur with what ?
occur with wide variety of cns conditions
seizure disorders
epilepsys
caused by
optimal treatment
- Two or more unprovoked seizures
- Caused by a variety of pathological processes in the brain
- Optimal treatment and prognosis require an accurate diagnosis and determination of cause
depending what lead up tot eh seizure happening
seizure disorders
epilepsys is only 1 percent canadian has it
true
most common one in children is febrile seizure more of because of high fever and doesnt ahppen repeatedly is this true or false.
this is true
true or false. 50 percent of chilren who has epilepsy seziure actually diaapear completely
true
seizure disorders
etiology
acute symptomatic
remote symptomatic
cryptogenic
idiopathic
acute symptomatic
remote symptomatic
cryptogenic
idiopathic
etiology of seziure diroders describe some dsescirption
head injury or meningitis
caused by prior brain damage ( encephalitis, stroke, meningitis )
no clear cause
genetic origin
seizure classificiation and clinical manifestation
focal partial sezirues
geenralize seizures
unknown onset seizures
focal partial seizures
generalized seizures
local onset ( invovles small location or small area of the brain )
generalized seizures - both hemisphere without focal onset ( more arwas of brain invovle )
seizure disorders
therapeutic manae,nt
the goal is to control seziures or reduce their fruqnyc and severity
discover and correct he cause
dwhat is the mamagement for seizure disorders
medication theraphy
ketogenic diet
vagus nerve stimulation
surgical therpahy
In hospital immediate medication given for seizure is IV Ativan (Lorazepam)
yes for seizure
just read this but understand it : parts of management medication is antipeleptic or antivconulsatn
implemented by some people and thats a high fat, low fat and adequate protein diet
children needed for vitamin and mineral supplements as well
where they do a programable sikcle genrator in the chest ( skin panted ) and elctrical is vagus nerve ( cranial nerve 10 ) when deleivered decrease seizure from happening again ( onset of sezirue ) biggest nerve stimulation
]this is more caused by scan ( brian tumor, hemtoma ) cranial surgery to remove that and remove the seizure or if refractural sezirue ( not being ammaged 0 remove opart of the brain or conection between the areas hwere seizure is happening
yes
what is febrile seizures
when a child has a fever
what is this describing : transient disorder of childhood
febrile seizures
what is the frequency of febrile seizures
usual age range they occur ?
this happens to 5 percent of children usually occur in 5 months to 5 years
what is the cause of febrile seizures
cause is uncertain once again associated with high fever
what is a tepid sponge bath and is it serious and how does this correlate to febrile seizures?
type of sponge bath can be done ( coolish can be done ) dripping the towel
helps bring down the temp and not serious this type of bath is a bath 37 degrees warm water
and cool water and then put the child in and try to cool them down
seizure disorders
management of seizures
what to do
protect the child from hurting themselves what we would do by hitting their head
may sure to sit or lay so they do not fall
if wearing glasses remove them
throw up - turn them to the side so they do not aspirate
what is a big thing with seizure disorders we have to do as nurses
big thing is we observe and time when the seizures starts and what time it is admitted and the length of the seizure
what do we not what to do with seziure disorders with pediatrics
we do not want to restrain them ( no hugging/no holdin g)
table remove, we do not put anything in their mouth
do not pull tongue, reocvery position will not close their airway
seizure precautoions in the hospitals for peds
in the hispital things like sideways up, medical alery bracelet , learning precuations of seziures, possiblity a helmet, or padded a helmet to cover their head
are these true in terms of seizure disorders : we do not want them to be walking and fall themselves
if they ar eliving at home making sur ethey are having a shower or a bath clos supervisiin - do not drown ensure other parents are aware , biking is also provision needed for guidelines
yes this is true
true or false . there is a computer and what do we look at here in terms of someone who had a seizure
done looking at the electrical activities( brain waves ) electrodes pasted on and here is the tech watching ( brain waves interpret in any serious activities )
what is cerebral palsy ?
a group of disorders that affect a persons ability to move and maintain balance and psoture
what is this describing : issues with mobility and balance - impaired movement
cerebral palsy
___ is the most common motor disability in childhood
CP
what does cerebral means
having to do with the brain
what does palsy mean
means weakness or pbpelms with using the muscles
cerebral palsy
causes impaired movement associated with
exaggerated reflexes, floppiness or spasticity of the limbs and trunks
true or false. unusual posture, involuntary movements, unsteady walking or some combination fo these are causes impaired movement with cerebral palsy.
this is true
is cerebra palsy a from of autism
it affects how the bran and muscles communicates but it is not a form of autism
true or false cerebral palsy is prpgressive.
false, it is not progressive it does not worsen overtime
may need changes or adjustments with meds to help with their muscles problems but not progressive
a significant numbers of ptietn who have cp have ______
- about 30 to 50 percent of pts have what ?
epilepsy
imapiment and issues with vision, speech and hearing
true or false. with cerebral palsy think about mobility and the tools they need such as wheelchair , may have spasms ( cna slip out of wheelchair ) different ways to support these kids , independent an as invovle in life as possible
true
cerebral palsy goals in pt’s care
early recognition and optimize the pts development child to grow up and autonomy
theraphy/interventions ( preventative and symptomatic efforts)
rehabilitation- pt, ot, speech therapy
meds- muscle relaxants ( baclofen )
analgesia, meds to tx comorbid conditions ( e.g antileptic meds )
botulism toxin injections
recall that for cerebral palsy therpahy/interventions :
* Rehabilitation – PT, OT, Speech therapy
- Medications – muscle relaxants (baclofen), analgesic, meds to tx comorbid conditions (e.g. antileptic meds), botulism toxin injections
what else ?
- Neurosurgical - selective dorsal rhizotomy, intrathecal baclofen pump
- Orthopedic – monitor, surgery
relaxation of some muscles
we would do something cutting problematic nerves in spainl cord, we have this pump inserted and delievers baclofen to what ?
otho- surgery why ?
decrease muscle spasm
surgery or any other type of bone issues to make them not as mobile ( they deal with that in surgery )
cerebral palsy why is nutrition/feeding important
- Child growing – energy expenditures, frequent rest periods * Feeding & swallowing – may need gastrostomy tube
nutrtion 0- needd minerals and vitamins - spends less energy frequent rest periods
explain this and correlate it to cerebral palsy
because of their jaw and tightness they get in there aw
often have their pyscholosis ) may trouble for vimitting and swallowing )
dental care is important when it comes to cerebral palsy why is this important ?
regular brushing and flossing
( bruxism )
meds that affect dental health
what is bruxism
dental care these children have teeth grinding ( bruxism and teeth clenching ) - hard to brush their teeth
antiepilelptics- affects dental
often times dental care ( have to be quie sedated., orgenral anesthethic ) so joints are relax
yes this is true
what is additional health issue commonly seen in cerebral palsy
GI
GU
RESP
SKIN
explain how these system are :
GI
GU
RESP
SKIN
constipation and gerd ( reflex )
poor bladder control lead to infections
chronic resp are aspiration pneumonia
might be related to positioning ( contractures, pressure sores, and dryness )
- not getting good nutrition could lead to problems with their skin
cerebral palsy : generally at home ( alot of appoitnments ) make sure immunizations is required
true
30 to 70 years of age , mild to mod invovlement 85% capability in ambulation from ages 2 to 7
less evere the greater their abiity can lead to healthy life
cerebral palsy : just read
life expectancy and cause of death for cerebral palsy ?
A severe cerebral palsy with severe mobility impairment and feeding difficulties.
Those are patients that often die because of a respiratory tract infection in childhood. And usually it’s something like aspiration pneumonia
Um, survivals influenced by the existing core morbidities that the child has.
