Nursing Management of the Adult Client with Neurologic Alterations NURS 228 Janie Best, MSN, RN, APRN, BC
Objectives <ul><li>Relate principles of anatomy and physiology to the nursing care of individuals with common health probl...
The Nervous System <ul><li>Central Nervous System (CNS) </li></ul><ul><ul><li>Brain </li></ul></ul><ul><ul><li>Spinal Cord...
Anatomy <ul><li>Brain </li></ul><ul><ul><li>Cerebrum </li></ul></ul><ul><ul><ul><li>Hemispheres </li></ul></ul></ul><ul><u...
 
Anatomy <ul><li>Protective Structures </li></ul><ul><ul><li>Dura mater </li></ul></ul><ul><ul><li>Arachnoid </li></ul></ul...
Brain Requirements <ul><li>Blood Flow </li></ul><ul><ul><li>750 ml / minute </li></ul></ul><ul><ul><li>20% of total oxygen...
Diagnostic Studies <ul><li>Skull and Spine Radiography </li></ul><ul><li>CT (Computerized Tomography) </li></ul><ul><li>MR...
Diagnostic Studies –  Cerebral Angiography <ul><li>Pre-procedure care  </li></ul><ul><ul><li>Assess for allergy to iodine ...
Diagnostic Studies –  Myelography / Lumbar Puncture <ul><li>Post Procedure Care </li></ul><ul><ul><li>HOB > 30 0  – 45 0  ...
Neurological Assessment <ul><li>Hx present illness </li></ul><ul><ul><li>A  – associated symptoms </li></ul></ul><ul><ul><...
Neurological Assessment <ul><li>Physical Exam </li></ul><ul><ul><li>Mental status  </li></ul></ul><ul><ul><li>Cranial Nerv...
 
Abnormal Findings <ul><li>Babinski Reflex </li></ul><ul><ul><li>CNS disease of pyramidal tract </li></ul></ul><ul><li>Clon...
Abnormal Findings <ul><li>Battle’s sign </li></ul><ul><li>Raccoon’s eye </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Oto...
<ul><li>Doll’s Eyes - Oculocephalic Reflex </li></ul>http:// connection.lww.com/Products/morton/documents/images/Ch33/jpg/...
 
No motor tone or function, limp   Cerebellar function Flacid posturing Extension & external rotation of arms & wrists, ext...
Altered LOC - Etiology <ul><li>Vowel   </li></ul><ul><li>A lcohol </li></ul><ul><li>E pilepsy </li></ul><ul><li>I nsulin <...
Altered LOC <ul><li>Arousal </li></ul><ul><ul><li>Alertness, response to stimuli </li></ul></ul><ul><li>Content </li></ul>...
Altered LOC <ul><li>Level of Consciousness </li></ul><ul><ul><li>Continuum </li></ul></ul><ul><ul><li>Terminology </li></u...
Glasgow Coma Scale <ul><li>Best Eye-opening response </li></ul><ul><ul><li>1 = no response </li></ul></ul><ul><ul><li>4 = ...
Assessment of Respirations <ul><li>Cheyne-Stokes </li></ul><ul><ul><li>Rhythmical pattern:  waxing/ waning in depth, follo...
Assessment of other Vital Signs Spinal shock Metabolic coma Drug overdose Brainstem lesions Decrease Temperature CNS infec...
Assessment of other Vital Signs Cerebral trauma – Cushing’s triad HTN Blood Pressure Poor cerebral oxygenation Late stages...
Brain Death <ul><li>Persistent vegetative state </li></ul><ul><li>Brain death </li></ul><ul><ul><li>Rule out  </li></ul></...
Altered LOC <ul><li>Nursing Interventions </li></ul><ul><ul><li>Airway maintenance </li></ul></ul><ul><ul><li>Fluid balanc...
Altered LOC <ul><li>Nursing Interventions </li></ul><ul><ul><li>Sensory stimulation </li></ul></ul><ul><ul><li>Family need...
Intracranial Pressure (ICP) <ul><li>Pressure exerted by the combined volume of </li></ul><ul><ul><li>Brain tissue </li></u...
Intracranial Pressure (ICP) <ul><li>Closed Box </li></ul><ul><ul><li>Brain tissue (80%) </li></ul></ul><ul><ul><li>Blood (...
Intracranial Pressure (ICP) <ul><li>Compensation: </li></ul><ul><li>Monro-Kellie  Hypothesis </li></ul><ul><ul><li>Change ...
Intracranial Pressure (ICP) <ul><li>Brain volume  – limited expansion; controlled by Blood – brain barrier </li></ul><ul><...
Blood-Brain Barrier <ul><li>Permeable to water, oxygen, CO 2 , other gases, glucose and lipid soluble compounds </li></ul>...
Cerebral Blood Flow / Volume <ul><li>Increased Flow / volume: </li></ul><ul><li>Effects </li></ul><ul><ul><li>Systemic hyp...
↑  Brain Volume <ul><li>Cause: </li></ul><ul><ul><li>Space – occupying lesions </li></ul></ul><ul><ul><li>Cerebral edema <...
Cerebrospinal Fluid <ul><li>Functions </li></ul><ul><ul><li>Support / cushioning </li></ul></ul><ul><ul><li>Maintain stabl...
Intracranial Pressure (ICP) <ul><li>Compensation depends on </li></ul><ul><ul><li>Location of lesion </li></ul></ul><ul><u...
Cycle of malignant progressive brain swelling ↑  ICP    Cerebral brain flow Tissue hypoxia ↑  pCO 2    pH Cerebral vasod...
IICP <ul><li>CPP (Cerebral Perfusion Pressure) </li></ul><ul><ul><li>CPP = MAP – ICP </li></ul></ul><ul><ul><li>Normal CPP...
IICP <ul><li>Cushing’s Triad </li></ul><ul><ul><li>↑  systolic blood pressure </li></ul></ul><ul><ul><li>   diastolic blo...
 
IICP <ul><li>Early Indicators </li></ul><ul><ul><li>∆ LOC ( earliest indicator ) </li></ul></ul><ul><ul><li>Slowing of spe...
IICP <ul><li>Later Indicators </li></ul><ul><ul><li>Continued deterioration of LOC </li></ul></ul><ul><ul><li>Pulse, Respi...
 
IICP - Complications <ul><li>Cerebral Herniation </li></ul><ul><li>DI (Diabetes Insipidus) - ↓ secretion ADH </li></ul><ul...
IICP – Complications DI <ul><li>DI (Diabetes Insipidus) - ↓ secretion ADH </li></ul><ul><ul><li>Clinical manifestations </...
IICP – Complications - DI <ul><li>Treatment </li></ul><ul><ul><li>Fluid and electrolyte management </li></ul></ul><ul><ul>...
IICP – Complications - SIADH <ul><li>SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) –  </li></ul><ul><l...
IICP – Complications - SIADH <ul><li>Clinical manifestations </li></ul><ul><ul><ul><li>Water retention -> water intoxicati...
IICP – Complications - SIADH <ul><li>Treatment </li></ul><ul><ul><li>Treat underlying disease </li></ul></ul><ul><ul><li>A...
IICP – Medical Management <ul><li>Goals </li></ul><ul><ul><li>Decreasing Cerebral Edema </li></ul></ul><ul><ul><li>Lowerin...
IICP – Medical Management <ul><li>Neuro Exam </li></ul><ul><li>Ventriculostomy </li></ul><ul><ul><li>ICP monitoring </li><...
<ul><li>AVOID Lumbar Puncture in IICP </li></ul><ul><ul><li>Risk of:  </li></ul></ul><ul><ul><ul><li>Herniation of brainst...
IICP – Medical Management <ul><li>Medications </li></ul><ul><ul><li>Osmotic diuretics (cerebral edema reduction) </li></ul...
Osmotic Diuretics <ul><li>Mannitol </li></ul><ul><ul><li>Increases cerebral tissue perfusion and reduces ICP </li></ul></u...
 
IICP – Nursing Diagnoses <ul><li>Ineffective cerebral tissue perfusion </li></ul><ul><li>Ineffective airway clearance </li...
IICP <ul><li>Planning and Goals </li></ul><ul><ul><li>Maintain patent airway </li></ul></ul><ul><ul><li>Adequate breathing...
IICP – Expected Outcomes <ul><li>Maintain patent airway </li></ul><ul><li>Attain optimal breathing pattern </li></ul><ul><...
Critical Thinking Case Study <ul><li>Chapter 6: Case Study 15, pp. 395-398. </li></ul>
References <ul><li>Deglin, J.H., Vallerand, A.H.  (2005).  Davis’s Drug Guide for Nurses, 10 th  Ed. Philadelphia.  F.A. D...
References <ul><li>LeMone, P., Burke, K. (2008).  Medical Surgical Nursing: Critical thinking in client care.  Pearson Edu...
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NurseReview.Org - Nursing Management of the Adult Client with Neurologic Alterations

  1. 1. Nursing Management of the Adult Client with Neurologic Alterations NURS 228 Janie Best, MSN, RN, APRN, BC
  2. 2. Objectives <ul><li>Relate principles of anatomy and physiology to the nursing care of individuals with common health problems of the nervous system. </li></ul><ul><li>Analyze the common health problems that accompany alterations in cerebral circulation in the adult patient </li></ul><ul><ul><li>Altered Level of consciousness (LOC) </li></ul></ul><ul><ul><li>Increased intracranial pressure </li></ul></ul>
  3. 3. The Nervous System <ul><li>Central Nervous System (CNS) </li></ul><ul><ul><li>Brain </li></ul></ul><ul><ul><li>Spinal Cord </li></ul></ul><ul><li>Peripheral Nervous System (PNS) </li></ul><ul><ul><li>Cranial nerves </li></ul></ul><ul><ul><li>Spinal nerves </li></ul></ul><ul><li>Autonomic nervous system </li></ul><ul><ul><li>Sympathetic </li></ul></ul><ul><ul><li>Parasympathetic </li></ul></ul>
  4. 4. Anatomy <ul><li>Brain </li></ul><ul><ul><li>Cerebrum </li></ul></ul><ul><ul><ul><li>Hemispheres </li></ul></ul></ul><ul><ul><ul><ul><li>Lobes: Frontal, Parietal, Temporal, Occiptial </li></ul></ul></ul></ul><ul><ul><ul><li>Thalamus, Hypothalamus, Basal ganglia </li></ul></ul></ul><ul><li>Cerebellum </li></ul><ul><li>Brain Stem </li></ul>
  5. 6. Anatomy <ul><li>Protective Structures </li></ul><ul><ul><li>Dura mater </li></ul></ul><ul><ul><li>Arachnoid </li></ul></ul><ul><ul><li>Pia mater </li></ul></ul><ul><li>CSF </li></ul><ul><ul><li>Clear, colorless </li></ul></ul><ul><ul><li>Produced by choroid plexus (ventricles/arachnoid layer) </li></ul></ul><ul><ul><li>500 mL daily; Most absorbed by body </li></ul></ul>
  6. 7. Brain Requirements <ul><li>Blood Flow </li></ul><ul><ul><li>750 ml / minute </li></ul></ul><ul><ul><li>20% of total oxygen uptake </li></ul></ul><ul><li>Glucose </li></ul><ul><ul><li>80% of body’s glucose use </li></ul></ul><ul><li>Blood Flow Regulation </li></ul><ul><ul><li>CO 2 </li></ul></ul><ul><li>Oxygen </li></ul>
  7. 8. Diagnostic Studies <ul><li>Skull and Spine Radiography </li></ul><ul><li>CT (Computerized Tomography) </li></ul><ul><li>MRI (Magnetic Resonance Imaging) </li></ul><ul><li>PET (Positron Emission Tomography) </li></ul><ul><li>EEG (Electroencephalogram) </li></ul><ul><li>EMG (Electromyography) </li></ul>
  8. 9. Diagnostic Studies – Cerebral Angiography <ul><li>Pre-procedure care </li></ul><ul><ul><li>Assess for allergy to iodine and shellfish </li></ul></ul><ul><ul><li>NPO 4-6 hrs </li></ul></ul><ul><ul><li>Baseline neuro assessment </li></ul></ul><ul><ul><li>Education </li></ul></ul><ul><ul><ul><li>Immobile during / following procedure </li></ul></ul></ul><ul><ul><ul><li>Expect brief feeling of warmth / burning in behind eyes, or in jaw, teeth, tongue, lips </li></ul></ul></ul><ul><ul><ul><li>May have metallic taste </li></ul></ul></ul><ul><li>Post Procedure Care </li></ul><ul><ul><li>Bedrest x 8 hrs </li></ul></ul><ul><ul><li>Increase Fluids </li></ul></ul><ul><ul><li>Monitor </li></ul></ul><ul><ul><ul><li>Neuro assessment / VS </li></ul></ul></ul><ul><ul><ul><li>Peripheral pulses </li></ul></ul></ul><ul><ul><li>Observe </li></ul></ul><ul><ul><ul><li>for s/s altered cerebral blood flow </li></ul></ul></ul><ul><ul><ul><li>Hematoma at femoral injection site </li></ul></ul></ul><ul><ul><li>Keep bed FLAT if femoral artery is used </li></ul></ul>
  9. 10. Diagnostic Studies – Myelography / Lumbar Puncture <ul><li>Post Procedure Care </li></ul><ul><ul><li>HOB > 30 0 – 45 0 for 3 – 8 hrs </li></ul></ul><ul><ul><li>Drink plenty of fluids </li></ul></ul><ul><ul><li>Monitor VS and Urinary output </li></ul></ul><ul><li>Pre Procedure Care </li></ul><ul><ul><li>NPO </li></ul></ul><ul><ul><li>Sedative may be given </li></ul></ul><ul><ul><li>Lateral recumbent position with knees drawn up to abdomen and chin onto chest </li></ul></ul><ul><ul><li>Patient Ed. - Position of x-ray table may be changed during procedure </li></ul></ul>LP is contraindicated if suspected IICP
  10. 11. Neurological Assessment <ul><li>Hx present illness </li></ul><ul><ul><li>A – associated symptoms </li></ul></ul><ul><ul><li>P – what provokes / pallliates symptoms </li></ul></ul><ul><ul><li>Q – Quality of pain </li></ul></ul><ul><ul><li>R – region and radiation </li></ul></ul><ul><ul><li>S – severity of pain on scale of 1-10 </li></ul></ul><ul><ul><li>T – timing </li></ul></ul><ul><ul><li>(start / stop, intermittent, constant) </li></ul></ul>
  11. 12. Neurological Assessment <ul><li>Physical Exam </li></ul><ul><ul><li>Mental status </li></ul></ul><ul><ul><li>Cranial Nerves </li></ul></ul><ul><ul><li>Motor system </li></ul></ul><ul><ul><li>Cerebellar - balance / coordination </li></ul></ul><ul><ul><li>Sensory system </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul>
  12. 14. Abnormal Findings <ul><li>Babinski Reflex </li></ul><ul><ul><li>CNS disease of pyramidal tract </li></ul></ul><ul><li>Clonus </li></ul><ul><ul><li>Hyperactive reflexes </li></ul></ul><ul><li>Corneal reflex </li></ul><ul><ul><li>Loss - dysfunction of Cranial nerve 5 </li></ul></ul><ul><li>Gag reflex </li></ul><ul><ul><li>Loss - Dysfunction of cranial nerves IX and X </li></ul></ul>Text: 1839-1840
  13. 15. Abnormal Findings <ul><li>Battle’s sign </li></ul><ul><li>Raccoon’s eye </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Otorrhea </li></ul>
  14. 16. <ul><li>Doll’s Eyes - Oculocephalic Reflex </li></ul>http:// connection.lww.com/Products/morton/documents/images/Ch33/jpg/Ch33-006B.jpg
  15. 18. No motor tone or function, limp Cerebellar function Flacid posturing Extension & external rotation of arms & wrists, extension, plantar flexion, internal rotation of feet Cerebellar function Decerebrate posturing Internal rotation of arms &wrists, extension, internal rotation & plantar flexion of the feet Cerebellar function Decorticate posturing Eyes fail to follow normal movements Brainstem Doll’s eyes
  16. 19. Altered LOC - Etiology <ul><li>Vowel </li></ul><ul><li>A lcohol </li></ul><ul><li>E pilepsy </li></ul><ul><li>I nsulin </li></ul><ul><li>O piates </li></ul><ul><li>U rates (renal failure) </li></ul><ul><li>TIPPS </li></ul><ul><li>T rauma </li></ul><ul><li>I nfection </li></ul><ul><li>P sych </li></ul><ul><li>P oisons </li></ul><ul><li>S hock </li></ul>
  17. 20. Altered LOC <ul><li>Arousal </li></ul><ul><ul><li>Alertness, response to stimuli </li></ul></ul><ul><li>Content </li></ul><ul><ul><li>Awareness of time, place, person </li></ul></ul>
  18. 21. Altered LOC <ul><li>Level of Consciousness </li></ul><ul><ul><li>Continuum </li></ul></ul><ul><ul><li>Terminology </li></ul></ul><ul><ul><ul><li>Alert </li></ul></ul></ul><ul><ul><ul><li>Confusion </li></ul></ul></ul><ul><ul><ul><li>Somnolent </li></ul></ul></ul><ul><ul><ul><li>Lethargic </li></ul></ul></ul><ul><ul><ul><li>Obtunded / Stupor </li></ul></ul></ul><ul><ul><ul><li>Comatose </li></ul></ul></ul>
  19. 22. Glasgow Coma Scale <ul><li>Best Eye-opening response </li></ul><ul><ul><li>1 = no response </li></ul></ul><ul><ul><li>4 = spontaneously </li></ul></ul><ul><li>Best Verbal response </li></ul><ul><ul><li>1= no response </li></ul></ul><ul><ul><li>5 = oriented </li></ul></ul><ul><li>Best Motor response </li></ul><ul><ul><li>1 = no response </li></ul></ul><ul><ul><li>6 = obeys commands </li></ul></ul>Score < 7 is consistent with significant alteration in LOC (coma)
  20. 23. Assessment of Respirations <ul><li>Cheyne-Stokes </li></ul><ul><ul><li>Rhythmical pattern: waxing/ waning in depth, followed by periods of apnea </li></ul></ul><ul><li>Neurogenic hyperventilation </li></ul><ul><ul><li>Regular, rapid (> 24 / min), deep sustained respirations </li></ul></ul><ul><li>Apneustic </li></ul><ul><ul><li>Irregular respirations with pauses at the end of inspiration & expiration </li></ul></ul><ul><li>Ataxic </li></ul><ul><ul><li>Totally irregular in rhythm & depth </li></ul></ul><ul><li>Cluster </li></ul><ul><ul><li>Clusters of irregular breaths with irregularly spaced apnea </li></ul></ul>
  21. 24. Assessment of other Vital Signs Spinal shock Metabolic coma Drug overdose Brainstem lesions Decrease Temperature CNS infection Subarachnoid hemorrhage, hypothalamic lesions, hemmorhage of hypothalamus or brainstem Increase Temperature Implications ↑ /  Vital Sign
  22. 25. Assessment of other Vital Signs Cerebral trauma – Cushing’s triad HTN Blood Pressure Poor cerebral oxygenation Late stages of IICP Increase Decrease Pulse Implications ↑ or  Vital Sign
  23. 26. Brain Death <ul><li>Persistent vegetative state </li></ul><ul><li>Brain death </li></ul><ul><ul><li>Rule out </li></ul></ul><ul><ul><ul><li>spinal cord injury </li></ul></ul></ul><ul><ul><ul><li>Other causes of neurologic impairment </li></ul></ul></ul><ul><ul><li>No neuromuscular paralyzing agent effects </li></ul></ul><ul><ul><li>Criteria documented in chart includes </li></ul></ul><ul><ul><ul><li>Flat EEG </li></ul></ul></ul><ul><ul><ul><li>Absence of spontaneous respirations </li></ul></ul></ul><ul><ul><ul><li>Pupils fixed and dilated </li></ul></ul></ul>
  24. 27. Altered LOC <ul><li>Nursing Interventions </li></ul><ul><ul><li>Airway maintenance </li></ul></ul><ul><ul><li>Fluid balance and Nutrition </li></ul></ul><ul><ul><li>Mouth care </li></ul></ul><ul><ul><li>Skin and joint integrity </li></ul></ul><ul><ul><li>Preventing injury </li></ul></ul><ul><ul><li>Temperature regulation </li></ul></ul><ul><ul><li>Bladder and bowel function </li></ul></ul>
  25. 28. Altered LOC <ul><li>Nursing Interventions </li></ul><ul><ul><li>Sensory stimulation </li></ul></ul><ul><ul><li>Family needs </li></ul></ul><ul><ul><li>Preventing complications </li></ul></ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul><ul><ul><ul><li>Aspiration </li></ul></ul></ul><ul><ul><ul><li>Respiratory failure </li></ul></ul></ul><ul><ul><ul><li>DVT/PE </li></ul></ul></ul><ul><li>Outcomes </li></ul>Assume the unconscious patient CAN hear!
  26. 29. Intracranial Pressure (ICP) <ul><li>Pressure exerted by the combined volume of </li></ul><ul><ul><li>Brain tissue </li></ul></ul><ul><ul><li>CSF </li></ul></ul><ul><ul><li>Blood </li></ul></ul><ul><li>Normal ICP: </li></ul><ul><ul><li>10 – 20 mmHg </li></ul></ul><ul><li>Normal CSF pressure </li></ul><ul><ul><li>5-13 mmHg </li></ul></ul>
  27. 30. Intracranial Pressure (ICP) <ul><li>Closed Box </li></ul><ul><ul><li>Brain tissue (80%) </li></ul></ul><ul><ul><li>Blood (10%) </li></ul></ul><ul><ul><li>CSF (10%) </li></ul></ul><ul><li>Brain Injury </li></ul><ul><ul><li>Skull may contain swollen brain tissue, blood or CSF </li></ul></ul><ul><li>Skull </li></ul><ul><ul><li>May become too full </li></ul></ul><ul><ul><li>↑ pressure on brain tissue </li></ul></ul>
  28. 31. Intracranial Pressure (ICP) <ul><li>Compensation: </li></ul><ul><li>Monro-Kellie Hypothesis </li></ul><ul><ul><li>Change in volume of one of the contents must have a change in volume of one or both of the other components in order to remain stable </li></ul></ul>
  29. 32. Intracranial Pressure (ICP) <ul><li>Brain volume – limited expansion; controlled by Blood – brain barrier </li></ul><ul><li>Cerebral blood volume – controlled by cerebral blood flow </li></ul><ul><li>CSF - </li></ul><ul><ul><li>↑ CSF absorption- or- </li></ul></ul><ul><ul><li> CSF production </li></ul></ul><ul><ul><li>Shunting of venous blood out of the skull </li></ul></ul>
  30. 33. Blood-Brain Barrier <ul><li>Permeable to water, oxygen, CO 2 , other gases, glucose and lipid soluble compounds </li></ul><ul><li>Movement across barrier depends on: </li></ul><ul><ul><li>Particle size </li></ul></ul><ul><ul><li>Lipid solubility </li></ul></ul><ul><ul><li>Chemical dissociation </li></ul></ul><ul><ul><li>Protein-binding capacity </li></ul></ul>
  31. 34. Cerebral Blood Flow / Volume <ul><li>Increased Flow / volume: </li></ul><ul><li>Effects </li></ul><ul><ul><li>Systemic hypotension </li></ul></ul><ul><ul><li>↑ metabolic rate </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul><ul><ul><ul><li>Hypercapnia, ischemia </li></ul></ul></ul><ul><ul><li>Cerebral vasodilation </li></ul></ul><ul><li>Decreased Blood flow / volume: </li></ul><ul><li>Effects </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>↓ metabolic rate </li></ul></ul><ul><ul><li>Alkalosis </li></ul></ul><ul><ul><ul><li>Hypocapnia </li></ul></ul></ul><ul><ul><li>Cerebral edema </li></ul></ul><ul><ul><li>Low cardiac output </li></ul></ul><ul><ul><li>Cerebral vasoconstriction </li></ul></ul>
  32. 35. ↑ Brain Volume <ul><li>Cause: </li></ul><ul><ul><li>Space – occupying lesions </li></ul></ul><ul><ul><li>Cerebral edema </li></ul></ul><ul><li>Effect : </li></ul><ul><ul><li>Herniation </li></ul></ul>http://www.uth.tmc.edu/radiology/test/er_primer/skull_brain/skull.html
  33. 36. Cerebrospinal Fluid <ul><li>Functions </li></ul><ul><ul><li>Support / cushioning </li></ul></ul><ul><ul><li>Maintain stable chemical balance of CNS </li></ul></ul><ul><ul><li>Excrete toxic wastes </li></ul></ul><ul><ul><ul><li>CO 2 , lactate, hydrogen ions </li></ul></ul></ul><ul><li>Causes of ↑CSF : </li></ul><ul><ul><li>↑ production </li></ul></ul><ul><ul><li>Obstructed circulation </li></ul></ul><ul><ul><li>↓ absorption </li></ul></ul>Effect : ↑ cerebral blood volume Hydrocephalus
  34. 37. Intracranial Pressure (ICP) <ul><li>Compensation depends on </li></ul><ul><ul><li>Location of lesion </li></ul></ul><ul><ul><li>Rate of expansion </li></ul></ul><ul><ul><li>Compliance or volume-buffering capacity of body </li></ul></ul>
  35. 38. Cycle of malignant progressive brain swelling ↑ ICP  Cerebral brain flow Tissue hypoxia ↑ pCO 2  pH Cerebral vasodilation & edema from From: Hudak, C.: Critical care nursing: p. 640
  36. 39. IICP <ul><li>CPP (Cerebral Perfusion Pressure) </li></ul><ul><ul><li>CPP = MAP – ICP </li></ul></ul><ul><ul><li>Normal CPP – 70 to 100 mmHg </li></ul></ul><ul><ul><li>IICP – CPP > 100 mmHg or < 50 mmHg </li></ul></ul><ul><ul><ul><li>< 50 mmHg – irreversible damage </li></ul></ul></ul><ul><li>Cushing’s Response (Cushing’s reflex) </li></ul><ul><ul><li>↑ SBP w/ widening pulse pressure </li></ul></ul><ul><ul><li>↓ pulse </li></ul></ul>
  37. 40. IICP <ul><li>Cushing’s Triad </li></ul><ul><ul><li>↑ systolic blood pressure </li></ul></ul><ul><ul><li> diastolic blood pressure </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><li>Activation </li></ul><ul><ul><li>ICP ≥ Mean arterial pressure </li></ul></ul><ul><li>Ominous sign </li></ul>
  38. 42. IICP <ul><li>Early Indicators </li></ul><ul><ul><li>∆ LOC ( earliest indicator ) </li></ul></ul><ul><ul><li>Slowing of speech </li></ul></ul><ul><ul><li>Delays in response to verbal suggestions </li></ul></ul><ul><ul><li>Pupillary changes, Impaired EOMs </li></ul></ul><ul><ul><li>Ipsilateral weakness </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><ul><li>(constant, increasing intensity, aggravated by movement) </li></ul></ul></ul>
  39. 43. IICP <ul><li>Later Indicators </li></ul><ul><ul><li>Continued deterioration of LOC </li></ul></ul><ul><ul><li>Pulse, Respiratory rate decreased/erratic </li></ul></ul><ul><ul><li>BP, Temp increase </li></ul></ul><ul><ul><li>Altered respiratory patterns </li></ul></ul><ul><ul><ul><li>Cheyne-Stokes respirations </li></ul></ul></ul><ul><ul><ul><li>Ataxic breathing </li></ul></ul></ul><ul><ul><li>Projective vomiting </li></ul></ul><ul><ul><li>Hemiplegia, Posturing </li></ul></ul><ul><ul><li>Loss of pupillary, corneal, gag, swallowing reflexes </li></ul></ul>
  40. 45. IICP - Complications <ul><li>Cerebral Herniation </li></ul><ul><li>DI (Diabetes Insipidus) - ↓ secretion ADH </li></ul><ul><ul><li>Clinical manifestations </li></ul></ul><ul><li>SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) - ↑ secretion ADH </li></ul><ul><ul><li>Clinical manifestations </li></ul></ul>
  41. 46. IICP – Complications DI <ul><li>DI (Diabetes Insipidus) - ↓ secretion ADH </li></ul><ul><ul><li>Clinical manifestations </li></ul></ul><ul><ul><ul><li>Polydipsia, polyuria, dehydration </li></ul></ul></ul><ul><ul><ul><li>Urine output increases dramatically (up to 20 L / 24hr) </li></ul></ul></ul><ul><ul><ul><li>Urine specific gravity falls to 1.001 – 1.005 </li></ul></ul></ul><ul><ul><ul><li>Urine osmolality ↓ to 50 – 100 mOsm/kg. </li></ul></ul></ul>
  42. 47. IICP – Complications - DI <ul><li>Treatment </li></ul><ul><ul><li>Fluid and electrolyte management </li></ul></ul><ul><ul><li>Vasopressin </li></ul></ul><ul><ul><li>Thiazide diuretics </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Cardiovascular collapse </li></ul></ul><ul><ul><li>Tissue hypoxia </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Encephalopathy </li></ul></ul>
  43. 48. IICP – Complications - SIADH <ul><li>SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) – </li></ul><ul><li>Pathophysiology: </li></ul><ul><ul><li>↑ secretion ADH or  production of ADH </li></ul></ul><ul><ul><li>Results in ↑ in total body water </li></ul></ul><ul><ul><li>Secretion continues with  osmolality of plasma </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Pituitary tumor </li></ul></ul><ul><ul><li>Head injury </li></ul></ul><ul><ul><li>CNS infection </li></ul></ul><ul><ul><li>Bronchogenic (oat cell), or pancreatic carcinoma </li></ul></ul>
  44. 49. IICP – Complications - SIADH <ul><li>Clinical manifestations </li></ul><ul><ul><ul><li>Water retention -> water intoxication </li></ul></ul></ul><ul><ul><ul><li>Hyponatremia </li></ul></ul></ul><ul><ul><li>Signs / symptoms </li></ul></ul><ul><ul><ul><li>Personality changes </li></ul></ul></ul><ul><ul><ul><li>Headache </li></ul></ul></ul><ul><ul><ul><li>Decreased mentation </li></ul></ul></ul><ul><ul><ul><li>Lethargy </li></ul></ul></ul><ul><ul><ul><li>N, V, diarrhea </li></ul></ul></ul><ul><ul><ul><li>Decreased tendon reflexes </li></ul></ul></ul><ul><ul><ul><li>Seizures, coma </li></ul></ul></ul>
  45. 50. IICP – Complications - SIADH <ul><li>Treatment </li></ul><ul><ul><li>Treat underlying disease </li></ul></ul><ul><ul><li>Alleviate excessive water retention </li></ul></ul><ul><ul><li>Nursing care – depressed LOC </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Death </li></ul></ul>
  46. 51. IICP – Medical Management <ul><li>Goals </li></ul><ul><ul><li>Decreasing Cerebral Edema </li></ul></ul><ul><ul><li>Lowering CSF Volume </li></ul></ul><ul><ul><li>Decreasing Cerebral Blood Volume </li></ul></ul>
  47. 52. IICP – Medical Management <ul><li>Neuro Exam </li></ul><ul><li>Ventriculostomy </li></ul><ul><ul><li>ICP monitoring </li></ul></ul><ul><ul><li>↑ risk infection, bleeding, destruction of neurons </li></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>Coagulopathies, small or collapsed ventricles, severe generalized cerebral edema </li></ul></ul></ul><ul><ul><li>CSF Drainage </li></ul></ul><ul><ul><ul><li>Clear CSF </li></ul></ul></ul>
  48. 53. <ul><li>AVOID Lumbar Puncture in IICP </li></ul><ul><ul><li>Risk of: </li></ul></ul><ul><ul><ul><li>Herniation of brainstem </li></ul></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Headache </li></ul></ul></ul>IICP – Medical Management
  49. 54. IICP – Medical Management <ul><li>Medications </li></ul><ul><ul><li>Osmotic diuretics (cerebral edema reduction) </li></ul></ul><ul><ul><li>Corticosteroids (cerebral edema reduction) </li></ul></ul><ul><ul><li>Inotropics (maintain CPP) </li></ul></ul><ul><ul><li>Antipyretics (fever control) </li></ul></ul><ul><ul><li>Barbiturates (reduces metabolic demands) </li></ul></ul>
  50. 55. Osmotic Diuretics <ul><li>Mannitol </li></ul><ul><ul><li>Increases cerebral tissue perfusion and reduces ICP </li></ul></ul><ul><ul><ul><li>Draws fluid from cerebral interstitial spaces into the vascular space </li></ul></ul></ul><ul><ul><ul><li>Test dose </li></ul></ul></ul><ul><ul><ul><li>Serum osmolality must be monitored </li></ul></ul></ul><ul><ul><ul><li>Complication – acute renal failure </li></ul></ul></ul><ul><ul><li>Contraindication – active intracranial bleeding </li></ul></ul><ul><ul><li>Monitor: </li></ul></ul><ul><ul><ul><li>neurologic and renal status </li></ul></ul></ul><ul><ul><ul><li>IV site for signs of Extravasation </li></ul></ul></ul>
  51. 57. IICP – Nursing Diagnoses <ul><li>Ineffective cerebral tissue perfusion </li></ul><ul><li>Ineffective airway clearance </li></ul><ul><li>Ineffective breathing pattern </li></ul><ul><li>Protection from injury </li></ul>
  52. 58. IICP <ul><li>Planning and Goals </li></ul><ul><ul><li>Maintain patent airway </li></ul></ul><ul><ul><li>Adequate breathing pattern </li></ul></ul><ul><ul><li>Optimal cerebral tissue perfusion </li></ul></ul><ul><ul><li>Maintain negative fluid balance </li></ul></ul><ul><ul><li>Absence of complications </li></ul></ul><ul><ul><li>Calm, safe environment (minimal noise, dim lights) </li></ul></ul>
  53. 59. IICP – Expected Outcomes <ul><li>Maintain patent airway </li></ul><ul><li>Attain optimal breathing pattern </li></ul><ul><li>Demonstrate optimal cerebral tissue perfusion </li></ul><ul><li>Attain desired fluid balance </li></ul><ul><li>Has no signs or symptoms of infection </li></ul><ul><li>Absence of complications </li></ul>
  54. 60. Critical Thinking Case Study <ul><li>Chapter 6: Case Study 15, pp. 395-398. </li></ul>
  55. 61. References <ul><li>Deglin, J.H., Vallerand, A.H. (2005). Davis’s Drug Guide for Nurses, 10 th Ed. Philadelphia. F.A. Davis. Pp. 739-741. </li></ul><ul><li>Hogan, M., Madayag, T. (2004). Medical-Surgical Nursing: Reviews and rationales. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 167 – 210. </li></ul><ul><li>Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Nervous System. In: Critical Care Nursing: A holistic approach, 7 th ed. Lippincott. Philadelphia. Pp. 613-637. </li></ul><ul><li>Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Endocrine System. In: Critical Care Nursing: A holistic approach, 7 th ed. Lippincott. Philadelphia. Pp. 834-836. </li></ul>
  56. 62. References <ul><li>LeMone, P., Burke, K. (2008). Medical Surgical Nursing: Critical thinking in client care. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 1503 – 1554. </li></ul><ul><li>Smeltzer, S., Bare, B. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott, Williams, & Wilkins. Philadelphia. Pp. 1821 -1886. </li></ul><ul><li>Wagner, K.D., Johnson, K., Kidd, P.S. (2006). Neurologic. In: High Acuity Nursing. Upper Saddle River, N.J. pp. 402-425. </li></ul>

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