Neuro diseases newest

Management of Patients with
Cerebrovascular Disorders

Nelia B. Perez RN, MAEd, MSN
PCU MJCN

BSN 2012

Brain Anatomy
• Cerebrum
– Reasoning
– Judgment
– Concentration,
– Motor, sensory, speech
• Cerebellum
– Coordination
• Brainstem
– Cranial nerves
– Respiratory center
– Cardiovascular center

• 20% of CO
Cerebral Blood Flow
• Cerebral tissues – Have no
oxygen or glucose reserves
• Blood flows through Carotid
Arteries to Circle of Willis

Intracranial Pressure (ICP)
Composition A medical emergency that can
• 80% brain tissue and water lead to:
Brain hypoxia, herniation, death
• 10% blood
• 10% cerebrospinal fluid (CSF)
Clinical Manifestations
Increased ICP caused by: • Vomiting
• Severe head injury/ Subdural • Headache
hematoma • Blurred vision
• Seizure
• Hydrocephalus • Changes in behavior
• Brain tumor • Loss of consciousness
• Meningitis/Encephalitis • Lethargy
• Aneurysm • Neurological symptoms
• Status epilepticus/Stroke

Neurological Assessment
• Rapid Neurological Assessment
– Emergent situations
– Sudden changes in neurologic status
1. LOC: first indicator of a decline in neurological
function and increase in ICP (intracranial pressure);
use the GCS
2. Pupils

3. PUPILS
Pupils equal and react normally

Pupils react to light (slowly or blriskly)

Dilated pupil (compressed cranial nerve II

Bilateral dilated, fixed (ominous sign)

Pinpoint pupils (pons damage or drugs)

Neuro-Diagnostic Tests CT SCAN

• Routine labs
• Radiology Tests
– CT scan, MRI
– Carotid ultrasound
– Cerebral angiogram/
MRA

Carotid US

MRA

Neuro-Diagnostic Tests:
Lumbar Puncture
• Spinal needle inserted into
SA
• L3/L4 or L-4 /L-5 using strict
asepsis
– Obtain CSF specimens and
pressure readings
– To remove bloody or purulent
CSF
– Administer spinal anesthesia

Cerebrovascular Disorders
• 53.6% Functional abnormality of the CNS that occurs
when the blood supply is disrupted

• Stroke is the primary cerebrovascular disorder and
the third leading cause of death in the U.S.

• Stroke is the leading cause of serious long-term
disability in the U.S.

• Direct and indirect costs of stroke are billion

Prevention
• Nonmodifiable risk factors
– Age (over 55), male gender, African American race
• Modifiable risk factors:
– Hypertension: the primary risk factor
– Cardiovascular disease
– Elevated cholesterol or elevated hematocrit
– Obesity
– Diabetes
– Oral contraceptive use
– Smoking and drug and alcohol abuse

Stroke
• “Brain attack”

• Sudden loss of function resulting from a
disruption of the blood supply to a part of
the brain

• Types of stroke:

– Ischemic (80% to 85%)

– Hemorrhagic (15% to 20%)

Ischemic Stroke
• Disruption of the blood supply due to an
obstruction, usually a thrombus or embolism, that
causes infarction of brain tissue
• Types
– Large artery thrombosis
– Small penetrating artery thrombosis
– Cardiogenic embolism
– Cryptogenic
– Other

Manifestations of Ischemic Stroke
• Symptoms depend upon the location and size of the
affected area
• Numbness or weakness of face, arm, or leg, especially on
one side
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Difficulty in walking, dizziness, or loss of balance or
coordination
• Sudden, severe headache
• Perceptual disturbances

Impaired comprehension &
Left -Sided CVA: Memory R/T language and math
LEFT BRAIN DAMAGE
R Hemianopsia

Impaired speech
(Aphasias)

Aware of deficits
Depression, Anxiety

R Hemiplegia
/paresis

Impaired discrimination
(R/L)

Slow performance,
Cautious

Right-sided CVA:
Impaired judgment
RIGHT BRAIN DAMAGE
L Hemianopsia

Impulsive/Safety
problems

Rapid performance
Short attention
span

L hemiplegia/paresis

Denies/Minimizes
problems

Left-sided
neglect
Spatial-perceptual
deficits

Cerebrovascular Terms
• Hemiplegia

• Hemiparesis

• Dysarthria

• Aphasia: expressive aphasia, receptive
aphasia

• Hemianopsia

Transient Ischemic Attack (TIA)
• Temporary neurologic deficit resulting from a
temporary impairment of blood flow

• “Warning of an impending stroke”

• Diagnostic work-up is required to treat and
prevent irreversible deficits

Treatment of Stroke:
Thrombotic Stroke
• Thrombolytic Therapy :
• rtPA (recombinant tissue Plasminogen Activator-
Retavase)
– A clot-buster delivered intravenously; breaks up the clot
allowing blood flow to return to the deprived area of the
brain
– Must be administered within 3 hours of the onset of
clinical signs of ischemic stroke
• Quick CT scan to see if stroke from clot or bleed

Treatment Cont:
Acute phase: Long Term Drug Therapy
To Prevent Stroke:
• Anticoagulant - Heparin • Antiplatlet Drugs
continuous infusion
• ASA, Ticlid, Persanti
ne, Plavix
• Osmotic Diuretics – to
reduce brain swelling • Anticoagulants
– Coumadin
• Anticoagulants – Lovenox
contraindicated in • Antiepileptics
Hemorrhagic Strokes

Treatment Cont:
Surgical Treatment
For Bleeds (Interventional
Radiology)

• Angiograms to see
arteries and detect
bleeding sites
• Aneurysm clips and
coils

Preventive Treatment and
Secondary Prevention
• Health maintenance measures including a healthy
diet, exercise, and the prevention and treatment of
periodontal disease
• Carotid endarterectomy
• Anticoagulant therapy
• Antiplatelet therapy: aspirin, dipyridamole
(Persantine), clopidogrel (Plavix), and ticlopidine
(Ticlid)
• Statins
• Antihypertensive medications

Medical Management During
Acute Phase of Stroke
• Prompt diagnosis and treatment
• Assessment of stroke: NIHSS assessment tool
• Thrombolytic therapy
– Criteria for tissue plasminogen activator (tPA):
– IV dosage and administration
– Patient monitoring
– Side effects: potential bleeding

Medical Management During
Acute Phase of Stroke (cont.)
• Elevate HOB unless contraindicated

• Maintain airway and ventilation

• Provide continuous hemodynamic
monitoring and neurologic assessment

• See the guidelines in Appendix B

Hemorrhagic Stroke
• Caused by bleeding into brain tissue, the
ventricles, or subarachnoid space

• May be due to spontaneous rupture of small
vessels primarily related to hypertension;
subarachnoid hemorrhage due to a ruptured
aneurysm; or intracerebral hemorrhage related to
amyloid angiopathy, arterial venous malformations
(AVMs), intracranial aneurysms, or medications
such as anticoagulants

Hemorrhagic Stroke (cont.)
• Brain metabolism is disrupted by exposure to
blood

• ICP increases due to blood in the
subarachnoid space

• Compression or secondary ischemia from
reduced perfusion and vasoconstriction
injures brain tissue

Manifestations
• Similar to ischemic stroke

• Severe headache

• Early and sudden changes in LOC

• Vomiting

Medical Management
• Prevention: control of hypertension
• Diagnosis: CT scan, cerebral angiography, and lumbar
puncture if CT is negative and ICP is not elevated to confirm
subarachnoid hemorrhage
• Care is primarily supportive
• Bed rest with sedation
• Oxygen
• Treatment of vasospasm, increased
ICP, hypertension, potential seizures, and prevention of
further bleeding

NURSING MANAGEMENT

•Improving Mobility and Preventing Joint Deformities
•Managing Sensory-Perceptual Difficulties
•Attaining Bowel and Bladder Control
•Improving Thought Processes
•Improving Communication
•Maintaining Skin Integrity
•Improving Family Coping
•Helping the Patient Cope with Sexual Dysfunction

Nursing Process—Assessing the Patient
Recovering From an Ischemic Stroke
• Acute phase
– Ongoing/frequent monitoring of all systems including vital
signs and neurologic assessment: LOC and
motor, speech, and eye symptoms
– Monitor for potential complications including
musculoskeletal problems, swallowing
difficulties, respiratory problems, and signs and symptoms
of increased ICP and meningeal irritation
• After the stroke is complete
– Focus on patient function; self-care ability, coping, and
teaching needs to facilitate rehabilitation

Nursing Process—Diagnosis of the Patient
Recovering From an Ischemic Stroke
• Impaired physical mobility

• Acute pain

• Self-care deficits

• Disturbed sensory perception

• Impaired swallowing

• Urinary incontinence

Recovering From an Ischemic Stroke (cont.)
• Disturbed thought processes

• Impaired verbal communication

• Risk for impaired skin integrity

• Interrupted family processes

• Sexual dysfunction

Collaborative Problems/Potential
Complications
• Decreased cerebral blood flow

• Inadequate oxygen delivery to brain

• Pneumonia

Nursing Process—Planning Patient Recovery
After an Ischemic Stroke
• Major goals include:
– Improved mobility
– Avoidance of shoulder pain
– Achievement of self-care
– Relief of sensory and perceptual deprivation
– Prevention of aspiration
– Continence of bowel and bladder

Nursing Process—Planning Patient Recovery
After an Ischemic Stroke (cont.)

• Major goals include (cont):
– Improved thought processes
– Achievement of a form of communication
– Maintenance of skin integrity
– Restoration of family functioning
– Improved sexual function
– Absence of complications

Interventions
• Focus on the whole person

• Provide interventions to prevent
complications and to promote rehabilitation

• Provide support and encouragement

• Listen to the patient

Impaired Communication
• Aphasia-loss of use and • Nursing Interventions:
comprehension
• Assess ability to speak and
– Receptive aphasia- understand
Wernicke’s area • Provide + reinforcement
(sensory)
• Picture board
– Expressive aphasia – • Repeat names of objects
Broca’s area (motor) routinely
• Allow plenty of time for
– Global aphasia- mixed client to answer

Improving Mobility and Preventing
Joint Deformities
• Turn and position the patient in correct alignment every 2
hours
• Use splints
• Practice passive or active ROM 4 to 5 times day
• Position hands and fingers
• Prevent flexion contractures
• Prevent shoulder abduction
• Do not lift by flaccid shoulder
• Implement measures to prevent and treat shoulder problems

Positioning to Prevent Shoulder Abduction

Prone Positioning to Help Prevent
Hip Flexion

Improving Mobility and Preventing
Joint Deformities
• Perform passive or active ROM 4 to 5 times day
• Encourage patient to exercise unaffected side
• Establish regular exercise routine
• Use quadriceps setting and gluteal exercises
• Assist patient out of bed as soon as possible: assess
and help patient achieve balance and move slowly
• Implement ambulation training

Interventions
• Enhance self-care
– Set realistic goals with the patient
– Encourage personal hygiene
– Ensure that patient does not neglect the affected side
– Use assistive devices and modification of clothing
• Provide support and encouragement
• Implement strategies to enhance communication: see Chart
62-4
• Encourage the patient with visual field loss to turn his head
and look to side

Interventions (cont.)
• Nutrition
– Consult with speech therapist or nutritionist
– Have patient sit upright to eat, preferably OOB
– Use chin tuck or swallowing method
– Feed thickened liquids or pureed diet
• Bowel and bladder control
– Assess and schedule voiding
– Implement measures to prevent constipation:
fiber, fluid, and toileting schedule
– Provide bowel and bladder retraining

Nursing Process—Assessment of the Patient
With a Hemorrhagic Stroke/Cerebral
Aneurysm
• Complete an ongoing neurologic assessment: use neurologic
flow chart
• Monitor respiratory status and oxygenation
• Monitor ICP
• Monitor patients with intracerebral or subarachnoid
hemorrhage in the ICU
• Monitor for potential complications
• Monitor fluid balance and laboratory data
• Reported all changes immediately

With a Hemorrhagic Stroke/
Cerebral Aneurysm

• Ineffective tissue perfusion (cerebral)

• Disturbed sensory perception

• Anxiety

Collaborative Problems/Potential
Complications
• Vasospasm

• Seizures

• Hydrocephalus

• Rebleeding

• Hyponatremia

Nursing Process—Planning Care of the Patient
With a Hemorrhagic Stroke/Cerebral
Aneurysm

• Goals may include:
– Improved cerebral tissue perfusion
– Relief of sensory and perceptual deprivation
– Relief of anxiety
– Absence of complications

Aneurysm Precautions
• Absolute bed rest

• Elevate HOB 30° to promote venous drainage or keep the
bed flat to increase cerebral perfusion

• Avoid all activity that may increase ICP or BP; implement
Valsalva maneuver, acute flexion, and rotation of the neck
or head

• Exhale through mouth when voiding or defecating to
decrease strain

Aneurysm Precautions (cont.)
• Nurse provides all personal care and hygiene

• Provide nonstimulating, nonstressful environment:
dim lighting, no reading, no TV, and no radio

• Prevent constipation

• Restrict visitors

Interventions
• Relieve sensory deprivation and anxiety
• Keep sensory stimulation to a minimum for
aneurysm precautions
• Implement reality orientation
• Provide patient and family teaching
• Provide support and reassurance
• Implement seizure precautions
• Implement strategies to regain and promote self-care
and rehabilitation

Home Care and Teaching for the Patient
Recovering From a Stroke
• Prevention of subsequent strokes, health
promotion, and implementation of follow-up care
• Prevention of and signs and symptoms of
complications
• Medication teaching
• Safety measures
• Adaptive strategies and use of assistive devices for
ADLs

Home Care and Teaching for the Patient
Recovering From a Stroke (cont.)

• Nutrition: diet, swallowing techniques, and tube
feeding administration
• Elimination: bowel and bladder programs and
catheter use
• Exercise and activities: recreation and diversion
• Socialization, support groups, and community
resources
• See Chart 62-6

SEIZURE
Seizures
sudden, excessive, disorderly electrical
discharges of the neurons.

EFFECTS OF SEIZURE: alteration in
the following
 mental status
 LOC
 sensory and speciual senses
 motor funtion

TYPES OF SEIZURE

GRAND MAL
most common type of seizure

The phases are as
follows:

AURA
(flashing light, smells, spots before eyes,dizziness)

TONIC – CLONIC PHASE
Tonic phase- contraction
Clonic phase – jerking movements
Accompanied by dyspnea, drooling of saliva, urinary continence

POST-ICTAL PHASE
Cessation of tonic-clonic movement
Characterized by exhaustion, headache, drowsiness, deep sleep of 1-2, disorientation

PETIT MAL (Absence Seizure or Little Sickness)

o not preceeded by AURA
o little or no toni-clonic
o charac blank facial expression, automatism like lip-chewing,
cheek smacking
o regain of consciousness as rapid as it was lot for 10-20secs
o usually occurs during childhood and adolescence
JACKSONIAN / FOCAL SEIZURE
o common for patients with organic brain lesion like frontal
lobe tumor
o aura is present(numbness, tingling, crawling feeling)
o charac by tonic-clonic movements of group muscle e.g.
Hands, foot, or face then it proceeds toi grand mal seizure
FEBRILE SEIZURE
o this is common for children <5yo, when temp. is rising
PSYCHOMOTOR SEIZURE
o aura is present (hallucinations or illusion)
o charac by mental clouding (being out of touch with the envt)
o appears intoxicated
o the client may commit violent or antisocial acts, e.g. Going
naked public, running

STATUS EPILEPTICUS
(ACUTE PROLONGED SEIZURE ACTIVITY)
IS A SERIES OF GENERALIZED SEIZURE THAT
OCCUR WITHOUT FULL RECOVERY OF
CONSCIOUSNESS BETWEEN ATTACKS
THE TERM HAS BEEN BROADENED TO INCLUDE
CONTINUOUS CLINICAL OR ELECTRICAL SEIZURES
LASTING AT LEAST 30 MINUTES, EVEN WITHOUT
IMPAIRMENT OF CONSCIOUSNESS.
A seizure is a sudden disruption of the brain's normal
electrical activity, which can cause a loss of
consciousness and make the body twitch and jerk. This
condition is a medical emergency.

CAUSES
 not taking anticonvulsant medication
 also caused by an underlying condition, such as
meningitis, sepsis, encephalitis, brain
tumor, head trauma, extremely high fever, low
glucose levels, or exposure to toxins.

Symptoms
The characteristic symptom of status
epilepticus is seizures occurring so frequently that they
appear to be one continuous seizure. These seizures
include severe muscle contractions and difficulty
breathing. Permanent damage can occur to the brain and
heart if treatment is not immediate. A person's
symptoms can range from simply appearing dazed to the
more serious muscle contractions, spasms, and loss of
consciousness. The specific symptoms depend on the
underlying type of seizure.

TWO CATEGORIES OF STATUS EPILEPTICUS

CONVULSIVE
Epilepsia partialis continua is a variant it involve an hour, day
or even week-long jerking. It is a consequence of vascular
disease, tumor or encepalitis and drug resistant.

NONCONVULSIVE
Complex Partial Status Epilepticus CPSE and absence status
epilepticus are rare forms of the condition which are marked
by nonconvulsive seizures. In the case of CPSE, the seizure is
confined to a small area of the brain, normally the temporal
lobe. But the latter, absence status epilepticus, is marked by a
generalised seizure affecting the whole brain, and an EEG is
needed to differentiate between the two conditions. This
results in episodes characterized by a long-lasting stupor,
staring and unresponsiveness.

HOW IT IS DIAGNOSED?
Status epilepticus is diagnosed according to its
characteristics symptoms. The doctor will order test to
look for the cause of the seizures. This may include

 blood test

 ECG to check for an abnormal heart rhythm

 EEG to check electrical activity in the brain

 MRI or CT scan to check for braing tumord or
signs of damage to the brain tissue.

Nursing Diagnosis
High Risk for Injury r/t Seizure
Activity

Individual Coping r/t perceive
social stigma, potential changes
in employment

MEDICATIONS
 diazepam (Valium)
this will stop motor movement

 Phenytoin (Dilatin)

 Phenobarbital (Barbita)

 Paraldehyde

 Thiopentahl sodium (Pentotal sodium)

 General anesthesia may also be used as a treatment of last
resort to stop seizure activity

NURSING INTERVENTION
PREVENTING INJURY

REDUCING FEARS OF SEIZURE

IMPROVING COPING MECHANISMS

PROVIDING PATIENT AND FAMILY EDUCATION

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

TEACHING PATIENTS SELF-CARE

PREVENTING INJURY

injury prevention for the patient with seizure is a PRIORITY.

 patient should be placed on the floor and remove any obstructive
items
 patient should never be forced into a position
 pad side rails

 do not attempt to pry open jaws that are clenched in a spasm to
insert anything.

 if possible place the patient on one side with head flexed forward,

PATIENT
EDUCACTION
 TAKE MEDICATION AT REGULAR
BASIS
 AVOID ALCOHOL. Lowers seizure
threshold
 ADEQUATE REST
 WELL-BALANCED DIET
 AVOID DRIVING, OPERATING
MACHINES, SWIMMING UNTIL SEIZURES
ARE WELL CONTROLLED.
 LIVE AN ACTIVE LIFE

REDUCING FEARS OF SEIZURE

Fear that a seizure may occur unexpectedly
can be reduced by the patients adherence to
the prescribed treatment regimen.
Cooperation of the patient and family and
their trust in the prescribed regimen are
essential for control of seizures
Periodic monitoring is necessary to ensure
the adequacy of the treatment regimen and
to prevent the side effects.

back

IMPROVING COPING MECHANISMS

it has been noted that the social,
psychological, and behavioral problems
frequently accompanying the attack can be
more handicap than the actual seizure.
Counselling assists the individual and family to
understand the condition and the limitations
imposed by it. Social and recreational
opportunities are good for mental health .
Nurses can improve the quality of life for
patients with the disorder by educating them
and their family about the symptom and also
the management.

PROVIDING PATIENT AND
FAMILY EDUCATION
Ongoing education and encouragement
should be given to patients to enable them to
overcome these feelings. The patient and
family should be educated about the
medications as well as care during a seizure.

perhaps the most valuable facets are
education and efforts to modify the
attitudes of the patient and family toward
the disorder.

MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
Patients should have plan to have
serum drug levels drawn at regular
intervals. The patient and family are
instructed about the side effects and
are given specific guidelines to
assess and report signs and
symptoms indicating medication
overdose.

TEACHING PATIENTS SELF CARE

Like thorough oral hygiene after each
meal, gum massage, daily flossing, and
regular dental care
The patient is also instructed to inform
all health care providers of the
medication being taken because of the
possibility of drug interactions. An
individualized comprehensive teaching
plan is needed to assist the patient and
family to adjust to this chronic disorder.

INCIDENCES
Other transport, 2%
Bicycle, 3% Suicide, 1%

Other , 7%

Fall, 28%
Unknown, 9%

Assault, 11%

Traffic accident,
Struck, 19% 20%

1. Dura mater
2. Arachnoid
3. Venae sagittalis superiores cerebri
4. Sinus sagittalis superior and Falx cerebri

Levels of consciousness
Level Description
Conscious Normal

Confused Disoriented; impaired thinking and responses

Disoriented; restlessness, hallucinations,
Delirious
sometimes delusions
Decreased alertness; slowed psychomotor
Obtunded
responses
Sleep-like state (not unconscious); little/no
Stuporous
spontaneous activity

Comatose Cannot be aroused; no response to stimuli

symptoms of mild head injury
– raised, swollen
– bruise
– small, superficial cut in the scalp
– headache

symptoms of moderate to
severe headpale skin color
– confusion
– injury
– loss of consciousness – seizures
– blurred vision
– severe headache – behavior changes
– vomiting – blood or clear fluid
– loss of short-term memory,
– slurred speech draining from the
– difficult walking ears or nose
– dizziness
– weakness in one side or – one pupil looks
area of the body larger than the
– sweating
other eye
– deep cut or
laceration in the
scalp
– open wound in the
head

Indication for admission
• Minor head injury
– Focal neurodeficit
– Post traumatic seizure
– Skull fracture
• Moderate head injury
• Severe head injury

Investigation
Imaging
• Skull x-rays
Studies
• CT scan of the head
• Magnetic resonance imaging
–MRI may be used later for
additional information about a
brain injury.
• Other x-rays may be performed to

• Initial blood tests
– blood alcohol level for any
patient who has an altered level
of consciousness
–Coagulation abnormalities, a
prothrombin time (PT), partial
thromboplastin time (PTT), and
a platelet count
– Bleeding time assessment may

Urgent Scan in adult if any of
– GCS < when first assessed
– GCS< two hours after injury
– Suspected open or depressed skull
fracture
– Signs of base of skull fracture**
– Post-traumatic seizure
– Focal neurological deficit
– > episode of vomiting
– Coagulopathy + any amnesia or LOC since
injury
**Signs of basal skull fracture: 'panda' eyes, CSF leakage (ears or nose) or
Battle's sign (bruising behind the ear in cases of basal skull

8 hours after injury, a CT scan is also
recommended
if there is either
– More than minutes of amnesia of events
before impact
– Or any amnesia or LOC since injury if
• Aged ≥ years
• Coagulopathy or on warfarin
• Dangerous mechanism of injury
–RTA as pedestrian
–RTA - ejected from car
–Fall > m or > stairs

Nursing Assessment

– History of Trauma
– Time, cause, direction and force of the blow
- Loss of consciousness, duration
Assess LOC – Glasgow Coma Scale
– Response to verbal commands or tactile stimuli
- Pupillary response to light
- Motor Function
Vital Signs
– Monitor for signs of increased ICP
Motor Function
- Move extremities, hand grasp, pedal push, speech

Emergency Care

• First consideration is to ensure a clear airway
• Keep spine straight; patient is carefully turned
to a lateral or semiprone position
• Flexion or hypertension should be avoided in
case there is a cervical fracture
• Keep patient covered, quiet and undistrubed

General Care:

• Establish airway
• Prevent aspiration pneumonia
• Check for cardiovascular complications
• Serach for new evidence of spinal injuries. Do not allow
the newly injured patient to move about even though
he/she is conscious.
• Observe the skull and scalp injuries. cover open head
wound with the cleanest material avaialble at the
scene
• Prevent infection. Gove prophylactic dose for tetanus.

General Care (Cont)
• Observe for CSF leakage –
otorrhea, rhinorrhea, Battle’s sign-tenderness
and eccymosis or mastoid bone especially for
basilar skull fracture
• Obeserve for signs and symptoms of increased
ICP; watch for nuclear rigidity.
• Control restlessness and pain. Narcotics are
contraindicated following head injury, and are not
given if ICP is prevent.
• Maintain fluid/electrolyte; acid-base balance and
adequate nutrition. Record I & O.

Management of Increased ICP
• - True emergency requiring prompt treatment
- Monitor ICP
- Intraventricular catheter, subarachnoid
bolt, epidural catheter
– Reduce Cerebral Edema
– Osmotic diuretics (mannitol)
- Corticosteroids ( dexamethasone)
Maintain cerebral perfusion
– Maintain cardiac output with fluids and
dobutamine
- Reduce CSF and blood volume
– Drain CSF
- Hyperventilation – results in vasoconstriction

Management of ICP
• Control Fever
– Fever increases cerebral metabolism and
edema
- Antipyretics, cooling blanket
- Avoid shivering which increases ICP
Reduce metabolic demands
– Barbiturates decrease ICP
- Muscle relaxants to paralyze patient

Ineffective airway clearance related
to accumulation of secretions and
decreased LOC
• Maintain patient airway
– Suction carefully
- Discourage coughing (causes increase in ICP)
- Elevate HOB 30 degrees
- Guard against aspiration
- Monitor ABGs to assess ventilation

Ineffective breathing pattern related
to neurological dysfunction
•
Monitor constantly for respiratory
irregularities
– Cheyne Stokes, hyperventilation,
Effective suctioning
HOB 30 degrees
Position patient lateral or semi prone

Altered cerebral tissue perfusion
related to increased intracranial
pressure
• Position patient to reduce ICP :
– head in midline position to promote venous
drainage
- Avoid extreme rotation or flexion of neck
- Avoid extreme hip flexion

• Prevent straining
- Stool Softeners
- High Fibre diet
Space Nursing activities
Maintain calm atmosphere, reduce stimuli

Risk for fluid volume deficit related to
dehydration procedures and
decreased LOC
Monitor electrolytes
- Brain damage can produce metabolic and
hormonal dysfunctions
Monitor intake and output
Monitor IV fluids carefully
Monitor urine for acetone, osmolality
Record daily weights

Altered nutrition related to metabolic
changes, inadequate intake.
• Start enteral feedings when patient stabilized
- NG feeding unless CSF rhinorrhea
- Aspirate for residual before feeding to
prevent distention and aspiration
- Use pump to regulate feeds

Risk for injury related to
disorientation, restlessness and brain
damage.
•
Assess for cause of restlessness
- Often present as patient emerges from coma
- May be due to hypoxia, fever, pain, full bladder
Use padded side rails or wrap hands in mitts
- Avoid restraints as straining against them increases
ICP
Minimize environmental stimuli
- Low lights, limit visitors, speak calmly
- Orient patient frequently

Risk for altered body temperature
related to damage to temperature -
regulating mechanism
•
Monitor temperature every 4 hrs.
- Can be increased as result of:
Damage to hypothalmus
Cerebral irritation from hemorrhage
Infection
Reduce temperature with acetaminophen and cooling
blankets
If infection suspected –
- Culture potential sites
- Start antibiotics

Potential for impaired skin integrity
related to bed
rest, immobility, unconsciousness
•
Assess all body surfaces every 8 hrs.
Turn every 2-4 hrs
Provide skincare every 4 hrs
Assist patient to chair (if possible)

Spinal cord injuries:
• cause myelopathy or damage to nerve roots or
myelinated fiber tracts that carry signals to and
from the brain.
• Depending on its classification and severity, this
type of traumatic injury could also damage the
gray matter in the central part of the
cord, causing segmental losses of interneurons
and motorneurons.

• Primary prevention important.
– Drive slow, use seat belts &
helmets, water safety, protective devices for
athletes, prevent falls.

Assessment
Clinical manifestations depend on type and level of injury

– Below level of injury there is total loss of sensory and motor
paralysis, loss of bladder and bowel control, loss of sweating and
vasomotor tone.

– Complains of acute pain in back or neck which may radiate along
involved nerve.

– Respiratory problems (T1-T11 and diaphragm are used in breathing)
– intercostal muscles.
– above C4 – phrenic nerve – paralysis of diaphragm.

• Respiratory status
– observe respiratory pattern, strength of
cough, auscultate lungs.
• Changes in motor or sensory function
– Squeeze hand, spread fingers, move toes.
– Pricking skin with dull item, start at
shoulders.

Signs of spinal shock
•
– Complete loss of all
reflexes, motor, sensory and autonomic below
level of injury.

Management of Spinal Cord Injuries
• High dose corticosteroids within 8 hrs of injury
– Methylprednisolone, loading dose followed by
infusion for 23 hrs.
• Oxygen, intubation if necessary
• Skeletal reduction and traction
– Immediate immobilization
– Reduction of dislocations (restore to normal
position)
– Stabilization of vertebral column.
– Traction used in cervical fractures.
• Surgery.

Nursing Interventions

• Promote adequate breathing and airway clearance.
– Monitor pulse oximetry, ABGs.
– Clear bronchial and pharyngeal secretions
– Use suctioning cautiously – can stimulate vagus
nerve causing bradycardia.
- Chest Physiotherapy, breathing exercises.
– Humidification.
– Adequate hydration.
– Assess for signs of respiratory infection.
– Intubate and ventilate.

Improve Mobility
• Maintain proper alignment at all times.
• Reposition frequently.
• Prevent foot drop – wear shoes.
• Prevent external rotation of hip joints – trochanter
rolls.
• Prevent contractures – range of motion exercises 4
times daily.
• If injury above midthoracic level, monitor BP when
turning (loss of sympathetic control of peripheral
vasoconstriction).

Maintain Urinary and Bowel Function

• Intermittent or indwelling catheter to avoid
overdistention of bladder.
– Urinary retention results from bladder becoming
atonic.
• Intake and output.
• Insert NG tube to relieve distention and prevent
aspiration.
– Paralytic ileus usually develops.
– Bowel activity usually returns within 1 week.
• High fibre, high protein diet.
• Stool softener.

Managing Potential Complications

• Thrombophlebitis and pulmonary embolism
– Assess for symptoms (chest pain, dyspnea, ABGs)
– Measure circumference of thighs and calves daily
– Anticoagulation – low dose heparin
– Pressure stockings.
– Adequate hydration
• Orthostatic Hypotension
– BP unstable and low for first 2 weeks.
– Monitor closely when repositioning patient.
– Reposition slowly, wear pressure stockings.

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