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Neuro assessment, Neurodiagnostic studies, Meningitis, Intracranial…
Neuro assessment
Glasgow coma scale
scale
verbal
inappropriate response but words discernible (3)
Incomprehensible sounds/speech (2)
confused but answers questions (4)
none (1)
oriented (5)
motor
Withdraws from pain (4)
spastic flexion, decorticate (3)
purposeful movement to pain (5)
extensor/rigid response, decorate (2)
Obeys commands (6)
none (1)
eye opening
to verbal command/speech/shout (3)
to pain (2)
spontaneous (4)
none (1)
results meaning
13-14
mild head injury
9-12
moderate head injury
<15
decreased LOC
3-8
severe head injury
limited with...
spinal cord injury, intubation, swollen eyes, shock, drug use, alcohol intoxication, and metabolic disturbances
Charting
E4 V5 M6
Pain
grab shoulder
VS
HR and rhythm
tachy and dysrhythmias common with...
brain injury
brady = sign of...
high ICP
BP
relatively stable early
changes due to
pressure on medulla
high BP with wide pulse pressure =
sign of high ICP
temp
neurogenic fevers
high and resistant to antipyretics
hypothermia
pituitary damage and spinal cord injuries
respirations
can be an assessment of patho or modified to be therapeutic
apneustic
cluster breathing
central neurogenic hyperventilation
ataxic
Cheyne Stokes
(remember the patterns)
Cushing's triad
late response to increased ICP
HRN or wide pulse pressure/increased BP
abnormal breathing
indication of pending herniation due to high ICP
bradycardia
Richmond agitation sedation scale (RASS)
assess every
2 hours
titrate
higher scores = increase meds, lower scores = decrease meds
use
with sedation, analgesia, and neuromuscular blockade
goal
0 - -1
Pupils
Dilated (mydriasis)
herniation, seizures, meds (meth, alcohol, crack), sympathetic stimulation (fear/anxiety, meds - epi/norepi)
Ansocia
one bigger than the other
indicates eye, brain, or nerve problem
1mm + difference is more significant
pupils dilate on side of herniation
Pinpoint (miosis)
opiates, glaucoma meds, brainstem damage, organophosphates parasympathetic stimulator, meds
responsiveness
prompt consensual constriction to light and accommodation is desired
may be affected by sedation and pain meds
Tests for brain stem functioning
Oculocephalic reflex (doll's eyes)
how to do it
hold eyelids open and briskly turn head right and left
good sign
eyes go to opposite side
don't perform if
suspected or known SCI
Oculovestibular reflex (iced water/cold caloric)
how to do it
elevate head 30 degrees
inject 30-50 mls iced water into ear canal
good sign
slow conjugate eye movement toward stimulus then rapid movement away
bad sign
eyes remain fixed
don't perform if
they are away or their eardrum isn't intact
other tests
apnea, pulpils dilated/unreactive to light, loss of corneal/cough/gag refleses, comal and flasccid, eeg, cerebral angiography, doppler, evoked potentials
mental status
orientation
person, place, time, situation
LOC/responsiveness
most sensitive indicator of neuro function
Babinski reflex
positive
toes flaring up
indicates upper motor neuron damage with MS and brain damage
negative
toes curl down
normal in adults
history
best provided by patient and family
motor assessments
assess strength and quality or upper and lower extremities
upper
have pt hold your wrists and have the push and pull you
lower
lift legs against resistance and plantar flex and dorsiflex (push pull)
Papilledema
swelling of optic disc form pressure by increased ICP
Neurodiagnostic studies
Xray
what is it
detect skull or vertebral fx or vertebral alignment
if pt has suspected SCI
immobilize spine first
not good for soft tissue
need to see vertebral fracture
CT
what is it
assesses for hemorrhages, tumors, lesions, tissue/space shifts
nursing/teaching
assess for contrast allergies, renal function, metformin use
need IV if contrast is ordered
pt must remain immobile for about 5 minutes
contrast not used if bleeding suspected
ensure hydration after CT if contrast is used
hold metformin if getting any contrast because of renal injury
CT without contrast first if bleed suspected
they have a ton of radiation
MRI
what is it
graphic image of bone, fluid, soft tissue with or without contrast, more detail than CT
nursing
no ferrous metal allowed!! even on staff!!
encourage hydration if contrast used
pre medicate if anxious/claustrophobic
test is loud
teach: must lie still in close confined tube for a long time
MRA
what is it
magnetic resonance angiography
MRI for blood vessels
Same care as MRI
PET scan
what is it
measures cerebral metabolism using radioactive gas or injection (not contrast)
nursing/teaching
must be NPO prior to scan to limit metabolic activity of digestion
no caffeine, alcohol, tobacco, or exercise 24 hours before scan
must lie still with limited stimuli for 2-4 hours during scan
encourage fluid intake after scan to clear tracer
Cerebral angiography
what is it
contrast injection and xrays/CT/MRI taken to identify vascular problems
nursing
assess for contrast allergies and renal function
if cerebral arteries are cannulated same procedure/car as cardiac cath
Myelography
what is it
contrast injected into subarachnoid space via LP then Xray/CT used to take picture
precautions, prep and care
same as LP
tell pt special tilt table may be used to take picture
put contrast in then go to imaging
nursing
keep environment quiet
assess for HA, fever, spasms, n/v (no phenothiazines like promethazine, prochlorperazine)
cerebral spinal fluid through your back
EEG
what is it
records electrical brain waves through electrodes placed on scalp detect to seizures, sleep disorders, death
nursing
no caffeine 8-12 hrs before test
remove heavy hair oils, creams, etc.
Evoked potential studies
what is it
brain's responses to types of stimuli are measured thru skin electrodes on forehead, mastoid and earlobes
nursing
may instruct to watch or listen to stimuli
may not have electrical devices on or touching pt
trying to get response
Transcranial doppler
what is it
ultrasound to detect cerebral blood flow
nursing
position changes may be needed so that US waves can pass thru "windows" in the skull (temporal bone is thin)
when/ when isn't blood getting to brain
at bedside
if they suspect brain death
Lumbar puncture
what is it
used to measure CSF pressure and obtain sample
not for
patients with high ICP because sudden release of pressure may cause herniation or pt on anticoagulants
pt side laying fetal or forward sitting position
local anesthesia given
hollow needed inserted in subarachnoid space between L3-4 or L4-5
help pt avoid sudden movements or coughing
CSF should be colorless, clear and odorless
continued pink or blooy color can indicate
blood in CSF
cloudy indicates
infection
initial pink tinge can indicate
trauma on insertion - should clear
yellow indicates
old blood in CSF
can measure pressure of CSF
approximates ICP
if develop HA may be treat with a blood patch
Meningitis
S/S
meningeal irritation
positive brudzinski sign (neck flex -> hip and knee flex)
positive kernig's sign (can't extend keep with hip flexed at 90)
nuchal rigidity (stiff neck)
photophobia/diplopia
severe headache
seizures
Restless, agitated, irritable
signs of increased ICP
Fever
petechial rash/ecchymoses
treatment
antibiotics IV for 14-21 days for bacterial begin with 3-6 hours of presentation
antivirals for viral
Steroids
seizure meds
analgesics (non opiates so it doesn't change mental status)
antipyretics
fluid and electrolyte replacement
Nursing
seizure precautions
ICP management
frequent neuro checks
maybe isolation precautions
elevate HOB to decrease ICP
teach need for extended abx therapy
quiet environment
risk factors
sinusitis
neuro surgery
otitis media
immunocompromised
head trauma (especially open skull)
very young or very old
Dx
CSF culture
EEG
CT or MRI
LP bacterial findings
cloudy fluid with...
low glucose
high CSF pressure
increased WBC's (pleocytosis) and protein
complications
hydrocephalus
increased ICP
cranial nerve damage
brain herniation
Types
Bacterial
epidemics in populations where people live close
more severe!
droplet precautions
Viral and aseptic
less severe and shorter duration
cause
ABX, NSAIDS, enteroviruses, herpes simplex/zoster, epstein-barr, cytomegalovirus, and west nile
what it is
infection/inflammation of the pia mater, arachnoid, sub arachnoid, and CSF
Inflammation
Increased ICP
bacterial prevention
promote meningococcal and pneumococcal vax
Intracranial pressure (ICP)
intracranial dynamics
what is the cranium
nonexpandable rigid box of bone containing....
10% blood
85% brain
5% CSF
monroe kellie doctrine
when 1 goes up, either 1 or both of the others has to go down to prevent increased ICP
compensatory mechanisms
CSF
produced in ventricles, circulates thru subarachnoid space
increased production, flow obstruction, or decreased reabsorption
increased ICP
decreased production or increased reabsorption
decreased ICP
brain/parenchyma
increased ICP with cerebral edema, space occupying lesions, hemorrhage
herniation = brain tissue shift
interventions
focused on preventing herniation and maintaining oxygen
types of herniation
:
top to bottom
external
uncal
supratentorial central
infratentorial
subfalcine
cerebral blood flow autoregulation
brain arterioles keep adequate blood flow by
dilating to increased blood flow
occurs with
hypercapnia
(potent)
acidosis
hypoxia
(what happens post code)
constricting to decreased blood flow
occurs with
alkalosis
lower PaCo2
(use this to control)
only functions with MAP 65-150
pressures
over 15
abnormal
over 20
pathologic (risk herniation)
0-10
normal
over 60
fatal
severity determined by
degree and duration of increased ICP
sudden change in ICP are....
poorly tolerated
slow changes in ICP allow...
compensatory mechanisms to work
normal body functions that can increased ICP
change in BP, coughing, respiratory cycle, valsalva
Cerebral perfusion pressure (CCP)
equation
MAP-ICP
what is it
amount of pressure that must be maintained so that oxygen and glucose get to the brain
reflects approximate cerebral blood flow
numbers
normal
60-100
hypoperfusion
less than 60
anoxia (severe hypoxia)
over 100
what happens when ICP increases
initially
decreased LOC
sluggish pupils : critical for unconscious
motor weakness/drift
combative
speech changes
restlessness
delayed response
confusion
progression
pupil sluggish or fixed
decreased motor function
further decreased LOC
posturing
decorticate
flex to core
decerebrate
extred out
worse
no activity
impending herniation
cushing's triad
irregular breathing
wide pulse pressure
decreased HR
Monitoring
invasive
sensors through hole drilled through skill or through LP
types
external strain (fluid filled)
just like art line
fiberoptic
leveled and zeroed at insertion so none needed after but can drift from accuracy and have to redo
locations
epidural
low infection risk but not as accurate and no CSF sampling/draining
subarachnoid and lumbar
requires intact skill, can't sample CSF, don't use lumbar with high ICP (lead to hearniate)
parenchymal
fiberoptic, most accurate, does not drain CSF
subdural
probe in subdural space, easy to insert, no CSF sampling/draining
intraventricular
very accurate, used to also drain CSF and give meds, need to level, increased infection and bleed risk
ensuring accuracy
levelling and zeroing with external transducers
level to external auditory canal or outer canthus of eye
transducer too low
false high reading
transducer too high
false low reading
troubleshooting
check connections for leaks
assess pt for fever/infection/flexion/airway obstruction/electrolytes
level and rezero
flush (NOT LIKE IV, flush AWAY from pt head with stopcokc to pt) closed, always with NS)
eliminate air bubbles in line
Data interpretation
ICP waveform
3 peaks corresponding to heart beat
the first peak should be the biggest
p2>p1
brain lost auto regulation
risk herniation
Cerebral oxygen monitoring
brain has high metabolic/oxygen demands so increased ICP ->
risk for decreased perfusion and oxygenation
measures of cerebral perfusion/oxygenation
CCP
other: brain tissue o2 sat (PtiO2), jugular venous bulb oximetry (sjo2)
medically managing high ICP
goals
ICP less than 20 and CCP over 60
CSF drainage
done with
intraventricular cath
intermittentn
drain x amount when ICP is above X
continuous
ICP goal on monitor and drain to get there
what to do
flawless aseptic technique
removal of even a small amount will dramatically decreased ICP
oder should note point to initiate and level drainage
complications
infection
over draining may cause subdural bleeding from contraction of brain tissue
Mannitol or 3% NaCl
hypertonic crystalloid that
increases intravascular osmotic pressures by
reduces blood viscosity
promotes diuresis
pulling fluid from tissue (everywhere - not just brain, watch BP)
what to do
must be filtered
rewarn or send back to pharmacy if crystallized
may need to give isotonic fluids to support BP
monitor serum osmo to give
monitor UO
can also use salt tabs PO or NG instead
respiratory support
mechanical vent to maintain oxygenation
positive pressure from vent and PEEP
increased intrathoracic pressure and decreased venous drainage from brain
increased ICP so avoid high peep
squish vena cava
brain can't drain
maintain CO2 normal levels
increased CO2
vasodilation
increased ICP
sedation and analgesia
why
reduce agination, coughing, and responses to stimuli
propofol, benzos, opioids, dexmedetomidine
reduce metabolic demands
decreased anxiety and ICP
neuromuscular paralysis
drugs
succinylcholine, pancuronium
why
last resort
reduces brain o2 demends and ICP
what todo
must have mech vent
must also sedate in conscious pt
Barbiturate coma
drugs
pentobarbital, phenobarbital
why
reduces metabolic activity and preserves brain funtion
what todo
must have mech vent
must WEAN off, do not stop suddenly
hyperventilation
why
lowering CO2
vasoconstriction
decreased ICP but also reduces cerebral blood flow
goal
pCO2 30-35
prevent seizures
occur in
15-20% of TBI pts
only detected in half
why they happen
increased ICP and metabolic rate
hypothermia
why
decreases brain metabolic demand
decompressive craniotomy
what
bone flap of skill removed (replace later)
why
release pressure
Nursing
environment
quiet soothing environment
brief stimulation if recovering
transportation
plan ahead
notify RT
RN at HOB during movement
basic care
some pts need cluster some need spread out to keep ICP lowest
glycemic control
insulin needed
Q4-6 glucose checks
positioning
head in neutral position
avoid hip flexion
HOB 30-45
turn every 2 hours with help
bowel and bladder
stool softeners and fiber
ensure urinary cath patency
I&O
Avoid straining and enemas
neuro assessments
evaluate baseline and hourly for changes
seizure prevention/control
administer anti seizure meds and use seizure precautions
administer vasopressors and vasoconstrictors
maintain MAP and CPP
nutrition
feed viable gut
monitor swallowing if oral feeding
ensure ventilation and oxygenation
what todo
frequent resp assessment
look for resp patterns, spo2, abgs and co2
suction
ONLY when NEEDED
drastic increases in ICP
if you NEED to
preoxygenation, limit to 1-2 passess, less than 5-10 seconds
traumatic brain injury
contributing factors
alcohol, drugs, failure to use safety devices
types
coup countercoup (hit, the bounce back)
rotation
acceleration deceleration (whip lash)
penetration
severity
loose consciousness
0-30 min
30 min - 24 hours
over 24 hours
mental state
a moment up to 24 hours
over 24 hours
over 24 hours
structural imaging
normal
normal or abnormal
normal or abnormal
post traumatic amnesia
0-1 day
1-7 days
over 7 days
criteria
mild
moderate
severe
GCS
13-15
9-12
less than 9
primary brain injury (occurs at time of injury)
skull fracture
types
depressed
fracture driven into brain and meninges
treat
removal needed
risk
meningitis
basilar skull fx
involve floor of skull
treat
conservative
prevent infection, heal on own, must not blow nose, no NG or nasotracheal tubes, no bipap
manifestations
raccoon eyes (periorbital edema and bruising)
halo signs (CSF leak from ears or nose, yellow CSF ring around blood in center on gauze)
battle's sign (bruising behind ear)
concussion
temporary alteration in mental status after trauma
treatment
none
manifestations
may last for up to a year, no radiological evidence, short term memory loss, headache, decreased attention, dizziness, irritability, difficulty with executive functioning, emotional lability, nausea
post concussion syndrome
headache, visual disturbances, nervousness, dizziness, confusion, gait disturbances, poor memory, decreased processing
possible treatment
amitriptyline
scalp laceration
just scalp
nursing
check underlying brain injury
treatment
suture, staples, glue
contusion
trauma to capillaries cause bruising of brain
dx
seen on CT
s/s
depend on size and location
subarachnoid hemorrhage
hemorrhage in subarachnoid space that contains CSF
blood irritaties brain stem
dysrhythmias, HTN
blood prevents CSF reabsoption
hydrocephalus and increased ICP
cerebral vasospasm possible
give nimodipine, calcium channel blocker, triple H (hemodilution, hypertension, hypervolemia
hematoma/intracranial bleed/hemorrhagic stroke
subdural
below dura and above arachnoid layer
mostly
venous
treatment
may need surgical evacuation
types
subacute
onset 2days - 2 weeks post trauma
chronic
small bleed or slow leak, possibly from cortical atrophy with aging
signs
headache, lethargy, confusion, seizures
acute
signs within 24-48 hrs post trauma
intraparenchymal/intracerebral
bleeding inside brain tissue
hard to get out, focus on controlling ICP
epidural
between dura and inside skull
mostly
arterial
rapidly expand and cause herniation
talk and die
peak size
6-8 hours
fatality
15-20%
excellent prognosis if
ID and evacuate immediately
diffuse axonal injury
direct tearing or shearing of axons
cerebral edema
little radiographic evidence
treatment
possibly steroids
rehab!
dx
transcranial doppler
angiography
CT or MRI
EEG
secondary brain injury
cause
hypoxia, hypotension, anemia, cerebral edema/ischemia increased ICP, hypercarbia, hyperthermia, infection, seizures, hyperglycemia
nursing
treat primary, prevent secondary
ASSESS, ASSESS, ASSESS
LOC, GCS neuro VS, airway
oxygenation
manage vent settings
preoxygenate before suction
maintain airway
oral hygiene
assess resp system
TDB and IS
early mobilization if ICP controlled
prevent and treat seizures
control body temp
circulation
monitor for MI and dysrhythmias, DVT prevention, early mobilization, assess BP and hemodynamics, administer inotropes, vasopressors, fluids
cerebral perfusion/ICP
fluids and electrolytes
strict hourly i&lo
monitor and replace electolytes
hormone replacements to treat SIADH and DI
consider insensible losses
mobility/safety
specialty mattress/bed
restraints
q2 turns
early mobilization
ROM and splinting
rehab
nutrition
collaborate with dietician
speech therapy for swallowing eval
enteral feed when possible
aspiration precautions
GI/GU
bowel training
encourage fiber and fluid intake
bladder training
stool softeners
intermittent cath
caring for the family
needs
specific truthful consistent information, involved in care, help make choices
complications
sympathetic storming
catecholamine release
s/s
diaphoresis, agitaton, restlessness, posturing, hyperventilation, tachy, fever, HTN
triggered by
stress
loud sound, suction, turning
treatment
suppress sympathetic NS with alpha and beta blockers + opiates and sedatives
prevent
quiet, calm, reduced light, reduced stimuli
Na imbalances
SIADH (decreased Na)
cerebral salt wasting syndrome
CNS mediated renal excretion of Na and water
treat
fluid and Na replacement
DI (increased Na)
CV
myocardial stunning
monitor card enxymes/protiens, ecg, echo, hemodynamics
leads to dysrhythmias
DVT/PE
pulmonary
ARDS, PE, flash pulmonary edema
hyperglycemia
from epinephrine and cortisol
treat with insulin
GI
stress ulcers, decreased motility, constipation
pressure injuries
Spinal injury
causes
vertebral fx
dislocations
hyperextend
fracture + dislocation
vascular supply disruptions
spinal stroke
intervertebral disk (cushion) rupture
expanding mass lesions
overstretching of neural tissue
impact of concussive force
penetration - shrapnel, stabbing
inflammation or infection
Level of Injury - level of injury and amount of cord damage determines deficits & level of functioning
Complete spinal cord injury - loss of ALL motor & sensory function below level of lesion/injury
C1-C2(atlas, odontoid, & hangman's fx, atlantoaxial sublux)
quadriplegia from neck down - no resp, bowel, bladder, sensation or motor abilities
vent dependent
C5
phrenic nerve (diaphragm intact, but not intercostals -> weak cough
able to move head, shoulders, some forearm
may use head/upper limb-controlled WC & devices adapted for mouth
quadriplegia: loss of all function below upper shoulders
C6
able to move arms, palms
may use arms & assistive devices for arms eat, dress, groom, motorized WC
quadriplegia - loss of function below shoulders and upper arms
C7
able to move most of arms/hands
push a WC with handgrips, maybe drive
quadriplegia - loss of control to some portions of hands/arms & all lower body
C8 (only 7 cervical vertebrae, nerves exit below C7)
independent with WC & most ADLs, can push self up & sit
portions of hands/arms & all lower body
quadriplegia - loss of control to some
T1-T5
full control of arms, live independent
phrenic nerve intact but with some intercostal
paraplegia - loss of function below mid-chest
T6-T12
full resp function
paraplegia - loss of control below waist
L1-L3
can flex hips & some of leg
paraplegia - loss of most of control to legs & pelvis
L3-L4
can move upper leg and knee
walking with braces possible
paraplegia - loss of some of control to legs
L4-S5
bowel/bladder possibly impaired
can move most of legs
walking with braces possible
paraplegia - loss of some control to legs, lower injury has more control
complications
spinal shock
short term/temporary physiologic spinal cord dysfunction post injury
starts within a few minutes of injury
can take hours for full effects to occur
lasts 4-6 weeks
during shock nervous system unable to transmit signals, not even reflexes
some function may return once spinal shock subsides
loss of movement and sensation below the level of injury may appear complete, but shock may mask the real extent of the damage
usually, over the first few weeks some function improves
during shock cannot accurately predict recovery or permanent paralysis
return reflexes = end of shock, spasticity may develop after shock
may be accompanied by neurogenic shock if injury at or above T6
Neurogenic shock
usually complete transection of spinal cord at T6 or above total loss of SNS
massive vasodilation
hypotension, brady and poikiolotermea
can be aggravated by
suctioning and past position changes
manage with
fluids, inotropes, vasoconstrictors, atropine, pacemaker
orthostatic hypotension
body loses ability to compensate for position changes because loss of signals from medulla to vasoconstrict
prevent by
changing positions slowly, put on compression stockings and abdominal binder before getting up
anatomic dysreflexia
emergency, occurs with T6 injury or above
s/s
vasodilation
flushing
HTN
headache
blurred vision
pupil constriction
bradycardia
sweating above level of injury
piloerection (goosebumps), cool, pale, skin vasoconstriction below injury
management
REMOVE STIMULUS
BP med if not resolved quick (nifedipine, methyldopa, hydralazine)
elevate HOB
Monitor VS
causes
suction, full bladder/bowel, pain, constrictive cloths, temp changes, etc
ileus
autonomic disruption to GI tract
may need NG to decompress bowel
urine retention
manage
indwelling cath, then self cath or urostomy
caution
don't empty more than 500 ml /cath
autonomic dyreflexia
pressure ulcers
from immobility, poor nutrition and incontinence
hygiene, turns (q15 min) or special bed that turns, optimize nutrition
poikilothermia
from loss of sympathetic function, temp drift toward room temp or hypothermia
assess temp, dress.cover appropriately
usually one more layer than normal
goal temp >35.8 C
depression/grief anxiety/poor coping
pulmonary
atelectasis pneumonia, PE from DVT
spasticity
manage with PT, ROM, muscle relaxers (baclofen)
dx
pinal cord damage can occur WITHOUT vertebral fracture
x-rays - to detect fractures, subluxation, & foreign bodies
CT - visualizes bony pathology well
CT myelography - shows disk, bony or mass lesions and cord compression
MRI - best detection of spinal cord damage
angiography/MRA - to detect vascular injury
CSF analysis - to identify infectious cause
classification
stability
always unstable until proven otherwise
stable
anterior/posterior ligmnets and 1 lamina or spinous process is intact
unstable
ligaments are torn, spine can't protect cord form bony displacement with normal movement
mechanism
type
contusion
ischemia
concussion
transection (complete or imcomplete)
level of injury
cause
management
goals
promote neurological recovery, pain relief, prevent complications, empoer pt and family
pre hospital
spinal immobilization, maintain airway
in hospital
early management
spinal immobilization
stable
minerva braces for cervicothoracic
jewett brace for thoracocolumbroscral
maim J or aspen collar for cervical
long term
robs, laminectomy, and fusion
unstable
traction or halo vest
neuro
thorough & frequent assessments (perianal reflex - good sign)
prepare for & transport to diagnostic tests (spinal immobilization remains on all times until injury has been ruled out, nurse in charge of head during transport/transfer)
airway and breathing
assess ability to inhale and cough, mechanical ventilation, cough assist, suctioning, tracheostomy care
CV
monitor BP/HR, hemodynamics, vasoconstrictors, vasodilators, inotropes, fluids, blood products
goal
SBP >90, MAP 85-90 first 7 days post injury
supportive care
above +
resp -
IS,T/C/DB, abd binder when up, mech vent, 02 sat, cough assist
with injury higher than T6 VC<15-20ml/kg or RR>30 risk for demise, if sat <90 or PaCO2 >45 anticipate intubation
rotational bed & kinetic therapy/chest physiotherapy mobilizes secretions
CV
monitor dysrhythmias & hemodynamics, vasoactive meds & inotropes, prevent DVT, early mobilization, compression hose & abd binder before mobilizing, change positions slowly
neuro
assess carefully & frequently, maintain neck in neutral position (traction - ensure secure device & wts hang freely; brace - ensure secure device; have wrench taped to vest)
mobility/safety
begin ROM early, collaborate with PT/OT, soft touch call light for higher injuries, log roll turns to maintain spinal alignment
skin
good hygiene
turns Q2 or rotational bed (Rotokinetic)
cushions on chair seat (Roho)
padded collars
proper fit of assistive devices
teach to reposition or shift weight 015 min while up pin/brace/traction care
keep knees and ankles from touching, may need splints prevent footdrop
nutrition
encourage/provide nutrition with fiber & hydration, enteral if possible, collaborate with OT for assistive devices to allow pt eat
fluid/electrolytes
monitor labs, 1&0/wts, replace f & e
elimination
bowel:
training (give stool softeners, suppository & rectal stim best post meals), monitor post void residuals. CAUTION if at risk for autonomic dysreflexia use nupercainal ointment for digital stimulation
bladder:
monitor for urinary retention that can cause distended bladder
I&0 hourly initially
teach self-cath or suprapubic cath care as needed
pain
nonpharm, sedatives, analgesics, antispasmodics
watch carefully for hypotension with opioids
neuropathic pain best treated with gabapentin or amitriptyline
spams treated with baclofen - can cause weakness in incomplete SCI injuries
psychosocial
see above + counselling & community resources
sexuality
men may be able to achieve erection, reproduction is possible/contraception may be needed, intercourse may trigger autonomic dysreflexia, collaborate with OT for sexuality concerns
DC/Teaching
bowel & bladder training, nutrition, avoid autonomic dysreflexia, repositioning/skin care, physical therapy/ROM/exercises, cough assist/vent/airway
long-term management
encourage full participation in rehab
treatment
surgical decompression
therapeutic hypothermia
35 C is safe and helpful
steroids?
patho
Primary injury
Secondary injury - injury to the spinal cord hours to days after the primary injury
Incomplete spinal cord injury
varying degrees of motor &/or sensory function preserved below level of tension/injury
Spinal cord syndromes associated with incomplete injuries:
central cord syndrome
edema or injury in cord center, more damage to cervical tracts to arms
greater motor loss in upper extremities than lower, sensory loss varies
Brown-Sequard cord syndrome
spinal cord severed in half laterally, hemisection
ipsilateral loss of motor, position, and vibration, contralateral loss of pain, temp and some touch below injury
anterior cord syndrome
anterior 2/3 of spinal cord disrupted
loss of motor, pain & temp below level of injury; proprioception, vibration, & light touch spared
posterior cord syndrome/dorsal column syndrome
rare, posterior column injury
proprioception, light touch & vibration lost below level of injury
indicate that some tracts are spared/remain functional
symptoms & abilities depend on
the tracts injured & spared
Encephalitis
causes
enteroviruses (hepes)
arboviruses (rabies and lyme)
usually viral
can be bacterial, fungal, or parasitic
what is it
acute inflammation of the brain
lasts
weeks to months
leads to
neuro injury
risk factors
immunocompromised
very old or very young
S/S
same as meningitis but seizures and focal neuro deficits (paresthesia/muscle spasms) are more common
Dx
same as meningitis
treatment
same as meningitis
nursing
same as meningitis
recovery
takes weeks to months
Intracranial aneurysms
what is it
weakening of the vessel wall causes dilation or ballooning which may rupture or put pressure on surrounding brain tissue
rupture primarily in subarachnoid space
risk factors
smoking
alcohol
HTN
female
congenital weakness in vessel wall
primary problems
rupture
vasospasm
s/s
nuchal pain and rigidity (bleed into subarachnoid -> meningitis s/s)
photosensitivity
sudden severe headache (thunder clap)
dx
LP (look for bilirubin in CSF)
cerebral angiogram
CT
treatment
treat electrolyte abnormalities
stool softeners (don't strain)
control hypertension
analgesics (limit narcs)
surgery
coiling
placed with endovascular procedure
surgical evacuation of hematoma if not in subarachnoid space
clipping
place with microsurgery
nursing
ASSESS
even subtle changes are significant
monitor and manage vasospasms!
caused by calcium in hemorrhaged bloor irritating vessels or by inflammation
peak incidence 5-9 days after rupture
s/s
change in LOC and new neuro deficits
dx
transcranial doppler
treatment
nimodipine
treat and prevent
triple H
hypervolemic expansion
hemodilution
hypertension
sometimes angioplasty
bowel regimen including stool softeners
monitor for complication of hydrocephalus, seizures, rebleed
BP management
pt and family emotional and social support
aneurysm precaution to prevent rebleed (decrease stress/environment/bear down/etc)
early ambulation
pulmonary toilet
Brain tumors
complications
Na imbalance (ADH in brain)
seizures
intracranial hemorrhage
DVT/PE/VTE
infection (wound, intracranial, meningitis, bone)
gastric ulcers (prevent with PPI or H2 blocker)(from stress)
Increased ICP
what is it
WHO tumor classes
I = benign
IV = highly malignan t
benign tumors can be bad because of edema, shifting structures and increased ICP
primary (start in brain) or secondary (start somewhere else)
symptoms
depend on location and tumor type
neoplasm in the cranium
classifications by cell type
meningeal tumors
growth rate
slow
treatment
surgery
usually
benign
metastatic tumors
% of cancer pt
20-40%
gliomas
astrocytoma
grades
I-IV
IV : glioblastoma multiforme (most common and fastest growing brain tumor glioma)
treatment
no cure, average survival 12-18 months
I : 85% cerebellar
treatment
craniotomy for tumor removal
ependymoma
usually
benign
originates in
lining of ventricles
treatment
radiation
pituitary tumors
??
treatment
radiation
usually used as primary or adjunctive treatment
chemotherapy
can be used but causes ...
systemic toxicities and may not cross blood brain barrier
may be delivered by...
ommaya reservoir (gradual release)
biodegradable wafer placed in resected cavity
can combine with surgery or radiation
surgery
may combine with angiography and embolization
types
stereotactic procedures
open craniotomy
endoscopic procedures
medications
anticonvulsants
antiemetics
steroids
analgesics
histamine receptor blockers
nursing
symptom management
control ICP
accurate and frequent neuro checks
promote rehab
S/S
related to
increased ICP and compression of brain structures
assess
duration, frequency, severity, and timing of symptoms
imaging
CT, MRI, EEG, PET
good dx needed (include family)
subtle changes
definitive dx
biopsy
stereotactic needle biopsy or craniotomy
Delirium
types
hypoactive
flat effect, withdrawal, lethargy, decreased responsiveness
hyperactive
agitation, restless, pulling at lines, emotional lability
what is it
acute change in consciousness + inattention and change in cognition OR perception
causes
THIINK mnemonic
Infection/sepsis
Immobilization
Hypoxemia
Nonpharmacologic interventions: no glasses/hearaids, sleep hygiene, noice, music, ambulation
Toxic situations: CHF, shock, dehydration, deliriogenic meds (sedatives), new organ failure
K+ or electrolyte problems
assessment
CAM-ICU
squeeze my hand when I say the letter A
does a rock float
Management
ABCDEFS bundle (ICU liberation)
Delirium
assess, prevent, and manage
Early mobility and exercise
Choice of sedation and analgesia
no drug has been shown to be affective but haloperidol (haldol) has higher mortality (as light as possible)
Family engagement and empowerment
Both spontaneous awakening/breathing trials
wake up and breathe protocol
decrease sedation, pts allowed to breathe spontaneously with T pice or change mode of vent
Sleep
Assess, prevent, and manage pain
arteriovenous malformation (AVM)
what is it
dilated arteries and veins without a capillary system
tangle of blood vessels tha tdoes not feed brain tissue
congenital and enlarge with age
s/s
seizures
headache
rupture
neuro deficits
dx
CR or MRI
treatment
radiation (shrink)
embolization (stabilize)
surgery (perferred)
nursing
same as aneurysms
Intracranial surgery
nursing
pre op
discuss anticipated post op appearance (bruises, swollen eyes), potential for a ventriculostomy, sensory changes, decreased attention span, pain, and behavior changes
encourage open communication
explain procedure
prophylactic steroids and antibiotics
post op
positioning
same as for increased ICP (HOB and neck neutral)
incision drainage
inspect dressing and linens for bleeding and CSF leak (halo)
ICP management and CSF drainage devices
monitor labs
sodium and serum osmolality and electrolytes
may develope DI or SIADH
continuously assess neuro status, any seizure activity and VS
respiratory support
same as for increased ICP, monitor ABGs, T/DB (no coughing)
neuro assessment
loc very important
meds
diuretics, steroids anticonvulsants, GI acid reducers, analgesics
anxiety
reinforce and clarify information, encourage verbalization
assess for potential complications
IICP, cerebral edema, hematomas, shock, hydrocephalus, respiratory infections, meningitis
prevent contamination of area leaking CSF
DON'T
suction nose or nasal packing, fingers in nose or ears, pick anything
DO
proper positioning on site of leak
nose
dressing under nose
ear
place dressing and turn to side of leak
anticipate self esteem disturbances from long term neuro deficits and appearance
management
patient/family yteaching
safety measures for neurologic deficits
assess and support speech, vision, cognitive motor abilities
referrals for support groups
encourage participation in care and rehab
why
to get biopsy, remove mass/lesion, repair abnormality, or place device
Craniotomy
what is it
part of skull removed for access to briain
guided by
ultrasound
types
endoscopic/keyhole surgery
hole made in skull or through lip/nose so that endoscopic instruments can be used
cortical mapping/somatosensory evoked potentials
language/ motor / sensory areas of brain identified during surgery thru electromyography (EMG)
data used to create a cortical map
pt can be awake during craniotomy to assess brain function
somatosensory response
direct stimulation
stereotaxy
CT or MRI done locate lesion and determine coordinates minimize manipulation
maximizes resection
frame or scalp markers placed
neuroendoscopy
angled, flexible endo scope improves visualization and evaluation
transsphenoidal and transnasal surgery
endoscopic instruments used to remove pituitary tumors and cysts thru nose and sphenoid sinus
complications
CSF leak (halo) and pneumocephalus (mt fuji sign, air) usually resolves spontaneously
teaching
avoid blowing nose, coughing, sneezing, drinking with a straw, bending over, straining on the toilet for 4 weeks
must take hormone replacement for life for pituitary tumor removal
nasal and sinus packing
sometimes with
fat from abd or thigh (also have to take care of that wound)
do not
remove nasal packing!
coma
unresponsive wakefulness syndrome (vegetative state)
what
period of sleep like coma followed by awake state with inability to respond to environment
cause
damage to cerebral hemispheres, brainsteem intact
dx
wait 4 weeks after surgery
nursing
multidisiplicary support
use principle of health literacy teaching
classifications
light coma, coma, deep coma
assess with ranchos los amigos scale
what
alterd LOC from damage to RAS
management
basic needs and coma stimulation (keep routine)
Hemorrhagic stroke
common causes
aneurysms
arteriovenous malformations
brain tumors
trauma
what is it
bleeding in the brain tissue (intracerebral), ventricles (intraventricular) or subarachnoid space
risk factor
anticoagulant use
endocrine system
diabetes insipidus (DI)
what
not enough ADH or poor response to ADH
kidneys don't reabsorb water
diuresis and hypovolemia (dry inside)
Causes
nephrogenic (kidneys do not respond to ADH) or neurogenic (decreased ADH production or pituitary removal)
management
chlorpropamide or thiazide diuretics for nephrogenic
fluid replacement
give ADH (pitressin, vasopressin, desmopressin) (may cause HA CP, n, or edema
I&O
daily wt
monitor electrolytes
assess LOC, VS often
allow to drink freely
IV fluid to replace volume
s/s
Polyuria
Polydipsia
Nocturia
dx
low ADH level high serum osmo (>295mOsm/kg)
low urine osmo <500mOsm/kg & specific gravity <1.001-1.005
hypernatremia
water deprivation test - hold all water - if kidneys do not concentrate urine then DI
Syndrome of inappropriate antidiuretic hormone (SIADH)
dx
hyponatremia, low serum osmo, high urine Na and osmo, high serum ADH
nursing
goal is to restore NA & fluid volume to safe level
fluid restriction (600-1000ml/day)
diuretics (furosemide)
3% NaCl if severe hyponatremia
warning - 3% NacI may cause seizures
give 3% NaCI with pump
frequent Na checks with 3% NaCl
don't give if serum osmo is >310
demeclocycline
(induces nephrogenic DI, evidence of effectiveness is limited
seizure precautions and phenytoin
daily weights and hourly i&o
conivaptan
ADH inhibitor
s/s
especially if Na <125
muscle twitching
seizures
confusion
decreased DTRs and weight gain
N/V
oliguria
what is it
posterior pituitary releases ADH even when serum osmo normal
water intoxication (soaked inside)
