Chapter 66:Management of Pt w/ Neuro Dysfunction

Three ways of craniotomy

1) supratentorial craniotomy - above the tentorium 2) posterior fossa- below the the Tentoruun 3 TRANSSPHENODIAL ( through the mouth nasal sinuses, often used to gain access to pituitary gland

Brain can maintain a steady perfusion if the systolic is ___-___ and ICP is < _____.

50-150; <40

Normal CPP

70-100

Epilepsy

At least two unprovoked seizures occurring more than 24 hours apart

As brain tissue swells, several mechanisms compensate for increasing ICP, these include

Autoregulation Decreased production and flow of CSF

Cushing response triad

Bradycardia Hypertension Bradypena Is a grave sign and needs intervention fast If not tx then herniation of brain stem and occlusion of brain flow occur

Common diagnostic procedures used to identify the cause of unconsciousness include

CT PCT MRI MRS EEG SPECT PET

Increased ICP may reduce ___ blood flow, resulting in ____ and cell death

Cerebral Ischemia

neurogenic diabetes insipidus presents with

Excessive urine output Decreased tribe osmolality Serum hyperosmolarity

Patient with Cpp less then 50 have

Irreversible neuro damage

Increased Intracranial Pressure (ICP) is usually measure in the

Lateral ventricles Normal pressure being 0 to 10 with 15 being the upper limit of normal

Later given to maintain seizure free

Phenytoin,, phenobarbital

Herniation refers to

Shifting of brain tissue from area of high pressure to an area of low pressure

The CPP is calculated by

Subtracting the ICP from mean arterial pressure (MAP) Ex: MAP Is 100 and ICP 15 then CPP IS 85

Equal, normal reactive pupils in pt who is unconscious

Suggest that coma is toxic or metabolic in organ

A decrease in PACO2 has a _____ effect limiting blood flow to the brain

Vasoconstrictive

If ICP is equal to MAP,

cerebral circulation ceases

Changes in ICP are closely linked with

cerebral perfusion pressure (CPP)

Glasgow Coma Scale

eyes, verbal, motor Max- 15 pts, below 8= coma, below 3 = severe neuro impairment, brain death, or pharm inhibition of neuro response

Primary headaches

migraine, tension, cluster, and chronic daily headaches No organic cause can be identified

Akinetic Mutism is a state

of unresponsiveness to the enviroment in which the pt makes no voluntary movement

craniotomy

opening of the skull Used to remove tumor, relieve increased ICP , rid of blood clot, control hemorrhage

Focal seizures

originate within one hemisphere in the brain

Intracranial Pressure ( ICP)

pressure exerted by the volume of the intracranial contents within the cranial vault

Migraine

severe, recurring, unilateral, vascular headache

Monro-Kellie hypothesis

theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents—brain tissue, blood, or cerebrospinal fluid—causes a change in the volume of the others; also referred to as Monro-Kellie doctrine

Coma

unarousable unresponsiveness in which there are no purposeful responses to internal/external stimuli Brainstem function may be present

aura phase of migraine

- aura is characterized by focal neuro symptoms - visual disturbance -numbness, tingling of face or hands - mild confusion - extremity weakness - dizzy

Before and during a seizure, the pt is assessed for

- circumstance prior to S - occuranxe of aura - first thing pt does in S ( stiffness, staring, shaking) - areas of body involved - type of movement - pupil size - automations - incontinence - unconsciousness - inability to speak after seizure - Cognitive status

An Altered level of consciousness (LOC) is present when PT is not

- not oriented -does not follow commands -needs persistant stimuli to achieve a state of alertness

Migraine with aura can be divided into 4 phases

- premonitory phase - aura -headache - recovery

Major complications for altered LOC may include

- respiratory distress/failure -pneumonia -aspiration -pressure ulcer - venous thromboembolism (VTE) -contractures

status epilepticus have a cumulative effects

- vigorous muscle contracts increase metabolic demand and interfere with Respiration

Those goals ( from last card) are accomplished by

-admin of osmotic diuretics -restricting fluids - draining CSF - controlling fever - maintaining systemic blood pressure and O2 - reducing cellular metabolic demands

Goals of care for pt with altered LOC

-clear airway -protection from injury -fluid volume balance - nutritional needs - intact oral membranes - normal skin integrity - no corneal irritation - thermoregulation -correct urinary elimination

major nursing diagnosis for altered LOC may include

-infective airway clearance - risk for injury -deficient fluid volume -risk for imbalance nutrition - imparted oral mucosa or skin/ tissue integrity

Assessment of Altered LOC INCLUDES evaluation of

-mental status -cranial nerve function - reflexes - motor/sensory function

Cheyne-Stokes respiration suggestions lesions deep both hemispheres

-upper brain stem -basal ganglia

In early stages of cerebral ischemia, vasomotor centers are stimulated causing

-↑ systemic BP to maintain cerebral blood flow -slow bounding pulse -irregular respirations *These changes may suggest ↑ ICP

Chart on of 2000 for all anticonvulsant meds I'm not writing that Shit

.

Cerebral edema or swelling is defined as

Abnormal accumulation of water/fluid in the intracellular space, extra cellular space or both associated with an increase in volume of brain tissue

The rigid cranial vault contains

Brain tissue ( 1400g) Blood 75ml CSF 75ml

Complications of increase ICP include

Brainstem herniation Diabetes insipidus Syndrome of inappropriate antidiureric hormone (SIADH)

_____ disease is the leading causes of seizures in older patients

Cerebrovascular

Brain stem herniation results from an excessive increase in ICP. This results in

Cessation of blood flow to brain, leading to brain anoxia and brain death

Autoregulation refers to the brains ability to

Change the diameter of its blood vessels to maintain constant cerebral blood flows during alterations is systemic blood pressure

Early clincal manifestations of ICP include

Changes in LOC ( agitation, slowing speech, and delay in response to verbal suggestions) This is later followed by : abnormal respiratory and vasomotor responses Then later pt becomes stuporus, reacts to only very loud and painful stimuli Then followed by coma, decorticate, decrebration, flaccidity position Then brain death

trigeminal autonomic cephalgias include

Cluster headaches Paroxysmal hemicrania

SIADH treatment

Fluid restriction (< 800 ml with no free water) ( correct the hyponatremia) 3% hypertonic saline solution

3 main seizures

Focal Generalized Unknown

LOC is an indicator of neuro function, it is assessed based on the criteris in the ____ scale

Glasgow coma

equal or unequal in diameter pupils in pt who is unconscious

Helps determine the location of lesions

cranial arteritis

In older generation

Ataxic respiration's with irregularity in depth/rare is an ominous sign of damage to

Medullary center

The first priority of tx for pt with altered LOC is to

Obtain and maintain patent airway

Generalized seizures

Occur In and rapidly bilaterally distributed networks

___ and ____ May be given to dehydrate the brain tissue and reduce cerebral edema

Osmotic diuretics (mannitol) Hypertonic saline (3%)

Locked-in syndrome results from a lesion affecting the pond and results in

Paralysis and the inability to speak, but vertical eye movements and kid elevation remain intact and are used to indicate responsiveness

SIADH pt presents with

Volume overloaded Urine output diminishes Serum sodium concentration become dilute

Cushings response ( Cushing reflex)

A clinical phenomenon is seen when cerebral blood flow decrease When pt is ischemic, the vasomotor response triggers and increase in arterial pressure in an effort to overcome ICP

Lab test used to identify the cause of unconscious include

Blood glucose Electrolytes Serum ammonia Liver function tests; BUN, serum osmolality, Calcium level, Pt, PTT

Increased ICP from any cause decreases

Cerebral perfusion, stimulates further swelling and may shift brain tissue, resulting in herniation- which is fatal

Medical management goal of increased ICP

Decrease cerebral edema, lower volume of CSF, decrease cerebral blood volume while maintaining cerebral perfusion

neurogenic diabetes insipidus is the result of

Decreased secretion of antidiuretic hormone (ADH)

What is given to halt seizures immediately

Diazepam (Valium) Lorazepam (Ativan) Fosphenytoin

Minimally Conscious State (MCS)

Differs from persistent vegative state in that the pt has inconsistent but reproducible signs of awareness

Cephalagia also means

Headache

premonitory phase of migraine

Hours- days before Depression, irritability feeling cold, cravings, anorexia, change in activity, increased urination, diarrhea, constipation

As brain tissue expands in the inflexible cranium, _____ rises, and _____ perfusion is impaired

ICP cerebral

Treatment of neurogenic diabetes insipidus includes

IV fluid Electrolyte replacement Synthetic vasopressin (desmopressin)

Concentration of CO2 in the blood and brain tissue plays a role in the regulation of cerebral blood flow. An increase in partial pressure of arterial carbon dioxide (PACO2) causes cerebral vasodilation learned to

Increased central blood flow and increased ICP

SIADH is a result of

Increased secretion of ADH

Progressive pupil dilation in pt who is unconscious

Indicated increasing ICP

Fixed dilated pupils in pt who is unconscious

Indicated injury at level of midbrain

clincal manifestations of alterations in LOC

Initial alterations - restlessness, increased anxiety Later - pupils become sluggish, as pt becomes comatose pupils become fixed, decreased verbal an motor response

ICP can be monitored with

Intraventricular catheter Subarachnoid bolt Epidural/ subdural catheter

CO may be manipulated to provide adequate perfusion to the brain. This can be done by using

Intropic agents such as dobutamine (dobutrex) and norepinephrine (levophed)

Women with epilepsy note an increase in seizures during

Menses

Hyperventilation suggests onset of ____ problem or _____ damage

Metabolic Brain stem

Tension-type headache

Mild to moderate bilateral headache with a sensation of a tight band or pressure around the head. Most common

If pt is comatose and has localized signs such as abnormal pupillary and motor responses, it is assumed that _____ ___ is present until proven otherwise

Neuro disease

PERSISTENT VEGATATIVE STATE (PVS) is a condition in which

The unresponsive patient resumes sleep wake cycles after coma but is devoid of cognitive of affective mental function

If the pt is comatose but pupillary light reflexes are preserved a ___ or ___ disorder is suspected

Toxic Metabolic

status epilepticus (acute prolonged seizure activity ) is a series of generalized seizures that occur

Without full recovery of consciousness between attacks Medical emergency