Module 9: Intracranial Regulation
What are some nursing interventions to decrease ICP
- Raise HOB to 30 - keep neck in neutral position - avoid hyperthermia - administer pharm (mannitol or high Na) - Manage pain = can increase ICP - manage seizures = can increase ICP - decrease stimulation: minimize visitors, decrease light and noise - minimize nursing task --> NEVER CLUSTER CARE this will be too much stimulation to pt. - hyperventilation --> decrease CO2 - make sure patient is well oxygenated (PaO2 >60mmHg) - may need NG tube to suction to relieve the intraabdominal pressure.
What are the latest signs of increased ICP or impaired intracranial regulation?
- abnormal posturing (decerebrate & decorticate) - Cushing's traid (systolic HTN, bradycardia, bradypnea)
What are clinical manifestations of impaired intracranial regulation or increased ICP?
- changes/decrease in LOC (early sign) - Severe HA (early sign) - Nausea/vomiting - alteration in breathing patterns - ocular signs (dilated or pinpoint nonreactive pupils) - cranial nerve deficit - seizures -deterioration in motor function - contralateral hemiparesis/hemiplegia - Abnormal posturing (decorticate/decerebrate) LATE - Change in VS - Cushing's triad (LATE SIGN) - change in body temp
List some nursing respiratory intervention you would do for a patient with a C6 SCI.
- monitor respiratory status (secure airway) = 1st PRIORITY - regularly assess breath sounds, ABGs, skin color, breathing patterns, subjective comments about the effort to breath & amount & color of sputum - provide O2 and suction PRN - maintain oxygen higher than 92% - reduces hypoxemia that causes bradycardia that can worsen secondary injury. - assist with intubation & mechanical ventilation if necessary. - assist client to cough by applying abdominal pressure when attempting to cough - teach the client about incentive spirometer use & encourage the client to perform coughing & deep breathing regularly
A patient is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV fibrinolytic therapy. What is the appropriate nursing response?
- patients must meet strict eligibility criteria for FIBRINOLYTIC (THROMBOLYTIC) therapy, including giving the drug ideally WITHIN 3 HOURS AFTER THE FIRST STROKE SYMPTOMS. - The patient's symptoms began well before the 3 hours
What is autonomic dysreflexia?
- uncontrolled HTN - this is triggered by: painful, irritating, or strong stimulus below the level of injury. - Ex: fecal impaction, distended bladder, PE, blisters, constrictive clothing Tx: SIT PATIENT UP; notify HCP; loosen any clothing, assess and correct any instigating cause. - in normal people, when you have this stimulus (ex: fecal impaction), it goes up the spinal cord and to the brain and the brain sends down messages. But with patients with SCI, the stimulus cannot go beyond that injury, so it keeps going back and forth.
what is the Serial Neurological Examinations order (nursing assessment)?
1. ABCs - maintain SpO2 @ least 92% - GCS under 8 = intubation likely - Maintain a target SBP >90 & <140 2. VS 3. LOC - orientation to person, place, time, situation - drowsy, sleepy, lethargic, obtunded, stuporous, coma 4. GCS --> determines severity
T/F An increase in the volume of 1 component of the intracranial content will result in a decrease of volume in 1 or 2 of the other components. A. true B. false
ANSWER: TRUE Rationale: - Monro-Kellie doctrine states intracranial contents are contained in a fixed vault (skull); therefore, their total volume must remain constant. - If one of the components increases a reciprocal decrease in one or both of the other components must occur or an overall increase in ICP will result. - ability to compensate is limited. If the volume continues to increase, the compensatory mechanisms deteriorate, resulting in neurologic decline, increase ICP, and ischemia.
Which assessment finding would the EARLIEST and MOST sensitive indicator that there is an alteration in intracranial regulation? A. change in level of consciousness B. subclinical seizures C. loss of primitive reflexes D. unequal pupil size
Answer: A Rationale: - A CHANGE IN LOC is the earliest & most sensitive indication of a change in intracranial processing. This is reviewed with the GCS. - the inability to focus may indicate a cange, but it not one of the earliest indicator or components of the GCS - a change in pupil size or unequal pupils or subclinical seizures may indicate a change, but they are NOT one of the earliest indicators or a component of the GCS.
You are called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, what do you think you should do FIRST? A. turn the patient to the side B. start oxygen by mask at 6L/min C. restrain the patient's arm and legs to prevent injury D. record the time sequence of the patient's movement and responses as they occur
Answer: A Rationale: - During the seizure, the nurse should maintain a patent airway, protect the patient's head, turn the patient to the side, loosen constrictive clothing, and ease the patient to the floor, if seated. - the patient should not be restrained and no objects should be placed in the mouth. - after the seizure, the patient may require repositioning to open and maintain the airway, suctioning, and oxygen. - when seizure occurs, the nurse should carefully observe and record details of the event because diagnosis and subsequent tx often rest solely on the seizure description.
Which is a priority non-operative treatment following a spinal cord injury? A. stabilization B. spinal fusion C. cervical traction D. pain management
Answer: A Rationale: - stabilization is mandatory to prevent further injury. - it eliminates any damaging motion at the injury site to avoid worsening the patient's condition - pain management is important, but it is a lower priority that stabilization
A client with a history of seizures is placed on seizure precautions. Which emergency equipment will the nurse provide at the bedside? (SATA) A. oxygen B. NG tube C. suction setup D. padded tongue blade
Answer: A & C Rationale: - seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available. - and pad the side rails if known ahead of time - padded tongue blades DO NOT belong at the bedside and should NEVER be inserted into the patient's mouth because the jaw may clench down as soon as the seizure begins
Which intervention would help to facilitate patient safety during eating for a patient who has dysphagia? (SATA) A. help the patient to maintain a sitting position for 30 minutes after completing a meal. B. help the patient to position the head in backward extension to promote swallowing. C. place patient in a low fowler's position. D. place food on the unaffected side of the mouth. E. check mouth for pocketing of food
Answer: A, D, E Rationale: - nurse should check the mouth for pocketing of food after eating to prevent collection and putrefaction of food and/or aspiration. - nurse should help the client to maintain a sitting position (not low fowler's position) for 30 minutes after completing a meal to prevent regurgitation of food. - placing food on the unaffected side of the mouth prevents it from collecting on the affected side. - the patient should be made to sit in an erect position to provide an optimal position for chewing and swallowing without aspiration. - the nurse should help the patient to position the head in forward flexion in preparation for swallowing.
A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to: A. breathe with respiratory support B. drive a vehicle without hand controls C. ambulate with long leg braces and crutches D. use a powered device to handle eating utensils.
Answer: B Rationale: - a patient with injury at the level of C7 to C8 may have the following rehabilitation potential: - ability to transfer self to wheelchair - roll over and sit up in bed - push self on most surfaces - perform most self care - use wheelchair independently - drive a car with powered hand controls
A client with a spinal cord injury at C5-C6 becomes flushed and reports a sudden severe HA. VS shows a blood pressure of 190/100 mmHg and a HR of 50 beats/min. What is the appropriate nursing intervention? A. notify the HCP B. place the client in a sitting position C. check the client for fecal impaction D. check the urinary catheter for obstruction
Answer: B Rationale: - placing the patient in a sitting position is something we can do IMMEDIATELY to bring the BP down. - autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is neurologic emergency in clients with spinal cord injury T6 and above. - manifestations: HTN (up to 300 mmHg systolic), throbbing HA, bradycardia, and diaphoresis - triggered by noxious stimuli - the 1st PRIORITY of care is to place the client in a sitting position. Then, contact the HCP to treat the increased BP. Rapid tx is essential to prevent a stroke. - all other actions can be taken after placing the client in the sitting position.
The patient's wife must leave her husband's bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to patient safety while she is gone? A. apply restraints B. maintain the bed in a lower position C. sit with the patient until his wife returns D. place the call light in the patient's right hand
Answer: B Rationale: - restraints should not be applied until all alternate methods have been attempted. - sitting with a client for 2 hours is impractical for the nurse - placing the call light in the client's right hand would not be effective because he has deficits in his right visual field and may have right field neglect
A patient with a head inury has an arterial BP of 92/50 mmHg and ICP of 18 mmHg. The nurse uses the assessments to calculate the cerebral perfusion pressure (CPP). How should the nurse interpret the results? A. the CPP is so low that brain death is imminent B. the CPP is low, and the BP should be increased C. the CPP is high and the ICP should be reduced D. the CPP is adequate for normal cerebral blood flow
Answer: B Rationale: - the CPP is the pressure needed to ensure blood flow to the brain to prevent secondary brain injury. - CPP = MAP - ICP - MAP = DBP + 1/3 (SBP-DBP) - CPP less than 50 mmHg is associated with ischemia and neuronal death. - CPP less than 30 mmHg results in ischemia and is incompatible with life. - it is critical to maintain MAP when ICP is elevated. A patient with a head injury may require a higher blood pressure. Increasing MAP and CPP, it increase perfusion to the brain and prevent further tissue damage.
An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which assessment findings does the nurse anticipate? SATA A. constant smiling B. intellectual impairment C. deficits in the right visual field D. disorientation to time, place, and person E. inability to discriminate words and letters
Answer: B, C, E Rationale: - patient's experiencing a LEFT HEMISPHERE STROKE display an inability to discriminate words and letters, intellectual impairment and defictis in the right visual field. - disorientation, constant smiling, and neglect of left visual field are manifestation of a right hemisphere stoke.
For the patient admitted for observation after a minor head injury, which assessment findings would support the nurse's suspicion of an increasing intracranial pressure? (SATA) A. the patient is alert and oriented B. the patient is vomiting without preceding nausea C. the patient is experiencing hemiplegia D. the patient has regular respiratory rate of 14 breaths/min E. the patient has unilateral pupil dilation
Answer: B, C, E Rationale: - unilateral pupil dilation, vomiting, and hemiplegia are signs of increased intracranial pressure. - a patient with increased ICP would likely have an impaired level of consciousness rather than being alert and oriented. - he or she would also have an irregular, NOT regular, respiratory rate.
The nurse is caring for a patient with a head injury. Which finding requires immediate nursing interventions? A. increased pupil size B. nausea & vomiting C. agitation & confusion D. elevated BP
Answer: C Rationale: - THE FIRST SIGN OF INCREASED ICP IS A DECLINING OR CHANGE IN LOC. - nurse must assess the patient immediately when this symptom is present. Patients may be agitated & slightly confused before progressing to difficult to arouse as an early assessment finding of increase ICP. - changes in VS, N&V, pupillary response occur as ICP increases
Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)? A. sims B. trendelenburg C. semi-fowler's D. prone
Answer: C Rationale: - position a patient with an increased ICP with his or her head elevated, as in semi-fowler's position (typically at 30 degrees). Wrong answer rationale: - Sims' position is side-lying with one leg flexed, which may elevate intracranial pressure. - a prone position is flat with the face down. - the trendelenburg position is supine with the feet higher than the head. - The head is not elevated in thesep positions, which is dangerous for someone with ICP.
Which is a priority non-operative treatment following a spinal cord injury? A. Pain management B. Spinal fusion C. Stabilization D. Cervical traction
Answer: C Rationale: - stabilization eliminates any damaging motion at the injury site to avoid worsening the patient's condition. - the patient should be stabilized before a care plan is implemented. Wrong answer rationale: - pain management is important, but it is a lower priority than stabilization. - spinal fusion is a surgical procedure --> operative - cervical traction is a closed reduction with skeletal traction and is used for early realignment (reduction) of the injury --> operative
The spouse of a patient brought to the ED reports that 6 hours ago, her husband began having difficulty finding words. The patient has since become progressively worse. Upon assessment, you not right hemiparesis and urine incontinence. What is the PRIORITY NURSING INTERVENTION for this patient currently? A. provide perineal care B. assess for gag reflex C. elevate the HOB D. perform a linen and gown change
Answer: C Rationale: - the airway must be protected. Elevating the HOB prevents swallowing concerns and allows for an open airway. - the patient should then be assessed for a gag reflex, perineal care should be provided, and linens changed.
JL is agitated and has multiple cerebral confusions reported on the CT of the head. The intracranial pressure monitor reveals a pressure of 28 mmHg. What drug will the nurse anticipate being prescribed for JL? A. morphine B. lorazepam C. mannitol D. phenytoin
Answer: C. Mannitol Rationale: - increased ICP is often the result of cerebral edema, as a result of TBI. Therefore, an osmotic agent (MANNITOL) is administered. Mannitol draws fluid from the brain into the blood to decrease cerebral edema. - important to monitor for adverse effects! - hyponatremia, hypokalemia, pulmonary edema, rebound increased ICP - the other listed drugs are NOT appropriate to manage increasing ICP
Which clinical manifestation does the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? A. HTN B. neurogenic spasticity C. bounding pulse pressure D. bradycardia
Answer: D Rationale: - Bradycardia, hypotension, and peripheral vasodilation - neurogenic shock is caused by the loss of vasomotor tone caused by injury and is characterized by BRADYCARDIA and HYPOTENSION. - loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output Hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.
T/F Acute sustained elevations in ICP above 20 mmHg will result in reduced cerebral perfusion pressure (CPP) and cause cerebral ischemia. A. true B. false
Answer: TRUE Rationale: - When ICP rises, CPP falls. - When CPP falls, blood flow to the brain is compromised, brain cells become ischemic and begin to die. b
Thirty minutes later, the wife asks for a glass of water because her husband is thirst. How will the nurse respond?
Before the aptient is given any liquids, food, or meds, he must be SCREENED for the ABILITY TO SWALLOW. - Also, his gag and cough reflexes must be checked, After he has a swallowing screen, and it is determined that he can tolerate liquids or food without aspirating, fluids and food will be provided
What is neurogenic shock clinical manifestations?
Bradycardia, hypotension, and peripheral vasodilation. Tx: IV fluids (MAP 85-90) & Vasopressors
What is the physiologic consequence of impaired ICR? - cerebral edema
CEREBRAL EDEMA - this results in increase brain size --> increased extravascular fluid in brain. - AFFECTS PERFUSION/OXYGEN Cause: - mass lessions (brian tumor, hemorrhage, hematoma) - trauma; head injuries; brain surgery - infection - toxic/metabolic conditions
What is the physiologic consequence of impaired ICR? - INCREASED INTRACRANIAL PRESSURE
INCREASED INTRACRANIAL PRESSURE - potentially life threatening - results from an INCREASE in ANY or all 3 (blood, brain tissue, CSF) within the skull - affects PERFUSION = increases risks of brain ischemia and infarction - sustained pressure > 20 mmHg = life threatening - normal = 5-15 mmHg
What is the normal and abnormal ICP?
Normal = 5-15 mmHg Abnormal = >20 mmHg (there is increased ICP)
What is the normal and abnormal CPP (cerebral perfusion pressure)?
Normal = 60-70 mmHg Abnormal = < 50 mmHg --> associated with ischemia and neuronal death
What decreases ICP?
Positioning/posture --> raise HOB ~30 degrees & keeping the neck in a neutral position maintain normal body temp - mannitol --> diuretic - limit visitors, dimming lights, sedatives, speaking quietly
What indicates critical neuro-worsening?
This is a serious deterioration in clinical neurologic status and requires an immediate physician notification: - NEW decrease in pupillary reactivity - NEW pupillary asymmetry or bilateral mydriasis - NEW focal motor deficit - herniation syndrome or Cushing's triad
For the patient with an increased intracranial pressure (ICP), which precautions would the nurse implement to protect the patient from potential seizure activity? (SATA) A. provide stimulation to the patient to avoid comatose behaviors. B. restrain the patient to the bed to protect from injury. C. keep suction equipment really available at the patient's bedside. D. pad side rails and maintain an airway at the bedside per facility protocol. E. Use prophylactic antiseizure therapy during first seven days after injury
answer: C & D rationale: - using padded side rails helps to prevent injury from falling. - keeping an airway at the bedside and suction equipment readily available is helpful in managing seizures if they occur. - Utilize prophylactic anti-seizure therapy during the FIRST seven days after injury to prevent seizures Wrong answer rationle: = providing stimulation to the patient may aggravate the condition; therefore, the environment should be quiet. - DO NOT restrain the patient, chances of injury are higher.
What is the earliest sign of increased ICP?
changes/decrease in level of consciousness = flattening of affect, changes in orientation, restlessness, irritability severe headache - pain worsens by coughing, sneezing, defecation
What increases ICP?
intra-abdominal and intrathoracic pressure - suctioning, coughing, valsalva maneuver, hip flexion Hyperthermia = increases ICP - if patient's head is not raised or is practically laying down - increased CO2 levels = causes vasodilation - Pain, seizure activity, fever, hypercapnia (increased CO2), suctioning, coughing, clustering cares
The nurse completes the NIHSS. The NIHSS scare is 6. The patient asks will be have permanent deficits? How would you respond?
the nurse knows that the NIHSS has been found to be an excellent predictor of patient outcomes. Higher stroke scale scores indicate higher severity and poorer prognosis (max score of 42 points). - stroke recovery is complex and individual recovery patterns differ, but he should see improvements with rehab.