Shock; Neurologic Ax; Seizures; Increased Intracranial Pressure; Head Injury and Cranial Surgery

* Distributive Shock *

* Defect in vascular smooth muscle tone * = blood volume stays the same but size of compartment increases (vasodilation) * Same mechanism for: ■ Neurogenic ■ Anaphylactic ■ Septic shock.

3. Cerebral Perfusion Pressure (CPP)

* Difference between the Mean Arterial Pressure (MAP) and the Intracranial Pressure (ICP). * CPP = MAP - ICP. * This represents the pressure gradient driving cerebral blood flow (CBF) and hence oxygen and metabolite delivery. *** the MAP or BP must kept up to allow for adeq. perfusion of the brain despite elevated ICP. Complications if: - High : herniation Patient may be at increased risk for hypoxemic respiratory failure and ARDS, which can contribute to cerebral ischemia and prolonged mechanical ventilation. - Low: anoxic brain injury Patient is at risk for further neurological injury from cerebral hypoperfusion. Consider interventions to increase MAP (e.g. vasopressors, fluid bolus) or decrease ICP (e.g. elevate head of bed, mannitol, CSF drainage). 1. No perfusion 2. Incr. ICP

Stage 1: FIRST / INITIAL STAGE

- Cellular changes only: client has no signs or symptoms! - Shock is reversable ■ Hypoxia ■ Decreased aerobic metabolism ■ Increased anaerobic metabolism ■ Increased lactic acid production

Fx of Each Parts of the Cortex

* Frontal Lobes: personality! * - concerned with the reasoning, planning, parts of speech and movement (motor cortex), emotions and problem solving. * Parietal Lobes: Sensory discrimination * - perception of the stimuli such as touch, pressure, temperature and pain. * Temporal Lobes: Speech and Hearing * - perception and recognition of auditory and memory. * Occipital Lobes: vision * * Cerebelluum: balance, coordination * - largest portion of the brain; composed of the cerebral hemispheres and responsible for integration of complex sensory and neural functions and initiation of coordination of voluntary activity in the body. * Brainstem: basic body Fxs * - connects cerebrum with the spinal cord. Consists of the midbrain, medulla and pons. Controls alertness, arousal, breathing, blood pressure,and digestion.

2. Motor Response

* Highest level of nl response - obeys commands * Don't ask pt to "squeeze my hand" as this may be a reflex and not a command; include " let go now" * Localizing: attempting to ease or avoid painful stimuli * All mvmnt, other than following commands or localizing is abnl * Posturing - legs are rigidly extended - Flexion (decortication) - Fx-ng withouthigher centers of the brain, arms come up toward the "core" of the body to painful stimuli - Extension (decerebration) - only brain stem is Fx-ng , arms extend down and outward to painful stimuli * If pt follows commands or localizes test motor strength: 5/5 - nl ROM against full resistance 4/5 - ROM with moderate resistance 3/5 - ROM against gravity 2/5 - rolls but cannot lift 1/5 - contraction without mvmnt 0/5 - no mvmnt * Pronator Drift: - Patient is asked to hold his or her arms outstretched with palms facing upward. The eyes are closed. - Abnl: the arm drifts downward and the palm turns toward the floor. * Coordination - to test have pt perform a variety of activities. - Dysmetria - inability to point finger to the nose (FTN), demonstrated by past pointing. - test lower extremities - touch heel to opposite shin and slide down leg - Rapid alternating mvmnts (RAMS) - play the piano, note discrepancy in speed and smoothness (dysdiadochokinesia).

STAGE 2 : Compensatory

* Incr. HR + Incr. RR + Decr. BP * Ax for Decr. CO and Perfusion Compensatory mechanisms kick in to return cells to pre-shock state * Most metab. needs of the body cont. to be met b/c of the effects of the SNS/RAAS * Decr. MAP activates SNS leading to selective peripheral vasoconstriction and bld shunts to brain and heart. * SNS also causes incr. in HR and contractility leading to incr. C.O. increasing O2 to myocardium. * Decr. bld flow to kidneys activates RAAS causing vasoconstr. and incr. BP. Also ADH released causing H2O reabsorp. , incr. bld volume. * Fluid shift from intracel. to intravasc. spaces d/t decr. hydrostatic pressure and osmotic gradient also incr. bld V. * All leads to incr. preload, HR,contractility, CO, and BP. * Classic sign that the body is trying to compensate:

**** Watch for

* Incr. systemic vasc. resistance * Poor skin tugor * Oliguria * Low systemic and pulm. preload * Rapid HR

RN Role - Tell the Seizure Story

* What hapend before the seizure * How did it start? * What do abnl bhvrs /mvmts look like? * How long does it last? * How does it end? * What hapens after the event? * Is awareness of the envirnmnt / LOC altered? * Doc. specific info r/t each seizure.

Absence Sz - Review

* What it looks like: * A blank stare, beginning and ending abruptly, lasting only a few sec., most common in children. May be accompanied by rapid blinking, some chewing mvmts of the mouth. Child is unaware of what's going on during the sz, but quickly returns to full awareness once it has stopped. May result in learning diff-ties if nor recognized and Tx-d. * What it is NOT: * - Daydreaming - Lack of attention - Deliberate ignoring of adult instructions * What to do: * - No first aid necessary, but if this is the first observation of the sz(s), med. eval. should be recommended.

Simple Partial Sz - Review

* What it looks like: * Jerking may begin in one area of the body, arm, leg, or face. Can't be stopped, but pt * stays awake and aware. * Jerking may proceed from one area of the body to another, and sometimes spreads to become a convulsive sz. Partial sensory sz may not be obvious to an onlooker. Pt experiences a distorted environment. May see or hear things that aren't there, may feel unexplained fear, sadness, anger, or joy. May have nausea, esxperience odd smells and have funny feeling in the stomach. This type of sz may be "aura" and can progress to other types. Rarely lasts more than 1 min. * What it is NOT: * - Acting out, bizzarre bhvr - Hysteria - Mental illness - Psychosomatic illness - Parapsychological or mystical experience * What to do: * - No first aid necessary unless sz becomes gener., then first aid.. (below) NOT emergency!

Generalized Tonic-Clonic Sz - Review

* What it looks like: * Usually begins with sudden cry, fall, rigidity, followed by muscle jerks, shallow breathing, bluish skin, possible loss of bladder or bowel control, usually lasts a couple of min. Nl breathing then starts again. There may be some confusion and /or fatigue, followed by return to full consc-s. * What it is NOT: * - Heart attack - Stroke * What to do: * - Look for Med Alert ID. - Protect form nearby hazards - Loosen ties or shirt collars - Protect head from injury - Turn on side to keep airway clear - Reassure when consc-s returns. - If single sz lasted less than 5 min., ask if hp eval. wanted. - If multiple sz's , or if one sz lasts more than 5 min., call an ambulance. - If person is pregnant, injured, or diabetic, call for aid at once. * What Not to do: * - Don't put any hard implements in the mouth. - Don't try to hold tongue - it can't be swallowed - Don't try to give liquids during or just after sz - Don't use artificial resp. unless breathing is absent after muscle jerks subside, or unless water had been inhaled. - Don't restrain Resp. compromised. > 5 min - status epilepticus

Complex Partial Sz - Review

* What it looks like: * Usually starts with blank stare, followed by chewing, followed by random activity. Person appears unaware of surroundings , may seem dazed and mumble. Unresponsive. Actions clumsy, not directed. May pick at clothing, pick up objects, try to take clothes off. May run, appear afraid. May struggle or frail at restraint. Once pattern established, same set of actions usually occur with each sz. Last few min., but post-sz confusion can last substantially longer. No memory of what happened during sz period. * What it is NOT: * - Drunkenness - Intoxication d/t drugs or alcohol - Mental illness - Disorderly conduct * What to do: * - Speak calmly and reassuringly to pt and other - Guide gently away from obv. hazards - Stay with person untill completely aware of envirnmnt. - Offer to help getting home * What Not to do: * - Don't restrain unless sudden danger (cliff edge, or a car) - Don't shout - Don't expect verbal instructions to be obeyed NOT emergency!

#3: Emergency Management: Ongoing Assessment

1. ABC 2. Tissue perfusion. ■ LOC ■ VS, O2 sat, peripheral pulses and CRT ■ Blood glucose monitoring ■ Telemetry - Cardiac rhythm ■ Urine output, I/O ■ Electrolytes ■ ABG's ■ Invasive Monitoring (ICU) - CVP What assessments above give us information about organ perfusion? * What are the RN's Priorities? * Info about CO! Airway #1 Oxygen IV access Fluid resuscitation Control bleeding Glycemic Control Administer and monitor effects of vasopressor therapy (used to maintain blood pressure / MAP) - Vasopressors = cause peripheral vasoconstriction ■ Prevent complications: - Mechanical Ventilation - Foley catheter - Central IV access - Parenteral / enteral feedings What is the common risk with all of these complications? INFECTION!!!!

1. Neurological Ax

1. Ax BL neuro signs of reAx and comparison to prev. findings (LOC, Pupils, Eye mvmt, motor/sensory fx). R: Subtle changes in neuro signs can indicate deterioration or improvement. These changes can only be detected by freq. monitoring and comparison with prev. findings. 2. Neuro Ax - routine monitoring of VS (Compare findings with prev. recordings to note trends). R: Intracranial Decomp. is noted by * Decr. HR, Incr. BP, Widening pulse pressure and irreg. resp. rate (Cushing's Triad). * It is generally accepted that VS correlate poorly with early neuro deterioration; changes in VS are a late indicator of Incr. ICP. 3. The temp. should be monitored and Tx initiated for elevations. R: Incr. Temp. may result in incr. O2 consumption. Then incr. production of by-products of metab. incr. ICP. Avoid sz and fever -> Incr. ICP

4. Pharmacologic Therapy

1. Common meds used : a. Osmotic diuretics (Mannitol, Lasix) - Cerebral edema, decr. ICP b. Dexamethasone (Decarbon) PO, IM, IV - Decr. Inflammation -> decr. edema c. Levetiracetam (Keppra) PO, IV - Prevent sz d. Colace (docusate sodium) PO - no valsava e. Protonix (Pantoprazole) PO, IV (or other PPI/H2 blocker) - prevent ulcers b/c of steroid therapy f. Acetaminophen (Tylenol) PO, PR - fever (causes incr. ICP) g. Prophylactic broad-spectrum antibiotics may be ordered if the pt has external ventricular drainage or cont. intracranial monitoring. - prevent infection h. Hypertonic Saline (3%) - decr. cerebral fluid. 2. Sedative and Pain meds. Pt may be placed in a "drug induced coma." R: Keeps metab. demand and cerebral O2 consumption down to allow for healing and prevents spikes in bP. However, changes in neuro state may be masked as most sedatives potetially alter neuro status. Pt may have * "sedation vacation" * reg-ly to permit Ax of neuro status. *** When there is incr. ICP - NO Dextrose- D5!!!

Conditions occurring with Shock

1. DIC: Disseminated Intravascular Coagulopathy ■ A disorder in which bleeding and clotting occur abnormally and simultaneously 2. SIRS: Systemic Inflammatory Response Syndrome ■ Systemic activation of the inflammatory-immune response. Inflammation occurs in many organs and/or organ systems at once 3. MODS: Multiple Organ Dysfunction Syndrome ■ Multiple organ system failure, respiratory system is usually 1st, (ARDS) followed by others... inflammation, ischemia...90% mortality.

All types of shock alter hemodynamics the same way!

1. Decreased Perfusion leads to Decreased CO and decreased MAP 2. Continued Decreased Perfusion causes Compensatory Mechanisms: - Incr. SV x Incr. HR = Incr. C.O. + Incr. SVR = Incr. MAP 3. And further continued decreased perfusion leads to Overwhelmed compensatory mechanisms: - DECR!!!! MAP - Body attempts to fix but fails

#2: Early Interventions

1. Fluids: • Crystalloid (NS or hypertonic(LR))- maintain intravascular volume • Colloid (albumin) - expand fluid volume 2. Medication: • Epinephrine - Increased HR and Increased CO a. B-adrenergic agonist - Cardiac stimulation - Bronchial dilation - Peripheral: vasoconstriction • Mimics the effects of the SNS • Increases SV, HR & CO which will increase BP b. A-adrenergic agonist - Peripheral: vasoconstriction c. How do we know that this was effective in a patient with shock? 3. Nutrition • Protein-calorie malnutrition is a primary manifestation of shock • TPN / tube feed early for improved outcomes

* Neuro Ax * - Review

1. Glasgow Coma Scale - Normal 14-15 - Less than 7 - airway protection - Kids under 5 - different scoring - Eye opening, verbal response, motor response 2. Pupil size and reaction 3. CMS checks

G. Documentation

1. Glasgow Coma scale: - Vernal response - Motor response - Eye opening Narrative note - be clinically specific and objective H. Sundowning Must seek help for change in neuro exam immediately!

*** Signs of Shock

1. Hypovolemic Shock - Vital Signs: Decreasing blood pressure, Narrowing pulse pressure, Tachycardia, Tachypnea, Pale cool and clammy skin, Unobtainable or poor SpO2 - Signs of Poor Perfusion: Anxiety (anxiousness that progresses to a decreased mental status), Pale cool clammy skin, Delayed capillary refill, Weak or absent peripheral pulses, Decreased urine output Cardiogenic Shock - Vital Signs: Decreasing blood pressure, Narrowing pulse pressure, Tachycardia or bradycardia; may be irregular, Tachypnea, Pale cool and clammy skin; cyanotic or mottled skin, Decreased SpO2 reading - Signs of Poor Perfusion: Anxiety (anxiousness that progresses to a decreased mental status), Pale cool clammy skin; cyanotic or mottle skin, Jugular vein distention and peripheral edema (right-sided heart failure), Weak or absent peripheral pulses, Decreased urine output, Other sign: Crackles or rales upon auscultation (left-sided heart failure) Distributive Shock - Vital Signs: Decreasing blood pressure, Tachycardia (anaphylactic and septic shock), Relative bradycardia or normal heart rate (Neurogenic shock associated with a spinal cord injury), Tachypnea with reparatory distress and wheezing (anaphylactic shock), Tachypnea (septic shock), Normal reparatory rate (neurogenic), Normal to flushed skin (early sepsis), Warm flushed skin (neurogenic), Warm flushed skin with hives possible cyanosis (anaphylactic), Mottled / cyanosis (late- sepsis, anaphylactic and neurogenic), severely decreased SpO2 reading (anaphylactic) - Sings of Poor Perfusion: Anxiety (anxiousness that progresses to a decreased mental status), Mottled / cyanosis (late- sepsis, anaphylactic and neurogenic), Weak or absent peripheral pulses, Decreased urine output, Other signs: Fever (sepsis), Loss of motor/sensory function (neurogenic due to spinal cord injury), Edema (anaphylactic)

* Increased Intracranial Pressure * - 1. Blood Brain Barrier

A filtering mechanism of the capillaries that carry blood to the brain and spinal cord tissue, blocking the passage of certain substances.

3. Positioning and Moving Pts

1. Maintain pt on bedrest or activity level as ordered by physician. Head elevation will vary depending or provider's order (usually 30o) and pt's MAP. Avoid prone position, exaggrerated neck flexion, and extreme hip flexion of 90o or more. R: HOB at 30o facilitates cerebral venous return. Neck flexion may interfere with venous return from the brain. Extreme hip flexion potentially incr. intraabdominal and intrathoracic pressure which interferes with cerebral venous return. Incr-ng HOB may decr. CPP by lowering SBP. Eval. the effect of HOB elevation on both CPP and ICP. *** All this can decrease perfusion. 2. Pts able to follow simple directions should be instructed to exhale upon turning and moving. Assist pt in moving up in bed. Do not ask pt to push with the heels. Do not allow pt to push or pull with his arms or push against the foot board. Do not encourage or suggest isometric exercises for your alert pt. Passive rOM exercises should be incorporated into the nursing plan of care. R: Valsava If BP is nl, always sit pt up as high as possible b/c it will decr. ICP.

7. Elimination

1. Monitor UO. Periodic SG of urine and serum osmolality may be ordered. R: Indicates the amount of diuresis or urinary concentr. Damage to pituitary may result in * DI or SIADH * (caused by brain injury) and would be evidenced by a change in SG and UO. 2. Stool softeners should be admin-d. Avoid enemas or straining R: Prevent valsava

Neuro Exam - Conference

1. Orientation: - x3; situation 2. Mental Status - interaction: a. What pt looks like in a situation (appearance, body odor, appropr. dressed, disheveled). b. Ask about current society events (president, war) c. Appropr. mood (reaction to something is not appropr). d. Thought process (suicide dilatation; paranoia, schizophrenia, fear) - physically something wrng with the brain, not mental illness. 3. Pupil Ax: - Med emergency - Unilateral fixed pupil -> incr. ICP -> brain may herniate if it won't stop. 4. Motor Ax: a. Pronator Drift: pt closes eye, palms are up straight. If one arm goes down, might be d/t stroke b. Balance: standing with closed eyes or hoe pt is sitting in the bed (leaning on one side). c. Coordination: FTN 5. Sensory Ax: sense of feeling -touch with cotton first - pin - pain stimulus (4 types ) 6. Posturing: Always involuntarily and serious - Decorticate - flexion - stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. - Decerebrate - extension, more serious - arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. The muscles are tightened and held rigidly. *** After stimulation

2. Establishing and maintaining Patent Airway and Adequate Ventilation

1. Perform a complete resp. Ax. R: Indicates patency of the airway. adeq-cy of resps, and proper lung expansion 2. Monitor Bld gases: - * PaO2 below 85 is LOW * - Maintain PaCO2 per provider's order (usually 30-40). * CO2 is a potent vasodilator! * Cerebral vessels dilation -> take up space. R: Decr. PaCO2 constricts cerebral bld vessels, wgich will decr. cerebral edema and reduce ICP. Unfortunately, prolonged cerebral vasoconstriction has the potential to impair cerebral tissue perfusion and lead to cerebral ischemia. Impaired cerebral bld flow decr. the availability of glucose and O2 to the cerebral tissues and can lead to cerebral anoxia. 3. Admin. O2 at the ordered % or titrate O2 to keep SpO2 within prescr. levels. R: Adeq. O2 is needed to meet metab. demands. 4. Suction only when necessary for no more than 10 sec. per catheter insertion. R: Time limit prevents the buildup of CO2, which is potent cerebral vasodilator able to aggravate Ince. ICP. (Usually intubation)

5. General Nursing Management

1. Plan nursing care so that those activities that are apt to produce spikes in intracranial pressure are not clustered together. R: Contrary to what has been considered good organization skills in pt management , it is best not to cluster pt care activities. Individually, these activities may not cause a large incr. in ICP but performed collectively rises in ICP can be expected. 2. Maintain sz precautions. 3. Maintain calm approach and calm quiet envrn. with min. noise. Limit interruptions. R; Decr pt's stimuli decrs. the pt's metab. demand and ICP. 4. Teach f-ly to limit pt's stimulation. R: F-ly members frq. stimulate loved ones attempting to get them to return to prior level of awarness however, this incr. the pt' metab. demand and ICP. *** Spread out activities! - to decr. ICP

1. Two Types of Brain Trauma

1. Primary Injury - occurs at time of trauma. - blunt injury - Coup - direct location; - contrecoup - opposite side; injury Direct injury to brain (may be irreversible) 2. Secondary Injury - occurs as a result of injury - Edema - Incr. ICP - Hypoxia - HOTN - Chemical changes in the brain - Hypo-hyper-capnia Goal of NI are to prevent these sequale from occurring.

3. Pupillary Ax

1. Size: - Constricted suggest pt has received narcotics, don't r/o neuro event. - Pinpoint in stroke pt suggest damage to ons - Bilaterally dilated suggest hypoxemia 2. Shape: - Nl-ly round unless ocular surgery - Oval suggest incrs. ICP 3. Equality: - Anisocoria - grossly unequal pupils 4. Reaction: - Generally don't need to darken room unless pupils are small - Test one eye at a time, pt looking straight ahead - Bring light in from side; turn light on when directly in front the eye - Brown eyes bring light in from over top of the head - Note pupil reaction: * Brisk: fast * Sluggish: delayed * Fixed (no response): confirm with a consensual response by shining light in opposite eye and watching reaction in fixed eye

* Pt Teaching on Seizure Disorders *

1. Take antiseizure meds as prescribed. Report any and all drug SE to HCP. When necessary, bld drawn to ensure maintenance of therap. med. levels. Schedule reg. communication with the HCP to explore additional Tx options. 2. Use non-drug techs such as relaxation, to potentially reduce the # of sz. 3. Be aware of community and online resources for education and help with tracking and explaining sz activity. 4. Wear Med. Alert bracelet or necklace, and carry ID card. 5. Avoid excessive alcohol intake, fatigue, and loss of sleep. 6. Eat reg. meals and snacks b/w if feeling shaky, faint, or hungry.

D. Stimulation is Applied at 4 Levels

1. Verbal 2. Shouting 3. Shaking 4. Pain Common error - being too gentle in attempt to arouse a pt and failing to establish adeq. BL.

6. External Ventricular Drainage

1. With external ventriculostomy drainage (EVD), the elevation of the HOB will depend on HCP. The nurse should know how high the drainage colection container should be kept above the level of insertion. R: Too low - too rapid removal of CSF and can lead to brain herniation. Too high - prevents CSF drainage from occurring. 2. Maintain integrity and sterility of Ventriculostomy drain and set up. 3. Drainage of CSF via Ventriculostomy per provider order. *** Infection prevention!!!

* Phases of Seizures * - 1. Aura

A simple partial seizure that is usually a * sensation or sensory phenomenon * that reflects the complicated connections and integrative Fxs of that area of the brain. The most common sensation is a strange feeling at the bottom of the stomach that rises toward the throat. This feeling may be accompanied by odd or unpleasant odors or taste, complex auditory or visual hallucinations, or ill-defined feelings of elation or strangeness (eg. deja vu, a feeling of familiarity in a strange environment). Many pts have an aura before complex partial or generalized seizure. this is called prodromal in some pts.

3. Status Epilepticus

A state of cont. seizure activity or when seizures occur in a rapid succession without return to consciousness b/w seizures.

Septic shock

A systemic infection that causes a cascade effect in the body = vasodilation and maldistribution of blood flow (relative hypovolemia) ■ Common organisms (gram negative bacteria, can see gram positive, viruses, fungi and parasites) ■ Endotoxin from micro organism cause vasodilation

* Neuro Ax: LOC, Motor, Pupillary Response *

A. Expectant Observation - eval. the pt b/c it is expected that something might happen. B. Basic Concepts: 1. Neuro pts almost never suddenly deteriorate 2. We often do not stimulate a pt enough to get the highest level of response. C. Common Ax Errors: 1. Inadeq. stimulation. To assure adeq. stimulation - max. stimulation for max response. 2. Inadeq. BL 3. Non-objective vocab. 4. Failure to recog. subtle clues 5. Failure to go up the chain of command for help

* Caregiver Teaching on Seizure Disorders *

A. Focal sz: 1. Stay calm. Guide pt to safety to prevent injury but do not restrain. 2. Observe for asymmetry of activity and focus on specific actions, such as lip smacking and abnl mvmnts. 3. Ax pt's LOC and ability to converse and respond appropr-ly. 4. Observe the time of event when it stearted and stopped. Pay attention to thee time of return to the BL. 5. Provide respect and explanation of occurrence. B. Gener. Tonic-Clonic Sz: 1. When sz occurs outside of the hp setting, activate ERS if: a. the duration is greater than 5 min b. events recur without the pt recovering to BL c. pt is unable to establish a nl breathing pattern, is injured or pregnant d. you don't know if this is a first time sz event. 2. Maintn pt safety: lower the pt to the floor or bed, remove glasses, and loosen restrictive clothing. 3. Do not place anything in the pt's mouth. Pt's teeth /dentures may be damaged, and caregiver might be bitten. 4. Position pt on the side (if possible) to improve the pt's ability to release oral secretions. 5. Observe the time of event when it stearted and stopped. Pay attention to thee time of return to the BL. 6. Ax for possible injury or any lingering motor weakness

2. 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right great toe. His assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/min; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis. b. septic shock. c. multiple organ dysfunction syndrome. d. systemic inflammatory response syndrome.

ANS: * b. septic shock. *

3. The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations. b. breath sounds, blood pressure, and body temperature. c. pulse pressure, level of consciousness, and pupillary response. d. level of consciousness, urine output, and skin color and temperature.

ANS: * d. level of consciousness, urine output, and skin color and temperature. *

Progression of Deteriorating Brain Fx - Changes From higher to Primitive to Life-sustaining 1. LOC

Alert: oriented x 3 Response to verbal stimuli; decr. concentr.; agitation, confusion, lethargy; disoriented Req. cont. stimulation to rouse ************* Reflexive positioning to pain stimulus ************ No response to stimuli

Hemodynamic Changes with Shock

All types of shock alter Hemodynamics the same way: Decrs. perfusion -> Decrs. C.O. -> Hypoxia of tissue (oxygenation problem) -> COMPENSATORY MACHANISMS (body tries to maintn. homeostasis): - Incr. SV x Incr. HR = Incr. CO + Incr. SVR = Incrs. MAP And further cont. decrs. perfusion -> Decr. C.O. = decrs. MAP

1. A patient has a spinal cord injury at T4. Vital signs include a falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing: a. a relative hypervolemia. b. an absolute hypovolemia. c. neurogenic shock from low blood flow. d. neurogenic shock from massive vasodilation.

Answer: * d. neurogenic shock from massive vasodilation. *

* Dexamethasone (Decadron) *

Anti-inflammatories (steroidal) A: - suppresses inflammation and the normal immune response. - Suppresses adrenal function at chronic doses - Suppression of inflammation and modification of the normal immune response. U: Inflammation; neoplasms; cerebral edema SE: - sleep problems (insomnia), mood changes; - acne, dry skin, thinning skin, bruising or discoloration; - slow wound healing; - increased sweating; - headache, dizziness, spinning sensation; - nausea, stomach pain, bloating; - muscle weakness NI: - Reduce dose gradually by scheduled regimen to prevent adrenal crisis - Monitor for s/s of infection - Monitor wt, BP, BG levels - Not recom. for use in traumatic brain injury d/t suppression of nl inflammatory response Eval: neuro status

* Levetiracetam (Keppra) *

Anticonvulsant *** Maintn. med; prevention of sz. A: Appear to inhibit burst firing without affecting normal neuronal excitability and may selectively present hyper-synchronization of epileptiform burst firing and propagation of seizure activity U: Partial-onset seizures, gener. tonic-clonic seizures. SE: Dizziness, Suicidal thoughts and behavioral abnormalities; lukopenia (decr. WBC) Routes: PO; IV; NG NI: - Monitor seizure activity - Ax mental status and mood - Assist with ambulation during early part of Tx d/t dizziness - Extended release product should not be used in dialysis pts

* Diazepam (Valium; Diastat) *

Anxiolytic; Benzodiazepine Management at home if sz > 5 min. A: enhances action of GABA U: Adjunct in seizure disorders; anxiety, ETOH withdrawal, rectally for acute repetitive seizure; usually for peds or home use SE: Resp. and CNS depression, HOTN NI: - Monitor BP, mental status, and resp. status - Rectal admin - Not more than 5 x a month 3-3-3- insert counting to 3; hold counting to 3, squeeze butt cheeks while counting to 3.

What are risk factors?

Shock manifests as a result of multiple diseases processes or trauma to the body ■ Age extremes ■ Poor general health ■ Immunosuppression ■ Trauma ■ Multiple medical/surgical therapies ■ Long term medical instrumentation

E. Types of Pain Stimuli

Apply pain for at least 15 ec. and no more than 30 sec. 1. Central - brings about a response from the brain. Examples: - Trapezius squeeze: pinching trapeze muscle sharply b/w thumb and two fingers of 2 inches and twisting it (where shoulder and neck connect). - Sternal rub (sufficient pressure). - Supraorbital pressure (notch of the orbital rim): causes sinus HA - Mandibular pressure: pushing on the jaw. 2. Periph. or spinal response - elicits a spinal response. Assessed if pt's limb has not moved or if a pt remains unconscious. - Nailbed pain

5. Brain (Tentorial) Herniation

Brain tissue, cerebrospinal fluid, and blood vessels are moved or pressed away from their usual position inside the skull. Causes: Brain herniation occurs when something inside the skull produces pressure that moves brain tissues. This is most often the result of brain swelling from a head injury, stroke, or brain tumor.

2. Pupillary Response

Brisk and equal; regular Small and reactive ******************* Pupils fixed (nonreactive) in midposition ************ Pupils fixed in midposition

4. GI

COMPENSATED: - NL or sl. N/V/D PROGRESSIVE: - Hypoactive BS - GI bleeding - Decreased absorption of nutrients. REFRACTORY: - Absent Bowel Sounds - Ischemic gut

6. Body Temp

COMPENSATED: - No significant change PROGRESSIVE: - Hypothermia - Sepsis -> hyperthermia REFRACTORY: - Very low

7. Skin

COMPENSATED: - Pale &cool - Warm & flushed in septic shock PROGRESSIVE: - Cold, clammy, cyanotic REFRACTORY: - Cyanotic, mottled, ashen

3. Respiratory

COMPENSATED: - Rate: NL or sl. increase PROGRESSIVE: - Rapid RR - Shallow breathing - Possible pulmonary edema. REFRACTORY: - Slow, irreg, cheyne stokes or resp. failure

* Progression of Signs and Symptoms of Shock * - 1. Neuro:

COMPENSATED: - Restless, irritable, apprehensive - Oriented, verbal - Subtle change in LOC. PROGRESSIVE: - Confused - Notable - Change in LOC - Decreased response to stimuli. REFRACTORY: - Unresponsive - Severely depressed LOC - Dilated non-reactive pupils.

5. Renal

COMPENSATED: Urine output normal or slightly decreased PROGRESSIVE: Oliguria - Increased BUN, and Creatinine - Metabolic acidosis REFRACTORY: - Anuria

2. CV

COMPENSATED: • BP is maintained to >90 systolic • HR increases to compensate in all types of shock except neurogenic shock where HR decreases. PROGRESSIVE: • BP is below 90 systolic. • Tachycardia >100, irregular, dysrthymias. • Peri-pulses weak, thready, prolonged CRT. REFRACTORY: • BP is falling to unobtainable. • Bradycardia.

2. ICP Values

Child: Nl: 0-10 Incr.: >10 Adult: Nl: 0-15 Incr.: >15

4. Cerebral edema

Clinico-pathological state that is characterised by an increase in brain water content (above the normal brain water content of approximately 80%). It usually occurs in response to brain insult. Cerebral edema increases brain volume. Because brain is confined within rigid skull, increase in brain water content ultimately results in raised intracranial pressure (ICP). Raised ICP decreases cerebral perfusion pressure leading to cerebral ischemia. In addition, cerebral edema may result in brain herniation due to the associated mass effect. Management of cerebral edema is a great challenge for both the neurosurgeons and neuroanaesthetists as current treatment modalities are largely symptomatic. They range from general measures to osmotherapy, barbiturate coma, steroids and decompressive craniectomy.

* Nursing Management of the Pt with Increased Intracranial Pressure *

Concepts of physiology, pathophys., and objectives of med/nursing management. In a pt for a potential for Incr. ICP, a major objective is to protect the pt at risk from sudden incr. in ICP. 1. Neurological Ax 2. Establishing and maintaining Patent Airway and Adequate Ventilation 3. Positioning and Moving Pts 4. Pharmacologic Therapy 5. General Nursing Management 6. External Ventricular Drainage 7. Elimination

* Decreased Intracranial Adaptive Capacity R/T *

Condition the causes a compromise to the intracranial fluid dynamic that usually compensates an increase in intracranial volumes. It results in a disproportionate increase in intracranial pressure as a response to various noxious and non-noxious stimuli. DC: - Disproportionate increase in the ICP after a single maneuver - Baseline ICP of 10mmHg - Elevation of P2 ICP waveform - Volume-pressure ration of more than 2 - Wide amplitude ICP waveform - Repeated increase of 10 mm Hg lasting more than after external stimuli RF: - Brain injuries - Sustained hypotension with- a. Sustained increased ICP b. Decreases cerebral perfusion intracranial hypertension NI: * AX: Temperature Pulse Heart rate and sounds Electrocardiogram Response to pain Response to light Respiratory rate, patterns, and depth Distension of jugular vein History of hypertension Pulse ICP waveforms over time for determining trends Assessment of cerebral perfusion pressure * MAINTAIN ANY ICP MONITORING SYSTEMS IN USE * PREVENT INFECTION

* Hypovolemic Shock *

Decreased circulating blood * volume * Actual hypovolemia: - Loss of whole blood or plasma - Loss of other body fluids Relative hypovolemia: - Internal shift of fluid from intravascular space to extravascular space Progression of events: Loss of fluid volume causes a decrease in: - Preload - SV - CO - Tissue Perfusion (i.e. CRT)

* Cardiogenic shock *

Defect in heart's ability * to pump * and move bld forward = decreased cardiac output ■ Risk factors: - Previous MI - Large MI - LVEF 35% or less - Elderly - Dysrhythmias - Structural Defects Causes of cardiogenic shock: - Most commonly ventricular ischemia particularly r/t MI Most common complaint: chest pain Also SOB. change in LOC.

Neuro Ax: Progression of Deteriorating Brain Fx

Describing pt's LOC should be done by accurately describing their bhvr, not by using terminology that is open to interpretation. Terms such as coma, deep coma, lethargy, stupor, obtundation, and many other cont. to be used. One scale in common use is Glascow Coma Scale (GCS). GCS is a part of neuro Check but not the complete check. The scale differs in accepted response according to the age of the pt. LOC deteriorates and improves in a predictable pattern. Progressive loss of the higher levels of Fx occurs initially, then the more premitive levels, and finally the life-sustaining Fxs. A diminished LOC and BHVR changes are early manifestations of cerebral involvement. The midbrain and brainstem Fxs are affected sequentially with charact. changes in motor Fx, pupillary response, and breathing pattern.

* Electroencephalogram (EEG) *

Description: - Electrical activity of brain is recorded using scalp electrodes. - Diagnostic for sz or brain death Purpose: To evaluate seizures disorders, cerebral disease, CNS effects of systemic disease, , brain injury, brain death. - Specific tests may be done to eval. brain's electrical response to lights and loud noises. NI: Before: - Inform pt that procedure is non-invasive and without danger of electric shock. - Determine if any meds should be withheld After: - Resume meds - Instruct pt to wash electrode paste out of hair after test. *** Can be cont-s at some institutions, called Long Term Monitoring (LTM). Pt is videotaped during this often days long Ax.

* Cerebral Angiogram *

Description: - Serial x-ray visualization of incranial and extracranial bld vessels. - Catheter is inserted in femoral (sometimes in bronchial) artery and passed through the aortic arch into the base of a carotid or a vertebral artery for injection of contrast medium. - Timed-sequence radiographic images are taken as contrast flows through arteries, smaller vessels, and veins Purpose: - To detect vascular lesions and tumors of the brain NI: Before: - - NPO at least 6 hrs. - Ax pt for stroke rik b/c thrombi may be dislodged during procedure. - Withhold preceding meal. - Explain that pt will have hot flush of head and neck when contrast is injected. - Explain need to be still during procedure During: - Allergic(anaphiylactic) reaction may occur from contrast. - May req. emergency CPR. After: - Monitor neuro s/s and VS q 15-30 min for the first 2 hrs, q hr for next 6 hrs, and q 2 hrs for 24 hrs. - Maintain bedrest for 6 hrs (1 hr if closure device is used) and monitor for bleeding. - Report any neuro changes - Monitor for bleeding

* Lumbar Puncture Procedure *

Description: Introduction of a specialized needle into the spine in the lumbar region for diagnostic or therapeutic purpose, such as to obtain cerebrospinal fluid for testing. Pt is placed on their side with the knee and head flexed. Common SE: Headache, pain at injection site Non-opioids after the procedure Contraindication: Incr. ICP (can cause brain herniation) Purpose: To obtain CSF for examination (cancer or infection) , to relieve pressure ICP, or to introduce dye or medication. NI: PRE: - Explain procedure: inform pt that he/she will feel temp., sharp pain or tingling radiating down the leg as a sterile needle is passed b/w two lumbar vertebrae; - obtain written consent; - have patient use restroom; - assist doctor with procedure if asked. POST: - place patient in supine position to prevent leakage - encourage fluids (to prevent HA); - assess patient for numbness or tingling, pain at injection site, drainage of blood or CSF; ability to void. - Neuro checks and VS - Monitor for HA, meningeal irritation, or s/s or local trauma. - Admin analgesia PRN

* Traumaic Brain Ijury (TBI) * - Video

Example of a disease process that causes Incr. ICP.

Driving License Restrictions in NY state for Ppl with seizures

For an applicant to be issued a driver's license in New York, a person with epilepsy must not have experienced a loss of consciousness within the previous 12-month period and must submit a physician's statement confirming this fact. A person who has experienced a loss of consciousness during this period may be licensed at the discretion of the Motor Vehicles Commissioner if: 1) it was due solely to a physician-directed change in medication and the physician submits a statement to that effect, or 2) the person submits a physician's statement confirming his knowledge of all such incidents and recommending licensing despite the medical history, because in his opinion the condition will not interfere with the safe operation of a vehicle and the Department's medical consultant has no objection to such issuance. Each case is reviewed individually. As a condition of licensing, a person may be required to submit periodic physicians' statements as to his or her fitness to drive, unless the person submits a physician's report that he or she has been seizure-free without medication for 1 year or more. Restricted licenses are not available.

* Seizure Precautions *

For the Hospitalized pt: - Side rails up x 4 - Side rails and other hard objects in room padded - Can place mats on the floor - Suction set up available - O2 available - Waterproof pad on mattress or crib - appropr. supervision and/or video monitoring For the pt in the Community: - Swim with a companion - use of protective helmet and padding for cycling, skateboarding, etc. - Med. ID - Avoidance of seizure triggers

4. ICU Care

Goal of NI - Prevention of secondary injury. Focus of Care: Keep brain oxygenated and well perfused Interventions: 1. Vent. with end tidal CO2 monitor: - High CO2 = cerebral vasodilation - Low CO2 = cerebral vasoconstriction - CO2 levels can be controlled by adjsuting resp. rate! 2. Arterial line for cont. measurement of BP/MAP - MAP can be controlled by admin. of vasosuppressor meds or anihypertensive meds. 3. PCWP monitored (used to maintain fluid V) 4. Glucose monitoring - keep to b/w 80-110 5. ICP monitoring - direct intracranial pressure monitoring (ventriculostomy) with ability to drain CSF prn for incr. ICP.

* Lorazepam (Ativan) *

High Alert if IV Anxiolytic; Benzodiazepine A: It increases the effectiveness of GABA, especially in the limbic system and the reticular formation. GABA is an amino acid that acts as a neurotransmitter. Its function is to decrease neuron activity and inhibit nerve cells from overfiring. U: Anxiety, seizures, status epilepticus, alcohol withdrawal, sedation; usual IVP med of choice for seizing pt in adult acute care setting. SE: Resp. and CNS depression, HOTN -> Tachycardia; drowsiness, dizziness, sleepiness. NI: - Monitor BP, mental status, and resp. status - Give IVP slowly - Instruct pt to change positions slowly

* Epinephrine *

High Alert if IV Sympathomimetic Naturally occurring catecholamine that stimulates the sympathetic nervous system. A: •Increase heart rate, conduction, and contractility. •Increase cardiac output, and blood pressure. •Relaxes bronchial smooth muscle, and reduce airway secretions. U: - Asystole - Bronchospasm - Anaphylaxis - Cardiac Arrhythmias - Shock - Cardiac arrest SE: CNS - Tachycardia!!!! Anxiety, headache, CVA (stroke) CV - Chest pain, Acute MI, Tachyarhythmias MISC - Vomiting, diaphoresis and pallor, local tissue necrosis NI: 1. Anaphylaxis: - Epipen given IM - Massgae injection site to incr. absorption - If anaphylactic Sxs persist after first dose, may repeat in 5-15 min. - More than 2 doses should be admin.under med. sup. - Monitor EKG 2. Cardiac Arrhythmias: - Monitor EKG - VS during infusion - Given IVP for asystole or card. arrest 3. Shock - Monitor EKG - VS during infusion - code car nearby

* ICP VS Shock *

ICP: - Incr. BP - Decr. HR - Decr. RR Shock: - Decr. BP - Incr. HR - Incr. RR

Why is it a syndrome?

It is the bodies attempt to achieve homeostasis in response to a perfusion / oxygenation problem. The body does not have enough oxygen (supply) to meet the bodies demand for oxygen.

* ND: Risk for Shock *

Life-threatening condition that occurs when the body is not getting enough blood flow. This can damage multiple organs. Shock requires immediate medical treatment and can get worse very rapidly. RF: - Reduction of arterial/venous blood flow: selective vasoconstriction, vascular occlusion-intimal damage, microemboli. - Relative or actual hypovolemia. CH: A person in shock has extremely low blood pressure. Depending on the specific cause and type of shock, symptoms will include one or more of the following: Anxiety or agitation/restlessness Bluish lips and fingernails Chest pain Confusion Dizziness, lightheadedness, or faintness Pale, cool, clammy skin Low or no urine output Profuse sweating, moist skin Rapid but weak pulse Shallow breathing Unconsciousness Goal: Shock does not occur during the treatment period. O: - Not decreased consciousness. - Vital signs within normal limits. - Good skin turgor. - Good peripheral perfusion (acral warm, dry and red). - Fluid balance in the body. NI: - Monitor vital signs, orthostatic blood pressure, mental status, and urine output. - Monitor laboratory values ​​as evidence of tissue perfusion inadekuat (eg increased levels of lactic acid, decreased arterial pH). - Give crystalloid IV fluids as needed (NaCl 0.9%, RL; D5% W) - Give vasoactive medications. - Provide oxygen therapy and mechanical ventilation - Monitor hemodynamic trend. - Monitor fetal heart rate (bradycardia if HR <110 beats / min) or (tachycardia when HR> 160 beats per minute) lasting longer than 10 minutes. - Take blood samples for blood gas analysis and the examination of tissue oxygenation monitor. - Get patency of venous access. - Give fluids to maintain blood pressure or cardiac output. - Monitor critical oxygen delivery to the tissues (SaPO2, hemoglobin level, cardiac output). - Record in the event of bradycardia or decreased blood pressure, or abnormal low systemic arterial pressure as pale, cyanosis or diaphoresis. - Monitor signs and symptoms of respiratory failure (low PaO2, PCO2 increased, paralysis of respiratory muscles) - Monitor blood glucose levels and handle if any abnormality. - Monitor coagulation and complete blood count with WBC differential. - Monitor fluid status include intake and output. - Monitor renal function. - Do a urinary catheter. - Perform installation of NGT and monitor gastric residual. - Position the patient to optimize perfusion. - Provide emotional support to the family. - Provide a realistic hope to the family.

F. Components of Neuro Ax - 1. LOC

Most sensitive. 1. Arousal/Wakefulness - Fx of the bran stem; clinical indication is simply the pt opening eyes. 2. Awareness - the cerebral cortex, "the thinking part of the brain" is Fx-ng; individual's expression that he/she can interact with, and interpret, the environment. 3. Ax and Eval. awareness: a. Orientation: - Person, Place, Time - usually lost first. b. Attention span: - Ability to respond to a specific cue - Vigilance; ability to maintain attention overtime; attention span - Ability to maintain attention during distractors c. Language: - Speak clearly - Slur words - Correct self - use incorrect names d. Memory: - Include short term and long term Never assume answers! Remember there are other factors that may influence LOC: - Hypoxia - Hypercapnia - Meds - Postictal state Build neuro BL on all pts!

What is a factor to consider in perfusion of the body?

Normal regulation of blood flow! ■ Adequate blood volume ■ Ability of heart to pump ■ Vascular tone This is what maintains BP

3. Time of Injury

Note use ABCs - Response to painful stimuli only - GCS = 7 (less than 8 = intubate) - Airway - intubated/end tidal CO2 monitor used - Vent. 100% O2 - Crystalloid fluid bolus to Incr. MAP - Unequal pupils - rapid transfer to hp. VS = Cushing's Triad - represents decompensation: 1. Decr. RR or apnea 2. Bradycardia - Decr. HR 3. Wide pulse pressure *** CT -> Large subdural hematoma with compression of brain tissue so the pt was taken to OR for hematoma removal.

* Mannitol (Osmitrol) *

Osmotic Diuretic A: Works along the entire nephron and is non-absorbable. It inhibits reabsorption of H2O and lytes. Take away- mannitol is pulling fluids from the interstitial spaces into the vasculature. U: Cerebral edema, ICP SE: tachycardia, sz, rebound incr. ICP NI: - Monitor I&O, BP, lytes (K, Na), bUN, Crt, Osmolality - Monitor for change in LOC - Sz precautions - May be contraindicated for severe renal disease Eval: mental status ( neuro)

2. Focal/Partial Seizures

Part of the brain 1. Simple partial seizures (no impairment of consciousness) 2. Complex partial seizures (impairment of consciousness ) * Can come on gradually * Abnl electrical discharges begin in focal area of the brain that is dysfunctional (chemically or structurally) * Focal/Partial seizures can secondarily generalize

STAGE 4: Refractory / Irreversible

Permanent damage occurs even if pt is doing better. Progressive end organ dysfunction becomes irreversible and unresponsive to interventions ■ Tissue hypoxia worsens ■ Anaerobic metab. takes over ■ Metab. lactic acidosis alters pH ■ Stasis of bld. in capillaries ■ Incr. capillary pressure (anasarca) ■ Fluid now shifts to extravasc. spaces ■ Decr. Venous return to heart ■ Decr. CO ■ Periph. vasoconstriction (SNS) * Signs and symptoms of Refractory Shock: * - Hypotension (decreased CO) - Tachycardia (SNS) - Decreased coronary blood flow - Myocardial depression/bradycardia - Depressed LOC (decreased cerebral blood flow) - Cerebral ischemia (brain death) - Central failure of SNS and loss of BP ■ Respiratory failure and cardiac arrest!

4 Stages of Shock

Progression from one stage of shock to the next can be halted/stopped with intervention

3. Motor Response

Purposeful mvmt; Responds to commands Purposeful mvmt; Responds to commands Decorticate positioning with upper extremity flexion (Flexion Posturing) * All posturing responses are involuntary *************************** Decerebrate positioning with adduction and rigid extension of upper and lower extremities. * All posturing responses are involuntary *********************************** Extension of upper extremities with flexion of lower ezxtremities; or flaccidity. * All posturing responses are involuntary

4. Breathing

Regular pattern with nl rate and depth Yawning, sighing resp-s Cheyne-Strokes reps. with crescendo pattern in rate and depth followed by periods of apnea ************************ Central neuro hyperventilation with rapid, regular, and deep reps.; apneustic breathing with prolonged inspiration and pauses at full inspiration ansd following expiration. ************** Cluster or ataxic breathing with irregular pattern and depth of reps.; gasping reps or apnea

2. Ictal

Seizure activity: the physical manifestations of * abnormal electrical brain activity. * NI should include: - Maint. pt's safety - Positioning pt on the side - Observation and documentation of body, facial, and eye mvmt - Resp. effort - Urination/Defecation The ictal phase is usually less than 5 min. in duration and is self-limiting

* Shock *

Shock is a syndrome characterized by hypo-perfusion of body tissue that leads to: - Decreased CO-> - Diffuse tissue hypoxia -> - Abnormal cellular metabolism - Ultimately cell death Shock develops when cells do not receive adeq. bld flow/O2 thus altering meab. * Supply/Demand problem - not enough supply to meet the demand for O2 at the cellular level Review: - Shock develops due to lack of perfusion on a cellular level: 1. Cells do not receive adequate blood flow or oxygen 2. Nutrient metabolism is altered.

6. Ventriculostomy (Intracranial Pressure Monitoring)

Sterile tech - risk for infection ! Catheter is surgically placed. May be used to measure ICP, drain CSF or instill intraventricular medication. ************************************ Also called ventricular catherization with an intraventricular catheter (IVC) or external ventricular drainage (EVD). In order to remove excess CSF, a catheter will be placed inside one ventricle leading to a collection device located outside the cranial cavity. Ventriculostomy may be performed in cases where there is bleeding into the ventricles *** To incr. CPP - need to incr. BP and maintain ICP.

3. Postictal

The * period of recovery following a seizure. * The pt may be drowsy, uncoordinated and have transient aphasia or confusion and display some sensory or motor impairment. This phase can last a few min. to a few hrs

Monroe-Kellie Doctrine

The adult skull is a rigid box containing brain tissue, cerebral spinal fluid, and bld. When the volume or amount of one of these substances changes there must be changes in the other to compensate

Cerebral Perfusion Pressure (CPP)

The amount of pressure needed to adeq. perfuse brain tissue (provides adeq. O2 and nutrients, removes wastes). CPP = MAP - ICP Note* MAP = DBP + 1/3 (SBP-DBP) *** Adults need 60, children need 40 to perfuse brain. ***Min. MAP req. to sustain brain perfusion and life in adults is 40. *** Decrs. MAP and Incr. ICP = Decr. CPP = Decr. O2 metabolite delivery to the brain.

2. Monroe-Kellie Doctrine

The sum of volumes of brain, CSF, and intracranial blood is constant. An increase in one should cause a decrease in one or both of the remaining two. *** Compensatory mech fails - problem

* Seizure Classification * - 1. Generalized Seizures

The whole brain 1. Generalized tonic-clonic 2. Absence * Sudden onset * Bilateral, symmetrical mvmnts * Excessive neuronal electrical discharges that are synchronous throughout entire brain 1. Airway 2. Safety 3. Time

* Risk for: Ineffective Tissue Perfusion; Cerebral *

Vulnerable to a decr. in cerebral tissue circulation, which may compromise health. RF: - Abnl PTT - Abnl PT - Aortic atheroscl. - Arterial dissection - A-fib - Brain injury - Carotid stenosis - MI - Substance abuse NI: * Monitor: - Pupils - LOC - GCS - Facial symmetry - C/o HA - BP * F-ly Hx * Quit smoking * BG control * Incr. HOB * Meds

Nursing Diagnoses for Pts in Shock

■ * Decr. C.O. r/t decr. mayocardial contarctility, dysrh. * ■ * Ineffective tissue perfusion r/t CP, periph. r/t arterial/venous bld flow exchange problems * ■ Risk for injury r/t * prolonged shock resulting in multiple organ failure * ■ Risk for infection r/t * invasive procedures * ■ Deficient fluid volume r/t * abnormal loss of fluid * ■ Ineffective protection r/t * inadeq. Fx-ng immune system *

STAGE 3: Progressive Stage: Uncompensated

■ Compensatory mechanisms fail and irreversible; cellular damage occurs ■ Tissue hypoxia/cell death ■ Metab. acidosis ■ Volume loss of 35-50% S/s of Progressive Shock: * ■ Diminished LOC - confusion, lethargic ■ Incr. HR ■ Incr. mayocardial contractility ■ Possible dysrh. ■ Decr. BP and MAP ■ Low PaO2 ■ Metab. acidosis, low pH ■ Aggressive management needed to reverse shock Always resp. system fails first Goal is to prevent progression

Neurogenic Shock

■ Massive vasodilation and decrease in vasomotor tone Causes: ■ Hemodynamic result of Spinal Cord Injury at T5 or above ■ Spinal anesthesia ■ Vasomotor center depression (severe hypoglycemia, injury)

Anaphylactic Shock

■ Systemic allergic reaction that results in massive VASODILATION ■ = fluids leaks from intravascular space to interstitial space ■ Possible causes - Contrast media - Blood/blood products - Medications - Insect bites - Anesthetic agents - Food/food additives - Vaccines - Environmental agents - Latex

Causes of Hypovolemic Shock

• Hemorrhage • Burns • Loss of other body fluids • Pooling of bld from ascites • Peritonitis • Internal bleeding from ruptures spleen All lead to shift in fluid volume

* Nursing Management of Shock * - #1: Prevention

■ Who's at risk? Recognize patients with conditions that reduce blood volume as at-risk patients. (Info above) ■ Fluid Balance ■ Prevent Infection ■ To decr. O2 demand - O2 admin, rest. ■ Early recognition - What are early / or subtle signs? - Change in VS, LOC, and mental status, cap refill, cool, pale, clammy skin. 1. BP: Early: nl Late: low 2. Pulse: Early: Increased Late: Incr. + weak 3. Skin: Early: nl Late: pale 4. Skin/Temp: Early: cool/moist Late: cold 5. Sensorium: Early: Anxious Late: Coma 6. Resp. Early: Incr. rate and depth Late: Incr. rate; shallow

Intraaortic Balloon Pump; IAPB

■ balloon inserted percutaneously into the descending aorta ■ ECG trigger inflation and deflation ■ Inflation of balloon occurs at beginning of diastole ■ Deflation of balloon occurs at beginning of systole ■ Reduces afterload (thus work of heart) ■ Improves oxygen supply to heart ■ Numerous potential complications