Ch. 66: Management of Patients with Neurologic Dysfunction

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? a) "The physician coordinates all the care delivered." b) "Clients and families are the focus of hospice care." c) "All hospice clients die at home." d) "Hospice care uses a team approach and provides complete care."

"Clients and families are the focus of hospice care." The most important component of hospice care is the focus that is placed on the care of the client as well as the family

Complications of increased ICP: (3)

1. Brain stem herniation (primary complication of ↑ ICP) 2. Diabetes Insipidus 3. Syndrome of Inappropriate Antidiuretic Hormone

The criteria of the Glasgow Coma Scale:

1. Eye opening 2. Verbal Response 3. Motor response

Patients with a CPP of less than ___ mm Hg experience irreversible neurologic damage.

50

The brain can maintain steady perfusion so long as the SBP is between ___ and ____ mm Hg and the ICP is less than ___ mm Hg.

50-100 40

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? a) 60 mm Hg b) 70 mm Hg c) 50 mm Hg d) 80 mm Hg

70 mm Hg Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? a) Encouraging oral fluid intake b) Suctioning the client once each shift c) Administering a stool softener as ordered d) Elevating the head of the bed 90 degrees

Administering a stool softener as ordered To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener.

This is present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.

Altered LOC

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention? a) Assess vital signs. b) Assess for a patent airway. c) Assess pupils. d) Assess Glasgow Coma Scale.

Assess for a patent airway. A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway.

Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Keeping the head flat with use of no pillow b) Rotating the neck to the far right with neck support c) Extreme hip flexion supported by pillows d) Avoiding flexion of the neck with use of a cervical collar

Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP.

A female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option. a) Because hypothermia is indicative of malaria b) Because hypothermia is indicative of severe meningitis c) Because hypothermia can cause death to the client d) Because shivering in hypothermia can increase ICP

Because shivering in hypothermia can increase ICP Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia

After a craniotomy, the patient is instructed to avoid coughing, sneezing, or nose-blowing because these activities may cause this to happen:

CSF to leak from the craniotomy site

What happens if ICP = MAP?

Cerebral Circulation Ceases

The opening of the skull surgically to gain access to intracranial structures.

Craniotomy

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? a) Complete a head-to-toe assessment. b) Administer morning dose of anticonvulsant. c) Administer Percocet as ordered. d) Elevate the head of the bed.

Elevate the head of the bed. The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF

T or F. Couging, suctioning, and Valsalva Maneuvers decrease ICP.

FALSE

The shifting of brain tissue from an area of high pressure to an area of lower pressure.

Herniation

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Status epilepticus b) Increased intracranial pressure (ICP) c) Encephalitis d) Shock

Increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure.

Intracranial Pressure (ICP) is usually measured in the _____ ventricles, with the normal pressure being __ to ___ mm Hg.

Lateral 0-10

Changes in ICP are closely linked with cerebral perfusion pressure (CPP). What is the formula for determining CPP?

MAP - ICP = CPP

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? a) Mannitol(Osmitrol) b) One-third normal saline (0.33% NSS) c) Dextrose 5% in water (D5W) d) Half-normal saline (0.45% NSS)

Mannitol(Osmitrol) With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells.

What are two ways to decrease cerebral edema?

Osmotic diuretics Fluid restriction

A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient? a) Restricting fluid intake and hydration b) Hyperoxygenation before and after tracheal suctioning c) Administering prescribed antipyretics d) Maintaining adequate hydration

Restricting fluid intake and hydration Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH.

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? a) Hypotension and bradycardia b) Rising blood pressure and bradycardia c) Hypertension and narrowing pulse pressure d) Hypotension and tachycardia

Rising blood pressure and bradycardia Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.

An intraventricular catheter monitoring device used for monitoring ICP. A fine-bore catheter is inserted into a lateral ventricle in the non-dominant hemisphere of the brain. Connected by a fluid-filled system to a transducer which records the pressure.

Ventriculostomy

ventriculostomy

a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid

craniotomy

a surgical procedure that involves entry into the cranial vault

craniectomy

a surgical procedure that involves removal of a portion of the skull

The initial sign of increasing ICP includes a) decreased level of consciousness. b) headache. c) vomiting. d) herniation.

decreased level of consciousness. The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits.

subarachnoid screw or bolt

device placed into the subarachnoid space to measure intracranial pressure

intracranial pressure (ICP)

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

transsphenoidal

surgical approach to the pituitary via the sphenoid sinuses

Cushing's response

the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure

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

Cushing's triad

three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation

altered level of consciousness (LOC)

when a patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness

Increased ICP may reduce cerbral blood flow, resulting in ischemia and cell death. What are 3 early clinical signs that this is occurring? (Cushing's Response)

1. Increased systolic BP 2. Widened Pulse Pressure 3. Decreased Heart Rate

Output greater than ____ ml per hour for 2 consecutive hours could indicate the onset of diabetes insipidus.

200

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a) elevated temperature. b) decreasing blood pressure. c) diminished responsiveness. d) pupillary changes.

diminished responsiveness. Usually, diminished responsiveness is the first sign of increasing ICP.

5 strategies for reducing fever for a patient who has sustained injury to the temperature-regulating center in the brain or with severe intercranial infection:

1. Remove all bedding (save for a small sheet) 2. Administer acetaminophen as ordered 3. Give cool sponge bath and allow electric fan to evaporate it 4. Use a hyopthermia blanket 5. Frequent temperature monitoring to assess the patient's response to the therapy and to prevent an excessive decrease in temperature and shivering.

Motor response includes: (3)

1. Spontaneous purposeful movement 2. Movement only in response to painful stimuli 3. Abnormal posturing

The most important complications to monitor the post-craniotomy patient for 2 weeks or later that may compromise recovery: (4)

1. VTE 2. Pulmonary infection 3. Urinary Tract Infection 4. Pressure Ulcers

While monitoring for the signs and symptoms of meningitis, the nurse monitors for: (4)

1. Fever 2. Chills 3. Nuchal rigidity 4. Increasing or persistent headaches

Craniotomies are performed for the following reasons: (4)

1. Remove a tumor 2. Relieve elevated ICP 3. Evacuate a blood clot 4. Control hemorrhage

____ mm Hg is the upper limit of normal ICP.

15

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following therapeutic effects? a) To dehydrate the brain and reduce cerebral edema b) To increase urine output c) To reduce cellular metabolic demands d) To lower uncontrolled fevers

To dehydrate the brain and reduce cerebral edema Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.