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