Module 5 - Intracranial Regulation 1
How is increased ICP treated?
(a true emergency and must be treated promptly): 1. invasive monitoring of ICP 2. administering osmotic diuretics 3. restricting fluids 4. draining CSF 5. controlling fever 6. maintaining systemic blood pressure and oxygenation 7. reducing cellular metabolic demands
What are clinical manifestations of increased intracranial pressure?
1. changes in level of consciousness 2. flattening of affect 3. decreased orientation and attention 4. papilledema, pupillary changes, impaired eye movement 5. abnormal posturing (decorticate, decerebrate, flaccid) 6. decreased motor function 7. headache 8. seizures 9. Cushing's triad vital signs 10. vomiting 11. changes in speech
What are the signs and symptoms of an acute subdural hematoma?
1. changes in the level of consciousness 2. pupillary signs (ipsilateral pupil dilated and fixed) 3. hemiparesis (paralysis of one side of the body) *may be minor or even no symptoms with small collections of blood*
What are the signs and symptoms of a rapidly expanding acute subdural hematoma?
1. coma 2. increasing blood pressure 3. decreasing heart rate 4. slowing respiratory rate *requires immediate intervention*
What are the types of brain injury?
1. contusion 2. intracranial hemorrhage 3. concussion 4. diffuse axonal injury (DAI)
What are the clinical manifestations of diabetes insipidus?
1. decreased ADH 2. polyuria (urine output of 4-24 L/day) 3. polydipsia (intense thirst) 4. dehydration - dry mucous membranes, decreased skin turgor 5. fluid volume deficiency 6. hypotension 7. high serum osmolarity 8. hypernatremia 9. low urine osmolarity
What does increased intracranial pressure cause?
1. decreased cerebral perfusion 2. stimulates further edema 3. may shift brain tissue, resulting in herniation
In terms of strokes, what is a non-contrast CT useful for?
1. differentiates between ischemic and hemorrhagic stroke 2. indicates size and location of lesion
What are the risks associated with a CT angiography?
1. dislodging an embolus 2. vasospasm 3. inducing further hemorrhage 4. allergic reaction to contrast media
What are the risks of using an angiography (MRA)?
1. dislodging an embolus 2. vasospasm 3. inducing further hemorrhage 4. allergic reaction to contrast media
What are possible visual deficits that can occur from a stroke?
1. disturbances in visual spatial relations 2. loss of half of the visual field (homonymous hemianopsia) 3. loss of peripheral vision 4. double vision (diplopia) 5. unilateral neglect
How is fluid and electrolyte balance restored for the client with SIADH?
1. diuretic agents such as furosemide 2. fluid restriction 3. severe hyponatremia - sometimes a hypertonic NaCl (3%) may be prescribed and administered IV
What is included in the musculoskeletal assessment of a client who sustained a head injury?
1. drift 2. muscle strength 3. sensations 4. tone 5. reflexes (corneal, cough, gag)
What are the causative agents of viral meningitis?
1. enteroviruses - enteric/GI 2. insects (West Nile) 3. body fluids (Herpes and flu)
What are the types of bleeding that can occur in the brain?
1. epidural hematoma 2. subdural hematoma 3. subarachnoid hematoma intracerebral hemorrhage and hematoma
What are nursing interventions for a client undergoing an MRI?
1. explain to the client they will be in a tight space, that it takes a while, and there will be loud noises 2. assess for metal objects 3. assess for pacemakers and defibrillators
What are the most common causes of TBIs?
1. falls 2. motor vehicle crashes 3. assaults 4. firearm related 5. sports-related trauma 6. recreational injuries 7. war-related injuries
What are risk factors for getting meningitis?
1. first-year college students and members of the military who have not been vaccinated 2. peak incidence is in the winter and early spring 3. tobacco use and viral upper respiratory infection 4. large numbers in close quarters 5. immune system deficiencies (AIDS & Lyme)
What is the nurse's role in the care of a client with SIADH?
1. frequently vital signs 2. close monitoring of I&0 3. monitor neneurologic status 4. monitor urine and blood chemistries 5. monitor daily weight
What are health promotion methods for viral meningitis?
1. general hygiene (cover cough, hanf hygiene) 2. vaccination (MMR, chicken pox, flu) 3. avoid mosquito bites
What can cause increased intracranial pressure?
1. head injury 2. brain tumors 3. subarachnoid hemorrhage 4. toxic and viral encephalopathies
What physical assessments should the nurse perform on a client who sustained a head injury?
1. head to toe shift assessment 2. focused neurological 3. musculoskeletal
What are the clinical manifestations of a head injury?
1. headache 2. projectile vomiting, maybe nausea 3. dizziness 4. seizures 5. memory loss 6. restlessness and irritability 7. change of LOC 8. dilated or pinpoint pupils 9. Cheyne-Stokes respirations 10. decerebrate, decorticate, or flaccid positioning 11. Cushing's triad 12. CSF leak
What is associated with an embolic ischemic stroke?
1. heart disease 2. has a sudden onset 3. can be temporary
What kind of disabilities can a stroke cause?
1. hemiparesis 2. inability to walk 3. complete or partial dependence for ADLs 4. aphasia 5. depression
What are possible motor losses that can occur from a stroke?
1. hemiplegia & hemiparesis 3. poor muscle control that causes clumsy voluntary movements (ataxia) 4. loss of the ability to execute or carry out skilled movements and gestures (apraxia)
What can a cerebral contusion cause?
1. hemorrhage and edema 2. increased ICP and possible herniation syndromes
What should be included in assessing the history of a client who sustained a head injury?
1. history of present illness (mechanism of injury) 2. ask about any loss of consciousness 3. obtain home medication list (especially for anticoagulants)
intracerebral hemorrhage (ICH)?
1. hypertension is the most common cause 2. hemorrhage occurs during activity
What is associated with a thrombotic ischemic stroke?
1. hypertension or diabetes mellitus (2/3) 2. preceded by TIA 3. collateral circulation
Deaths occur at which three points in time after TBIs?
1. immediately after the injury 2. within 2 hours after the injury 3. 3 weeks after the injury
What are other sensory or motor deficits that can be caused by a stroke?
1. inability to recognize and identify objects or persons (agnosia) 2. loss of voluntary movement (akinesia) 3. impairment of integration of movements 4. alterations in reflexes
What factors influence cerebral blood vessel tone?
1. increase in PaCO2 causes cerebral vasodilation - increased blood flow and ICP 2. decrease in PaCO2 has a vasoconstrictive effect - limiting blood flow which can also raise ICP 3. O2 is a vasoconstrictor
What are the clinical manifestations of SIADH?
1. increased ADH 2. retain H2O 3. low urine output 4. increased weight 5. risk for fluid overload 6. hypertension 7. increased HR 8. low serum osmolarity 9. sodium deficiency known as dilutional hyponatremia 10. confusion 11. seizures
What are complications of a basal skull fracture?
1. increased ICP 2. cranial nerve damage - ocular, tinnitus, hearing loss, facial paralysis 3. infection - hospital acquired UTI, pneumonia, sepsis and meningitis
What is Cushing's triad?
1. increased systolic BP (widening pulse pressure) 2. decreased pulse 3. irregular respiratory pattern
How can intracranial pressure be monitored?
1. intraventricular catheter (ventriculostomy) 2. subarachnoid bolt 3. epidural or subdural catheter 4. fiberoptic transducer-tipped catheter
How does the nurse optimize cerebral tissue perfusion for a client with increased intracranial pressure?
1. keep head in a neutral (midline) position by a cervical collar if necessary (promotes drainage) 2. elevate the head at 30 to 45 degrees 3. avoid extreme rotation and flexion of the neck 4. avoid extreme hip flexion (intra-abdominal pressure increases ICP) 5. avoid Valsalva maneuver 6. Stool softeners may be prescribed to prevent straining 7. turn slowly and instruct client to exhale while changing positions 8. provide a calm, restful environment
What are interventions for clients who sustained a basal skull fracture and have leaking CSF?
1. keep head of bed elevated 2. loose collection pad 3. no sneezing or blowing nose 4. no NG tube 5. no nasotracheal suctioning 6. no packing the nose
What are the manifestations of a subdural hemorrhage?
1. level of consciousness change 2. unequal pupils 3. may extend over time
What should be done after a lumbar puncture?
1. lie prone for few minutes 2. maintain a supine position for 4-8 hours 2. monitor for post-lumbar puncture headaches (notify physician)
What are the types of skull fractures?
1. linear / simple = break in the continuity of the bone 2. comminuted = splintered or multiple fracture line 3. depressed = when bones of the skull are forcefully displaced downward
What are possible communication losses that can occur from a stroke?
1. loss of ability to understand or express speech (aphasia) 2. difficulty speaking (dysarthria) 3. loss of peripheral vision 4. double vision (diplopia) 5. unilateral neglect
Why is a subarachnoid hemorrhage (SAH) called the silent killer?
1. loss of consciousness may or may not occur 2. high mortality rate 3. survivors often suffer significant complications and deficits
What are the manifestations of an epidural hemorrhage?
1. lucid level of consciousness 2. headache 3. nausea and vomiting 4. is focal & size dependent
What is nursing care focused on for a client who sustained a head injury?
1. maintaining respiratory function 2. maintaining circulation 3. preserving cognitive function 4. preventing complications
How is an epidural hematoma treated?
1. making openings through the skull to decrease ICP emergently, remove the clot, and control the bleeding 2. craniotomy may be required 3. drain is usually inserted after creation of burr holes or a craniotomy to prevent reaccumulation of blood
What medications are used to maintain optimal ICP?
1. mannitol 2. hypertonic saline 3. corticosteroids (dexamethasone) 4. anti-seizure drugs 5. opioids for pain 6. barbiturates (pentobarbital) for sedation
The client with DAI in severe head trauma experiences:
1. no lucid interval 2. immediate coma 3. decorticate and decerebrate posturing
What diagnostic studies are used for strokes?
1. non-contrast CT 2. 12 lead ECG 3. carotid ultrasound 4. CT angiography (CTA) 5. magnetic resonance imaging (MRI) 6. angiography (MRA) 7. transcranial Doppler flow studies
What are the clinical manifestations of a stroke?
1. numbness or weakness of the face, arm, or leg, especially on one side of the body 2. confusion or change in mental status 3. trouble speaking or understanding speech 4. visual disturbances 5. difficulty walking, dizziness, or loss of balance or coordination 6. sudden severe headache
What is the nurse's role in treatment of a client with diabetes insipidus?
1. obtain hourly vital signs 2. maintain strict intake & output 3. perform frequent neurological assessments 4. obtain and monitor frequent labs 5. administer fluid replacement (IV with ½ NS or ¼ NS)
Skull fractures can also be considered:
1. open = scalp laceration or tear in the dura 2. closed = dura is intact
What are the symptoms of right-sided brain damage?
1. paralysis or weakness on left side of body 2. left visual field deficit 3. spatial and perceptual deficits 4. increased distractibility 5. impulsive behavior and poor judgement 6. lack of awareness of deficits
What are the symptoms of left-sided brain damage?
1. paralysis or weakness on right side of body 2. right visual field deficit 3. aphasia (expressive, receptive, or global) 4. altered intellectual ability 5. slow, cautious behavior
What is post-op nursing care for a craniotomy focused on?
1. reducing cerebral edema 2. relieving pain and preventing seizures 3. monitor ICP 4. monitor fluid and flectrolytes 5. preventing infection 6. regulate temperature 7. improve gas exchange
What are nursing interventions for the client who suffers from dysphagia due to stroke?
1. refer to speech therapist (for a swallow test, diet accommodations & oral pharyngeal exercises) 2. elevate the head of the bed 3. keep chin tucked 4. start with ice chips 5. perform oral care after eating (to eliminate pocket food) 6. ensure adequate intake of nutrition (count calories) 7. administer tube feedings or IV feedings
How is SIADH treated?
1. restoring fluid and electrolyte balance 2. treating the underlying cause (besides head injury)
What must be done before tPA can be administered for an ischemic stroke?
1. rule out hemorrhagic stroke via CT scan 2. determine time of symptom onset (within 3 hours) 3. obtain health history (surgery, head trauma, GI bleed, prior CVA will disqualify tPA)
Describe a scalp injury.
1. scalp is highly vascular which causes profuse bleeding 2. major complications are blood loss and infection
What are the signs and symptoms of meningitis?
1. steady or throbbing and very severe headache 2. high fever and chills 3. nuchal rigidity (a stiff and painful neck) 4. photophobia (extreme sensitivity to light) 5. red macular rash, skin lesions (ranging from a petechial rash with purpuric lesions to large areas of ecchymosis)
How does the nurse maintain respiratory function for a client with increased intracranial pressure?
1. suction respiratory secretions with care (increases ICP) 2. adequately oxygenate (hypoxia / poor oxygenation causes cerebral ischemia and edema) 3. coughing is discouraged because it increases ICP 4. elevating the head of the bed helps clear secretions and improves drainage of the brain 5. hyperventilation therapy sometimes reduces ICP (collaborate with respiratory therapist)
Describe the progression of an intracerebral hemorrhage (ICH).
1. sudden onset of symptoms 2. progression over minutes to hours because of ongoing bleeding
What are pharmacological ways to treat an ischemic stroke?
1. tPA (tissue plasminogen activator) to break down the clot 2. platelet inhibitors or anticoagulants 3. metoprolol or nicardipine if systolic BP is < 220 or MAP is < 130 4. medications for seizure treatment and prevention
The brain can maintain a steady perfusion pressure if:
1. the mean arterial pressure is 70 to 150 mm Hg 2. and the ICP is less than 40 mm Hg
Because every client with a head injury is presumed to have a cervical spine injury:
1. they are transported on a board with the head and neck maintained in alignment 2. a cervical collar should be applied and maintained 3. cervical spine x-rays are obtained to rule out spinal cord injury
How is nephrogenic diabetes insipidus treated?
1. thiazide diuretics 2. mild salt depletion 3. prostaglandin inhibitors (indomethacin and aspirin)
What are surgical / invasive ways to treat an ischemic stroke?
1. thrombectomy (Merci Retriever) 2. carotid embolectomy (prevents embolic strokes)
What causes an ischemic stroke?
1. thrombosis (plaque --> slows blood flow --> clot formation --> narrow path --> ischemia) 2. embolus (clot breaks free --> travels --> arrives at smaller vessel --> occlusion)
What percentage of ischemic strokes are either thrombotic or embolic?
1. thrombotic = 60% total CVA cases 2. embolic = 25% of total CVA cases
What are the three types of stroke?
1. transient ischemic attack (TIA) or pre-stroke 2. ischemic (thrombotic or embolic) 3. hemorrhagic (intracerebral or subarachnoid)
What are surgical ways to treat a transient ischemic attack (TIA)?
1. transluminal angioplasty 2. stenting 3. carotid endarterectomy
What causes a subdural hematoma?
1. trauma (most common) 2. coagulopathies 3. rupture of an aneurysm
What underlying causes of SIADH can be treated to resolve the disease?
1. tumors 2. certain medications 3. thyroid disorders *SIADH is generally self-limiting once these underlying causes are eliminated*
What are health promotion methods for bacterial meningitis?
1. vaccination 2. prophylactic treatment for close contact with an infection
What lab values are consistent with diabetes insipidus?
1. very high output of diluted urine 2. low urine specific gravity (< 1.005) 3. high serum sodium (> 145 mEq/L) 4. decreased urine sodium 5. high serum osmolality (> 295 mOsm/L) 6. low urine osmolality (< 200 mOsm/kg) 7. BP = hypotension and tachycardia 8. neuro = irritability, seizures, coma
What lab values are consistent with SIADH?
1. very low output of concentrated urine 2. high urine specific gravity (> 1.025) 3. low serum sodium (< 130 mEq/L) 4. high urine sodium (> 40 mEq/L) 5. low serum osmolality (< 275 mOsm/L) 6. high urine osmolality (> 900 mOsm/kg) 7. BP = varies but can be normal 8. neuro = N & V, confusion, delirium, coma
Where is an intracerebral hemorrhage located and what is its cause?
1. within brain tissue 2. gunshot wound, CVA, depressed skull fracture
What are the manifestations of a subarachnoid hemorrhage?
1. worst HA ever 2. projectile vomiting 3. also locale and size dependent 4. often associated with other intracranial bleeds
What scale is used to assess head injuries?
Glasgow Coma Scale
How can you remember SIADH?
SI = "soaked inside"
What should the nurse monitor for the client taking hypertonic saline?
BP and serum sodium levels
How is a basal skull fracture definitively diagnosed?
CT scan
What is the best diagnostic test to determine craniocerebral trauma?
CT scan
What other diagnostic tools are used for head injuries?
CT scan and MRI
What are the most common tests to diagnose increased ICP?
CT scanning and MRI (others may include cerebral angiography, PET, SPECT, and tanscranial doppler)
How can you remember diabetes insipidus?
DI = "dry inside"
What is the Kernig sign?
When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. When Kernig sign is bilateral, meningeal irritation is suspected.
What is the Brudzinski sign?
When the client's neck is flexed, flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity. (Brudzinski sign is a more sensitive indicator of meningeal irritation than Kernig sign.)
Why are metoprolol or nicardipine used to treat ischemic strokes?
elevated BP is common immediately after a stroke, which may reflect body's attempt to maintain cerebral perfusion
What is decerebrate posturing?
extensor response: arms are like E's
What is syndrome of inappropriate anti diuretic hormone (SIADH)?
failure of the negative feedback system that regulates the release and inhibition of ADH (excessive production of ADH)
What is decorticate posturing?
flexor response: "arms are like C's, moves in towards the core
What should the nurse monitor for the client taking mannitol?
fluid and electrolyte status
How are skull fractures classified based on location?
frontal, temporal, and basal
What is the benefit of an angiography (MRA)?
good visualization of blood vessels
How is neurogenic diabetes insipidus treated?
hormone replacement therapy with desmopressin (synthetic ADH without the vascular effects of the natural form)
What 2 disease processes are the etiology of most thrombotic strokes?
hypertension & diabetes
What fluids should the nurse avoid giving to the client with increased ICP?
hypotonic solutions (D5W or 0.45% sodium chloride) by themselves can cause cerebral edema
What puts the client who sustained a cerebral contusion at greater risk for hemorrhage?
if they are taking anticoagulants
What is the client with a ventriculostomy at risk for?
infection
What is meningitis?
inflammation of the meninges, which cover and protect the brain and spinal cord
What is diabetes insipidus?
injury to the hypothalamus or pituitary gland with a deficiency of ADH (vasopressin)
After a stroke has stabilized for 12 to 24 hours:
interprofessional care shifts from preserving life to lessening disability and attaining optimal functioning (client may be transferred to a rehabilitation unit, outpatient therapy, or home care-based rehabilitation)
What is a subarachnoid hemorrhage (SAH)?
intracranial bleeding into cerebrospinal fluid-filled space between arachnoid and pia mater
What happens when cerebral perfusion pressure (CPP) is less than 50 mm Hg?
irreversible neurologic damage
How does a subarachnoid bolt work?
it can only be used to monitor ICP, not drain
What is unique about the diagnosis of a chronic subdural hematoma?
it can resemble other conditions (like a stroke) and there is an increased risk of misdiagnosis
What happens when cerebral perfusion pressure (CPP) is less than 30 mm Hg?
it is incompatible with life
How is an MRI useful when diagnosing a stroke?
it is more accurate than a CT in terms of extent of injury
What characterizes a cerebral contusion?
loss of consciousness associated with stupor and confusion
How is cerebral perfusion pressure (CPP) calculated?
mean arterial pressure (MAP) - intracranial pressure (ICP): CPP = MAP - ICP
How does hypertonic saline decrease ICP?
moves water out of cells and into blood
When is further intervention required for a concussion?
occurrence of these symptoms: 1. decrease in LOC 2. worsening headache 3. dizziness 4. seizures 5. abnormal pupil response 6. vomiting 7. irritability 8. slurred speech 9. numbness or weakness in the arms or legs
In what population are chronic subdural hematomas most common?
older adults who are prone to seemingly minor head injuries
What is considered an acute subdural hematoma?
one that occurs within 24 to 48 hours of injury
What is a craniotomy?
opens the skull surgically to gain access to intracranial structures
What does chronic traumatic encephalopathy look like?
presentation is similar to Alzheimer's disease, characterized by personality changes, memory impairment, and speech and gait disturbances
What is the best medical approach to the burden of strokes?
prevention: 1. healthy lifestyle (not smoking, physical activity, healthy weight and diet) 2. identifying people or groups of people who are at high risk (older than 55 years, younger men, older women, African Americans and Hispanic/Latino Americans 3. treatable conditions that increase risk (sickle cell diseases, cardiomyopathy, and valvular heart disease) 4. anticoagulants (aspirin, clopidogrel, warfarin)
What is the best approach to head injury?
prevention: 1. obey traffic laws and avoid speeding 2. wear seatbelts and use car seats for kids 3. wear helmets 4. protective devices for athletes 5. prevent falls, particularly in older adults 6. gun safety
What does decerebrate posturing indicate?
problem within midbrain or pons
What does decorticate posturing indicate?
problems with cervical spinal tract or cerebral hemisphere
Describe the mortality of an intracerebral hemorrhage (ICH).
prognosis is poor with a 30-day mortality rate of 40%-80%
What are nursing interventions for the client who suffers from unilateral neglect due to stroke?
protect the affected side from injury
What should the client who sustained a cerebral contusion be monitored for?
seizures
What can cause bleeding in the brain?
skull fractures or penetrating objects
What is a stroke?
sudden loss of function resulting from disruption of the blood supply to a part of the brain (also called cerebrovascular accident or brain attack)
How are chronic subdural hematomas treated?
surgery to evacuate the clot: 1. multiple burr holes 2. craniotomy for a large mass that cannot be suctioned or drained through burr holes
What are the signs and symptoms of a chronic subdural hematoma?
symptoms fluctuate as the brain adapts: 1. severe headache, which tends to come and go 2. alternating focal neurologic signs 3. personality changes 4. mental deterioration 5. focal seizures
What causes a transient ischemic attack (TIA)?
temporary ischemia (impairment of blood flow) to a specific region of the brain
What is a concussion?
temporary loss of neurologic function with no apparent structural damage to the brain
What is cerebral blood flow?
the amount of blood in mL passing through 100 g of brain tissue in 1 minute
What is a cerebral contusion?
the brain is bruised and damaged in a specific area because of severe acceleration-deceleration force or blunt trauma (impact of the brain against the skull)
How is cerebral blood flow regulated?
the brain's ability to change the diameter of its blood vessels to maintain a constant cerebral blood flow during alterations in systemic blood pressure (called autoregulation)
What is the downside of using an MRI?
the cost is expensive
What are the clinical manifestations of an epidural hematoma?
the expanding hematoma causes: 1. a brief loss of consciousness 2. followed by a lucid interval (is awake and conversant) 3. then becomes increasingly restless, agitated, and confused as the condition progresses to coma 4. signs of herniation appear (deterioration of consciousness and signs of focal neurologic deficits, such as dilation and fixation of a pupil or paralysis of an extremity)
What is the prevalence of a transient ischemic attack (TIA)?
there is no way to predict outcome: 1. 1/3 do not experience another event 2. 1/3 have additional TIAs 3. 1/3 progress to stroke
What are nursing interventions for the client with meningitis?
they are critically ill, so collaborate with other health care teams: 1. start isolation as soon as you suspect the patient has meningitis of any type 2. assisting with pain management 3. assisting with getting rest in a quiet, darkened room 4. treat fever with antipyretic agents and cooling blankets 5. ensure hydration 6. close neurologic monitoring 7. ET tube (or tracheotomy) and mechanical ventilation may be needed to maintain adequate tissue oxygenation 8. blood pressure (usually monitored using an arterial line) 9. protecting from injury secondary to seizure activity or altered LOC 10. preventing complications associated with immobility (pressure injuries, pneumonia)
What are the clinical manifestations of a basilar skull fracture?
they tend to traverse the paranasal sinus of the frontal bone or the middle ear and may cause: 1. bruising around the eyes (Raccoon eyes) 2. bruising over the mastoid under the ears (Battle sign) 3. CSF rhinorrhea or otorrhea other manifestations include: 4. loss of consciousness followed by period of normal LOC again 5. nausea and vomiting 6. hearing and vision changes 7. facial numbness
Which population is chronic traumatic encephalopathy most commonly seen in?
those participating in contact sports such as football and boxing
What is important about obtaining a non-contrast CT with suspected stroke?
time is of the essence (scan and read within 1 hour)
Skull fractures are classified by:
type and location
How is meningitis best prevented?
vaccinations: 1. meningococcal conjugated vaccine - given to youth at 11 to 12 years of age, with a booster dose at 16 years of age 2. Haemophilus influenzae and S. pneumoniae vaccines - children and adults who are at-risk
What does a CT angiography (CTA) do?
visualizes intra- and extracranial vasculature
What test is performed to differentiate neurogenic diabetes insipidus from nephrogenic?
water deprivation test: 1. deprived of water for 8-12 hours 2. administer Desmopressin Acetate (DDAVP) 3. exhibits dramatic decrease in urine volume
What is an open (penetrating) traumatic brain injury?
when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain
What is a closed (blunt) traumatic brain injury?
when the head accelerates and then rapidly decelerates or collides with another object (e.g., a wall, the dashboard of a car) and brain tissue is damaged but there is no opening through the skull and dura
What is considered a chronic subdural hematoma?
when the time between injury and onset of symptoms is 3 weeks to months
What is a diffuse axonal injury (DAI)?
widespread shearing and rotational forces that produce damage throughout the brain to axons in the cerebral hemispheres, corpus callosum, and brain stem
How quickly should a concussion resolve?
within 72 hours
What should be done during a lumbar puncture?
1. cannonball position 2. relaxation 3. manometer 4. CSF specimen collection
What are the two types of diabetes insipidus?
1. central / neurogenic 2. nephrogenic - kidney related
How does mannitol decrease ICP?
decrease fluid in the brain tissue and reduce cerebral edema by drawing water across membranes, reducing the volume of the brain and extracellular fluid
When CSF drainage is suspected in a basal skull fracture, how can the CSF be distinguished from other discharge?
1. CSF has glucose (testing via dextrostic or tes-tape strip) 2. halo sign (testing via gauze)
How is meningitis diagnosed?
1. CT scan is done first to rule out brain herniation or other suspected causes 2. lumbar puncture is the gold standard 3. bacterial culture and gram staining of CSF and blood 4. radiology - x-ray, CT scan, MRI
What is included in the neurological assessment of a client who sustained a head injury?
1. Glasgow Coma Scale number 2. assess pupils for PERRLA 3. assess extra ocular movements, gaze, and convergence
What nursing assessments techniques can be used to diagnose meningitis?
1. Kernig sign 2. Brudzinski sign 3. cranial nerve damage 4. health history (viral or bacterial infections, medications, risk factors like being immunocompromised, age, and recent travel)
What other diagnostic tools can be used to evaluating brain structure and assess brain function?
1. MRI 2. positron emission tomography (PET) 3. transcranial doppler
What are the causative agents of bacterial meningitis?
1. Neisseria meningitidis 2. Streptococcus pneumoniae and Group B Streptococcus 3. Haemophilus influenzae type b (Hib) 4. Listeria monocytogenes
What happens during a chronic subdural hematoma?
1. bleeding is less profuse, but compression of intracranial contents still occurs 2. blood within the brain changes in character in 2 to 4 days, becoming thicker and darker 3. in a few weeks, the clot breaks down and has the color and consistency of motor oil 4. calcification or ossification of the clot eventually takes place
What are clinical manifestations of increased intracranial pressure in infants?
1. bulging fontanels 2. cranial suture separation 3. increased head circumference 4. high pitched cry
How is viral meningitis treated?
1. by treating the symptoms (usually self-limiting) 2. limited use of anti virals (only for herpes or influenza origin)
How does a ventriculostomy work?
1. a catheter is inserted into a lateral ventricle 2. a transducer records the pressure in the form of an electrical impulse 3. catheter allows CSF and blood to drain 4. medications can be administered through catheter
What is prevalence, morbidity, and mortality of strokes?
1. affect more than 795,000 people in U.S. 2. about 610,000 of these are first or new strokes 3. about 185,000 strokes - nearly 1 in 4 - are in people who has had a previous stroke 4. ~25 % of clients die in 1st year 5. $53 billion annual cost per year 6. 5th most common cause of death 7. #1 cause of long-term disability
What are the manifestations of an intracerebral hemorrhage?
1. altered LOC 2. pupil changes 3. focal and size dependent 4. worst prognosis
What are possible complications from head injury or increased ICP?
1. altered nutrition 2. impaired skin integrity 3. seizures 4. fluid and electrolyte imbalances (monitor for diabetes insipidus and SIADH) 5. infection from open head injury or drainage sites
How is bacterial meningitis treated?
1. antibiotics: Penicillin G in combination with one of the cephalosporins (ceftriaxone, cefotaxime) 2. adjunct therapy with dexamethosone 3. dehydration and shock are treated with fluid volume expanders 4. seizures are treated with anticonvulsant medications
Describe the incidence and mortality of TBIs?
1. are twice as common in males 2. high potential for poor outcome
What are pharmacological ways to treat a transient ischemic attack (TIA)?
1. aspirin 2. ticlopidine (Ticlid) 3. clopidogrel (Plavix)
What are nursing interventions for a client undergoing a CT scan?
1. assess for allergies 3. evaluate renal function 3. insert an IV with 20 gauge 5. monitor ABC's (RN with patient) 6. explain to the client what to expect (narrow table, laying still)
What is involved in pre-op nursing care for a craniotomy?
1. assist with diagnostic tests 2. administer medications 3. shower or wash hair with preferred cleansing solutions 4. hair is removed 5. an indwelling catheter is placed in OR
What is involved in the immediate care of anyone who sustains a head injury?
1. assume spine injury and stabilize the neck 2. ABCs (CABs) - intubate for GCS score below 8 3. diagnostics (CT, x-rays, etc.) 4. frequent or continuous vital signs and neuro assessment 5. establish IV access and cautious fluid resuscitation 6. assess for and treat other injuries (remove clothing, control bleeding, treat pain and sedate as appropriate, maintain normothermia)
What are non-surgical ways to treat a hemorrhagic stroke?
1. bed rest with sedation 2. calcium channel blocker nimodipine (Nimotop) for transient changes in LOC and muscle strength 3. IV hypertonic 3% saline to treat hyponatremia 4. vitamin k + fresh frozen plasma if bleed is due to warfarin 5. prothrombin complex concentrates or administration of recombinant activated factor VII 6. NEVER GIVE aspirin, tPA, heparin, or warfarin
Where is a subarachnoid hemorrhage located and what is its cause?
1. below arachnoid layer - directly on surface of brain 2. aneurysm and cardiovascular accident
Where is a subdural hemorrhage located and what is its cause?
1. below dura but above subarachnoid layer 2. blunt force trauma and motor vehicle crashes
Where is an epidural hemorrhage located and what is its cause?
1. between dura & interior of skull 2. falls
What are surgical / invasive ways to treat a hemorrhagic stroke?
3 "ings" 1. evacuating 2. coiling 3. clipping
What is normal intracranial pressure?
5 to 15 mm Hg
What is the normal/average cerebral blood flow?
50 mL/min per 100 g of brain tissue
What is the normal cerebral perfusion pressure (CPP)?
60 to 100 mm Hg
How is intracranial pressure regulated?
compensation typically is accomplished by: 1. displacing or shifting CSF 2. increasing the absorption or diminishing the production of CSF 3. or decreasing cerebral blood volume
An epidural hematoma is:
considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes
What is a skull fracture?
a break in the continuity of the skull caused by forceful trauma
What is a head injury?
a broad classification that encompasses any damage to the skull, scalp, or brain
Any client with a head injury is presumed to have what until proven otherwise?
a cervical spine injury
What is a subdural hematoma?
a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid
What is an epidural hematoma?
a collection of blood in the epidural space between the skull and the dura mater
What disease process is the etiology of most embolic strokes?
a fib and rheumatic disease
What causes an epidural hematoma?
a head injury can cause a rupture or laceration of the artery that runs between the dura and the skull
What is increased intracranial pressure?
a life-threatening increase in any of three components: 1. brain tissue 2. blood 3. CSF
What is a transient ischemic attack (TIA)?
a neurologic deficit that completely resolves in 24 hours (most last less than 1 hour)
How is a transient ischemic attack (TIA) manifested?
a sudden loss of motor, sensory, or visual function
What is considered elevated intracranial pressure?
a sustained pressure greater than 20 mm Hg
How are subdural hematomas classified?
acute or chronic
What is a traumatic brain injury (TBI)?
an injury that is the result of an external force and is of sufficient magnitude to interfere with daily life and prompts the seeking of treatment
What score on the Glasgow Coma Scale requires provider attention and intervention?
anything less than 8
What are the two main types of meningitis?
bacterial and viral
What must be done before receiving a lumbar puncture?
be aware of risks: 1. anticoagulants 2. brain herniation (CT scan) 3. bladder emptying
What is the Monro-Kellie doctrine?
because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others
What is a intracerebral hemorrhage (ICH)?
bleeding within brain tissue caused by rupture of a vessel
What influences intracranial pressure?
brain tissue, blood, and CSF
Repeated concussive incidents can lead to a syndrome known as:
chronic traumatic encephalopathy
What type of CSF fluid is suspicious of meningitis?
cloudy, positive gram stain that identifies agent, increase in WBC and protein
What causes a subarachnoid hemorrhage (SAH)?
commonly caused by rupture of a cerebral aneurysm, AVMs, trauma, hypertension, or drug abuse
