MS 2 Neuro Content

Which assessment data does the nurse recognize as the most sensitive indicator of increased ICP?

LOC

a closed skull fracture

may be palpated through the scalp or visualized on x-ray or other radiographical imaging.

key characteristics that differ increased ICP from cerebral herniation

LOC: progressive confusion and increasing lethargy pupillary assessment: sluggish reaction and ovoid shape motor assessment: Focal contralateral motor weakness vital signs: no change

normal ICP

0-15 mm Hg and is typically treated in a stepwise approach when the pressure exceeds 20 mm Hg

an open skull fracture

is associated with a disruption of the scalp such that the skull is exposed to the atmosphere.

Cushing's Triad

3 late and most recognized clinical manifestations of cerebral herniation; include: widened pulse pressure (increased SBP/decreased DBP), bradycardia, and irregular respiratory pattern

laboratory tests in stroke pts

are used to determine if hypercoagulability is the cause; Examples of tests that may be requested include lupus anticoagulant; anticardiolipin antibodies, protein C activity, protein S activity, and factor V Leiden mutation.

A patient with a head injury has an intracranial pressure of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure is 108 mm hg. What is the cerebral perfusion pressure?

90 mm Hg

The nurse recognizes which patient is at greatest risk for death secondary to stroke? A. A 36-year-old Caucasian male B. A 45-year-old Asian male C. A 56-year-old African American female D. A 62-year-old Hispanic female

A 56-year-old African American female

electroencephalogram (EEG) nursing considerations

A patient must be completely still for this type of test because any movement, including shivering, is recorded as artifact and obscures the electrical tracing. Some patients may require mild sedation to reduce movement artifact on the recording. The technician records the amount of medication given so that the tracing can be interpreted in the context of sedation administration. During continuous monitoring, the scalp electrodes are typically placed by a technician, and the patient's head is wrapped in a bandage to keep the electrodes in place. It is important that the nurse inspects the head to ensure that all electrodes are in place so that the recording is continuous.

spinal cord injury at T6-T12 results in

paraplegia with fair ability to control balance and trunk, little or no voluntary bowel or bladder control

A patient is admitted with a stroke/brain attack. Which predisposing factor in the patient's history places this patient at greatest risk for ischemic stroke? History of hypertension Right sided heart failure Carotid plaque DVT in subclavian vein

Carotid plaque

spinal cord injury at T1-T5 results in

paraplegia with trunk and leg involvement, normal arm and hand movement

nursing actions for the pt with a brain tumor

Administer glucocorticoids as ordered, dexamethasone (Decadron) (typically given postoperative to treat and prevent further local cerebral edema) monitor serum electrolytes, particularly serum sodium and glucose (need to be monitored as dexamethasone may lead to elevated serum glucose levels) replace urine loss and electrolytes as ordered elevate head of bed 30-45 degrees and maintain head in good alignment administer stool softners administer antiepileptic medications as ordered (based on tumor location and a history or risk of seizure activity) apply mechanical VTE devices and administer pharmacological prophylaxis of VTE as ordered (presence of cancer as well as tissue injury during surgery increases a patient's risk of VTE; pharmacological prophylaxis may not be administered immediately after surgery because of concern for bleeding risk; however, medication may be initiated further into the patient's hospital course)

populations at increased risk of Delirium

African American; hispanic; male (vs. Female); non english speaker; medical ICU (vs. SICU)

patients that are better candidates for aneurysm clipping instead of coiling

Aneurysms with a wide neck and tortuous vascular anatomy

Wrapping of cerebral aneurysms

is not considered a definitive treatment because it remains at risk for rupture because blood continues to flow through the weakened aneurysmal vessel wall.

presenting symptomology of a brain tumor in the optic chiasm

Bitemporal field cuts

nerve damage from spinal cord tumor compression

is often permanent, with disabilities continuing after it is removed

clinical manifestations of SCIs

level of injury helps predict what parts of the body might be affected; other effects include chronic pain, low BP, inability to sweat below the level of injury, and decreased temp control

if the dura is damaged in a skull fracture

CSF begins to leak, placing a patient at risk for infection and herniation syndrome as intracranial contents shift with the loss of CSF

medical management of ischemic strokes

Cerebral blood vessels may be opened or recanalized using IV recombinant tissue plasminogen activator (rt-PA), which allows a blood clot to be dissolved at the site and restores blood flow to ischemic neuronal tissue. intra-arterial thrombolytic administration; involves a cerebral angiogram to locate a vessel occlusion accompanied by delivery of thrombolytics directly into a blood clot (also called endovascular technique) using a device such as the MERCI clot retrieval system, where a corkscrew-shaped catheter is introduced into the clot, ensnaring it and allowing it to be retrieved using suction in the artery also includes measures to prevent complications including: VTE prophlylaxis, management of BP, and control of risk factors for stroke to prevent recurrence diagnostic work-up aimed at finding the cause is essential to guid focused treatment

a major complication of SAH affecting 30% of patients

Cerebral vasospasm causing delayed ischemic neurological deficits; occurring between days 4 and 14 after the stroke

if vascular structures, such as jugular veins and carotid arteries are damaged due to skull fractures or TBI

life-threatening hemorrhage can result

other systemic complications that may occur secondary to SAH include

myocardial ischemia and infarction, acute left ventricular failure, and acute respiratory distress syndrome (ARDS)

nursing considerations for serum osmolality test

Ensure that the blood sample is drawn within 1-2 hours of osmotic diuretic administration

key characteristics that differ cerebral herniation from increased ICP

LOC: unresponsive pupillary assessment: unilateral or bilateral pupillary dilation (depending on type of herniation) without reaction Motor assessment: contralateral hemiparesis including flexor or extensor posturing vital signs: cushing's triad (increased systolic pressure, widening of pulse pressure, bradycardia, and change in respiratory pattern)

Nursing Interventions for Complications of Radiation Therapy

Fatigue: nutritional supplements (i.e., Boost, Ensure); Those patients experiencing weight loss are more susceptible; therefore, maintaining weight is important. Skin: utilization of sunscreens, sun-protective covering, skin emollients; Reddened, dry areas of the skin and hair loss are sometimes complications. Ensuring proper sun protection and relief from dry, itching skin is essential. Headache/Nausea and vomiting: dexamethasone (Decadron), ondansetron (Zofran), dronabinol (Marinol); Radiation therapy of the brain can cause swelling around the area of the tumor, thereby increasing intracranial pressure, causing headache, nausea, and vomiting. Medications such as dexamethasone (Decadron) are used to reduce swelling. Medications to reduce effects such as nausea and vomiting are important because they can cause dehydration and weight loss and negatively impact quality of life.

peak risk period for cerebral vasospasm

occurs from days 5-9 after the SAH and is a narrowing of a segment of a cerebral artery that leads to local cerebral ischemia

Hunt and Hess Grading Scale for Subarachnoid hemorrhage

Grade I: Asymptomatic or slight headache and neck stiffness Grade II: Headache and neck stiffness, cranial nerve deficit Grade III: Headache, neck stiffness, focal motor deficit, lethargy Grade IV: Stuporous, dense hemiparesis or posturing Grade V: Comatose, posturing, moribund

risk factors for SAH include

HTN, smoking, heavy alcohol use, use of SNS stimulants such as cocaine, female gender, history of cerebrovascular disease, and postmenopausal state

CV system spinal cord injury complications

Hypotension, bradycardia, decreased cardiac output, venous pooling, impaired tissue perfusion

patients in a barbiturate coma are monitored using

ICP monitoring, and in some cases EEG recordings to document suppression of electrical activity in the brain

things that are critical to do after discharge of stroke patients to promote wellness and prevent recurrence

Implementation, teaching, and reinforcement of secondary stroke prevention measures such as taking antiplatelet therapy and lipid-lowering and antihypertensive medications and follow-up cerebrovascular care In addition to rehabilitation services, it is important to consider the psychosocial aspects of the illness affecting patients' position in their family (e.g., main wage earner), their employment, and their need for caregiver support.

management of skull fractures

In certain circumstances, require a surgical procedure to elevate and stabilize the bone (titanium plates and screws may be used). Direct visualization of the dura and underlying structures (e.g., arteries, dural sinuses, brain tissue) is possible in the operating room and is important in identifying additional injury.

nursing diagnoses for increased ICP

Ineffective airway clearance related to diminished protective reflexes (cough, gag) • Ineffective breathing patterns related to neurological dysfunction (brainstem compression, structural displacement) • Ineffective cerebral tissue perfusion related to cerebral edema, hemorrhage, or hydrocephalus • Fluid volume deficit related to osmotic diuretic administration • Ineffective thermoregulation related to damage to the hypothalamus • Interrupted family processes related to unresponsiveness of the patient, unpredictability of the outcome, prolonged recovery period, and the patient's uncertain residual physical, emotional, and cognitive disabilities

A patient is admitted to the neuroscience intensive care unit (NICU) after a TBI. If the goal of ICP monitor insertion is to measure ICP and drain CSF to control ICP, what device should the nurse anticipate being inserted?

Intraventricular catheter

patient teaching for brain tumors

It is important to provide clear direction to the patient and family regarding the tapering of the steroid dose over the prescribed number of days. Rapid withdrawal of glucocorticoids can cause an adrenal crisis. Some patients become hyperglycemic as a result of steroid administration and require home testing of glucose levels while they are receiving glucocorticoids. Typically, this monitoring is temporary until the medication is tapered off. Importance of continuing antiepileptic medications and obtaining prescribed blood levels Some antiepileptic medications may require serum medication levels to ensure that they are maintained at therapeutic levels. Because of previous or new motor weakness or visual deficits, patients may have an increased risk of experiencing a fall either in the hospital or at home. Discussions and planning with the patient regarding potential fall or tripping hazards in the hospital and at home are necessary. Wear hat or head covering as needed Chemotherapeutic agents affect cells that divide quickly, which makes the patient at risk for sores in the mouth. Using a soft toothbrush and non-alcohol-containing mouthwash decreases mouth discomfort.

common areas and causes of embolic stroke

Left atrium (atrial fibrillation or thrombus; atrial myoxma; atrial septal aneurysm) Left ventricle (recent MI; ventricular aneurysm; cardiomyopathy) heart valves (prosthetic valve complications; endocarditis; RHD; calcification; syphilis; valve prolapse) septal/shunt diseases and disorders (patent foramen ovale; atrial septal defect; ventriculoseptal defect; congenital heart disease; pulmonary arteriovenous fistula)

Neuro/musculoskeletal system spinal cord injury complications

Loss of sensation/function (paralysis), contractures, spasticity, muscle atrophy

tests that can be used to diagnose a spinal tumor

MRI is considered gold standard; myelography with CT can be used if MRI is unavailable; if a primary mass is detected, the patient needs a biopsy to diagnose the type and a CT of the chest and abdomen (for staging purposes)

treatment options for spinal tumors include

Monitoring: often used for small, benign tumors that are not growing or pressing on surrounding tissues; periodic scans are needed to monitor the tumor Surgery: usually the first step in treating tumors that can be removed with an acceptable risk of nerve damage; often an option used with benign tumors Radiation therapy: used following an operation to eliminate the tumor remnants or to treat inoperable tumors; often first-line therapy for metastatic tumors Stereotactic radiosurgery: delivers a high dose of targeted radiation; effective in brain tumors and currently being studied for spinal cord tumors Chemotherapy: has not been proven effective for most spinal cord tumors Corticosteroids: to reduce swelling following surgery or during radiation treatments

nursing assessments for pt w/ brain tumor

Neurological assessment including level of consciousness, orientation, motor strength, and sensation. Cranial nerve assessment may also be helpful in monitoring a patient's response to a craniotomy Vital signs including temperature, blood pressure, heart rate, respiratory rate, and pulse oximetry estimated blood loss (should be taken into account during a handoff from the OR or RR) intake and urinary output (especially in patients who have undergone a craniotomy where the pituitary gland has been manipulated; these patients are at risk for DI, where the nurse observes a large UO per hours that can rapidly result in intravascular volume deficit) urine specific gravity and osmolality; serum sodium and osmolality pain (NSAIDs are not preferred due to increase in bleeding risk)

glia

provides the physical structure of the brain and supports the endothelial cells of the BBB; also provides nutrients and ionic balance and is involved in the repair and scarring processes

if the patient complains of problems swallowing with a halo device

Notify the health-care provider; The provider may need to adjust the halo to help resolve the problem, or a speech and language pathologist can be consulted to evaluate dysphagia.

The nurse is caring for a patient status post craniotomy for resection of a right frontal tumor. Upon admission, the patient was alert and oriented X 3, moving all extremities symmetrically, and the cranial nerves were intact. Three hours after admission, the nurse notes that the patient is slower to awaken than during previous assessments, requiring vigorous shaking, and cannot recall location. The patient also exhibits a left pronator drift. What are the nurse's next actions?

Notify the patient's provider and prepare the patient for a computed tomography (CT) scan.

patients with SCIs are at risk for developing

PEs because of fluid shifts after injury; must be carefully monitored

nursing assessments for spinal tumors

Pain in the middle or lower back is the most common symptom of both benign and malignant types; Other clinical manifestations are related to the area of the spine involved. Common findings include: • Back pain radiating to other parts of the body • Loss of sensation or muscle weakness, often in the legs • Difficulty walking • Decreased sensitivity to pain, heat, or cold • Loss of bladder or bowel function • Paralysis • Scoliosis or other spinal deformity

GI system spinal cord injury complications

Paralytic ileus, septic or necrotic bowel, GI bleed, malnourishment, retention, neurogenic bowel, impaction

MRI nursing considerations

Patients must be screened for metal that may be embedded in and around the eyes (metal workers and welders) or in any other part of the body including joint implants, cardiac stents, pacemakers, and other implanted devices. If the patient has a history of working with metal, x-rays may be requested by a radiologist to locate or rule out the existence of metal fragments. During MRI, implanted metal can heat up, causing tissue damage. Certain implanted devices such as a pacemaker or deep brain stimulator (used in patients with movement disorders) may malfunction. Patients may not be able to have MRI because of the above-mentioned factors. An MRI clearance form is often used by MRI technicians to ensure that a patient is safe to be scanned. Transport of critically ill patients to MRI requires planning because the time to acquire the images is longer than a CT scan, and cardiorespiratory monitoring has to be changed to an MRI-compatible monitoring system. IV fluids or other necessary infusions have to be changed to an MRI-compatible infusion pump or lengthened with extension tubing so that the pump does not enter the room. Patients receiving mechanical ventilation must be changed over to an MRI-compatible ventilator. Conventional medical equipment including cardiac monitors, ventilators, infusion pumps, oxygen tanks, and IV poles may not enter the MRI scanning room because the strong magnetic field may pull metal equipment into the magnet, which could injure a patient or staff in the room. Many devices do not operate properly in the strong magnetic field. Assess the patient's ability to remain still during the procedure because movement of the head causes decreased clarity (artifact) of the images, which could obscure an abnormality. Patients with increased ICP may be confused, restless, or agitated, requiring sedation or anxiolysis to ensure capture of high-quality images. Many patients know that they are claustrophobic and require anxiolysis (benzodiazepines are commonly used for this purpose) in order to enter the small scanning tube of the MRI scanner. A pregnancy test should be performed prior to scanning a woman of childbearing age so that appropriate precautions may be applied depending on the stage of pregnancy and in consultation with a radiologist.

nursing considerations for sedatives used in the treatment of increased ICP

Patients should have a secure airway (typically an endotracheal tube) in place when any one of these continuous infusions is initiated in order to ensure that retention of carbon dioxide (hypercarbia) does not occur. Hypercarbia causes cerebral blood vessel dilation, resulting in increased cerebral blood volume and increased ICP. These infusions should be titrated to the desired effect, either a goal ICP measurement or a specific rating on a validated sedation scale such as the Nursing Instrument for the Communication of Sedation Scale (NICS) or the Richmond Agitation Sedation Scale (RASS). Propofol infusion syndrome (PrIS) may occur in patients receiving propofol for greater than 48 hours or in patients receiving high doses of propofol (greater than 75 mcg/kg/min). Signs and symptoms of PrIS include acidosis, hyperkalemia, hyperlipidemia, and rhabdomyolysis causing acute kidney injury. It is important to note that propofol is not an analgesic; therefore, if the patient is suspected to be in pain, it is important to advocate for medication to treat pain in addition to the sedative.

initial surgical management of brain tumors

Patients undergo biopsies to sample the tissue within the mass so that the cells can be examined and a specific diagnosis can be made; performed using advanced radiological techniques that allow the neurosurgeon to map the location of the mass in multiple dimensions. Radiographical images are obtained using CT and MRI scans and are transferred to a computer system that integrates each image into a precise, well-defined coordinate of the area to be biopsied to define an exact location and path for retrieval of brain tissue. This procedure allows for the retrieval of specimens for identification and assists in the determination of an appropriate treatment regimen while minimizing the risk of injury to blood vessels and surrounding healthy brain tissue. The sample of tissue is then examined by a pathologist, and a pathological or histological (cellular) diagnosis is made that guides further therapy and treatment planning.

patients that are better candidates for aneurysm coiling instead of clipping

Patients with high-grade Hunt and Hess scores (grade 4 or 5), as well as patients with multiple comorbid conditions and with hemodynamic instability at baseline

respiratory system spinal cord injury complications

Poor cough, atelectasis, pneumonia, ineffective breathing pattern, ARDS

patient teaching for spinal tumors

Preoperative teaching if scheduled for surgery to decrease anxiety level and help promote compliance; Report symptoms of increased weakness, loss of bowel/bladder function that may be due to recurrent tumor or spinal cord edema

integumentary system spinal cord injury complications

Pressure areas leading to skin breakdown and potential pressure ulcers

Which action is the highest priority in the patient who presents with autonomic dysreflexia?

Remove the stimulus

Nursing assessment interventions for patients with stroke

Serial neurological assessments every 1 to 2 hours -- Neurological deterioration during or after IV rt-PA can signal intracranial hemorrhage. When IV rt-PA is administered, neurological assessments including level of consciousness, motor strength, and pupillary reflexes are performed every 15 minutes X 6 hours, every 30 minutes X 2 hours, and every 1 hour X 16 hours. Vital signs every 1 to 2 hours or more often when administering medications that alter BP. When IV rt-PA is given, the frequency of vital signs is as follows: BP, HR, and RR every 15 minutes X 6 hours, every 30 minutes X 2 hours, and every 1 hour X 16 hours. Electrocardiogram (ECG) and cardiac enzymes -- A possible etiology of ischemic stroke is atrial fibrillation, and continuous ECG monitoring assists in identifying cardiac dysrhythmias. In patients with hemorrhagic stroke, particularly after SAH, these patients may experience myocardial stunning or injury. Trending of 12-lead ECGs and cardiac enzymes allows identification of potential myocardial infarction and/or reversible myocardial stunning. Serum electrolytes, particularly sodium -- Hyponatremia is a common complication of ICH due potentially to SIADH, which increases the risk for cerebral edema and neurological deterioration. Intake and output, cumulative fluid balance-- Accurate accounting of fluid balance is important in evaluating potential sodium and water imbalances as well as approximating volume status, especially in patients with SAH receiving triple-H therapy.

blood clots ejected from the LV

travel up the aorta and often flow easily in the left common carotid artery, where they may lodge in a large or small-caliber blood vessel depending on the size of the blood clot

types of cerebral herniation syndromes

Tentorium cerebelli Tonsillar herniation Lateral ventricle Falx cerebri Subfalcine herniation Central herniation Uncal (trantentorial) herniation

in severe DAI

many neurons have been injured, patients may not regain consciousness; treatment for this type of injury does not concurrently exist; can be visualized on MRI but may not be visible 24 hours after injury

right homonymous hemianopia

may be caused by stroke on the left optic radiation (more towards the occipital lobe)

bitemporal hemianopia

may be caused by stroke on the optic chiasma

left homonymous hemianopia

may be caused by stroke on the right optic radiation (more towards the occipital lobe)

unilateral blindness

may be caused by stroke present on the optic nerve

Nursing actions for increased ICP include:

The head of the bed should be maintained at greater than 30° with the patient's head in midline. Avoid sharp hip flexion. Avoid placing the patient in a position that allows pressure directly on the operative side after craniectomy Perform endotracheal suction only as necessary; pre-oxygenate with 100% oxygen for 1 to 2 minutes prior to suctioning Administer sedative medications as prescribed Administer osmotic agents (mannitol and hypertonic saline) Ensure continuous drainage of CSF through the external ventricular drainage system when applicable (Kinks in the ICP monitoring tubing decrease drainage and may result in increased ICP) Administer antipyretics and/or implement cooling measures (this prevents an increase in cerebral metabolism that accompanies elevated boy temp)

why blood pressure monitoring is so important in the patient with ischemic or hemorrhagic stroke

The injured brain is not able to effectively regulate blood flow independently of systemic blood pressure (this usual protective mechanism is called autoregulation); changes in blood pressure may require further medical management. Blood pressure values that exceed ordered limits may result in hemorrhage into a region of ischemic or infarcted tissue or place a patient at risk for increased ICP because of an inability of the brain to automatically constrict blood vessels (autoregulation), reducing intracranial blood volume.

craniotomy

The most common surgical procedure for all types of brain tumors; During this procedure, a section of the skull is removed (known as a bone flap) in order to provide access to the brain. In some instances, this can be done in order to biopsy brain tissue or to excise (remove) a tumor. If the entire tumor is not able to be removed, the tumor is debulked, removing as much of the tumor as possible. Following the procedure, the bone flap is then replaced with the use of small plates and screws. Should the bone flap not be returned, the procedure is then called a craniectomy.

nursing considerations for CT scan

The serum creatinine should be monitored at least once after the contrast administration in the critically ill patient and more often if acute kidney injury is suspected. Typically an increase in serum creatinine of at least 0.5 mg/dL is expected, which will decrease over 24 to 48 hours. If contrast material is expected to be given, risk factors for contrast-induced nephropathy (CIN), such as hypotension, diabetes, and chronic kidney disease, should be assessed and a serum creatinine (within 24 hours of test) should be evaluated because contrast can damage the kidney. If a patient is at risk for CIN, strategies to prevent CIN including prehydration with IV saline, administration of a bicarbonate-based IV solution, or administration of N-acetylcysteine (Mucomyst) IV may be employed. In emergent situations, full assessment of risk factors and prevention strategies may not be undertaken because of the urgency of obtaining needed scans to guide further care. Because of the exposure to ionizing radiation, a pregnancy test should be performed in women of childbearing age, and the abdomen should be shielded if no alternative to the CT scan exists. Assess the patient's ability to remain still during the procedure because movement of the head causes decreased clarity (artifact) of the images, which could obscure an abnormality. Patients with increased ICP may be confused, restless, or agitated, requiring sedation or anxiolysis to ensure capture of high-quality images. Assess the patient's ability to lie flat during the scan. Patients with congestive heart failure or lung disease may not be able to maintain adequate oxygenation while lying flat, as evidenced by decreased oxygen saturation and increases in work of breathing and restlessness. If the patient cannot lie flat for at least 5 minutes, the medical team should be made aware to consider another test or a strategy to manage the patient during the test. Assess allergy to iodine or shellfish because a patient with these allergies may also be allergic to some contrast agents. Assess the patient's IV access if IV contrast will be administered during the CT; a larger-gauge peripheral IV catheter (typically an 18-gauge) will be required for administration of the contrast through a device called a power injector. Certain types of central lines called power injectable lines may also be able to be utilized for this type of contrast injection.

serum osmolality

This blood test is used to monitor the diuretic effect of osmotic diuretics such as mannitol (Osmitrol). Osmotic diuretics cause interstitial fluid throughout the body to shift into the vascular space where it is filtered and eliminated by the kidneys, causing dehydration. This action is necessary to treat edema in the brain; however, severe dehydration as indicated by a rising levels of this which can cause renal failure. Mannitol is typically not given if this value reaches 320 mOsm in order to prevent acute kidney injury.

intraventricular catheter

This device and procedure are also commonly known as a ventriculostomy or external ventricular drain (EVD).; May be connected to a filled transducer system; May have an embedded ICP monitoring sensor/probe advantages: Ability to monitor pressure and drain CSF (is a monitor and a method of treatment for ICP); Considered "gold standard" for ICP measurement because of the location of the tip of the catheter in the lateral ventricle; Can be inserted at the bedside or in the operating room (OR) disadvantages: Increased risk of infection, particularly when the catheter dwells for greater than 7 days; Measurement drift exists over time when pressure is transduced with a fluid-filled transducer system.

genitourinary system spinal cord injury complications

Urinary incontinence, urinary tract infection, neurogenic bladder, chronic kidney disease

patent foramen ovale

a hole or communication between the right and left atria; patients with this are at risk of a clot traveling from the periphery into the heart from the right to the left atrium and then out the left side of the heart through the aorta and ejected toward the brain

risk factors for contrast-induced nephropathy (CIN)

a nursing consideration for patients with increased ICP going in for a CT scan; include hypotension, diabetes, and CKD; should be assessed and a serum creatinine (within 24 hours of test) should be evaluated bc contrast can damage the kidney

hyperventilation

a physical intervention to reduce blood volume in the intracranial space; increasing the respiratory rate either through manual ventilation, using a resuscitation bag or mechanical ventilator, causes an increased clearance of carbon dioxide and constriction of cerebral blood vessels; established guidelines used for the management of patients with severe TBI recommend that arterial carbon dioxide (PaCO2) be maintained in the range of 30-35 mm Hg when this method is employed to decrease ICP

if an excessive amount of CSF is drained rapidly through an IVC

a subdural hematoma (collection of blood in the subdural space) can result because of contraction of brain tissue that stretches small bridging blood vessels traversing the space between the dura and brain tissue

SAH is characterized by

a sudden severe headache, often termed a "thunderclap" headache bc of the intensity of the pain experienced at the onset; Subsequent neck stiffness and pain ensue because of the irritation of the meninges, particularly at the base of the skull where pooling of blood occurs. Photosensitivity may also be associated with meningeal irritation or inflammation.

ischemic penumbra

a zone of tissue surrounding an infarction that contains ischemic tissue that is not irreversibly damaged; this is the target of therapies aimed at opening blocked cerebral blood vessels and reestablishing blood flow to ischemic brain tissue, providing the optimal chance for functional recovery

risk factors for SCI include

activities such as participating in high-risk physical activities, nonuse of protective fear, and alcohol and substance use; in the older population, increased risk related to fall-related injuries

nursing actions for spinal tumors

administer medications (pain meds, corticosteroid therapy to decrease swelling and inflammation, and meds as ordered for patient comfort) increase intake of fluid and fiber in diet to decrease complications associated with bowel constipation that may develop ROM exercises to prevent contractures and loss of muscle tone; strengthen unaffected muscles reposition every 2 hours and as needed to prevent skin impairment and pressure ulcers and maintain comfort

medical and surgical management of SAH

aims to prevent and mitigate complications such as aneurysm rebleeding and cerebral vasospasm.

Nursing Actions for patients w/ stroke

administer rt-PA as ordered -- In order to receive IV rt-PA, patients must present within 3 hours of stroke symptom onset. In some defined cases, IV rt-PA may be given up to 4.5 hours after stroke symptom onset. Perform bedside swallow screening Elevate head of bed greater than or equal to 30 degrees Place a nasogastric or postpyloric feeding tube for nutrition and medication administration implement aspiration precautions Bleeding precautions are necessary for patients who have received thrombolytics or anticoagulants. Specific precautions include utilizing an electric razor instead of a razor blade for shaving, utilizing a soft toothbrush for oral hygiene, alternating a BP cuff from the left to the right arm to prevent bruising during serial BP measurement, avoiding rectal temperature measurement, and observing strict fall precautions because these patients are at a greater risk for injury related to a fall. Frequent repositioning, elevate paralyzed or weak limbs to minimize dependent edema, advocate for evaluation of the patient by OTs and physical therapists (PTs) early

immediate treatment of seizures includes

administration of benzodiazepines to stop them and antiepileptic medications to prevent recurrence

According to primary stroke center accreditation guidelines

after a stroke, patients should be discharged with antiplatelet therapy, lipid-lowering therapy if indicated, anticoagulation if indicated for atrial fibrillation, and a blood pressure control strategy in patients with hypertension.

spinal cord tumors

an abnormal tissue growth (benign or malignant) in or around the spine; primary types originate within the CNS; secondary types originate outside the CNS then metastasize or spread to the spine ; as this abnormal tissue grows, it causes compression and stretching of the fiber tracts; growth can be benign or malignant, primary, or secondary

when blood flow is disrupted

an area of brain tissue suffers irreversible damage, and this is referred to as in infarction

medications prescribed for secondary stroke prevention

antihypertensives (beta blockers, Ca channel blockers, diuretics) lipid-lowering medications (statins, niacin, bile acid sequestrants) platelet inhibitors (cyclooxygenase inhibitors, ADP receptor inhibitors, combination mediations like Aggrenox which is Dipyridamole and aspirin combined) anticoagulants (unfractionated heparin, warfarin (coumadin), dabigatran (Pradaxa))

Gardner-Wells tongs

are U-shaped tongs used for spinal traction; pressure-controlled pins are inserted into the skull at opposite ends to permit a longitudinal force to be applied to the axis of the spinal column; the tongs are attached to weights using a pulley system at the head of the bed

malignant brain tumors in particular

are associated with swelling as the rapid growth damages brain tissue

Patients with hemiparesis or hemiplegia

are at greater risk for development of pressure ulcers because of decreased mobility. Frequent repositioning allows off-loading of pressure from bony prominences (e.g., ankles, heels, ischium, and occiput). Occupational therapists and PTs recommend passive or active range-of-motion regimens and functional splinting, which prevent musculoskeletal and functional complications that can hinder a patient's rehabilitation.

cerebral herniation syndromes

are classified according to the region of tissue that is displaced; the most often recognized sings include increased systolic blood pressure with decreased diastolic BP (widened pulse pressure), bradycardia, and irregular respiratory pattern, actually occur late in the process as the brain stem is compressed and are referred to as "Cushing's triad";

clinical manifestations of brain tumors

are dependent upon their location in the brain; referred to as space-occupying lesions that may cause increased ICP depending on the rate of growth and location

pituitary tumors

are generally found in the anterior lob of the pituitary, the most common of which is the adenoma (typically a benign tumor)

secondary spinal tumors

are metastases and therefore always malignant unlike primary ones; these often spread from lung, breast, prostate, renal, gland, or thyroid cancer

subacute subdural hematomas

are more common in the elderly and in patients with a history of alcohol abuse bc of cerebral atrophy placing gradual stretch forces on the bridging veins coupled with a high risk of falling

clinical manifestations of pituitary adenomas

are related to hypersecretion of hormones by the pituitary gland, including acromegaly from hypersecretion of GH, amenorrheagalactorrhea from PL hypersecretion, changes in UO secondary to changes in ADH secretion, and disorders of the adrenal cortex from hypersecretion of adrenocorticotropic hormone; can be found within all age groups

most common causes of death for patients with SCI

are respiratory disease and cardiovascular events

acoustic neuromas (CNVIII)

are slow-growing benign tumors that generally do not invade other tissue; however compression on other cranial nerves (V, VIII, IX, and X) and tissue (cerebellum and brainstem) can manifest in severe complications; also known as schwannomas; originate from the protecting covering around nerve fibers (CN VIII) at the anatomical location of the cerebellopontine angle

meningiomas

are the most common form of brain cancer arising between the ages of 40-70 years, affecting females greater than males; arise from the meninges (layers of the brain); 90% are benign; but they can still cause devastating damage bc they are space-occupying lesions that can increase ICP; damage may occur based upon size and location

anaplastic gliomas (grade III)

are tumor cells out of control, lacking differentiation and/or orientation to one another and to surrounding vessels

TTE and TEE

are utilized to directly visualize myocardial wall movement and contraction of the chambers of the heart. In stroke, the TTE is utilized to evaluate overall cardiac function as well as the presence of blood clots within the heart that could embolize to the brain. Presence of a patent foramen ovale (PFO) may be revealed on TTE with the assistance of an IV agitated saline injection, where small bubbles may be seen traversing an abnormality in the atrial septum. A TEE may reveal a PFO not found on TTE. A TEE allows better visualization of the left atrial appendage, which may be a source of blood clots, particularly in patients with atrial fibrillation.

oligodendrogliomas

arise from oligodendrocytes (main functions are to provide support and insulation to axons in the CNS, equivalent to the function of schwann cells in the PNS); these are slow-growing tumors that generally do not spread to surrounding tissue; arising from the fatty covering that protects nerves, they generally occur in the cerebrum; are generally found in middle-aged parents

A patient is admitted to a unit with a diagnosis of left middle cerebral artery acute ischemic stroke and is not eligible for thrombolytic therapy. The nurse recognizes that this patient is at a high risk for which complication?

aspiration

different types of primary central nervous system tumors

astrocytoma; ependymoma; meningioma; neurofibroma; sarcoma; schwannoma

placing a nasogastric tube or postpyloric feeding tube for stroke patients

may be placed to facilitate enteral feeding to allow time for swallowing function to improve or for more formal swallowing evaluation to be completed.

in situations where increased ICP does not respond to standard treatments

barbiturates such as pentobarbital can be used to induce a coma, significantly reducing metabolic demands in the brain

presenting symptomology of a brain tumor in the suprasellar

bitemporal field cuts with abnormal endocrine function

spinal injuries to the cervical or high thoracic spinal cord may also result in

blood pressure problems, abnormal sweating, and difficulty maintaining normal body temp

complications of spinal tumors

both benign and malignant types can compress spinal nerves and cause loss of movement or sensation below the tumor level, spinal instability, changes in bowel and bladder function, and sexual dysfunction; unless the cause is quickly identified and removed, permanent nerve damage can occur

causes of intracerebral hemorrhage

brain tumor; AVMs; Moyamoya disease; cerebral amyloid angiopathy

overdrainage of CSF prevention methods

by maintaining proper leveling (0 point on drainage system leveled at the external auditory meatus) of the drainage system and proper adjustment of the drainage burette at the ordered level above the external auditory meatus

the effects of increased ICP on functional outcome

can be diminished with early recognition of deterioration and rapid treatment; identification and control of the primary problem is also essential

intracranial pressure monitoring

can be done by using a catheter or sensor placed in one of the lateral ventricles of the brain, in the brain tissue or parenchyma, or in the subarachnoid space; an additional assessment tool used to trend a patient's response to medical treatments and progression of an intracranial process causing increased ICP; recognized guidelines suggest that patients with TBI and a GCS score of 8 or less should have one placed

large cerebral blood vessel occlusion

can cause ischemia in large areas of brain tissue depending on the location of the occlusion (proximal or distal) called territories, and the territory name is based on the blood vessel that perfuses that particular area; a territory may contain more than one lob of the brain

suctioning a patient with increased ICP

can introduce risk of further elevation of ICP because the act induces coughing, which raises pressure inside the chest and may transiently reduce drainage of blood from veins in the neck, causing a spike in ICP in some patients; should only be performed when the patient demonstrates mucus in the endotracheal tube or every 4-6 hours to maintain patency of the tube; administering 100% oxygen just prior to doing this is performed to prevent hypoxia, which can occur during the interruption of mechanical ventilation

cervical spinal cord injuries

can result in inability to breathe (above C4) and quadriplegia

the loss of autoregulation and reduced sympathetic stimulation in SCI patients result in

cardiac arrhythmias (interruptions to the cardiac accelerator nerves from a cervical SCI can cause the heart to beat dangerously slowly or pound rapidly and irregularly; medications and even pacemaker may be required to control the irregular heartbeat), hypotension, decreased blood vessel tone (causes blood to pool in the vessels , and results in low BP; IV fluids, vasopressors, and inotropes are often used to provide adequate fluid resuscitation, increase tone, and increase CO) and reduced cardiac output

spinal cord injury below L1 results in

cauda equina injury, variable motor and sensory loss in lower extremities; a reflexive bowel and bladder

medical management of brain tumors

chemotherapy and radiation are used in place of or in conjunction with surgery depending on the type and location; chemotherapeutic agents used to treat them must have the ability to cross the BBB (including carmustine, lomustine, thiotepa, and high doses of methotrexate); Radiation treatment is provided in divided doses, maximizing the recovery of normal cells. Radiation is delivered in a focused manner, concentrating on the affected area. Other technologies such as the CyberKnife are used to direct radiation to the tumor, avoiding healthy brain tissue.

hyponatremia

common complication in patients with SAH, which may be caused by syndrome of inappropriate antidiuretic hormone (SIADH) or by cerebral salt wasting syndrome, also known as renal salt wasting syndrome.

cranial nerves IX, X, XI, and XII

exit from the medullar in the brainstem; contribute to swallowing and innervate the palate and pharynx, assisting in airway protection; when these cranial nerves have been damaged, aspiration of food or fluid into the lungs can occur

anterior cerebral artery territory

colored in blue

middle cerebral artery territory

colored in red

posterior cerebral artery territory

colored in yellow

brain tissue

composed primarily of water and makes up 80% of the intracranial contents; while blood and CSF each make up 10% of the remaining contents within the cranium

clinical manifestations of vasospasm include

confusion, changes in LOC, or new focal (localized area) motor weakness, often in a waxing and waning pattern

the initial approach to the emergency management of increased ICP

consists of airway management and therapies to decrease intracranial contents, such as administration of an osmotic diuretic and hyperventilation; vigilant monitoring of the patient's neuro status is critical during treatment bc there may be subtle changes in LOC that may indicate further compromise.

territory names of the brain

correlate to the blood vessel that perfuses the specific area

potential complications of MERCI clot retrieval system include

damage or rupture of a blood vessel; breakage of the blood clot, which could travel forward and lodge in another blood vessel; and intracerebral hemorrhage

The nurse monitors for which expected outcomes after the administration of an osmotic diuretic in the patient with increased ICP?

decrease in ICP and increase in urine output

Fisher Grading Scale for Subarachnoid hemorrhage

determined by amount of blood visualized on CT scan Grade 1: No blood on CT scan Grade 2: Blood layering less than 1-mm thickness Grade 3: Blood layering greater than 1-mm thickness Grade 4: Intraparenchymal or intraventricular blood

the pressure-volume curve

depicts the body's ability to compensate for the addition of one or more of the three intracranial components without a significant increase in ICP until a critical volume is reached (A). At this point, continued accumulation of volume causes a disproportionate increase in ICP referred to as decreased compliance (B). Finally, on the last section of the curve, any addition in volume causes a sustained increase in ICP, which represents a loss of compliance (C). Loss of intracranial compliance leads to cerebral herniation syndrome where brain tissue is displaced, and if the displacement is not resolved, the brainstem becomes compressed, eventually causing brain death.

CT scanning is performed in pts with signs and symptoms of stroke in order to

determine whether hemorrhage is the cause of symptoms; Radiographical changes associated with ischemic stroke are typically not visualized within the first several hours following a stroke. When initially evaluating a patient with suspected stroke, contrast is not used so that blood can be easily visualized. IV contrast may be helpful in visualizing a mass lesion in the brain (e.g., tumor).

patient teaching for increased ICP

devices used during the course of treatment medications used for treatment complications of the disease process (many complications may occur and are closely associated with the primary cause) rationale for helmet after craniectomy (often placed whenever patient is out of bed to prevent injury to the unprotected portion of the head) importance of allowing the patient rest (constant stimulation may exacerbate situation)

to prevent permanent spinal cord damage, spinal cord compression must be

diagnosed and treated immediately

clinical manifestations of a basilar artery stroke syndrome

dizziness ataxia tinnitus nausea and vomiting weakness on one side of the body that may be ipsilateral to the side of ischemia or injury or contralateral decrease in sensation on one side of the body that may be ipsilateral to the side of ischemia or injury or contralateral difficulty in the articulation of speech difficulty with swallowing and managing oral secretions

cytotoxic cerebral edema

does not impact BBB; and primarily involves individual cellular swelling caused by failure of the Na-K pump

spinal tumor classification

done in several ways including the area of the spine in which they occur (cervical, thoracic, lumbar), their location in the spine: anterior (front) or posterior (back), and their relationship to the dura (outermost membraneous layer surrounding the brain and spinal cord); types include extradural located outside the dura, intrdural located within the dura, extramedullary located inside the dura but outside the cord, and intramedullary located within the cord

common vasopressors given to SCI patients

dopamine hydrochloride (dopamine), norepinephrine bitartrate (Levophed), phenylephrine hydrochloride (Neosynephrine), epinephrine, vasopressin (Pitressin), and dobutamine

transependymal cerebral edema treatment

drainage of cerebrospinal fluid is the primary method to decrease this type of edema

f there is evidence of spinal cord compression, progressive deficits, compound vertebral fractures, penetrating spinal cord wounds, or bony fragments in the spinal canal,

early surgery is performed for decompression and fusion to stabilize the spinal column. Otherwise, patients with neurological evidence of spinal instability are admitted to the ICU for a comprehensive diagnostic work-up, and neurological monitoring.

current management strategies for SCI focus on

early surgical intervention if indicated, immobilization, and hemodynamic and respiratory support to prevent secondary injury and optimize recovery

nursing diagnoses for spinal tumors

• Impaired physical mobility related to neuromuscular impairment • Acute pain related to nerve impingement • Ineffective coping related to diagnosis

Vigilant monitoring of the neurological assessment, observing for changes from the patient's preoperative and postoperative baseline is

essential for early identification of potentially life-threatening neurological deterioration. Changes in level of consciousness are the most sensitive indicator of increased ICP and can signal complications of brain tumor resection and craniotomy, such as intracranial bleeding and cerebral edema (swelling). Subtle changes in motor strength on one side of the body when compared to the other are significant when they occur during the recovery period after a craniotomy. The baseline neurological assessment after a surgical procedure should be determined and agreed upon by the nurse and providers or nurse practitioners caring for the patient in order to facilitate future comparisons and interpretation. Pupil reaction to light is part of the assessment and changes in reaction is indicative to damage/compression to CN III (Oculomotor nerve).

exclusion criteria 0- to 3-hour therapeutic window for the administration of rt-PA

evidence of intracranial hemorrhage on pretreatment CT scan minor or rapidly improving symptoms symptoms of subarachnoid hemorrhage even with normal head CT active internal bleeding: gastrointestinal or urinary bleeding within last 21 days or known bleeding risk, including not not limited to: platelet count less than 100,000; heparin during the preceding 48 hours associated with elevated aPTT; currently taking oral anticoagulants or recent use with an elevated prothrombin time greater than 15 seconds or INR greater than 1.7; major surgery or other serious trauma during preceding 14 days; stroke serious head trauma, or intracranial surgery during preceding 3 months; recent arterial puncture at a noncompressible site; recent lumbar puncture during preceding 7 days

gliomas

generally originate in the cerebrum; included to develop along the curved areas of the brain, making the frontal lobes more susceptible; are grade I and II and are slow-growing tumors

consequence of hyperventilation

global cerebral vasoconstriction, which may result in ischemia to uninjured brain tissue

treatment of vasospasm

has historically been centered on hypertension, hypervolemia, and hemodilution, widely known as triple-H therapy, with the goal of maintaining arterial patency and preventing cerebral infarction. Hypertension may be accomplished by withholding antihypertensive medications in patients with a history of hypertension, or elevating the blood pressure may be induced with vasoactive medications. Hypervolemia may be achieved by administering crystalloid or colloidal solutions such as albumin, targeting a hemodynamic parameter that measures or approximates intravascular volume (e.g., central venous pressure, pulmonary capillary wedge pressure (PCWP), global end-diastolic volume). Cardiac output may also be chosen as an endpoint for therapy. The intent of hemodilution is to decrease the viscosity of the blood in order to facilitate flow through often narrowed arteries. Hemodilution may be achieved as hypervolemia is employed, although minimum thresholds for hemoglobin are typically maintained at approximately 30 g/dL with the intent of ensuring adequate oxygen delivery to the brain tissue.

clinical manifestations of a spinal tumor

has manifestations similar to low-back pain (LBP) and herniated nucleus pulposus, as well as multiple sclerosis; on the basis of location, the paitent may present with back pain that may radiate down the arms or legs; may include numbness and tingling, weakness in the distal extremities, urinary incontinence, and bowel pattern changes

Surgical management of intracranial hemorrhage above the tentorium cerebelli (supratentorial)

has not been shown to improve outcomes unless a hematoma is superficial in location.

clinical presentation observed in the pt with a brain tumor often includes

headache; change in LOC; pupillary changes secondary to compression of CN III; vision changes; seizure activity; elevated BP with widening pulse pressure; decreased HR; nausea and vomiting; numbness and tingling

complications of acute ischemic stroke

hemorrhage into the area of infarcted (nonviable or dead) brain tissue, termed hemorrhagic transformation, which patients may experience in the absence of thrombolytic therapy or anticoagulation therapy cytotoxic edema weakness or paralysis of the extremities disorders of speech apraxia depression

complications of ischemic stroke include

hemorrhagic transformation; cytotoxic edema; as ischemia persists and infarction occurs, cerebral edema may increase, causing increased ICP and placing a patient at risk for cerebral herniation syndrome; aspiration of fluid, food, or secretions into the lungs is a common due to decreased LOC, as well as potential impairment of CNs, facial muscles, and function of the palate

other modifiable risk factors for stroke

hypercholesterolemia and illicit drug use (cocaine use is associated with ICH); major ones include: age greater than 55, gender, and race.

The nurse correlates which clinical manifestations to autonomic dysreflexia in a spinal cord injured patient?

hypertension with bradycardia

patients with high cervical injuries require

immediate ventilatory support

Administration of nimodipine, a calcium channel blocker

improves outcomes in patients experiencing vasospasm; however, this drug is associated with hypotension, which may necessitate alteration in dosing by increasing the frequency of dosing and decreasing the dose or discontinuing the therapy in some instances.

IV rt-PA administration

in order to receive it; patients must present within 3 hours of stroke symptom onset in some cases, it may be given up to 4.5 hours after stroke symptom onset must be give as soon as possible after ischemic stroke but not outside established therapeutic windows most significant risk associated with this is intracranial bleeding, which occurs in approximately 6.4% of pts receiving it benefits approximately 30% of treated patients as evidenced by decreased or absence of neuro deficits at 90 days after treatment adhering strictly to established inclusion and exclusion criteria is associated with a lesser incidence of symptomatic ICH

cervical cord injuries that occur in the neck result

in symptoms that affect the arms, legs, and middle of the body; clinical manifestations include: difficulty breathing loss of bowel and bladder control numbness weakness or paralysis pain sensory changes spasticity

A list of all risk factors for stroke include

incidence greater in men than women until age 55 death secondary to it is greater in women and African Americans HTN cigarette smoking hypercholesterolemia illicit drug use age greater than 55 gender race

exclusion criteria 3- to 4.5-hour therapeutic window for the administration of rt-PA

include all exclusion criteria for the 0-3 hour therapeutic window, and additional ones including: age greater than 80 years old, receiving anticoagulants, even if the INR is normal, prior history of stroke and diabetes

types of surgery utilized to stabilize SCIs

include decompression laminectomies, using anterior cervical and thoracic approaches, with fusion in which one or more laminae are removed to allow for cord expansion because of edema, posterior laminectomy and fusion with bone graft to immobilize the neck and prevent further damage to the spinal column, and a posterior approach using either a bone graft or the insertion of rods or other instruments to correct and stabilize the deformities.

clinical manifestations of spinal shock

include flaccid paralysis of all skeletal muscles, absence of deep tendon reflexes, impaired proprioception, decreased visceral and somatic sensations, penile reflex, urinary and fecal retention, anhidrosis (absence of sweating), and paralytic ileus. This can last from 24 hours to 1 to 6 weeks, and the return of reflex activity below the level of injury indicates the end of it

complications of CSF drainage

include infection, overdrainage, and introduction of air into the ventricular system if proper leveling is not maintained

complications with the use of halo brace/traction devices to stabilize the head and neck

include pin infections, skin breakdown, loosening or movement of pins, swallowing problems, and possible dural tears The sites must be frequently assessed for signs of infection and site care provided once a shift and as needed.

nursing considerations to prevent CIN if patient is at risk

include prehydration with IV saline, administration of a bicarbonate-based IV solution, or administration of n-acetylcyseine (mucomyst) IV may be employed

clinical manifestations of neurogenic shock

include vasodilation, bradycardia, body temperature instability, and hypotension; can be very dangerous and can lead to serious complications such as organ dysfunction and even death if not promptly identified and treated.

MRI for suspected stroke

includes sequences that capture necrotic tissue and areas of the brain that are hypoperfused, and directly visualizes the blood vessels to detect blood vessel obstruction or another abnormality such as an aneurysm.

clinical manifestations of increased ICP

including subtle changes in LOC, increased BP, decreased pulse rate, widening pulse pressure, changes in resp pattern, and pupillary changes should be reported immediately to the HCP in order to ensure prompt intervention to decrease changes of permanent neuro injury

complications of surgical management of brain tumors include

increased ICP (which can severely hamper cerebral blood flow, causing decreases in cerebral perfusion pressure (CPP) leading to secondary injury of the brain via cytotoxic and anoxic injury and herniation of the brain) bleeding (risk of intracranial bleeding postoperatively is high variable and dependent upon features of the tumor, location in the brain, proximity of the tumor to blood vessels, and the surgical approach) cerebral edema (most commonly, vasogenic edema, where the BBB becomes increasingly permeable) seizures (pre or postoperatively; location closer to the upper regions of the brain are at greater risk when tissues are disrupted during a surgical procedure) Venous thromboembolism (VTE; the nurse should assure preventive measures such as mechanical VTE prevention devices like SCDs and pharmacological prevention like heparin are applied and administered as ordered

significance of the problem delrium causes

increased morbidity and mortality; increased length of stay; increased risk for AE (falls, aspiration, pneumonia, and pressure ulcers); inability to return to same level of care at discharge; long term cognitive impairment/PTSD; only 4% is resolved at discharge; 1/3 never return to baseline

in brain tumor patients who have undergone pituitary surgery, DI can be diagnosed using a combo of conditions including

increased urinary output, decreased urine specific gravity (less than 1.005), and increased serum sodium concentration (greater than 145), and an increase in serum (greater than 280 mOsm/kg) and urine osmolality (less than 200 mOsm/kg); increased UO may decreased BP further, compromising CPP

the volume of water in brain tissue observed in cerebral edema is reduced by

increasing the osmolarity of the blood (increasing solute in the blood), thereby changing the osmotic gradient, resulting in diffusion of water from an area of low concentration (brain tissue) to an area of high concentration (the blood)

patient teaching for strokes

information regarding the specific type of stroke and usual course to enable them to become involved in their own care or the care of their family member. Activation of EMS Warning signs and symptoms of stroke Patient-specific and family risk factors for stroke smoking cessation Medications for secondary prevention of stroke (Adherence to medication regimens to reduce BP and hypercholesterolemia and prevent blood clotting is important in instructing patients about their care)

Nurses caring for patients play a central role in patient outcome along the continuum of stroke care from

initial presentation through rehabilitation and discharge to the community.

cerebral ischemia

insufficient blood flow to the brain to meet metabolic demand

patients with SAH require

intensive multidisciplinary, neurological, and general intensive care monitoring in order to optimize functional outcomes.

types of hemorrhagic strokes

intracerebral hematoma (ICH); subarachnoid hemorrhage (SAH)

Moyamoya disease

involves constriction or narrowing of the end of the internal carotid arteries and narrowing of the smaller branches of the arteries in the anterior circulation (e.g., middle cerebral artery, anterior cerebral artery). An arterial network (collateral circulation) develops in response to the narrowing of arteries over time in order to augment blood supply to the affected areas of the brain.

cerebral amyloid angiopathy (CAA)

involves the deposition of beta-amyloid into the walls of blood vessels, rendering them fragile and at risk for damage, resulting in intracerebral hemorrhage. Beta-amyloid is one of the substances thought to play a role in Alzheimer's disease, and in this case, the substance is deposited into blood vessels. Cerebral amyloid angiopathy occurs mainly in the elderly.

most common initial method of intracranial compensation

involves the displacement of CSF from the cranial vault down through the foramen magnum at the base of the skull and around the spinal cord

a significant risk factor for stroke

is HTN, followed by cigarette smoking.

cerebral perfusion pressure (CPP)

is a commonly used parameter to indirectly measure cerebral blood flow and is generally maintained above 60 mm Hg; measured by subtracting ICP from mean arterial pressure (MAP - ICP)

the most sensitive indicator of ICP

is a decrease in LOC; in order to detect subtle changes in this it is imperative to establish an accurate baseline of functioning from which to judge deterioration; need to ask expanded orientation questions like what state are you in right now or what city are you in right now or why are you here today

neurogenic shock

is a distributive type of shock that occurs in patients with brain, upper thoracic, and cervical injuries and is caused by the sudden loss of the autonomic nervous system signals to the smooth muscle in the vessel walls. This results in loss of vasomotor tone and sympathetic innervation of the heart. The cardiac output decreases because the vessels lose tone, allowing blood to pool in the periphery and blood pressure to fall; the sympathetic pathways to the heart are blocked or damaged, resulting in bradycardia. Clinical manifestations include vasodilation, bradycardia, body temperature instability (poikilothermia), and hypotension. can be very dangerous and can lead to serious complications such as organ dysfunction and even death if not promptly identified and treated. Treatment often includes fluid, vasopressors, and other medications such as atropine.

the most frequent cause of autnomic dysreflexia

is a full bladder, and the second most is a full bowel; other causes include tight clothing, GI disturbances, DVT, pressure ulcer, bladder or kidney infection, temp extremes, shoes, lying or sitting on a hard object, or a minor injury

left atrial appendage

is a muscular outpouching of the left atrium where blood clots form; contribute to the pathogenesis of atrial fibrillation-associated cardiac emboli

a lacunar stroke

is a small infarction caused by an obstruction of a small blood vessel or group of small blood vessels; Neurological deficits may fluctuate between improvement and worsening in the acute phase.

autonomic dysreflexia

is a syndrome of massive imbalanced reflex sympathetic discharge occurring in 80% of patients with spinal cord injury above the T5-T6 level; It most often occurs after the first year of injury but can occur any time after spinal shock subsides. A strong sensory input, such as pain, distended bladder, rapid temperature changes, infection, or a full rectum, is carried into the spinal cord via intact peripheral nerves. This input travels up the spinal cord and evokes a massive sympathetic surge from the intact thoracolumbar sympathetic nerves, resulting in widespread vasoconstriction, causing peripheral arterial hypertension. The brain detects this hypertensive crisis through intact baroreceptors (receptor cells in the bloodstream that relay information about blood pressure to the brain) in the neck and utilizes two methods to stop its progression. First, the brain attempts to shut down the sympathetic surge by sending descending inhibitory impulses. Unfortunately, these impulses are blocked in the injured spinal cord. Second, the brain attempts to decrease blood pressure by slowing the heart rate via the vagus nerve (parasympathetic). This bradycardia is inadequate, and the hypertension continues. clinical manifestations include severe headache, HTN, bradycardia, tachycardia, diaphoresis, and flushing above and pallor below the injury level once the inciting stimulus has been removed, reflex HTN resolves

acute spinal cord injury (SCI)

is an unexpected catastrophic event that results in the loss of function such as mobility or sensation; mechanism of this injury may be caused by hyperextension, hyperflexion, rotation, and vertical compression (axial loading), or penetrating injuries

Increased intracranial pressure (ICP)

is best described by the Monro-Kellie doctrine of hypothesis, which states that 3 components- brain tissue, blood, and CSF- occupy a rigid box, the skull; when one of these 3 components increases, the other components must decrease to maintain equilibrium within the fixed box

transpendymal cerebral edema

is caused by increased pressure in the ventricular system that results in cerebrospinal fluid moving into the brain parenchyma

TBI

is classified by the GCS score into three different categories: mild (13-15), moderate (9-12), and severe (less than or equal to 8); This disease process is marked by heterogeneity in that there are several possible mechanisms of injury, which can cause different injury patterns and damage in the same patient. Often, more than one cranial or cerebral structure is involved in a; for example, a patient may have sustained a frontal contusion as well as a temporal epidural hematoma

A videographical swallowing assessment performed by an SLP

is common for stroke patients and enables the practitioner to visualize all phases of the swallowing process to determine the type and extent of swallowing dysfunction that is present. If swallowing dysfunction is thought to be a long-term problem or permanent, a percutaneous endoscopically placed gastrostomy tube may be placed by a surgeon or gastroenterologist.

the role of the nurse in performing, trending, and communicating neurological assessment findings in increased ICP

is critically important to the preservation of neuro function; positive patient outcomes are related to maximizing neuro function and minimizing complications associated with this disease process

IV rt-PA for use in treating patients with acute ischemic stroke

is currently the only treatment approved by the FDA for ischemic stroke; in order to receive it; patients must present within 3 hours of stroke symptom onset

spinal cord injury

is damage to the spinal cord with resulting functional loss of mobility and/or sensation; result from concussion, contusion, compression, tearing, laceration, transection or ischemia of the spinal cord; minutes after the initial injury, the SC can swell and fill the entire spinal cavity at the level of injury (resulting in anoxia due to lack of blood flow and oxygen to the spinal cord tissue); as the body loses its ability to self-regulate, BP drops, interfering with the electrical activity of neurons and axons

ability to elicit a neuro assessment from a patient in a barbiturate coma

is limited because of the suppression caused by the meds; therefore, other parameters such as pupillary size and reaction are performed: application of moisture chambers with artificial tears to prevent corneal injury and frequent repositioning to prevent pressure ulcer development.

serum sodium

is monitored when targeting a specific level of solute concentration in the blood with the administration of hypertonic saline solutions. A target above the normal range (135-145 mEq/L) is chosen on the basis of the severity of cerebral edema and the specific disease process. A goal range above 145 mEq/L and typically less than 160 mEq/L is set, and serum levels are measured every 4-6 hours to ensure that the goal is achieved and not exceeded.

pin site loosening of halo traction devices

is one of the most common complications associated with this treatment; can lead to cervical instability and infection. Signs that may indicate this include redness, swelling, drainage, site pain, or areas where the skin has pulled away from the site. If no infection is present, the health-care provider may tighten the pins. if left untreated, the halo ring may migrate, resulting in loss of immobilization The patient often complains of neck pain and that "the vest does not fit correctly/feel the same." Some patients may notice the ability to move their neck. If this occurs, notify the health-care provider immediately, place the patient in a hard c-collar for spinal immobilization, and prepare for radiological imaging to assess for a change in spinal alignment. The nurse also needs to perform a thorough neurological examination to determine if the patient has worsening or new deficits. The halo will likely be reapplied using new pin sites.

surgical intervention of subdural hematomas

is primarily dependent on the patient's initial neuro status; if poor (severe focal neuro deficits or coma), surgery may be perfomred emergently; however, pts with a mild neuro deficit or absence may be monitored for neuro worsening and undergo surgery later if needed

cerebral angiography

is the "gold standard" for visualizing abnormalities such as aneurysms or occlusions in blood vessels as they pass into the skull and brain (intracranial vessels). The right and left carotid and vertebral arteries are entered separately in order to visualize the anterior (carotid arteries) portion of the circle of Willis and the posterior (vertebral arteries) portion of the circle of Willis, including the basilar artery. The femoral artery is typically cannulated for this procedure, although alternative sites such as the brachial artery may be used in specific instances. Procedures such as angioplasty and stent deployment for narrowed blood, flow-limiting atherosclerotic deposits, and coiling of aneurysms are performed using this radiographical modality.

Glioblastoma multiforme (grade IV astrocytoma)

is the most aggressive and lethal type of tumor, especially when located in or near the brainstem

A CT scan

is the most common test performed in critically ill patients with a deterioration of neurological status, such as a decrease in level of consciousness, new motor deficit, or new cranial nerve deficit, because the test can be performed quickly.

the optimal position for a patient with increased ICP and decreased intracranial compliance (inability to compensate for increase in intracranial contents)

is thought to be 45-90 degrees with the neck in a neutral position in order to promote drainage of venous blood through the jugular veins in the neck

hemorrhagic transformation

is thought to occur as a result of blood vessel spasm around a blood vessel that has been occluded by a blood clot, which in time resolves, causing the blood clot to break apart and restoring blood flow to surrounding ischemic and infarcted brain tissue. During ischemia, tissues may become friable or fragile, and when normal blood flow or pressure is reestablished, this pressure may cause tissue damage or bleeding.

ideal goal of therapy for spinal tumors

is to completely remove it; this is complicated by the type and location; removing some may result in permanent nerve damage

the initial goal in managing increased ICP

is to prevent cerebral herniation

The role of health-care providers, from initial encounters with EMS personnel to the ED and critical care units for patients with TBI

is to prevent or attenuate the effects of secondary brain injury; Treatment paradigms, algorithms, and protocols are aimed at preventing or aggressively managing hypotension and hypoxemia in the immediate period after injury because these factors have been implicated in increased mortality of patients with severe cases

subarachnoid hemorrhage

is typically caused by a ruptured aneurysm and less commonly by arteriovenous malformations (AVMs), which is a mass of arteries and veins that is not connected by a capillary network; despite intensive treatment, an estimated 50% of these types of pt survivors have significant, lasting neuro deficits grading scales include: Hunt and hess grading scale; fisher grading scale, determined by amount of blood visualized on CT scan

halo traction device

is used to maintain cervical immobilization for specific types of cervical fractures; made up of a ring around the patient's head attached to a special vest by four rods; Titanium screws are screwed into the skull bone and attached to the halo traction device; weights connect to the halo at the head of the bed over a pulley system. Weights are slowly added, with x-rays taken between each additional weight, until spinal alignment is achieved.

doppler ultrasound of the carotid arteries

is utilized to detect narrowing of the inner lumen of the carotid vessels by atherosclerotic plaque. Evaluation of this artery with ultrasound can detect narrowing in the carotid vessels before they enter the skull.

neurological and systemic complications of SAH include

ischemic stroke, cerebral edema, pulmonary edema, and myocardial ischemia. Morbidity and mortality of patients is influenced by the management of systemic medical complications, which can cause or exacerbate brain injury.

occlusion of small intracranial blood vessels supplying the peripheral regions of the brain and deep brain structures causes

lacunar stroke syndromes, which vary in the severity of functional deficits

different types of ischemic strokes

large vessel; small vessel (lacunar); embolic; cryptogenic defined as a sudden blockage of a cerebral blood vessel causes a reduction in supply of oxygenated blood to the region of the brain fed by the involved artery, resulting in an abrupt onset of clinical manifestations. These clinical manifestations are grouped into stroke syndromes, which can be correlated or localized to a particular cerebral blood vessel

loss of intracranial compliance

leads to cerebral herniation syndrome where brain tissue is displaced, and if the displacement is not resolved, the brainstem becomes compressed, eventually causing brain death

presenting symptomology of a brain tumor in the brainstem

loss of cranial nerves on one side with loss of motor or sensory on contralateral side

lumbar sacral injuries occur at the lower back level; varying degrees of symptoms can occur including:

loss of normal bowel and bladder control numbness pain sensory changes spasticity (increased muscle tone) weakness and paralysis

thoracic cord injuries occur at chest level, and the following clinical manifestations can occur

loss of normal bowel and bladder control (may include constipation, incontinence, and bladder spasms) numbness sensory changes spasticity (increased muscle tone) pain weakness, paralysis

presenting symptomology of a brain tumor in the pineal gland

loss of upward gaze; loss of light reflex

presenting symptomology of a brain tumor in optic nerve

loss of vision in one eye

presenting symptomology of a brain tumor in the optic tract or occipital lob

loss of visual field on the same side in both eyes

during the acute stage of SCI, treatment focuses on

maintaining airway patency, adequate breathing and oxygenation, preventing spinal shock, restoring and maintaining blood pressure, preventing further cord damage, spinal immobilization and avoiding possible complications; Patients are monitored for vital sign changes that may indicate spinal shock.

different types of medications used to treat cerebral edema

mannitol (Osmitorl) and high-concentration sodium chloride solutions (3% for example)

some patients with an established spinal cord lesion depend on

manual evacuation (the digital removal of feces) as their routine method of bowel care because they have lose normal bowel function All nursing staff must be aware of the possible risk of autonomic dysreflexia occurring if the patient's bowel becomes distended because of constipation or impaction. Health-care staff requires training in the procedure of manual evacuation to prevent this medical emergency from occurring.

clinical presentation of increased ICP

may be subtle, particularly in the early stages, and is in sharp contrast to the presentation of cerebral herniation; these signs must be detected early in order to implement treatment and prevent herniation syndrome

skull fractures occurring at the base of the skull

may involve a breach of the dura and subsequent cerebrospinal leak and can damage or impinge cranial nerves and blood vessels that traverse the foramina in the skull base; it is important to evaluate extraocular movements bc cranial nerves IV and VI could be damaged if a fracture occurs near the foramen through which they travel

central pontine myelinolysis

may result due to sodium levels rising too quickly (more than 10 mEq/L in 24 hours) in a patient with chronic hyponatremia; causes damage to myelin (the sheath covering neurons to enhance speed of impulse transmission) in the pons, resulting in a decrease in neuronal transmission in the pons. Features of this disorder may include generalized weakness on both sides of the body, quadriplegia in severe cases, lethargy, and paralysis of eye movements.

hypotension in the setting of vasospasm

may worsen ischemia caused by narrowing of the blood vessel

inclusion criteria for the administration of tissue plasminogen activator (rt-PA)

measurable neurological deficit using NIHSS no hemorrhage on head CT time since last time patient was seen to be normal is within 3 or 4.5 hours (if additional exclusions not present) before the infusion was begun symptoms present for 30 minutes, not rapidly improving of attributable to another disease imaging of head is consistent with an acute ischemic stroke not hemorrhage or brain tumor

intracerebral hemorrhage is typically managed using

medical therapies to manage BP and prevent expansion of the hematoma as well as therapies to reverse coagulopathy and treat increased ICP (osmotic therapy, hyperventilation, drainage of CSF)

nursing interventions for the treatment of the patient with autonomic dysreflexia

monitor BP closely, at least every 5 minutes administer antihypertensive medication as ordered HOB at 45 degrees or sit the patient up loosen restrictive clothing; remove braces, antiembolism stockings, shoes, look for source of pain from these items check the bladder; if patient has an indwelling catheter, ensure patency and adequate drainage; if patient does not have one, perform intermittent catheterization or place indwelling catheter per order; collect sample for UA check the bowel for impaction check the patient's body for other sources of noxious stimuli- pressure ulcers, wounds, bites, scratches, etc

nondisplaced skull fractures

must be visualized using radiographical imaging and rarely involve disruption of the meninges bc the edges of the fracture are approximated and have not moved from their original position

nursing assessment and analysis of patients with acute ischemic or hemorrhagic stroke include

neuro assessments is integral in detecting potentially treatable neuro deterioration rapidly, which allows for the best chance to preserve or restore function A clear understanding of a patient's baseline neurological status serves as the basis for future assessments and enables the nurse to quickly identify and analyze changes. In patients after hemorrhagic stroke, close monitoring of vital signs, particularly blood pressure, is necessary to prevent rebleeding or expansion of a hematoma. Identification of rhythm disturbances such as atrial fibrillation, ST segment, or T-wave changes associated with myocardial ischemia, is essential in determining potential causes of stroke and intervening in complications of stroke. Close monitoring of serum electrolytes, particularly sodium, is necessary to identify disorders of salt and water imbalance resulting in hyponatremia, which places patients who have suffered a stroke at high risk for cerebral edema and neurological deterioration. Regular assessment of systems enables the nurse to identify potential complications early, track progress, and make appropriate referrals to the interdisciplinary team, ensuring the best possible outcome for the patient.

nursing assessment interventions for spinal tumors

neuro status -- Locate level of function - sensory and motor to determine necessary interventions as well as to evaluate for signs of deterioration as well as for signs of improvement with treatments Pain Bowel or bladder function -- patient may present with incontinence, urinary retention, or constipation identify current coping skills that work and the patient's support system

when spinal cells are injured

neurons flood the injured area with an excitatory transmitter (glutamate) normally used to stimulate activity in neurons; this excessive release results in excitotoxicity, a process in which neurons are damaged and destroyed by overstimulation

proposed theories of delirium

neurotransmitters (dopamine/gamma-aminobutyric acid; acetylcholine) involved; alteration in synthesis, release, inactivation resulting in excess dopamine, acetylcholine depletion; additional neurotransmitter imbalances: serotonin imbalance, endorphin hyperfunction, and increased nonadrenergic activity

three main subtypes of hemorrhagic stroke

nontraumatic subarachnoid hemorrhage (SAH); intracerebral hemorrhage (ICH), and intraventricular hemorrhage (IVH)

uncal herniation

number 1 on graph; an expanding lesion causes the tip of the temporal lob (uncus) to shift downward and inward toward the midbrain and through the tentorium, compressing cranial nerve III; CN III is innervated by the PNS, and stimulation of this nerve causes pupillary constriction; compression of this CN causes dilation of the pupil and an inability to constrict (fixed and dilated pupil) clinical manifestations: unilateral dilated pupil; contralateral motor weakness or flexion/extensor posturing; positive Babinski's reflex; coma

nursing care of the patient with autonomic dysreflexia includes

observing for a rapid rise in BP (often 20-40 mm Hg above the patient's baseline); bradycardia, diaphoresis, flushing of the skin above the level of the lesion, chills, and pallor below the lesion level; the patient often reports a severe headache with one or more of the following clinical manifestations: nasal congestion, anxiety, blurred vision, chest pain, or a sense of impending doom

disorders of sodium imbalance

occur frequently in the neurosurgical population for reasons that are not clearly understood; common ones in this population are SIADH, diabetes insipidus, and cerebral salt wasting syndrome (also called renal salt wasting syndrome)

spinal shock

occurs immediately after injury and applies to all phenomena surrounding spinal cord transection. This results in a complete but temporary loss or depression of all or most spinal reflexes as well as sensory, motor, and autonomic activity below the injury level. the brain is unable to transmit signals to muscles and organs, resulting in loss of sensation, movement, and other body functions. Clinical manifestations include flaccid paralysis of all skeletal muscles, absence of deep tendon reflexes, impaired proprioception, decreased visceral and somatic sensations, penile reflex, urinary and fecal retention, anhidrosis (absence of sweating), and paralytic ileus. This can last from 24 hours to 1 to 6 weeks, and the return of reflex activity below the level of injury indicates the end of it

vasogenic cerebral edema

occurs when the blood-brain barrier (BBB) is disrupted; this type primarily impacts white matter and is caused by leakage of fluids out of capillaries into the interstitial space

occlusion of large cerebral blood vessels by atherosclerotic plaque

occurs when the plaque ruptures, causing a blood clot to form and block the vessel, or when the plaque accumulates to a point that it critically narrows and then completely obstructs blood flow

management of cerebral edema regarding brain tumors

often includes increasing the dose of glucocorticoids as these medications decrease the inflammatory process associated with damage in and around the tumor

pressure ulcers that develop under the vest portion of the halo brace

often result from improper size, poor application, or insufficient padding Meticulous skin care and assessment for early signs of skin irritation are key to reducing/preventing breakdown. Other ways to prevent skin breakdown include turning and repositioning every 2 hours and as needed and making sure the vest fits properly and has sufficient padding.

thoracic spinal cord injuries

often result in paraplegia and can include poor trunk control

secondary injury countrecoup ("counter-blow")

one of the phases of TBI; encompasses all processes that occur subsequent to the initial injury

primary injury coup ("blow")

one of the phases of TBI; occurs with the initial mechanical insult

primary brain tumors

originate in the brain and range from slow-growing, benign tumors to highly malignant, aggressive ones; originate from brain cells, brain meninges, nerves, and glands; classification is generally based on the type of brain cells involved and the location in which the cancer evolves; can also be classified on the basis of the WHO classification system from least aggressive (grade I) to most aggressive (grade IV) depending on the rate of growth and behavior of the cells

vasogenic cerebral edema treatment

osmotic therapy (mannitol and/or hypertonic saline), hyperventilation, or surgical decompression

clinical manifestations of increased ICP due to space-occupying tumors

papilledema (swelling of the optic disk), headache, nausea, and vomiting, decreased alertness, cognitive impairment, personality changes, ataxia, hemiparesis, abnormal reflexes, and cranial nerve palsies

Increased ICP is detected by

performing serial neuro assessments including the elements of wakefulness, arousal, cranial nerves, and motor function

Which interventions are indicated to treat the loss of vasomotor tone in the patient with an acute SCI? (Select all that apply.) A. Positive inotropes B. Corticosteroids C. Antispasmodics D. IV fluids E. Vasopressors

positive inotropes, vaspressors, and IV fluids

two phases of TBI

primary and secondary brain injury

intra-arterial thrombolytic administration

procedure includes the introduction of a catheter into the femoral artery that is then threaded up the aorta and across the direct visualization of the patency or nonpatency of the blood vessel dye is injected into the blood vessels through the catheter, and images are obtained in quick succession using x-ray. during this procedure, the catheter is advanced to the clot and small doses of rt-PA are injected directly onto the clot with goal of dissolving the clot

compression of the CN III

produced pupillary dilation on the same side as the cranial nerve compression, or ipsilateral to the CN compression

The ICP waveform

produces three waves, numbered P1, P2, and P3; in cases of decreased intracranial compliance, the P2 wave is elevated above the P1 and P3 waves

specific methods used to prevent aspiration include

providing supervision of the patient while eating to observe for signs of choking, maintaining the head of bed at least 45 degrees or greater while eating or drinking, reducing distractions to assist a patient in concentrating on eating and drinking, advocating for evaluation of the patient by an SLP. Some patients require additional measures, which are often recommended by an SLP and include tucking the chin when swallowing and thickening liquids with fiber additives. Ensure that patients receive the prescribed therapeutic food preparation such as a soft or pureed diet. Other members of the health-care team may be involved in the feeding of patients; therefore, it is critical for the nurse to communicate the appropriate precautions and diet to these team members in order to ensure safety around meals. Patients with dysphagia are typically evaluated by an SLP and may be able to take food and fluid by mouth with a customized plan to prevent aspiration of liquids or solids into the lungs.

nursing management of SCI also encompasses

pulmonary care (suctioning or assisting with cough), turning to prevent pressure ulcers, DVT prophylaxis, bowel and bladder training , and management of nutrition, limb edema, and orthostatic hypotension Throughout the hospitalization, providing emotional support is essential for the patient and family. Assisting with the challenging adjustment to the new onset in alterations of daily living is an important focus for this patient population.

spinal cord injury at C6, C7 results in

quadriplegia with biceps intact, diphragmatic breathing

spinal cord injury at C5, C6 results in

quadriplegia with gross arm movements, phrenic nerve intact

spinal cord injury at C1-C4 results in

quadriplegia with loss of spontaneous respiratory function

spinal cord injury at C4, C5 results in

quadriplegia with possible phrenic nerve involvement

spinal cord injury at C7, C8 results in

quadriplegia with triceps, biceps, and wrist extension intact and some function of intrinsic hand muscles

Which intervention is typically the initial treatment of a metastatic spinal cord tumor?

radiation therapy

diagnoses methods to determine the cause of increased ICP

radiographic imaging of the brain, typically a CT scan; lab testing such as serum osmolality and ABG testing is necessary to guide medical treatments

physical interventions to reduce the blood volume in the intracranial space

raising the head of the bed to greater than 45 degrees to facilitate drainage of venous blood through the jugular venous system positioning a patient so that the neck is in a neutral position and hip flexion is minimized also assists in facilitating venous drainage from the head hyperventilation external drainage of CSF is an effective method to for rapidly decreasing increased ICP; may be continuous or intermittent according to the patient's specific needs

prior to arrival to the hospital for SCI patients

rapid assessments of vital signs including the patient's respiratory effort need to be evaluated bc a high cervical cord injury at or above C3, 4, or 5 affects the phrenic nerve that innervates the diaphragm

In cases where neither clipping nor coiling the aneurysm is feasible,

reinforcement of the aneurysmal wall by wrapping the outside of the aneurysm with synthetic material or muscle during the surgery may be accomplished.

guidelines for the management of SAH

recommend management of blood pressure while considering the risk of either hypoperfusion or rebleeding in the period prior to securing the aneurysm.

changes in vital signs

reflect late changes in increased ICP as herniation occurs

surgical management of refractory increased ICP

removing a section of the cranium and dura in order to create space for the swelling brain (a hemicraniectomy with a durotomy); involves removal of a section of the skull and opening of the dura; the skull is removed and typically stored in a tissue bank or stored in a tissue pocket within the patient's abdomen; the dura is replaced with a synthetic material that allows for brain tissue expansion and watertight closure of the meningeal layer

cryptogenic classification

represents the portion of patients diagnosed with ischemic stroke, but the cause cannot be determined even after a comprehensive evaluation; meaning a discrete cause cannot be identified

The nurse correlates phrenic nerve damage to which complication in the patient with a spinal cord injury?

respiratory distress

nursing assessments for spinal cord injury patients

respiratory function (Loss of intercostal muscle function results in decreased tidal volume and may lead to hypoventilation; C5 and higher injuries result in complete loss of diaphragmatic effort.) vital signs motor function/sensory level pain (may be increased pain above the level of injury as a result of damage to the spinal cord or nerve roots.) intake and output surgical and/or pin sites (assessed for infection, bleeding, or CSF leak) bowel sounds (decreased perfusion to the GI tract can lead to decreased GI motility and paralytic ileus)

lumbar and sacral spinal cord injuries

result in decreasing control of legs, bowel, and bladder function, and sexual function

a complete spinal cord injury

results in a total loss of motor and sensory function below the level of injury

cytotoxic cerebral edema treatment

same interventions as vasogenic shock (osmotic therapy-mannitol and or/ hypertonic saline, hyperventilation, or surgical decompression)

delirium is common in older adults who have

short-term illness such as lung or heart disease, infection, poor nutrition, and drug interaction

things that should be considered and incorporated into the patient w/ a brain tumor's plan of care

should be customized to particular to type, location, and functional status; should include complications such as VTE, seizures, falls, infection, and aspiration

serum creatinine monitoring after CT scan

should be done at least once after the contrast administration in critically ill patient and more often if acute kidney injury is suspected; typically an increase of at least 0.5 mg/dL is expected, which will decrease over 24-48 hours

nursing considerations for serum sodium

should not rise by more than 10 mEq/L in 24 hours for patients who have chronic hyponatremia. If sodium levels rise too quickly in a patient with chronic hyponatremia, a disorder called central pontine myelinolysis may result. In patients with cerebral edema, a decrease in serum levels may affect the level of consciousness because of an exacerbation of cerebral edema.

pin site care for halo brace/traction devices

sites must be frequently assessed for signs of infection and site care provided once a shift and as needed are kept clean using a clean cotton-tipped applicator or gauze soaked with normal saline. A new clean applicator or gauze is used for each pin site. If crusting is noted on assessment, wrap a gauze soaked with normal saline around the pin site for 15 minutes. After removing the gauze, use a clean cotton-tipped applicator to gently remove the crust from the pin site. Ointments and solutions such as hydrogen peroxide should not be used because they can irritate the skin and may cause breakdown at the pin site.

controllable risk factors for stroke

smoking, hypertension, and hypercholesterolemia. Knowledge of the role that these factors play in recurrent stroke may be empowering to patients who must be encouraged to take control of their health in order to prevent recurrent stroke or other conditions such as heart disease.

presenting symptomology of a brain tumor in the left inferior frontal lobe (Broca's area) or the left temporal lobe (Wernicke's area)

speech

intracranial compliance

the ability of the body to compensate by adjusting the levels of the three main components of the skull (brain tissue, blood, and CSF)

Contraindications for t-pa

stroke or serious head injury in past 3 months hemorrhagic stroke recent Mi increased PTT anticoagulant therapy pregnancy

displaced skull fracture

the edges of the fractured bone are no longer approximated and can be displaced or depressed downward toward the brain; fragments from a comminuted fracture may also be present. The edges of fractured bone or individual bone fragments are often sharp and irregular and can tear the dura mater covering the brain, underlying blood vessels, and venous sinuses, and in some circumstances, these sharp edges can violate the meninges, directly injuring brain tissue.

the higher the level of spinal cord injury

the more extensive the disability and the greater the risk of complications

nontraumatic intracranial hemorrhage has several causes

the most common of which is hypertension typically occurring in the deep structures of the brain such as the basal ganglia and thalamus. Another common cause is oral anticoagulation use (e.g., warfarin [Coumadin] and dabigatran [Pradaxa]). can also be caused by tumors and AVMs, as well as other disease processes such as Moyamoya disease and amyloid angiopathy

if the acute episode of autonomic dysreflexia is not identified and treated

the patient may develop seizures, pulmonary edema, myocardial infarction, cerebral hemorrhage, and death.

with spinal tumors in the cervical area

the patient may notice loss of manual dexterity and clumsiness

when caring for a patient with increased ICP, it is important for the nurse to evaluate

the patient's response to movements such as turning, side-lying, and lying flat; the nurse can evaluate the patient's response by assessing the patient's ICP during a given activity and noting how quickly the ICP value return to baseline after the activity is completed patients may tolerate routine patient care activities such as bathing, turning, and lying flat for diagnostic tests such as x-rays, and other patients may not.

cerebral autoregulation

the protective process by which cerebral blood vessels dilate when systemic BP is reduced and constrict when systemic blood pressure is elevated to maintain constant blood flow; this process is dysfunctional after stroke, making it necessary to implement interventions to protect the brain from abnormally low systemic blood pressure in the absence of this protective mechanism automatic alteration in size of cerebral arterioles sensitive to: changes in blood pressure PaCO2 high levels vasodilate PaO2 low levels vasodilate

once a SCI patient is stable, focus shifts to

the rehabilitation phase and the optimal recovery of neuro function; physical therapy is needed to minimize muscle wasting and to prevent contractures; patients require intense inpatient therapy and are often sent to a facility that specializes in spinal trauma.

when an epidural hematoma is caused by an artery

the speed and force of the blood collection has a rapid effect on intracranial pressure (ICP) and can cause neurological deterioration and coma very quickly; This type of injury typically requires emergency neurosurgery to evacuate the hematoma and decompress the brain structures displaced

different methods of monitoring ICP

the subarachnoid bolt (SAB); intraparenchymal monitors; intraventricular catheter (IVC); an alternative method is to place an intraparenchymal ICP-monitoring probe with the IVC, eliminating the need for attachment of a pressure transducer

if postoperative intracranial bleeding is identified

the surgical team determine whether an additional surgical procedure is required or whether medical management can be pursued

it is important for the nursing to closely monitor if blood pressure is lower than the prescribed target in patients after stroke bc

there is a risk of cerebral hypoperfusion

it is important for the nursing to closely monitor if blood pressure is higher than the prescribed target in patients after stroke bc

there is a risk of increased ICP and rebleeding

incomplete spinal cord injury

there is incomplete structural damage with some function preserved below the primary injury level; includes 4 types: central cord syndrome, anterior cord syndrome, posterior cord syndrome, brown-sequard syndrome

MERCI clot retrieval system

these procedures require highly specialized teams of physicans and nurses trained in neurointerventional radiology and have the benefit of extending the time window after which a pt is ineligible for a therapy that could recanalize a blood vessel, as these procedures may be performed up to 8 hours after the onset of stroke symptoms a corkscrew-shaped catheter is introduced into the clot, ensaring it and allowing it to be retrieved using suction in the artery

aneurysm management

they are secured either by applying a titanium clip to their neck during surgery using a microscope or by deploying platinum coils into the actual structure during angiography, both with the goal of reducing blood flow into it

When changes in neurological assessment are noted postoperatively (of the cranitomy) and reported to the physician or nurse practitioner

they localize the findings to their reference areas in the brain and may order CT imaging to determine whether a structural change has occurred to produce the new findings.

medical management of SCIs

time between SCI and treatment greatly affects patient outcome; if patient is admitted with this type of suspected injury, the spine is immobilized (cervical collar, spine backboard) until an exam is performed to identify the level of injury; any significant movement can result in further damage thorough physical and neuro exam, including reflexes is performed; an x-ray may be performed to look for damage to the vertebrae if patient has symptoms (inability to move/feel), a CT scan or MRI may be performed to show the location and extent of damage and to reveal problems such as hematomas. The level of injury refers to the vertebra closest to the site of the injury.

Patients who have received thrombolytics for acute stroke typically are considered

to be at risk for bleeding up to 24 hours after thrombolytic administration because of the inhibition of normal clotting mechanisms (decrease in fibrinogen) caused by rt-PA.

if a patient with a spinal tumor requires surgery, other complications include:

• Bleeding or hematoma • CSF leak • Meningitis • Chronic pain • Injury to CNS tissue • Spine instability • Sensory loss • Sexual dysfunction • Paralysis • Infection • Ventilator dependence • Wound dehiscence

intraparenchymal sensor/probe

type of ICP monitoring device; Micro strain gauge attached to the tip of a small catheter used to measure ICP; Fiber-optic technology used to measure ICP advantages: Accurate measurement of ICP with less mechanical drift of the measurement over time when compared to devices using a fluid-filled transducer to measure pressure; Can be inserted at the bedside or in the OR disadvantages: inability to drain CSF

subarachnoid bolt (SAB)

type of ICP monitoring device; bolt or screw connected to a fluid-filled transducer system advantages: can be inserted at the bedside or in the OR; lower rate of infection when compared to the IVC because it does not have a fluid reservoir disadvantages: inability to drain CSF; inaccuracy of measurement due to measurement drift that is inherent with a fluid-filled transducer system

intraparenchymal hematoma subarachnoid hemorrhage

type of brain injury; is a focal area of bleeding in the brain tissue usually below the cortex. Surgical intervention is typically not performed for this injury because the procedure could cause additional injury, and the blood typically breaks down and is reabsorbed over time. These hematomas are associated with cerebral edema.

central herniation

type of cerebral herniation syndrome (number 2 on the graph); occurs when the structures of the diencephalon (thalamus, hypothalamus, pituitary gland) and the tips of both temporal lobes are displaced in a downward direction through the tentorium (portion of the dura that creates a seperation bw the occipital lobs and the cerebelli), compressing the brain stem clinical manifestations: abnormal flexion or extension (posturing); bilateral pupillary dilation; abnormal eye movements such as downward and outward eye movements as cranial nerves controlling eye movements are compressed; positive Babinski's reflex; coma; cushing's triad

subfalcine or cingulate herniation

type of cerebral herniation syndrome (number 3 on picture); in this type, brain tissue is shifted over and underneath the falx cerebri; one of the main concerns is the risk of compression to the anterior cerebral artery, which could cause a stroke in this region of the brain tissue. clinical manifestations: specific signs and symptoms do not exist; however, this type of herniation may be found on a CT scan when evaluating signs and symptoms of increased ICP, such as decreased LOC, unilateral weakness of extremities, or a change in pupillary assessment, and places the patient at risk for further herniation

tonsillar herniation

type of cerebral herniation syndrome (number 4 on the graph); occurs, and the bottom portion of the cerebellar hemispheres (tonsils) descend through the foramen magnum, damaging the medulla clinical manifestations: abnormal flexion/extension (posturing); bilateral pupillary dilation; positive Babinski's reflex; coma; cushing's triad

ideational apraxia

type of disturbance in the planning of motor activities that occurs in strokes that involve the frontal and temporal lobes of the brain; may be able to correctly identify an object such as a comb but proceed to brush their teeth with the comb (Occupational therapists (OTs) work with patients, families, and the health-care team to develop strategies for recoupling common meanings with objects or activities.)

skull fracture

type of head injury; can be linear or displaced. The skull fragments in a displaced fracture can remain in the same plane or can become depressed into the dura or brain tissue.

concussion

type of head injury; caused by blunt force to the head causing the brain to strike the inside of the skull. Although structural injury does not appear on conventional imaging such as a CT scan, damage has occurred at the cellular level causing an increase in cellular metabolism, resulting in an imbalance between supply of oxygen and glucose and demand because of a decrease in cerebral blood flow; multiple recurrences can result in permanent brain injury

diffuse axonal injury (DAI)

type of head injury; is caused by rotational and acceleration-deceleration forces and results in direct injury to the axon. Swelling and microscopic hemorrhages can occur. Often, this type of injury occurs deep within the white matter in the area of the reticular activating system, which controls wakefulness.

epidural hematoma

type of head injury; is often caused by damage to an artery traveling in grooves on the inside of the skull when the skull is impacted or fractured. This blood collects in the space between the inside of the skull and the dura, pushing the dura farther away from the skull. Because the dura is tethered to the inside of the skull at the suture lines, the collection of blood is confined in width and expands inward toward the brain, displacing structures laterally and having a convex appearance.

contusion

type of head injury; is superficial bleeding that occurs on the surface of the brain (cortex), often at the point of initial impact or "coup" location; they may expand into hematomas and are often associated with cerebral edema; Patients are often monitored in a setting where they can receive frequent neuro assessments to capture a neurological decline from development of cerebral edema or an expanding hematoma.

subdural hematoma

type of head injury; is typically caused by damage to a vein or network of veins called bridging veins. When the brain moves within the dural covering, small bridging veins that span the inside of the dura to the surface of the brain can be stretched or disrupted, causing bleeding; includes three types: acute where symptoms occur within 24 hours after injury, subacute where symptoms occur within 2 weeks of injury, and chronic where symptoms occur from 2 weeks to months or year after injury.

penetrating injury

type of head injury; occur often as a result of a projectile such as a bullet and can also be caused by a knife or other projectile such as a bomb fragment; can cause catastrophic brain injury depending on the location of the injury; shock wave-type forces also causes shearing and stretching injury to neurons, resulting in neuronal injury and death.

anterior cord syndrome

type of incomplete spinal cord injury; etiology: acute anterior compression from bony fragments or acute disk herniation; clinical manifestations: loss of motor function (paresis or paralysis), pain, temp, crude touch and pressure below the level of injury; preserved sense of proprioception (position sense), fine touch and pressure, and vibration

posterior cord syndrome

type of incomplete spinal cord injury; etiology: acute compression; clinical manifestations: loss of proprioception, fine touch, and pressure, and vibration; intact pain, temp, and crude touch and pressure

brown-sequard syndrome

type of incomplete spinal cord injury; etiology: hemisection of the spinal cord resulting from penetrating injury; may also occur as a result of primary ischemia, infection, or hemorrhagic event; clinical manifestations: ipsilateral loss of motor function, prioprioception, and vibration; contralateral loss of pain and temp

central cord syndrome

type of incomplete spinal cord injury; most common; etiology: hyperextension injury with central cord swelling; clinical manifestations: function motor loss greater in arms than legs, bladder dysfunction, and variable loss of sensation

mannitol (osmitrol)

type of medication used to increase the osmolarity in the blood in order to pull water from the interstitial spaces across the blood-brain barrier into the vascular space, and then a diuresis occurs at the level of the kidney; in order to compensate for systemic dehydration and hypovolemia that occurs with administration, IV fluid should be administered to replace losses.

ependymoma

type of primary central nervous system tumor; originate from cells lining the center of the spinal cord; most are benign

astrocytoma

type of primary central nervous system tumor; originate from cells of tissue that support nerve cells; most are benign or low-grade malignant tumors

schwannoma

type of primary central nervous system tumor; originate from cells that form myelin sheath around peripheral nerve fibers; are benign tumors

neurofibroma

type of primary central nervous system tumor; originate from peripheral nerve cells (arise from Schwann cells); usually are benign

sarcoma

type of primary central nervous system tumor; originates from connective tissue cells; are malignant tumors

meningioma

type of primary central nervous system tumor; originates from tissue cells covering the spinal cord (meninges); most are benign but can recur and can become malignant based upon location and damage to vital structures

other late signs of ICP excluding Cushing's triad

unilateral fixed and dilated pupil; this phenomenon occurs as the bottom portion of the temporal lob or uncus is displaced through the tentorium cerebelli and compresses CN III (oculomotor nerve) and is called uncal or transtentorial herniation; motor paresis accompanies pupillary dilation on the opposite side of the herniation

triple-H therapy

used to treat possible vasospasms in patients with SAH who are more susceptible to this post 4-14 days includes pushing BP high, trying to prevent those vessels from going into spasm; may give calcium channel blocker, hydrate them to try to increase the perfusion; ultimately try to buy some time to go in an fix the anuyersm

three types of cerebral edema

vasogenic; cytotoxic, and transependymal; all can impact ICP

treatment for neurogenic shock often includes

vasopressors, and other medications such as atropine

The nurse receives report on a patient in the ICU with an SAH and clarifies that the date of the patient's initial bleed was 4 days before. The nurse needs this information to gauge the patient's risk of which complication of SAH?

vasospasm

Injuries to the scalp

warrant careful inspection and palpation for irregularities signifying skull fractures and consideration of concomitant brain injury.

nursing assessment and analysis for increased ICP include

vigilant serial assessments of a patient's neuro status to identify neuro deterioration that places a patient at risk for cerebral herniation syndrome; every 1-2 hours in the critical phase, decreasing in frequency as the risk of cerebral edema and secondary brain injury decreases assessments of oxygenation, ventilation, and hemodynamic parameters are needed to optimize therapy and prevent or mitigate brain injury; vital signs and SpO2 every 1-2 hours temperature every 1-2 hours; elevations may indicate damage to the hypothalamus, increasing cerebral metabolism may exacerbate existing brain injury by increasing the demand for oxygen and nutrients where there is existing poor blood flow intracranial pressure and CPP every 1-2 hours or more frequently if the patient is experiencing an increase in ICP and/or a deterioration of neuro assessment Cardiac rhythm; serum markers of myocardial injury (creatinine kinase, creatinine kinase specific to cardiac muscle, and troponin) intake and output every 1-2 hours BUN and Cr End-tidal carbon dioxide (EtCO2) continuously to guide hyperventilation therapy during treatment of increased ICP; When hyperventilation therapy is employed, EtCO2 is monitored in order to maintain carbon dioxide in a specified range (30-35 mm Hg). End-tidal carbon dioxide values may be higher or lower than PaCO2; therefore, it is necessary to document the EtCO2 value at the time that a blood sample for an ABG is performed so that a correlation can be made between the EtCO2 and the PaCO2 measured in the arterial blood sample. ABGs performing a full-systems assessment assists in identifying signs of complications or conditions that may negatively impact the patient, such as respiratory compromise. assessment of lab values such as serum electrolytes and serum osmolality is needed to detect electrolyte imbalance and dehydration, which can lead to renal insufficiency or failure medication levels may also be monitored (particularly when the dosage is decreased)

clinical manifestations of a right middle cerebral artery stroke syndrome

weakness of the left face, arm, and leg decrease in sensation on the left side of the body left homonymous hemianopia (loss of vision in the left temporal field of vision and right nasal field of vision, requiring patients to scan an area in order to visualize objects on their right side) inattention or neglect of the left side

clinical manifestations of a left middle cerebral artery stroke syndrome

weakness of the right face, arm, and leg (arm weakness greater than leg) decrease in sensation on the right side of the body right homonymous hemianopia (loss of vision in the right temporal field of vision and left nasal field of vision, requiring patients to scan an area in order to visualize objects on their right side) dysphasia- in most patients, the language center of the brain is located on this effected side; language deficits may involve the motor speech (Broca's area) and cause patients to have difficulty expressing thoughts and to make errors in speech that they are able to detect. Injury of ischemia to the sensory speech area (Wernicke's area) results in an inability to process speech input in the brain, causing patients to make errors in speech of which they are unaware inattention or neglect of the right side

chronic complications of stroke may include

weakness or paralysis of the extremities and associated risk of muscle contracture (splinting, passive ROM, and physical and occupational therapies assist in preserving function and increasing the probability of the return of function to the extremities) Neglect or inattention of one side of the body occurs on the opposite side of the body from the area of brain injury and causes a patient not to recognize or acknowledge the affected side of the body Visual field deficits, such as homonymous hemianopia, commonly occur and affect an entire side of vision (both nasal and temporal fields) Disorders of speech due to facial muscle or cranial nerve weakness and language are common residual deficits of stroke that often require intensive speech and cognitive therapies. Disturbances in the planning of motor activities, or apraxia, often occur when the frontal and temporal lobes of the brain are involved depression is important to consider when working with these patients because it can significantly impact recovery and rehabilitation.

SCI most commonly affects

young men between the ages of 15-35

nursing diagnoses for SCIs

• Alteration in respiratory function related to paralyzed muscles, hypoventilation secondary to loss of diaphragm function due to denervation of phrenic nerve • Decreased cardiac output related to loss of vasomotor tone secondary to spinal/neurogenic shock • Impaired physical mobility related to neuromuscular impairment secondary to loss of nerve cells at injured level • Fear/anxiety secondary to loss of motor function and potential for permanent impairment

nursing diagnoses for strokes

• Impaired swallowing related to lower cranial nerve dysfunction or decreased level of consciousness • High risk for impaired gas exchange related to aspiration • Sensory perceptual alterations related to damage to sensory input areas in the brain and/or integration of sensory inputs • Impaired physical mobility related to hemiparesis • Impaired verbal communication related to decreased perfusion to the speech centers in the brain (Broca's [motor speech] and Wernicke's [sensory speech]) • Impaired family coping related to catastrophic illness and uncertain outcome

nursing diagnoses for brain tumors

• Impaired tissue perfusion (cerebral) related to decreased cerebral circulation secondary to increased ICP • Self-care deficit related to decreased level of consciousness and neuromuscular dysfunction • Fear related to the surgical procedure (craniotomy) to remove the brain tumor • Risk for infection related to the surgical procedure and immunosuppression secondary to chemotherapeutic agents • Altered body image secondary to potential hair loss secondary to chemotherapy, the surgical procedure, and radiation markings

nursing actions for the spinal cord injury patient

• Maintain suction equipment at the patient's bedside With decreased cough effectiveness, the patient may require suctioning to clear the airway. • Facilitate cough effectiveness Because of muscle weakness or lack of diaphragmatic innervation, assistance is needed to remove secretions. • Maintain spinal immobilization and stabilization To prevent further injury from an unstable spinal column • Passive ROM Prevents contractures and loss of muscle tone; strengthens unaffected muscles • Reposition and maintain in good alignment Prevents pressure ulcers and decreases risk of DVT due to immobility • Perform routine pin site care Pin sites are kept clean using a clean cotton-tipped applicator or gauze soaked with normal saline. A new clean applicator or gauze is used for each pin site. If crusting is noted on assessment, wrap a gauze soaked with normal saline around the pin site for 15 minutes. After removing the gauze, use a clean cotton-tipped applicator to gently remove the crust from the pin site.

patient teaching for spinal cord injury

• Signs and symptoms of autonomic dysreflexia To inform patients and their families about the signs and symptoms of this potentially life-threatening emergency • Skin care/management To help identify causes of and prevent skin breakdown. In patients who require a wheelchair, they need to be taught to refrain from sitting in one position too long because it can lead to decreased perfusion. • Signs and symptoms of respiratory distress To help patients and families identify potential respiratory complications

evidence suggests that the following interventions reduce the rate of CAUTI in patients who require short-term indwelling catheterization:

• Using catheters only when medically necessary • Daily assessments of the need for catheterization and documenting the continued need • Using reminder systems targeting early removal of catheters • If appropriate, use external catheters on males • Consider intermittent catheterization instead of indwelling catheter insertion with the use of a portable ultrasound bladder scanner to check for residual amounts of urine • Early removal of all unnecessary urinary catheters Specific nursing interventions that have also been noted to reduce incidence include daily cleaning of the urethral meatus using a perineal cleanser, maintaining a closed urinary drainage system, use of catheter securement devices to prevent movement and urethral traction, maintaining the drainage bag below the level of the bladder, and changing the indwelling catheter only when necessary, not at a routine interval.