NURS 220 Exam 4

Sacrum and Coccyx Vertebrae

-sacrum formed by fusion of 5 vertebrae -attached to pelvic girdle -coccyx formed by fusion of 4 vertebrae

Thoracic Spine Vertebrae

12

Lumbar Spine Vertebrae

5

Cervical Spine Vertebrae

7

Cranial Nerve XI

Accessory (motor)

Head Injury

Any injury or trauma to the scalp, skull, or brain the most common cause is falls and MVAs men are more likely to sustain a TBI death from injury mainly occurs at 3 points post injury -immediately -within 2 hrs -about 3 weeks after most deaths occur immediately, either from direct trauma or hemorrhage and shock death after a few hours are from progressive worsening or internal bleeding deaths 3 weeks or after result from multisystem failure Types -scalp lacerations -skull fractures -headtrauma (concussion, diffuse axonal injury, contusions, hematomas, or CN injury) Scalp Lacerations an easily recognized type of external head trauma bc the scalp contains many blood vessels with poor constrictive abilities, most scalp lacerations are associated with profuse bleeding Relatively small wound complete significantly The major complications associated with scalp laceration are blood loss and infection Skull fractures Often occur with head trauma Fractures may be closed or open, depending on the presence of a scalp laceration or extension of the fracture into the air sinuses or Dura Location of the fracture determines the manifestations Basilar skull fractures are a special type of linear fracture involving the base of the skull Manifestations kind of all over the course of several hours and very with the location and severity of fracture These manifestations may include cranial nerve deficits, battles sign which is post a regular bruising, and periorbital bruising or raccoon eyes This fracture is often associated with a tear in the Dura and subsequent leakage of CSF Rhinorrhea which is CSF leakage from the nose or otorrhea which is CSF leak it's from the ear generally confirms that a fracture has transversed the Dura Ryan area may also manifest as post nasal sinus drainage The risk for meningitis is high with the CSF leak and ABX should be given as a preventative measure The two methods that can be used to determine if fluid is CSF is either the dextrosticks or test tape strip CSF gives a positive reading for glucose If blood is present in the fluid, testing for glucose is unreliable because blood also contains glucose In this event, look for the halo or ring sign The halo a ring sign is when the blood coulisses into the center and a yellowish ring incircles the blood if CSF is present The major complications of skull fractures are intracranial infections, hematoma, and meningeal and brain tissue damage When a basilar skull fracture suspected, in Orogastric tube should be in certain rather than an NG tube Head Trauma Brain injuries are categorized as diffuse or generalized and focal or localized Interviews injury such as a concussion, or diffuse axonal injury, damage to the brain is not a localized in one area In a focal injury such as a contusion, or a hematoma, damage is localized to a specific area of the brain Brain injury can be classified as minor which is a GCS of 13 to 15, moderate which is a GCS of 9 to 12, or severe which is a GCS of 3 to 8 Diffuse injury A concussion is a sudden transient mechanical head injury with disruption of neuron activity and a change in the level of consciousness, and is considered a minor diffuse head injury The patient may or may not lose consciousness Typical size include a brief description of level of consciousness, amnesia about the vent or retrograde amnesia, and headache manifestations are generally of short duration If the patient has not lost consciousness, or if the loss of consciousness lasts less than five minutes, the patient is usually discharge with instructions to notify the healthcare provider if symptoms persist or if behavioral changes are noted Post concussion syndrome a developing some patience, usually from two weeks to two months after the injury Manifestations include persistent headache, lethargic, personality and behavioral changes, shortened attention span, decreased short term memory, and changes in intellectual ability The syndrome can significantly affect the patients ability to perform ADLs Concussion is generally considered benign and usually result spontaneously, but for some of the signs and symptoms may be the beginning of a more serious, progressive problem, especially in a patient with a history of prior concussion or head injury At the time of discharge, it is important to give the patient and caregiver instructions for observation in accurate reporting Diffuse axonal injury (DAI) A widespread axonal damage occurring after a mild, moderate, or severe TBI The damage occurs primarily around axons in the sub cortical white matter of the cerebral hemispheres, basal ganglia, families, and brainstem Initially we thought the AI occurred because of the tinsel forces of trauma Sheard axons, resulting in axonal disconnection Now we think the trauma changes the function of the axon, resulting in axon swelling and disconnection This process takes 12 to 24 hrs to develop in may persist longer The clinical signs of DAI very and they may include a decreased level of consciousness, increased ICP, decortication or decerebration, and global cerebral edema About 90% of patients with DAI stay in a persistent vegetative state Focal injury Focal injury consist of lacerations, confusion, hematoma, and cranial nerve injury's Lacerations involve actual tearing of the brain tissue and they often occur in association with depressed and open fractures and penetrating injuries Tissue damage is severe, and surgical repair of the laceration is impossible because of the nature of brain tissue Medical management consist of antibiotics until meningitis is ruled out, and preventing secondary injury related to the increased ICP Weenies deep into the brain tissue, focal and generalized signs develop With major head trauma, mini delayed responses can occur that include hemorrhage, hematoma formation, seizures, and cerebral edema Intracerebral hemorrhage is generally associated with cerebral laceration and the hemorrhage manifest as a space occupying lesion accompanied by unconsciousness, hemiplegia on the contralateral side, and a dilated pupil on the ipsilateral side Is the hematoma expands, signs of increased ICP become more severe subarachnoid hemorrhage and intraventricular hemorrhage can occur from head trauma Contusion is bruising of the brain tissue within a focal area It is associated with a closed head injury and often occurs at a fracture site A contusion may have areas of hemorrhage, infarction, necrosis, and edema What conclusion, the phenomenon of coup-contrecoup is often noted Demons from coup-contrecoup injury occurs when the brain moved inside the skull due to high energy or high impact injury mechanisms Contusions or lacerations occur both at the site of the direct impact of the brain on the skull which is coup and at a second area of damage on the other side away from injury or contrecoup Contrecoup injuries tend to be more severe and the overall prognosis depends on the amount of bleeding around the confusion site Contusions we continue to bleed or re-bleed in appear to blossom on subsequent CT scans of the brain Bleeding worsens analogical outcome and neurological assessment me show focal and generalized manifestations, depending on the contusion size and location Seizures can occur because of a brain contusion, particularly when the injury involves the frontal or temporal lobes Anticoagulant use and coagulopathy are associated with increased hemorrhage, more severe head injury, and an increased mortality rate This is especially important with older adults who are taking anticoagulants and if they fall, the confusion is likely to be more severe do take anticoagulant use Assess for risk for falls in all patients taking anticoagulants

Spinal Cord Injury Diagnostics

CT scan is the preferred imaging study to diagnose location and degree of injury in the degree of spinal canal compromise Cervical x-rays are done when CT scan is not readily available however it is hard to see C7 and T1 a cervical x-ray, decreasing the ability to fully evaluate a cervical spine injury MRI is used to assess soft tissue injury MRI results guide clinical decisions about surgery Patients with cervical injuries who have altered mental status may need a CT angiogram to rule out vertebral artery damage

Spinal Cord Injury Nursing Care

Goes immediately after injury include ABC's in preventing extension of spinal cord damage or secondary injury Spinal motion should be restricted with a combination of rigid cervical collar and a supportive backboard with straps Patients should be kept supine and may be log rolled for transfers Uncooperative patients may need chemical sedation or physical restraints to protect them from further injury Reverse Trendelenburg position may be used if necessary Spinal immobilization in patients with penetrating trauma should be tried as long as it does not affect resuscitation Intubation to secure the airway is done as soon as possible for patients with respiratory distress The patient stable airway in the field may need intubation at the medical facility Systemic and neurogenic shock or treated with IV fluids in vasopressors to maintain systolic blood pressure greater than 90 After cervical injury, all body systems must be maintained until the extent of the damage can be evaluated Compared to cervical injury, patients with SCI of the thoracic and lumbar vertebrae need less intense support At this level of injury, respiratory compromise is not a severe, and bradycardia is usually not a problem Obtain history with emphasis on how the incident occurred ABC's and vital signs to ensure secure airway and maintain oxygenation saturation greater than 92% and a map of greater than 85 Avoid systemic blood pressure less than 90 Start at the toes in work upward toward the head using a pin prick to assess the muscles and sensation Assess rectal tone and note the presence of priapism Voluntary anal contractions indicate incomplete SCI If time and conditions permit, assess position sense and vibration Assess for history of unconsciousness, signs of concussion, and increased ICP Because the patient may have altered or no muscle, bone, or visceral sensations with all the level of injury, the only clue to internal trauma with hemorrhage may be a rapidly decreasing blood pressure and tachycardia Check urine for hematuria, which indicates internal injuries Nonoperative treatment involves stabilization of the injured spinal segments and decompression, either through traction or realignment Stabilization illuminates damaging motion at the injury site and it is meant to prevent secondary spinal cord damage caused by narrowing of the spinal canal, or continue contusion or compression of the spinal cord at the level of injury Early realignment of an unstable fracture dislocation injury by closed reduction through craniocervical traction is effective and safe Surgical treatment is used to manage instability and decompress the spinal cord Early surgery within 24 hours after the injury is recommended for persons with central cord syndrome and for adults with an acute SCI at any level Surgery to stabilize the spine can be done from the back of the spine or posterior approach or from the front of the spine or anterior approach Both approaches maybe needed in some cases Taxation involves attaching metal screws, plates, or other devices to the bones of the spine to help keep them aligned This process is usually done when two or more vertebrae are injured Small pieces of bone maybe attached to the bone to help them fuse into one solid piece, the bone used is obtained from the patient's spinal bone harvested during surgery, from another bone in the patient's body, or from donor bone Drugs current evidence for the use of methylprednisolone is mixed but some suggest a 24 hr infusion of high dose within 8 hrs of injury DTE prophylaxis with low molecular weight heparin such as Lovenox or fixed low-dose heparin should we started within 72 hours after injury unless contra indicated Complications include internal or external bleeding in recent surgery For those with abnormal kidney function, heparin is best as low molecular weight heparin or Lovenox is mainly excreted by the kidneys Vasopressor agents such as phenylephrine, or norepinephrine are used in the acute phase of injury as adjuncts to treatment They maintain the map to improve perfusion to the spinal cord use a vasopressors has significant risk for complications Please include ventricular tachycardia, troponins elevation, metabolic acidosis, and a fib Dopamine has more complications in phenylephrine in SCI Considerations for vasopressor selection include the level of injury, the patient's age, and comorbidities such as heart problems nursing interventions for the prevention of SCI includes identifying high-risk patients in providing teaching Teach people to use child safety seat in helmets for motorcycles and bicycles Promote programs for older adults aimed at preventing accidental death and injury Nursing interventions include teaching in counseling, referring programs such as smoking cessation classes, recreation programs, and alcohol treatment programs, and performing routine physical exams for non-neurologic problems Nurses should advocate for wheelchair accessible exam rooms, adjustable height exam tables, and appointment scheduling that allow extra time if needed High cervical cord injury caused by flexion rotation is the most complex SCI To restrict spinal motion, maintain the neck in a neutral position Closed reduction with skeletal traction is used for early realignment or reduction of the injury traction must be maintained at all times If pen displacement occurs, hold the patient's head in a neutral position and get help, immobilized ahead while the healthcare provider reinserts the tongs The goal is spinal reduction Some patients with spinal fractures with or without acute SCI may not be able to have surgery but still need immobilization for the cervical fracture In these patients, the halo frame can be attached to a special vest This allows the patient to move in ambulate while cervical bones fuse Surgery is used instead of the halo if the patient has ligament instability from injury, severe cervical deformity, or is morbidly obese, older, cachectic, or non-compliant Infection at the tongue or opinion certain sites as a potential problem, and preventative care is based on agency protocol A common protocol involves cleansing sides twice a day with chlorhexidine, an antibiotic ointment is that apply to act as a mechanical barrier to the entrance of bacteria Patience with stable or thoracic lumbar spine injuries maybe immobilized with a custom thoracolumbar sacral orthosis or body jacket to limit spinal flexion, extension, and rotation Unstable injuries may require surgical decompression and fusion in addition to orthotics The effects of immobility can be great, throw skin care is important because decreased sensation and circulation increase the risk for skin breakdown Remove the patient's backboard as soon as possible and replace it with other forms of immobilization to prevent skin breakdown Fit cervical collars properly Carefully assess under areas of any device used for immobilization Kinetic therapy involves continuous side to side rotation of a patient to 40° or more to help prevent lung complications This lateral rotation also redistributes pressure, helping prevent pressure injuries Respiratory complications are the leading acute and chronic causes of morbidity and mortality in SCI During the first 48 hours after injury, spinal cord edema may increase the level of dysfunction and respiratory distress may occur Injury at or above C4 affects the phrenic nerve, which leads to the diaphragm and breathing can stop Monitor carefully for respiratory compromise and be prepared for quick action if arrest occurs Wrigley assess breath sounds, ABGs, tidal volume, vital capacity, skin color, breathing patterns especially the use of accessory muscles, subjective comments about breathing, and the amount and color of sputum Appeal to greater than 60 in a PaCO2 less than 45 or acceptable values in a patient with uncomplicated tetraplegia A patient who is unable to count to 20 allowed without taking a breath needs immediate attention If the patient is exhausted from labored breathing or ABGs show inadequate oxygenation organization, endotracheal intubation or tracheostomy and mechanical ventilation is needed Patients who have chest trauma or difficulty waiting from the ventilator may need a tracheostomy for airway management Clearing secretions is vital in reducing the risk for lung complications impossible respiratory failure Perform tracheal suctioning if crackles or coarse breath sounds are present Chest physiotherapy and assisted or augmented coughing can help Perform assisted coughing either manually, by placing the heels of both hands just below the xiphoid process and exert firm upward pressure to the area times with the patients efforts to cough Or mechanically with an insufflation X suffocation device Encourage the use of incentives spirometry Older adults have more difficulty responding to hypoxemia and hypercapnia Heart rate is fluid, often lead to 60 beats a minute because of unsupposed vagal response Any increase in vagus simulation, as occurs with turning or suctioning, can cause cardiac arrest Loss of SNS tone in peripheral vessels results in chronic low blood pressure with potential orthostatic hypotension The lack of muscle tone to eat venous return can call sluggish blood flow and predispose the patient to VTE Dysrhythmias may occur Is bradycardia symptomatic, give an anticholinergic drugs such as atropine When giving atropine make sure the patient is on continuous ECG monitoring A temporary or permanent pacemaker may be inserted in certain patients Maintain systolic blood pressure greater than 90 and keep MAP between 85 and 90 for the first seven days after injury Manage hypotension with fluid replacement and a vasopressor agent, such as phenylephrine or norepinephrine Maintain a normal blood volume If blood loss has occurred from other injuries, monitor hemoglobin and hematocrit and give blood according to protocol Assess the patient for signs of hypovolemic shock from hemorrhage Orthostatic hypotension is likely to occur in the patient with injury at T6 or above The patient may have lightheadedness, dizziness, and nausea Assess orthotic blood pressure when mobilizing the patient Some lose consciousness when moved from the bed to a chair For symptomatic patients, used in abdominal binder and graduated compression stockings to promote venous return Drugs used to increase intravascular volume includes salt tablets in fludrocortisone Midodrine may be given to promote blood vessel contraction and increase venous return Consider the effects of aging on the cardiovascular system of the older adult The older patient is less able to manage the stress of traumatic injury because her contractions weekend, and cardiac output is reduced Maximum heart rate is reduced in the older adult may also have cardiovascular disease Use low molecular weight heparin or low-dose heparin in combination with intermittent pneumatic compression devices or graduated compression stockings to promote venous return and reduce the risk for VTE Remove stockings every eight hours for skin care in assess the thighs and calves every shift for signs of VTE Regularly perform range of motion exercises and stretching Continue VTE prophylaxis for 3 months after injury During the first 48 to 72 hours after injury, the G.I. tract way stop functioning or have a paralytic ileus A nasal gastric to must be inserted if ileus occurs Because the patient cannot have oral intake, monitor fluid and electrolyte status Nutrition should be stored within the first 72 hours after injury Due to severe kind of wisdom, a high protein high calorie diet is needed for energy and tissue repair If the patient cannot be fed through the G.I. system, either orally or through EN, PN should be started to reduce nitrogen losses that occur during the hypermetabolic state What's vowel sounds are present or flattest has passed, and the patient is not receiving mechanical ventilation, informal swallow evaluation is done If no risk for aspiration is identified, gradually introduce oral fluids and foods If the patient fails to swallow eval or is an able to eat due to an endotracheal tube or tracheostomy, a more secure feeding tube may be placed in the stomach or jejunum Patients may have anorexia due to depression, boredom with agency food, or discomfort of being fed often by a hurry person Some patients have a normally small appetite, and sometimes refusal to eat is a way of a certain control, if the patient is not eating adequately, access the cause For example, provide a pleasant evening environment, allow adequate time to eat including any self feeding the patient can achieve, encourage the family to bring in special food, and plan social rewards for eating to encourage eating Consult a dietitian Obtain a daily weight Include increased dietary fiber to promote bowel function Immediately after the injury, urine retention occurs because of the loss of autonomic and reflex control of the bladder and sphincter or neurogenic bladder Because there's no sensation of fullness, over distention of the bladder can result in reflux into the kidney and cause renal failure Bladder overextension may even result in rupture of the bladder Thus an dwelling catheter may be inserted soon after injury Is your a Peyncy of the catheter by frequent inspection and irrigation if needed, and some agencies, the healthcare provider orders this because it's required for the procedure Strict aseptic technique for catheter care is essential to prevent infection, during the period of indwelling catheter isolation, encourage large fluid intake, and check the catheter to prevent kinking in ensure free flow of urine Catheter acquired urinary tract infection is a common problem, and the best way to prevent it is regular and complete bladder drainage What's the patient is stabilized, access the best means of managing long-term urinary function Clean intermittent catheterization or CIC is the preferred method for emptying the bladder CIC should be done 4 to 6 times daily to prevent bacterial overgrowth from urinary stasis Keep urine residuals under 500 mL to prevent bladder distention If the urine is cloudy or has a strong odor or if the patient develops symptoms of urinary tract infection, send a specimen for culture Consider age related changes in renal function, as the older daughters more likely to develop renal stones, and older men may have benign prostatic hyperplasia, which may interfere with urinary flow in complicate management of urinary problems, it can affect the ability to complete CIC Start a bowel program to come back constipation from neurogenic bowel This involves inserting a rectal stimulant such a suppository or small volume enema daily at the regular time, followed by gentle digital stimulation or manual evacuation until evacuation is complete At first, the program may be done in bed with a patient in the sideline position, however as soon as the patient has resumed sitting, the patient should be in the upright position on a padded bedside commode chair These programs typically take 30 to 60 minutes to complete, and measures to reduce constipation include adequate fluid intake, I don't high in fiber and vegetables, and increased activity and exercise Monitor the environment closely to maintain appropriate temperature, and regularly assess the patient's body temperature Do not use excess covers or unduly expose the patient during a bath If infection with a high fever develops, more aggressive methods for temperature control may be needed such as a cooling blanket Stress ulcers can occur in the patient with SCI because of the physiological response to severe trauma and physiologic stress Peak incidence of stress ulcers is 6 to 14 days after injury Test stool and gastric contents daily for blood Monitor the hematocrit for a slow drop Histamine receptor blockers such as ranitidine or proton pump inhibitor such as pantoprazole or omeprazole given prophylactically decrease the secretion of HCl acid and prevents ulcers To prevent sensory deprivation, compensate for the patients absent sensations by stimulating the patient above the level of the injury Conversation, music, and interesting food can be part of the nursing care plan If the head of the bed must lay flat, provide prism glasses to help the patient read and watch television Help the patient avoid withdrawing from the environment, promote adequate rest and sleep, and assess for changes in mood Depression is common Musculoskeletal nociceptive pain can develop from injuries to bones, muscles, and ligaments The pain is worse with movement or palpation Anti-inflammatory drugs such as ibuprofen help with pain, and opioids may be used to manage nociceptive pain Visceral nociceptive pain is a dull, tender, or cramping pain in the thorax, abd, or pelvis It may originate in the bladder or bowel, so it says the patience of bowel and bladder function to avoid bladder distention or constipation Other causes of nociceptive pain include UTI and renal stones Notify the healthcare provider if the patient has persistent pain despite treatment, and diagnostic imaging may be needed to determine the cause Neuropathic pain in the initial phase is usually at the level of SCI It may occur on one or both sides of the body within the affected dermatome and up to three levels below The patient will describe hot, Bernie, tingling, shooting, electric pain Pregabalin is used to reduce symptoms Neuropathic pain can occur months or years after injury, become chronic come in negatively affect sleep The patient's mood, certain noise, constipation, and infection can affect the pain Teach the patient and caregiver about possible pain triggers and offer relaxation techniques Other modes of treatment may include tricyclic antidepressant, intrathecal drugs, anti-seizure drugs, epidural stimulation, and destructive surgical intervention The most common long-term complication in SCI is pressure injury formation Healthy skin requires adequate blood circulation, and constant pressure in one position can compressor blood vessels and limit one supply, causing cell death and pressure injury Little evidence addresses interventions, and factors associated with increased risk include heart and renal disease, smoking, alcohol or drug use, diabetes, hypoxia, hypotension, and pneumonia, UTI, and other infections Prevent injury by performing a risk assessment with daily comprehensive visual and tactile examination of the skin Areas most vulnerable to breakdown include the sacrum, ischia, trochanters, and heels Assess surgical incisions for healing and skin integrity under collars and braces, regularly assess nutritional status, both weight loss and weight gain can contribute to skin breakdown, and teach the patient and caregiver about the causes and risk factors for development A consult with a wound, ostomy, incontinence nurse can assist with prevention and management Monitor incontinence and implement appropriate neurogenic bowel and bladder management interventions, and apply skin barrier creams Carefully position and reposition the patient at least every two hours, gradually increase the times between turns if no redness of her bony prominences is seen when turning, while the patient is supine in bed, float the heels to reduce pressure, consider prophylactic dressings to prevent sacral and heel wounds, move the patient carefully during turns and transfers to avoid stretching and folding of the soft tissues or sheer or region, they may need a specialty mattress, when the patient is moved to a chair or wheelchair, used pressure relieving cushions, pressure relief should be scheduled every 15 to 20 minutes when the patient is in a chair and should last 30 to 60 seconds each time What spinal cord shock is resolved, return of reflexes me complicate rehab Why can't control from the higher brain sinners, reflexes are often hyper active and have exaggerated responses Penile erection can occur from various stimuli, causing embarrassment and discomfort Spasms ranging from mile twitches to compulsive movements below the level of injury may occur, and the patient and caregiver me interpret this reflex activity as return of function Tactfully explain the reason for the activity and told the patient of the positive use of these reflexes in sexual, bow, and bladder retraining Anti-spasmodic drugs such as baclofen, dantrolene, and tizanidine may help control spasms, botulism toxin injections may be given to treat severe spasticity The return of reflexes after the resolution of spinal shock mean the patient with injury at T6 or higher may develop autonomic dysreflexia I don't know my dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the SNS It involves stimulation of sensory receptors below the level of the injury The intact SNS below the level of injury response to the stimulation with a reflex arteriolar constriction that increases blood pressure The parasympathetic nervous system is unable to directly counteract these responses of the other spinal cord, barrow receptors in the carotid sinus and aorta since the hypertension and stimulate the parasympathetic system, so this causes a decrease in heart rate, but visceral and peripheral vessels do not daily because efferent impulses cannot pass through the injured spinal cord This mostly occurs in the chronic phase after injury The most common precipitating cause of AD is a distended bladder or rectum However any sensory stimulation including contraction of the bladder or rectum, stimulation of the skin, or stimulation of pain receptors can cause it It is a life-threatening condition that requires immediate resolution, and proper identification and elimination of the inciting stimulus can resolve the event, and if uncorrected it can lead to status epilepticus, stroke, myocardial infarction, and even death Manifestations include hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia 30 to 40 bpm, piloerection from pilomotor spasm, Flushing of the skin above the level of injury, blurred vision or spot in visual field, nasal congestion, anxiety, and nausea Measure of the blood pressure when a patient reports headache, and suspect it in adults with systolic blood pressure elevation of 20 to 40 above baseline IMMEDIATE nursing interventions include elevating the head of the bed 45° or sitting the patient upright to lower the blood pressure, and determining the cars either from bowel impaction, urinary retention, UTI, pressure injury, or tight clothing, and notify the healthcare provider The most common causes water irritation, so immediate catheterization to relieve bladder distention may be needed, and still lidocaine jelly in the urethra before catheterization, and if a catheter is already in place, check it for kinks or folds If it is plugged, perform small volume irrigation slowly and gently to open the catheter or insert a new catheter Stool impaction can cause it, so apply an anesthetic ointment to avoid increasing symptoms, then perform a digital rectal exam if trained Remove all skins stimuli, such as constrictive clothing and take shoes, and monitor blood pressure often during the episode If symptoms persist after the source has been relieved, give a rapid onset and short duration agent such as nitroglycerin, nitroprusside, or hydralazine, and carefully continue to monitor until vital signs stablize many of the problems that began in the acute period become chronic and continue throughout life, rehab focuses on retraining physiological processes as well as extensive patient and caregiver teaching about how to manage the physiologic and life changes resulting from SCI Rehab care is organized around the patient's goals and needs, the patient is expected to be involved in therapies and learn self-care, progress maybe slow, and the rehab nurse has a key role in providing encouragement, specialize in nursing care, and patient and caregiver teaching The patient may need chest percussion or postural drainage to manage secretions to lower the risk for atelectasis and pneumonia Some patience with high cervical SC I have a crew respiratory function with phrenic nerve stimulator's or electronic diaphragmatic pacemakers Some ventilators are portable, allowing ventilator dependent patients with tetraplegia to be mobile and less dependent If the patient was weaned from the ventilator during hospitalization, downsizing or gradually decreasing in size and removal of tracheostomy will be done during rehab Teach assisted coughing, regular use of incidence perimetry, and breathing exercises to the patient who is not ventilator dependent They should limit exposure to persons with fever, cold, and cough, and it here to swallow precautions such as proper positioning of the head and neck and diet recommendations to prevent aspiration THE PATIENT WITH UNILATERAL LUNG DISEASE SUCH AS PNEUMOTHORAX, ATELECTASIS, OR PNEUMONIA OF ONE LUNG SHOULD BE POSITIONED IN A MANNER TO PROMOTE PERFUSION OF THE HEALTHY LUNGS AND IMPROVE OXYGENATION IN MOST CASES, POSITION THE PATIENT WITH THE GOOD LUNG DOWN IN THE PRESENCE OF PULMONARY ABSCESS OR HEMORRHAGE, POSITION THE PATIENT WITH THE AFFECTED LUNG DOWN TO PREVENT DRAINAGE TOWARD THE HEALTHY LUNG FOR BILATERAL LUNG DISEASE, THE BEST POSITION DEPENDS ON THE SEVERITY OF THE DISEASE After the patient's overall condition is stable and assessment she was return of neurologic reflexes, urodynamic testing and a urine culture may be done The goal is to improve quality of life and safety through preserving renal function, minimizing UTI and bladder stones, and developing a plan for urinary continence Various drugs can be used to treat patients with a neurogenic bladder Anticholinergic drugs such as oxybutynin, and tolterodine maybe used to suppress a bladder contraction Hey adrenergic blockers such as terazosin and doxazosin can relax the urethral sphincter Anti-sposmadic drugs such as baclofen may decrease spasticity of pelvic floor muscles and botulinum toxin is an effective alternative in patients with neurogenic detrusor overactivity who cannot tolerate or had an inadequate response to anticholingeric drugs Numerous drainage methods are possible, which include bladder reflex training if partial voiding control remains, and welling catheters, CIC, and external catheters or condom catheters The I wait long-term use of indwelling catheters because of the associated high incidents of CAUTI, fistula formation, and diverticula Patient with a dwelling catheters need to have adequate fluid intake of at least 3 to 4 L/day Regularly check the patency of the catheter CIC is recommended as the first line option for bladder management Nursing assessment is important in selecting the time interval between catheterizations, at first, catheterization is done every four hours Measure bladder volume before catheterization using a bladder ultrasound machine If less than 200 mL of urine is present, the time interval until catheterization may be extended If more than 500 mL of urine is present, the time interval of shortened CRC is usually done 4 to 6 times daily Suprapubic catheter's are safe option and select patients Urinary diversion surgery for the treatment of recurrent UTI patient with renal involvement or repeated stones may be needed Surgical treatment of neurogenic bladder includes bladder neck revision or sphincterotomy, bladder augmentation or augmentation sister plasty, perineal urostomy, cystotomy, vesicostomy, and anterior urethral transplant Placement of a circle cord stimulator, penile prosthesis, or artificial sphincter is possible Usual measures for preventing constipation include high fiber diet and adequate fluid intake These measures may not be adequate to simulate evacuation suppositories like duplex or glycerin or smaller volume enemas and digital stimulation down 20 to 30 minutes after suppository by the nurse may be needed In the patient with upper motor neuron injury, digital stimulation can relax the external sphincter to promote the vacation since they have spasticity Install software, such as docusate or coolies can help regulate store, but oral stimulant laxative should be used only if absolutely necessary and not on a regular basis Valsalva maneuver in manual stimulation are useful in patients with lower motor neuron injuries because they have flaccidity Because the Valsalva maneuver requires intact abdominal muscles, it is used in patients with injuries below T 12 In general, a bowel movement every other day is considered adequate, however considered pre-injury patterns, and fecal incontinence can result from too much stool softener or a fecal impaction Timing of defecation is important, so plan for defecation for 30 to 60 minutes after the first meal of the day to enhance success by taking advantage of the Gastro colic reflex induced by eating This reflex by also be stimulated by drinking a warm beverage right after a meal Discuss timing of the bowel program among the professional team so that there are no interruptions when the patient is doing therapy Spasticity can be both beneficial and undesirable It is with mobility, especially for the patient with incomplete SCI Specificity improve circulation by promoting venous return, decreasing orthostatic hypotension and the risk for VTE Unfortunately, the patient with marked spasticity and tone may have difficulty with positioning and mobility from spasms, spasms can cause significant pain and make activities of daily living difficult Treatment includes range of motion exercises to prevent muscle and joint tightness and reduce the risk for contractures, anti-spasmodic drugs such as baclofen or tizanidine, or botulinum toxin injections for specific muscle involvement Chronic pain can result from overuse of muscles in the shoulders and arms for movement and repositioning Pain often disrupts sleep so assessed, evaluate, and treat pain routinely Use analgesics and interventions such as massage and repositioning to help the patient during therapy Alternative method of obtaining sexual satisfaction such as oral general six maybe suggestion, explicit films may help, such as filming showing sexual activities of a patient with paraplegic and a nondisabled partner, but use graphics cautiously because they may focus too much on the mechanics of sex rather than on the relationship Men normally have two types of directions, psycho genic and reflex Psychogenic Erection begins in the brain with sexual thoughts Men with low level in complete injuries are more likely to have psycho genic erection than men with higher level incomplete injuries When was complete injuries are less likely to have psycho genic erection A reflex erection occurs with direct physical contact to the penis or other erotic areas The short-lived, uncontrolled, erection is involuntary and does not require sexually stimulating thoughts Most men with SCI can have a reflex erection with physical stimulation Phosphodiesterase inhibitors such as sildenafil or Viagra have become the first line treatment and men with SCI between T6 and L5 Sexual stimulation is needed to get an erection after taking the medication Penile injection of vasoactive substances such as papaverine, alprostadil, or a combination is another medical treatment Risk includes scarring, bruising, and infection and use may lead to priapism Vacuum suction device is used negative pressure to encourage blood flow into the penis, indirection is maintained by construction band placed at the base of the penis The main surgical option is implantation of a penile prosthesis SCI affects male fertility, causing poor sperm mobility and ejaculatory dysfunction Recent advances in methods of sperm retrieval include Pinot vibratory stimulation and rectal probe electroejaculation Surgical removal of sperm is the last resort for sperm retrieval Women of childbearing age with SCI usually stays fertile, and the injury does not affect the ability to become pregnant or deliver normally through the birth canal Menses may cease for as long as six months after injury If sexual activity is resume, protection against unplanned pregnancy is needed Pregnancy is associated with increased risk for diabetes and UTI and higher rates of autonomic dysreflexia, pressure injury, increased specificity, and catheter related issues Labor and delivery have higher rates of complications care should be taken out to dislodge an indwelling catheter during sexual activity A patient with an external catheter should refrain from fluids and remove the catheter before sexual activity Patients should we talked about the risk for autonomic dysreflexia The bowel program should be included in the morning of sexual activity The woman may need a water soluble lubricant to supplement vagina secretions and ease vagina penetration Depression after SCI is common and disabling Patience with SYMA feeling overwhelming sense of loss, and they may temporally lose control over every day activities as they depend on others for ADLs and for life-sustaining measures pts may feel they are useless and burdens, and at a life stage one independent is of great importance, they may be totally dependent on others The goal of recoveries related to more adjustment than to acceptance I just met implausibility to go on with living with certain limitations Nonacceptance is more predictive of psychological stress, disengagement, denial, fantasy, and dependence on drugs and alcohol When the patient is depressed, be patient SYMPATHY IS NOT HELPFUL Treat the patient as an adult and encourage participation in planning some patients become clinically depressed and may need treatment for depression and evaluation by a psychiatric nurse or psychiatrist is recommended Caregivers need counseling to avoid promoting dependency in the patient through guilt or misplaced sympathy support groups may be helpful Falls are the leading cause of SCI for people 65 and older Daily schedule inspections and UTI prevention measures are critical, regular breast exams for women and prostate cancer screening for men are recommended, heart disease is the most common cause of morbidity and mortality among older adults with SCI, the lack of sensation, including chest pain, and persons with high-level injuries my mask acute myocardial ischemia, altered autonomic nervous system function and decreases in physical activity can place a patient at risk for heart problems, including hypertension Rehab for the older adult with a SCI may take longer because of pre-existing conditions and poor health status at the time of injury

Cranial Nerve XII

Hypoglossal (tongue movement)

nuchal rigidity

Inability to flex the neck and place the chin on the chest presence of Kernig's and Brudinski's Signs

nystagmus

Involuntary rapid eye movements

Monitoring ICP and Cerebral Oxygenation

ICP should be monitored in pts with a Glasgow Coma Scale (GCS) score of 8 or less and an abnormal CT or MRI these indicate the pt may have bleeding, contusion, edema, or other issues The GOLD standard for monitoring ICP is through ventriculostomy, in which a special catheter is inserted into the lateral ventricle and coupled to an external transducer this directly measures the pressure within the ventricles, facilitates removal and or sampling of CSF, and allows for intraventricular drug admin the transducer is external A reference point for this foramen is the tragus of the ear Every time the pt is repositioned, assess the system to ensure it is level ICP is represented on the monitor as a mean pressure in millimeters of mercury FACSF drainage device is in place, the drain must be closed for at least six minutes to ensure an accurate reading Record the wave form strip along with other pressure monitoring waveforms The normal ICP waveform has 3 phases Is important to monitor the ICP waveform in the mean CPP When ICP is normal, P1, P2, and P3 resemble a staircase going from top to bottom As ICP increases, P2 rises above P1 This indicates poor ventricular compliance IMMEDIATELY report to the healthcare provider any ICP elevation, either as a mean increase in pressure or as an abnormal waveform configuration P1 is the percussion wave and it represents arterial pulsations Normally the highest of the 3 wave forms P2 is the rebound wave or the tidal wave and it reflects intracranial compliance or relative brain volume When P2 is higher than P1, intracranial compliance is compromised P3 is the dicrotic wave and it follows the dicrotic notch and represents venous pulsations It is normally the lowest wave form Inaccurate ICP readings can be caused by CSF leaks around the monitoring device, obstruction of the intraventricular catheter from tissue or a blood clot, a difference between the height of the catheter and the transducer, kinks in the doing, and incorrect height of the drainage system relative to the patient's reference point Bubbles or air in the tubing can dampen the wave form Infections of serious complication with ICP monitoring and factors that contribute to infection include ICP monitoring for more than five days, use of a ventriculostomy, CSF leak, and a concurrent systemic infection Routinely assess the insertion site, use aseptic technique, and monitor the CSF for a change in drainage color or clarity With the ventricular catheter, it is possible to control ICP by removing CSF They are typically orders a special level at which to start drainage and the frequency of drainage When the ICP is above the indicated level, the system is opened by turning a stopcock in allowing the drainage of CSF, that's relieving pressure inside the cranial vault Although CSF removal decreases ICP in improve CPP, there are no universal guidelines for CSF removal The two options for CSF drainage are in a minute or continuous Drainage is used, open the system at the indicated ICP and allow CSF to drain for 2 to 3 minutes Then closest Alcock to return the ventriculostomy to a closed system If continuous ICP drainage is ordered, carefully monitor the volume of CSF drained Keep in mind that normal CSF production is about 20 to 30 mL/hr There's a total CSF volume of about 150 mL within the ventricles and subarachnoid space Post to sign above the patient's bed to notify anyone before turning, moving, or suctioning the patient to prevent the removal of too much CSF, which can result in other complications Complications include ventricular collapse, infection, and herniation or sub dural hematoma formation from rapid decompression Strict aseptic technique during dressing changes or sampling of CSF is crucial to prevent infection and the system must stay intact to ensure that the ICP readings are accurate because treatment is based on the pressures Cerebral oxygenation monitoring These systems provide continuous monitoring of the pressure of oxygen in brain tissue Normal range for PBT 02 is 20 to 40 a low PBT O2 level indicates ischemia These catheters can also measure brain temperature Cooler brain temperature such as 96.8 may produce better outcomes Jugular venous oxygen saturation which indicates turtle Venus brain tissue extraction of oxygen is a measure of cerebral oxygen supply and demand The normal SJVO2 range is 60 to 75% Values less than 50% indicate impaired cerebral oxygenation which indicate the brain using excess oxygen from anoxia

Bell's Palsy Diagnostics

Is a clinical diagnosis No definitive diagnostic test exist Current guidelines do not support routine labs, imaging, or neuropsychological testing at first presentation If indicated, MRI and CT can eliminate other causes for facial paralysis Blood tests can diagnose infections or other diseases Electromyography (EMG) can confirm the presence of nerve damage, and patients should be referred to a neurologist or otolaryngologist as soon as possible to exclude other neurologic conditions

Cranial Nerve III

Oculomotor (eye movement)

Cranial Nerve I

Olfactory (smell)

Cranial Nerve II

Optic (vision)

CSF

PROTEIN UP GLUCOSE DECREASED IN MENINGITIS

Encephalitis Nursing Care

Prevention of encephalitis focuses on mosquito control Measures including cleaning rain gutters, removing all tires, draining bird baths, and removing water where mosquitoes can breed Insect repellent should be used during mosquito season Care is symptomatic and supportive Acyclovir ear is used to treat encephalitis caused by HSV Its use reduces mortality rates, although neurologic complications may still occur For maximum benefit, treatment should start before the onset of coma Treat seizure disorders with anti-seizure drugs and prophylactic treatment with antiseizure drugs may be used in severe cases of encephalitis

Kernig's Sign

Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip/knee is flexed to 90 degrees in meningitis

Trigeminal Neuralgia (TN) Manifestations

The first episode of TN in a sudden with a memorable onset In TN 1, the patient has an abrupt onset of waves of excruciating pain, it is described as a burning, nightlight, or lightning like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose Facial twitching, grimacing, and frequent blinking and tearing of the eye can occur during the acute attack giving rise to the term tic douloureax Some patience we have facial sensory loss Attacks are usually brief, lasting only seconds to 2 to 3 minutes, and frequency ranges from 1 to over 50 times a day Pain episodes are usually started by a triggering mechanism of light touch at a specific point or trigger zone along the distribution of the nerve branches Precipitating stimuli include chewing, brushing the teeth, feeling a hot or cold glass of beer on the face, washing the face, yawning, or even talking As a result, the patient may eat in properly, neglect hygienic practices, wear a cloth over the face, and withdraw from interaction with others The patient me sleep excessively as a means of coping with the pain TN 2 manifests as chronic constant aching, burning, crushing, or stabbing pain The pain has a lower intensity and does not subside completely The distinct attacks associated with TN 1 do not occur into TN 2

Increased intracranial pressure nursing care

The underlying cause of increased ICP is usually an increase in blood from hemorrhage, brain tissue from tumor or edema, or CSF from hydrocephalus in the brain For any patient with increased ICP, it is important to maintain adequate oxygenation to support brain function and prevent secondary injury An endotracheal tube or tracheostomy may be needed to maintain adequate ventilation Arterial blood gas analysis guides oxygen therapy The goal is to maintain the PaO2 at 100 or greater and to keep PaCO2 in normal range of 35 to 45 The patient may need to be on a mechanical ventilator to ensure adequate oxygenation If increased ICP is caused by mass legion such as a tumor or a hematoma, surgical removal of the mass is the best treatment In aggressive situations, a craniectomy or removal of part of the skull may be done to reduce ICP and prevent herniation Drugs Mannitol is an osmotic diuretic given IV Minnesota decreases ICP in two ways Plasma expansion and osmotic affect The media plasma expanding affect reduces the hematocrit and blood viscosity This increases CBF and cerebral oxygen delivery A vascular osmotic gradient is created by mannitol Those fluid moves from the tissues into the blood vessels, reducing the ICP because of the decrease in the total brain fluid content Mannitol may be contraindicated if renal disease is present and serum osmolality is increased Hypertonic saline produces massive movement of water out of a demon to swollen brain cells and into blood vessels This movement can reduce swelling and improve CBF Care during an infusion includes frequent monitoring of blood pressure and serum sodium levels because intravascular fluid volume excess can occur Corticosteroids are used to treat vasogenic edema around tumors and abscesses These drugs are not recommended for TBI Corticosteroid stabilize the cell membrane and inhibit the synthesis of prostaglandins, preventing the formation of pro-inflammatory mediators Corticosteroids also improve neuronal function by improving CBF and restoring autoregulation Complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and G.I. bleeding Regularly monitor fluid intake and sodium levels and perform BG monitoring at least every six hours Patient receiving corticosteroid should receive an acid, histamine receptor blockers, or proton pump inhibitors to prevent G.I. ulcers and bleeding cemetidine and ranitidine are H2 receptor blockers and pantoprazole is a PPI Ivy 0.9% sodium chloride is the preferred solution for giving secondary medication's If 5% dextrose in water or 0.45% sodium chloride is used, serum osmolality decreases and an increase in cerebral edema may occur Metabolic demands, such as fever greater than 100.4, agitation or shivering, pain, and seizures can increase ICP Implement measures to reduce the smell bog demands to lower the ICP in the at risk patient Monitor patient's for seizure activity, as they may need prophylactic anti-seizure medication Maintain the temperature at 96.8 to 98.6 by using antipyretics such as Tylenol, cool bass, cooling blanket, ice packs, or intravascular cooling devices as needed Avoid letting the patient shiver Shea, since this increase is the metabolic workload on the brain and if this occurs, the patient may need sedatives or a different cooling method Reducing the metabolic rate decreases the CBF and therefore the ICP High doses of barbiturates such as phenobarbital, or theopintal are used in patients with increased ICP refractory to other treatments Burbage you watch decree cerebral metabolism, causing a decrease in ICP and a reduction in cerebral edema What does treatment, monitor the patient ICP, blood flow, and EEG Orbiter adducing is typically based on analysis of the bedside EEG tracing and the ICP VHEP orders the garbage with infusion at a rate that achieve the desired level of brainwave suppression to control ICP Total burst suppression, recognized by the absence of spikes showing brain activity on the EEG monitor, shows that maximal therapeutic affect has been achieved Nutritional therapy Because my nutrition promotes continued cerebral edema, maintaining optimal nutrition is important The patient with increased ICP is in a hypermetabolic and hyper catabolic state that increases the need for glucose as fuel for metabolism of the injured brain If the patient cannot maintain adequate oral intake, other means of meeting nutritional requirements, such as enteral feedings or parenteral nutrition should be started Early feeding after brain injury may improve patient outcomes and nutritional replacement should begin within 3 days after injury and reach full nutritional replacement within 7 days after injury The patient is fluid and electrolyte status and metabolic needs should be used as guides for feedings or supplements The patient should be kept in a euvolemic fluid state Continuously evaluate the patient based on clinical factors such as your an output, insensible fluid loss, serum and urine osmolality, and serum electrolytes The total GCS score is the sum of the numeric values assigned to each of the 3 areas The highest GCS score is 15 for a fully alert person, and the lowest possible score is a 3 GCS score of eight or last generally indicates,, and mechanical ventilation should be considered Although the GCS is the GOLD standard assessment tool for level of consciousness other scales can be used In cases of stroke or hemorrhage associated with increased ICP, use the NIH stroke scale If the oculomotor nerve or cranial nerve three is compress, the people on the affected side or ipsilateral becomes larger until it fully dilates If ICP continues to increase, both pupils dilate Test pupillary reaction with a pen light The normal reaction is a bridge construction when the light is shone directly into the eye Noah consensual response or slight constriction in the opposite people at the same time Sluggish reaction can indicate early pressure on cranial nerve III Fix pupils unresponsive to light stimulus usually indicates increased ICP and coma Note that there are other causes of a fix people, including direct injury to cranial nerve III, previous eye surgery, atropine administration, and use of mydriatic eyedrops Assess iMovie is controlled by cranial nerve three, cranial nerve four, and cranial nerve six and the patient who is awake and able to follow commands They can be used to assess brainstem function Testing the corneal reflex gives information about the functioning of cranial nerve five and cranial nerve seven If this reflects is absent, start routine eye care to prevent corneal abrasion eye movements of the uncooperative or unconscious patient can be elicited by reflects with the use of head movements To test the oculocephalic reflex or dolls eye reflex, turn the patients head briskly while holding the eyelids open A normal response is movement of the eyes across the midline in the direction opposite of the turning Next, quickly flex in the next in the neck I move it should be opposite to the direction of head movement, up when the next flex, and down when it's extended These responses can help locating intracranial lesion, and this test should not be done at the cervical spine problem is suspected To test the ocular vestibular reflex or cold caloric, the patient is positioned with the head of the bed elevated A syringe of ice cold water is instilled into the external auditory ear canal in the patient's eyes are assessed for a total of one minute The absence of eye movement or response indicate severe neurologic demise and this test requires patent external auditory canal's and tympanic membranes Text motor strength by asking the awake and cooperative patient to squeeze your hands to compare strength in the hands The printer drift test is an excellent measure of strength in the upper extremities The patient raises the arms in front of the body with the palms facing upward and eyes closed If there is any weakness in the upper extremity, the palmar surface turns downward in the arm drifts down This would indicate a problem in the opposite motor cortex Ask the patient to raise the foot from the bed or to bend the knee up in bed is a good assessment of lower extremity strength Test offer extremities for strength and for any asymmetry in strength or movement Assess the motor response of the unconscious or uncooperative patient by observation of spontaneous movement If no spontaneous movement as possible, apply a pain stimulus to the patient and note the response Resistance to movement during passive range of motion exercises another measure of strength Do not include hand squeezing as part of the assessment of motor movement in the unconscious or uncooperative patient, since this is a reflex action and can misinterpret the patient status Record vital signs, and be aware of Cushing's Triad, which indicates severely increased ICP Maintaining a patent airway is critical in a patient with increased ICP and is a major nursing responsibility As a level conscious decreases, the patient is at an increased risk for airway obstruction from the tongue dropping back and occluding the airway or from accumulation of secretions Snoring sounds indicate obstruction and require immediate intervention Remove accumulated secretions by suctioning as needed An oral airway facilitates breathing and provides an easier suctioning route in the comatose patient In general, any patient with a GCS of 8 or less or an altered level of consciousness who is unable to maintain a patent airway or affect the ventilation is intubation and mechanical ventilation Frequently monitor and evaluate ABGs Prevent hypoxia and hypercapnia to minimize secondary injury Suctioning and coughing cause transient decreases in the PaO2 and increases in the ICP Keep suctioning to a minimum and less than 10 seconds in duration Give 100% oxygen before and after to prevent decreases in the PaO2 To avoid cumulative increases in the ICP with suction income limit suctioning to two passes per section procedure if possible Patient with increased ICP are at an increased risk for a lower CPP during suctioning from increased resistance Try to prevent abdominal distention, since it can interfere with respiratory function Inserting a nasogastric tube to aspirate the stomach contents can prevent distention, vomiting, and aspiration However, in patients with facial and skull fractures, and NG tube is it contraindicated due to risk for inadvertent intracranial placement Oral insertion of a gastric tube is preferred Pain from anxiety, and fear related to the primary injury, therapeutic procedures, or noxious stimuli can increase ICP in blood pressure, thus complicating the patient's management in recovery The appropriate choice or combination of sedatives, paralytics, and analgesics for symptom management is a challenge and giving these agents me alter the neurologic state, thus making more true neurologic changes Opioids, such as morphine and fentanyl, or rapid onset analgesics with minimal affect on CBF or oxygen metabolism The IV sedative propofol is used to manage anxiety and agitation in the ICU because if it's rapid onset and short half-life An accurate neurological assessment can be done soon after stopping in infusion of propofol Dexmedetomidine, an A2 adrenergic agonist, is used for continuous IV sedation of intubated and mechanically ventilated patients in the ICU setting for up to 24 hours When using continuous IV sedatives, be aware of the side effects of these drugs, especially hypotension since this can lower CPP Non-depolarizing neuromuscular blocking agents such as vecuronium, and C besylate are useful for achieving complete ventilatory control in the treatment of refractory intracranial hypertension Because these agents paralyze muscles without blocking pain or noxious stimuli, they are used in combination with sedatives, analgesics, or benzodiazepines Benzodiazepines, although useful for sedation, are usually avoided in the managing the patient with increased ICP because of the hypotensive affect and long half-life They are usually given as an adjunct to neuromuscular blocking agents The patient should be in a quiet, calm environment with minimal noise or interruptions Observe the patient for signs of agitation, irritation, or frustration Teach the caregiver and family about decreasing stimulation, and coordinate with team members to minimize procedures that may cause agitation closely monitor fluid and electrolytes, and taken output, insensible losses, and daily weights Especially monitor glucose, sodium, potassium, magnesium, and osmolality Monitor your an output to detect problems related to diabetes insipidus or SIADH Diabetes insipidus is caused by a decrease in ADH and results in increased urine output and hypernatremia The usual treatment for diabetes insipidus is fluid replacement, vasopressin, or desmopressin and if it is not treated, severe dehydration will occur SIADH is caused by excess of creation of ADH SIADH result in decreased you're not put and illusional hyponatremia, and it may result in cerebral edema, changes in level of consciousness, seizures, and coma Suctioning, hypoxemia, and arousal from sleep or factors that can increase ICP Be alert to these factors and try to minimize them Increased intrathoracic pressure can increase ICP by impeding the venous return, so coughing, straining, sneezing, and the Valsalva maneuver should be avoided Proper positioning is important Maintain the patient with increased ICP in the head up position Keep the head and midline, avoiding extreme neck flexion Flexion cause Venus obstruction and contribute to increased ICP Adjust the body position to decrease ICP and improve CPP Elevating the head of the bed promotes drainage from the head and decreases the vascular congestion that can produce cerebral edema However, raising the head of the bed above 30° my decrease CPP by lowering systemic blood pressure Carefully evaluate the effects of elevating the head of the bed on both ICP in CPP and position in the bed so that it lowers the ICP well optimizing the CPP and other indices of cerebral oxygenation Take care to turn the patient was slow, gentle movements Rapid change in position may increase ICP Prevent discomfort when turning in positioning the patient because painter agitation increases pressure Avoid extreme hip flexion to decrease the risk for raising the intra-abdominal pressure which increases ICP Decorticate or decerebrate posturing is a reflex response and some patient with increased ICP Turning, skin care, and even passive range of motion can elicit these posturing reflexes Provide the physical care to minimize complications of immobility, such as atelectasis and contractures Turn the patient at least every 2 hours The patient with increased ICP and decreased level of consciousness needs protection from self injury Confusion, agitation, and the possibility of seizures increases the risk for injury Use restraints judiciously in the agitated patient and if restraints are necessary to keep the patient from removing tubes or falling out of bed, they should be secure enough to be effective Observe skin under the restaurant regularly for irritation Agitation mean increase with the use of a strange, which indicates the need for other measures to protect the patient from injury What sedation with sedative Agent may be needed and having a family member stay with the patient may have a calming affect For the patient with seizures, or the patient at risk for such activity, institute seizure precautions These include padded side rails, and Ambu bag at the bedside, readily available suction, accurate and timely administration of anti-seizure drugs, and close observation Anti-seizure prophylaxis against early seizures within the first 7 to 10 days is recommended in severe brain injury The patient can benefit from a quiet, non-stimulating environment and always use a calm, reassuring approach Touch and talk to the patient, even when he was in a coma Short, simply explanations are appropriate and allow the patient and caregiver to acquire the amount of information they desire

Brain Tumors Nursing Care

Treatment goals are aimed at identifying the tumor type and location, removing or decreasing tumor mass, and preventing or managing increased ICP Surgical removal is the preferred treatment for brain tumors Stereotactic surgical techniques are used with greater frequency to perform a biopsy and remove small brain tumors Meningiomas and oligodendroglioma's are usually completely removed The more invasive gliomas and medulloblastoma can only be partially removed Computer guided stereotactic biopsy and ultrasound, fMRI, and cortical mapping can localize brain tumors during surgery Complete surgical removal of brain tumors is not always possible because the tumor is not always accessible or may involve vital parts of the brain Surgery can reduce tumor size., which decreases ICP, provide relief of symptoms, and extends survival time Hydrocephalus due to a tumor obstructing the CSF flow can be treated with the placement of a ventricular shunt A catheter with one-way valve is placed on the lateral ventricle and then tunnel under the skin to drain CSF into the peritoneal cavity Rapid decompression of ICP can cost total body collapse and weakness Headache may be prevented by gradually introducing the patient to the upright position Manifestations of short malfunction, which are related to increased ICP, include decreasing LLC, restlessness, headache, blurred vision, or vomiting Is may require shunt revision or replacement and infection may occur, as exhibited by high fever, persistent headache, and stiff neck Antibiotics are used to treat infection and in some situations, the shunt may need to be replaced CSF drainage is managed with an extra ventricular drainage system while the infection is treated Radiation therapy and stereotactic radiosurgery Radiation therapy maybe used as a follow up measure after surgery radiation seeds can be implanted into the brain Cerebral edema and rapidly increasing ICP may be a complication of radiation therapy in these problems can be managed with high doses of corticosteroids Stereotactic radiosurgery as a method of delivering a highly concentrated dose of radiation to a precise location within the brain Stereotactic radiosurgery maybe used when conventional surgery has failed and or is not an option because of to my location The effectiveness of chemotherapy has been limited by the difficulty with getting drugs across the blood brain barrier, tumor cell heterogeneity, and tumor cell drug resistance Chemotherapy drugs called nitro-soureas such as carmustine, or lomustine are used to treat brain tumors Normally the blood brain barrier prohibits the entry of most drugs into the brain but cancer can cause a breakdown of the blood brain barrier in the areas of the tumor, thus allowing chemotherapy agents to be used to treat cancer Chemotherapy laden biodegradable wafers implanted at the time of surgery can deliver chemotherapy directly to the tumor site Other drugs being used include methotrexate and procarbazine When we used to deliver chemotherapy directly into the CNS is intrathecal administration Temozolomide is an oral chemotherapy agent they can cross the blood brain barrier and in contrast with many chemotherapy drugs, which require metabolic activation to exert their effects, temozolomide can convert spontaneously to a reactive agent that directly interferes with tumor growth It is not interact with other come and drugs taken by patience with brain tumors such as anti-seize or drugs, corticosteroids, and anti-emetics Destruction caused myelosuppression so before using, the absolute neutrophil count should be over 1500 and platelet count should be over 100,000 To reduce nausea and vomiting, take on an empty stomach or a bedtime Bevacizumab is used to treat patients with glioblastoma that continues to progress after standard therapy Is a target in therapy that inhibits the action of vascular endothelial growth factor, which helps form new blood vessels These vessels can feed a tumor, helping it to grow, and provide a pathway for cancer cells to circulate in the body Other therapies include electros that are placed on the service of the patient scalp to deliver low intensity, changing electrical fields called tumor treatment fields to the tumor site Assess for a history of nervous system infections and trauma A tumor of the frontal lobe can cause behavior and personality changes Lots of emotional control, confusion, disorientation, memory loss, impulsivity, and depression may be signs of a frontal lobe lesion The patient often does not receive these changes and they can't be disturbing in frightening to the caregiver and family These changes can also cause of distancing to occur between the family and the patient Confused patient with behavioral instability can be a challenge and protecting the patient from self harm is an important part of nursing care Essential interventions include close supervision of activity, use of side rails, judicious use of restraint, appropriate sedatives, padding of the rails in the area around the bed, and calm reassuring approach Perceptual problems associated with frontal and parietal lobe tumors contribute to a patient's disorientation and confusion Minimize environmental stimuli, create a routine, and use reality orientation for the confused patient Tumors in the temporal lobe can cause hallucinations, which may be confused with dementia or delirium Seizures which often occur with brain tumors, are managed with anti-seizer drugs Use seizure precautions for the patient protection some behavioral changes seen in the patient or a result of seizure disorders and can improve with adequate seizure control Patients at risk procedures may be unable to drive, so be aware of the extra resources needed and collaborate with the social worker and family Motor and sensory dysfunctions interfere with activities of daily living Encourage the patient to provide as much self-care as physically possible Self image often depends on the patient's ability to take part in care within the limitations of the physical deficits Language deficits may be present Motor or expressive or sensory or receptive dysphagia may occur The problem with communication can be frustrating for the patient and may interfere with your ability to meet the patients needs Try to establish a communication system that both the patient and staff can use Nutritional intake may be decreased because of the patients inability to eat, loss of appetite, or loss of desire to eat Asses nutritional status and ensure adequate nutritional intake Encourage the patient to eat and some patients may need intro or parenteral nutrition

Cranial Nerve V

Trigeminal (chewing face & mouth touch & pain)

Cranial Nerve IV

Trochlear (eye movement/motor)

Cranial Nerve X

Vagus (PSNS and gag, tested with CN IX)

Cranial Nerve VIII

Vestibulocochlear (hearing and balance)

Head Injury Nursing Care

a pt with a head injury always has an increased risk for increased ICP use GCS to assess LOC determine if CSF leakage is present use appropriate interventions for the pt stay afebrile the best way to prevent head injury is to wear protection while driving and teach driver safety general nursing care during the acute phase is to maintain cerebral oxygenation and perfusion and prevent secondary cerebral ischemia from edema, hemorrhage, or infection the pt may deteriorate rapidly behavioral s/s with head injury can result in a frightened, disoriented pt who is combative approach them calmly and gently a family member may be available to stay with the pt to decrease anxiety report any s/s of deteriorating LOC major focus of nursing care is managing increased ICP eye problems may include loss of corneal reflex, periorbtial edema and bruising, and diplopia loss of the corneal reflex may require lubricating eye drops or taping the eyes shut to prevent abrasion Periorbital bruising and edema decrease with time Cold and later warm compresses provide comfort and hasten the process Wearing an eyepatch can relieve diplopia Consider a consult with an ophthalmologist Fever may occur from injury to or inflammation of the hypothalamus Fever can cause increased CBF, cerebral blood volume, and ICP Increased metabolism from fever increases metabolic waste, which in turn causes further cerebral vasodilation Avoid fever with a goal of a temperature of 96.8 to 98.6 Use interventions to reduce temperature as previously discussed If CSF rhinorrhea or otorrhea occurs come in for a healthcare provider at once The head of the bed may be raised to decree CSF pressure so that a tear can seal Loose collection pad may be placed under the nose or over the ear Document the amount of drainage each shift Teach the patient not to sneeze or blow their nose Do not use in NG-tubes Do not perform nasotracheal suctioning on these patients because of a higher risk for meningitis Nursing measure specific to the care of the immobilize patient such as those related to bladder and bowel function, skin care, and infection are needed Nausea and vomiting may be a problem and can be relieved by anti-emetic drugs Hey can usually be controlled with acetaminophen or small doses of Codeine If the patient's condition deteriorates, intracranial surgery may be needed A burr hole opening or craniotomy may be done, depending on the other line injury that is causing the problem Emergency nature of the surgery may hasten the usual preoperative prep The patient is often unconscious before surgery, making it necessary for a family member to sign the consent form for surgery This is a difficult in frightening time for the patient's caregiver and family and requires sensitive nursing management The sons of the situation makes it especially hard for the family to cope Use a team approach to help the patient and family through the hospital and recovery time Ambulatory care Nutrition problems, bowel and bladder problems, spasticity, dysphagia, and hydrocephalus maybe conditions that need nursing management Mini of the principles for managing the patient with a stroke or appropriate for these patients Seizure disorders may occur in patients with non-penetrating head injury Seizures may develop during the first week after the head injury or not until years later Antiseizure drugs maybe used prophylactically to manage post traumatic seizure activity, but this practice is controversial The mental and emotional sequelae are often the most incapacitating problems What are the consequences of TBI is at the person may not realize that a brain injury has occurred Mini patient with her injuries who were comatose for more than six hours undergo some personality change and may have a loss of concentration in memory and deffective memory processing Personal drive me decrease, apathy may increase, and euphoria and mood swings along with assuming lack of awareness of the seriousness of the injury may occur The patient behavior may indicate a loss of social restraint, judgment, tact, and emotional control The patients outwards physical appearance does not necessarily reflect what has happened in the brain it is not a good indicator of how well the patient will ultimately function in the home or work environment Give the family special consideration as they need to understand what is happening Provide guidance and referrals and help the family and involving the patient and family activities whenever possible Hope the patient in family remain hopeful and try to talk with the family as they often have unrealistic expectations of the patient has the coma begins to recede The family expects full return to pre-trauma status In reality the patient usually has reduced awareness and ability to interpret environmental stimuli Prepare the family for the patient emergence from, and explain that the process of awakening often take several weeks Include no drinking of alcoholic beverages, no driving, no use of firearms, no working with hazardous implements and machinery, and no unsupervised smoking in the discharge planning

Brain Abscess

accumulation of pus within the brain tissue from a local or systemic infection direct extension from an ear, tooth, mastoid, or sinus infection is the main cause Other causes for brain abscess formation include spread from a distance site such as from pulmonary infection, or bacterial endocarditis, skull fractures, and prior brain trauma or surgery Streptococci and staphylococcus aureus are the most common infective of organisms Manifestations are similar to those of meningitis and encephalitis and include headache, fever, and nausea and vomiting Size of increased ICP may include drowsiness, confusion, and seizures focal symptoms may reflect the local area of abscess For example, visual field defects or psycho motor seizures are common with temporal lobe abscesses, and visual impairment and hallucinations may accompany an occipital lobe abscess CT and MRI are used to diagnose a brain abscess Antimicrobial therapy is the primary treatment for brain abscess, other manifestations are treated symptomatically If your therapy is not effective, the abscess may have to be drained or removed if it is encapsulated Nursing measures are similar to those for management of meningitis or increased ICP If surgical drainage or removal is the treatment of choice, nursing care similar to that of a patient having cranial surgery

Bitemproal hemianopsia

bilateral peripheral vision is affected

hemianopsia

blindness in half the visual field

quadrantanopia

blindness of one quadrant (1/4) of the visual field

paraplegia

paralysis from the waist down

Tetraplegia

paralysis of all four limbs

hemiplegia

paralysis of one side of the body

Brain Tumors Manifestations and Complications

A wide range of manifestations are possible Headache is common and tumor related headaches tend to be worse at night and may awaken the patient Headaches are usually dull and constant but sometimes throbbing Seizures are common in gliomas and brain meta-stasis Brain tumors can cause nausea and vomiting from increased ICP Cognitive dysfunction, including memory problems and mood or personality changes, is common, especially in patients with brain meta-stasis Muscle weakness, sensory loss, aphasia, and visual spatial dysfunction may occur If the tumor mass obstructs the ventricles or includes the outlet, ventricular enlargement or hydrocephalus can occur As the brain tumor expands, it may produce manifestations of increased ICP, cerebral edema, or obstruction of the CSF pathways Unless treated, all brain tumors eventually caused death from increasing tumor volume leading to increased ICP Brainstone tumors make cost headache on a weakening, drowsiness, vomiting, ataxic gait, facial muscle weakness, hearing loss, dysphagia, dysarthria come a crossed eyes or visual changes, or hemiparesis Cerebellopontine tumors may cause tinnitus and vertigo or deafness Cerebral hemisphere Frontal lobe tumors may cause unilateral hemiplegia, seizures, memory deficits, personality and judgment changes, and visual changes Parado lube tumors make a speech problems if the tumor is in the dominant hemisphere, inability to write, special disorders, and unilateral neglect Occipital lobe tumors may cause vision changes and seizures Temporal lobe tumors me cause seizures, dysphagia, hallucinations, and auras Cerebellar tumors may cause headache, nausea, papilledema from increased ICP, a taxi gate, and changes and coordination Meningeal tumors cause symptoms associated with compression of the brain and depend on location Metastatic tumor cause headache, nausea, vomiting from increased ICP, and other symptoms depend on the location Sub cortical tumors can cause hemiplegia, and other symptoms may depend on the area of infiltration Thalamus and sellar tumors may cause headache, nausea, vision changes, papilledema, and nystagmus from ICP DI may occur

Cranial Nerve VI

Abducens (motor) PERRLA eye movements and 6 cardinal fields of gaze

Encephalitis

Acute inflammation of the brain, and a serious and sometimes fatal disease It is usually caused by a virus, in many different viruses can cause encephalitis Summer associated with certain seasons of the year or endemic to certain geo areas Text and mosquitoes transmit epidemic encephalitis Non-epidemic encephalitis may occur as a complication of measles, chickenpox, or mumps HSV encephalitis is the most common cause of acute non-epidemic viral encephalitis Cytomegalovirus encephalitis occurs in patients with AIDS

Bell's Palsy

Acute, usually temporary, facial paralysis or palsy resulting from damage or trauma of the facial nerve or cranial nerve VII It usually affects only one side of the face but both sides can be affected Acres equally between men and women and the peak incidence is between ages 15 and 60 There's a high incidence during pregnancy and in person with upper respiratory tract infections such as the flu or cold, obesity, diabetes, and hypertension We do not know the exact cause but some think it is a reactivation of HSV or the herpes zoster virus (shingles) The viral infection causes information, leading to nerve compression and the subsequent clinical features Another cause may be a cute demyelination similar to what happens in Gillian Barre syndrome The prognosis for persons with Bell's palsy is generally very good, and the extent of nerve damage determine the extent of recovery Most begin to get better within two weeks after the onset and recover some or all facial function within 6 months In some cases, there may be residual effects, including facial asymmetry and abnormal facial movements

Trigeminal Neuralgia (TN)

Also called tic douloureux six is characterized by sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of the trigeminal nerve (CN V) it affects more women in occurs most often people over age 50 We classify TN as classic or TN type 1 or a typical or TN type 2 Trigeminal nerve, the fifth cranial nerve has both motor and sensory branches TN most affects the sensory or afferent branches of the second and third division or maxillary and mandibular branches Most cases result from vascular compression of the trigeminal nerve root by abnormal loop of the superior cerebral artery This artery compresses the nerve as it exists the brain stem Constant compression appears to lead to chronic injury, causing flattening and atrophy of the nerve and damage to the myelin sheath

Head Injury Complications

An epidural hematoma results from bleeding between the Dura in the inner surface of the skull An epidural hematoma is a neurologic emergency and it is usually associated with the linear fracture crossing a major artery in the Dura causing a tear Venus epidural hematoma's are associated with a tear of the dural venous sinus and develop slowly What are true hematomas, the middle meningeal artery lying under the temporal lobe is often torn Hemorrhage occurs into the epidural space, which lies between the Dura and the inner surface of the skull Because this is an arterial hemorrhage, the hematoma develops rapidly Classic manifestations of an epidural hematoma include initial period of unconsciousness, with a brief lucid interval followed by a decrease in level of consciousness, headache, nausea and vomiting, or focal findings Rapid surgical intervention to evacuate the hematoma and prevent cerebral herniation, alongside with medical management for increasing ICP, dramatically improves outcomes Sub dural hematoma occurs from bleeding between the Dura Mater and the arachnoid layer of the meninges Sub dural hematoma usually results from injury to the brain tissue and it's blood vessels Because it is usually associated with venous origin, a sub dural hematoma baby slower to develop However in arterial hemorrhage can cause a sub dural hematoma, in which case of develops more rapidly And a cute subdural hematoma manifest within 24 to 48 hours of the injury Signs and symptoms are similar to those associated with brain tissue compression an increased ICP and they include decreasing level of consciousness and headache The patient appearance me range from drowsy and confused unconscious and the ipsilateral pupil dilates it becomes fixed if ICP is significantly increased Blunt force injuries that produce a cute subdural hematoma's make a significant underlying brain injury, resulting in cerebral edema The resulting increase in ICP from the cerebral edema can cause morbidity and mortality A subacute subdural hematoma usually occurs within 2 to 14 days of the injury and after the initial bleeding, this hematoma may appear to enlarge overtime is the breakdown products of the blood draw fluid into the subdural space A chronic subdural hematoma develops over weeks or months after seemingly minor head injury They are more common in older adults because of a potentially larger subdural space from brain atrophy and with atrophy, the brain stays attached to the support of structures and tension is increased This makes it subject to tearing and because the subdural space is larger, the presenting problem is focal symptoms specific to a certain area of the brain rather than signs of increased ICP Patient with a history of alcohol use are prone to sub dural hematoma's because of an increased incidence of falls and increased coagulopathy Diagnosis of a sub dural hematoma in the older adult may be delayed because symptoms mimic other problems such as somnolence, confusion, lethargic, and memory loss The manifestations of a sub dural hematoma are often attributed to a stroke, TIA, or dementia Intracerebral hematoma Intracerebral hematoma occurs from bleeding within the brain tissue It usually happens in the frontal and temporal lobes, possibly from rupture of intracerebral vessels at the site of injury The size and location of the hematoma are key in determining the patient outcome

Brudinkski Sign

An involuntary flexion of the hip and knee when neck is flexed in meningitis part of nuchal rigidity

Increased Intracranial Pressure (ICP)

Any patient who becomes unconscious acutely, regardless of the cars, should be suspected of having increased ICP Increased ICP is a potentially life-threatening situation that results from an increase in any or all three of the components within the school such as the brain tissue, blood, or CSF Increased ICP is clearly significant because it decreases CPP, increases risk for brain ischemia and infarction, and is associated with a poor prognosis Common causes of increased ICP include a mass such as a hematoma, confusion, abscess, or tumor, and cerebral edema from brain tumors, hydrocephalus, head injury, or brain inflammation The cerebral insults may result in hypercapnia, cerebral acidosis, impaired auto regulation, and systemic hypertension, increase the formation and spread of cerebral edema This edema distorts brain tissue, further increasing that ICP, and leads to even more tissue hypoxia and acidosis Is critical to maintain CBF to preserve tissue and thus minimize secondary injury Sustained increase is an ICP result in brainstem compression and herniation of the brain Herniation occurs as the brain tissue is forcibly shifted from the compartment of greater pressure to compartment of lesser pressure Displacement and herniation of brain tissue can cause a potentially reversible process to become irreversible Ischemia and edema are further increase, compounding the pre-existing problem Compression of the brain stem and cranial nerves may be fatal Herniation force is the cerebellum and brainstem downward through the foreman magnum and if compression of the brain stem is unrelieved, respiratory arrest will occur due to compression of the respiratory control center in the medulla In this situation intense pressure is placed on the brain stem and if herniation continues, brainstem death is imminent

Bacterial Meningitis Nursing Care

Bacterial meningitis is a medical emergency Patient is usually in a critical state when healthcare is sought Play meningitis a suspected, antibiotic therapy has begun after the collection of specimens for cultures, even before the diagnosis is confirmed Ampicillin, penicillin, vancomycin, cefuroxime, cefotaxime, ceftriaxone, ceftizoxime, and ceftazidime are the main drugs given to treat bacterial meningitis Dexamethasone may be given before with the first dose of anabiotic's Collaborate with all Cooper butter to manage headache, fever, and nuchal rigidity often associated with meningitis Prevention of respiratory tract infection through vaccination programs for pneumococcal pneumonia and influenza is important Early and vigorous treatment of respiratory tract and ear infections is important Person who had close contact with anyone who has bacterial meningitis should receive prophylactic antibiotics The patient with bacterial meningitis is usually acutely ill Fever is high and head pain is severe Irritation of the cerebral cortex may result in seizures The change in mental status and LLC depend on the degree of increased ICP Assess and record vital signs, Neuro status, fluid intake and output, skin, and lung fields at regular intervals based on the patient's condition Head and neck pain with movement requires attention Coding provides some relief without undue sedation for most patients This is the patient to position of comfort, often curled up with the head slightly extended The head of the bed should be slightly elevated A darkened room and a cool cloth over the eyes relieve the discomfort of photophobia For the patient with delirium, low lighting may decrease hallucinations All patients have some degree of mental distortion and hypersensitivity They may be frightened and misinterpret the environment Make every attempt to minimize environmental stimuli and prevent injury Familiar person at the bedside may have a calming affect have an attitude of caring and unhurried gentleness The use of touch and a soothing voice to give simple explanation of activities is helpful If seizures occur, make appropriate observations antique protective measures Give antiseizure drugs, such as phenytoin or levetiracetam Manage problems associated with increased ICP Fever is vigorously treated because it increases cerebral edema and the risk for seizures Neurological damage may result from an extremely high fever over prolonged time Acetaminophen or aspirin maybe used to reduce fever If the fever is resistant to aspirin or acetaminophen, more vigorous means are needed such as a cooling blanket Take care not to reduce the temperature to rapidly because shivering may result, causing a rebound effect in increasing the temperature and ICP Wrap the extremities in soft towels or a blanket covered with a sheet to reduce shivering If a cooling blanket is not available or desirable, tepid sponge baths with water may be effective in lowering the temperature Protect the skin from excessive drying and injury and prevent breaks in the skin Because I fever increases the metabolic rate and thus insensible fluid loss, assess the patient for dehydration and adequate fluid intake Diaphoresis further increases fluid losses and should be noted on the output Calculate replacement fluids is 800 mL a day for respiratory losses and 100 mL for each degree of temperature above 100.4 Supplemental feeding such as enteral nutrition to maintain adequate nutritional intake may be needed follow the needed ABX schedule to maintain therapeutic blood levels Meningitis generally requires respiratory isolation until the cultures are negative Meningococcal meningitis is highly contagious, while other causes a meningitis may pose minimal to no infection risk with the patient contact However, standard precautions are essential to protect the patient and nurse Ambulatory care In this period, stress the importance of adequate nutrition, with an emphasis on high protein, high calorie diet and small frequent feedings He may persist in the neck and back of the legs Progressive range of motion exercises and warm baths are useful Have the patient gradually increase activity as tolerated would encourage adequate rest and sleep Residual effects can result in sequelae such as dementia, seizures, deafness, hemiplegia, and hydrocephalus Assess vision, hearing, cognitive skills, and motor and sensory abilities after recovery

Cerebral Edema

Cerebral edema is an increase accumulation of fluid in the extravascular (interstitial or intracellular) spaces of the brain tissue Regardless of the cause, cerebral edema results in an increase in the tissue volume that can increase ICP There are three types of cerebral edema -vasogenic -cytotoxic -interstitial Vasogenic cerebral edema This is the most common type in occurs mainly in the white matter of the brain It is characterized by leakage of large molecules from the capillaries into the surrounding extracellular space This results in an osmotic gradient that favors the fluid fluid from the intravascular to extravascular space A variety of problems such as brain tumors, abscesses, and ingested toxins, may increase the permeability of the blood brain barrier and produce an increase in the extra cellular fluid volume The speed an extent of the spread of edema are influenced by systemic blood pressure, the site of injury, and extent of the blood brain barrier defect This edema may produce a continuum of symptoms, ranging from headache to a decrease in consciousness, including, which is a profound state of unconsciousness and focal neurologic deficit It is important to recognize that all the way headache may seem to be a benign symptom, in cases of cerebral edema you can quickly progress to coma and death Cytotoxic cerebral edema Results from disruption in the integrity of the cell membranes It develops from destructive lesions or trauma to the brain tissue, resulting in cerebral hypoxia or anoxia and SIADH secretion In this type of edema, the blood brain barrier stays intact Cerebral edema occurs from fluid and proteins shifts from the extracellular space directly into the sales, with subsequent swelling and loss of cellular function Interstitial cerebral edema It is usually result of hydrocephalus Hydrocephalus is a buildup of fluid in the brain and is manifested by ventricular enlargement It can be due to excess CSF production, obstruction of flow, or an inability to reabsorb the CSF Hydrocephalus treatment usually consist of a ventriculostomy or ventriculoperitoneal shunt

Trigeminal Neuralgia (TN) Diagnostics

Diagnosis is based almost entirely on history, along with the results from physical and neurologic exams Other disorders that can cause facial pain should be ruled out before diagnosing MRI maybe used to assess for other issues 3-D reconstruction and angiography MRI or helpful A complete neurological assessment is required

Encephalitis Manifestations and Diagnostics

Encephalitis can be acute or subacute Don't say that's typically nonspecific, with a fever, headache, nausea and vomiting Signs of encephalitis appear on day two or three and may vary from minimal changes in mental status to coma Virtually any CNS abnormality can occur, including hemiparesis, tremors, seizures, cranial nerve palsy's, personality changes, memory impairment, amnesia, and dysphasia Diagnostics Brain imaging techniques includes CT, MRI, and PET scans PCR test allow for early detection of HSV and West Nile encephalitis West now virus should be strongly considered an adult over 50 who have developed encephalitis or meningitis in summer or early fall The best diagnostic test for west now virus is a blood test that detects viral RNA

Cranial Nerve VII

Facial (controls most facial expressions & secretion of tears & saliva & taste)

Bacterial Meningitis Manifestations and Complications

Fever, severe headache, nausea, vomiting, and nuchal rigidity or neck stiffness are key signs of meningitis Photophobia, a decreased LOC, and signs of increased ICP may be present Coma is associated with a poor prognosis Seizures occur in 1/3 of all cases The headache becomes progressively worse and may be accompanied by vomiting and irritability If the infecting organism is a meningococcus, a skin rash is common Petechiae may be seen on the trunk, lower extremities, and mucous membranes Tumblr test can be done by pressing the base of a drinking glass against the rash, and the rash does not blanche or fade under pressure Complications The most common a cute complication of bacterial meningitis is increased ICP Most patients have increased ICP, and it is a major cause of an altered mental status Another complication is residual neurologic dysfunction, it involves many cranial nerves Cranial nerve irritation can have serious residuals The optic nerve or cranial nerve two is compressed by increased ICP, papilledema is often present, and blindness may occur We're going on or three, cranial nerve four, and cranial nerve six or irritated, ocular movements are affected Ptosis, unequal pupils, and diplopia are common Irritation of cranial nerve five results and sensory loss is a loss of the corneal reflex Irritation of cranial nerve seven results and facial paresis Irritation of cranial nerve eight causes tinnitus, vertigo, and deafness The dysfunction usually disappears within a few weeks, however hearing loss may be permanent Hemiparesis, dysphagia, and hemianopsia may occur The signs usually resolve overtime, and if they do not, suspect a cerebral abscess, sub dural empyema, subdural effusion, or persistent meningitis Acute cerebral edema may cause seizures, cranial nerve three palsy, bradycardia, hypertensive coma, and death Headaches may occur for months after the diagnosis of meningitis until irritation and inflammation have completely resolved Is important to implement pain management for chronic headaches Noncommunicating hydrocephalus may occur if the accident causes adhesions that prevent the normal flow of CSF from the ventricles CSF reabsorption by the arachnoid villi maybe obstructed by the arachnoid villi, and in this situation, surgical implantation of a shunt is the only treatment Waterhouse-Friderichsen syndrome is a complication of meningococcal meningitis As manifested by petechiae, DIC, adrenal hemorrhage, and circulatory collapse DIC and shock, which are some of the most serious complications of meningitis, are associated with meningococcemia

Cranial Nerve IX

Glossopharyngeal (taste and gag)

Trigeminal Neuralgia (TN) Nursing Care

Goal is relief of pain Electrical stimulation of the nerves and nerve blocks with local nerve anesthetics or botulinum toxin our options Drugs Antiseizure drug therapy may reduce pain by stabilizing the neuronal membrane and blocking nerve firing These drugs are usually effective in treating TN 1 but less effective in TN 2 First line drugs include carbamazepine, oxcarbazepine, topiramate, clonazepam, phenytoin, Lamota green, gabapentin, and valproic acid or Depakote Tricyclic antidepressant, such as amitriptyline or nortriptyline can help with a constant burning or aching pain in TN 2 Analgesics or opioids are usually not effective and controlling pain in TN 1 but may help with pain in TN 2 Patients usually receive outpatient treatment Assess the attacks in detail including triggering factors Assess for suicidal tendencies and no behavior such as withdrawal Discuss complementary pain management measures such as acupuncture, biofeedback, and yoga Environmental assessment is essential during an acute attack to decrease triggering similar The room should be kept at an evening, moderate temperature and free of drafts The patient may prefer to complete all self-care activities fearing someone will inadvertently cause injury Assess the patient's nutritional status and hygiene especially oral Teach the patient about the importance of nutrition, hygiene, and oral care Convey understanding if oral neglect is apparent A small, soft bristle toothbrush or a warm mouthwash helps promote oral care Hygiene activities are best done when analgesia at its peak Encourage food that is high in protein and calories and easy to chew Who should be served lukewarm and offered frequently If oral intake is sharply reduced in the patient's nutritional status is compromised, and NG tube can be inserted on the unaffected side for EN Patient needs to know they will be awake during local procedures in order to cooperate with corneal and cillary reflexes and facial sensations are checked After the procedure, compare the patient's pain with the preoperative intensity Evaluate the corneal reflex, extraocular muscles, hearing, sensation, and facial nerve function often If corneal reflex impaired, take special care to protect the eyes that includes using artificial tears or eye shields After a percutaneous radio frequency procedure, apply an ice pack to the jar on the operative side for 3 to 5 hours To avoid injuring the mouth, the patient should not chew on the operative side until sensation has returned If intracranial surgery was done, general post operative nursing care after a craniotomy is appropriate Plan for a regular follow up care, and although the pain may be relieved, encourage the patient to keep environmental stimuli to a moderate level into use stress management techniques If anesthesia is present or the corneal reflex is altered, teach the patient to chew on the unaffected side, avoid hot foods or beverages, which can burn the mucus membranes, check the oral cavity after meals to remove food particles, practice meticulous oral hygiene and continue with semi annual dental visit, protect the face against extremes of temperature, used an electric razor, wear a protective eye shield and avoid rubbing eyes, and examine eyes regularly for symptoms of infection or irritation

Increased Intracranial Pressure (ICP) manifestations

LOC is the most sensitive changes in LOC are a result of impaired CBF, which causes O2 deprivation to the cells of the cerebrum and reticular activating system (RAS) RAS is found in the brainstem an intact RAS can maintain a state of wakefulness even in the absence of a functioning cerebral cortex interruptions of impulses from the RAS or changes in functioning of the cerebral hemispheres can cause unconsciousness, an abnormal state of complete or partial unawareness of self or environment the patients state of consciousness is defined by the pt's clinical responses and pattern of brain activity on EEG changes in LOC can be dramatic or subtle in the deepest state of unconsciousness which I coma, the pt does NOT respond tp painful stimuli corneal and pupillary reflexes are absent the pt cannot swallow or cough and is incontinent EEG shows suppressed or absent neural activity increasing pressure on the thalamus, hypothalamus, pons, and medulla causes changes in VS Cushing's Triad which consists of systolic HTN with a widening pulse pressure, bradycardia with a full bounding pulse, and irregular respirations may be present ALWAYS recognized Cushing's Triad as a medical emergency as it IS A SIGN OF BRAINSTEM COMPRESSION AND IMPENDING DEATH A CHANGE IN BODY TEMP MAY OCCUR BC INCREASED ICP AFFECTS THE HYPOTHALAMUS compression of CN III, the oculomotor nerve, results in DILATION OF THE PUPIL ON THE SAME SIDE (IPSILATERAL) as the mass lesion, SLUGGISH OR NO RESPONSE TO LIGHT, INABILITY TO MOVE THE EYE UPWARD AND ADDUCT, AND PTOSIS OF THE EYELID The sound can be the result of the brain shifting from midline, compressing the trunk of cranial nerve three, and paralyzing the muscles controlling pupillary response and shape In the situation of fixed, unilateral, dilated pupil is considered a neurologic emergency that indicates brain herniation Other cranial nerves might be affected, including the optic nerve for cranial nerve II, the trochlear nerve or cranial nerve IV, and the other uses for cranial nerve VI Signs of problems with these cranial nerves include blurred vision, diplopia, and changes in extra ocular eye movements central herniation may initially manifest as sluggish but equal pupil response uncal herniation may cause a dilated unilateral pupil papilledema which is an edematous optic disc seen on retinal exam) is a non specific sign associated with persistent increases in ICP a contralateral (opposite side the mass lesion) hemiparesis or hemiplegia may occur localization or withdrawal from painful stimuli may occur noxious stimuli may elicit a decorticate (flexor) or decerebrate (extensor) posturing DECORTICATE posture consists of internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers it results from an interruption of voluntary motor tracts in the cerebral cortex extension of the legs may be seen DECEREBRATE posture may indicate more serious damage it results from disruption of motor fibers in the midbrain and brainstem in this position the arms are stiffly extended, adducted, and hyperpronated there is hyperextension of the legs with plantar flexion of the feet the brain itself is insensitive to pain, but compression of other intracranial structures such as arteries, veins, and cranial nerves can cause HA nocturnal HA and or a HA in the morning upon wakening is cause for concern and may indicate a tumor or other space occupying lesion that is caused increased ICP straining, agitation, or movement may worsen the pain vomiting is usually NOT preceded by nausea this is called unexpected vomiting and is r/t pressure changes in the cranium projectile vomiting may occur and is r/t increased ICP

Spinal Cord Injury Manifestations

Manifestations are generally the direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection They are related to the level and degree of injury Sensory regions are called dermatomes, and each segment of the spinal cord innervates a specific area of skin Respiratory complications closely corresponds to the level of injury Cervical injuries above C3 present special problems because of the total loss of respiratory muscle function These patients have respiratory arrest within minutes of injury if not intubated Patients with high cervical injury C3 through 5 have respiratory insufficiency due to loss of phrenic nerve innervation to the diaphragm and decreases in chest and abdominal wall strength Patients with complete SCI above C5 should be intubated at once, patients with incomplete SCI injury will have a high degree of variability in their respiratory function Cervical and thoracic injuries cause paralysis of abdominal muscles and often the intercostal muscles The patient cannot cough affectively enough to remove secretions, increasing the risk for aspiration, atelectasis, and pneumonia Hyperventilation and impairment of the intercostal muscles lead to a decrease in vital capacity and tidal volume Associated traumatic injuries, such as long contusions, can further compromise pulmonary function Fluid overload can cause pulmonary edema Neurogenic pulmonary edema maybe due to a dramatic increase in SNS activity at the time of injury Maintaining an arterial saturation of 92% reduces hypoxemia, which can lead to bradycardia and worse and secondary injury Patients are assessed from manifestations of respiratory distress, including dyspnea, decreased the vital capacity, and PCO2 over 20 above baseline, which would indicate the need for intubation Any cord injury above T6 leads to dysfunction of the SNS There were so it may be bradycardia, peripheral vasodilation, and hypotension or neurogenic shock Peripheral vasodilation causes relative hypovolemia because of the increase in the capacity of the dilated veins Decreases venous return blood to the heart, cardiac output then decreases, leading to hypotension Other injuries can cause hemorrhagic shock and further reduce blood pressure Is important to identify all causes of hypotension in the person with SCI Those on beta blockers, young healthy pts, and older adults may not be tachycardic with hemorrhage Urinary dysfunction occurs in most patients after SCI Originally butter describes any type of bladder dysfunction related to abnormal or absent bladder innervation The ability for the bladder muscles and the micturition center in the brain to transmit information is impaired after injury Both the detrusor muscle or bladder wall muscle and sphincter muscle which is the valve around the top of the urethra may be over active due to the lack of brain control This may cause high blood pressure and urinary retention Incontinence results from reflex emptying in failure to store urine Neurogenic bladder can have no reflex Trusel contractions or be flaccid/hypotonic which can result in bladder stretching from over distention, or have hyperactive reflex detrusor contractions or spastic bladder seen above T 12, leading to incontinence or lack of coordination between detrusor contraction and urethral relaxation or dyssynergia, resulting in reflux of urine into the kidneys Reflux into the kidneys kidney to stone formation, hydronephrosis, pyelonephritis, and renal failure Decreased GI motor activity contributes to gastric distention and the development of paralytic ileus gastric emptying may be delayed, especially in higher SCI excessive release of HCl in the stomach may cause stress ulcers dysphagia may be present in pts who need intubation, tracheostomy, and anterior spine surgery intraabd bleeding may be hard to dx because the person may not have pain or tenderness continued hypotension, and decreases in HgB and Hct may be the only s/s of bleeding expanding abd girth may be seen Loss of voluntary control of the bowel after injury results neurogenic bowel SCI above the level of the conus medullaris results in hyperreflexic bowel with increased rectal and sigmoid compliance combined increased anal sphincter tone and the inability to sense a full rectum causes stool retention and constipation SCI at or below the conus causes the bowel to be areflexic peristalsis is impaired and stool movement is slow defection reflex may be damaged and anal sphincter tone relaxed this leads to constipation, increased incontinence risk, possible impaction, ileus, or megacolon hemorrhoids can occur skin breakdown risk over bony areas of decreased or absent sensation is a major concern of immobility pressure injuries can occur quickly and lead to infection and sepsis Poikilothermic where is the inability to maintain a constant core temperature, with the patient assuming the temperature of the room It occurs because interruption of the SNS prevents peripheral temperature sensations from reaching the hypothalamus There is a decreased ability to sweat or shiver below the level of injury, which affect the ability to regulate body temperature Cervical injuries are associated with a greater loss of ability to regulate temperature than are thoracic or lumbar injuries The person has increased nutritional needs due to increased metabolism and more protein breakdown Lean body mass decreases and muscles atrophy, waiting to weight loss Stress on the body from hemodynamic instability and medical interventions, such a surgery can worsen stress Nutritional support should start early Venus thromboembolism is a common problem due to hypercoagulability, venous stasis, and venous endothelial injury Immobilization promotes venous stasis and thrombi of the lower extremities Usual signs and symptoms, such as pain and tenderness or not present Patience physical functioning and emotions influence pain Pain can be nociceptive or neuropathic Nociceptive pain can result from musculoskeletal, visceral, and or other types of injury from skin ulceration, or headache Patience often described musculoskeletal pain as dull or aching It starts or worsens with movement Visceral pain is in the thorax, abdomen, and or pelvis It may be dull, tender, or cramping Neuropathic pain occurs from damage to the spinal cord or nerve roots Pain can be at or below the level of the injury Pain is often described as hot, burning, tingling, pins and needles, cold and or shooting They may be extremely sensitive to stimuli, as even light touch can cause significant pain

Brain Tumors Diagnostics

Nuances of seizures or adult onset migraines may indicate a brain tumor and should be investigated Diagnostic studies are similar to those used for a patient with increased ICP The sensitivity of techniques such as MRI and PET scans allow for detection of small tumors and may provide more reliable diagnostic information than a CT CT with contrast an MRI are used to identify the lesions location Other test include fMRI, , EEGs to rule out seizures, LPs but they are used seldom because they carry the risk for cerebral herniation, cerebral angiography can determine blood flow to the tumor and further localized the tumor, and other studies are done to rule out a primary lesion elsewhere in the body Endocrine studies are hopeful wanna pituitary adenoma is suspected The correct diagnosis of a brain tumor can be made by obtaining tissue for biopsy and in most patients tissue is obtained at the time of surgery

Head Injury Diagnostics

Similar diagnostics to those used for a patient with increased ICP are used CT scan is the best diagnostic test to evaluate for head trauma and it allows for rapid diagnosis and intervention in the acute care setting MRI, PET, Andy evoked potential studies maybe used to diagnose hand injury MRI scan is more sensitive than the CT scan into taking small lesions Transcranial Doppler studies allow for the measurement of cerebral blood flow velocity Cervical spine x-ray series, CT scan come over MRI of the spine may be done soon cervical spine trauma often occurs at the same time as a head injury Treatment of skull fractures is usually conservative For depressed fractures and fractures with loose fragments, a craniotomy is done to elevate the depressed bone and remove the free fragments if large amounts of bone are destroyed, the bone may be need to be removed with craniectomy and a cranioplasty will be needed later In case of large acute sub dural and epidural hematoma which are associated with severe neurologic impairment, the blood must be removed surgically evacuation A craniotomy is generally done to see and allow control of the bleeding vessels Burr Hole openings maybe used in extreme emergency for more rapid decompression followed by a craniotomy A drain may be placed after surgery for several days used to prevent blood from re-accumulating in cases of extreme swelling such as in DAI or hemorrhage, a craniotomy may be done This involves removing a piece of school to reduce the pressure inside the cranial vault and reduces the risk for herniation

Spinal Cord Tumors

Spinal cord tumors can I have a devastating impact due to spinal compression and neurologic dysfunction Tumors are classified as primary that arise from some part of the spinal cord, Dura, nerves, or vessels or secondary from primary gross and other places in the body that has metastasized to the spinal cord Spinal cord tumors are either extradural on the outside of the Dora, intradural/extra medullary which are between the spinal cord and the Dura, or intramedullary which is within the substance of the spinal cord itself Many patients with cancer will have meta-stasis to the spine Metastatic lesions can invade intradural he and compress the spinal cord Tumors that often metastasized to the spinal epidural space are those that spread to Bone, such as prostate, breast, Long, and kidney cancer Many spinal cord tumors are slow growing, and their symptoms are due to the mechanical effects of slow compression and irritation of nerve roots, displacement of the spinal cord, or gradual obstruction of the blood supply The slowness of growth does not cause secondary injury as Intermatic SCI, thus complete functional restoration may be possible when the tumors removed The most common early symptoms of spinal cord tumor is back pain or pain radiating along the compressed nerve route Pain may worsen with activity, coughing, straining, and or lying down There may be slowly increasing clumsiness, weakness, and spasticity Paralysis can develop Century disruption occurs as corners, numbness, and tingling in one or more extremities Neurogenic bowel and bladder on marked by incontinence, constipation, and urgency with difficulty and starting the flu, progressing to retention with overflow incontinence Extradural tumors can be seen on routine spinal x-rays Intradural extra medullary and intramedullary tumors require MRI, CT scan, or CT myelogram for detection CSF analysis may reveal tumor cells Spinal cord compression is an emergency, and relief of ischemia related to the compression is the goal of therapy Corticosteroids are generally given immediately to relieve tumor related edema Emergency surgery may be needed to decompress the spinal cord, obtain tissue for biopsy, and hope to determine appropriate treatment Primary spinal tumor's may be removed with the goal of cure Impatient with metastatic tumor, treatment is mainly palliative The goal is to restore a preserve neurologic function, stabilized is fine, and alleviate pain Radiation and or chemotherapy maybe used to treat the tumor Relieving pain in maximizing neurologic function are the ultimate goals of treatment Assess the patient's neuro status before and after treatment Giving analgesia as needed is an import nursing responsibility, depending on the amount of neurologic dysfunction, care of the patient may be similar to that of a patient recovering from SCI

Brain Tumors

The brain is a frequent site for a meta-stasis from other sites of cancer Males have a slightly higher incidence of brain tumors than females Brain tumors often occur in middle-age persons but they may be seen at any age Types Brain tumors can occur in any part of the brain or spinal cord Tumors of the brain maybe primary that arise from tissues within the brain Or they may be secondary resulting from meta-stasis of cancer from elsewhere in the body Metastatic brain tumors are the most common brain tumor and cancers that most often metastasize to the brain are lung and breast Meningiomas are the most common primary brain tumor Other come and brain tumors are gliomas More than half a brain tumors are malignant and they infiltrate the brain tissue and are not amendable to complete surgical removal Other tumors maybe histological benign but I located such that complete removal is not possible Brain tumors rarely metastasize outside of the central nervous system because they are contained by structural meninges and physiologic barriers such as the blood brain barrier

Bell's Palsy Manifestations

The key features of Bell's palsy is the acute onset of unilateral lower motor facial weakness 50 to 60% have pain around and behind the ears and neck Other manifestations include drooping of the eyelid in corner of the mouth or ptosis, drawing, facial twitching, dryness of the eye or mouth, facial numbness, alter taste, hearing loss, and excessive tearing in 1 eye Most often the symptoms begin suddenly and reach their peak within 48 to 72 hours Quality of life is often decrease due to problems with eating, swelling, speech, and taste Patients may have psychological drama because of the changes in appearance, nutrition, dehydration, mucous membrane trauma, corneal abrasions, muscle stretching, and facial spasms and contractures They may have the inability to wrinkle the brow, drooping of the island, or inability to close the eye, the inability to pop the cheeks, dripping mouth and the inability to smile or pucker

Viral Meningitis

The most common causes of viral meningitis or intro viruses, arbovirus, human immunodeficiency virus, and herpes simplex virus Enteroviruses most often spread through direct contact with respiratory secretions Viral meningitis usually presents as headache, fever, photophobia, and stiff neck Fever may be moderate or high The expert EV test can rapidly diagnose viral meningitis, a sample of CSF is used to determine if enteroviruses present, and results are available within hours The CSF can be clear cloudy, and the typical finding is lymphocytosis Organisms are not seen on Gram stain or acid fast mirrors, PCR used to detect virus specific DNA or RNA is a sensitive method for diagnosing CNS viral infections Erotic should be given after the LP while waiting for the results of the CSF analysis Antibiotics are the best defense for bacterial meningitis We can easily discontinued them if the meningitis is found to be viral Viral meningitis is manage symptomatically because the disease is self limiting For recovery is expected Rare sequelae include persistent headaches, mild mental impairment, and incoordination

Bell's Palsy Nursing Care

The patient is treated outpatient Ciara focuses on relieving symptoms, prevent complications, and protecting the eye on the affected side Trim is often started to try to improve the chance of a complete recovery Oral corticosteroid therapy to reduce inflammation and swelling should we started within 72 hours of onset Some patients should receive an antiviral agent, such as acyclovir, in addition to the steroid therapy Cervical decompression of the facial nerve is controversial but it's considered in refractory cases Mild analgesics can relieve pain Moist heat can reduce discomfort and aid in circulation Electrical stimulation of the nerve, face on massage, and physical therapy help maintain muscle tone and ease pain A facial slang may be helpful to support affected muscles, improve lip alignment, and facilitate eating When function begins to return, active facial muscle exercises are done several times a day Tell the patient to protect the face from cold and drafts because trigeminal hyperesthesia or extreme sensitivity to pain or touch may occur Eye protection is important, the patient may wear dark glasses for protective and cosmetic reasons Artificial tears such as methyl cellulose should be installed often during the day to prevent drying of the cornea, ointment and an impermeable eyeshield can be used at night to retain moisture In some patience, taping the lids close at night maybe needed Teach the patient to report ocular pain, drainage, or discharge Maintaining good nutrition is important, teach the patient to chew on the unaffected side of the mouth to avoid trapping food and to enjoy the taste of food Thorough oral hygiene must be done after each meal to prevent parotitis, caries, and periodontal disease from accumulated residual food The change and physical appearance from Bell's palsy can be devastating, reassure the patient that a stroke did not occur and that chances for a full recovery are good Tell the patient most people recover within 3 to 6 months after onset of symptoms Enlisting support from friends and family is important

Bacterial Meningitis Diagnostics

When a patient has manifestations of stuffed of a bacterial meningitis, blood culture and CT scan should be done Diagnosis is usually verified by doing an LP with analysis of CSF And I'll be should be done only after CT scan has ruled out an obstruction in the foreman Magnum to prevent a fluid shift resulting in herniation Specimens of the CSF, sputum, and nasal pharyngeal secretions are taken for culture before the start of antibiotic therapy to identify the causative organism A Gram stain is down to detect bacteria and the predominant white blood cell type in the CSF with bacterial meningitis is neutrophils X-rays of the score Michelle infected sinuses, CT scans and MRI may be normal and I'm company to meningitis, and other cases, CT scans may reveal evidence of increased ICP or hydrocephalus

Bacterial Meningitis

acute inflammation of the meningeal tissues surrounding the brain and spinal cord Meningitis usually occurs in fall, winter, or early spring Is often related to a viral respiratory disease Older adults in person to her debilitated or more often affected than the general population Call students living in the dorms and people living in institutions such as prisoners have a higher risk for contracting it Streptococcus pneumonia and Neisseria meningidis are the leading causes of bacterial meningitis Haemophilus influenzae was once the most common cause of bacterial meningitis however the use of H influenza vaccine has resulted in a significant decrease in meningitis from this organism Organisms usually gain entry to the CNS through the upper respiratory tract or bloodstream However they may enter by direct extension from penetrating wounds of the skull or through fractured sinuses in basilar skull fractures The inflammatory response to the infection tends to increase CSF production with a moderate increase in ICP In bacterial meningitis the purulent of secretions quickly spread to other areas of the brain through the CSF and cover the cranial nerves and other intracranial structures If this process it extends into the brain parenchyma or if concurrent encephalitis is present, cerebral edema and increased ICP become more of a problem Closely observe all patients for manifestations of increased ICP ICP can increase from swelling around the Dura and increased CSF volume

Spinal Cord Injury

caused by trauma or damage to the spinal cord Can result in temporary or permanent alteration in the function of the spinal cord The average life expectancy for persons with SCI is less than those without Mortality rates are high in the first year after injury SCI is usually a result of trauma Motor vehicle collisions, falls, violence, and sports injuries are common causes Types Neurologic damage caused by SCI occurs in two phases: primary injury which is initial physical disruption of the spinal cord and secondary injury which is from processes such as ischemia, hypoxia, hemorrhage, and edema Primary injury results from direct physical trauma to the spinal cord due to blunt or penetrating trauma Trauma can call spinal cord compression by bone displacement, interruption of blood supply, or distraction from pulling Penetrating trauma, such as gunshot and stab wounds, can cause tearing and transection Secondary injury refers to the ongoing, progressive damage that occurs after the primary injury Secondary injury causes further permanent damage It begins a few minutes after injury and lasts for months These events result in edema, ischemia, and inflammation They were sold in cell death, disruption of the blood brain barrier, and demyelination And seconds after the incident, mechanical disruption leads to small hemorrhages in the white and gray matter, damage to the axons, and the cell membrane destruction Over the next minutes to hours, neuron destruction occurs Blood spinal barrier disruption allows for an influx of inflammatory cytokines This further increases spinal cord edema and promotes ongoing information Edema due to the inflammatory response is especially harmful because of limited space for tissue expansion Thus compression of the spinal cord occurs Edema extends above and below the injury, increasing ischemic damage Within 24 hours, permanent damage may occur from edema The resulting hypoxia reduce his oxygen levels below the metabolic needs of the spinal cord Lactate metabolites and an increase in vasoactive substances, including norepinephrine, serotonin, and dopamine occur High levels of these substances cause vasospasms and hypoxia with subsequent necrosis, and unfortunately, the spinal cord has a minimal ability to adapt to vasospasm Apoptosis or programmed cell death continues for weeks, and it contributes to post injury demyelination Inflammatory response at the site of the initial injury focuses on clearing up the initial cellular debris's without damaging normal tissue This results in a central non-neural core of connective tissue that we referred to as a glial scar The glial scar creates a physical barrier, and restricts the cells and the spinal cord from migration and regeneration This leads to irreversible nerve damage and permanent neurologic deficit Spinal and neurogenic shock Spell shock make her shortly after SCI, and it is characterized by loss of deep tendon and sphincter reflexes, loss of sensation, in flaccid paralysis below the level of the injury This syndrome can last days to weeks and it often masks post injury neurologic function Neurogenic or vasogenic shock can occur in cervical or high thoracic injury T6 or higher It occurred from unopposed parasympathetic response due to loss of sympathetic nervous system innervation Causes purple vasodilation, Venus pulling, and decreased cardiac output Manifestations include significant hypotension, bradycardia, and temperature dysregulation Neurogenic shock and continue for 1 to 3 weeks Hypotension can result in poor perfusion and oxygenation to the spinal cord and worsen spinal cord ischemia The major mechanism of injury includes flexion, flexion rotation, hyper extension, vertical compression, extension rotation, and lateral flexion Flexion rotation injury is the most unstable because ligaments that stabilize the spine or torn, and this injury most often contributes to severe neurologic deficit Skeletal level of injury is the vertebral level with the most damage to vertebra and related ligaments Neurologic level is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body The level of injury may be cervical, thoracic, lumbar, or sacral Cervical and lumbar injuries are the most common because those areas of the spine are associated with the greatest flexibility and movement Injury from C1 to T1 can cause paralysis of all four extremities resulting in tetraplegia formally called quadriplegia The degree of impairment in the arms after cervical injury depends on the level of injury The lower the level, the more function is retained in the arms Paraplegia or paralysis and loss of sensation and the legs can occur in SCI below the level of T2 The degree of spinal cord involvement may be complete or incomplete/partial Complete corn involvement results in total loss of sensory and motor function below the level of injury Incomplete cord involvement results in a mixed loss of voluntary motor activity and sensation and leaves some tracks intact

grey matter of the brain

consists of unmyelinated cell bodies and dendrites

white matter of the brain

contains myelinated axons which make it white

strabismus

crossed eyes

order of meninges

dura mater, arachnoid mater, pia mater (from outter to inner) DAP

Cranial Surgery Nursing Care

general pre and post op similar to increased ICP nursing care explain some hair may be removed hair is normally removed in the OR after anesthesia the main goal post op is to prevent increased ICP closely monitor neuro status, labs, SIADH and DI possibility, and VS Nausea and vomiting are common and can be treated with antiemetics PROMETHAZINE IS DISCOURAGED BC IT CAN INCREASE SOMNOLENCE AND ALTER NEURO ASSESSMENTS the brain itself has no pain receptors, pts often report HA caused by edema or incision pain control with short acting opioids and monitor neuro status the surgical dressing is usually in place for a few days with incision over the anterior or middle fossa, the pt will return with the HOB at 30-45 degrees the HOB should stay elevated at least 30° unless the surgical approach is in the posterior fossa or a burr hole has been made And these cases, the patient is generally kept flat or a slight elevation of 10 to 15 degrees during the postoperative phase Turning in positioning the patient will depend on the side of the operation If a bone flap has been removed with the craniectomy, do not position the patient on the operative side Play the sign at the head of the bed, alerting everyone of the craniectomy site and position of the surgical site Observe the dressing and notify the older brother immediately if any excess bleeding or clear drainage is present Checking drains for placement and assess in the area around the dressing are important in scalp care should include meticulous care of the incision to prevent wound infection Clean the area and tx it following agency protocol or the orders What's the dressing is removed, use an antiseptic soap for washing the scalp Psychologic impact of hair removal can be lessened by using away, turban, scarves, or cap For the patient is receiving radiation, teach the patient to use a sunblock and head covering if any sun exposure is expected Ambulatory care Three how potential for a patient after cranial surgery depends on the reason for surgery, the postop course, and the patients general state of health Base your nursing interventions on a realistic appraisal of these factors and specific rehab potential cannot be determined until cerebral edema and increased ICP subside postop Overall goal is to foster independence where is long as possible and to the highest degree possible These patients mental and physical deterioration, including seizures, personality disorganization, empathy, and wasting is difficult for both family and healthcare professionals Talkative and emotional residual deficit are often harder to accept than the motor and sensory losses Social workers can help with the patient and family to adapt to changes in their home, work, and financial life

Cranial Surgery

indications for cranial surgery are r/t to brain tumors, CNS infection such as abcesses, vascular abnormalities, trauma, seizures, and pain Types Burr Hole opening into cranium with a drill used to remove fluid and blood beneath the dura Craniectomy excision into the cranium to cut away a bone flap Cranioplasty repair of cranial defect from trauma, malformation, or previous surgery artificial material used to replace damaged or lost bone Craniotomy opening into the cranium with removal of bone flap and opening into the dura to remove a lesion, repair damaged areas, drain blood, or relieve increased ICP Healthcare provider drills a set of burr holes and uses a saw to connect the holes to remove the bone fla Sometimes operating microscopes are used to magnify the site and after surgery the bone flap is secured with small plates or wired shut Sometimes drains are placed to remove fluid or blood Shunts pathway to redirect CSF Stereotactic precise location of specific area for biopsy, radiosurgery, or dissection CT scan and an MRI are used to image of the target of tissue The patient is under general or local anesthesia, in the healthcare provider drills of Burrell or create a bone flap for an entry site and then introduces a probe and biopsy needle Stereotactic procedures are used for removal of small brain tumors and abscesses, drainage of hematoma's, ablative procedures for extrapyramidal diseases, and repair of AV malformations A major advantage of the stereotactic approach is a reduction in damage to surrounding tissue Stereotactic radiosurgery is not a form of surgery in the traditional sense Radio surgery uses a high dose of cobalt radiation that it's delivered to a precisely target in tumor tissue in the dose of radiation is delivered in a single treatment lashing a few hours or in multiple sessions Side effects include fatigue, headache, and nausea In combination with stereotactic procedures to identify and localize tumors, surgical lasers can be used to destroy tumors Lasers work by creating thermal energy, which destroys the tissue on which is focused Laser therapy provides the benefit of reducing damage to surrounding tissue

Babinski's Sign

reflex response; when sole of the foot is stroked, the big toe turns up instead of down and the toes fan out and dorsal flexion occurs of the foot normally the toes would curl down and the foot would plantar flex

Increased Intracranial Pressure (ICP) complications and diagnostics

the major complications of uncontrolled increased ICP are inadequate cerebral perfusion and cerebral herniation Tentorial Herniation (central herniation) occurs when a mass lesion in the cerebrum forces the brain to herniate downward through the opening created by the brainstem Uncal Hernation occurs when there is lateral or downward herniation Cingulate Herniation occurs when there is lateral displacement of brain tissue beneath the falx cerebri CT and MRI are used to discern the many conditions that can cause increased ICP and assess the affect of TX other tests such as EEG, cerebral angiography, ICP monitoring, PET, doppler, and evoked potentials can be done lumbar puncture (LP) is NOT done when increased ICP is suspected the reason for this is that cerebral herniation could occur from the sudden release of pressure in the skull from the area above the LP

intracranial regulation

the skull is an enclosed space with 3 different complements -brain tissue -blood -CSF Normal Intracranial Pressure (ICP) ICP is the hydrostatic pressure measured in the subarachnoid space where CSF resides Factors that influence ICP -arterial pressure -venous pressure -intraabdominal pressure -intrathoracic pressure -posture -temperature -blood gases especially CO2 normally the if volume of any one of the 3 components increases within the cranial vault in the volume from another component is this place, the total intracranial volume will not change This hypothesis is applicable only in situations in which the skull is closed and it is not valid in persons with displaced skull fractures or craniectomy from removal of part of the skull The normal ICP range is from 5 to 15 A sustained pressure greater than 20 is considered abnormal and must be treated The first compensatory mechanism can include changes in the CSF volume CSF volume can be changed by altering CSF absorption or production and buy displacing CSF into the spinal subarachnoid space Changes in intracranial blood volume can occur through the collapse of cerebral veins and dural sinuses, regional cerebral vasoconstriction or dilation, and changes in venous outflow Brain tissue volume compensates through distention of the Dura or compression of brain tissue Cerebral blood flow (CBF) is the amount of blood in milliliters passing through 100 g of brain tissue in 1 minute The global CBF is about 50 mL per minute per 100 g of brain tissue Maintaining blood flow to the brain is critical because the brain requires a constant supply of O2 and glucose Regulation of cerebral blood flow The brain regulates its own blood flow in response to its metabolic needs to spite wide fluctuations in systemic arterial pressure Cerebral autoregulation is the automatic adjustment and the diameter of the cerebral blood vessels by the brain to maintain a constant blood flow during changes in arterial blood pressure The purpose of autoregulation is to ensure a consistent CBF Lower limit of systemic arterial pressure at which autoregulation is effective in a normal tense of person is a mean arterial pressure (MAP) of 70 below this, CBF decreases, and symptoms of cerebral ischemia, such a syncope and blurred vision occur The upper limit of systemic arterial pressure at which autoregulation as effective as a map of 150 When this pressure is exceeded, the vessels are maximally constricted, and further vasoconstrictor responses lost This rebel perfusion pressure or CPP is the pressure needed to ensure blood flow to the brain CBP is equal to the MAP minus the ICP Normal CPP is 60 to 100 As CPP decreases, autoregulation fails and CBF decreases A CPP of less than 50 is associated with ischemia and neural death A CPP of less than 30 results in ischemia and is incompatible with life Those CPP is clinically useful, it is not consider the effect of cerebral vascular resistance Mom server of vascular resistance, generated by the arterial aise within the cranium, links CPP and blood flow Windsor brew vascular resistance is high, blood flow to the brain issue is impaired Transcranial Doppler is a non-invasive technique used in intensive care units to monitor changes in cerebrovascular resistance Normally, autoregulation maintains an adequate CBF and CPP by adjusting the diameter of cerebral blood vessels and metabolic factors that affect ICP It is critical to maintain MAP when ICP is increased Remember that CPP may not reflect perfusion pressure in all parts of the brain and there may be local areas of swelling and compression limiting regional perfusion pressure Does a higher CPP may be needed for these patients to prevent localized tissue damage For example a patient with an acute stroke may need a higher blood pressure, increasing MAP and CPP, to increase perfusion to the brain and prevent further tissue damage CO2, 02, and hydrogen ion concentration affect cerebral blood vessel tone An increase in the partial pressure of CO2 in arterial blood relaxes smooth muscle, dilate cerebral vessels, decreases cerebrovascular resistance, and increases CBF a decrease in partial pressure CO2 constricts cerebral vessels, increases cerebrovascular resistance, and decreases CBF Cerebral 02 tension of less than 50 results in cerebrovascular dilation Installation decreases for real vascular resistance, increases CVF, and increases O2 tension However if O2 tension is not increased, anaerobic metabolism begins, resulting in an accumulation of lactic acid As lactic acid increases and hydrogen ions accumulate, the environment becomes more acidic Within this acidic environment, further vasodilation occurs in a continued attempt to increase blood flow The combination of a severely low partial pressure of O2 and our trail blood and increased hydrogen ion concentration or acidosis which are both potent vasodilators, may produce a state in which autoregulation is lost and compensatory mechanisms do not me tissue made about demands Regional CBF can be affected by trauma, tumors, cerebral hemorrhage, or stroke When regional or global autoregulation is lost, CBF is no longer maintain a constant level was directly influenced by changes in systemic blood pressure, hypoxia, or catecholamines

Where is CSF located?

ventricles and subarachnoid (between Archnoid and Pia Mater/under the Arachnoid Mater) space of the brain/spinal cord

hemiparesis

weakness on one side of the body