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Assessment and dx
- timely assessment, dx and tx
- treat initial injury and prevent secondary injury
- - cerebral edema, inc icp, hypoxia, hypotension
- initial neuro assessment
- - hx of injury
- - tools describing THI
- --- glascow coma scale
- stabilize pt
- - ABC
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methods of describing THI
- mild- GSC from 13-15 w/loss of consciousness for 15 mins
- moderate- loc of for about 6 hoursw/assessment of systemic injury. GCS 9-12
- severe- GCS 3-8, loc > 6hr, pt needs critical care and monitor for both homodynamic and ICP
- immediate craniotomy
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Glascow Coma scale
- tells u what is going on with the patient
- gives you an idea
- the higher the number the better
- < 8 u are in trouble
- eye movement, verbal, motor
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C/O of THI Increased Intracranial Pressure
- normal ICP- total pressure in skull
- cranial contents
- - blood
- - csf
- - brain tissue
- normal ICP 0-15 mmhg
- abnormal ICP- > 15
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Monroe Kellie Doctrine
- three components
- blood, brain, csf
- if one of these incr the others will dec to compensate bc it wants to create balance
- mins 21
- autoregulation refers to the brain ability to change the diameter of its blood vessels to maintain constant cerebral blood flow during alterations in systemic blood pressure
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s/s of icp
1. loss of consciousness
- 1. change in level of consciousness
- a. impaired CBF
- - cerebral cortex (know who you are)/RAS (reticular activity system- wakefulness- alert-cognition)
- -- lethargic- stuporous- unconscious
- - subtle- change affect/orientation/attention
- Dramatic
- - coma/loss of pain response
- - absent pupillary response
- - loss of swallowing/gag reflex
- - incontent of urine and stool
- significant impairment of brain circulation- poor sign
- GCS is probably low
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s/s of ICP
2. change in VS
- Fever- involving the hypothalmus. early sign something with brain. poor sign
- hypo/hypertension-
- - widening pressure pulse
- dysrhthmias, bradycardia-- hypothalmus
- tachyapnea, irr respir- as it continues
- Crushing triad- medical emergency****
- - late sign
- - something going on with brain stem- no intervention could lead to death
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Cushing's triad
- due to decre CBF
- CNS ischemic response
- immediate intervention is needed- heriniation of brain stem and further occulsion of cbf
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cushing triad s/s ***
- LATE sign of incr ICP
- severe hypertension
- irreg respirations
- bradycardia
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s/s of ICP
3. occular signs
- report all changes: indicative of increasing icp
- changes are lack of spontaneous eye opening (no tracking ie following, no movement to voice, dolls eye), pupil response, visual field and vision
- - diplopia, blurred vision, ptosis
- cranial nerve damage is a late sign
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more s/s icp
3 occular sign
- pinpoint/non reactive pupils- brainstem injury
- - fixed/non reactive, significant ICP/brainstem injury- poor prognosis
- Asymmetric pupils, not reactive
- - herniation of brain/ inc ICP
- Papilledema (edema of optic disc)
- - late sign of ICP
- (md will see this)
- non reactive poor sign
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s/s ICP
4. decreased motor function
- lack of spontaneous movement
- - response to pain
- contra lateral hemiparesis
- flaccidity
- - not getting nerve impulses
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decordicate and decerebrate
- decordicate posturing is to the core the cerebral cortex is affected
- decerebrate posturing is outwards which involves the brain stem
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ICP s/s
- 5 headaches, vomiting w/nausea, HA incr in the AM- worst with activity
- 6. seizures
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ICP s/s
7 fluid and eletrolytes
- SIADH (incre ADH)- lung sound changes crack;es, mental status chx (due to low NA), oliguria, incr volume, inc BP FVE, edema, HA, SOB
- diabetes insipidous- (dec ADH)- mental status chx, low NA, polyuria, thirst-dehydration, FVD
- damage to the hypothalmus u worry about ADH
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unresolved ICP
- brain herniation
- irrversible brain damage or brain death
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nx dx for ICP
- altered tissue perfusion
- self care deficit
- at risk for injury- due to fall risk
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dx Increased ICP
- Ct scan, MRI, PET, SPECT
- transcranial doppler- look for occulusion
- eeg- brain waves
- NVS, GCS, VS
- ABG's chem- hypoxia
- No LP's are done- bc u dont want to inc pressure
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medical management of ICP
- emergency
- invasive monitoring of ICP is required
- immediate release of ICP
- - decre cerebral edema
- - lower volume of CSF
- - decre CBF volume- still perfuse brain but trying to create balance
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medical management of ICP
ICP monitoring
- identify early changes
- initiate tx
- access to CSF- can remove fluid- can look for oxgenation
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Medical management
LICOX
- LICOX cathether-surgical management
- - brain tissue oxygen monitoring
- prevent ischemia and apnea
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Nursing management of ICP
- Ineffective airway pattern
- 1. aiway
- - assessment **
- - ventilator
- - HOB 30 degrees
- - hyper oxygenation/suction
- - monitor respirations
- - prevent abd distention- pressure of the diaphragm- lungs
- - assess aspiration
- - assess ABG
be aware of potential thickening of secretions d/t diuretic admin
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risk for ineffective tissue perfusion
- goal- dec cerebral edema
- assess for s/s of ICP, ICP monitoring
- assess VS
- cardiac monitoring
- - prevent hyper/hypotension
- - cardiac dysrhymias
- report all changes
- positioning
- - HOB elev, avoid neck and hip flexion- could cause more pressure
- - slow and gentle position changes, log roll
- dont cluster care
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risk for ineffective tissue perfusion
2
temp, activities, pain environment
- manage temp- think hypothalmus
- - hypothermia therapy- cooling blanket
- limit activities that increa ICP
- - suctioning, coughing, straining, hypoxemia
- assess and manage pain, anxiety
- - morphine, fentanyl (narcan-antedote)
- - ativan (benzo), versed
- decrease environmental stimuli
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decrease cerebral edema
medications
- Mannitol IV- Osmostic directic
- MOA: increases plasmaosmolarity. draws water across the blood brain barrier into blood vessels
- USe: dec ICP, dec edema and incre oxygen delivery
- S/e- edema, hypervolemia, hypoatremia, h/a
- so think where is the fluid going
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nursing care on Mannitol
- foley cath- accurate I&O, daily weights
- VS, BP, Wt, lytes, BUN/Cre
- lasix can be given with mannitol- potentiated the effects of mannitol
- Alternative: if not working or cant be given
- Infuse IV hypertonic solutions
- - given with or alone
- - assess neuro/VS/LABS
- - careful monitoring
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other meds to decr cerebral edema
- corticosteriods
- given if the cause of ICP is a tumor
- decadron will help reduce the edema around the tumor
- see med sheet for s/e- will be a question on test
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other meds to decre cerebral edema
2
- neuromuscular blocking agents )(NMBA)
- - for severe agitation with increasing icp
- - must be used with sedative/analgesia
- - last resort
- barbiturate coma
- - dec metabolic demands of brain, dece vasospasm, and improve cbf
- - used only when other measures are unsuccessful
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management of ICP
nutrition
- Imbalance nutrition
- needs:
- ICP increases glucose need d/t hypermetabolic state
- - malnutrition promotes cerebral edema
- nutritional assessment
- TPN/PPN/Tube feeding
- long term needs
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management of ICP
risk for injury
- high risk for injury
- sedate
- family at bedside
- protect eyes- can scratch cornea d/t lost of blinking reflex
- seizure precautions
- - AED, antipyretic meds
- agitated
- restrain if needed
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management of ICP
risk for imb fluids/lytes
- assessment
- all IV fluid on pump
- foley cath, accurate I&O hourly
- daily weight
- assessment of renal fx and lytes, serum urine osmolarity, specific gravity
- assess type of fluids ordered
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management of ICP
impaired sensory perception
- decrease risk for injury
- sensory stimulation
- - assess sensory needs and overstimulation- sounds can agitate pt
- - provide sensory stimulation- massage, touch, calming
- short term memory loss
- - reorient as needed, consistency
- - bring familiar
- - simple instructions
- cognitive deficits- simple instructions
- sense of hearing is the last to go---sing to pt :-)
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management of icp
ineffective coping/antipatory grieving/anxiety/powerlessness
- assess indiv/family needs/support
- provide info and education
- allow to participate in care
- support for family
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surgical manage of THI/ICP
options
- craniotomy
- - incision into the cranium opening the skull to gain access to intracranial structures
- done to:
- - remove tumors
- - improve symptoms r/t lesions
- - relieve icp
- - evacuate blood clot
- - control hemorrhage
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burr holes
- circular openings in the skull
- determine cerebral swelling/injury
- size, position of ventricles
- evacuates intracranial hematomas/abscess
- relieves pressure, evacuates blood clots
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cranioplasty
repair of cranial defect using a plastic or metal plate
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Post op management of surgery
- assessment
- - neuro/icp
- - post- op c/o
- - dressings
- Meds
- - analgesics
- - antipyretics
- - AED
- - decadron
- DC teaching- rehab
- at risk for infection, and tonic-clonic seizure
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brain death
- criteria according to MASS
- irreversible cessation of spontaneous brain function, loss of function of brain including brain stem
- clinically/legally dead
- - coma
- - absences of brain reflex- primitive reflexes
- - apnea
- organ donation
- nurses role
- ethical dilemma
- eeg will show no brain waves
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