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Questions and Answers
What is a priority finding with ICP/ Head injury?
What is a priority finding with ICP/ Head injury?
Change in mentation (LOC)
What is ventriculostomy and what is it indicate for?
What is ventriculostomy and what is it indicate for?
Monitoring ICP, brain perfusion and treatment if drain in is indicated
A patient with ICP has serum sodium level of 120 mEq/L. She is complaining of H/A and is increasingly somnolent. What do you expect to give?
A patient with ICP has serum sodium level of 120 mEq/L. She is complaining of H/A and is increasingly somnolent. What do you expect to give?
IV Hypertonic Saline
What is the biggest concerns with Cervical injuries above C5?
What is the biggest concerns with Cervical injuries above C5?
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What are potential Thoracic injury-paraplegia patients able to do?
What are potential Thoracic injury-paraplegia patients able to do?
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What is Autonomic Dyreflexia?
What is Autonomic Dyreflexia?
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What is the most cause?
What is the most cause?
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What is the biggest preventative treatment?
What is the biggest preventative treatment?
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A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA. When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available?
A patient with homonymous hemianopsia is in the rehabilitation phase of a CVA. When arranging this patient's environment where should the nurse assure persons approaching and important items are visible and available?
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How do we keep our patients safe?
How do we keep our patients safe?
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A 16 yr old who has just been diagnosed with epilepsy tells the nurse, "I don't want to go out with my friends anymore, I'm afraid I'll have a seizure in public." Which nursing diagnosis is the most appropriate?
A 16 yr old who has just been diagnosed with epilepsy tells the nurse, "I don't want to go out with my friends anymore, I'm afraid I'll have a seizure in public." Which nursing diagnosis is the most appropriate?
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What's one of the biggest clinical s/sx difference between ischemic and hemorrhagic strokes?:
What's one of the biggest clinical s/sx difference between ischemic and hemorrhagic strokes?:
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Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA?
Pneumonia is the most frequent cause of death after a stroke. Which intervention would be contraindicated in the acute care of a patient with a hemorrhagic CVA?
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The role of ASA in stroke prevention is to prevent the development of a thrombus or embolus.
The role of ASA in stroke prevention is to prevent the development of a thrombus or embolus.
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Which action by the new RN indicates a need for more education?
Which action by the new RN indicates a need for more education?
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What is it?
What is it?
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What is normal findings for this shock?
What is normal findings for this shock?
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What is normal compensatory vs. signs of worsening?
What is normal compensatory vs. signs of worsening?
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What is the cornerstone of therapy for septic, hypovolemic, and anaphylactic shock?
What is the cornerstone of therapy for septic, hypovolemic, and anaphylactic shock?
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Study Notes
Intracranial Pressure (ICP)
- ICP is the pressure exerted by brain tissue, cerebrospinal fluid (CSF), and blood inside the skull.
- Normal ICP ranges from 5 to 15 mmHg.
- Elevated ICP (greater than 20 mmHg) requires treatment.
- Changes in any of these components (CSF, blood, brain tissue) will affect ICP.
Intracranial Pressure (ICP) and Head Injury
- A head injury can cause changes in ICP.
- One early sign of increased ICP may be a change in mental status (LOC).
- Decorticate posturing involves flexion of arms, wrists, and fingers with adduction in upper extremities and extension, internal rotation, and plantar flexion in lower extremities.
- Decerebrate posturing involves rigid extension of all four extremities, with hyperpronation of forearms and plantar flexion of feet.
- Cushing's Triad (late sign) includes increased systolic blood pressure, decreased heart rate, and decreased respiratory rate (RR).
Calculating Cerebral Perfusion Pressure (CPP)
- CPP is the pressure needed to ensure adequate blood flow to the brain.
- Formula: CPP = MAP - ICP
- MAP (Mean Arterial Pressure) = (2 × Diastolic Blood Pressure) + Systolic Blood Pressure / 3
- Normal CPP range is typically 60-100 mmHg.
Nasogastric (NGT) and Orogastric (OGT) Tubes in Head Injuries
- NGT and OGT tubes are used in patients with head injuries for feeding and medication administration.
- These tubes can increase ICP if improperly inserted or if there is increased abdominal pressure.
- OGT might be preferred over NGT for patients with facial trauma.
Ventriculostomy
- A ventriculostomy is a procedure where a catheter is inserted into a ventricle of the brain to monitor ICP and drain excess CSF.
- Management includes ensuring placement, monitoring ICP readings regularly, and carefully regulating drainage to prevent hypotension.
- Indicated for managing hydrocephalus, severe head injuries, and high ICP.
ICP and Hyponatremia
- Hyponatremia (low sodium levels) is a common complication in patients with increased ICP.
- It can result from SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion).
- Hyponatremia can exacerbate brain edema and increase ICP, leading to more severe symptoms, like confusion, seizures, and coma.
- Treatment includes monitoring and minimizing increases in ICP, restricting fluids, and carefully administering hypertonic saline.
Nursing Interventions for Improved Cerebral Perfusion
- Maintain the head in the midline position, prevent extreme neck flexion, and elevate the head of the bed appropriately (less than 30 degrees).
Effects of Mannitol
- Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid out of the brain and into the bloodstream.
- This decreases cerebral edema.
- Side effects include dehydration, electrolyte imbalances, and renal dysfunction.
- It's important to monitor renal function and fluid balance.
- Used concurrently with hypertonic saline sometimes.
Nursing Interventions to Prevent or Decrease ICP
- Avoid coughing, straining, and Valsalva maneuvers to decrease intrathoracic pressure and the risk of increased ICP.
- Avoid hip/neck flexion.
- Provide support to the family.
- Implement simpler explanations of procedures for the patient and family.
Cerebral Edema
- Three Types of Cerebral Edema:
- Vasogenic Edema
- Cytotoxic Edema
- Interstitial Edema
- Cerebral edema involves an accumulation of fluid in the brain tissue.
- Variety of causes that affect the degree of Cerebral Edema.
Clinical Manifestations of Increased ICP
- Changes in LOC are a result of impaired CBF (cerebral blood flow).
- The most sensitive and reliable indicator of a patient's neurologic status.
Diagnosic Studies for Head Injury
- CT Scan
- MRI
- PET scans
- Transcranial Doppler (TCD) Studies
- Glasgow Coma Scale (GCS)
Cerebral Blood Flow
- Stages of increased ICP:
- Total Compensation
- Compensation
- Compensatory Mechanisms Fail
- Herniation
Discharge Instructions for Concussion
- Report symptoms: worsening headaches, nausea, vomiting, confusion.
- Rest and gradually return to regular activities.
- Avoid driving, alcohol, and hazardous activities.
- Advise family members on issues of memory and concentration, and any other changes/concerns
- Special policies: No driving, no drinking of alcoholic beverages, no driving, no firearms, no work with hazardous implements and machinery, no unsupervised smoking.
Subdural Hematoma
- Bleeding between dura mater and arachnoid membranes.
- Acute occurs within 24–48 hours.
- Symptoms include decreased LOC, headache, and possibly a dilated and fixed ipsilateral pupil.
- Subacute develops over 2–14 days and may expand.
- Chronic develops weeks to months later, especially in older adults.
CSF
- Glucose Test --> Use Dextrostix
- Halo Test --> Drop the fluid onto gauze
- Results if Positive (yellow halo around the blood means CSF is present).
Blood Thinners and Trauma Patients
- Blood thinners increase the risk of intracranial bleeding in trauma patients.
- Closely monitor for delayed signs of hematoma after falls or trauma.
Emergent Interventions for Epidural Hematoma
- Neurological emergency.
- Immediate surgical intervention is required.
- Symptoms include unconsciousness, lucid interval, and deterioration in LOC.
Seizures
- Types: Tonic-clonic, Absence, Myoclonic.
Interventions During a Seizure
- Protect the patient from injury, maintain airway patency, and do not restrain movements.
- Place the patient on their side to promote airway clearance.
Dilantin Administration
- Dilantin should be taken with food, avoid antacids, and don't stop abruptly.
Seizures Precautions in Hospital
- Monitor for signs.
- Keep the bed in a low position, pad side rails, keep airway equipment at bedside.
- Avoid sharp objects, cushion head with a pillow, and suction/oxygen delivery system.
- Maintain a quiet environment.
Status Epilepticus
- Persistent seizure activity that may cause permanent/serious brain damage.
- Any seizure lasting longer than 5 minutes requires immediate intervention.
- Treated with rapid-acting IV medication (lorazepam, diazepam).
- Meds like Dilantin do not stop status epilepticus.
TIA (Transient Ischemic Attack)
- Brief episode of neurologic dysfunction.
- Can be caused by focal brain, spinal cord, or retinal ischemia.
- History of TIA elevates the risk of stroke.
- DO NOT give anticoagulants, such as those used during a heart condition or stroke.
Ischemic vs. Hemorrhagic Stroke
- Ischemic stroke: Interruption of blood flow to part of the brain.
- Hemorrhagic stroke: Bleeding into the brain tissue.
- One main difference is noticeable in the symptoms. Hemorrhagic strokes present very severe headaches, potentially to the extent of being described as the worst a person has ever experienced.
Priority Diagnosis in CVA (Cerebrovascular Accident/Stroke)
- Assess for airway patency, breathing, and circulation (ABC).
- Ischemic vs. hemorrhagic stroke.
Stroke Prevention
- Antiplatelet drugs, like aspirin, are used to prevent thromboembolic strokes.
- Use cautiously with patients on anticoagulants and monitor closely.
Hypovolemic Shock
- Loss of intravascular volume (blood loss, vomiting, diarrhea, drainage).
- Causes decreased perfusion to organs.
- Treatment includes fluids, monitoring, elevate legs/legs elevated, oxygen as needed, and monitoring for fluid overload.
Cardiogenic Shock
- Results from systolic and/or diastolic pump failures, and decreased cardiac output.
- Symptoms include: tachycardia, tachypnea, hypotension, pulmonary congestion (crackles), and narrow pulse pressure.
Sepsis
- Body's response to an infection.
- Signs include: fever/hypothermia, hypotension, tachycardia, tachypnea, elevated RR, altered mental status, and possible warm, flushed skin, which is a result of the inflammatory response. This is part of the compensatory stage, not a definite sign.
- Treatment includes oxygen, fluid resuscitation, and antibiotics.
Anaphylactic Shock
- Life-threatening allergic reaction, leading to hypotension, bronchospasm, and angioedema.
- Treatment includes epinephrine, antihistamines, and corticosteroids. Closely monitor respiratory and hemodynamic status.
Respiratory Interventions
- Oxygen administration
- Mechanical Ventilation
- Respiratory Monitoring
- Monitoring vital signs
- Early identification and treatment of complications.
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