TBI & Increased ICP Management

Head Injury / Traumatic Brain Injury (TBI)

• Decrease ICP through interventions such as elevating the head of the bed to 30 degrees.
• Avoid passive head ROM, extreme flexion, extension, or rotation.
• Maintain a patent airway, administer oxygen, and use stool softeners to prevent the Valsalva maneuver.
• Steroids can be administered to reduce inflammation.
• Diuretics such as Mannitol, an osmotic diuretic and hypertonic saline help to draw fluid from the brain into the blood.
• Barbiturates induce coma to reduce cellular metabolic demand until ICP decreases.
• Phenytoin is used to prevent or treat seizures prophylactically.
• Opioids are used to manage pain and restlessness.
• Temperature should be monitored due to the potential for very high elevation (104°+) because of loss of autonomic regulation.
• Shivering increases metabolism, decreases glucose can increase ICP and body temperature; decreasing environmental stimuli can help.

Monroe-Kellie Doctrine

• The total volume of the brain (1400 mL or 80%), CSF (150 mL or 10%), and intracranial blood (150 mL or 10%) remains constant; an increase in one component should decrease one or both of the remaining components.

Increased Intracranial Pressure Symptoms

• Signs include altered mental status, severe headache, nausea and vomiting, deteriorating level of consciousness, restlessness, irritability, dilated or pinpoint pupils, and altered breathing patterns like Cheyne-Stokes.
• Cheyne-Stokes breathing involves progressively deeper and faster breathing, followed by a gradual decrease, resulting in temporary apnea, with each cycle taking 30 seconds to 2 minutes.

Increased Intracranial Pressure Causes

• Causes include too much cerebrospinal fluid, bleeding into the brain, swelling in the brain, aneurysm, blood pooling, brain or head injury, brain tumor, infections (encephalitis or meningitis), hydrocephalus, high blood pressure, and stroke.

Halo Testing

• Halo or double-ring test indicates cerebrospinal fluid in bloody discharge from ears, nose, mouth, or head.

SoluMedrol (methylprednisolone)

• Used off-label for acute spinal cord injury; administer 30 mg/kg IV over 15 minutes for the first hour, then 5.4 mg/kg/hr IV by continuous infusion for the next 23 hours.
• Steroids are administered to decrease swelling, but blood glucose levels must be monitored as it may cause an increase in glucose.
• Give as scheduled and taper off when stopping steroid therapy.

Cushing's Triad

• Consists of severe hypertension with a widening pulse pressure (systolic - diastolic) and bradycardia.
• It's a late finding, a precursor to brain herniation, and needs medical intervention immediately.

Coup-Contrecoup Brain Injury

• The shearing force of brain membranes leads to bruising and tearing of brain tissue and blood vessels; this results in ICP.

Uncal Herniation

• A subtype of transtentorial downward brain herniation involving the uncus, typically due to cerebral mass effect increasing intracranial pressure; it can be unilateral or bilateral.

Recovery Expectations

• Patients may not return to their previous state; it is possible to have permanent changes in mental status, personality, and memory.
• Patients recovering from head injury should not be suctioned nor should they bend at the waist, lift, be left alone for poor judgement, or have passive head ROM.

Intracranial Pressure (ICP) Monitoring

• ICP, or "pressure in the skull", is monitored via intraventricular catheter, subdural screw, or epidural sensor.
• Normal ICP is 0-15 mmHg; levels greater than 20 mmHg indicate high mortality.

Cerebral Perfusion Pressure (CPP)

• This is the amount of pressure needed to maintain blood flow to the brain.

Concussion or Mild Traumatic Brain Injury

• Concussions occur after head trauma causing a change in neurologic function without identified brain damage.
• Symptoms usually resolve within 72 hours, and patients typically go home rather than staying in the hospital.
• The patient must return to the hospital if LOC decreases or the patient requires painful stimuli to awaken or is not oriented to person, place, time, or event.

CVA: Left vs Right Side Stroke

• Left-side stroke symptoms include expressive and receptive aphasia (inability to speak and understand language), agnosia (inability to recognize familiar objects), alexia (reading difficulty), agraphia (writing difficulty), right extremity hemiplegia or hemiparesis, slow and cautious behavior, depression, anger, quick frustration, and visual changes, such as loss of visual field in one or both eyes.
• Right-hemisphere stroke symptoms include altered perception of deficits (overestimation of abilities), unilateral neglect syndrome (ignoring one side of the body), loss of depth perception, poor impulse control and judgment, and visual changes like hemianopsia.

Modifiable Risk Factors for Stroke

• Risk factors include smoking, weight, exercise, compliance with medications, blood pressure, and alcohol use, while sex assigned at birth is non-modifiable.

Coumadin (warfarin)

• Used to treat blood clots like PE and DVT and prevent new clots from forming in patients with mechanical valves or atrial fibrillation.
• Dietary considerations include vitamin K which reverses the action of Warfarin, and is found in green leafy vegetables, and thus Quiche Lorraine is not recommended as it contains spinach.
• Blood laboratory tests are often evaluated every 2-4 weeks, monitoring the International Normalized Ratio (INR); the normal INR range is 1.1 for healthy people and 2.0-3.0 for those on warfarin; PT normal range is 11-16 sec.

Fibrolytic Therapy (TPA)

• Fibrolytic therapy is not for hemorrhagic strokes; "time is brain."
• There is a limited time frame from onset of symptoms to administration of fibrolytic therapy; a CT scan must confirm the stroke is not hemorrhagic.
• Contraindications include trauma, bleeding, and recent surgery.

Priority Assessment for Stroke

• Airway, Breathing, Circulation are essential; maintain a MAP of 90 for brain perfusion; NIH (Stoke Scale)

Warning Signs of CVA

• Warning signs include transient ischemic attack (TIA), usually resolving within 48 hours, out-of-control hypertension, confusion, and loss of motor movement on one side.

Stroke Symptoms

• Facial droop, hemiplegia (one-sided extremity weakness), and speech problems are all common symptoms of stroke.

Hemorrhagic Stroke Characteristics

• Hemorrhagic stroke results from a ruptured artery or aneurysm, leading to headache, photophobia, patients often reporting "hearing a pop", and hypertension.

Epidural Hematoma Characteristics

• Epidural hematoma is marked by LOC followed by a lucid interval and a second LOC; Cheyne-Stokes respirations are also common.

Stoke Assessment Key Questions

• Determining when symptoms started is crucial, to determine the time frame for medication or treatment; lower NIH scores are better.
• Provide close monitoring for right-sided stroke patients due to poor impulse control.
• Strokes involve maximizing patient function before discharge; patients need to be functional rather than in nursing homes.

Crainiotomy Interventions and Delegation

• LVNs can perform focused assessments on 2-3 day patients to assess for neuro changes.
• LVNs should not be primary nurses in ICU, ER, OR, or PACU, and should not be delegated admission or discharge teaching and assessments
• Fresh craniotomy (critical) patients should not be cared for by LVNs.

Seizure Nursing Care

• Prioritize safety and place patient safe/rescue psotion.
• Time the length of the seizure and do not leave the patient alone.
• Assist standing patients to the floor; do not restrain them and call for help.
• Important Equipment: suction, padding for the bed, bed in a low position, oxygen, blow-by

Types of Seizures

• Absence seizures primarily affect children involving staring into space with subtle body movements- usually last 5-10 seconds but may happen hundreds of times per day resulting in brief loss of awareness.
• Tonic seizures cause stiffening of muscles (arms legs and back) and ground fall. Atonic seizures cause loss of muscle control (resulting in head drops, sudden collapses/falls).
• Clonic seizures are associated with repeated rhythmic and jerking muscle movements (neck arms and face).
• Myoclonic seizures appear as brief jerks/twitches of arms and legs, often without loss of consciousness.
• tonic-clonic seizures (Grand mal) abrupt loss of consciousness, body stiffening/shaking, loss of bladder control/biting tongue.

diazepam (Valium)

• Used IV for status epilepticus

phenytoin (Dilantin)

• Used as an antiepileptic to prevent and treat seizures.
• Induces hepatic metabolizing enzymes, which may enhance metabolism of vitamin D and decrease vitamin D levels.
• Can give gingival hyperplasia
• Softening and overgrowth of gum tissue, tenderness, and gum bleeding
• Important not to take with dairy and that doses of calcium and anti-seizure medications should be taken at least 2 hours apart, because each interferes with the absorption of the other.
• Monitor the therapeutic range: 10-20 mcg/mL (total) or 1-2 mcg/mL free drug.
• Stop if a skin rash occurs.
• Administer slowly via IV at 50mg/min.
• Avoid use in patients with sinus bradycardia, sinoatrial block, or Stoke-Adams syndrome
• Acute alcoholic intake may increase phenytoin serum levels, while chronic alcoholic use may decrease serum levels.
• May raise glucose levels
• May increase blood levels of warfarin

Lorazepam

• Interventions/What is it used for

Parkinson's Disease

• Progressively debilitating disease grossly impacting motor function, characterized by tremors, muscle rigidity, bradykinesia (slow movement), and postural instability.
• caused by overstimulation of the ganglia by acetylcholine.

Parkinson's Disease Treatments

• Focuses on increasing dopamine and decreasing acetylcholine.

Parkinson's Disease Medications

• Carbidopa/levodopa maintains balance between dopamine and acetylcholine in the extrapyramidal nervous system.
• Does not halt progression- provides relief from dyskinesias and increase ability to perform ADLs
• Function improvements are seen with decreased symptoms and walking without shuffle.

Parkinson's Disease Hospital Care

• Safety measures include elevated toilet seats, chairs with armrests to assist standing, meals cut into small pieces (as cutting motions are difficult), fall-risk precautions, and proximity to the nurses' station.

Meningitis Types

• Meningitis can be bacterial (very contagious) or viral (self-limiting).
• Meningitis is more easily passable/acquired from cramped living conditions

Meningitis Outcomes and Treatments

• Isolation is part of the treatment

Meningitis Assessment

• Assessment findings include excruciating constant headache, nuchal rigidity (stiff neck), and photophobia (sensitivity to light).

Meningitis Lumbar Puncture Test

• A lumbar puncture to analyze cerebrospinal fluid is the diagnostic test for meningitis.
• Lumbar puncture is contraindicated when there is increased intracranial pressure (ICP).
• Encourage the patient to empty the bladder prior to the procedure and must lay flat after the procedure for recovery.

Diabetes Insipidus

• It is characterized by "water wasting," with over 1200 mL per shift.
• Head injury patients may develop diabetes insipidus when there is pressure on the pituitary gland, leading to a deficiency of ADH (Antidiuretic Hormone).
• Also called arginine vasopressin it increases resorption of water in the kidneys.
• It reduces the kidney's ability to collect and concentrate urine resulting in excessive diluted urination, thirst, electrolyte imbalance, and fluid intake.

DI Nursing Considerations

• Nursing considerations include completing fluid replacement, matching I&Os, and monitoring daily weights.

Hydrocephalus Information

• Hydrocephalus is a disturbance of cerebrospinal fluid (CSF) formation, flow, or absorption, leading to increased fluid volume in the central nervous system (CNS).
• Ventriculoperitoneal (VP) shunts drain fluid from the ventricles in the brain into the peritoneum
• VP shunts are used to treat Hydrocephalus
• Tapping/Aspirating shunts may be performed for diagnostic reasons or to reduce fluid off a blocked shunt. More Frequent among infants and adults over 60

VP Shunt Warning Signs

• An altered mental status indicates the shunt failing, and blood pressure is also a concerning vital sign that requires assessment of level of consciousness.

Glasgow Coma Scale (GCS)

• Decreasing level of consciousness increases the risk to the airway; therefore, patients with decreased LOC should not be fed, nutrition/LOC must be assessed, and GCS of less than 8 requires intubation.