Cerebral Disorder (PDF) - Increased Intracranial Pressure & Stroke

Increased Intracranial Pressure Cerebral Vascular Disorders  Learning Objectives  Describe the causes, clinical manifestations, and medical management of various neurologic dysfunctions.  Use the nursing process as a framework for care of the multiple needs of the pa...

Increased Intracranial Pressure Cerebral Vascular Disorders  Learning Objectives  Describe the causes, clinical manifestations, and medical management of various neurologic dysfunctions.  Use the nursing process as a framework for care of the multiple needs of the patient with altered level of consciousness.  Identify the early and late clinical manifestations of increased intracranial pressure.  Apply the nursing process as a framework for care of the patient with increased intracranial pressure.  Describe the incidence and impact of cerebrovascular disorders.  Learning Objectives  Identify the risk factors for cerebrovascular disorders and related measures for prevention.  Compare the various types of cerebrovascular disorders: their causes, clinical manifestations, and medical management.  Explain the principles of nursing management as they relate to the care of a patient in the acute stage of an ischemic stroke.  Use the nursing process as a framework for care of a patient recovering from an ischemic stroke.  Apply the nursing process as a framework for care of a patient with a hemorrhagic stroke.  Discuss essential elements for family education and preparation for home care of the patient who has had a stroke.  Intracranial Pressure  ICP is a measurement of the pressure of the brain tissue and the CSF that cushions and surrounds the brain and spinal cord.  ICP is the pressure inside the skull  Factors that influence ICP  Arterial Pressure  Venous Pressure  Intraabdominal and intrathoracic pressure  Posture  Temperature  Blood gases (CO2 levels)  ICP  Transient activities – not harmful  Coughing, sneezing, straining, bending forward  Sustained  ICP – tissue ischemia  Cerebral edema, head trauma, tumors, stroke, inflammation, hemorrhage,  CSF, birth trauma, hydrocephalus  Monroe-Kellie Hypothesis  The intracranial space comprises three compartments  Brain substance (80%)  Cerebrospinal fluid (10%)  Blood (10%)  Changes in any of the three components can lead to change in ICP  Under normal conditions, the normal ICP is 0 to 15 mmHg mean pressure. Elevated if >22 mmHg.  Regulation and Maintenance  Normal compensatory mechanisms  Change in CSF volume  Increased absorption  Change in intracranial blood volume  Change in tissue brain volume Ability to compensate starts to fail  If volume increase continues, ICP rises and leads to decompensation  Herniation may occur  Autoregulation  The normal brain has a complex capacity to maintain a CBF despite wide ranges in MAP  This effect is known as autoregulation  MAP of 50 to 150 mmHg does not alter CBF when autoregulation is present  Cerebral Perfusion Pressure (CPP)  Pressure needed to ensure blood flow to the brain is called CPP  Blood Pressure and Intracranial pressure affect the CPP  CPP is the difference between the MAP and Intracranial pressure (ICP)  Normal CPP is 60 to 100 mmHg  What does this mean?  If the blood pressure is low and/or the intracranial pressure is high the blood flow to the brain may be limited  Cerebral Perfusion Pressure (CPP)  Cerebral hypoperfusion occurs when CPP drops to 40 to 60 mHg  Irreversible ischemia and infarction result when CPP is less than 40 mmHg  CPP of 0 to 40 mmHg signifies brain death  Factors Affecting CBF  Acidosis  Alkalosis  Changes in metabolic rate  Hypoxia: vasodilatation  Ischemia  Hypercapnia: vasodilatation  Hypocapnia: vasoconstriction  Volume Pressure Curve  The brain can tolerate significant increases in intracranial volume without much increase in ICP  The amount of intracranial compliance is limited  Once that limit is reached, a state of decompensation with increased ICP results  As ICP rises, the relationship between volume and pressure changes  At this point, even small increases in volume may cause major elevations in ICP  Mechanisms of ICP Elevation Disorders of CSF Space  Overproduction of CSF  Choroid plexus papilloma  Rare type of benign brain tumor  Hydrocephalus  “Water on the brain”  Interstitial edema Mechanisms of ICP Elevation Disorders of Intracranial Blood  Intracranial hemorrhage  Vasospasm  Vasodilatation  Increased intracranial blood volume  Mechanisms of ICP Elevation Disorders of Brain Substance  Expanding mass lesion with local vasogenic edema causing increased ICP  Brain tumors  Ischemic brain injury with cytotoxic edema increasing ICP  Increased cerebral metabolic rate increasing cerebral blood flow and ICP Glasgow Coma Scale (GCS)  Early Signs & Symptoms Of Increased ICP  Restlessness  Blurred vision  Irritability  Diplopia  Personality changes  Decreased visual  Agitation acuity  Lower GCS  Ptosis  Decreased grasp  Delayed or sluggish  Early morning reactivity headache with  Unilateral change in pupil size nausea & vomiting  Slow or slurred speech  Dysarthria  Late Signs & Symptoms of Increased ICP  Difficult to arouse  Flaccidity  Decreased GCS  Only posturing to painful  Unilateral pupil stimulus enlargement  Worsening headache with  Bilateral fixed, dilated projectile vomiting pupil  Only groaning/moaning to  “Blown pupil” painful stimulus  Dense weakness  Irregular respirations  Decorticate or decerebrate posturing  Cheyne-Stokes respirations  Rising systolic BP  Central neurogenic  Widening pulse hyperventilation pressure  Respiratory arrest  Late Signs & Symptoms of Increased ICP  Temperature changes  Tachycardia  Cushing’s response  Sinus bradycardia  Rise in systolic blood  Heart blocks pressure  Widening pulse pressure  Agonal rhythm  Bradycardia leading to cardiac  Irregular breathing arrest  Absent gag reflex  Absent corneal reflex  Babinski reflex  Stroke Statistics According to American Stroke Association: About 795,000 people in the United States suffer a new or recurrent stroke every year Stroke is the 5th leading cause of death in the United States Stroke is the leading cause of disability Transient Ischemic Attack (TIA) TIAs are also known as “warning strokes” or “mini strokes” This occurs when blood flow to a vessel in the brain is briefly blocked or reduced Symptoms resolve rapidly A person who has a TIA is 9.5 times more likely to have a major stroke TIAs are a Medical Emergency!  Common Risk Factors for Stroke  Age > 45 years  Ethnicity (Black,  History of TIA, previous stroke Hispanic) or myocardial infarction  Smoking  Atrial fibrillation (increases  Sedentary style risk 5-fold)  Substance abuse or  Sleep apnea alcoholism  Obesity  Female gender (women ages 55-75 have a  Hypertension slightly higher risk of stroke compared to men)  Heredity 80% of all strokes are preventable by: Eating Healthy Exercise Annual physicals Take medications like prescribed Control and reduce stress Stop smoking Limiting alcohol use Knowing your risk factors The Major Circulation to the Brain What Parts of the Brain are Affected by a Stroke?  What Are the Effects of a Stroke?  Right Brain  What Are the Effects of a Stroke?  Left Brain What Should You Do If You See Signs of a Stroke? You Should – Act Time is Brain  During a Stroke about 2 million brain cells die every minute  Every Second, 32,000 neurons die When Does the Hospital Activate a Stroke Alert? When EMS pre-notifies of in coming stroke patient. and When a patient has sudden neurological symptoms within 24 hours of last known well. Signs of a Stroke  Sudden numbness or weakness of the face, arm or leg, especially on one side of the body  Sudden confusion, trouble speaking or understanding  Sudden vision changes; blindness or trouble seeing out of one or both eyes  Sudden trouble walking, dizziness, loss of balance, or coordination  Sudden severe headache, with no known cause  The Golden Hour  The AHA and American Stroke Association (ASA) developed the 60-minute or less stroke protocol with a goal of intervention within 60 minutes upon arrival to the Emergency Department  Types of Stroke Ischemic: A blood vessel in the brain is blocked by plaque or a blood clot This is the most common type of stroke Hemorrhagic: (SAH and ICH) A blood vessel inside the brain bursts The blood from the burst blood vessel takes up space meant for brain tissue  Stroke Treatments  A medication that can  Goal: break clots (clot buster)  Achieve a Door to called tissue Needle (DTN) time plasminogen activator within 60 minutes on (tPA) may improve the 75% of Ischemic stroke chances of getting better patient treated with IV tPA  The medication is time sensitive, meaning the person only has 4.5 hours from the time symptoms started to get treatment  Contraindications for t-PA  Recent history of CVA, intracranial neoplasm, aneurysm or AV malformation  Recent trauma or surgery/procedure less than 2 months  Active internal bleeding  Prolonged or traumatic CPR  Suspected aortic dissection  Pregnancy  Diabetic hemorrhagic retinopathy  Severe uncontrolled hypertension greater than 185/110 mm/Hg  Known bleeding diathesis  During t-PA Administration  Check BP every 15 min for 2 hours  Treat hypertension/hypotension as ordered  Monitor Neuro status every 30 min x4  Watch for bleeding – puncture sites, urine, stool etc.  Know signs/symptoms of Intracerebral Hemorrhage  Any acute neurological deterioration  New HA  N/V  Sudden HTN  Medical Management  ABC’s  Surgical decompression if infarction is large  Thrombolytic therapy  Carotid endarterectomy  Carotid angioplasty Neuro-Intervention Services For Ischemic Strokes: For Hemorrhagic Embolectomy is a Strokes: procedure that can Coiling, or stenting, remove large clots in and clipping through the brain. Neuro Surgery are Treatment is only other type of available up to 24 treatments available. hours from the time symptoms started.  Neuro Intervention Procedure: Embolectomy  PENUMBRA  That tissue surrounding the infarct that is salvageable, but at risk  Best visualized on MRI Rapid transfer to the stroke center will allow for protection of penumbra through emergency interventions and medical management  Hemorrhagic Strokes  Subarachnoid Hemorrhage  Intracerebral Bleed  Subarachnoid Hemorrhage (SAH)  SAH is a common and devastating condition  Risk Factors  SAH affects 30, 000  Hypertension persons annually in the united states  Smoking  Cocaine-related to SAH occurs in  Heavy alcohol younger patients use  45% -30 day  Female gender mortality rate after SAH  Subarachnoid Hemorrhage (SAH)  Bleeding into the subarachnoid space  Rupture of cerebral aneurysm  Bleeding from a cerebral tumor  Pathophysiology of SAH Cerebral Aneurysm  Sac like  Berry like  Frequently occur at the base of the circle of Willis  Stress develops on the poorly developed vessel wall, especially with rising BP  Vessel wall becomes thin and ruptures  Blood enters the subarachnoid space  Acute Evaluation-Diagnosis  “The worst headache of my life” or “explosive headache” is described by 80% of the patients  Nausea/vomiting  Stiff neck  Loss of consciousness  Focal deficits occur  Pathophysiology of SAH Arteriovenous Malformation  AVM is fed by one or more cerebral arteries known as “feeders”  Enlargement over time which in turn increases the size of the AVM  Pressures in the venous portion increase, leading to vessel rupture  Cerebral atrophy is common as the result of shunting of normal blood flow through the AVM and away from cerebral circulation  Assessment and Diagnosis  Severe headache  Cranial nerve deficits  LOC  Diagnostic CT scan  Vomiting  Cerebral angiogram (later)  Focal neurological deficits  Nuchal rigidity  Stiff neck  One or more previous incidents of headache accompanied by nausea and vomiting (warning leaks)  Subarachnoid Hemorrhage Medical Management  Medical emergency  Preservation of neurological function is the goal  ABC’s  Ventriculostomy to control ICP if the patient’s LOC is depressed  Surgical aneurysm clipping  Cerebral aneurysm coiling  Surgical AVM excision  Cerebral Aneurysm Coiling  Gamma knife embolization  Oral nimodipine Aneurysm Coiling and Clipping Gamma Knife Radiosurgery  Tiny beams of radiation on a tumor or other target  Extremely accurate  Subarachnoid Hemorrhage Rebleeding  Incidence is 20% to 30% in the first month  Mortality is 50% to 80%  BP control essential to prevent rebleeding  Maintain systolic BP < 150 mmHg  Fluctuations in BP may be more significant than the absolute value  Subarachnoid Hemorrhage Cerebral Vasospasm  Presence or absence of vasospasm significantly affects the outcome of SAH  50 % of all patients will develop some degree of vasospasm  Can lead to ischemic stroke  Onset is usually 3 to 5 days after initial hemorrhage and can last 3 to 4 weeks  Intracerebral Hemorrhage (ICH)  Bleeding directly into cerebral tissue, usually from a small artery  AVM rupture  Aneurysm  Trauma  Hypertensive hemorrhage  Blood dyscrasias  Anticoagulation therapy  Brain tumors  Intracerebral Hemorrhage (ICH)  Continued elevated BP leads to increased pressure on cerebral arteries causing rupture  Sudden onset of severe headache  ICP rises quickly  Unconsciousness common  Cushing’s response  Deep labored respirations  Nursing Care of Stroke Patients  Support airway, breathing and circulation  Provide supplemental oxygen to maintain oxygen saturation > 94% in hypoxic patients.  Ventilator support for respiratory depression, fatigue, decreased consciousness or a compromised airway.  Monitor vital signs at least every 15 minutes.  Neurologic assessments should be performed hourly or as needed.  Monitor for signs of brain stem herniation (increased intracranial pressure, decreased strength in extremities, focal or global seizure activity, or asymmetrical pupils.)  Monitor for seizure activity, implement seizure precautions.  Nursing Care of Stroke Patients  Treat hyperthermia with antipyretic medications  Tylenol  Treat hyperglycemia to keep blood glucose levels between 140-180 mg/dL and treat hypoglycemia (blood glucose < 60 mg/dL) per protocol  Keep the head of bed elevated at a minimum of 30 degrees unless contraindicated  Screen for dysphagia  Difficulty swallowing  Monitor VS especially BP  Implement DVT prophylaxis measures as ordered  Practice Question The nurse admits a patient to the ED with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a) Assess for the presence of a headache b) Assess the patient’s general orientation c) Determine the patient’s drug allergies d) Determine the time of symptom onset  Practice Question A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition? a) Widening pulse pressure b) Decrease in the pulse rate c) Dilated, fixed pupil d) Decrease in LOC