Neuro, TBI, ICP (RNUR 2050) PDF

NEURO, ICP RNUR 2050  GCS MOTOR RESPONSE- SCORE 6-1 *Brain Function- Table 42.1* 6- Obey commands- responds to commands, purposeful movement 5- Localizing pain- responds to painful stimuli, purposeful movement in response to pain...

NEURO, ICP RNUR 2050  GCS MOTOR RESPONSE- SCORE 6-1 *Brain Function- Table 42.1* 6- Obey commands- responds to commands, purposeful movement 5- Localizing pain- responds to painful stimuli, purposeful movement in response to pain (reaches toward pain) 4- Withdrawal from pain- responds to painful stim, normal flexion response (pulls away from pain) 3- Abnormal flexion- response to painful stim- Decorticate posturing- (flexion “towards the core”) 2- Abnormal extension- response to painful stim- Decerebrate posturing- (extension and internal rotation) 1- No motor response- absence of response to painful stim  Respiration changes- irregular patterns (ie Cheyne-Stokes) ADDITIONAL SIGNS Pupillary and Oculomotor OF DETERIORATION responses- (shape/size of pupil, eye movement- Doll’s eye response) Level of consciousness- (see CVA lecture slide)  Injury of skull, scalp, or brain Leading cause of death and disability in the US for TRAUMATIC children and adults up to 44 BRAIN (Brain Trauma Foundation, INJURY (TBI) 2024) Results in disability: Cognition Movement Sensation Sensation Emotions  Blasts- military personnel Crashes- bike, motorcycle, cars Falls- adults over 75 CAUSES Violence- Sports injuries- At least half of TBIs involve alcohol or drug use  Contact phenomena- struck by moving object (ie, swinging a bat) Acceleration-deceleration injury- head hits an object and brain rebounds within skull Coup- injury at point of impact MECHANISM OF Contrecoup- injury at opposite INJURY side Compression or tension Rotational injury- twist or shearing https://youtu.be/55u5Ivx31og?si= YTXwP-ZLQHf5kKQf  Please review *Tables 42.7 and 42.8* SKULL FRACTURES Linear skull fracture 75% of cranial trauma Results from large impact to skull Benign unless middle meningeal artery nicked and then epidural hematoma is formed Depressed skull fracture Indentation forms – “ping-pong” appearance May cause skull & fragments to press into brain tissue hematoma forms on top  Basilar skull fracture Frontal, ethmoid, sphenoid, temporal or occipital bones Racoon’s eyes- Periorbital ecchymosis Battle’s sign- Ecchymosis over mastoid bone Halo Sign- CSF leakage from nose or ears check for glucose ring  Damage to brain at point of impact and rebound effect Contusion- bruise on surface of the brain Epidural hematoma- develops in space between dura and skull Usually results from skull fracture that tears FOCAL INJURIES- artery Most common- temporal bone CONFINED TO Subdural hematoma- blood collects between ONE AREA OF THE dura and arachnoid matter BRAIN More common than epidural- anywhere in cranium Acute develop within 48 hours of injury Intracerebral hematoma- directly in brain tissue Most common- frontal/temporal region  Damage caused by shaking with twisting movement (rotational injury) Mild concussion- “violent shaking”- momentary interruption of brain function Immediate, brief loss of consciousness on impact Amnesia immediately before DIFFUSE INJURY- (antegrade)/after (retrograde) injury is common AFFECTS ENTIRE Cerebral concussion- diffuse cerebral BRAIN disconnection from brainstem Immediate loss of consciousness lasting less *SEE PG. 1581 than 6 hours Antegrade/retrograde amnesia occurs with possible cerebral contusion Seizure, respiratory arrest, bradycardia, hypotension may be present Postconcussion syndrome Diffuse axonal injury- high- speed acceleration- deceleration injury Typically with MVC Immediate LOC with coma Causes 50% of brain injuries and 35% of deaths  PREVENTION Helmets Seatbelts Lock up firearms Safety with dangerous activities Fall prevention- ages 65+ Higher rate of anticoagulants Dura has adhered to skull  Most TBI clients require intensive care at trauma center Concussions- mild- observe in ED then home with instructions if LOC for more than 2 minutes, admit for observation TREATMENT Acute TBI- Fluids to keep BP above 90 mmHg- hypertonic saline reduces ICP Assess for ABCs ICP monitoring Osmotic diuresis- mannitol to reduce ICP  SURGICAL INTERVENTIONS Burr hole- hole in skull to evacuate clot Craniotomy- surgical opening in cranial cavity Craniectomy- complete removal of portion of skull (brain flap) Emergency, Life-saving procedures Goal is to decrease cerebral edema Med with mannitol, dexamethasone Monitor for infection, change in ICP  BURR HOLE DRAINAGE https://youtu.be/H0vO_y18-yY?si=7NOdcVvHhn5XK5sx  CRANIOTOMY AND CRANIECTOMY https://youtu.be/N7-wNsANn8g?si=ILS7Il9EWH-mC6uf  Normal Pressure 5 to 15 mmHg Monitored by screw, catheter, or sensor INTRACRANIAL PRESSURE Client with TBI is at high risk for increased intracranial pressure (IICP) Overhydration from rapid IV fluids increases ICP  MONITORING INTRACRANIAL PRESSURE Signs of IICP Monitor GCS, LOC, pupils Bradycardia Breathing pattern changes- slow (early), rapid (late) Vomiting, headache, changes in mentation- early indicators of IICP Monitor temp and hypothermia treatment- Hyperthermia- may increase ICP Osmotic diuretics (mannitol)- may cause hypotension and decreased cardiac output Seizures  **LATE SIGN** Cushing’s triad- 1. Bradycardia 2. Widened pulse pressure (high systolic and low diastolic) 3. Irregular respirations (Cheyne-Stokes) Medical emergency- must reduce ICP and treat symptoms *Indicates impending herniation  Life-threatening “Brain Code” Downward shift of brain tissue due to cerebral edema Limited space in brain- shifts BRAIN contents HERNIATION Findings: Fixed, dilated pupils Deteriorating LOC Cheyne-Stokes respirations Abnormal Posturing  ACTIONS TO DECREASE ICP Elevate Elevate HOB to 30 degrees Maintain Maintain midline, neutral position of head Maintain Maintain airway, O2 above PaO2 60 mmHg Hyperventilate mechanical vent –brief periods to Hyperventil decrease ICP ate -causes vasoconstriction and reduced cerebral blood flow Avoid Avoid Valsalva maneuver, prolonged suctioning Calm Calm environment, limit visitors/noise  Mannitol- osmotic diuretic Draws fluid from brain into blood IV for acute cerebral edema Monitor electrolytes, fluid status, urine output Phenytoin- anticonvulsant Prophylactically prevent/treat seizures MEDICATIONS Requires therapeutic levels Barbiturate- sedative/hypnotic Reduces cerebral metabolism Places client in coma (pentobarbital) Requires mechanical vent, hemodynamic/cardiac monitoring, ICP monitoring  Encourage self-care and independence Avoid additional head injuries Avoid alcohol Write things down if memory is affected EDUCATION Therapy for lost skills TOPICS (speaking, walking, reading) Vocational counseling Medical equipment needs Support groups (client and family)  TBI RECOVERY VIDEOS https://youtu.be/pJlEwRPrI04?si=dUkIAU1xT6CBAkhL Brett https://youtu.be/5xjxs1OIOiE?si=8Mb8QCe6inYf3MaY Ryan A NURSE IS CARING FOR A CLIENT WHO HAS A. Hyperglycemia INCREASED ICP AND A NEW ORDER B. Hyponatremia FOR MANNITOL. FOR WHICH OF C. Hypervolemia THE FOLLOWING ADVERSE EFFECTS D. Oliguria SHOULD THE NURSE MONITOR?  B. Mannitol is a powerful diuretic. Adverse effects include electrolyte imbalances such as hyponatremia. A NURSE IS CARING FOR A CLIENT WHO WAS A. Keep neck stabilized ADMITTED FOLLOWING A MVC. B. Insert NG tube THE CLIENT IS C. Monitor pulse and BP UNRESPONSIVE, HAS RESPS OF frequently 22/MIN, AND HAS A D. Establish IV access LACERATION ON and start fluid HIS FOREHEAD. replacement WHICH OF THE FOLLOWING IS THE PRIORITY?  A. The greatest risk is permanent damage to the spinal cord if a cervical injury exists. The priority is to keep the neck immobile until cervical spine injury has been ruled out. The rest are correct but not the priority. A NURSE IS A. Glascow Coma CARING FOR A CLIENT WHO HAS Scale JUST BEEN ADMITTED B. Cranial nerve FOLLOWING function SURGICAL EVACUATION OF A C. Oxygen SUBDURAL HEMATOMA. saturation WHAT D. Pupillary ASSESSMENT IS THE PRIORITY? response  C. Airway, breathing, circulation are the priority. Brain tissue has permanent damage from prolonged hypoxia. The others are important, but not the priority  A. Suction the ET tube WHEN CARING frequently FOR A CLIENT WITH A CLOSED- B. Decrease the noise HEAD INJURY level in the room WITH ELEVATED ICP OF 16MMHG, C. Elevate the client’s WHICH ACTIONS head on 2 pillows DECREASE THE POTENTIAL FOR D. Administer a stool FURTHER softener RAISING THE ICP? SATA E. Keep the client well hydrated.  B, D A. Suctioning increases ICP and should be performed when needed C. Hyperflexion of the neck can increase ICP. HOB should be raised to at least 30 degrees, but head should upright and neutral position. E. Overhydration can increase ICP and should be avoided. Monitor fluid and electrolyte levels closely WHEN COMPLETING AN A. Headache ADMISSION ASSESSMENT B. Dilated pupils ON A CLIENT C. Tachycardia WITH A GSW TO THE HEAD, D. Decorticate WHAT FINDINGS posturing INDICATE INCREASED ICP? E. Hypotension SATA  A, B, D C. Bradycardia, not tachycardia, is associated with increased ICP E. Hypertension, not hypotension, is a finding of increased ICP