Module 4A Intracranial Regulation PowerPoint PDF

Intracranial Regulation Unit 4 Module 4A Jill Huffman, MSNed, RN Learning Outcomes • Collaborate with the interprofessional team to coordinate high-quality care for patients with increased intracranial pressure. • Implement nursing interventions to help the patie...

Intracranial Regulation Unit 4 Module 4A Jill Huffman, MSNed, RN Learning Outcomes • Collaborate with the interprofessional team to coordinate high-quality care for patients with increased intracranial pressure. • Implement nursing interventions to help the patient and family cope with the psychosocial impact caused by increased intracranial pressure. • Apply knowledge of anatomy, physiology, and pathophysiology to assess patients with increased intracranial pressure. • Use clinical judgment to plan care for patients with increased intracranial pressure. • Teach the patient and caregiver(s) about common drugs for increased intracranial pressure. Learning Resources • Ignatavicius, D. (2021). Pp. 912-922 • Ignatavicius, D. (2021). Study Guide Chapter 41 (questions 18-34) • Silvestri, L. (2023). Pp. 855, 858-859. • ATI RN Adult Medical Surgical Nursing 11.0 – Chapter 14 • ATI RN Nursing Care of Children 11.0 – Chapter 14. Traumatic Brain Injury (TBI) • Damage to the brain from an external mechanical force and not caused by neurodegenerative or congenital conditions. • Can lead to temporary and permanent impairment in cognition, mobility, sensory perception, and/or psychosocial function. • Direct injury – force produced by a blow to the head • Indirect injury – force applied to another body part with a rebound effect to the brain • Acceleration Injury – caused by an external force contacting the head, suddenly placing the head into motion • Deceleration Injury – occurs when the moving head is suddenly stopped or hits a stationary object Traumatic Brain Injury (TBI) • Can be either an open or closed head injury • Head injuries are classified as mild, moderate, or severe, depending upon the Glasgow coma Scale ratings and the length of time the client was unconscious. Types of Brain Injury • Concussion or mild traumatic brain injury • Contusion • Diffuse Axonal Injury (shearing) • Intracranial Hemorrhage Secondary Brain Injury • Process that occurs after the initial injury and worsens or negatively impacts the patient’s outcome. • The result of insufficient oxygen and nutrients to the cells in the brain. • Post Concussion Syndrome – headaches, impaired cognition, vertigo, dizziness. Can last for weeks to months after injury. Most common in mild TBI • Hypotension and Hypoxia – most common cause of secondary injury in moderate to severe TBI • Increased Intracranial Pressure - intracranial pressure (ICP) of 10-15 mmHg is normal, and greater than 20 mmHg is considered detrimental to the brain. Leading cause of death from head trauma. • Hemorrhage – all hematomas are potentially life-threatening because they take up space and are surrounded by edema • Brain Herniation Syndrome – with the presence of ICP the brain tissue may shift and herniate downward. Life-threatening and rapid-response teams must be notified • Hydrocephalus – abnormal increase in the cerebral spinal fluid (CSF) Risk Factors • Motor vehicle accidents or motorcycle crashes • Illicit drug and alcohol use • Sports injuries • Assault/Shaken Baby • Gunshot wounds • Falls Assessment Findings • Amnesia • Loss of Consciousness – length of time is significant • CSF leakage from the nose and ears – “halo sign” • Severe headache • Restlessness and irritability • Personality changes • Dilated or pinpoint pupils • Cranial nerve dysfunction Assessment Findings ● Hypotension ● Hypoxemia ● Hypercarbia (Paco2 greater than 40 to 45 mmHg) ● Alterations in breathing pattern ● Deterioration in motor function (decerebrate, decorticate, flaccidity) ● Cushing’s triad: severe HTN, widening pulse pressure, and bradycardia ● Seizures Subtle changes in blood pressure, consciousness, and pupillary reaction to light can be very informative about neurologic deterioration. Abnormal Posturing “Halo Sign” Important Nursing Assessments ● Airway and Breathing - The first priority!! ○ Injuries to the brain stem may cause major life-threatening changes in the patient’s breathing pattern, such as Cheyne-Stokes respirations and/or apnea ● Spine Precautions ○ Place the patient supine and align the spinal column in a neutral position ○ Cervical collar remain in place until cervical spine injury is ruled out with diagnostic studies ○ Bedrest, no neck flexion with a pillow or roll, not thoracic or lumbar flexion, manual control of the cervical spine anytime the collar is removed, and use of “log roll” procedure to roll the patient. ● Vital Signs Assessment ○ Cushing Triad Important Nursing Assessments ● Neurologic Assessment ○ LOC - Most important variable to assess with any brain injury!! ○ Glasgow Coma Scale - a change of 2 points is considered clinically significant ○ Pupil Response ■ Pinpoint and non-responsive pupils are indicative of brainstem dysfunction ■ Asymmetric pupils, loss of light reaction, or fixed dilated pupils are treated as herniation of the brain from increased ICP. ■ Pupils that are fixed and dilated are a poor prognostic sign (May be referred to as “blown” pupils ○ Severe Headache ○ Nausea and Vomiting ○ Papilledema - edema of the optic disc in the eye. Always a sign of increased ICP ○ Loss of Motor function or dysfunction Lab Tests ● ABGs ● CBC with Diff ● Blood Glucose ● Electrolytes ● Blood and Urine Osmolarity ● Toxicology Screen ● Monitor anti-seizure medication blood levels Diagnostic Procedures ● Cervical Spine films to diagnose cervical spine injury ● CT scan ● MRI of head and neck with and without contrast ● Calculation of cerebral perfusion using the ICP monitor Increased Intracranial Pressure ● Monitored by placing a screw, catheter, or Sensor through a burr hole. ● Expected normal range is 10 to 15 mmHg ● ICP can be increased by: ○ Hypercarbia ○ suctioning ○ coughing ○ extreme neck or hip flexion/extension ○ HOB <30 degrees ○ Increased intra-abdominal pressure (Restrictive clothing, Valsalva maneuver) Nursing interventions to decrease ICP ● Elevate HOB greater than 30 degrees ● Avoid extreme flexion, extension, or rotation of the head and maintain the body in midline, neutral alignment ● Maintain a patent airway ● Administer oxygen as ordered ● Stool softeners to prevent Valsalva maneuver ● Provide a calm, restful environment (limit visitors, minimize noise) Nursing Care ● Provide education and support for the family ● Maintain cervical spine stability until cleared by X-ray ● Report presence of CSF to the provider ● Determine if there are any factors that may impair neurologic responsiveness and affect monitoring. ex drugs or alcohol ● Implement measures to prevent complications of immobility. May need to obtain a specialty bed ● Monitor fluid, electrolytes, and osmolality to detect changes in sodium regulation, onset of diabetes insipidus, or severe hypovolemia ● Provide adequate fluids to maintain cerebral perfusion and to minimize cerebral edema ● Talk to the patient and explain actions being taken and why. The hearing is the last sense affected by a head injury. Nursing Care ● Monitor vital signs every 1 to 2 hours or more often depending on acuity ● Keep HOB elevated at least 30 degrees ● Monitor ABGs ● Monitor for fever - fever from any cause is associated with higher morbidity and mortality rates ● Initiate therapeutic hypothermia if ordered ○ To reduce brain metabolism and prevent the cascade of molecular and biochemical events that contribute to secondary brain injury. ○ Rapidly cool the patient to 89.6 - 93.2 degrees F for 24-48 hours after the primary injury ○ Rewarming requires specialized training because rapid fluid and electrolyte shifts can cause cardiac dysrhythmias and changes to systemic and cerebral pressures. Medications ● Man nitol - An osmotic diuretic used to treat cerebral edema and increased ICP ○ draws fluid from the brain into the blood ○ monitor electrolytes, renal function, and osmolality closely ● Barbiturates - used to place patient in a coma to decrease cellular metabolic demand ○ assessment of neurologic function is impaired ○ mechanical ventilation, cardiac and hemodynamic monitoring, and ICP monitoring are required ● Phenytoin - used to prophylactically prevent or treat seizures ○ dosing is patient specific and based on therapeutic blood levels ● Opioids - used to control pain and restlessness ○ avoid if the patient is not mechanically ventilated due to CNS depressant effects ○ prevents accurate assessment of neurologic assessment ○ can cause respiratory depression ○ administer naloxone to reverse agent if patient becomes overmedicated or does not tolerate Craniotomy ● Removal of nonviable brain tissue and allows for expansion ● Involves drilling a burr hole or creating a bone flap to permit access to the affected area. ● Life-saving procedure ● Many complications including: ○ severe neurologic impairment ○ infection ○ persistent seizures ○ neurological deficiencies ○ death Organ Procurement ● Patients with severe TBI often die and the patient may be an organ donor ● Before brain death is declared, contact the local organ-procurement organization as soon as possible ● Determine if the patient is an organ donor. This information is usually on the drivers licenses, state issued card, or advanced directives ● Some families may not agree with the patients decision to be an organ donor resulting in an ethical dilemma. Many agencies have an ethics specialist or committee who can help with these situations. Health Promotion and Disease Prevention ● Wear helmets when skateboarding, riding a bike or motorcycle, skiing, and playing football or any other sport that can cause a head injury ● Wear seat belts when driving or riding in a car ● Avoid dangerous activities such as speeding, driving under the influence of alcohol or drugs ● Lock up all firearms ● Avoid riding in the back of pickup trucks ● Prevent falls especially in older adults ○ older adults are at a greater risk of complications including systemic and wound infections, diminished coping mechanisms, and complications related to other medical conditions