Week 10 - Acute Intracranial Regulation, TBI, Meningitis, Encephalitis Student Notes PDF

8/9/2024 Week 10 – Acute Intracranial Problems, Traumatic Brain Injury, Meningitis, Encephalitis Elizabeth Martin, MSN, RN, MFCS 1 1 Do on your own. Neurological...

8/9/2024 Week 10 – Acute Intracranial Problems, Traumatic Brain Injury, Meningitis, Encephalitis Elizabeth Martin, MSN, RN, MFCS 1 1 Do on your own. Neurological Assessment Chapter 60 2 2 1  8/9/2024 CONCEPT: INTRACRANIAL REGULATION EXEMPLARS: TRAUMATIC BRAIN INJURY BACTERIAL MENINGITIS ENCEPHALITIS 3 3 NCLEX Test Plan 4 4 2  8/9/2024 Weekly Readings/Lesson Plan 5 5 Intracranial Regulation Will learn more about ICP in Concepts III 6 6 3  8/9/2024 Brain Pathophysiology = 100% 7 7 ICP Pathophysiology 8 8 4  8/9/2024 Terminology Mean arterial pressure (MAP) – Is the lower limit of systemic arterial pressure for perfusion – Need to have a MAP of greater than _____ mmHg to perfuse the brain 9 9 What Affects Blood Flow to Brain? 1. Carbon dioxide CO2 is a vasoDILATOR = decr. resistance in the brain = increases cerebral blood flow A low CO2 constricts the cerebral vessels = incr. cerebrovascular resistance and decreased cerebral blood flow 2. Oxygen 3. Hydrogen ion concentrations – Acidic environments = vasoDILATION 4. Other: – Cardiac/resp arrest, systemic hemorrhage, diabetic coma, encephalopathy, infections, trauma, tumors, stroke 10 10 5  8/9/2024 Common Cause of ICP intracranial swelling or edema – From incr. fluid accumulation in the extravascular spaces – Ex: Infection: encephalitis, meningitis Trauma/surgery: contusion, hemorrhage, post-traumatic brain swelling Lesions/masses: abscesses, tumors, hematoma, hemorrhage Vascular: venous thrombosis or embolism, strokes Toxic: hepatic encephalopathy, lead, arsenic, uremia 11 11 Clinical Manifestations 12 12 6  8/9/2024 Complications Herniation Death Infection Brain damage 13 13 Nursing Response - GCS 14 14 7  8/9/2024 Nursing Assessment - Neuro Neuro – Pupils Size, shape, movement, reactivity – Eye movement How? – Test motor strength How? On unconscious pt? – VS 15 15 Nursing Response – Acute Care NEURO LOC? Avoid noxious stimuli Quiet, dark room Approach quietly, calmly, nonthreatening Sedation with meds Manage pain and anxiety Avoid coughing, sneezing, vomiting, straining Seizure precautions (see next slide) 16 16 8  8/9/2024 Seizure Precautions 17 17 Nursing Response – CV Electrolyte monitoring and replacement IVF fluids –Which one? Strict I&Os –Why? Weigh ________________ Monitor for SIADH (LOW conc UOP) and DI (high UOP and diluted) –Why? 18 18 9  8/9/2024 Nursing Response - Resp Monitor for oral obstructions – Suction prn but not too frequently Why limit? _________ Less than ____ sec per duration Hyper O2 before, during, after Limit to _____ passes Evaluate ABGs as drawn Types of breathing – Cheyne-Stokes – Ataxic breathing 19 19 Nursing Response – GI/GU/MS GI/GU MS Proper head positioning: HOB GI up 30 degrees, midline, avoid May need: NGT to LIWS (or extreme neck flexion Orogastric tube) Turn pt SLOWLY, gentle movements GU Avoid hip flexion Indwelling urinary cath Monitor posturing and for abnormal Skin care with each turn 20 20 10  8/9/2024 Encephalitis 21 21 Encephalitis - Causes What is it? Causes: – Viral, fungal, parasitic – Ticks, mosquitos (West Nile virus) – Herpes simplex virus (HSV) – Complications of measles, chickenpox, mumps, cytomegalovirus (CMV in AIDS pts) 22 22 11  8/9/2024 Clinical Manifestations – Encephalitis Nonspecific with – Fever – HA – NV – Minimal change in LOC to coma – Any CNS problem (tremor, seizures, paralysis, etc) 23 23 Diagnosis - Encephalitis CT scan EEG MRI PET scan Serum IgM antibodies to the virus Cerebral spinal fluid 24 24 12  8/9/2024 Medical Treatment – Encephalitis Treat symptoms Supportive care Prevent increased ICP If a herpes virus – treat with acyclovir Seizure precautions Prophylactic antiseizure drugs 25 25 Bacterial Meningitis 26 26 13  8/9/2024 Pathophysiology & Etiology Pathophysiology – Acute inflammation of the meningeal tissue surrounding the brain and spinal cord – Highly contagious Etiology – Staph, strep, H. influenzae – Viruses, fungi – URI – CSF leaks 27 27 Clinical Manifestations – BM Fever Severe HA NV Nuchal rigidity Photophobia Decr. LOC Coma Seizures Irritability Skin rash – non-blanching Petechia on trunk, lower extremities, mucous membranes 28 28 14  8/9/2024 Complications of BM IICP Residual neurologic dysfunction Blindness, Ptosis, Unequal pupils, Diplopia, Decr. corneal reflex Tinnitus, vertigo, deafness Hemiparesis, dysphagia, hemianopsia Has Hydrocephalus DIC, shock 29 29 Diagnostic Testing - BM CT scan/ MRI/ Xrays Blood cultures Labs: – Which ones? __________________________ Lumbar puncture and examination of CSF – bacteria/viruses: _______________ – WBCs: ________________ – Proteins: ________________ – Glucose: _________________ – Color/Clarity: ___________________ 30 30 15  8/9/2024 Medications - BM IV ATB – Ampicillin, PCN, cephalosporins (ceftriaxone) Codeine – why? Dexamethasone – why? APAP or ASA – why? Phenytoin or levetiracetam IV – why? Mannitol IV – why? 31 31 Nursing Interventions - Vaccines Health Promotion 32 32 16  8/9/2024 Nursing Response – BM - Acute Care Place in respiratory isolation Indwelling urinary cath until cultures are neg. Weight: ________ Promote rest H-T, focused assessments q____h Med. For temp Assist pt to position for comfort and _____ pillow under head IVF (which type?) Keep room dark, cool, decr. noise, Administer IV ATB decr. blankets on bed (cover with Monitor neuro status and LOC sheet) ______2h and prn Avoid shivering VS q______h and prn Cooling blanket Strict I&Os Minimize environmental stimuli Fall precautions Seizure precautions 33 33 Head Injuries 34 34 17  8/9/2024 Pathophysiology & Etiology - HI Pathophysiology – Any injury or trauma to the scalp, skull, brain – Associated with poor outcomes Etiology – Falls – MVAs – Firearms – Assaults – Sports-related injuries – War-related injuries 35 35 Types of Head Injuries Traumatic brain injury (TBI) Scalp lacerations 36 36 18  8/9/2024 Types of Head Injuries – Skull Fx Skull fractures 37 37 Skull Fx - Manifestation 38 38 19  8/9/2024 Rhinorrhea 39 39 Otorrhea Confirms that a fx has gone into the skull and dura See increased risk for meningitis 40 40 20  8/9/2024 Types of Head Injuries - Concussion Head Trauma – Classified as minor, moderate, severe – Generalized (diffuse) concussion 41 41 Types of Head Injuries – Contusion, hematoma, coup-contercoup Head Trauma – Localized (focal) Lacerations, contusion, hematoma, coup-contrecoup 42 42 21  8/9/2024 Complications - HI Death Intracranial infections Hematoma – Epidural – Subdural – intracerebral Meningitis Brain tissue damage 43 43 Diagnostic Studies - HI CT scan MRI PET Transcranial doppler studies Cervical spine X-ray 44 44 22  8/9/2024 Medical Management – Surgery - HI Craniotomy – Depressed fx and fx with loose fragments – hematomas Craniectomy with cranioplasty – If large amounts of bone is destroyed: Burr hole openings: ICP 45 45 Types of brain surgery 46 46 23  8/9/2024 Emergency management of head injury 47 47 Helpful hints of warning signs of head injury 48 48 24  8/9/2024 Nursing Response – Health Promotion 49 49 Patient caregiver teaching of head injury 50 50 25  8/9/2024 Nursing Response – Acute Care - Goal Acute care Goal: maintain cerebral O2 and perfusion, and prevent ischemia Emergency management: on previous slide 51 51 Nursing Response – EENT/GI EENT GI ❑Rhinorrhea or otorrhea ❑NGT to LIWS – Test with dextrostick – if __= CSF leak – Check placement q_____h – Let HCP know _____ CSF leak – Check for skin breakdown – Apply sterile nasal sling q____h – Notes color, appearance, amount – Oral care q____h – Note and document: color, amount – Try to avoid sneezing or blowing nose – Do NOT nasotracheal sx pt with rhinorrhea – incr. incidence of meningitis 52 52 26  8/9/2024 Nursing Response – N/Misc Neuro MISC Antibiotics IV Cold compresses to bruising Neuro checks q_____h and prn Monitor VS q_______h and prn GCS q______h and prn If temp: administer antipyretics Monitor for changes in LOC, affect, HOB up behavior, demeaner Assess bladder and bowel Lubricate eyes or tape eyes shut to functioning prevent abrasions Assess skin and perform skin care Seizure precautions for any open areas Medicate for N/V See if pt has POA, living will 53 53 Nursing Response – Ambulatory Care - Rehab Acute rehab management Bowel and bladder management Motor Psychosocial Sensory deficit Support – may have PTSD or amnesia Communication Support caregiver Memory Do NOT drink ETOH Intellectual functioning NO driving May develop seizure disorder No use of firearms Nutrition NO working with hazardous or sharp ?dysphagia instruments NO unsupervised smoking 54 54 27  8/9/2024 questions 55 55 28