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PC ICP Inadequate perfusion Herniation - one sided (uncal or transitory)= ipsilateral blown pupil, ipsilateral paralysis, unconsciousness, altered VS (Cushing's response bradycardia, hypotension, Bradypnea); both sided = symptoms on both sides, two blown pupils, etc. Pathology Changes in level of arousal/consciousness r/t Ascending Reticular Activating System & Cortical Effects Hemodynamic, global or generalized changes r/t Altered intracranial volume-pressure relationship Focal/localizing signs r/t Functional changes based on location of lesions Lobe/CNS dysfunctions r/t Compression of CNS structures Regional, global effects r/t Interference in CSF & blood flow Necrosis of hemispheric regions r/t Ischemia Brain stem dysfunctions: CN III-XII Loss of autoregulation-> Cushing’s triad Interference with neuronal pathways -> Motor,sensory loss Altered blood-brain barrier Altered reflexes and autonomic functions ND Altered thought process - r/t cerebral pressure Altered cerebral tissue perfusion r/t decreased blood flow and flow of ICF Risk for injury r/t change in LOC Disuse syndrome r/t loss of function associated with Risk for aspiration r/t cranial nerve disfunction Ineffective thermoregulation Ineffective breathing pattern Inability to sustain spontaneous ventilation r/t barbiturate coma Planning and Implementation Acute o Respiratory - ventilation o CPP and ICP management - measure and prevent raise/lower o Fluid and electrolyte balance - monitor sodium and serum osmo(290) o Body positioning - BP low = flat, if BP norm and ICP = 30degree elevation o Family support Therapeutic management o Head positioning - do not flex or hyperextend, do not use trach tie - use tape instead o Space nursing activities - all activities ICP so space them out, do not do more than two things (ie take VS, turn, rest. Suction, VS, rest. Bath, rest) o Avoid valsalva maneuvers and hip flexion o Short term hyperventilation therapy - closely monitored, used to blow off CO2 o Prevent and tx seizures and fever (r/t increased basal metabolic rate) hypothalamic threshold can be disabled, tx fever as low as 100 o Suction - prn only! and preoxygenate always, no more than 2-3 passes o Monitor and maintain fluid balance - avoid plain D5W due to hypotonicity after usage of dextrose o Prevent hypoxia and hypercarbia - keep PaCO2 on low end of normal o Nutritional therapy need for glucose r/t hypermetabolic and hypercatabolic state Keep patient normovolemic - strict I&O o Meds for Cerebral Edema Osmotic diuretics: Mannitol - monitor for serum osmolarity >3.10; desired is 290-300; goal is individualized If crystals in Mannitol solution, warm water over the bottle will dissolve them Loop diuretics - decrease volume and CSF production Glucocorticoids - dexamethasone (solumedrol) for tumors and abscesses; not helpful for cerebral edema due to traumatic injury - faster acting steroids, no prednisone Immunosuppressive Cushingoid appearance Fragile skin r/t weakened cell membrane Adrenal suppression - must wean Peptic ulceration Sodium retention Fluid retention Potassium depletion Osteoporosis - Aseptic necrosis of the bone Cataracts Muscle weakness Anticonvulsants - (Dilantin) phenytoin, (Dilantin-like for IM) fosphenytoin (good, stable, can be IM), benzodiazepines CNS depressants, sedatives, neuromuscular blockers - fentanyl, sufentanil, propofol, vecuronium, doxacurium - induced coma, Causal therapy Hydrocephalos - shunts Tumor - surgery Space Occupying Regions o Hemorragic injuries Epidural (usually arterial) Subdural - acute (head injury, blunt trauma), subacute (2wks to 2 mo after injury), chronic (no injury identified) (usually venous in nature) o Brain Tumors - abnormal cellular proliferation inside the cranium Types Malignancy and benign less important than location o Glioma - begins benign but can become malignant o Meningioma - benign at menigies o Acoustic neuroma - in the acoustic areas of the brain o Site of origin Primary - intracerebral, extracerebral Metastatic - metastasized from somewhere else compose majority of brain tumors 70% of adult brain tumors are above the tentorium (division between cerebrum and more primitive parts of the brain) 70% of childhood brain tumors are below the tentorium Patho o Compression, infiltration displacement, cerebral edema, necrosis, exudates o Mass effect = ICP o Cranial nerve involvement o CSF obstruction -> hypdrocephalus o Pituitary dysfunction o Disruption of neuron -> seizures Nursing Management See evolve Lewis website for animation for nursing assessment ND o All same as ICP + PC: ICP, o Clinical manifestations S&S varie based on structures compressed or infiltrated Focal neuro deficits (localized symptoms) Altered cognition, personality changes H/A, vomiting, papilledema Seizures, visual impairment o Seizures tx - document beginning, duration, type of seizure, protect from injury, turn to side, do not restrain, when seizure is over may need suctioning, manage with anticonvulsants (use of prophylactic anticonvulsant is convulsant in trauma, but used routinely in brain tumors) ICP S&S, cranial nerve deficits Review assessment in Lewis table 55-30 Complications PC: ICP Dx Studies Nursing management Collaborative Care Surgical therapy (all above for hematoma) o Craniotomy - removal of hematoma, abscess, etc o Steriotactic surgery - stabilize the head and use a precision tool to aim for area of lesion without damaging nearby normal tissue - used for gamma radiation o Craniectomy - removal of a portion of the skull o Cranioplasty - repair of the site of previous craniectomy o Burr-hole - for small, soft hematoma that can be aspirated No pressure on affected side, if VS ok HOB elevated 30degrees o Transnasal resection of pituitary - first 24-48 hours, edema can cause symptoms of SIADH or Diabetes Insipidis. Review treatments and assessments SIADH - restrict fluid DI - replace fluid cc for cc, give ADH subcu if appropriate o POST OP CARE Neuro assessment and VS Prevent injury with least restrictive device Incisional care Strict aseptic technique Physician orders dictate specifics PC meningitis, PC encephalitis PC CSF leakage (if positive for glucose and clear, then probably CSF, if blood tinged, glucose test does not apply) Assess for protective reflexes Suction PRN Electrolyte balance Positioning Supratentorial - if BP ok, HOB 30degrees or a more Infratentorial - if BP ok, HOB 10degrees at most, turned on side always - incision will be at the base of the skull PC IICP, PC aspiration, PC CSF leak Respiratory failure (especially posterior fossa surgery (intratentorial) - due to edema on the respiratory centers Corneal abrasion Gastric complications Fluid restrictions or replacement if DI/SIADH Analgesics H2 blockers Proton pump inhibitors Stool softener - prevent Valsalva Radiation therapy and radiosurgery Chemotherapy o Given in the ommaya reservoir to pass the blood-brain barrier o Temozolamide (Temodar) - oral agent that crosses bloodbrain barrier