Download NSG 224 Notes

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
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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
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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