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RNSG 2432 Enhanced Concepts of Adult Health Fall 2011 Lisa Randall, RN, MSN, ACNS-BC Define and discuss altered cerebral function and increased ICP Analyze etiology and pathophysiology of altered cerebral function Discuss/illustrate signs and symptoms, diagnostics, and treatment Formulate nursing diagnoses that address physical, psychosocial, and learning needs Prioritize and evaluate nursing interventions Cerebral function ◦ ◦ ◦ ◦ ◦ ◦ ◦ Mental status Speech Eyes Cranial nerves Motor Sensory Reflexes Consciousness ◦ Arousal ◦ Awareness Lethargy ◦ < alertness ◦ < awareness ◦ < thought process Obtundation ◦ << A/A ◦ Clouding Stupor ◦ Deep sleeplike state ◦ Vigorous stimulation Coma ◦ Unresponsiveness PVS MCS Unarousability Absence of sleep/wake cycles Inability to interact with the environment GCS =/< 8 Intermittent wakefulness Sleep-wake cycles No awareness of self or environment http://youtu.be/Pl1IPTpHUHs Altered consciousness Evidence of self or environmental awareness is demonstrated Anatomy http://www.youtube.com/watch?feature=player_detailpage&v=HVGlfcP3ATI Reticular Activating System (RAS) ◦ Reticular Formation ◦ Gray cells within brainstem extends into thalamus Wakefulness Arousal Alertness Lesion/injury to the RAS or cerebral cortex Metabolic disorders Anoxic injury Drugs Seizures LOC Health history ◦ drugs/head injury/metabolic Physical exam Vital signs ◦ Temperature ◦ Cushing’s reflex/triad Neuro Vital Signs ◦ LOC, Pupils, Strength/Movement, Sensation Glasgow coma scale NIH Stroke Scale Edema Increased intracranial pressure ◦ Increased systolic BP ◦ Widening pulse pressure Normal = 40 mmHg ◦ Decreased pulse rate ◦ Irregular respirations Eyes Spontaneous opening Open to speech Open to pain Do not open Verbal Response Oriented Confused Inappropriate Incomprehensible None 4 3 2 1 5 4 3 2 1 Motor Response Obeys commands Localizes to pain 6 5 Pushes your hand away Withdraws from pain Decorticate/flexion Decerebrate/extension None 4 3 2 1 Range of possible scores = 3-15 A score of 13 to 14 indicates mild deficit. A score between 9 and 12 points to moderate deficit, and a score of 8 or less indicates severe coma. Mental status General appearance/behavior State of conciousness Mood and affect Thought content Intellectual capacity Sensory: CN II - Optic ◦ Visual acuity Motor: CN III - Oculomotor ◦ PERRL ◦ Direct/consensual ◦ EOMs (CN IV/VI) http://www.youtube.com/watch?v=cuZXz92hd8g&feature=relate Eye movement CN III,IV,VI Oculocephalic reflex Dolls eyes ◦ Doll’s eyes ◦ Sensory CN VIII ◦ Motor CN III,IV,VI ◦ (+) opposite direction ◦ intact brain stem ◦ (-) no movement Trigeminal (V) ◦ Corneal reflex ◦ Sensory ◦ mastication Facial (VII) ◦ Expression ◦ Taste Glossopharyngeal (IX) ◦ Gag/swallow Vagus (X) ◦ Gag/Swallow Acoustic (VIII) Spinal Accessory (XI) ◦ Shoulder shrug Hypoglossal (XII) ◦ TML Ability to move, strength, and symmetry ◦ Grips, arm strength, & drift ◦ Planter flexion, dorsiflexion, & leg strength Coordination ◦ Finger to nose, heel up and down shin Planter Reflex- Babinski testing Meningeal signs- Brudzinski & Kernig’s sign Babinski's reflex ◦ (+) great toe flexes and the other toes fan out Abnormal after the age of 2. Hips and knees flex when the neck is flexed Stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. Visual fields Dull vs. sharp ◦ Sensation same or different with eyes closed Face Hands Arms Abdomen Feet Legs Brainstem compression ◦ ◦ ◦ ◦ ◦ ◦ Yawning & sighing Cheyne-Stokes Central neurogenic hyperventilation Apneustic breathing Cluster breathing Ataxic respirations http://www.youtube.com/embed/CUaEwgfKO Ec A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patient’s GCS score as ◦ ◦ ◦ ◦ A. 6 B. 8 C. 9 D. 11 The nurse recognizes the presence of Cushing’s triad in the patient with ◦ A. increased pulse, irregular respiration, increased BP ◦ B. decreased pulse, irregular respiration, increased pulse pressure ◦ C. Increased pulse, decreased respiration, increased pulse pressure ◦ D. decreased pulse, increased respiration, decreased systolic BP CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by ◦ ◦ ◦ ◦ A. assessing for nystagmus B. testing the corneal reflex C. testing pupillary reaction to light D. testing for oculocephalic (doll’s eyes) reflex An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the healthcare provider when arterial blood gas (ABG) measurement results reveal a ◦ ◦ ◦ ◦ A. pH of 7.43 B. SaO2 of 94% C. PaO2 of 50mm Hg D. PaCO2 of 30mm Hg ◦ BG ◦ Electrolytes/Osmolali ty ◦ ABGs ◦ CBC ◦ Liver function ◦ Kidney function ◦ Toxicology ◦ ◦ ◦ ◦ ◦ ◦ CT MRI EEG Cerebral angiogram TCD LP Monro-Kellie hypothesis ◦ 80/10/10 rule Autoregulation ◦ Cerebral arterioles ◦ MAP (Mean arterial pressure) Perfusion depends on B/P and chemical (CO2) Normal MAP is 70 to 100 < 60 - peripheral organs not perfused < 50 – brain not perfused Critical to maintain normal MAP with Increased ICP Vasoconstriction Decreased CSF CSF shunting Increased CSF reabsorption Brain’s ability to tolerate an increase in volume without an increase in pressure Indications of decreased compliance: ◦ Sustained increase in ICP in response to stimuli ◦ Greater increases to non-noxious stimuli NP Compensated Uncompensated 10mmHg 15mmHg 30mmHg Blood 10%, CSF 10% Blood 5%, CSF 5% Blood 4%, CSF 4% Stable Stiff ICP increases A slowly expanding mass is tolerated better that a rapidly expanding mass Brain tissue is compressible, but functional impairment, possibly irreversible does occur Location matters Pressure needed for adequate blood flow to brain ◦ CPP = MAP – ICP Need higher MAP if ICP increased ◦ 70-100 mmHg ◦ <50 mmHg = ischemia ◦ <30 mmHg = death Arterial Blood Pressure - Brain & CS Fluid Compression = Actual Cerebral Blood Flow CPP Danger of CPP < 50 mmHg MAP 50 to 150 mmHg Normal ICP 0 to 15 mmHg Edema, CS Fluid, Tumor Autoregulation 70 to 100 mmHg Increased ICP > 20 mmHg Increased MAP needed to perfuse brain Changes in contents of cranial vault Mass effect ◦ Tumor ◦ Blood clot ◦ Edema ◦ ◦ ◦ ◦ Increased CBF ◦ ◦ ◦ ◦ Increased blood flow Increased PaCO2 Decreased PaO2 Vasodilators Increased intrathoracic pressure Coughing Straining Suctioning Peep Impairment of cerebral venous drainage ◦ Positioning Changes in LOC Worsening headache Cognitive deficits Pupillary changes Increasing B/P with widening pulse pressure Irregular respiratory patterns Bradycardia Seizures Aphasia Dysconjugate gaze Hemiparesis or hemiplegia Health history- assess brain involvement PE ◦ Altered cerebral function assessment Frequency depends on potential IICP Early sign- change in LOC 3rd Cranial nerve compression Papilledema Projectile vomiting Vision changes Seizures ◦ Late sign- Cushing VS changes Ineffective tissue perfusion: cerebral ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Assess/report sign IICP Adequate airway Promote venous drainage Control environment stimuli Plan nursing care – avoid clustering care Avoid Valsalva’s maneuver If bone flap out post op- assess & position Assess external shunts/drains Maintenance of airway and ventilation Endotracheal intubation Oxygenation Mechanical ventilation Fluid balance/Euvolemia Medications Sedation, analgesia, neuromuscular blockade Barbiturate coma Prophylactic anticonvulsant Mannitol/3% NaCl Lasix Atracrium Vasopressors Tylenol Temperature control Electrolyte balance Proper positioning Adequate nutrition Ventriculostomy Paralytics Hypothermia Pentobarbital coma Craniectomy LICOX Jugular venous bulb cath ICP Waveforms (P1, P2, & P3) ◦ PbtO2 ◦ Normal 37-47 mmHg ◦ SjvO2 ◦ Normal SjvO2 is 60% to 80% ◦ <50 to 55% of O2 in venous blood indicates impairment of flow and brain taking out more O2 than normal ◦ P1 arterial pulse wave should be highest ◦ P2 is intracranial compliance – if higher than P1 compliance is compromised ◦ P3 is the venous pulsation and should be the lowest P1 P2 P3 Standing Orders Per hospital policy Neurological Meningitis Seizures Cerebral salt wasting (CSW) Syndrome of inappropriate antidiuretic hormone (SIADH) ◦ Hydrocephalus ◦ Cerebral edema/Increased ICP ◦ ◦ ◦ ◦ Increased secretion of ADH from abnormal stimuli Results in water retention Hyponatremia ◦ Na+ excreted in urine Decreased UOP Increased urine specific gravity Low serum osmo Hyponatremia Hypervolemia Fluid restrictiion Replace sodium ◦ ◦ ◦ ◦ Democlocycline Fludrocortisone Hypertonic saline Oral salt Diuretics Controversial Hyponatremia Failure of CNS to regulate Na+ reabsorption Increase in circulating atrial natriuretic peptide (ANP) Increased UOP Hyponatremia Normal to increased osmo Hypovolemia Increased urine specific gravity Volume replacement Sodium replacement Reducing renal Na+ excretion ◦ Fludrocortisone ◦ Urea Parameter SIADH CSW Serum Na+ Decreased Decreased Serum osmolarity Decreased Decreased Urine Na+ Increased Normal-increased Urine OP Decreased Increased Volume Normo/hypervolemic Hypovolemic Body weight Increased Decreased Cerebral edema ◦ Vasogenic ◦ Cytotoxic ◦ interstitial Hydrocephalus ◦ Noncommunicating ◦ Communicating ◦ ICP Production – choroid plexus; Absorption – arachniod villi Normal MRI Brain MRI Hydrocephalus Irreversible coma Locked-in Syndrome (not true coma) ◦ Persistent vegetative state ◦ Functioning RAS & cortex; pons level interference ◦ Aware, communicate with eyes ◦ http://youtu.be/xWHnkFaxMxM Brain death ◦ Loss of all brain function- flat EEG, no blood flow A. Cingulate B. Uncal C. Central D. Extracranial E. Tonsillar Cingulated Herniation (a) Cingulate gyrus slips under falx cerebri Usually caused tumor or bleed Non life threatening Uncal or Lateral Herniation (b) Uncus of temporal lobe slips through notch of tentorium and compresses the ipsilateral CN 3, brainstem, & vital centers Life threatening Central or Transtentorial Herniation (c) Downward pressure General cerebral edema Brainstem compression Compresses RAS & vital centers Abnormal heart rhythms, disturbances or cessation of breathing, cardiac arrest, and death Life threatening Infratentorial (subtentorial or Tonsillar) Herniation (e) Downward displacement of infratentorial structures through the foramen magnum Life threatening Extracranial Herniation (d) Occurs with displacement of brain through a cranial defect. Usually Non-life threatening Surgical Decompression (Craniectomy) http://youtu.be/dLMCwGmWvrw A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is ◦ ◦ ◦ ◦ A. aseptic technique to prevent infection B. constant monitoring of ICP waveforms C. removal of CSF to maintain normal ICP D. sampling CSF to determine abnormalities A patient has a nursing diagnosis of altered cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is ◦ A. avoiding positioning the patient with neck and hip flexion ◦ B. maintaning hyperventilation to a PaCO2 of 1520mm Hg ◦ C. clustering nursing activities to provide periods of uniterrupted rest ◦ D. routine suctioning to prevent accumulation of respiratory secretions The earliest signs of increased ICP the nurse should assess for include ◦ ◦ ◦ ◦ A. Cushing’s triad B. unexpected vomiting C. decreasing level of consciousness (LOC) D. dilated pupil with sluggish response to light VS/NVS ICP CPP MAP PbtO2 PaCO2 CVP Labs Imaging Category status Advanced directives Prognosis Withdraw of care Palliative care End of life specialists SW/Chaplain Varies according to underlying cause and pathologic process GCS GOS Physical/mental disability 22 yo female Harvard law student Horseback riding GCS 7 ◦ Localized Day 2 ◦ ICP ◦ Hypothermia ◦ Tracrium Day 3 ◦ Flexion AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St. Davis, F.A. (2001). Taber’s Cyclopedic Medical Dictionary. F.A. Davis, Philadelphia. Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida. Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. (2007). Medical-Surgical Nursign. Assessment of Management of Medical Problems. Mosby Elsevier, St. Louis, Missouri Silvestri, Linda. (2008). Comprehensive review for the NCLEX-RN Examination. Saunders Elsevier, St. Louis, Missouri.
