Acute Neuro Conditions PPT Pt. 1

• After successful completion of this module, you will be able to:
  Utilize the clinical judgment measurement model as a framework for care of patients with:
    - Skull Fracture
    - Brain Injury
    - Intracranial Bleed/Hemorrhage
    - Progressive Neuromuscular (ALS, Guillain Barre Syndrome)   requiring ventilation

• Describe the management of patients with increased intracranial pressure (ICP).

• Monitor and manage the acute complications of spinal cord injury.

• Discuss the surgical interventions for patients with cranial/vascular and/or spinal cord injury.

• TBI= Traumatic Brain Injury

OBJECTIVES

OBJECTIVES

what is the content focus for this PPT?

•Spinal Injuries & Surgeries 

•Brain Trauma 

•ICP Monitoring 

•Endarterectomy 

•Intracranial Bleeds 

—•Hematoma Evacuation/Vascular Clipping 

Review assessment info – particularly neuro assessment and which nerves control what – how to assess each of the cranial nerves.

Review assessment info – particularly neuro assessment and which nerves control what – how to assess each of the cranial nerves.

nervous system anatomy

nervous system anatomy

Assessments – Indications things aren’t right with the head……..What are a few?

1. changed LOC

2. pupil changes (indicate stroke, opioids, or other)

3. entire neuro assessment (different spinal injuries=different presentations)

4. motor function

5. ASK QUESTIONS - what brought them to this state is a big help on what happened

what is the first cue that there is a neuro change?

they’ll have an inability to respond to stimuli and a change in:

• Wakefulness

• Alertness

• Cognition

what are some observation cues to lock in on that a pts mental status is shifting?

changes in…

• Patient’s Grooming & Hygiene

• Posture/Gestures

• Motor Movements

• Facial Expressions

• Speech

• Sensation

Glasgow coma scale

Glasgow coma scale (MEMORIZE)

what are the portions of the eye opening response in the GCS?

1. no response

2. to pain

3. to speech

4. spontaneously

what are the portions of the verbal response in the GCS?

1. no response

2. incomprehensible sounds

3. inappropriate words

4. confused

5. oriented to time, person, and place

what are the portions of the motor response in the GCS?

1. no response

2. abnormal extension

3. abnormal flexion

4. flex to withdraw from pain

5. moves to localized pain

6. obey’s command

what are the portions of LOC?

• motor ability

• language ability

• cranial nerves

(just GCS portions essentially)

how do you assess for motor ability with regards to LOC?

Assess Cortical Motor Integration:

•Comb Hair

•Brush Teeth

how do you assess for language ability with regards to LOC?

Understand Written & Spoken Language:

•Can Patient Read?

•Answer Questions Appropriately

how do you assess the cranial nerves with regards to LOC?

Compare Bilateral Face & Neck:

•Eye Movement (CN III, IV, VI)— pts should close eye when you bring finger close to eyeball

•Dysphagia (CN IX, X, XII) — BIG ONE TO LOOK AT, if they can’t swallow they’re at risk for PNA

when does an altered LOC exist/occur?

when a patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.

what does altered LOC exist ON? — what does it look like?

LOC exists on a continuum from a normal state of alertness to coma (with coma may still have brainstem reflexes but no purposeful movement).

what can be some causes of altered LOC?

may have neurologic, metabolic, or toxicologic causes.

what is altered LOC often caused BY?

brain herniation and/or increased intracranial pressure.

what are seizure precautions?

• pad the bed

• get the rails up

• DO NOT hold the pt down

• TIME THE SEIZURE and how long is the pt postictal

in the event of altered LOC, what is absolutely NEEDED?

Systematic, thorough assessment is necessary.

what is the most common cause of death from trauma in the United States?

head injuries

what is the “primary injury” in a head injury?

the initial damage to the brain.

what is the “secondary injury” in a head injury?

the damage from the sequelae of the primary injury (e.g., increased intracranial pressure).

define head injury.

broad term for any injury of the scalp, skull, or brain.  1.4M receive treatment for head injuries each year.

what is the most serious type of head injury?

TBIs — Only about 40% have good outcomes.

what types of TBI are there— break it down?

-Can be primary or secondary injury:

-- primary: related to actual injury

-- secondary: related to ischemia, seizure, infection, etc.

what do you NEED to consider in the event of a TBI or head injury?

all of the potential complications of TBI or head injury; the brain affected the whole body in different ways – endocrine abnormalities like diabetes insipidus, SIADH

what is THE big question to ask in the event of a head injury?

IS THE BRAIN INJURED????

define skull fracture

A break in the continuity of the skull caused by forceful trauma

what happens to the brain in the event of a skull fracture?

May occur with or without damage to the brain

what are the characteristics of treating a NONDEPRESSED skull fracture?

they generally do not require surgical treatment

what are the characteristics of treating a DEPRESSED skull fracture?

they usually require surgery

what is our BIGGEST concern in the event of a skull fx?

• CSF leak

• Increased ICP

skull fx visual

skull fx visual

• not too serious and not compressing the brain (nondepressed)

what is this image showing and what does it mean?

• this is a battle sign

• happens in the event of a skull fx

your pt presents w this^^. what is this and what is going on?

• The patient is leaking cerebrospinal fluid. (halo sign)

• they have a significant skull injury

if your pt presents w a halo sign, indicating they’re possibly leaking CSF, what do you need to do as the nurse?

this clear fluid that is draining from the nose or ears should be collected and tested for glucose. If the drainage is CSF, it will be positive for glucose. It is unlikely that the patient would be leaking plasma from his or her nose. Diuresis would not cause this phenomenon.

what is the nursing management in the event of skull fx/brain injury?

• Test for CSF leak

• Keep HOB at 30 degrees to reduce ICP and help with spontaneous leak closure

• NO NGT only OGT

• No Nasal suction

• Do not allow pt to blow their nose

• Typically, does not require surgery if early CSF rhinorrhea

  • If late onset (>/=7 days post-injury usually requires surgical intervention)

what’s “early CSF rhinorrhea”?

leaking CSF from the nose within 6 days of head trauma. if it presents AFTER 6 days, then they’ll likely need surgery

what’s a LONG TERM problem in a skull fracture?

INFECTION!!!!!

what’s a priority in a skull fx?

• getting the CSF where it needs to be

• CSF leak is a concern and can lead to infection among other things.

what do you need to do continuously in the event of a head trauma?

Continued frequent assessments for changes to cognition or leaking fluid/bruises is important.  Check all clear fluids for the potential of CSF.

what are the big portions of brain injury?

• Concussion

• Contusion

• Diffuse axonal injury

define concussion

• An alteration in mental status that results from trauma, and may or may not involve loss of consciousness

• Mild TBI

• Result of trauma – may or may not lose consciousness

what’s the tx for a concussion?

involves observing the patient for symptoms, including headache, dizziness, lethargy, irritability, anxiety, photophobia, phonophobia, difficulty concentrating, and memory difficulties

define postconcussive syndrome

symptoms after injury – can last years.

how long should loss of consciousness last if it occurs in a concussion?

no longer than 24 hours

define contusion

A more severe injury, involving bruising of the brain, with possible surface hemorrhage

what is the progression a pt will go through in the event of a contusion?

• Pt has short period of unconsciousness

• May go through period of cerebral irritability

what are some things you can do for a pt who has a brain contusion and is presenting w cerebral irritability?

decrease things that can disturb the patient

 - lights, sounds, voices, stimulation

what do the s/sx of a contusion depend on?

on the size of the contusion and amount of swelling.

BP and temp – subnormal

define diffuse axonal injury

Involves widespread damage to axons in the cerebral hemispheres

in what severity of a head trauma will you see a diffuse axonal injury?

Seen in mild, moderate, or severe head trauma

a pt presents w the following:

• immediate Coma, global cerebral edema

• Posturing

what’s going on?

diffuse axonal injury

what are the different types of posturing (to assess for)?

decorticate and decerebrate

define decorticate posturing?

• think everything coming to the “Core”

• Flexion of BUE (bilateral upper extremities) and BLE

• Indicative of damage to the upper midbrain

define decerebrate posturing?

• Extension of BUE and BLE

• Indicates severe brain damage to lower midbrain and upper pons

Decorticate (A)

Decerebrate (B)

hematoma visual

hematoma visual

how severe are hematomas?

• all bad

• some are more severe than other

• epidural hematoma is the worst

do you ever say “pt asleep” in an assessment?

NOOOO

• say “pt appears to be resting”

• then give all vitals and resp status as well as positions

define a hematoma

Collections of blood that develop within the cranial vault; the most serious type of brain injury

define epidural hematoma

Collection of blood in the space between the skull and the dura

define subdural hematoma (SDH)

Collection of blood between the dura and the brain — may be acute or chronic

define intracerebral hemorrhage (ICH)

Bleeding into the parenchyma of the brain

what is the tx for all hematomas

it’s directed toward preserving brain homeostasis and preventing secondary brain injury

what does an injury causing an epidural hematoma cause?

nature of injury leads to bleeding and rapid increase in pressure on the brain.

THIS IS AN EXTREME EMERGENCY

what can happen when a pt as an epidural hematoma?

• this is a bleed that has NOWHERE TO GO!!!! so we need to get the blood to go elsewhere and not compress the brain

• Neuro defect and respiratory arrest can happen in minutes. 

• Need to remove the pressure/bleeding or clot – burr holes, craniotomy, and/ or drain.

what type of hematoma is most common cause is trauma or coagulopathies/bleeding disorders?

Subdural hematoma

what can cause an ICH (intracerebral hemorrhage)?

trauma like bullet/knife

your pt presents w the following:

Can be insidious onset related to something else (hypertension, aneurysm rupture, tumor, etc.)

what type of hematoma would you suspect?

ICH – (trauma like bullet/knife)

how do we dx brain aneurysms?

•CT head

•MRI Brain

what are the precautions for c-spine things?

•Log roll

•C-collar

•Backboard

what is the tx for aneurysms?

•Craniotomy

•Craniectomy

•Burr Hole

•ICP monitoring

•Vascular clip

what assessments do you need to prioritize for an aneurysm pt?

•RESPIRATORY

•NEURO

•Cranial nerves  (reflexes)

craniotomy visual (tx for aneurysm)

craniotomy visual (tx for aneurysm)

vascular clipping of an aneurysm (tx for aneurysm)

vascular clipping of an aneurysm (tx for aneurysm)