NURS-433: Management of Care 3 (Module 9, Part 1)

What is the normal range for intracranial pressure (ICP)?

5-10 mmHg

What is cerebral autoregulation?

The brain's ability to maintain relatively consistent cerebral blood flow despite changes in systemic blood pressure

What is the Monro-Kellie Doctrine?

The principle that the skull contains a fixed volume of brain tissue, blood, and cerebrospinal fluid; an increase in one component must be compensated by a decrease in another to prevent increased ICP

What is the formula for calculating mean arterial pressure (MAP)?

[SBP + 2(DBP)] / 3

What is the formula for calculating cerebral perfusion pressure (CPP)?

MAP − ICP

What four categories of factors can contribute to increased ICP, and what are examples of each?

Increased brain volume (edema or hemorrhage), increased cerebral fluid (hydrocephalus or choroid plexus tumor), increased blood volume (elevated central venous pressure or venous stasis), and other causes (skull deformities or tetracycline use)

What physiological effects can result from increased ICP?

Long-term neurological deficits that may affect functional outcomes

What psychosocial effects can result from increased ICP?

Impaired social cognition, challenges with inhibitory control, and worsening executive function

What nutritional concerns can result from increased ICP?

Risk for malnutrition and increased metabolic demands, including eb and flow phases

What measure is identified for evaluating functional outcomes after brain injury?

Brain Injury Functional Outcome Measure (BI-FOM)

What are the early signs of increased ICP?

Headache, nausea/vomiting, confusion, and visual changes such as blurred or double vision

What are the late signs of increased ICP?

Cushing's triad, fixed and dilated pupils, decorticate or decerebrate posturing, and coma

What three findings make up Cushing's triad?

Widening pulse pressure, bradycardia, and irregular breathing patterns

What is decorticate posturing?

Abnormal flexion of the upper extremities toward the body, often accompanied by extension of the lower extremities

What is decerebrate posturing?

Abnormal extension of the upper and lower extremities associated with severe neurological dysfunction

What is brain herniation?

Displacement of brain tissue due to increased intracranial pressure, potentially compressing vital brain structures

What assessments and diagnostic methods are used to evaluate increased ICP?

Physical assessment, CT scanning, noninvasive or invasive ICP monitoring, and the Glasgow Coma Scale (GCS)

What three responses are evaluated using the Glasgow Coma Scale?

Eye opening, verbal response, and motor response

What is the maximum possible Glasgow Coma Scale score?

15

What are the four eye-opening scores on the Glasgow Coma Scale?

1 = None; 2 = To pain; 3 = To speech; 4 = Spontaneously

What are the five verbal-response scores on the Glasgow Coma Scale?

1 = None; 2 = Incomprehensible sounds; 3 = Inappropriate words; 4 = Confused; 5 = Oriented

What are the six motor-response scores on the Glasgow Coma Scale?

1 = None; 2 = Extension; 3 = Abnormal flexion; 4 = Withdrawal from pain; 5 = Localizes pain; 6 = Obeys commands

What GCS score indicates mild traumatic brain injury?

13-15

What GCS score indicates moderate traumatic brain injury?

9-12

What GCS score indicates severe traumatic brain injury?

Less than 9

What five invasive monitoring methods are used for increased ICP?

Subdural bolt, subdural catheter, epidural transducer, intraparenchymal catheter, and ventriculostomy

What is evaluated using an intracranial pressure waveform?

Changes and trends in intracranial pressure

What are the primary nursing responsibilities when caring for patients with increased ICP?

Assessment and monitoring for secondary neurological injury, airway management, fluid volume and sedation monitoring, equipment and procedure management, interdisciplinary collaboration, and education

What five categories of pharmacological therapies are used to manage increased ICP?

Diuretics/osmotic agents, sedatives, pain medications, barbiturates, and neuromuscular blocking agents

What three surgical interventions are implemented for increased ICP?

Hemicraniectomy, ventriculostomy, and subarachnoid bolt

What is a hemicraniectomy?

Surgical removal of a portion of the skull to relieve pressure caused by brain swelling

What is a ventriculostomy?

Placement of a catheter into a cerebral ventricle to monitor ICP and/or drain cerebrospinal fluid

What is the primary goal of nursing interventions for a patient exhibiting increased ICP following a head injury?

To recognize neurological deterioration, prevent secondary neurological injury, and support cerebral perfusion

What is a subarachnoid hemorrhage (SAH)?

Bleeding into the space between the arachnoid and pia mater membranes, initiating a signaling cascade that can cause increased ICP and cerebral vasospasm

What is cerebral vasospasm?

Constriction of cerebral blood vessels that can reduce blood flow to brain tissue

What are the early signs of subarachnoid hemorrhage?

Sudden severe thunderclap headache described as the worst headache of the patient's life, double vision, neck pain or stiffness, altered consciousness, cranial nerve palsy, and nausea/vomiting

Which cranial nerves may be affected by SAH?

Cranial nerves III and VI

What are the late complications of subarachnoid hemorrhage?

Vasospasm, cerebral ischemia, coma, seizures, rebleeding, and hydrocephalus

What conditions or events are associated with subarachnoid hemorrhage?

Aneurysm rupture, falls, traumatic brain injury, vascular malformations, hypertension, and alcohol use disorder

What risk factors increase the likelihood of subarachnoid hemorrhage?

Untreated hypertension, smoking, alcohol or substance use, genetic disorders, and age greater than 40 years

Which genetic disorders are associated with increased SAH risk?

Vascular Ehlers-Danlos syndrome (type IV) and Marfan syndrome

What four areas of health may be affected by SAH, and what are examples of each?

Mobility (hemiparesis), sensory perception (language difficulties), perfusion (neurogenic stress cardiomyopathy), and cognition (difficulty with recall)

What three scales are used to assess the severity of SAH?

Hunt and Hess Scale, World Federation of Neurological Surgeons (WFNS) Scale, and Fisher Scale

Which SAH severity scale evaluates the appearance of hemorrhage on CT?

Fisher Scale

What four diagnostic tests are used for SAH?

Noncontrast CT, lumbar puncture, MRI, and CT angiography

How does magnetic resonance imaging (MRI) produce images?

It uses a large magnet, radio waves, and a computer to create cross-sectional images of internal structures

How does CT angiography (CTA) produce images of cerebral arteries?

It uses injected contrast dye during CT scanning to visualize arteries

In what setting are patients with acute SAH commonly managed, and what are the primary nursing responsibilities?

The intensive care unit (ICU); nurses review environmental and individual factors, address safety concerns, monitor the patient, provide education, and evaluate responses to interventions

What treatment approaches are used for subarachnoid hemorrhage?

Guideline-directed care, pharmacological therapy, surgical clipping or endovascular coiling, and hyperbaric oxygen therapy

What is nicardipine used for in SAH treatment?

It is a calcium channel blocker used to control elevated blood pressure and reduce the risk of rebleeding while maintaining adequate cerebral perfusion

What is nimodipine used for in SAH treatment?

It is a calcium channel blocker used to reduce the risk of delayed cerebral ischemia and improve neurological outcomes following aneurysmal SAH

What is levetiracetam used for in SAH treatment?

It is an anticonvulsant used to prevent or treat seizures in patients with SAH when clinically indicated

What is acetaminophen used for in SAH treatment?

It is an analgesic and antipyretic used to manage headache, pain, and fever, helping reduce discomfort and increased metabolic demands

What three mechanical forces can cause traumatic brain injury?

Direct, rotational, and sphere forces

What two classifications describe TBI injury progression?

Primary injury and secondary injury

What are the three different categories of head injuries?

Closed, penetrating, and explosive/blast injuries

What is a coup–contrecoup injury?

Brain injury occurring at the site of impact and on the opposite side as the brain moves within the skull

What are the clinical manifestations of mild TBI?

Brief loss of consciousness lasting seconds to minutes, headache, confusion, dizziness, blurred vision, tinnitus, fatigue, mood or behavior changes, sensitivity to light or sound, nausea/vomiting, and sleep changes

What are the clinical manifestations of moderate to severe TBI?

Loss of consciousness lasting minutes to hours, persistent headache, seizures, vision loss, dilated pupils, extremity weakness, impaired coordination and balance, sensory changes, aggression, depression, and difficulty understanding, communicating, or concentrating

What three categories are considered when evaluating TBI epidemiology and risk?

Risk factors/incidents, comorbidities, and epidemiology

How is traumatic brain injury characterized in relation to long-term health, and what complications may occur?

TBI is considered a chronic condition that can cause cognitive difficulties, emotional disorders, and an increased risk for falls with aging

What is chronic traumatic encephalopathy (CTE)?

A neuropathological brain disease associated with multiple traumatic brain injuries

What cognitive, behavioral, and mood changes are associated with CTE?

Impaired memory and thinking, increased aggression and impulsivity, depression, and anxiety

What factors may complicate the diagnosis of CTE?

Comorbidities such as sleep disruption and mood disorders

What laboratory and imaging studies may be used to evaluate TBI?

Complete metabolic panel, noncontrast CT, MRI, and angiography

What are the three different categories of potential causes of cerebral fluid leakage?

Craniofacial trauma, unintentional medical outcomes, and other varied etiologies

What is Battle's sign?

Bruising over the mastoid region behind the ear

What are raccoon eyes?

Bruising around the eyes associated with possible skull injury

What are the primary nursing responsibilities when caring for patients with neurological injuries?

Monitor level of consciousness, airway, ventilation, and signs of worsening neurological status; address safety concerns; and provide patient/family education

What pharmacological treatments are implemented for TBI?

Treatment of increased ICP or SAH, sedation and pain management, seizure prophylaxis, fever control, and other medications

What surgical interventions are implemented for TBI?

External ventricular drains, cisternostomy, and decompressive craniectomy

What additional therapy is used to treat TBI?

Therapeutic hypothermia

Why is family support an important nursing responsibility following neurological injury?

Neurological injuries may occur unexpectedly and cause long-term impairment, with nurses frequently serving as the primary contact for patients and families

What structures make up the central nervous system?

Brain, spinal cord, meninges, and cerebrospinal fluid

What are the three layers of the meninges?

Pia mater, arachnoid mater, and dura mater

Where does the spinal cord originate, and what two types of matter compose it?

It extends from the medulla oblongata through the vertebral column and is composed of white and gray matter

What are the primary functions of the spinal cord?

Transmitting sensory information through ascending pathways, transmitting motor instructions through descending pathways, and directing reflexes

How many pairs of spinal nerves are present, and how are they distributed?

31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal

What three mechanisms can cause spinal cord injury?

Compression, distraction (tearing), and transection

What is the difference between complete and incomplete spinal cord injuries?

Complete injuries result in no preserved sensory or motor function below the injury level, while incomplete injuries preserve some sensory or motor function below the injury level

What is the difference between paraplegia and tetraplegia?

Paraplegia results from a spinal cord injury typically between T2-S5 and causes paralysis of the lower extremities, while tetraplegia results from an injury between C1-T1 and causes paralysis of all four extremities, potentially affecting the trunk and respiratory muscles

What structures may be damaged in spinal cord injury?

The spinal cord, vertebrae, ligaments, and intervertebral discs

What are the leading causes of spinal cord injury?

Motor vehicle accidents and falls

What is the focus of health promotion and risk reduction education for spinal cord injuries?

Addressing modifiable risk factors and preventing injury-related events

What six areas of overall health are affected by spinal cord injury?

Life expectancy, prevention needs, mobility, sexuality, psychosocial health, and aging

What spinal cord injury levels are associated with tetraplegia?

C1-T1

What spinal cord injury levels are associated with paraplegia?

T2-S5

What additional clinical condition may occur in cases of spinal cord injury?

Spinal shock

What four complications are associated with spinal cord injuries?

Venous thromboembolism, atelectasis and pneumonia, heterotopic ossification, and autonomic dysreflexia

What four additional areas of nursing care are emphasized for spinal cord injury patients?

Skin issues, interprofessional collaboration, mobility and environmental considerations, and cultural competency

What four areas should be addressed when applying the nursing process to spinal cord injuries?

Cardiovascular and respiratory function, neurogenic shock, genitourinary and gastrointestinal function, and pain management

What three pulmonary considerations are emphasized when implementing nursing interventions for spinal cord injury?

Immobilization, airway management, and secretion management

What two complications require nursing interventions related to cardiovascular function after spinal cord injury?

Cardiovascular instability and autonomic dysreflexia

What findings occur above the level of injury during autonomic dysreflexia?

Severe hypertension, flushed face, headache, distended neck veins, decreased heart rate, and increased sweating

What findings occur below the level of injury during autonomic dysreflexia?

Pale and cool skin with an absence of sweating

What level of spinal cord injury is associated with autonomic dysreflexia?

T6-T8 or higher

What six intervention areas must be considered in spinal cord injury management?

Halo fixation devices, surgical management, diet, bowel and bladder management, mobility and injury prevention, and sexuality interventions

What three interventions are emphasized in the final phase of spinal cord injury care?

Rehabilitation, education, and pharmacology