Complex 2 Exam 3

Enteral nursing assessment

Assessments q 4 hr:

· asses patency Q4: flush with water before/after feedings if not on continuous fluids to loosen any excess that may clog up tubes

· Assess shape & feel of abdomen (assess for tenderness upon palpation)

· Abdominal x-ray before initial feeding

· Auscultate bowel sounds (all bowel quadrants)

· Stability of tube: look at marker outside of tube

· Monitor I/O & daily weight

· Glucose checks first 24 hr typically q 4-6hrs

Enternal Complications: Dumping Syndrome

- Results from emptying of formula too quickly into small intestine, which causes a fluid shift

- May manifest as dizziness, tachycardia, diaphoresis, pallor

Enternal Complications: Metabolic Issues

dehydration, hyperglycemia, electrolyte imbalance, fluid overload, refeeding syndrome, weight gain

- Provide adequate free water (balance between dehydration & overload), consider change in formula, monitor labs (electrolyte, glucose), monitor weight, Tx hyperglycemia with insulin

Enternal Complications: Overfeeding

- N/V, abdominal distention

- Check residual Q4-6

- Hold for residual volumes of 100-200mL then restart at a lower rate

- Ensure the feeding pump is working right

Enternal Complications: Diarrhea

- D/t concentration of feeding

- Slow the rate & notify provider

- Provide skin care and increase fiber

- Evaluate for C.Diff if diarrhea continues especially if very foul odor

Enternal Complications: Aspiration pneumonia

Tube displacement – LIFE THREATENING

- STOP the feeding

- Turn pt to one side, suction airway, provide O2

- Monitor VS for elevated temp

- Auscultate breath sounds

- Notify provider & obtain chest x-ray

Enternal Complications: Refeeding syndrome

LIFE THREATENING

- When pt is in a starvation state & given enteral feeding, body begins to catabolize protein & fat for energy

- Monitor for new onset of confusion, seizures, & increased muscular weakness

- Assess for shallow respirations

- Notify provider & obtain blood electrolytes

Enteral nursing interventions

- Check patency q 4 hrs and before and after use of tube for feeding

- if you need to lay pt down turn feeding off

- HOB at least 30-45 once resumed feeding and up to at least 1 hr after feeding

- Check placement q shift

Aspirate and test the pH of stomach contents

- pH < 4 = tube is in the stomach (gastrostomy tube)

- pH > 6 = tube is in the jejunum (jejunostomy tube)

- Residual checks for NG tubes

Parenteral composition

· Amino acids (protein) & glucose (dextrose) make up the base solution (along with sterile water)

· Electrolytes, minerals, vitamins, & trace elements are added according to client needs

· Lipids (fats) may be added to the solution OR given as a separate intermittent infusion

Parenteral prioritization

· Always admin via infusion pump to prevent accidental fluid overload NOT GRAVITY

· TPN must have a filter in tubing to collect particles from solution

· Gradually adjust the flow rate to allow the body to adjust & then keep it consistent (increasing the rate can lead to overload or hyperosmolar diuresis)

· Monitor BUN

· NEVER abruptly stop TPN --> D/C gradually to prevent rebound hypoglycemia

· CANNOT change the rate after reaching the target rate

- If TPN solution is not available: admin dextrose in water until TPN can be resumed (maybe D10W…10%-20% dextrose)

Parenteral nursing interventions/complications: Infection/ Sepsis

may be a result of contamination during catheter insertion or contamination solution (high concentration of dextrose=fuel for bacteria)

- Change CVL dressing using sterile technique q 48-72

- Monitor for S/Sx of infection (fever/chills, elevated WBC, redness at cath insertion site)

- Change solution bag & IV tubing Q24

- DO NOT USE TPN LINE FOR OTHER IV BOLUS FLUIDS/MEDS)

- observe the central insertion for local infection (erythema, exudate, tenderness)

Parenteral nursing interventions/complications: Hyperglycemia

(during feeding) hypoglycemia(in btwn feeding), electrolyte/vitamin imbalance

- Monitor glucose & admin sliding scale insulin to treat hyperglycemia

- Review Daily labs & get results BEFORE NEW TPN is made (nsulin may be added to the solution by pharmacy)

- Admin additional dextrose to treat hypoglycemia

Parenteral nursing interventions/complications: Catheter Misplacement

leads to pneumo/hemothorax, thrombosis, air embolism

- Monitor for S/Sx of air embolus (sudden respiratory distress, decreased O2 sat, SOB, cough, chest pain, hypotension)

- Clamp catheter & lay on L side in Trendelenburg to trap air in Right Atrium - Admin high flow O2 - Notify provider

Parenteral nursing interventions/complications: Fluid Overload

TPN is hyperosmotic which can cause FVE

- Monitor daily weight & I/O

-assess lung sounds for crackles

- gradually increase flow rate

Acute abdominal pain: how do all of the below issues manifest in the patient?

· Appendicitis: RLQ pain, dull pain around naval area

· Pancreatitis: epigastric pain radiating to back, left flank, or left shoulder pain

· Perforation: severe pain all over abdomen

· Diverticulitis: LLQ pain

· Cholycystitis/Cholelithiasis: RUQ pain radiating to R shoulder

Acute abdominal pain: know the specific clinical manifestations for each disease process

RUQ

• Liver - Hepatitis

Transplant rejection:

• Duodenal ulcer

• Cholecystitis

RLQ

• Appendicitis

• Crohn's disease

LUQ

• Gastric ulcer

• Perforated colon

• Pyelonephritis

LLQ

• Diverticulitis

• Acute pancreatitis

• Early appendicitis

• Ulcerative colitis

• Crohn's disease

Appendicitis clinical manifestations

· RLQ pain, dull pain around navel area to upper abdomen

· Loss of appetite, N/V

· Spiked temperature of 99-102 (infection/inflammation)

· Loss of pain = appendix rupture (do not give pain meds, will mask pain - won't know if ruptured)

Appendicitis Dx

· Rebound tenderness

· Press on LLQ & pain increases on RLQ

· CT scan -> visualize inflammation (most effective way to dx)

· CRP and ESR

Appendicitis priority interventions

- Treatment: Appendectomy - Go to OR - IVF & ABX pre op care
Assess post op complications:
- Bleeding - black tarry stools, bright red blood
- Bowel sounds
- VS + pain - EXPECTED immediately post-op
- Infection
No laxatives, enemas, opioids, & heat to abdomen

Appendicitis complications

Rupture: abdominal washout w wound irrigation with antibacterial solution

- maintain NPO after surgery

- Can lead to peritonitis

Peritonitis

- Rigid, board-like abdomen

- N/V

- Rebound tenderness

- Abdominal distension

- Admin hypertonic IVF & ABX

Drug-induced hepatitis plan of care/teaching

Most common causes

- Acetaminophen

- Statins

- Combining drugs with alcoholic drinks

Acetaminophen

- > 30 mg/dL

- Give acetylcysteine, activated charcoal for OD (their AST and ALT will be really high)

- May remain Sx free for up to 24 hr

- Once sx occurs, damage already occurred (N/V, poor appetite, confusion)

- Cared for in-home unless acutely ill

- Hepatic rest:

- Admin only necessary meds, including OTC meds

- Avoid alcohol

- Limit physical activity

Drug-induced hepatitis: nursing care

Monitor for:

- Jaundice, elevated AST/ALT, poor appetite, confusion

- Long-term: ascites, hepatic encephalopathy, esophageal varices

Drug-induced hepatitis: prevent transmission

- Avoid SI until hep antibody testing is negative

- Proper hand hygiene

- contact precautions if necessary

What does the liver do?

· Synthesizes clotting factors (helps blood clot by producing proteins)
· Processes proteins
· Removes by-products: ammonia & bili (excreted through stool)

Acute hepatic failure clinical manifestations

· Jaundice

· Coagulation abnormalities: bleeding, petechiae

· Dependent edema: d/t albumin not being able to hold water in intravascular space

· Hepatic encephalopathy: confusion, asterixis

· Ascites: accumulation of fluid in abdomen

· Fector hepaticus: fruity, musty breath

· Fatigue/sleepy

· Constipation, diarrhea, chalky stool, steatorrhea

· Abdominal pain: right side epigastric pain

· Decreased hepatic flow:

- Splenomegaly (L side)

- Esophageal varices: tx with octreotide

- Caput medusae: swollen veins near umbilicus

Acute hepatic failure Dx

1. Bili, ammonia, AST/ALT, PT/INR(risk for bleeding) – ALL elevated

- Get ammonia from venous blood draw

2. Albumin/total protein, Hgb/Hct – ALL decreased

3. Drug screening: too much acetaminophen?

4. CT scan/MRI: identify size of liver, presence of ascites, tumors, & patency of blood vessels

5. Liver biopsy (definitive): careful d/t decreased Hgb/Hct & decreased clotting time

Acute hepatic failure priority interventions

- Monitor airway and resp status, ET tube and oral airway at the bedside, daily weights, measure abdominal girth, manage fluids, maintain skin integrity, monitor GI status and pain

- Frequent neuro checks, monitor for increased ICP:

· Avoid overstimulation, dim the lights, calm voice

· Avoid sedatives! Can mask neuro Sx Paracentesis (for ascites)

· Have pt void before, record amount & color, send specimen to lab

· Monitor VS for fluid shift (hypovolemia)

- Liver transplant is the only treatment for acute liver failure (acute graft rejection)

- New-onset restlessness, confusion, deteriorating LOC = priority when ABCs are stable

Acute hepatic failure medications

· Lactulose: reduces ammonia levels from hepatic encephalopathy (expect 3-4 stools/day or diarrhea)

· Spironolactone (diuretic)

· BB: prevents varices by controlling BP & portal HTN

· Octreotide: Tx caput medusae

· Vitamin K for clotting

· Pain meds: DO NOT give hepatotoxic meds

Acute hepatic failure complications

Hepatic encephalopathy

- S/Sx: ascites, water & sodium retention, jaundice, coagulation abnormalities, confusion

- Report asterixis & fector hepaticus ASAP

- Admin lactulose, spironolactone, vitamin K

Portal Hypertension:

- Transjugular intrahepatic portosystemic shunt (TIPS): shunt is placed between the systemic & portal venous systems which redirects blood flow

- Monitor for bleeding, aspiration

Other complications:

- liver failure, cerebral edema, sepsis, hypoglycemia

Acute hepatic failure nutrition

· High carb, high calorie, high protein, low-mod fat, and supplements such as ensure, boost

· Vitamin supplementation: thiamine, folate, B12, K, A, D, E

· Restrict sodium to 2g/day

· Avoid ETOH & hepatotoxic meds

· For hepatic encephalopathy: LOW protein

Esophageal varices clinical manifestations

pt may experience no symptoms until varices begin to bleed

- Hematemesis (1st sign)(bright red blood)

- Melena: black tarry blood in stool d/t iron being left in

- Hypotension, tachycardia

- Decreased Hgb/Hct

- Shock

- Cool, clammy skin

Activities that precipitate bleeding

- Valsalva maneuver: avoid bearing down

- Alcohol consumption

- Sneezing

- Lifting heavy objects

- Coughing

Esophageal varices priority interventions

#1 GOAL is to control bleeding & prevent hemorrhage and hypovolemic shock

Stop the bleeding

- Get to OR ASAP

- Have pt as stable as possible

- Suction equipment available

- IV access with large bore needle (18 gauge)

- Monitor VS & report tachycardia or hypotension

- Monitor for bleeding & estimated blood loss

- Monitor for decreased Hgb/Hct, RBC, PLT

- Monitor for hypovolemic shock

Esophageal varices: treatments

- NG tube decompression

- Endoscopy

- Band ligation: place rubber bands at base of varices to stop bleeding

- Balloon tamponade (short-term): esophagogastric tube with esophageal & gastric balloon used to compress blood vessels into the esophagus & stomach

Esophageal varices medications

PPI’s: to decrease gastric secretions

Propranolol: Beta blocker; decrease HR/BP and reduces hepatic venous pressure & portal HTN & causes vasoconstriction in GI tract

Octreotide:

- Does NOT affect BP

- Decreases bleeding from varices

- Reduces portal HTN

Vasoconstictors: Vasopressin (if bleeding)

- Causes constriction in esophageal & proximal gastric veins

- Reduces portal pressure

- Works at site of varices

- Can NOT give to pts with CAD: d/t already obstruct vessels

- Fluid retention & hyponatremia

- Has an antidiuretic effect

IVF/blood/blood products: replacement

Esophageal varices risk factors

- Portal HTN

- Alcoholic cirrhosis

- Viral hepatitis

- OLDER adults

Acute GI hemorrhage clinical manifestations

Upper GI bleed

· Hematemesis: bloody vomit

· Melena: dark sticky stools (further from rectum)

· Pain

Lower GI bleed

· Hematochezia: bright red bloody stool (closer to rectum)

· Abdominal pain

Hemodynamic Compromise

· Pallor, fatigue

· Chest pain (NOT GOOD), palpitations

· Dyspnea(SOB)(ALSO NOT GOOD) tachypnea, tachycardia

· Postural changes

· Syncope

(SOB will be a priority question for GI bleed**)

Acute GI hemorrhage Dx

· Hgb/Hct

· Type & cross match to replenish fluids

· H. Pylori: for pts with upper GI bleed

· Stool sample

· BUN

Upper GI: endoscopy

· NG tube: aspiration of stomach content will determine if bleeding is upper or lower

Lower GI: colonoscopy (1st one)

· Endoscopy: locate & evaluate lesion

· Abdominal CT scan/MRI/X-ray

Acute GI hemorrhage priority interventions

· ABC, VS

2 large bore IVs

- Admin fluids: NS or isotonic solution (LR)

- Transfuse PRBC’s or other blood products

Urinary catheter: urine output has to be closely monitored because of perfusion to the kidneys

· Preventative measures to stop bleeding: endoscopy

Diet & education if stable

- NPO

- After bleeding episode: clear liquids to determine tolerance

Acute GI hemorrhage medications

UPPER

· IVF

· PPI's: prevent reoccurrence & Tx PUD

· ABX: if H. Pylori present (Metronidazole/flagyl)

LOWER

· IVF

· Transfusions

Acute GI hemorrhage complications

MED EMERGENCY

Hypovolemic shock: volume replacement!! IV FLUIDS!

- Observe signs of bleeding and chest pain

- Monitor VS (tachycardia & hypotension, restlessness, pallor) & labs, note EBL

- Admin O2

- Transfuse PRBCs or other blood products (albumin)

- Transfer to ICU

Who are NOT liver transplant candidates?

must go through rigorous screenings

· Severe cardiac/respiratory disease

· Metastatic malignant liver cancer

· Alcohol/substance abuse

Liver transplant nursing assessment: pre-op

· Witness consent

· Labs

· X-ray

· Enema

· Shower with chlorhexidine soap

Liver transplant nursing assessment: post-op

· Monitor VS, neuro status, signs of infection (fever, redness, drainage)

· Rejection

(Tachycardia, fever, RUQ flank pain)

( Jaundice: increased AST/ALT)

(Clay-colored stool)

· Clotting issues: blood in drainage tubes or petechiae

· Acute renal failure: change in urine output, increased BUN/Cr

· Admin immunosuppressant meds (life-long med): avoid crowds

· Admin ABX/antivirals/antifungals

Acute pancreatitis clinical manifestations

· Sudden onset of epigastric area pain radiating to back, L flank, or L shoulder pain (worsens when laying down) -->Relieve pain by sitting in fetal position or sitting still

· N/V/anorexia/weight loss, constipation, steatorrhea, ascites

Tetany: d/t hypocalcemia (SIGN OF SEVERE disease & NEEDS intervention): carefully give calcium gluconate/carbonate

- Positive Chvostek’s sign: tap face and it twitches

- Trousseau’s sign: hand contracts at wrist with BP cuff

How do you know it's pancreatitis?

INCREASED amylase/lipase, WBC, AST, ALT, Glucose (can't get rid of it)

DECREASED calcium & magnesium

Acute pancreatitis prioritization/nursing interventions

· #1 is ABC: monitor OXYGENATION

· Rest the pancreas! NPO: consider TPN if malnourished or if severe

· NGT: helps to reduce vomiting & gastric distention (empty stomach so no more enzymes are released)

· Fluids!!!: hypovolemic shock or MODS if severe enough

· Watch electrolytes & replace as needed

· Unstable glucose? May need to supplement insulin

· Treat pain! Hydromorphone (opoid)

· ABX: Imipenem (check renal function, can damage kidneys)

Acute pancreatitis complications

Hypovolemia: d/t third spacing, can develop shock

Infection

- Pseudocyst or abscess

- Leakage of fluid out of damaged pancreatic duct

Type 1 DM: lack or absence of insulin

MODS: inflammation of the pancreas is believed to trigger system inflammation

- Caused by necrotizing hemorrhagic pancreatitis

Vasopressor: if fluid resuscitation has been done & pt is still hypotensive & tachycardic

Pyloric stenosis/intestinal obstruction clinical manifestations

· Hypoactive bowel sounds after blockage
· Abdominal distension, rigidity, abdominal pain
· Anorexia, weight loss
· Steatorrhea
· N/V, constipation
· Tetany

Pyloric stenosis/intestinal obstruction Dx

· Hgb/Hct, BUN/Cr, amylase, WBC = all elevated d/t dehydration
· Sodium, chloride, potassium = all decreased
· Abnormal ABG: metabolic imbalance
· X-ray: flat plate & upright abdominal X-ray to evaluate presence of free air & gas patterns
· CT: determines the cause & exact location of obstruction

Diverticulosis/Diverticulitis clinical manifestations

· Acute onset of abdominal pain in LLQ
· Fever, chills, N/V
· Tachycardia
· Abdominal distention

Diverticulosis & diverticulitis

Diverticulosis: small diverticula in colon without inflammation

Diverticulitis: inflammation & infection of diverticula from bacteria, food, or fecal matter are trapped

Diverticulosis/Diverticulitis nursing interventions

· Avoid laxatives & enemas

· Clear liquid until manifestations subside

· Progress to low fiber diet once solid foods are tolerated

· Severe: NPO, NG suctioning, IVF, ABX, opioids

· Avoid seeds/popcorn/nuts: can block the diverticulum

· Avoid foods that can irritate bowel: alcohol, limit fat to 30%

ABX: ciprofloxacin, metronidazole, sulfathoxazole-trimethorpim

Bowel perforation/obstruction clinical manifestations

· Severe abdominal pain and epigastric pain spreading across the abdomen: can radiate to shoulders

· Rigid & board-like abdomen (stiff)

· Rebound tenderness

· Hypoactive bowel sounds: diminished bowel sounds

· N/V, fever

· Hypotension, tachycardia

Bowel perforation nursing interventions

· NPO & go to surgery

· Frequent VS checks & pain assessment

· O2 & ventilator support

· 2 large bore IV’s for blood products & fluids

· Repair the hole surgically: monitor for peritonitis, infection, sepsis

How does dumping syndrome occur?

· Occurs after eating from gastrectomy surgery
· Shift of fluids to the abdomen -> triggered by rapid epigastric emptying or high-carb ingestion

Dumping syndrome complications

· Malnutrition
· Fluid & electrolyte imbalances
· Reduced circulatory volume
· Hypoglycemia is a late symptom: (rapid release of blood glucose then increase in insulin production)

Dumping syndrome nursing interventions

· Have pt lie down after eating

· Monitor glucose frequently

Meds

- Octreotide SQ: help manage s/sx & blocks gastric pancreatic hormones

Diet

- High protein, high fat, low fiber, low carb

- Avoid milk & sugars

- Eat 5-6 meals/day (small/frequent) with no fluids

Increased intracranial pressure (ICP) clinical manifestations

- Earliest sign of increased ICP = altered LOC & change in respirations

- SEVERE HA, N/V, seizures

- Deteriorating LOC, restlessness, irritability

- Pupillary response: dilated, fixed/sluggish, pinpoint (damage to the optic & oculomotor nerves): Doll’s eyes: oculocephalic reflex

- RR < 6 = intubate and GCS < 8 intubate

Cushing’s Triad: LATE sign, outcome will likely be poor:

- Cheyene’s stokes → Altered respirations→ the most common sign of deteriorating LOC (hyperventilation to get rid of of CO2)

- SEVERE HTN with widening pulse pressure: SBP goes up, DBP goes down

- Bradycardia

Posturing

- Decorticate: arms flex in to make C

- Decerebrate: arms extend out to make E (stem damage) = WORSE

Increased intracranial pressure (ICP) plan of care

Neuro assessment

· Q15 min initially & then gradually Q1

· LOC/mental status, GCS, PERRLA

· Gag reflex: shows something is wrong with medulla oblongata

Monitoring pressures: intraventricular catheter

· Direct monitor & can drain CSF

· Candidates: comatose or GCS <8

· Low CVP = give fluids

· Normal CVP but low BP = give pressors

Intraventricular catheter care

· Sterility: reduce infection

· Inspect site at least Q24 for redness, swelling, drainage

Increased intracranial pressure (ICP) priority interventions- decrease

- Maintain C-spine until cleared with CT: head in neutral position & log roll

- HOB at least 30 degrees

- Maintain body/head position at MIDLINE

- calm, quiet environment

- Meds: mannitol & vasopressors

Increased intracranial pressure (ICP) priority interventions- increase

avoid these

· ETT suctioning: no more than 10 sec, hyper oxygenate 100% after

· Hypercarbia (excessive buildup of carbon dioxide)

· Extreme neck or hip flexion/extension

· HOB less than 30 degrees

· Increased intra-abdominal pressure: tight clothing, Valsalva maneuver (bearing down), up in bed, straining to poop, coughing, sneezing, holding breath

Increased intracranial pressure (ICP) pharm interventions

1. Mannitol (diuretic)

- increases cerebral oxygen delivery and decreases ICP

- Must monitor serum osmolality (norm = 265-295)

- Neuro deficits will be seen at 315

- CONTRAINDICATED in renal disease

2. Hypertonic saline (3% NS): pulls fluid out of the brain(monitor BP and Sodium levels --> risk of FVE)

3. Corticoidsteroids: decreases inflammation & edema in brain (swelling)

4. Sedation: to relax them bc pain increases ICP

5. Barbiturates: decreases ICP & cerebral edema

- Monitor brainwaves closely

6. Antiseizure meds: prophylactic

7. Opioids: avoid, can't get accurate neuro assessment

What is a normal ICP?

10-15 mmHg

How do you calculate cerebral perfusion pressure (CPP)?

Cerebral perfusion pressure: pressure it takes for the heart to provide the brain with blood

- If this is too low = cellular death

Normal CPP: 70-95 mmHg

MAP calculation:

SBP + 2 (DBP) divided by 3

MAP – ICP = CPP

What is herniation?

The movement of the brain downward, it is the end result of untreated ICP
- Once it moves down, there is no "stuffing it back in"
- Major compression of vital parts of the brain
- Major deficits, likely death
- This is what we are PREVENTING in increased ICP

Head injuries clinical manifestations: concussion

Mild traumatic brain injury: brief loss of consciousness, retrograde amnesia (confusion, memory loss)

- Acute Sx go away w/in 72 hrs

Head injuries clinical manifestations: contusion

· Sx get worse over days: capillaries damaged (brain bruise)
· Period of stupor, confusion, or unconsciousness present

Head injuries clinical manifestations: diffuse axonal injury

· Widespread brain injury & pt presentation does not match CT/MRI
· Results in coma (more than 6 hrs) w/o mass hemorrhage/hematoma
· No fixing, just supportive care/lifelong disability

Head injuries clinical manifestations: intracranial hemorrhage

Intracerebral hemorrhage = hemorrhagic stroke

Epidural hemorrhage: arterial blood flow, bleeding fast, ICP decreases fast

Subdural hemorrhage: bleeding between dura & arachnoid

- Subdural hematoma: head hurts on side of injury, eyes slow to react, eye bigger on side of injury, weakness/paralysis is on side of injury

Head injuries clinical manifestations: skull fracture

- Amnesia, loss of consciousness: length of time of unconsciousness is significant

- CSF leak - halo sign (clear/yellow-tinged ring surrounding drop of blood = basilar skull fracture)

- NO NGT placement if basilar or facial fracture

- Battle's sign: bruising over mastoid process

- Raccoon eyes: periorbital edema, ecchymosis, rhinorrhea, & otorrhea

Head injuries Dx

- Get all labs (CBC, CMP, drug screen)

- CT of head to r/o c-spine injury, MRI

- Lumbar puncture: not done with increased ICP (can cause herniation)

Head injuries 6 priority interventions

· Assess GCS when pt first arrives: increased ICP?

· Stabilize with c-collar until spinal injury is r/o

· Turn Q2, use footboard, splints, keep head midline

· Seizure precautions

· Insert 2 large bore IV’s

· Foley to gravity

Head injuries surgical interventions

- Craniotomy: bone is replaced

- Craniectomy: bone is not immediately replaced

Post-op nursing interventions

- Admin. meds to reduce cerebral edema: mannitol, dexamethasone can be given for up to 72 hr

- Monitor ICP

- Infratentorial(lower back brain): keep pt flat & on either side for 24-48 hr

- Supratentorial(upper brain): maintain HOB at 30 degrees

- Assess dressing for drainage

Head injuries complications

· Want to prevent increased or out of control ICP (can lead to herniation)

· Permanent neuro defects

· Seizure disorders

· Infection

· Death

· Chronic traumatic encephalopathy (CTE)

Intracranial hemorrhage:

- Epidural: develops rapidly, arterial blood, skull fractures

- Subdural: venous, Sx occur gradually

Spinal cord injuries (SCI) clinical manifestations

· Spinal shock: complete loss of function below injury but only on temporary basis (days to weeks)
· Lack of sensation: inability to feel light touch
· Absent DTR
· Injuries below T1 = paraplegia in lower extremities
· Neck or back pain
· Flaccidity of muscles
· Hypotension
· Shallow respirations

Spinal cord injuries (SCI) priority interventions

Airway

- Provide O2 & suction PRN

- Intubation & mechanical ventilation if necessary

- Incentive spirometry

- Monitor neuro status: report any decline in neuro function

Fluid & nutritional support are key as pt will more than likely be NPO:

- Promote normal elimination as much as possible

Muscle strength & tone:

- encourage passive ROM

Mobility

- Complete injuries --> will not regain mobility

- Incomplete injuries --> can regain some function with the assistance of various types of braces (PT/OT)

Sensation

Spinal cord injuries complications

Autonomic dysreflexia - MED EMERGENCY - (above T6) sudden onset of excessively high BP, severe HA, pallor below the level of the spinal cord lesion

- Other S/Sx: blurred vision, diaphoresis, restlessness, nausea

- Sit pt up to decrease BP

- Distended bladder is most common cause: unclog & irrigate

Neurogenic shock: total loss of communication within the SNS which maintains muscle tone in our blood vessels

- Occurs within 24 hrs of SCI

- Decrease in CO, BP, & HR

Neurogenic shock clinical manifestations

EVERYTHING DECREASED

- hypotension, bradycardia

- decreased BP, HR, CO, CVP, SVR, CPP

- loss of temperature regulation: abrupt fever

Neurogenic shock complications

Venous Thromboembolism (VTE): caused by blood pooling

- Monitor for clots

- Admin anticoagulants

Postural Orthostatic hypotension when transferring pt

- Raise HOB: be ready to lower if they become dizzy

- Transfer into reclining wheelchair

- Lock & lean wheelchair back to fully reclining position if pt reports dizziness

- DO NOT attempt to return pt back to bed

Neurogenic shock priority interventions

· Stabilize C-spine after injuries to prevent further damage (more damage = less perfusion)

· Monitor VS for hypoTN and bradycardia

· Cooling blanket for fever, NO antipyretic

· Lay flat to increase BP

Meds

- IV fluids to increase BP

- Atropine to increase HR

- Vasopressors: dopamine to treat hypoTN

What are the different types of meningitis?

Viral (most common)

- Aseptic meningitis

- Usually resolves on its own

- Clear CSF

Bacterial

- Septic meningitis –> contagious infection

- High mortality rate –> give vaccines

- Cloudy CSF –> droplet precautions

Fungal

- uncommon

Meningitis clinical manifestations

· Nuchal rigidity - stiff neck

· Photophobia - sensitive to light

· Fever/chills

· N/V, HA

· Hyperactive DTRs

· Tachycardia

· Seizures

· Red macular rash (meningococcal)

· Restlessness, irritability

· Kernig’s sign: resistance & pain with extension

· Brudziski’s sign: flexion of legs occur with flexion of neck

Meningitis Dx

- CBC

- CULTUREEEE

Cerebral spinal fluid (CSF) analysis: obtained with lumbar puncture:

- CT before to rule out hemorrhage/tumor that might cause herniation during lumbar puncture

Viral meningitis, clear CSF:

- Increased glucose

- Increased WBC & protein

Bacterial meningitis, cloudy CSF

- Decreased glucose

- Increased WBC & protein

Meningitis plan of care/medications

Meds
- Prophylactic ABX
- Phenytoin: prevent seizures
- Analgesics
- Opioids: use carefully, can mask neuro Sx
- Monitor fluid & electrolytes & replace accordingly
Older adults are at risk for secondary complications such as pneumothorax

Meningitis safety

Prevention is key!! Vaccinate!! ONLY for BACTERIAL

- Hib (Haemophilus influenza type b) if given during infancy

- PPSV (PCV 13 or 23) “pneumonia vaccine”

- Meningococcal (MCV4): reportable condition

Seizure precautions

Meningitis priority interventions

- Droplet precautions immediately & until ABX have been administered for 24 hrs and nasal secretions are no longer infectious

· If bacterial meningitis: may stay on droplet precautions entire time

- Decrease environmental stimuli, minimize exposure to bright light(seizure precautions)

- Maintain HOB at 30 degrees (no more than 30): optimizing drainage off of brain

- Monitor for increased ICP: avoid coughing & sneezing

Hemorrhagic stroke prioritization

ABC: circulation
- Cerebral blood flow is decreased

Hemorrhagic stroke clinical manifestations: transient

· TIA(transient ischemic attack) = only lasts a few minutes

· Loss of balance/loss of vision or double vision

· Facial droop

· Arm weakness (1 side)

· Speech impairment

· Time to call 911

Hemorrhagic stroke clinical manifestations: L-sided hemisphere (language & logic, math & analytic thinking)

· Expressive & receptive aphasia: inability to speak & understand language

· Agnosia: inability to recognize objects

· Alexia: difficulty reading

· Agraphia: difficulty writing

· Right extremity paralysis (hemiplegia) or weakness (hemiparesis)

· Slow, cautious behavior

· Depression, anger, frustrates easily

· Hemianopsia: loss of visual field in one or both eyes

Hemorrhagic stroke clinical manifestations (R-sided hemisphere: intuition, emotion, creativity)

· Overestimation of abilities: altered perception of deficits (Reckless)

· UNILATERAL neglect: more common in R-sided stroke

· Loss of depth perception

· Poor impulse & judgement

· Weakness or paralysis to L side

· Visual changes: hemianopsia

Hemorrhagic stroke priority interventions

· o2 sat >92%
· CT scan without contrast
· Monitor for fever (can cause increased ICP)
· Monitor for S/Sx of decreased LOC
· Cardiac monitor
· HOB at least 30 degrees
· Seizure precautions
· NPO until SLP can perform swallow eval
- Assist with safe feeding
- Assess swallowing & gag reflexes before feeding
- Flex neck while swallowing, add thickening agents to fluids
· ROM Q2

Hemorrhagic stroke risk factors

· HTN

· A-fib

· AV malformations

· Cerebral aneurysm

· DM, obesity

· Atherosclerosis, hyperlipidemia

· Oral contraceptive use

· Smoking & cocaine use

Brain tumors clinical manifestations

· Cranial nerve dysfunction
· Dysarthria: difficulty controlling speech
· Dysphagia: swallowing
· Hemiparesis: impaired function on one side
· HA
· Vertigo: dizziness
· Papilledema: optic nerve swelling d/t increased ICP
· Positive Babinski sign: toes fan upward
· Positive Romberg: sways back & forth

Brain tumors prioritization

· Continue anti-epileptics if given pre-op

· Stop aspirin 72 hours before surgery

· Power of attorney should be implemented

· Report use of any supplements

· NO ETOH, tobacco, anticoagulants, or NSAIDs 5 days before surgery

· Maintain airway

· Neuro checks: changes in LOC, neuro deficits, seizures

· Safety: ambulation assist & provide assistive devices as needed

· Seizure precautions

Brain tumors: medication

· Non-opioid analgesics

· Steroids to reduce cerebral edema

· Anticonvulsants (antiseizure)

· H2 antagonists: decrease acid reflux & stress ulcers

· Antiemetics: masks neuro Sx

Brain tumors Dx

· CT/MRI: determines size & location of tumor

· Lumbar puncture: should not be performed if increased ICP is suspected, can cause herniation

· Biopsy: identify cellular pathology (does not remove tumor)

· Labs: CBC, blood alcohol/toxicology screening, TB & HIV screening

Brain tumors complications

1. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

2. Diabetes insipidus (excessive urination)

· Seen most often after craniotomy

· Large amounts of urine excreted as a result of a deficiency of ADH

Calculate the CPP = BP is 90/42, ICP is 19

39

(42 × 2 = 84, 84 + 90 = 174, 174 ÷3 = 58 (MAP), 58-19 = 39 (CPP)

what is the range for a normal ICP (ATI)?

10-15 mmHg

What is the normal CPP range (ATI)?

60-100