Intracranial Regulation 1

Alterations in ICR

Alterations in ICR

• Early

• Decline

• Late

Early Alterations in ICR

• Altered LOC

• Behavioral changes

• Respiratory changes

Decline Alterations in ICR

• Disorientated

• Continuous stimulation to arouse

• Reflexive positioning to painful stimulus

Late Alterations in ICR

No response to stilmulus (coma)

Levels of Level of Consciousness (LOC)

• Full Consciousness

• Lethargy

• Obtundation

• Stupor

• Coma

Full Consciousness

The patient is alert, attentive, and follows commands. If asleep, she responds promptly to external stimulation and, once awake, remains attentive.

Lethargy

The patient is drowsy but awakens—although not fully—to stimulation. She will answer questions and follow commands, but will do so slowly and inattentively.

Obtundation

The patient is difficult to arouse and needs constant stimulation in order to follow a simple command. She may respond verbally with one or two words, but will drift back to sleep between stimulation.

Stupor

The patient arouses to vigorous and continuous stimulation; typically, a painful stimulus is required. She may moan briefly but does not follow commands. Her only response may be an attempt to withdraw from or remove the painful stimulus.

Coma

The patient does not respond to continuous or painful stimulation. She does not move—except, possibly, reflexively—and does not make any verbal sounds.

The Glasgow Coma Scale (GCS)

used to give a standardized numeric score of the neurologic patient assessment. This is a widely used measurement tool that consists of three components: eye opening, verbal response, and motor response

GCS Scale Range: Minor (mild) Head injury

GCS score = 13-15

GCS Scale Range: Moderate Head Injury

GCS score = 9-12

GCS Scale Range: Severe head injury

GCS score = 3-8

GCS Scale Range: Brain Death

Less than 3

True

True or False: A child with a GCS score of 9-12 should be hospitalized

What is the best score to get in the GCS?

15

Head injury Diagnostic Tests

• Neuroimaging: CT/MRI

• Skull X-Rays

• EEG

• Brain biopsy: 

• Lumbar Puncture: CSF assessment

Pharmacology Sedative

Lorazepam (Ativan)

Interventions and Therapies for ICP

• May require mechanical ventilation

• IV Fluids: possible fluid restrictions

• Control seizures: seizure precautions: Seizure drugs

• Medications to reduce ICP: Osmotic Diuretics Steroids

• ICP Monitors: Hyperventilate to reduce paCO2:

  • Bolt placement

• Surgical Procedures to reduce IICP:

  • Burr holes

  • Craniotomy

  • Internal/external shunts

Nursing Interventions: Assessment Priorites

• Monitoring ICP

• Vital Signs

• LOC and pupillary response to light

• Full respiratory assessment (w/ ABGs)

• Monitoring fluid intake and output

Sunset Eyes

Rim of the sclera above the irises

Early Signs of increased ICP in Infants

•irritability/lethargy

•High Pitched cry

•Bulging, tense fontanel

•Wide cranial sutures

•↑ Head circumference

•Dilated scalp veins

•Poor feeding or vomiting

Early Signs of increased ICP in Children

•Headache

•Vomiting (projectile)

•Dizziness

•↓ pulse and RR

•Blurred vision, Diplopia

•Sluggish, unequal  pupils

•↓ LOC, irritability

•Slurred speech

Late Signs of increased ICP

• Severely ↓ LOC

• ↓ motor & sensory response (PGCS)

• ↑ B/P, widened pulse pressure

• Bradycardia

• Irregular Respirations

• Cheyne-Stokes respirations

• Decerebrate & decorticate posturing

• Fixed & dilated pupils

Cushing's Triad

Brain herniation

(refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain.

consists of bradycardia,, irregular respirations, and a widened pulse pressure)

True

True or False: Cushing’s triad is indicative of a medical emergency and medical attention is required.

Crushing’s Triad Clinical Manifestations

• Increased BP with widened pulse pressure

• Bradycardia

• Irregular respirations (also known as Cheyne–Stokes respirations)

  • Cheyne-Stokes respirations consist of periods of slow, deep breaths followed by periods of apnea, when breathing comes to a complete stop.

• Hypertension, or increased blood pressure

Early Sign

Sunset eyes is a(n) [Fill in the blank] of increased ICP in infants and toddlers with hydrocephalus

Hydrocephalus

A brain condition that happens when Cerebrospinal fluid can’t drain from the brain.  It pools, causing a buildup of fluid in the skull. 

Treatment for Hydrocephalus

Ventriculo-Peritoneal Shunt (VP Shunt)

Post-op VP Shunt

•  Lie flat for 24 hours (on unaffected side)

•  Vital signs and neurological status

•  Pain management

•  IV fluids

•  Antibiotics

•  The shunt will be checked to make sure it is working properly

•  Measure head circumference

Complications of VP Shunt

•  Blood clot or bleeding in the brain

•  Brain swelling (monitor of s/s of increased ICP)

•  The shunt may stop working and fluid will begin to build up in the brain again

•  Infection

•  Damage to brain tissue

•  Seizures

Parental Teaching (S/S)

• Headache

• vomiting

• drowsiness

• fever

need immediate evaluation!

Neural Tube Defects

Malformation of the spinal cord and spinal canal

Defect in vertebrae through which the spinal cord contents can protrude

Neural Tube Defects Types

• Occulta

• Meningocele

• Myelomeningocele

Occulta

• Mildest form

• Small separation of the spinal bones

• Usually lower spine

• Abnormal tuft of hair

• Collection of fat

• Small dimple or a birthmark

• Spinal nerves aren’t involved

• No neurologic problems

Neural Tube Defects Causes

Cause unknown

• Folic acid deficiency plays a part

• Genetic component

• Viral trigger

Neural Tube Defects Risk Factors

• Neural tube defect in a previous child

• Lack of folic acid

• Medications: valproic acid, carbamazepine

• Maternal diabetes

• 95% no known family history

Neural Tube Defects Screening & Dx

•  Blood tests

  • Maternal serum alpha-fetoprotein test (MSAFP)

  • Human chorionic gonadotropin (HCG),

  • Estriol

•  Ultrasound

•  Amniocentesis

• X-rays, CT scans or MRI

  • performed after delivery to determine the  degree of the impairment

Neural Tube Defects Prevention

 Folic acid (vitamin B-9) 400 micrograms:

• start at least 1 month prior to conception and during the first trimester of pregnancy

Neural Tube Defects Nutrition

• fortified breakfast cereals

• dark green vegetables

• egg yolks

• some fruits

Spina bifida

Type of Neural Tube Defect

• Occurs when the neural tube fails to close (osseous spine)

Meningocele

Rarest form of spina bifida

• Protective covering around the spinal cord (meninges) pushes out through the opening in the vertebrae

•  Spinal cord develops normally

•  Sac can be repaired with very little damage to nearby nerves

Myelomeningocele

 Most severe form

•  Spinal canal remains open along several vertebrae in the lower or middle back

•  Spinal cord and membranes protrude at birth, forming a sac on the baby’s back

•  Tissues and nerves are directly exposed

•  Neurologic impairment - partial or complete paralysis, is common

Meningocele Treatment

Involves surgery to put the meninges back in place and close the opening over the meningocele. This surgery usually occurs soon after birth.

Myelomeningocele Treatment

Surgery within hours to several days after birth

• ↓ risk of infection

• Helps protect the spinal cord from additional trauma

• T_x hydrocephalus w/ ventriculo-peritoneal shunt

  Irreparable nerve damage has already occurred!