Week 11 CNS/Brain injuries/Conditions

Head injury involves

trauma to scalp, skull, and brain

Result of head injury is

mild concussion to coma to death

Traumatic brain injury (TBI)

• can be open, closed, diffuse, focal

• most common cause: falls

Clinical manifestations of head injury depend on

• location and severity of injury

• symptoms of hemorrhage are delayed until hematoma is large enough to increase intracranial pressure

• can involve personality and physical function

Epidural hemorrhage refers to bleeding that are

• above dura, under skull

medical emergency

• rupture of middle meningeal artery

Epidural hemorrhage results in

• herniation

• loss of consciousness

• focal neuro deficits

  • pupil dilation, paralysis of extremity

Subdural hemorrhage refers to bleeding that are

• below dura, between dura and brain

• usually venous

• may be acute, subacute, chronic

Intracerebral hemorrhage refers to bleeding that are

within the brain tissue

Intracerebral hemorrhage are the result of

focused injury or system issues (hypertension→ CVA)

Concussion is

• global, microscopic

• widespread, homogenous impairment of brain cells

  • cell under-perform

• no visible bleeding

• confusion, irritability, disorientation, headache

Contusion is

• localized, macroscopic

• structural damage to cells

  • cells die

• effects peak 18-36 hours after injury

• “Coup-conTrecoup”

• can cause increase ICP d/t bleeding

• blurred vision, disorientation, unsteady gait, vomiting, slurred speech, coma

Intracranial bolt (ICB) is

a device inserted into the skull to directly monitor intracranial pressure

identify increases in pressure quickly so treatment can be started before severe complications occur

Vomiting is associated with

increased ICP in head injuries

Coup-contrecoup

severe traumatic brain injury involving contusions at both sides

Diagnostics for head injuries

• CT or MRI

  • identifies / evaluates injury to brain tissue

• skull x rays

  • penetrating injuries to the skull

• angiography

Medical care for head injuries

• control ICP

• reduce cellular demands with medically induced coma

• surgical interventions

• minimize secondary injury

How do you control ICP?

• Intracranial Bolt (ICB)

• mechanical ventilation

  • prevent hypoxemia bc

  • increased lactic acidosis→ increased vasodilation and increased ICP

  • cerebral vessels dilate→ increased ICP

How hypoxemia and hypercapnia affect ICP?

low O2 and high CO2 cause cerebral vessel dilation and widening of vessels mean more blood in brain’s limited space→ increases ICP

Goals of nursing care for head injury

• address acute issues

• prevent / treat secondary complications

• prevent / treat / minimize consequences

Nursing care of head injury involves 2 steps

1. assess all systems for direct impact (primary compromise)

2. assess all systems for secondary impact (secondary compromise)

Primary compromise involves checking for

• patient airway

• optimal breathing pattern

• optimal cerebral tissue perfusion

• appropriate fluid balance

Secondary compromise involves checking for

• S/S of infection

• complications and consequences

Post-concussion syndrome lasts

1 week→ 1 year

Post concussion syndrome S/S

• headache

• dizziness

• lethargy

• emotional lability

• fatigue

• poor concentration

• decreased attention span

• memory difficulties

• intellectual dysfunction

Monitor and notify MD if patient is showing

• difficulty awakening or speaking

• confusion

• severe headache

• vomiting

• unilateral weakness

What does Intracranial surgery do?

• reduce elevated ICP

• remove tumor / foreign body

• evacuate a blood clot

• control hemorrhage

Craniectomy

removal of part of skull to allow room for swelling

Cranioplasty

repair of skull using metal / plastic plate after craniectomy

Pre op medical care for head injury

• define diagnosis / surgical approach

• general pre and post op considerations

• medications

Pre op nursing care for head injury

• document baseline neuro status

• routine pre op care and education

• continue with established care (diet, activity, meds)

Post op medical care for head injury

• reduction of cerebral edema

• relieving pain

• preventing seizure

• monitoring intracranial pressure

Post op nursing care

• assess every hour (glasgow coma scale, respiratory, ABGs, VS, ICP)

• proper positioning, depends on surgical approach

• routine post op care (In and Out, bleeding? drainage?

• check with MD for deep breathing and coughing

Glasgow Coma Scale (GCS)

• most widely used method for evaluation of coma

Shortcomings for Glasgow Coma Scale

• limited utility in intubated patients

• inability to assess brainstem reflexes

Full Outline of UnResponsiveness (FOUR)

• provides further neurological details

• better predictor of outcome

• useful for intubated patients

Glasgow Coma Scale

FOUR Score

	Points	4	3	2	1	0	Total Score
System
Eyes		4 = Eyelids open or opened, tracking or blinking to command	3 = Eyelids open but not to tracking	2 = Eyelids closed but opens to loud voice	1 = Eyelids closed but opens to pain	0 = Eyelids remain closed with pain stimuli
Motor Response		4 = Thumbs up, fist, or peace sign	3 = Localizing to pain	2 = Flexion response to pain	1 = Extension response	0 = No response to pain or generalized Myoclonus status
Brainstem Response		4 = Pupil and corneal reflexes present	3 = One pupil wide and fixed	2 = Pupil or corneal reflexes absent	1 = Pupil and corneal reflexes absent	0 = Absent pupil, corneal, or cough reflex
Respiration		4 = Regular breathing pattern	3 = Cheyne-Stokes breathing pattern	2 = Irregular breathing	1 = Triggers ventilator or breathes above ventilator rate	0 = Apnea or breathes at ventilator rate.
System Score

Potential post op complications

• bleeding and hypovolemic shock

• fluid and electrolyte disturbances

• infection

• increased ICP

• seizures

• diabetes insipidus

• SIADH

What is intracranial pressure?

balance of brain tissue, blood, cerebrospinal fluid

Normal ICP is

7-15 mmHg

increases in ICP can be due to

• injury

• brain tumors

• subarachnoid hemorrhage

• toxic or viral encephalopathies

Monroe Kellie Doctrine

increase in any component→ compensatory changes in other or ICP will increase

Early responses to increased ICP

• change in LOC

• pupillary changes

• impaired ocular movements

• weakness in one extremity / side

• headache - constant

  • increase in intensity

  • aggravated by movement / straining

Late response to increased ICP

• further deterioration of LOC

• respiratory pattern alterations

• loss of brainstem reflexes

  • pupillary, gag / swallowing, corneal

• Cushing’s Triad

• Hemiplegia or flaccidity

• decorticate or decerebrate posturing

Cushing’s Triad is

hypertension / widening pulse pressure

bradycardia

bradypnea

Increased ICP acronym

Increasing pulse pressure

Changes: LOC, respiratory, speech, heart rate

Pupils, Puking, Pain, Posturing

Decorticate posturing indicates severe damage to

• the brain at corticospinal tract

• serious, but more favorable than decerebate posture

• may progress to decerebrate posture, or the two may alternate

Decorticate posturing looks like

• arms adducted and flexed

• hands clenched

• may be uni or bilateral

Decerebrate posturing indicates severe damage to

the brain at brainstem level

worse than decorticate

Decerebrate posturing looks like

• arms adducted, extended and pronated

• wrists flexed

• head and neck arched backwards

• muscles are tightened, held rigid

Risks for compromise d/t increased intracranial pressure

• cerebral perfusion

• airway clearance

• fluid balance / imbalance

• bowel / bladder function

• infection

Nursing interventions for ↑ICP r/t Cerebral Perfusion

1. elevate HOB to 30-45 degrees with head in neutral position & use a cervical collar if necessary

2. avoid extreme hip flexion

3. note abnormal distension

   • avoid Valsalva maneuver

4. no closed mouth coughing

5. ask patient to exhale when being moved or turned

6. avoid enemas, suppositories

7. avoid isometric exercises

8. pre-oxygenate and hyperventilate prior to suctioning

9. avoid high levels of PEEP

10. space nursing interventions

11. assess level of cognition, orientation, and ability to follow commands

12. avoid emotional distress and frequent arousal from sleep

What is the Valsalva maneuver?

a breathing technique performed by attempting to forcefully exhale against a closed airway—typically by pinching the nose and closing the mouth while straining (bearing down) for 10–15 seconds

Why do we discourage patients from Valsalva maneuver?

to prevent straining

• ask patient to exhale when moving / turning and avoid closed-mouth coughing and enemas

Nursing interventions for ↑ICP r/t Airway

• elevate HOB

• auscultate lung fields

• O2 as needed

• monitor pulse ox

• suction as needed

• hyperoxygenation for suctioning

• note nasal drainage

Why should you never suction the nares?

it can lead to brain trauma or infection

Nursing interventions for ↑ICP r/t fluid balance / imbalance

• monitor vital signs, I & O, skin turgor, mucous membranes, serum and urine osmolality

• monitor intraventricular fluid

• observe for congestive heart failure and pulmonary edema if giving Mannitol

• good oral hygiene

  • non-drying mouth rinse

  • lip lubrication

Nursing interventions for ↑ICP r/t bowel / bladder function

• monitor urinary output every 2-4 hours

• test urine for specific gravity and glucose

• monitor bowel sounds

• monitor for abdominal distension

• test stools for occult blood

Nursing interventions for ↑ICP r/t infection

• aseptic technique when managing the intra-ventricular catheter / direct ICP monitoring

• observe character of the CSF drainage

  • report increasing cloudiness or blood

• monitor for signs / symptoms of meningitis

  • fever, chills, nuchal rigidity, increasing / persistent headache

• monitor temperature, labs, urine, lungs

Nursing interventions for ↑ICP r/t hyperventilation

• PaCO₂ range:  25-30 mm Hg

Nursing interventions for ↑ICP r/t temperature control

• Prevent hyper- or hypothermia

Nursing interventions for ↑ICP r/t B/P control

• High range normal essential for adequate perfusion pressure

• Too high may increase ICP

• Sedation 

Recommended positioning for a patient with increased ICP?

elevate HOB to 30-45 degrees with head in a neutral, midline position

Why should extreme hip flexion avoided in patients with increased intracranial pressure?

it increases intra-abdominal and intrathoracic pressure, which can impede venous return from the brain and raise ICP

How should a nurse prevent the Valsalva maneuver during patient movement?

instruct the pt to exhale while being moved or turned and avoid closed-mouth coughing

What are the respiratory nursing considerations before suctioning a patient with increased ICP?

pre-oxygenate and hyperventilate the pt

What is the target PaCO2 range for therapeutic hyperventilation in ICP management?

25-30 mmHg

When administering Mannitol, what two major complications must the nurse observe for?

Congestive Heart Failure (CHF) and pulmonary edema

What are the classic signs of meningitis to monitor for in a patient with an ICP drain?

fever, chills, nuchal rigidity (stiff neck), and increasing/ persistent headache

Why should nursing itnerventions be “spaced out” for patients with increased ICP?

to prevent cumulative increases in ICP and allow the pressure to return to baseline between tasks

What should the nurse test for if the patient has a risk of compromised bowel / bladder function?

urine specific gravity / glucose, abdominal distension, bowel sounds, and occult blood in stool

Management of increased ICP include

control intracranial pressure

• medications

  • Mannitol

  • Corticosteroids

  • Dilantin

  • Antibiotics

  • Anti-anxiety

Mannitol is an

osmotic diuretic

Corticosteroids

reduce cerebral edema

Dilantin manages

Prophylaxis seizure activity

Complications to monitor for d/t increased ICP

• brains tem herniation

• respiratory distress or failure

• pneumonia

• aspiration

• pressure ulcer

• deep vein thrombosis (DVT)

• contractures / position

• seizures

• diabetes insipidus

• syndrome of inappropriate anti-diuretic hormone (SIADH)

Pathology of seizures

uncontrolled, abnormal, recurring electrical discharges in brain

Causes for seizures

• idiopathic

• acquired

  • cerebrovascular disease, hypoxemia, fever, head injury / surgery, hypertension, CNS infection, metabolic and toxic conditions (renal failure, hypoglycemia), brain tumor, drug / ETOH withdrawal, allergies

Classifications of seizures

• Generalized seizures: involve the whole brain

• Partial (focal) seizures: begin in one part of the brain

  • Simple partial: consciousness remains intact

  • Complex partial: impairment but no loss of consciousness

Manifestations of seizures

• Loss of consciousness

• Excessive movement

  • Not all seizures cause convulsions

• Loss of muscle tone

• Disturbances of behavior, mood, sensation, perception

Static Epilepticus

emergency where a seizure lasts longer than 5 minutes without waking in between

Seizure assessments

• Precipitating factors

• Presence of an aura

• Initial presentation 

• Type of movements

• Areas of body involved

• Eyes

  • Size of pupils

  • Eyes open or closed

  • Any deviations  

• Incontinence

• Duration

• Periods of unconsciousness

• Paralysis or weakness after the seizure

• Inability to speak

• Movements at the end of the seizure

• Post-ictal period

• Cognitive status after the seizure

Nursing actions when a pt is having a seizure

• Maintain and protect airway

  • Suction set-up available

  • Turn sideways

  • Intubation to protect airway? 

• Limit seizure duration

  • Medications 

    • Valium (diazepam), Ativan (lorazepam), Dilantin (phenytoin)

• Prevent patient/personal injury

• Observe seizure activity

  • Neuro/cardio/pulmonary monitoring 

• Documentation

Nursing actions post seizure

• Reorient patient when awake

• Provide comfort and reassurance

• Treat any injury from seizure activity

• Maintain seizure precautions

• Anti-seizure medication if ordered

• Education

  • Medication

  • Triggers

  • At-home/school care

Nursing actions for a pt with history of Status ePILEPTICUS

• Limit seizure duration

  • Medications 

    • IV Valium (diazepam)

    • Ativan (lorazepam)

    • Dilantin (phenytoin)

• Establish and protect airway

  • Turn sideways

  • Intubation may be necessary

• Neuro/cardio/pulmonary monitoring

• Maintain safety

• Documentation

Diabetes Insipidus is

deficiency anti-diuretic hormone (ADH) secretion

fluid Drains out

result of Diabetes Insipidus

• polydipsia and polyuria

• low urine specific gravity

• dehydration

Causes of Diabetes Insipidus

• increased intracranial pressure

• surgical ablation or irradiation of pituitary

• infections of CNS

Syndrome of Inappropriate ADH is

excess anti-diuretic hormone (ADH) secretion

fluid Stays in

result of SIADH

fluid retention, no edema = dilutional hyponatremia

causes of SIADH

• increased ICP

• bronchogenic carcinoma

  • paraneoplastic syndrome

• severe pneumonia

• hemothorax

Paraneoplastic syndrome

ADH is secreted by the tumor cells

how to treat DI

• replace fluid

  • hourly IV fluid volume dependent on urine output

• replace ADH

  • vasopressin

Complications d/t DI

• dehydration

• electrolyte imbalance

• unintentional weight loss

how to treat SIADH

• restrict fluid intake

  • 1200-1800mL/day to increase serum sodium

• replace sodium

  • hypertonic saline

complications d/t SIADH

• water overload

• electrolyte imbalances

• fluid shifts

if Na+ > 140 mEq

dehdyration

if Na+ <135

confusion

Spinal cord injuries risk factors

youth, male, drug / alcohol use