Adult Health 2 Exam 3

Intracrainial Pressure (ICP) Normal Range

5-15 mm/mercury

Primary Causes of Increased ICP

Initial Injury

Secondary Cause of Increased ICP

• Hypoxia

• Ischemia

• Hypotension

• Edema

What in the Skull?

• Brain tissue

• Blood

• Cerebral spinal fluid (CSF)

• The brain autoregulates/compensates until it cant

Causes of Cerebral Edema

1. Infections (meningitis, encephalitis)

2. Head injury (brain surgery)

3. Brain Abscess

4. Brain tumor

5. Metabolic issues: DKA, hepatic encephalopathy, lead or arsenic poisoning.

Clinical Manifestations of Cerebral Edema

1. Changes in LOC

2. Cushings Triad

3. Pupillary changes

4. Decreased motor function

5. HA

6. Vomiting

7. Posturing

Cushings Triad

• Pending brain herniation

• S/S: bradycardia, hypotension with wide pulse pressure, irregular respirations

Posturing

1. Decorticate

2. Decerebrate

Decorticate Posturing

• Everything heads towards the core of the body

• Abnormal flection

Decerebreate Posturing

• Body going outward

• Abnormal Extension

• Lower brain stem issue

Cerebral Edema Diagnostics

1. CT scan

2. MRI

3. EEG→ to look for seizure activity

4. ICP measurement: Ventriculostomy→ drill a burr hole

5. Glascow Coma Scale

Ventriculostomy

• Risk for infection

• Monitor CSF

• NO lumbar punctures→ may cause herniation

Cerebral Edema Treatment

1. Drug therapy

• Osmotic diuretics: Mannitol

• Hypertonic saline

• Corticosteroids: Dexamethasone

2. Nutritional therapy

• Increase glucose requirements due to hyper-metabolic state

Hypertonic saline

Monitor BP and Sodium levels

Glascow Coma Scale (GCS)

1. Eyes

2. Verbal

3. Motor

GCS Eyes

4. Open Spontaneously

3. Opens to speech

2. Opens to pain

1. NO response

GCS Verbal

5. A/O x 3

4. Confused

3. Inappropriate words

2. Incomprehensible Sounds

1. NO response

GCS Motor

6. Obeys commands

3. Abnormal Flection

2. Abnormal extension

1. NO response

Goals to Decrease GCS

1. Airway

2. Normal ICP

3. Fluid/electrolyte/nutritional balance

4. Decrease complications from immobility

Considerations

• HOB 30 degrees to improve jugular vein outflow

• Head should be midline to improve jugular vein outflow and help pressure

Head Injuries

1. Scalp Lacerations

2. Skull Fractures

3. Concussions

4. Diffuse Axonal Injury

5. Contusions

6. Epidural Hematoma

7. Subdural Hematoma (SDH)

Scalp Lacerations

Bleed a lot→ skin around the head is very vascular

Skull Fractures

Basilar Skull fracture→ substantial Blunt force

• Battle’s Signs: bruising behind ears

• Raccoon eyes: bruising under eyes

• CSF from nose/ears: do not block from coming out

Concussions

NEED REST

Diffuse Axonal Injury

• Normal CT scan

• Sheering injury→ causes not a great outcome

Contusions

Bruising of brain

Epidural Hematoma

• Bleeding between the dura and inner skull surface

• initial unconsciousness→ awake/”fine”→ decreased LOC quickly

Subdural Hematoma (SDH)

In-between dura and arachnid space

• Acute

• Subacute: slow bleed; 2-14 days post injury start to get symptoms

• Chronic: Place always bled and hasn’t fully healed

Concussion Teaching

• S/S of neurologic emergency

• Limit screen time

• Do not return to sports the same day

• May require someone to stay overnight

• NO driving until cleared by health care provider

Head Injuries Nursing Considerations

• Frequent Neuro checks

• NO nose blowing

• Do not block nose/ears if CSF leak

• Health promotion→ ex: wear a helmet.

Meningitis Definition

• Acute inflammation of the meninges surrounding the brain and spinal cord

• Associated with fall/winter/early spring

Bacterial Meningitis

• 50-100% fatal if not treated

• Common causes

1. Streptococcus pneumoniae

2. Neisseria meningitidis

How do People get Bacterial Meningitis?

1. Respiratory tract→ blood stream

2. Penetrating skull injuries

3. Fracture to sinuses/skull bones

Clinical Manifestations of Bacterial Meningitis

1. Fever

2. HA

3. N/V

4. Nuchal rigidity (stiff neck)→ can not touch chin to chest

5. Photophobia

6. Decreased LOC

Complications of Bacterial Meningitis

1. Increased ICP

2. Residual Neurologic dysfunction

3. Waterhouse-Friderchesen Syndrome

Waterhouse-Friderchesen Syndrome

Extremely Rare

• DIC

• Petechia

• Adrenal Hemorrhage

• CV collapse

Bacterial Meningitis Diagnostics

1. H+P

2. CT→ rule out other reasons (ex: stroke)

3. Blood cultures

4. Lumbar puncture

5. CBC→ elevated neutrophils

Bacterial Meningitis Treatment

• Medical emergency

• Antibiotics prior to confirmation via lumbar puncture

• Pain management

• IV fluids

• Rest

• Maybe mannitol→ if increased ICP

• Maybe anti-seizure meds

Viral Meningitis

• Treat with antibiotics while waiting confirmation

• Enterovirus most common pathogen

• Self limiting→ has to run its course

• Symptom management→ treat HA, N/V, ect.

• Send patients home from hospital

Primary Spinal Cord Injury

Direct Physical Trauma

Secondary Spinal Cord Injury

Swelling/bodies response to injury

Spinal Shock

• Loss of deep tendon and sphincter reflexes

• Occurs shortly after acute spinal cord injury

• Loss of sensation

• Flaccid paralysis below level of injury

• Lasts days-weeks

• CAN recover

Autonomic Dysreflexia

• Life Threatening

• Can occur after return of reflexes post spinal shock

• Massive, uncompensated CV reaction

• Can be caused by Distended bladder/rectum

• Can be caused by pain or stimulation of skin

Autonomic Dysreflexia Signs and Symptoms

• Throbbing HA

• Diaphoresis above level of injury

• Bradycardia

• Piloerection (goosebumps)

• Flushing above level of injury

• Anxiety

• Nausea

• Blurred/spotty vision

• Nasal congestion

Autonomic Dysreflexia Nursing Management

1. Elevate HOB to 90 degrees/sitting position

2. Fix the cause (ex: distended bladder→ cath)

3. Monitor BP/vitals

Neurogenic Shock

• Level of injury: Cervical/high thoracic injury (Cspine-T6 and above)

• Worsens cord ischemia

Neurogenic Shock Signs and Symptoms

1. Hypotension

2. Bradycardia

3. Temperature disregulation

Area of Injury to Spinal Cord

• Above C3: Total loss of respiratory function (need mechanical ventilation)

• C3-C5: Respiratory Insufficiency

• Below T2: Paraplegia

• C1-T1 Tetraplegia/Quadriplegia

Systems Affected by Neurogenic Shock

• Motor/Sensory

• Respiratory

• CV

• Urinary

• GI

• Integumentary

• Metabolism

• Peripheral Vascular

Neurogenic Shock Diagnostics

• CT

• MRI→ more info

Neurogenic Shock Treatment

1. Venous Thromboembolism (clot that travels) Prophylaxis

2. Surgical Stabilization

3. Skeletal Traction: tongs/halo ring

Neurogenic Shock Nursing Considerations

• Respiratory Status

• CV instability

• Skin

• Bowel/bladder management→ cath/bowel regiment

• Stress ulcers→ PPI for prophylaxis

• Spinal immobilization

• Fluid/nutritional management

CNS

Brain, Spinal cord, cranial nerves 1-2

PNS

Cranial Nerves 3-7, spinal nerves, ANS ( nerve fibers ganglia)

Meninges

Three protective layers which protect the brain and spinal cord

1. Dura mater

2. Arachnoid mater

3. Pia mater

Nervous System Gerontologic Considerations

1. Gradual loss of neurons, ventricles in brain widen, decreased cerebral blood flow

2. Changes in myelin sheath→ decreased conduction

3. Autonomic nervous system changes→ ortho hypotension

4. Decreased taste, smell, balance, and response to temp changes

Normal CSF

Clear, no RBC present, small amount of protein present, glucose present.

How to get CSF?

1. Lumbar puncture

2. Ventriculostomy

Lumbar Puncture

• Rule out meningitis (see decreased glucose)

• Pre: coags, vitals, neuro status (circulation, movement)

• Post: vitals, must lay flat for one hour, check they can void, check for numbness and tingling

Nervous System DX Studies

• CSF

• Tissue biopsy

• Head CT

• MRI

• EEG

• PET Scan

• Carotid Artery ultrasound

Tissue Biopsy

Nerve, muscle, brain, artery tissue

Head CT

Plain or with angiography

EEG

For seizures

Carotid Artery Ultrasound

Present with stroke like symptoms

The nurse is caring for a patient post lumbar puncture. Which statement is correct?

The patient should lie flat for one to two hours post procedure

Your patients CSF lab results post lumbar puncture show very low glucose levels. What should you prepare for?

Administration of IV antibiotics. Patient most likely has bacterial meningitis

Which statement reflects an understanding of gerontologic considerations by the nurse caring for a 79 year old male who is admitted for new onset seizures?

The client should be instructed to take his time when going from lying to standings because he is a greater risk for orthostatic hypotension

Characteristics of Parkinson’s

• Bradykinesia: Slow movements

• Rigidity

• Tremor at rest

• Gait changes: shuffling

Who gets Parkinson’s

• Males>Females

• Increase with age

• Possible genetic link

• Secondary Parkinson’s risk: environmental exposures (cooper, lithium, etc)

Complications of Parkinson’s

1. Aspirations

2. Falls

3. Demential

4. Psychosis

Dx for Parkinson’s

1. NO real test

2. H+P

3. Clinical features/symptoms

4. CT/MRI: to rule out other things (stroke, tumors)

Parkinson’s Drug Therapy

• Enhance release or supply of dopaminergic neurotransmitters

• Block effects of overactive cholinergic neurons

• We want to give medications ON TIME

Parkinson’s Drugs

Levodopa/Carbidopa

• Enhances release/supply of dopaminergic

• Give WITH food

• Give ON TIME

• S/E: N/V, dyskinesia, lightheadedness

Parkinson’s Surgical Therapy

• Occurs when patient has no response to medications

• Types:

1. Deep brain stimulation

2. Ablation→ burn off part of tissue

3. Transplantation→ with fetal neuro tissue

Parkinson’s Nutritional Therapy

• 6 Small meals a day

• Reduce constipation→ increase fiber, fluids, and exercise

Which statement below would indicate a need for further education for a patient with Parkinson’s disease?

My partner should do everything around the house for me

The nurse is caring for a patient with Parkinson’s disease. Which statement by the client would indicate a need for further teaching?

I should keep throw rugs around the house because they are easy to clean

Clinical Manifestations of Guillain-Barre Syndrome

• Acute, ascending, rapidly progressive symmetric weakness of the limbs

• Autonomic nervous system dysfunction

• Pain

Most serious complication of Guillain-Barre Syndrome

Diaphram effected→ need to be intubated

Guillain-Barre Syndrome Treatment

• Supportive: Ventilator is diaphragm is effected

• Plasmapheresis→ similar to dialysis; filtering plasma

• High does of immunoglobulin (IVIG)

Guillain-Barre Syndrome Outcomes

• Most recover spontaneously in 28 days

• 80% walk independently in 6 months

• 60% make a full recovery in a year

• Worse outcomes: people with GI infection, older in age, poor upper extremity strength, or those who need mechanical ventilation.

Ischemic Stroke

1. Thrombotic-Injury to vessel, clot forms (most common)

2. Embolic- embolus lodges and blocks flow (ex: blood embolus, fat embolus, air embolus)→ sudden onset

Hemorrhagic Strokes

1. Intracerebral: prognosis is poor (deep in brain)

2. Subarachnoid hemorrhage: usually caused by ruptured aneurysm

Stroke Risk Factors

• Hypertension

• Age

• Race

• Obesity

• Diabetes (multiplies risk by 5)

• Family Hx

• Heart disease→ A-Fib

• Smoking

Transient Ischemic Attack (TIA)

• Ischemia without infarction, transient (short time)→ S/S<1hr

• 1/3 people with a TIA end up having a stroke

Stroke: Right Brain Damage

1. Impulsivity

2. Impaired judgment

3. Left side deficits

4. Deny that they are having a problem

Stroke: Left Brain Damage

1. Decreased speech/language

2. Aware of deficits (usually cry)

3. Impaired comprehension related to math and language

Clinical Manifestation of a Stroke

1. Motor deficits

2. Communications deficits (aphasia, dysarthria)

3. Affect mood

4. Intellectual function

5. Spatial problems

Stroke Dx

• Onset of symptoms is very important

1. CT to rule out a bleed

2. MRI: better than a CT to identify ischemic stroke

3. BP management: 220/120 is OK for ischemic stroke is no fibrinolytic given→ if TPA is given BP should be <185/110 to start, BP 180/105 max 24 hours post TPA

Stroke: Fibrinolytic- TPA

• 3-4.5 hour window past onset of symptoms to give

• Careful screening: no recent GIB, stroke, head trauma, no major surgery within 14 days, no internal bleeding with 22days

• Frequents vitals and neuro assessment using NIHSS

• Important to have accurate patient weight

• NO anticoagulation during acute phase due to risk for bleeding (HOLD warfarin)

Other Stroke Treatments

Endovascular therapy: balloon/stent/clot retrieval

Hemorrhagic Stroke Treatment

1. Surgical decompression

2. Clip/coil ruptured aneurysm

Stroke Meds

• Statins for high cholesterol and TIA hx

• Anticoagulation for A-Fib

• Antithrombotics for ischemic stroke: either anticoagulants or antiplatelets

Nursing Management Stroke

• Assessment: NIHSS

• Health promotion: decrease modifiable risk factors

• NPO until swallow eval/study performed: important to assess gag reflex before attempting to feed.

• Communication

A patient presents to ED with onset of right sided weakness and difficulty speaking onset 2 hours ago. What is the priority?

Take patient to CT

You just received shift report: which patient should you see first

Patient who is receiving TPA

Your patient has just returned from MRI and has been diagnosed with an ischemic stroke. Her BP is 189/84. Her husband is asking if you can give her something for her hypertension.

You explain to the husband that this BP is ok due to the type of stroke she had