321 final icp

What are the three parts of the skull?

* Brain tissue 80%
* Blood 10%
* Cerebrospinal fluid 10%

What is a normal ICP?

* 0-15 mm HG (>20 no good)

What influences ICP?

* Arterial/venous pressures
* Intraabdominal and intrathoracic pressure
* Posture
* Temperature
* Blood Gases (CO2)

What is monroe-kellie doctrine?

* If volume of one of the components increases, the other ones prob will too
* Change in CSF
* Change in intracranial blood volume
* Change in brain tissue volume

What are clinical manifestations of increased ICP?

* Changes in Level of Consciousness
* Ocular signs
* Altered motor function
* Headache
* Vomiting
* Vital Signs (Cushing’s Triad)
* Complications → Inadequate cerebral perfusion and herniation
* Widening pulse pressuer

What is cushing’s triad? Where do you see it?

* Increased BP
* Decreased HR
* Decreased Respirations

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* Increased ICP

What happens if MAP is too high?

* CBF increases and maximal vasoconstriction of blood vessels

What happens if MAP is too low?

* CBF decreases and cerebral ischemia can occur

What is normal CPP? What happens if it decreases?

* MAP-ICP = CPP
* Normal CPP is 60-100 mm HG
* When decreased, autoregulation fails and CBF decreases

What is decorticate and decerebrate rigidity?

* Decorticate have arms flexed towards the core
* Decerebrate has extensions and usually more serious

How to diagnose ICP?

* Respiratory and neurological assessments
* ABGs
* Cushing’s triad
* MRI and CT
* EEG
* Cerebral angiography
* ICP measurement
* Ventriculostomy / Fiberoptic catheters

Would you perform a lumbar puncture on a patient with increased ICP?

* No because it can cause herniation

What is proper positioning for lumbar puncture?

* On the side
* Sitting, leaning over

What to make sure with lumbar punctures?

* Make sure there are pulses distal to the area

How would you care for increased ICP? Surgery?

* Provide quiet, calm environment → Decrease stimuli
* Nutrition Therapy → Should be initiated ASAP after a cerebral injury (increase protein or calories)
* Surgery:
* Craniotomy: Remove part of skull
* Ventriculostomy: Remove CSF fluid

What is drug therapy for ICP?

* Corticosteroids
* Osmotic diuretics (mannitol IV)
* Intravenous Hypertonic Saline
* Acetaminophen
* Sedatives
* Ativan (Lorazepam)

What are nursing interventions for increased ICP?

* Maintain oxygen and respiratory (ventilation if needed)
* Monitor cardiac function (telemetry)
* Fluid and electrolyte balances
* IVFs and electrolyte balances
* I/Os and daily weights
* Monitor ICP
* Avoid activities that can increase ICP
* Avoid long suction and flexions
* Positioning (30-40)
* Skin care; Q2 hour turning
* Prevent injury
* Psychological and psychosocial care

Who is more likely to have brain tumors?

* Middle aged males are more likely

What is a primary brain tumor? How are they classified?

* Forms within brain tissue
* Classified by tissue where developed
* Meningomas most common (benign)
* Gliomas are mostly malignant
* Oligodendrogliomas
* Acoustic neuromas

What are secondary brain tumors?

* Most common; metastasis from another cancer

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What are clinical manifestations of brain tumors?

* Headache
* Nausea and vomiting
* Seizures
* Mood/Personality changes
* Aphasia
* Motor weakness opposite side
* Muscle weakness

What kind of medications with tumors?

* Steroids for edema
* Check blood glucose
* H2RA’s and PPIs for ulcers
* Kepra for seizure

What kind of changes will you see with a frontal lobe tumor?

* Changes in:
* Personality
* Judgement
* Intellect
* Memory
* Broca’s aphasia (understand)

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What kind of changes will you see with a parietal lobe tumor?

* Changes in:
* Speech
* Writing
* Sensory

What kind of changes will you see with a Occipital lobe tumor?

* Changes in:
* Vision

What kind of changes will you see with a temporal lobe tumor?

Changes in:

* dysphagia

What are treatments for brain tumors?

* Surgery
* Radiation
* Ventricular Shunting
* Chemotherapy
* IV, PO, Intrathecal
* Targeted therapy

What is meningitis? What is the patho? Cause?

* Inflammation of the brain tissue
* Caused by Bacteria, virus, or aseptic
* Bacteria/Virus enter cns via blood or respiratory → Inflammation occurs due to infection → Increases CSF production and ICP

Who is most at risk for meningitis?

* Older adults
* Debilitated
* Institutionalized people (prisons)
* College students

What are clinical manifestations of meningitis?

* Fever, severe headache, nuchal rigidity, photophobia
* Decreased level of consciousness → coma (poor prognosis)
* Signs and symptoms of increased ICP
* Skin rash and petechiae (meningococcal)
* Hyperextension of head and back arch (opisthotonus)
* Kernig and Brudzinski

What are complications of meningitis?

* Increased ICP: most common
* Headaches (for months)
* Residual neurological dysfunction
* Hemiparesis, Dysphasia, Hemianopsia (blindness in half of visual field)
* Cranial Nerve dysfunction
* Cerebral edema → seizures → coma → death
* Waterhouse-Friderichsen syndrome
* Shock
* Disseminated intravascular coagulation (DIC)

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How to diagnose meningitis?

* Neuro assessment first
* CT scan of head/brain
* Blood cultures
* Lumbar puncture → CSF shows neutrophils, protein
* Presence of CSF pleocytosis (increased cells)
* CBC
* Culture sputum/throat/nose
* Xpert EV test - rapid test; sample of CSF tested for enterovirus
* Polymerase chain reaction (PCR)

How to care for meningitis?

* Rest
* IV fluids (monitor fluids, I/Os)
* Calm environment/Decrease stimuli
* Drug therapy
* Codeine
* Acetaminophen or aspirin
* Dexamethasone (decadron) (steroid for inflammation)
* Mannitol (Osmitrol)
* IV antibiotics → Penetrate BBB
* Penicillins
* Cephalosporins

What are nursing interventions for meningitis? (not direct care)

* Health promotion
* Vigorous treatment of respiratory illness
* Vaccinations
* Pain relief and fever treatment
* Proper positioning
* Photophobia treatment
* Seizure precaution
* Fluid replacement
* Droplet precautions
* Nutrition
* Psychosocial care
* Treat residual side effects
* Rest but slowly reinitiate activities

What is viral encephalitis?

* Acute inflammation of the brain caused by a virus
* Ticks, mosquitoes, west nile virus
* Potential complications from chickenpox, measles, or mumps

What are clinical manifestations of viral encephalitis?

* Fever, headache, nausea, vomiting
* Alteration in mental status (mild to coma)
* Symptoms of increased ICP
* Focal neurological deficits

How to diagnose viral encephalitis?

* MRI, CT scan of brain and PET scan
* Lumbar puncture
* PCR testing for HSV and West nile Virus
* Blood test for west nile virus → Detects viral RNA

What are meds and things we can do to manage encephalitis?

* Focus on prevention and treat symptoms
* Mosquito control
* Diuretics (decrease cerebral edema)
* Corticosteroids
* Antiviral medications (acyclovir)
* Anti-seizure medications

What are primary headaches?

* Headaches that are either tension type, migraine, or cluster headaches

What is a tension headache?

* Bilateral frontal-occipital headache
* Constant, heavy pain to face, head, & neck; photophobia may be present
* Muscle tightness in neck
* Band like pain/pressure
* most common

What is a cluster headache?

* Neurovascular
* Severe, extreme pain (unilateral)
* In and around the eye (most severe)
* Sharp, stabbing pain
* Agitation/Restlessness
* Photo/phonophobia

What are migraine headaches?

* Vascular
* Pulse like or throbbing headache
* Unilateral
* Auras can be present
* Want to “hibernate”
* Photophobia and phonophobia
* Dizziness, nausea/vomting, etc

What are risk factors for migraines?

* Family history, foods triggers, stress, hormones, medications, fatigue, tension headaches

How to care for headaches?

* Increase comfort and decrease anxiety
* Patient teaching → avoid stressors
* Development of positive coping strategies
* Increased quality of life and decreased disability
* Headache diary
* Relaxation, cognitive behavioral therapy

What to do during a headache?

* Calming environment; dim lighting
* Massage neck; moist heat

What are drug therapies for headaches?

* Non-opioid analgesics (Aspirin, Tylenol, NSAIDS)
* Combination analgesics
* Muscle relaxants
* Tricyclic antidepressants, SSRIS, or mirtazapine
* Antiseizure medications - topiramate (topamax) or gabapentin (neurontin)
* Triptans (sumatriptan)

How to treat cluster headaches?

* !00% oxygen at 6-8L/min
* Triptans (sumatriptan)
* Verapamil (Calcium channel blockers/antihtn), lithium, antiseizures
* Possibly for prevention
* Nerve block deep brain stimulation, or neurosurgical ablative procedures
* Botulinum toxin A (botox) injections

What is trigeminal neuralgia? What nerve does it affect

* AKA tic douloreux
* Involves the trigeminal nerve 5
* Compression of the superior cerebellar artery
* Causes irritation and compression of the trigeminal nerve

What are risk factors for trigeminal neuralgia?

* Herpes viral infection, tooth/jaw infections, trauma, or cerebral masses
* Women, multiple sclerosis

What are clinical manifestations of trigeminal neuralgia?

* Lots of pain
* Twitching, grimacing
* Blinking an tearing
* Sometimes senosory loss
* Occur as brief attacks (unilateral)
* 2-3 mins, once/multiple per day
* Precipitated by stimuli/triggers

How to diagnose trigeminal neuralgia?

* H&P neurological assessment
* Magnetic resonance image (MRI)
* Computed tomography (CT)
* Electromyography (EMG)

How to care for the patients with Trigeminal neuralgia?

* Nerve block, electrical stimulation of nerves, botox injection
* Surgery:
* Percutaneous: Glycerol rhizotomy or radiofrequency rhizotomy
* Microvascular decompression: craniotomy to decompress affected blood vessels
* Stereotactic radiosurgery (gamma knife): precise radiation to trigeminal nerve

What drugs are used for Trigeminal Neuralgia?

* Focus on nerve firing


* Antiepileptic medications (carbamazepine)


* Tricyclic antidepressants

What to do as a nurse for trigeminal neuralgia?

* Monitor patients reflexes and sensations
* Protect eyes if corneal reflex is impaired
* Hygiene, oral care, nutrition
* Warm water
* Soft towels
* Electric razors
* Decreasing environmental stressors
* Post op procedures
* Emotional support

What is Seizure/Epilepsy?

* Epilepsy: Spontaneous recurring seizures
* Uncontrolled electrical discharge of neurons
* Can cause loss of oxygen and perfusion

What risk factors and causes seizures/epilepsy?

* Risk: Alzheimer’s or stroke family history
* Idiopathic/cryptogenic
* Due to systemic/metabolic disturbances
* Metabolic: acidosis, electrolyte imbalances, hypoglycemia, hypoxia, alcohol/drug withdrawal, dehydration, water intoxication
* Systemic: Lupus, diabetes
* Extracranial: heart, liver, lung diseases, hypertension, septicemia

What are the three seizure phases?

* Preictal phase
* Aura experienced
* Ictal phase
* Postictal phase

What are tonic clonic seizures (gran mal)?

* Tonic (stiffness)
* Clonic (Jerking)
* Don’t remember

What are absence seizures?

* Inattentive
* Blank stare
* don’t remember

What are myoclonic seizures?

* Brief Contraction of muscles

What are atonic seizures?

* Brief loss of muscle like toys

What are focal seizures (focal)?

* One part of brain is affected
* Like speech (aphasia)
* Automatisms: like chewing

How to diagnose seizures/epilepsy?

* H & P
* Seizure history
* electroencephalogram (eeg)
* CT/MRI of brain → rule out lesions
* Metabolic labs
* CBC, Liver Function tests, urinalysis

How to care for seizures?

* Goal: treat underlying cause, prevent seizures
* Seizure precautions
* Surgical: Remove epileptic focal area
* Vagal nerve stimulator
* Keto diet (decreases glucose)
* Patient training

What are drugs for seizure/epilepsy?

* Rapid (short acting)
* Ativan
* Long acting
* Single/Combination therapy

What is amyotrophic lateral sclerosis? (ALS)

* AKA lou gehrig’s disease
* Rare disease that degenerates motor neurons in brainstem and spinal cord
* Brain intact
* Quick progression → death in 2-10 years

How to diagnose ALS?

* No diagnose
* History of present illness

Who is more at risk of ALS?

* Men usually > 50s

What are the manifestations of ALS?

* Weakness in extremities
* Dysarthria, dysphagia, drooling
* Muscle wasting (spasticity/cramping)
* Pain
* Sleep disorders, emotionally labile; depression
* No cognitive impairments

How to care for ALS patients?

* Exercise → Endurance based to decrease spasticity
* Support cognitive and emotional functioning
* Nutrition
* Reduce risk of aspiration and decrease risk of injury
* Treat pain
* Support family/friends

What are drug therapies for ALS?

* Riluzole (rilutek)
* Decreases glutamate in the brain
* Delays need for tracheostomy
* Delays death

What is Guillain-Barre syndrome? What does it affect?

* Acute, rapidly progressing polyneuritis/polyneuropathy
* Ascending bilateral paralysis affecting peripheral nervous system and cranial nerves (stars in lower extremities)
* Rare; can be fatal

What is the cause and patho of Guillain-Barre syndrome?

* Occurs due to cell mediated or humoral immunological response
* Trauma, viral, vaccine, or bacterial infection
* Most common → campylobacter jejuni/cmv
* Loss of myelin, edema, and inflammation of affected nerves
* Decreased or absent nerve impulses leading to paralysis, loss of reflexes, and muscle tone

What are clinical manifestations of Guillain-Barre Syndrome?

1. Pain, paresthesia, and hypotonia (v muscle)
2. Areflexia (no tendon reflexes), weakness/paralysis of lower extremities
3. Progressive paralysis occurs rapidly


1. thoracic area and cranial nerves
2. Facial paralysis
4. Autonomic nervous system dysfunction

How to diagnose guillain-barre syndrome?

* Based on clinical manifestations and patient history
* CSF analysis
* EMG
* MRI of brain

How to treat Guillain-Barre syndrome?

* Ventilation and respiratory support (trachs)
* Monitor respiratory function, cardiac status, reflexes, and muscle tone
* Monitor vitals
* Skin care; turning and repositing, exercises
* Emotional support
* Plasmapharesis
* Immunoglobulins (IVIG, sandoglobulin)
* Tube feeds or TPN

What is carpal tunnel syndrome? Cause?

* Compression of the median nerve
* Caused by pressure related trauma or edema
* Occupation and hobbies requiring repetitive movements of the wrist
* Hormones
* Other disorders

What are the clinical manifestations of carpal tunnel syndrome?

* Weakness, pain, numbness, and impaired sensations
* Along distribution of median nerve
* Difficult performing fine hand movements

How to diagnose carpal tunnel syndrome?

* Tinel test
* Phalen test
* Radiographic studies
* Atrophy of thumb muscles; dysfunction of hand (in late stages)

How to care for carpal tunnel syndrome?

* Adaptive devices
* Braces or splints
* Special keyboard pads or mouse for computer
* Ergonomic changes
* Proper body mechanics
* Avoid extreme temperatires
* Frequent breaks
* Exercises/PT if needed
* Corticosteroid injections
* Surgery
* Open release surgery/endoscopic
* Rehab post op
* Monitor pain and neurovascular status post op
* Check below pulses and cap refill

What is gout?

* Accumulation of uric acid crystals
* Incidence → predominantly in middle aged men; higher incidence in african american

What is primary and secondary gout?

* Primary: hereditary
* Secondary: Caused by other diseases and medications (or others)
* Diuretics (thiazide diuretic), renal disease, crash dieting/fasting, immunosuppressive drugs after organ transplantation

What are risk factors for gout?

* Obesity


* Use of thiazide diuretics
* Hypertension
* Excessive alcohol intake
* High purine diet

What are clinical manifestations of Gout? Phases?

* Acute, intercritical, and chronic
* Acute:
* Pain and inflammation at affected joints
* Joint tenderness, swelling, and warmth (sometimes redness)
* Chronic gout (Tophaceous)
* Repeated gout attacks and presence of Tophi
* Arthritis like symptoms
* Complications → Urinary or kidney stones; pyelonephritis; renal obstruction; and joint destruction

What are drugs used for acute gout and to prevent it?

* Colchicine, NSAIDS, glucocorticoids
* To prevent further attacks → Allopurinol or probenecid (sometimes with colchicine and NSADIs)

What are drugs used for chronic gout due to hyperuricemia?

* Febuxostat (uloric)
* Allopurinol (zyloprim)

How to treat gout?

* Rest and immobilization during gouty attacks
* Elimination of alcohol and high purine foods
* Weight loss
* Encourage proper fluid intake
* Avoid aspirin

What is a sprain?

* Injury to ligament surrounding a joint
* Most common in ankles, wrist, and knees (ex. acl)
* Can be very painful
* Pain, edema, ecchymosis, decreased function/weight bearing

What is a strain?

* Excessive stretching of a muscle or tendon
* Most common in lower back, calves, and hamstrings
* Pain, edema, spasms, ecchymosis, internal bleeding (3rd degree strain)

What is management for sprains/strains?

* RICE x 24 → 48 hrs for 1st and 2nd
* R: Rest
* I: ICE
* C: Compression
* E: Elevation
* After 48hrs, apply warm moist heat
* Encourage use of limb but support it
* Aim to strengthen the affected area
* Use of brace if warranted
* Health promotion and prevention
* Proper stretching, warm up before exercise

What is causes amputations?

* Harzardous occupation, circulation impairment, thermal injury, trauma, or tumor

When are amputations indicated when?

* Extremity has:
* Loss sensation
* Inadequate circulation
* Pallor/Necrosis
* Local infection
* Vascular studies indicate the patient is not a candidate for revascularization

What are closed (flap) amputations?

* Usually elective and performed when infection is not present
* Creation of a weight-bearing residual limb (stump)
* Covered with a sutured flap of skin

What is an open (guillotine) amputation?

* Performed when infection is present or suspected (or in an emergency situation as traumatic)
* Surface of residual limb is left open
* Second surgery needed for closure after infection resolves

What is a disarticulation?

* Amputation through a joint

What is nursing management for amputations?

* Control underlying disease/problem
* Pain control
* Cope w body image changes
* Achieve maximum rehab potential
* Make appropriate lifestyle adjustments

What are preop nursing managements for amputations?

* Educate patient
* Phantom limb pain
* Compression bandages
* potential prosthesis
* Mobility and rehab expectations
* Strengthening exercises
* Build arm strength
* Provide emotional support

What are postop nursing managements for amputations?

* Prevention of complications
* Treat pain
* Assess for signs of bleeding or oozing
* surgical tourniquet at bedside
* Elevate stump for first 24hrs, then place flat on bed (depend on surgeon)
* ROM exercises and early ambulation with assistive devices
* Compression bandage
* Reduce edema, increase healing, decrease pain, promote shrinkage
* Limit hip flexion
* Position on abdomen 3-4 times a day
* Limit time sitting in chair
* Rehab Needs
* Monitor limb
* Manage coping
* Provide family support

What are risk factors of low back pain?

* Lack of muscle tone
* Obesity
* Poor posture
* Smoking
* Pregnancy
* Stress
* Spinal abnormality
* heavy lifting, prolonged sitting

How to diagnose low back pain?

* History and physical exam
* MRI and CT
* X rays
* Myelogram
* EMG