CONCEPTS IV TEST TWO

What factors can impair intracranial regulation

reduced blood flow

compromised neurotransmission

damage to brain tissue

Population risk factors for impaired intracranial regulation

ICR problems r/t degenerative pathology are more common in elderly

injury related problems are more common in adolescents and young adults

most common causes of traumatic brain injuries (TBI)

falls

struck by or against object

MVAs

individual risk factors for impaired ICR

dependent on cause of injury or pathology

physiologic consequences of impaired ICR

cerebral edema

increased ICP

brain tumours

Types of cerebral edema

vasogenic

cytotoxic

interstitial

normal ICP

5-15 mmHg

increased ICP level

>20 mm Hg sustained

S/S of increased ICP

headache

decreased LOC

vomiting

cranial nerve 6 palsies

papilledema

periorbital bruising

cushing triad

what is cushing triad

sign of increased ICP

increased sys BP

bradycardia

irregular respirations

causes of impaired ICR

impaired perfusion

compromised neurotransmission

glucose regulation

pathological (tumours, etc.)

What is non-contrast CT / MRI good for

see skull fx, intracranial bleeding, cerebral edema and tumours

what is a skull radiograph good for

fx, bone erosion, calcification or abnormal vasculature

what is an electroencephalogram good for

measures and records brains electrical activity

useful for dx seizures and origin location

what is a brain biopsy used for

staging and grading of tumour

what is a lumbar puncture used for

when infection is suspected

interrelated concepts of ICR

cognition

mobility

hormonal regulation

gas exchange

perfusion

What are some neurological symptoms associated with compromised ICR?

Numbness, paralysis, tingling, neuralgia

What are some cognitive symptoms associated with compromised ICR?

Changes in recent or remote memory

What are some sensory symptoms associated with compromised ICR?

Changes in vision, hearing, balance, gait

What are some speech-related symptoms associated with compromised ICR?

Speech problems

What are some swallowing-related symptoms associated with compromised ICR?

Chewing or swallowing issues

What are some motor symptoms associated with compromised ICR?

Muscle weakness or loss of bowel/urinary control

What are some movement-related symptoms associated with compromised ICR?

Onset of unexplained tremors or other motion disturbances

What is a common physical symptom associated with compromised ICR?

Unexplained, severe headache

What are some gastrointestinal symptoms associated with compromised ICR?

Vomiting

What is an important factor to consider in the history of a patient with compromised ICR?

History of head injury

Examination for compromised ICR

Mental status

GCS

Cranial nerves

ICP

early signs of increased ICP

change in LOC

Headache characterized with...

-nocturnal awakening

-pain worsened by cough or defecation

-recurrent and localized

-vomiting typically not preceded by nausea

late sign of increased ICP

pupil and vision changes

cushing triad

-Sys HTN

-bradycardia

-irregular resps

where can an ICP measuring catheter be placed

intraventricular

intraparenchymal

subarachnoid

epidural

most common placement of ICP catheter

lateral ventricle

Primary prevention of ICR issues

healthy lifestyle

smoking cessation

health weight

controlling BP

exercise

injury prevention

Osmotic diuretics for increased ICP

· Draws water across the BBB, leading to decrease in in interstitial vol and subsequent decrease in ICP

Common: Mannitol, hypertonic saline

Sedative use for increased ICP

can decrease ICP by reducing metabolic demand

propofol

barbiturate coma

benzodiazepines

Analgesic use for increased ICP

pain increases O2 demands, therefore controlling pain helps avoid compromising sufficient o2 delivery to ischemic neuronal cells

SA narcotics: fentanyl or morphine

antiepileptics for increased ICP

seizures can exacerbate or cause increased ICP and oxygen demand (prophylactic)

phenytoin, valrpoic acid

glucocorticoids for increased ICP

dexamethasone can reduce cerebral edema r/t tumours, abscesses and CNS infections

NOT for just ICP

surgical interventions for increased ICP

decompressive craniectomy

craniotomy

stereotactic procedures

shunt procedures

Nursing interventions for increased ICP

HOB 30º

activity management

airway management (coughing increases ICP, suction when indicated)

prophylactic hyperventilation

bowel management (constipation raises ICP, indication for stool softeners or laxatives

nutrition management

pt education and rehab

physiologic mechanisms that maintain normal ICP

changes in CSF volume

alterations in intracranial blood volume

brain tissue volume compensation

what is a seizure

transient, uncontrolled electrical discharge of neutrons in the brain that interrupts normal function

Causes of seizures in first 6mo of life

severe birth injury

CNS congenital defects

infections

inborn errors of metabolism

2-20 yrs causes of seizures

birth injury

infection

trauma

genetics

20-30yrs causes of seizures

structural lesions like trauma, tumours or vascular disease

50yrs+ seizure cause

typically d/t cerebrovascular lesions and metastatic brain tumours

What are generalized seizures characterized by?

Bilateral synchronous epileptic discharges in the brain

What happens to consciousness during generalized seizures?

In most cases, the individual loses consciousness for a few seconds to several minutes

Is there a warning or aura before generalized seizures?

No, because the entire brain is affected, there is usually no warning or aura

what is the most common type of seizure

tonic-clonic

sequence of tonic-clonic seizure

tonic phase for 10-20s and then clonic phase for 30-40s

Tonic manifestations of tonic-clonic seizures

LOC, falling to group, followed by stiffening of the body 10-20s

Clonic manifestations of tonic-clonic seizures

Jerking of the extremities 30-40s

Other manifestations of tonic clonic seizures

cyanosis, excessive salivation, tongue or cheek biting and incontinence

Postictal phase

period following the cessation of seizure activity; patient is confused, may have muscle soreness and fatigue

typical absence seizure

usually only in children

brief staring spell that only lasts a few seconds, with possible LOC

if un tx may occur up to 100x daily

atypical absence seizure

Staring spell with other symptoms like brief warnings and peculiar behaviour during seizure and confusion after seizure

myoclonic seizure

sudden excessive jerk, brief, can occur in clusters

atonic seizures

"drop attack"

tonic episode which begins w person falling to ground

consciousness returns by the time the person hits the ground

tonic seizure

sudden onset of sustained increased tone in extensor mm

clonic seizure

begin with LOC and loss of mm tone, followed by limb jerking that may or may not be symmetrical

focal seizures

Electrical activity that is focal to a particular area of the brain, resulting in unilateral manifestations

Focal aware seizures

no LOC

motor, sensory, or autonomic phenomena

usually not longer than 1 min

focal impaired awareness seizure

Behavioural, emotional, affective, sensory and cognitive impairment

Longer than a minute and have a postictal confusion phase

Alterations in consciousness

Confused state most common manifestation

Lip smacking, automatisms

how are seizures diagnosed

complete health hx

EEG

seizure hx

important things to note when taking seizure hx

antecedent events

precipitating factors

seizure description

initial interventions for seizures

ensure patent airway

suction if indicated

stay with pt until its over

protect from injury

establish IV access

anticipate med admin (ativan)

reposition to side lying

remove or loosen tight clothing

ongoing interventions for seizures

VS, LOC, O2sat, GCS, PERLA

reorient pt

never force airway b/w clenched teeth

IV dextrose for hypoglycaemia

health promotion for seizures

Helmets for safety

prenatal care

good health habits

identify events leading to seizures

avoid excessive alcohol, loss of sleep

learn to manage stress