Studied by 2 people
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
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
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)
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)
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?
Pain, paresthesia, and hypotonia (v muscle)
Areflexia (no tendon reflexes), weakness/paralysis of lower extremities
Progressive paralysis occurs rapidly
thoracic area and cranial nerves
Facial paralysis
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
