Week 4 - Neuro ~ IICP Flashcards

Question

IICP: Later Findings - Cerebral Herniation Increased ICP that continues to develop will result in cerebral herniation Brain tissue pushed __________ thru tentorial notch > herniates (________) thru it > Results: severe consequences or death if not treated aggressively

Answer 1

Increased ICP that continues to develop will result in cerebral herniation Brain tissue pushed downward thru tentorial notch > herniates (protrudes) thru it > Results: severe consequences or death if not treated aggressively

Answer 2

Adult should not have Babinki's reflex

Answer 3

Do they blink when an eye drop/cotton is near eye If not, cranial nerves not intact

Answer 4

gag reflex

Answer 5

Quickly turn head horizontally from side to side (CN III, VI) or vertically up and down (CN III) while holding eyelids open Doll’s eyes present = intact brainstem; eyes lag behind movement of head Doll’s eyes absent = brainstem not intact; eyes move passively with head

Answer 6

IICP: Later Findings - Oculovestibular Reflex (Cold Caloric Testing) More sensitive test of brainstem function Comatose patient only Results: slow eye deviation toward irrigated ear if brainstem intact Procedure Raise patient's HOB 30 degrees Irrigate one ear at time with 30-50 ml iced cold water over 30 seconds Wait > 5 minutes before irrigate other ear

Answer 7

if pt breathes

Answer 8

LOC Pupils Motor Cushing’s Triad Herniation Reflexes Cranial Nerves

Answer 9

Positioning: Elevate HOB 30 degrees Body alignment Avoid prone position

Answer 10

Decrease activities that result in IICP: Avoid valsalva maneuver Avoid arousal from sleep, especially REM sleep Avoid noxious stimuli Avoid coughing Limit suctioning Try to space activities

Answer 11

Management of patent airway and optimum ventilation: Maintain PaO2 - 100 mm Hg Maintain PaCO2 35-45 mm Hg

Answer 12

Vasodilators: (If MAP too high) Nipride (Nitroprusside) IV Decreases preload & afterload > decreased B/P, CBF, ICP Vasopressors: (If MAP too low) Dopamine Increases myocardial contractility, CO, thus B/P 5-10 mcg/kg/min

Answer 13

Fluid administration Usually NS Hypertonic Solutions (3% NS) Intake and Output Consider insensible losses & daily weights

Answer 14

Every degree of Temp increase > increases O2 demands and CBF > increases ICP Monitor and prevent infections (WBC’s, fever) Culture, ATB’s, Tylenol Cooling blanket Prevent shivering

Answer 15

Goals: Prevent/Minimize IICP - Reduce metabolic demands Relieve pain, fear, anxiety: can increase HR, B/P, BMR which lead to an ↑ CBF > ↑ ICP Pain relief Opioids: Morphine Sulfate Control of anxiety/agitation Anesthetic sedative: IV Diprivan (propofol): rapid onset, short half life; able to assess neuro status after turning off infusion Benzodiazepines (Diazepam, Lorazepam)

Answer 16

Refractory intracranial hypertension Neuromuscular blockade (NMBA’s): Vecuronium, Pancuronium Barbiturate Coma: Pentobarbital, thiopental Both v metabolism > v metabolic demands> v CBF v ICP

Answer 17

Hypermetabolic, hypercatabolic state: need glucose for metabolism Prevent hypoglycemia Early feeding following brain injury improves outcomes Enteral feedings, TPN

Answer 18

Agitated Seizures → increase CBF → ↑ICP Use restraints only if absolute necessary: ↑ agitation → ↑ CBF → IICP Ativan, Haldol, Dilantin Padded side rails, suction

Answer 19

diabetes insipidus (DI)

Answer 20

Burr hole Craniotomy/Craniectomy Ventriculostomy

Answer 21

Intracranial Pressure Monitoring - Ventriculostomy: Gold standard for monitoring ICP Intraventricular space: most accurate Directly measures pressure within ventricles Can remove CSF, decreasing ICP Obtain samples of CSF

Answer 22

Reentry into Community Chronic problems r/t motor/sensory/memory deficits, communication, intellectual functioning Mental/emotional issues Personality changes, loss of concentration, mood swings Lack of awareness of seriousness of injury Loss of social restraint, judgment, tact, emotional control

Answer 23

Risk factors Symptoms DI Seizures Medications Activity Restrictions May need psychological & family support Referral for specific services: speech therapy, physical therapy

Answer 24

D. a normal balance between brain tissue, blood, and cerebrospinal fluid

Answer 25

A. patency of airway

Answer 26

C. a patient with meningitis who is suddenly agitated and reporting a HA of 10 on a scale of 0-10

Answer 27

Brain Tissue The skull contains the brain tissue, which is the central nervous system and controls all functions of the body. Blood The skull houses the blood vessels that supply oxygenated blood and essential nutrients to the brain tissue. Cerebrospinal Fluid (CSF) The skull contains the cerebrospinal fluid, which cushions and protects the brain and spinal cord from trauma and provides nutrients

Answer 28

Understanding the three essential components of the skull - brain tissue, blood, and cerebrospinal fluid - is crucial for recognizing and managing any injuries or conditions affecting the skull and its contents.

Answer 29

◦ Arterial pressure ◦ Venous pressure ◦ Intraabdominal and intrathoracic pressure ◦ Posture ◦ Temperature ◦ Blood gases (CO2 levels)

Answer 30

Monro-Kellie -closed

Answer 31

Amount of blood in mL passing through 100 g of brain tissue in 1 minute Global CBF is about 50 mL/min/100 g of brain tissue The brain uses 20% of the body’s O2 and 25% of its glucose

Answer 32

◦ Automatic adjustment in diameter of cerebral blood vessels ◦ Ensures consistent CBF to provide for metabolic needs of brain ◦ Only effective if mean arterial pressure (MAP) 70 to 150 mm Hg

Answer 33

* CPP = MAP - ICP * Normal is 60 to 100 mm Hg * < 50 mm Hg is associated with ischemia and neuronal death * CPP < 30 mm Hg incompatible with life Effect of cerebral vascular resistance CPP= flow x resistance

Answer 34

* Stage 1: Total Compensation The body's initial response to increased ICP, with mechanisms in place to maintain normal ICP and cerebral perfusion pressure (CPP). * Stage 2: Decreased Compensation Compensatory mechanisms become inadequate, leading to a rise in ICP and a risk of further increases. * Stage 3: Failing Compensation Clinical manifestations of increased ICP appear, such as Cushing's triad (hypertension, bradycardia, and irregular respirations). * Stage 4: Herniation Imminent Unchecked ICP rise leads to brain herniation, which is life-threatening and requires immediate intervention to prevent death

Answer 35

Factors affecting cerebral blood vessel tone ◦ CO2 ◦ O2 ◦ Hydrogen ion concentration CBF can be affected by ◦ Cardiac or respiratory arrest ◦ Systemic bleeding ◦ Other pathophysiologic states

Answer 36

Increased extravascular fluid in brain Variety of causes 3 types of cerebral edema Vasogenic Cytotoxic Interstitial

Answer 37

Vasogenic cerebral edema ◦ Most common type ◦ Occurs mainly in white matter ◦ Results from disruption of blood-brain barrier ◦ Fluid leaks from intravascular to extravascular space ◦ Exposes brain cells to toxic products from the blood ◦ Causes fluid to flow from intravascular to extravascular space ◦ Variety of causes ◦ Edema produces continuum of symptoms → coma

Answer 38

◦ Disruption of cell membrane integrity ◦ From destructive lesions or trauma to brain tissue ◦ Results in cerebral hypoxia or anoxia and SIADH secretion ◦ Cerebral edema occurs ◦ Fluid and protein shifts from extracellular to intracellular ◦ Subsequent swelling and loss of cellular function

Answer 39

◦ Usually result of hydrocephalus ◦ Manifested by ventricular enlargement ◦ Excess CSF production, obstruction of flow, or inability to reabsorb CSF ◦ Treat with ventriculostomy or shunt

Answer 40

Increased ICP can take many forms Depends on cause, location, and rate of increase Change in level of consciousness Flattening of affect to coma Change in vital signs Cushing’s triad * Systolic hypertension with * widened pulse pressure, bradycardia, irregular respirations) Change in body temperature

Answer 41

◦ Ipsilateral pupil dilation ◦ Sluggish or no pupil response to light ◦ Inability to move eye upward, adduct ◦ Eyelid ptosis ◦ Fixed, unilateral, dilated pupil is considered a neurologic emergency ◦ Indicates brain herniation

Answer 42

pupillary changes

Answer 43

* Headache Severe, continuous headache that is often worse in the morning * Vomiting Sudden, projectile vomiting that is not preceded by nausea * Altered Motor Function Contralateral hemiparesis or hemiplegia, decerebrate or decorticate posturing, indicating more serious damage Decorticate and Decerebrate Posturing For any of these, notify Dr.

Answer 44

* Inadequate Cerebral Perfusion Decreased blood flow to the brain can lead to tissue ischemia and damage. * Cerebral Herniation The brain can become displaced and compressed as intracranial pressure rises, leading to life-threatening complications. * Tentorial Herniation The brain can herniate downward, pushing through the tentorial opening and causing compression of the brainstem. * Uncal Herniation Lateral and downward displacement of the brain, often caused by a mass lesion, can lead to compression of the midbrain and brainstem. * Cingulate Herniation Lateral displacement of brain tissue beneath the falx cerebri can cause further intracranial crowding and injury.

Answer 45

Maintain Cerebral Oxygenation and Perfusion Prevent Secondary Cerebral Ischemia Monitor for Changes in Neurologic Status Provide Patient and Family Teaching

Answer 46

Observe and Record Seizures Prevent injury and administer antiseizure drugs as ordered. Vigorously Manage Fever Fever increases cerebral edema and risk of seizures. Prevent neurologic damage from high, prolonged fever. Maintain Cerebral Oxygenation and Perfusion Prevent secondary cerebral ischemia and monitor for changes in neurologic status. Minimize Environmental Stimuli Provide a calm, soothing environment to avoid delirium and hallucinations. Prevent Complications Implement measures to maintain normal cerebral perfusion pressure, achieve maximal cognitive/ motor/ sensory function, and prevent infection or fever.

Answer 47

◦ CT scan / MRI / PET ◦ EEG ◦ Cerebral angiography ◦ ICP and brain tissue oxygenation measurement (LICOX catheter) ◦ Transcranial doppler and evoked potential studies ◦ NO lumbar puncture

Answer 48

Ventriculostomy ◦ Gold standard for monitoring ICP ◦ Catheter inserted into lateral ventricle ◦ Coupled to an external transducer ◦ Directly measures pressure within the ventricles ◦ Facilitates removal and/or sampling of CSF ◦ Allows for intraventricular drug administration

Answer 49

Goals are to ◦ Identify and treat underlying cause of increased ICP ◦ Support brain function Adequate oxygenation ◦ PaO2 greater than or equal to 100 mm Hg ◦ PaCO2 of 35 to 45 mm Hg ◦ Mechanical ventilation Surgical removal of mass or lesion

Answer 50

◦ Mannitol (Osmitrol) ◦ Plasma expansion ◦ Creates vascular osmotic gradient ◦ Monitor fluid and electrolyte status ◦ Hypertonic saline solution ◦ Moves water out of cells and into blood ◦ Monitor BP and serum sodium levels Corticosteroids ◦ Used to treat vasogenic edema ◦ Improve neurogenic function ◦ Monitor fluid intake, serum sodium and glucose levels ◦ Concurrent antacids, H2 receptor blockers, proton pump inhibitors ◦ Antiseizure medications ◦ Antipyretics ◦ Sedatives ◦ Barbiturates ◦ IV 0.9% NaCl preferred over D5W or 0.45% NaCl

Answer 51

◦ Hypermetabolic and hypercatabolic state increases the need for glucose ◦ Enteral or parenteral nutrition ◦ Early feeding (meet caloric needs by at least 5 days after injury) ◦ Keep patient euvolemic

Answer 52

Level of consciousness (LOC) Glasgow Coma Scale ◦ Opening the eyes ◦ Best verbal response ◦ Best motor response

Answer 53

◦ Eye movements ◦ Corneal reflex ◦ Oculocephalic reflex (doll’s eye reflex) ◦ Oculovestibular (cold caloric reflex)

Answer 54

Pupillary Check for Size and Response Motor strength * Squeeze hands * Pronator drift test * Raise foot off bed or bend knees Motor response * Spontaneous or to pain Vital signs

Answer 55

INCREASED INTRACRANIAL PRESSURE INADEQUATE TISSUE PERFUSION RISK FOR INJURY

Answer 56

◦ Maintain a patent airway ◦ ICP within normal limits ◦ Normal fluid, electrolyte, and nutritional balance ◦ Prevent complications from immobility and decreased LOC

Answer 57

◦ Maintain patent airway ◦ Elevate head of bed 30 degrees ◦ Suction as needed ◦ Prevent abdominal distention ◦ Monitor ABGs ◦ Maintain effective ventilation

Answer 58

* Opioids Potent analgesics that can be used to manage severe pain associated with increased intracranial pressure * Propofol (Diprivan) A sedative-hypnotic agent that can be used to induce and maintain sedation, reducing anxiety and agitation * Dexmedetomidine (Precedex) A selective alpha-2 agonist that provides sedation and analgesia without respiratory depression, useful in managing agitated patients * Nondepolarizing neuromuscular blocking agents Used to provide neuromuscular blockade, facilitating mechanical ventilation and reducing muscle tone that can contribute to increased ICP * Benzodiazepines Anxiolytic and sedative medications that can be used to manage anxiety and agitation in patients with acute intracranial problems

Answer 59

◦ HOB elevated, head midline ◦ Avoid extreme neck flexion ◦ Turn slowly ◦ Prevent pain or discomfort ◦ Avoid hip flexion

Answer 60

Minimize complications of immobility Protection from self-injury Judicious use of restraints; sedatives Seizure precautions Quiet, nonstimulating environment Psychologic considerations

Answer 61

Maintain ICP and CPP within normal limits Ensure the patient's intracranial pressure (ICP) and cerebral perfusion pressure (CPP) remain within the acceptable range to support proper brain function and perfusion. Prevent serious increases in ICP Closely monitor the patient's ICP and quickly intervene to address any significant increases that could lead to further complications. Avoid complications of immobility Implement strategies to prevent issues like pressure ulcers, deep vein thrombosis, and muscle atrophy that can arise from the patient's decreased mobility. By maintaining ICP and CPP within normal parameters, preventing serious increases in ICP, and avoiding complications of immobility, the nurse can help ensure the best possible outcomes for the patient with a head injury.

Answer 62

* Scalp Lacerations Tears in the highly vascular scalp tissue, which can cause profuse bleeding and potential complications like infection. * Skull Fractures Breaks in the skull bone, which can be linear, depressed, or compound, and require specific management based on the type and location. * Concussion A sudden, transient mechanical injury to the brain, resulting in a brief disruption of consciousness, retrograde amnesia, and potential post-concussion syndrome. * Contusion Bruising of the brain tissue, associated with closed head injuries, which may result in areas of hemorrhage, infarction, necrosis, and edema. * Intracerebral Hematoma Bleeding within the brain tissue, which typically occurs in the frontal and temporal lobes, and can significantly impact patient outcome based on the size and location. * Cerebral Edema Increased fluid accumulation in the brain, which can be vasogenic (disruption of the blood-brain barrier), cytotoxic (cell membrane disruption), or interstitial, and requires specific management strategies.

Answer 63

Battle sign is prominent when there is a fracture of the petrous temporal bone. It may also be associated with rhinorrhea and bruising over the eyes

Answer 64

Head injury Most common causes * Falls * Motor vehicle accidents Other causes * Firearms * Assaults * Sports-related trauma * Recreational injuries * War-related injuries

Answer 65

Head injury TBI are twice as common in males High potential for poor outcome Deaths occur at 3 points after injury * Immediately after the injury * Within 2 hours after injury * About 3 weeks after injury

Answer 66

◦ Tearing of brain tissue ◦ With depressed and open fractures and penetrating injuries ◦ Intracerebral hemorrhage ◦ Subarachnoid hemorrhage ◦ Intraventricular hemorrhage ◦ Management ◦ Antibiotics ◦ Preventing secondary injury

Answer 67

◦ May continue to bleed or rebleed ◦ Focal and generalized manifestations ◦ Monitor for seizures ◦ Potential for increased hemorrhage if on anticoagulants

Answer 68

◦ Initial period of unconsciousness ◦ Brief lucid interval followed by decrease in LOC ◦ Headache, nausea, vomiting ◦ Focal findings ◦ Requires rapid evacuation

Answer 69

◦ Acute subdural hematoma ◦ Subacute subdural hematoma ◦ Chronic subdural hematoma

Answer 70

◦ Bleeding between dura mater and arachnoid ◦ Most common source ◦ Veins that drain brain surface into sagittal sinus ◦ Can also be arterial—develops more rapidly

Answer 71

◦ Within 24 to 48 hours of injury ◦ Symptoms related to increased ICP ◦ Decreased LOC, headache ◦ Ipsilateral pupil dilated and fixed if severe

Answer 72

◦ Within 2 to 14 days of the injury ◦ May appear to enlarge over time ◦ Breakdown products of blood draw fluid into subdural space

Answer 73

◦ Weeks or months after seemingly minor head injury ◦ More common in older adults ◦ Presents as focal symptoms ◦ Increased risk for misdiagnosis

Answer 74

Bleeding within brain tissue Occurs in about 16% of head injuries Usually happens within frontal and temporal lobes Size and location of hematoma are key in determining patient outcome

Answer 75

◦ Head of bed raised ◦ Loose collection pad under nose/over ear ◦ No sneezing or blowing nose ◦ No NG tube ◦ No nasotracheal suctioning

Answer 76

Circulation, airway, breathing Stabilize cervical spine Oxygen IV access Intubate if GCS less than 8 Control external bleeding Remove patient’s clothing

Answer 77

Maintain normothermia Ongoing monitoring Intubation if gag reflex impaired or absent Give fluids cautiously

Answer 78

Ooh, ooh, ooh to touch and feel very good velvet Some say marry money but my brother says big brains matter most

Answer 79

A. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately lifethreatening process.

Answer 80

C. Decorticate posturing Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

Answer 81

C. Intracranial pressure Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration.

Answer 82

C. Keep the head of the bed elevated to 30 degrees. The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

Answer 83

B. Check the drainage for glucose content. Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

Answer 84

B. Insert nasogastric tube to low suction. Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

Answer 85

B. Impaired judgment The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

Answer 86

B. Report the BP and ICP to the health care provider. Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] – ICP). MAP = DBP + 1/3 (Systolic Blood pressure[SBP] -Diastolic blood pressure [DBP]). Therefore, the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient’s therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

Answer 87

A. Check oxygen saturation. Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

Answer 88

C. The patient is more difficult to arouse. The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

Week 4 - Neuro ~ IICP Flashcards

(118 cards)