NR240 Nursing II - PowerPoint PPT Presentation

Title: NR240 Nursing II


1
NR240Nursing II

• Care of clients with coma increased
  intracranial pressure
• Review self study slides 1-6

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Review Chapt 43 neuro A P key terms

• Structure of Neurons
• Mechanism of nerve impulse conduction
• Neurotransmitters
• Acetylcholine
• Serotonin
• Dopamine
• Norepinephrine
• Structures of the brain
• Supratentorial/infratentorial

• Cerebral circulation
• Circle of Willis
• Blood-brain barrier
• Cerebrospinal fluid circulation
• Spinal cord structures
• Ascending tracts
• Spinothalamic tracts
• Spinocerebellar tracts
• descending tracts
• Extrapyramidal tracts
• Basal ganglia
• Peripheral nervous system
• Sensory receptors
• Plexuses
• Lower motor neuron
• Reflexes
• Cranial nerves

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Review Chapt 43 neuro diagnostic assessment

• Emphasize understanding of prep, indications and
  outcomes
• Radiographic exam
• Cerebral angiography
• CT scanning
• MRI
• MRA
• EEG
• EMG
• Lumbar puncture

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Review Terms related to Coma

• Obtundation
• Reduced alertness
• Lethargy
• Abnormal drowsiness
• Persistent vegetative state
• state results when the cerebrum, which controls
  thought and behavior, is destroyed, but the
  thalamus and brain stem, which control sleep
  cycles, body temperature, breathing, and heart
  rate, are spared
• Locked- in state
• people are conscious and able to think but are so
  severely paralyzed that they can communicate only
  by opening and closing the eyes in response to
  questions

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Review Terms related to Coma

• Delirium
• state of acute confusion, inattention, and
  altered level of consciousness (LOC), usually
  abrupt in onset (over several hours to several
  days).
• Stupor
• is an unresponsive state from which a person can
  be aroused only briefly and with vigorous,
  repeated attempts.
• Coma
• is an unresponsive state from which a person
  cannot be aroused, even with vigorous, repeated
  attempts.
• Brain death
• brain has permanently lost the ability to perform
  all vital functions, including maintenance of
  breathing

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Defining Altered Mental State

• Change in neurological function on a continuum
  affecting
• Arousability
• Cognition, verbal response
• ability to follow commands
• Motor function
• Sensory function
• Presence of reflexes

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Neurological Assessment

• Level of consciousness (LOC),Mental status
• Cognition, emotional status
• cranial nerves
• reflexes
• motor function
• Cerebellar
• strength
• sensory function

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Eliciting a Focal Neurological Deficit

• A deficit that occurs in any of the areas of
  neurological exam
• Does not need to be all-encompassing
• May be focused in one area or a few areas that
  are related
• Can manifest in and effect
• Level of consciousness, motor, sensory, reflexes,
  cranial nerve function
• Elicited through comprehensive assessment

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Performing a neurocheck

• Rapid neurocheck
• Glasgow coma scale (eye opening, motor response,
  verbal response)
• Pupilary response
• Motor strength
• Vital signs
• Sensation
• Seizure activity

10
Documenting Neuro status

• Neurological Flowsheet
• Key points
• Must be compared to baseline
• Must evaluate right and left separately when
  possible
• Should be performed with vital signs
• Physician notification must be timely

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Reporting criteria based and neurocheck results

• Drop in GCS of 2 points or more
• Deterioration in neuro status
• Abnormal vitals signs
• rising systolic with unchanged diastolic (widened
  pulse pressure), bradycardia and change in
  respiratory pattern (Cushings triad)
• Rising body temperature (can increase brain
  oxygen demand)
• New onset seizure activity
• CSF leakage

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Acute changes requiring emergency intervention

• Notify MD within 5 minutes of discovering
• Unilateral pupil dilation,
• Loss of pupil response
• Abnormal flexion or extension
• Loss of brain stem reflexes (gag reflex, corneal
  reflex)
• Initiate emergency response
• Ensure airway, provide oxygen, increase frequency
  of assessment establish IV access

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Abnormal posturing

• Decorticate
• Decerebrate

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Brain stem reflexes (3 types)

• Caloric stimulation
• Cold calorics video (performed by MD)
• Injection of 20-30 cc syringe with an 18 gauge
  angiocath filled with ice water and squirted into
  the ear while evaluating eye movement.
• In a Normal response, eyes conjugately deviate
  away from the cold ear, then snap back to midline
  
• Corneal Reflex
• Touch the lateral lower corner of the cornea.
• In a Normal response, ipsalateral eye blinks
• Cough, gag reflex
• Jiggle the endotracheal tube or NG tube to
  stimulate the larynx or pharynx
• In a Normal response, patient coughs or gags

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PC neurologic dysfunction (AMS/Coma)
Change in mental status new onset focal
neurological deficit
Perform a comprehensive assessment (see next
slide) Evaluate possible cause or contributing
problem (see etiology) Monitor results of rule
out lab/diagnostics (see workup) Treat the
underlying cause Provide supportive care until
reversed NIC hemodynamic monitoring NIC
Neurological monitoring Report acute declines in
LOC, pupillary changes, abnormal posturing,
abnormal brainstem reflexes and initiate NIC
shock management
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Perform comprehensive Assessment

• Determine if the individual has a history of
  altered mental states
• Assess the current signs and symptoms of AMS
• Determine if the patient is at high risk for
  developing AMS
• focus on correctly identifying the causes of AMS
• Define the duration and course of symptoms

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Evaluate possible cause of AMS

• Determine if conditions or situations that may
  affect mental status are present
• Medications/non-compliance with regimen
• Fluid or electrolyte imbalance
• Infections
• Hypo- or hyperglycemia
• Recent hospitalization
• Recent surgery under general anesthesia
• Recent change in living situation or environment
• Recent fall or other trauma

18
Evaluate possible cause of AMS (contd)

• Significant pain
• Alcohol or drug abuse
• Hypo- or hyperthyroidism
• Nutritional deficiency
• Recent stroke or seizure
• Primary metastatic brain tumors or other
  malignancies
• Cardiac arrhythmia/myocardial infarction
• Always review the patient's medications, as these
  are a common source of AMS

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Perform Lab/diagnostics to rule out cause

• Electrolytes, BUN, glucose, creatinine, serum
  osmolality/urine sodium (to identify fluid/
  electrolyte imbalance)
• Urinalysis and/or urine culture (if urinary tract
  infection is suspected)
• TSH/free T4 (to identify possible thyroid
  dysfunction)
• Complete blood count (CBC) (if infection,
  inflammatory processes, bleeding, or anemia are
  suspected)
• Chest x-ray/Oxygen saturation (if pneumonia or
  pulmonary embolism are suspected)
• EKG/rhythm strip (if a cardiac arrhythmia or
  other heart dysfunction is suspected)
• Albumin (if undernutrition is suspected)
• Serum drug levels, when appropriate

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Perform Lab/diagnostics to rule out cause

• Radiological examination
• CT
• MRI

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Nursing Priorities for the unconscious client
(source Carpenito)

• PC Respiratory insufficiency
• PC Pneumonia/Atelectasis
• PC Increased intracranial pressure
• PC Seizures
• PC Sepsis
• PC Thrombophlebitis
• PC Fluid/electrolyte imbalance
• PC Negative nitrogen balance
• PC Bladder distention
• PC Stress ulcers
• PC Renal calculi
• PC Urinary tract infection

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Nursing Priorities for the unconscious client
(source Carpenito) contd

• Nursing Diagnoses
• Infection, Risk for related to immobility and
  invasive devices (tracheostomy, Foley catheter,
  venous lines)
• Risk for Tissue Integrity, Impaired Corneal
  related to corneal drying secondary to open eyes
  and lower tear production
• Family Anxiety/Fear related to present state of
  individual and uncertain prognosis
• Risk for Oral Mucous Membrane, Impaired related
  to inability to perform own mouth care and
  pooling of secretions
• Total Incontinence related to unconscious state
• Disuse Syndrome
• Powerlessness (family) related to feelings of
  loss of control and restrictions on lifestyle
• Risk for Ineffective Airway Clearance related to
  stasis of secretions secondary to inadequate
  cough and decreased mobility

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Understanding ICP
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Mean Arterial Pressure

• Calculation of systolic and diastolic blood
  pressure that indicates the degree of tissue
  perfusion to vital organs
• Equation 
• Mean Arterial Pressure 1/3 SBP 2/3 DBP
• Usual range  70-110
• Should exceed 70 to ensure cerebral tissue
  perfusion

25
Cerebral perfusion pressure (CPP)

• Cerebral perfusion pressure (CPP) is a measure of
  adequate supply of blood to cerebral tissue.
• CCPMAP - ICP

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cerebral blood flow (CBF)

• cerebral blood flow (CBF) is ensured through
  regulation of arterial blood supply and
  cerebrovascular resistance (CVR)
• CBFCPP CVR.
• Determinants of supply occur as a result of
• Vasomotor control of cerebral arteries
• Influenced by circulating levels of carbon
  dioxide, oxygen, products of metabolism, and pH.
• Autoregulatory response to changes in MAP

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Factors contributing to Cerebral arterial
vasodilation to preserve Cerebral blood flow
Contributing Factors
Increased PaCo2
Decreased PaO2 lt 50
pHlt7.35
Decreased blood pressure
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Factors contributing to Cerebral arterial
vasoconstriction to preserve Cerebral blood flow
Contributing Factors
decreased PaCo2 lt 35
pHgt7.45
decreased body temperature
Increased blood pressure
29
Maladaptation in Autoregulation

• Decreased systolic BP results in decreased CPP
• Decreased CPP leads to increased vasodilation
• Increased vasodilation increased cerebral blood
  volume
• Increased cerebral blood volume increases ICP
  which in turn decreases cerebral perfusion
  pressure and the cycle repeats itself

30
Defining Intracranial Pressure

• measure of pressure inside the cranium
• has an arbitrary numeric amount
• Can be monitored using pressure devices
• Intracranial pressure monitoring

31
Causes of an increased ICP

• Conditions Increasing Brain Volume
• intracranial mass (tumor, hematoma, aneurysm,
  AVM)
• cerebral edema
• CNS infection (abscess, inflammatory process)
• Conditions Increasing Blood Volume
• obstruction of venous outflow
• hyperemia
• hypercapnea
• Conditions Increasing CSF Volume
• increased production
• decreased reabsorption of CSF (meningitis, SAH)
• obstruction to flow of CSF

32
High Risk Populations for Increased ICP

• Intracerebral masses
• blood clots
• blockage of venous outflow
• head injuries
• inflammatory diseases
• cranial surgery

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Physiology of Intracranial Pressure

• The cranium is a fixed box containing brain
  tissue, blood and CSF that can not readily
  accommodate increasing volumes because it can not
  expand.

It has similar properties to a suitcase its size
is fixed and it contains an assortment of
necessary things but there is a limit as to what
you can put in it.
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Physiology of Intracranial Pressure

• When the volume inside the cranium is subject to
  stressors that can increase it precipitously, it
  results in an increase in intracranial pressure.
• Such events include
• Cerebral vasodilation and edema, decreased venous
  return, masses and lesions

It is like an overstuffed suitcase
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Physiology of Intracranial Pressure

• Intracranial pressure must be normalized to
  ensure adequate function of the Central Nervous
  system
• Normal ICP is 10-15 mm Hg
• This is accomplished by shunting CSF( to lumbar
  subarachnoid space), returning venous blood to
  the heart, and, if necessary, shifting away from
  the site of edema inside the skull.

SHUNTING
SHUNTING
It would be like packing the extra stuff into a
second suitcase
SHUNTING
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Relationship of volume to pressure
Monroe-Kellie Hypothesis to maintain a normal
ICP, a change in the volume of one compartment
must be offset by a reciprocal change in the
volume of another compartment
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When you have too much in your suitcase, you have
to unpack some of it
Your brain needs to do the same thing when the
ICP is too high.
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Physiology of Intracranial Pressure

• If the stressors that increase volume are too
  great inside the cranium it becomes difficult to
  get anything else in such as
• Oxygenated blood and nutrients, exacerbating
  cerebral edema and intracranial pressure

The only way you could get anything else in is by
force
39
Physiology of Intracranial Pressure

• Mean arterial pressure will reflexively rise to
  overcome a rising intracranial pressure to
  restore perfusion

There is only just much force that can be applied
40
Physiology of Intracranial Pressure

• If the pressure elevated too markedly, the brain
  tissue will displace through the foramen
  occipitalis.
• This is referred to as brain herniation

The suitcase will open and its content will spill
over
41
Brain Herniation

• Profound Neurological dysfunction
• Progressive loss of consciousness
• Coma
• Irregular breathing
• Respiratory arrest (no breathing)
• Irregular pulse
• Cardiac arrest (no pulse)
• Loss of all brainstem reflexes (blink, gag,
  pupillary reaction to light)
• Source Medline plus
• Determining brain death

42
Management of increased ICP

• Identification of clients at risk
• Initiation of ICP monitoring if indicated
• Airway maintenance and ventilation
• Oxygenation and low normal PaCO2
• Fluid balance to maintain cerebral perfusion
• Avoiding positions that increase ICP
• Sedation and decreased external stimulation
• Osmotic and loop diuretics
• Temperature maintenance
• Blood glucose control
• Pain management and stool softeners
• See ICP sheet

43
Definition of ICP monitoring

• type of device that is calibrated to detect the
  internal pressure readings
• Interpretation of the readings assist in guiding
  actions to restore cerebral tissue perfusion.
• Types
• Ventriculostomy
• Subarachnoid
• Epidural
• Subdural
• Parenchymal

44
Types of Intracranial Pressure Monitoring Devices
see page 1059
45
Indications for ICP monitoring

• Head injury
• Craniotomy
• Intracranial hemorrhage
• Cerebral edema

46
Goal if ICP monitoring

• CFS clear
• ICPlt 20
• CPP between 60-75

47
Strategies to maintain normal ICP
Source UNC Policy and Procedure
48
Actions to avoid that can increase ICP
Source UNC Policy and Procedure
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(No Transcript)
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Collaborative care

• PC CNS infection
• For all types of devices
• PC brain herniation
• For devices that communicate with CSF and become
  obstructed
• PC decompression hemorrhage
• For devices that communicate with CSF and rapidly
  empty ventricle

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PC CNS infection
Are s/s of acute CNS infection (meningeal
irritation) present? Nuchal rigidity,
photophobia, headache
Assess for s/s of meningeal irritation q 4
hrs and prn Mon VS and temp as per ICU
protocol Inspect insertion site for drainage,
purulence, CSF leak Inspect CSF for clarity every
4 hours If present, obtain CSF culture and sent
to lab Initiate antibiotics as prescribed
52
PC brain herniation
Are s/s brain herniation present? Pupillary
changes, loss of brainstem reflexes, Change in LOC
Perform neurological assessment as per
protocol Keep system free from kinks to avoid
disruption in CSF drainage. Assess for the
presence of obstruction and call MD If present ,
initiate emergency interventions to minimize
herniation Administer O2, Intubate, Initiate
shock management Call MD
53
PC decompression hemorrhage
Are s/s of acute decompression hemorrhage
present?
Assess for presence of bleeding in CSF drainage,
if present call MD Assess for proper positioning
of device and settings each hour to avoid
accidental CSF drainage Do not allow system to
fall below height of head to avoid accidental
drainage Initiate emergency interventions to
treat decompression Increase frequency of
assessment Call MD Prepare to change equipment
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Summary of Plan for PC increased ICP

• Assess for s/s of increased ICP
• Monitor labs/vitals and diagnostics and
  collaborate if indicators require treatment
• Perform ICP monitoring if indicated
• Avoid positions, maneuvers, situations that
  increase ICP
• Administer agents that restore cerebral perfusion