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RNSG 2432 Enhanced Concepts of Adult Health Lisa Randall, RN, MSN, ACNS-BC.

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Presentation on theme: "RNSG 2432 Enhanced Concepts of Adult Health Lisa Randall, RN, MSN, ACNS-BC."— Presentation transcript:

1 RNSG 2432 Enhanced Concepts of Adult Health Lisa Randall, RN, MSN, ACNS-BC

2  Define and discuss altered cerebral function and increased ICP  Analyze etiology and pathophysiology of altered cerebral function  Discuss/illustrate signs and symptoms, diagnostics, and treatment  Formulate nursing diagnoses that address physical, psychosocial, and learning needs  Prioritize and evaluate nursing interventions

3  Cerebral function ◦ Mental status ◦ Speech ◦ Eyes ◦ Cranial nerves ◦ Motor ◦ Sensory ◦ Reflexes

4  Consciousness ◦ Arousal ◦ Awareness  Lethargy ◦ < alertness ◦ < awareness ◦ < thought process  Obtundation ◦ << A/A ◦ Clouding  Stupor ◦ Deep sleeplike state ◦ Vigorous stimulation  Coma ◦ Unresponsiveness  PVS  MCS

5  Unarousability  Absence of sleep/wake cycles  Inability to interact with the environment  GCS =/< 8

6  Intermittent wakefulness  Sleep-wake cycles  No awareness of self or environment

7  Altered consciousness  Evidence of self or environmental awareness is demonstrated

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9  Reticular Activating System (RAS) ◦ Reticular Formation ◦ Gray cells within brainstem extends into thalamus  Wakefulness  Arousal  Alertness

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11  Lesion/injury to the RAS or cerebral cortex  Metabolic disorders  Anoxic injury  Drugs  Seizures

12  LOC  Health history ◦ drugs/head injury/metabolic  Physical exam  Vital signs ◦ Temperature ◦ Cushing’s reflex/triad  Neuro Vital Signs ◦ LOC, Pupils, Strength/Movement, Sensation  Glasgow coma scale  NIH Stroke Scale

13  Edema  Increased intracranial pressure ◦ Increased systolic BP ◦ Widening pulse pressure  Normal = 40 mmHg ◦ Decreased pulse rate ◦ Irregular respirations

14 Eyes Spontaneous opening4 Open to speech3 Open to pain2 Do not open1 Verbal Response Oriented5 Confused4 Inappropriate3 Incomprehensible2 None1

15 Motor Response Obeys commands6 Localizes to pain Pushes your hand away 5 Withdraws from pain4 Decorticate/flexion3 Decerebrate/extension2 None1 Range of possible scores = 3-15 A score of 13 to 14 indicates mild deficit. A score between 9 and 12 points to moderate deficit, and a score of 8 or less indicates severe coma.

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17  Mental status  General appearance/behavior  State of conciousness  Mood and affect  Thought content  Intellectual capacity

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20 Sensory: CN II - Optic ◦ Visual acuity Motor: CN III - Oculomotor ◦ PERRL ◦ Direct/consensual ◦ EOMs (CN IV/VI)

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22  Eye movement  CN III,IV,VI  Oculocephalic reflex ◦ Doll’s eyes ◦ Sensory CN VIII ◦ Motor CN III,IV,VI  Dolls eyes ◦ (+) opposite direction ◦ intact brain stem ◦ (-) no movement

23  Trigeminal (V) ◦ Corneal reflex ◦ Sensory ◦ mastication  Facial (VII) ◦ Expression ◦ Taste  Acoustic (VIII)  Glossopharyngeal (IX) ◦ Gag/swallow  Vagus (X) ◦ Gag/Swallow  Spinal Accessory (XI) ◦ Shoulder shrug  Hypoglossal (XII) ◦ TML

24  Ability to move, strength, and symmetry ◦ Grips, arm strength, & drift ◦ Planter flexion, dorsiflexion, & leg strength  Coordination ◦ Finger to nose, heel up and down shin  Planter Reflex- Babinski testing  Meningeal signs- Brudzinski & Kernig’s sign

25  Babinski's reflex ◦ (+) great toe flexes and the other toes fan out  Abnormal after the age of 2.

26 Hips and knees flex when the neck is flexed

27 Stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

28  Visual fields  Dull vs. sharp ◦ Sensation same or different with eyes closed  Face  Hands  Arms  Abdomen  Feet  Legs

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30  Brainstem compression ◦ Yawning & sighing ◦ Cheyne-Stokes ◦ Central neurogenic hyperventilation ◦ Apneustic breathing ◦ Cluster breathing ◦ Ataxic respirations

31  Ec Ec

32  A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patient’s GCS score as ◦ A. 6 ◦ B. 8 ◦ C. 9 ◦ D. 11

33  The nurse recognizes the presence of Cushing’s triad in the patient with ◦ A. increased pulse, irregular respiration, increased BP ◦ B. decreased pulse, irregular respiration, increased pulse pressure ◦ C. Increased pulse, decreased respiration, increased pulse pressure ◦ D. decreased pulse, increased respiration, decreased systolic BP

34  CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by ◦ A. assessing for nystagmus ◦ B. testing the corneal reflex ◦ C. testing pupillary reaction to light ◦ D. testing for oculocephalic (doll’s eyes) reflex

35  An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the healthcare provider when arterial blood gas (ABG) measurement results reveal a ◦ A. pH of 7.43 ◦ B. SaO2 of 94% ◦ C. PaO2 of 50mm Hg ◦ D. PaCO2 of 30mm Hg

36 ◦ BG ◦ Electrolytes/Osmolali ty ◦ ABGs ◦ CBC ◦ Liver function ◦ Kidney function ◦ Toxicology ◦ CT ◦ MRI ◦ EEG ◦ Cerebral angiogram ◦ TCD ◦ LP

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39  Monro-Kellie hypothesis ◦ 80/10/10 rule  Autoregulation ◦ Cerebral arterioles ◦ MAP (Mean arterial pressure)  Perfusion depends on B/P and chemical (CO2)  Normal MAP is 70 to 100  < 60 - peripheral organs not perfused  < 50 – brain not perfused  Critical to maintain normal MAP with Increased ICP

40  Vasoconstriction  Decreased CSF  CSF shunting  Increased CSF reabsorption

41  Brain’s ability to tolerate an increase in volume without an increase in pressure  Indications of decreased compliance: ◦ Sustained increase in ICP in response to stimuli ◦ Greater increases to non-noxious stimuli

42 NPCompensatedUncompensated 10mmHg15mmHg30mmHg Blood 10%, CSF 10%Blood 5%, CSF 5%Blood 4%, CSF 4% StableStiffICP increases

43  A slowly expanding mass is tolerated better that a rapidly expanding mass  Brain tissue is compressible, but functional impairment, possibly irreversible does occur  Location matters

44  Pressure needed for adequate blood flow to brain ◦ CPP = MAP – ICP  Need higher MAP if ICP increased ◦ mmHg ◦ <50 mmHg = ischemia ◦ <30 mmHg = death

45 MAP 50 to 150 mmHg Normal ICP 0 to 15 mmHg CPP 70 to 100 mmHg Increased ICP > 20 mmHg Increased MAP needed to perfuse brain Danger of CPP < 50 mmHg Autoregulation Arterial Blood Pressure - Brain & CS Fluid Compression = Actual Cerebral Blood Flow Edema, CS Fluid, Tumor

46  Changes in contents of cranial vault

47  Mass effect ◦ Tumor ◦ Blood clot ◦ Edema  Increased CBF ◦ Increased blood flow ◦ Increased PaCO2 ◦ Decreased PaO2 ◦ Vasodilators  Increased intrathoracic pressure ◦ Coughing ◦ Straining ◦ Suctioning ◦ Peep  Impairment of cerebral venous drainage ◦ Positioning

48  Changes in LOC  Worsening headache  Cognitive deficits  Pupillary changes  Increasing B/P with widening pulse pressure  Irregular respiratory patterns  Bradycardia  Seizures  Aphasia  Dysconjugate gaze  Hemiparesis or hemiplegia

49  Health history- assess brain involvement  PE ◦ Altered cerebral function assessment  Frequency depends on potential IICP  Early sign- change in LOC  3rd Cranial nerve compression  Papilledema  Projectile vomiting  Vision changes  Seizures ◦ Late sign- Cushing VS changes

50  Ineffective tissue perfusion: cerebral ◦ Assess/report sign IICP ◦ Adequate airway ◦ Promote venous drainage ◦ Control environment stimuli ◦ Plan nursing care – avoid clustering care ◦ Avoid Valsalva’s maneuver ◦ If bone flap out post op- assess & position ◦ Assess external shunts/drains

51  Maintenance of airway and ventilation  Endotracheal intubation  Oxygenation  Mechanical ventilation  Fluid balance/Euvolemia  Medications

52  Sedation, analgesia, neuromuscular blockade  Barbiturate coma  Prophylactic anticonvulsant  Mannitol/3% NaCl  Lasix  Atracrium  Vasopressors  Tylenol

53  Temperature control  Electrolyte balance  Proper positioning  Adequate nutrition  Ventriculostomy  Paralytics  Hypothermia  Pentobarbital coma  Craniectomy

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55  LICOX ◦ PbtO2 ◦ Normal mmHg  Jugular venous bulb cath ◦ SjvO2 ◦ Normal SjvO2 is 60% to 80% ◦ <50 to 55% of O2 in venous blood indicates impairment of flow and brain taking out more O2 than normal  ICP Waveforms (P1, P2, & P3) ◦ P1 arterial pulse wave should be highest ◦ P2 is intracranial compliance – if higher than P1 compliance is compromised ◦ P3 is the venous pulsation and should be the lowest P1 P2 P3

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58 Standing Orders Per hospital policy

59  Neurological ◦ Meningitis ◦ Seizures ◦ Cerebral salt wasting (CSW) ◦ Syndrome of inappropriate antidiuretic hormone (SIADH) ◦ Hydrocephalus ◦ Cerebral edema/Increased ICP

60  Increased secretion of ADH from abnormal stimuli  Results in water retention  Hyponatremia ◦ Na+ excreted in urine

61  Decreased UOP  Increased urine specific gravity  Low serum osmo  Hyponatremia  Hypervolemia

62  Fluid restrictiion  Replace sodium ◦ Democlocycline ◦ Fludrocortisone ◦ Hypertonic saline ◦ Oral salt  Diuretics

63  Controversial  Hyponatremia  Failure of CNS to regulate Na+ reabsorption  Increase in circulating atrial natriuretic peptide (ANP)

64  Increased UOP  Hyponatremia  Normal to increased osmo  Hypovolemia  Increased urine specific gravity

65  Volume replacement  Sodium replacement  Reducing renal Na+ excretion ◦ Fludrocortisone ◦ Urea

66 ParameterSIADHCSW Serum Na+Decreased Serum osmolarityDecreased Urine Na+IncreasedNormal-increased Urine OPDecreasedIncreased VolumeNormo/hypervolemicHypovolemic Body weightIncreasedDecreased

67  Cerebral edema ◦ Vasogenic ◦ Cytotoxic ◦ interstitial  Hydrocephalus ◦ Noncommunicating ◦ Communicating ◦ ICP Production – choroid plexus; Absorption – arachniod villi

68 Normal MRI BrainMRI Hydrocephalus

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71  Irreversible coma ◦ Persistent vegetative state  Locked-in Syndrome (not true coma) ◦ Functioning RAS & cortex; pons level interference ◦ Aware, communicate with eyes ◦  Brain death ◦ Loss of all brain function- flat EEG, no blood flow

72  A. Cingulate  B. Uncal  C. Central  D. Extracranial  E. Tonsillar

73 Cingulated Herniation (a) Cingulate gyrus slips under falx cerebri Usually caused tumor or bleed Non life threatening

74 Uncal or Lateral Herniation (b) Uncus of temporal lobe slips through notch of tentorium and compresses the ipsilateral CN 3, brainstem, & vital centers Life threatening

75 Central or Transtentorial Herniation (c) Downward pressure General cerebral edema Brainstem compression Compresses RAS & vital centers Abnormal heart rhythms, disturbances or cessation of breathing, cardiac arrest, and death Life threatening

76 Infratentorial (subtentorial or Tonsillar) Herniation (e) Downward displacement of infratentorial structures through the foramen magnum Life threatening

77 Extracranial Herniation (d) Occurs with displacement of brain through a cranial defect. Usually Non-life threatening

78 Surgical Decompression (Craniectomy)

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80  A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is ◦ A. aseptic technique to prevent infection ◦ B. constant monitoring of ICP waveforms ◦ C. removal of CSF to maintain normal ICP ◦ D. sampling CSF to determine abnormalities

81  A patient has a nursing diagnosis of altered cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is ◦ A. avoiding positioning the patient with neck and hip flexion ◦ B. maintaning hyperventilation to a PaCO2 of mm Hg ◦ C. clustering nursing activities to provide periods of uniterrupted rest ◦ D. routine suctioning to prevent accumulation of respiratory secretions

82  The earliest signs of increased ICP the nurse should assess for include ◦ A. Cushing’s triad ◦ B. unexpected vomiting ◦ C. decreasing level of consciousness (LOC) ◦ D. dilated pupil with sluggish response to light

83  VS/NVS  ICP  CPP  MAP  PbtO2  PaCO2  CVP  Labs  Imaging

84  Category status  Advanced directives  Prognosis  Withdraw of care  Palliative care  End of life specialists  SW/Chaplain

85  Varies according to underlying cause and pathologic process  GCS  GOS  Physical/mental disability

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88  22 yo female  Harvard law student  Horseback riding  GCS 7 ◦ Localized  Day 2 ◦ ICP ◦ Hypothermia ◦ Tracrium  Day 3 ◦ Flexion

89  AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4 th Ed Saunders. St.  Davis, F.A. (2001). Taber’s Cyclopedic Medical Dictionary. F.A. Davis, Philadelphia.  Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida.  Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. (2007). Medical-Surgical Nursign. Assessment of Management of Medical Problems. Mosby Elsevier, St. Louis, Missouri  Silvestri, Linda. (2008). Comprehensive review for the NCLEX-RN Examination. Saunders Elsevier, St. Louis, Missouri.


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