Presentation on theme: "Altered Cerebral Function & Increased Intracranial Pressure"— Presentation transcript:
1 Altered Cerebral Function & Increased Intracranial Pressure RNSG 2432Enhanced Concepts of Adult HealthLisa Randall, RN, MSN, ACNS-BC
2 ObjectivesDefine and discuss altered cerebral function and increased ICPAnalyze etiology and pathophysiology of altered cerebral functionDiscuss/illustrate signs and symptoms, diagnostics, and treatmentFormulate nursing diagnoses that address physical, psychosocial, and learning needsPrioritize and evaluate nursing interventions
3 Definitions Cerebral function Mental status Speech Eyes Cranial nerves MotorSensoryReflexes
4 Definitions Consciousness Lethargy Obtundation Stupor Coma Arousal AwarenessLethargy< alertness< awareness< thought processObtundation<< A/ACloudingStuporDeep sleeplike stateVigorous stimulationComaUnresponsivenessPVSMCS
5 Comatose State Unarousability Absence of sleep/wake cycles Inability to interact with the environmentGCS =/< 8
6 Persistent Vegetative State Intermittent wakefulnessSleep-wake cyclesNo awareness of self or environment
7 Minimally Conscious State Altered consciousnessEvidence of self or environmental awareness is demonstrated
14 GLASGOW COMA SCALE Eyes Spontaneous opening 4 Open to speech 3 Open to pain2Do not open1Verbal ResponseOriented5ConfusedInappropriateIncomprehensibleNoneGLASGOW COMA SCALE
15 GLASGOW COMA SCALE Motor Response Obeys commands 6 Localizes to pain Pushes your hand away5Withdraws from pain4Decorticate/flexion3Decerebrate/extension2None1GLASGOW COMA SCALERange of possible scores = 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.
20 Assessment of arousal/cognition Vision & Pupillary light reflex Sensory: CN II - OpticVisual acuityMotor: CN III - OculomotorPERRLDirect/consensualEOMs (CN IV/VI)Compare pupil size, shape, movement, and reactivity.CN III compressed pupil on that/ipsilateral side dilates.Pin point pupils – pons or meds.Fixed pupil unresponsive to light – IICP, nerve injury, previous surgery, or mydriatic eye gtts.
24 Motor Ability to move, strength, and symmetry Coordination Grips, arm strength, & driftPlanter flexion, dorsiflexion, & leg strengthCoordinationFinger to nose, heel up and down shinPlanter Reflex- Babinski testingMeningeal signs- Brudzinski & Kernig’s signMotor- squeeze nurse’s hands, palmar drift, raise foot off bedResistance to movement during ROM or movement to painful stimuli also indicate ability to move and strength
25 Planter Reflex and Babinski testing Babinski's reflex(+) great toe flexes and the other toes fan outAbnormal after the age of 2.
26 Meningeal signs- Brudzinski, nuchal rigidity Hips and knees flex when the neck is flexed
27 Meningitis signs- Kernig’s sign Stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
28 Neuro assessment - Sensation Visual fieldsDull vs. sharpSensation same or different with eyes closedFaceHandsArmsAbdomenFeetLegs
32 QuestionA 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 asA. 6B. 8C. 9D. 11
33 QuestionThe nurse recognizes the presence of Cushing’s triad in the patient withA. increased pulse, irregular respiration, increased BPB. decreased pulse, irregular respiration, increased pulse pressureC. Increased pulse, decreased respiration, increased pulse pressureD. decreased pulse, increased respiration, decreased systolic BP
34 QuestionCN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem byA. assessing for nystagmusB. testing the corneal reflexC. testing pupillary reaction to lightD. testing for oculocephalic (doll’s eyes) reflex
35 QuestionAn unconscious patient with increased ICP is on ventilatory support. The nurse notifies the healthcare provider when arterial blood gas (ABG) measurement results reveal aA. pH of 7.43B. SaO2 of 94%C. PaO2 of 50mm HgD. PaCO2 of 30mm Hg
36 Diagnostics R/O and identify cause of LOC BGElectrolytes/Osmolali tyABGsCBCLiver functionKidney functionToxicologyCTMRIEEGCerebral angiogramTCDLP
39 ICP Concepts Monro-Kellie hypothesis Autoregulation 80/10/10 rule Cerebral arteriolesMAP (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 perfusedCritical to maintain normal MAP with Increased ICP
41 ComplianceBrain’s ability to tolerate an increase in volume without an increase in pressureIndications of decreased compliance:Sustained increase in ICP in response to stimuliGreater increases to non-noxious stimuli
42 Normal Pressure v Compensated v Uncompensated NPCompensatedUncompensated10mmHg15mmHg30mmHgBlood 10%, CSF 10%Blood 5%, CSF 5%Blood 4%, CSF 4%StableStiffICP increases
43 “Rules” of Compensation A slowly expanding mass is tolerated better that a rapidly expanding massBrain tissue is compressible, but functional impairment, possibly irreversible does occurLocation matters
44 Cerebral Perfusion Pressure Pressure needed for adequate blood flow to brainCPP = MAP – ICPNeed higher MAP if ICP increasedmmHg<50 mmHg = ischemia<30 mmHg = death
45 MAP – ICP = CPP Autoregulation Danger of CPP < 50 mmHg Arterial Blood Pressure - Brain & CS Fluid Compression = Actual Cerebral Blood FlowCPP70 to 100 mmHgDanger of CPP < 50 mmHgMAP50 to 150 mmHgAutoregulationEdema, CS Fluid, TumorIncreased ICP> 20 mmHgNormal ICP0 to 15 mmHgIncreased MAP needed to perfuse brain
46 PathophysiologyChanges in contents of cranial vault
47 Causes of Increased ICP Mass effectTumorBlood clotEdemaIncreased CBFIncreased blood flowIncreased PaCO2Decreased PaO2VasodilatorsIncreased intrathoracic pressureCoughingStrainingSuctioningPeepImpairment of cerebral venous drainagePositioning
48 ICP indicators Changes in LOC Worsening headache Cognitive deficits Pupillary changesIncreasing B/P with widening pulse pressureIrregular respiratory patternsBradycardiaSeizuresAphasiaDysconjugate gazeHemiparesis or hemiplegia
49 Assessment Health history- assess brain involvement PE Altered cerebral function assessmentFrequency depends on potential IICPEarly sign- change in LOC3rd Cranial nerve compressionPapilledemaProjectile vomitingVision changesSeizuresLate sign- Cushing VS changes
50 Pertinent Nursing Problems and Interventions Ineffective tissue perfusion: cerebralAssess/report sign IICPAdequate airwayPromote venous drainageControl environment stimuliPlan nursing care – avoid clustering careAvoid Valsalva’s maneuverIf bone flap out post op- assess & positionAssess external shunts/drains
51 Medical Management Concurrent Nursing Care Maintenance of airway and ventilationEndotracheal intubationOxygenationMechanical ventilationFluid balance/EuvolemiaMedications
55 Intracranial monitoring LICOXPbtO2Normal mmHgJugular venous bulb cathSjvO2Normal SjvO2 is 60% to 80%<50 to 55% of O2 in venous blood indicates impairmentof flow and brain taking out more O2 than normalICP Waveforms (P1, P2, & P3)P1 arterial pulse wave should be highestP2 is intracranial compliance – if higher than P1 compliance is compromisedP3 is the venous pulsation and should be the lowestP1 P2 P3
56 Intraventricular and subarachnoid monitoring devices for IICP
80 QuestionA patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient isA. aseptic technique to prevent infectionB. constant monitoring of ICP waveformsC. removal of CSF to maintain normal ICPD. sampling CSF to determine abnormalities
81 QuestionA patient has a nursing diagnosis of altered cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient isA. avoiding positioning the patient with neck and hip flexionB. maintaning hyperventilation to a PaCO2 of mm HgC. clustering nursing activities to provide periods of uniterrupted restD. routine suctioning to prevent accumulation of respiratory secretions
82 QuestionThe earliest signs of increased ICP the nurse should assess for includeA. Cushing’s triadB. unexpected vomitingC. decreasing level of consciousness (LOC)D. dilated pupil with sluggish response to light
88 Case Study Day 2 22 yo female Harvard law student Day 3 ICPHypothermiaTracriumDay 3Flexion22 yo femaleHarvard law studentHorseback ridingGCS 7Localized
89 ReferencesAANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th 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, MissouriSilvestri, Linda. (2008). Comprehensive review for the NCLEX-RN Examination. Saunders Elsevier, St. Louis, Missouri.