Presentation on theme: "Updated Fall 2009 by John Nation, RN, MSN"— Presentation transcript:
1Neurosensory: Altered Cerebral Function and Increased intracranial pressure (IICP) Updated Fall 2009 by John Nation, RN, MSNFrom the notes of Charlene Morris, RN, MSN&Marnie Quick, RN, MSN, CNRN
2Overview of Today’s Lecture Discuss altered cerebral functionAnatomy and physiologyDefinition of common termsNeurological assessment techniquesIncreased intracranial pressureClinical manifestationsInterventionsNursing concerns
3Have you read Lewis pages 1467- 1481? YesNoAbstain
8Flow of CSF: Produced by filtration of the blood by the choroid plexus of each ventricle flows inferiorly through the lateral ventricles, intraventricular foramen, third ventricle, cerebral aqueduct, fourth ventricle and subarachnoid space and to the blood.
9Altered Cerebral Function: Arousal/cognition (LOC) Patho/assessment Reticular Activating System (RAS) – Reticular Formation - meshwork of gray cell within brainstem extending to the thalamus.Controls wakefulness, arousal and alertness.Reticular Activating System- You TubeCerebral cortex outer layer of gray cell bodies of brain. Controls cognition, thought process.
11Altered Cerebral Function: What is Consciousness? Consciousness (Merriam- Webster): waking life (as that to which one returns after sleep, trance, or fever) in which one's normal mental powers are present “the ether wore off and the patient regained consciousness”Dynamic stateContinuum from awareness of self and environment to unawarenessConsciousness to deep comaComa- prolonged unconsciousness
12Causes of Changes in LOC Alcohol intoxicationDrug intoxication (particularly opiates, narcotics, sedatives, and anti-anxiety or seizure medications)ArrhythmiaBrain disordersCentral nervous system diseasesLack of oxygen (hypoxia)Abnormal blood sugars (diabetic coma)Electrolyte or mineral imbalanceExposure to heavy metals or hydrocarbonsExtreme fatigue or sleep deprivationKetoacidosisHead traumaHeart failureHypoglycemia (low blood sugar)Increased carbon dioxide levels (hypercarbia) often seen in emphysemaInfectionLow blood pressure (hypotension)Metabolic disordersThyroid or adrenal gland disordersSeizures such as those related to epilepsyShockStrokeSource: National Institute of Health
13Causes of Coma: Coma can be caused by: Traumatic brain injuries. Brain injuries that result from traffic collisions or acts of violence are the most common cause of comas.Stroke. Acute loss of blood flow to the brain followed by swelling or no blood flow to a major part of the brainstem can result in a coma.Diabetes. Blood sugar levels that get too high (hyperglycemia) and stay too high or get too low (hypoglycemia) and stay too low can cause coma.Source: Mayo Clinic:
14Causes of Coma (Cont’d): Lack of oxygen. People who have escaped drowning or been resuscitated after a heart attack may not awaken due to lack of blood flow and oxygen to the brain.Infections. Encephalitis and meningitis are infections that cause inflammation of the brain, spinal cord or the tissues that surround the brain. Severe cases of either encephalitis or meningitis can result in a coma.Toxins. Exposure to toxins, such as carbon monoxide or drug overdoses, can cause brain damage and coma.Source: Mayo Clinic:
15Altered Levels of Consciousness: Definitions of Terms Lethargy - a slight reduction in alertness, less aware of what is happening around them and think more slowly.Obtundation - a moderate reduction in alertness or clouding of consciousness.Stupor - an excessively long or deep sleeplike state. Arousal is brief by vigorous stimulation, such as repeated shaking, loud calling, pinching.Coma - is a state of complete unresponsiveness, cannot be aroused, in a deep coma lacks avoidance of pain.Some reflexes may be present.
16Altered Cerebral Function: Assessment of arousal/cognition (LOC) Is the patient alert?Assess to person/place/time/event (A&O x 4)Respond to verbal stimuli?Respond to painful stimuli?Purpose: shows the brain receives the impulse, interprets it, and respondsTypes of painful stimuli:Trapezius pinch- grasp at least two inches of trapezius muscle. Squeeze and twist.Supraorbital pressure- carefully applied upward pressure on the ridge along the upper portion of the bony orbital structurePressure on finger nailsSternal rub- not considered appropriateIs the patient unresponsive?A-----V-----P-----U!
21Glasgow Coma ScaleChart both total and sub scores to indicate where the deficits are. Also not why..periorbital edema may make opening eyes impossible.Also chart the patient’s best effort not necessarily the first response.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.
22Assessment of Vital Signs Temperature - hypothalamus pressure can lead to alterations in body temperatureCushing’s triad – caused by edema & increased intracranial pressure1) Increased systolic BP2) Decreased pulse rate3) Irregular respirations
23Eleven Twelve Thirteen Fourteen A 44 y/o male presents to the ED after a motor vehicle accident. When you ask him where he is, he opens his eyes and states “work” before closing his eyes again. He states that his abdomen hurts, and he points to the specific location when you ask. What is his GCS?ElevenTwelveThirteenFourteen
24Lethargy is defined as a deep sleep like state where the patient is aroused only with loud noise or painful stimuli.TrueFalse
25Assessment of arousal/cognition - Respiratory Respiratory- changes occur as brainstem is being compressedYawning & sighingCheyne-Stokes – crescendo-decrescendo with apneaCentral Neurogenic hyperventilationApneustic breathing – Pauses in inspiration and expirationCluster breathing – irregular deep to shallow with apneaAtaxic respirations - grossly irregular
29Assessment of arousal/cognition Pupillary light reflex Occipital lobeBrain stemSensory: CN 2 - OpticMotor: CN 3 - OcculomotorNote pupil size; darken room; shine light in and note reaction and sizeCompare 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.
30Assessment of arousal/cognition Pupillary light reflex PERRLA- “Pupils equal, round, reactive to light and accommodation”Anisocoria: The two pupils are not of equal size.Light-near dissociation, refers to a condition where the light reflex is absent or abnormal but the near response is intact. There is no clinical condition in which the light reflex is present and the near response is absent.Amaurotic: blind eye still has consensual response
32Assessment Arosual/cognition EOM’S & Brain stem function Eye movement- CN 3,4,6In Deep COMA- test EOM’s by Oculocephalic reflexDoll’s eyes- Sensory- CN 8; Motor- CN 3,4,6Good Dolls eyes: eyes move in opposite direction of head movement – intact brain stem at Pons & nervesBad/negative Dolls eyes: eyes do not move head turnedEye movement 3,4,& 6 also tests brain stem functionCorneal reflex – CN 5 & 7How tested with spinal cord injury?
34Assessment arousal/cognition Additional Motor Assessment Ability to move, strength, and symmetryGrips, arm strength, & driftPlanter flexion, dorsiflexion, & leg strengthCoordinationFinger to nose, heel up and down shinPlanter Reflex- Babinski testingMeningeal signs- Brudzinski, nuchal rigidityMotor- 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
35Planter Reflex and Babinski testing Babinski's reflex – present when the great toe flexes toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked.Postitive response indicates damage to nerve paths connecting the spinal cord and the brain (corticospinal tract)Abnormal after the age of 2.
36Meningeal signs- Brudzinski, nuchal rigidity One of the physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
37Meningitis signs- Kernig’s sign Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
38Neuro assessment - Sensation Dull vs. sharp – use broken tongue depressor or cotton tip applicatorInclude face, hands, arms, abdomen, feet, and legs
43A RN needs an order from a physician to conduct a neurological assessment on a patient showing new symptoms of a CVA.TrueFalse
44Altered cerebral function Nursing assessment for Cerebral Dysfunction Terms used to describe LOCDescription more important than termHealth history- drugs/head injury/metabolicPhysical exam- modify as individual cooperationNeuro Vital SignsLOC, V/S, Pupils, Strength/Movement, SensationGlasgow coma scaleNIH Stroke Scale – want low scoreNIH Stroke Scale pdf
45Common manifestations/Complications Coma states and brain death Irreversible coma- persistent vegetative stateDoes not have functioning cerebral cortexCaused by anoxia or severe brain injurySleep-wake cycles; chew/swallow/cough, no trackingLocked-in Syndrome (not true coma)Functioning RAS & cortex; pons level interferenceAware, communicate with eyesBrain deathLoss of all brain function- flat EEG, no blood flow
46Prognosis of individual with altered cerebral functioning Outcome varies according to underlying cause and pathologic processThe longer the individual unconscious, the longer has absent Doll’s eyes; the poorer the cognitive recoveryResidual mental problems typically outweigh the physical
47Altered Cerebral Function Therapeutic Interventions Diagnostic tests- to R/O & identify cause of altered cerebral functionCT, MRI, EEG, blood workMedications- vary according to problemOverdose; fluid/electrolyte replacement; antibioticsSurgery- (Ex. tumors, intracranial bleeds)Other- airway/vent; treat IICP; enteral feeding
48MRI of the brain EEG CT of the head X- Ray of the head Your patient becomes disoriented and reports a severe headache. Which diagnostic test would you expect the physician to order first?MRI of the brainEEGCT of the headX- Ray of the head
49Which of the below options would be your priority nursing diagnosis for a patient with altered cerebral function?Risk for aspirationIneffective tissue perfusionIneffective airwayRisk for imbalance nutrition
50Altered Cerebral Functioning: Pertinent Nursing problems Identify the priorities:Impaired physical mobilityRisk for aspirationIneffective coping- FamilyIneffective tissue perfusion (cerebral)Risk for impaired skin integrityIneffective airwayRisk for imbalanced nurtitionAlteration in breathing patternHome care
52Increased Intracranial Pressure- Overview Normal ICP ControlAutoregulationCauses of Increased ICPClinical ManifestationsDiagnostic StudiesMonitoring Increased ICPTreatment
53ICPSkull is a closed box with three essential components: blood 12%, brain tissue 78%, and cerebrospinal fluid (CSF) 10%Normally, arterial pressure, venous pressure, intraabdominal and intrathoracic pressure, posture, temperature, and blood gases keep ICP relatively constant
54Monro-Kellie hypothesis Brain tissue, blood, and CSF are mostly constant in volumeIf the volume of one component increases, another component will be displacedIn total, the intracranial pressure will not change while compensation is possible(ex. Change in CSF production or absorption, vasoconstriction or dilation, compression or distention of brain tissue)The ability to accommodate change is limited
55Measuring Increased ICP Normal ICP is 0 to 15 mm HgUsually treated once above 20 mm Hg
56Cerebral Blood Flow (CBF) Cerebral Blood Flow- amount of blood in mls passing through 100g of brain tissue in 1 minuteGlobal CBF is 50ml/minNormal blood flow 25ml/min in white matterNormal blood flow 75 ml/min in gray matterBrain requires constant supply of oxygen and glucoseBrain uses 20% of oxygen and 25% of glucose
57AutoregulationAutoregulation- the automatic adjustment in diameter of cerebral blood vessels to maintain constant blood flow despite changes in blood pressureAutoregulation is not effective with a MAP less than 50 mm HgAutoregulation is not effective with a MAP greater than 150 mm Hg
58Autoregulation (Cont’d) Cerebral Perfusion Pressure (CPP)- pressure needed to ensure blood flow to the brainCPP= MAP- ICPNormal CPP is 70 to 100 mm HgCPP < 50 mm Hg causes ischemia and neural deathCPP< 30 mm Hg is not compatible with life
60Cerebral Edema-Increased accumulation of fluid in extravascular spaces of brain tissueResults in increased tissue volumeCaused by brain abscess, brain tumor, hematoma, hemorrhage, contusion, posttraumatic brain swelling, meningitis, enephalitis, anoxic and ischemic episodes, cerebral infarction, venous thrombosis, lead or arsenic intoxication, hepatic encephalopathy, uremiaThree types: vasogenic, cytotoxic, and interstitial (more than one type can occur at the same time)
61Cerebral Edema (Cont’d) Vasogenic Cerebral Edema-Most commonChanges in endothelial lining of cerebral capillaries allow leakage of macromolecules into extravascular spaceFluid flows to extravascular space due to osmotic gradientCan be caused by tumors, abscesses, and toxins
62Cerebral Edema (Cont’d) Cytotoxic Cerebral Edema-Occurs most often in gray matterLesions or trauma cause cerebral hypoxia, sodium depletion, and syndrome of inappropriate antidiuretic hormone (SIADHFluid then shifts from extracellular space directly into the cells
63Cerebral Edema (Cont’d) Interstitial Cerebral Edema-Periventricular diffusion of ventricular CSF in a patient with uncontrolled hydrocephalus
64Causes of Increased ICP Aneurysm rupture and subarachnoid hemorrhageBrain tumorEncephalitisHydrocephalusHypertensive brain hemorrhageIntraventricular hemorrhageMeningitisSevere head injurySubdural hematomaStatus epilepticusStrokeSource: National Institute of Health
65Stages of Compliance with IICP Compensation is effective & autoregulation present – CSF, Blood, and BrainCompliance less effective & increase risk for IICPAny small increase in volume causes great increase in ICP, loss of autoregulation & Cushing's triadHerniation
66Increased Intracranial Pressure (IICP) Cerebral edema/hydrocephalus Cerebral edema- Increases the volume of brain tissue which can cause herniationHydrocephalus-Build up of CSF inside the skull
68Health history- assess brain involvement Physical exam- Increased intracranial pressure (IICP): Nursing assessment specific to IICPHealth history- assess brain involvementPhysical exam-Altered cerebral function assessmentFrequency depends on potential IICPEarly sign- change in LOC3rd Cranial nerve compression- pupil dilation, no response to light, ptosis of the eyelid on ipsilateral side as lesionPapilledema, projectile vomiting, vision changes, seizuresLate sign- Cushing’s Traid – Widening pulse pressure (increasing SBP & decreasing DBP) decreased HR, and irregular respiratory pattern
69Increased Intracranial Pressure (IICP): Therapeutic Interventions Diagnostic tests-CT ScanMRIPETEEGAngiographyTranscranial doppler studiesECGCBC, Coags, BMP, ABGs, drug screenBarbiturate Coma – pentobarbital or Pentothal longer actingPropofol – short acting, permits ability to do neuro checksCan do pupil checks even in medication comaNeed to treat B/P less than 90 or 100 systolic or Cerebral Perfusion Pressure 70 or 80 also treat B/P > 150 in some cases some suggest permitting B/P to be higherMED coma can lead to low B/P treatment is considered a failure if:Hypotention not responsive to cardiac inotropes, peripheral vaso- pressors, or intravenous fluid therapy (cardiac isotopes: dopamine, dobutamine, epinephrine) (peripheral vasopressors: ephedrine, phenylephrine)(IV fluids: packed RBCs, albumine, hetastarch, LR) The temperature of the body is regulated by neural feedback mechanisms which operate primarily through the hypothalmus. The hypothalmus contains not only the control mechanisms, but also the key temperature sensors. Under control of these mechanisms, sweating begins almost precisely at a skin temperature of 37°C and increases rapidly as the skin temperature rises above this value. The heat production of the body under these conditions remains almost constant as the skin temperature rises. If the skin temperature drops below 37°C a variety of responses are initiated to conserve the heat in the body and to increase heat production. These includeVasoconstriction to decrease the flow of heat to the skin.Cessation of sweating.Shivering to increase heat production in the muscles.Secretion of norepinephrine, epinephrine, and thyroxine to increase heat productionIn lower animals, the erection of the hairs and fur to increase insulation.
71ICP monitoringLICOX cath – brain tissue oxygenation of frontal white matter PbtO2Normal PbtO2 is mmHgLICOX CatheterJugular venous bulb cath SjvO2 indicates brain tissue removal of O2 from bloodNormal SjvO2 is 60% to 80%<50 to 55% of O2 in venous blood indicates impairment of flow and brain taking out more O2 than normalICP Waveforms (P1, P2, & P3) see Lewis p. 1474P1 arterial pulse wave should be highestP2 is intracranial compliance – if higher than P1 compliance is compromisedP3 is the venous pulsation and should be the lowest
72 Intracranial pressure monitoring can be used to continuously measure ICP. The ICP tracing shows normal, elevated, and plateau waves. At high ICP the P2 peak is higher than the P1 peak, and the peaks become less distinct and plateau.
73ICP Monitoring (Cont’d) Pg 1473 Intraventricular Monitoring:Considered gold standard of ICP monitoringSurgically placed into ventricular systemHas drainage bag, pressure transducer, and three way stopcockAccurate, can drain CSFInfection occurs in up to 20% of patientsRisk of hemorrhage during placement (2%)
74ICP Monitoring (Cont’d) Intraparenchymal Monitoring:Inserted into brain parenchyma via small hole drilled in skullThin cable with fiberoptic transducer at the tipEasier to place, lower risk of infection, lower risk of bleedCannot drain CSFNot as accurateMechanically complex design carries greater risk of failure
75ICP Monitoring (Cont’d) Subarachnoid Monitoring:Hollow screw placed through skull into duraDura is then punctured, allowing CSF to communicate with the transducerFrequently clog and are considered unreliableRarely used
76ICP Monitoring (Cont’d) Epidural Monitoring:Rest against the dura after passing through the skullOften inaccurate and are of limited clinical utilityUsed for coagulopathic patients with hepatic encephalopathy
77ICP Monitoring (Cont’d) Noninvasive Monitoring-Tissue resonance analysis (TRA)- ultrasound-based methodTranscranial dopplerIntraocular pressureTympanic membrane displacementNone of above have demonstrated reproducible clinical success at this time
82Ineffective tissue perfusion: cerebral Increased intracranial pressure (IICP): Pertinent Nursing Problems and InterventionsIneffective 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
83A patient has ICP monitoring with an intraventricular catheter A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is :Aseptic technique to prevent infectionMaintain the bed in Trendelenburg positionRemoval of CSF to maintain normal ICPSampling CSF to determine abnormalities
84A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except mutturing when stimulated, and flexes his arm in response to painful stimuli. The GCS is:sixeightnineeleven
85Match the following treatment for increased ICP with it’s effect: Oxygen administration Decreased cerebral metabolismPrevention of hypoxiaDecreased volume of brain waterCerebral arterial vasoconstrictionDecreased lesion edema
86Match the following treatment for increased ICP with its effect: Mild hyperventilation Decreased cerebral metabolismPrevention of hypoxiaDecreased volume of brain waterCerebral arterial vasoconstrictionDecreased lesion edema
87Match the following treatment of increased ICP with its effect: Osmotic diuretics Decreased cerebral metabolismPrevention of hypoxiaDecreased volume of brain waterCerebral arterial vasoconstrictionDecreased lesion edema
88Match the following treatment of increased ICP with its effect: Dexamethasone (Decadron) Decreased cerebral metabolismPrevention of hypoxiaDecreased volume of brain waterCerebral arterial vasoconstrictionDecreased lesion edema
89Match the following treatment for increased ICP with its effect: Barbiturates Decreased cerebral metabolismPrevention of hypoxiaDecreased volume of brain waterCerebral arterial vasoconstrictionDecreased lesion edema
90VP shunt (a narrow piece of tubing) is surgically placed in the ventricle of the brain to drain CSF to the abdomen where it is absorbed by the body. CSF Shunt
91After VP Shunt SurgeryThere is mild pain involved with this surgery. Acetaminophen (Tylenol ) or ibuprofen may be used for postoperative discomfort. You will be in the hospital for days. Once you are eating and drinking, and there are no complications, you will be able to go home. You will have a follow-up appointment in the neurosurgery clinic in 7-10 days. Your head dressing and staples will be removed at that time. After discharge, you may resume your regular activities unless you are told otherwise. In the future, you will need antibiotics before dental work and other invasive procedures.
92After VP Shunt Surgery (Cont’d) When to Call your Neurosurgeon or Nurse PractitionerSometimes a shunt malfunctions by becoming clogged, disconnected, or infected. If this happens, you may experience any of the following signs and symptoms:Redness, pain or swelling of the skin along the length of the shunt or at the incision sitesDrainage from the incisionFever greater than 101.5° F-usually within the first six months of surgeryIrritability or excessive sleepinessNausea or vomitingRecurring headachesBlurred or double visionSudden or gradual change in personalityRubbing of the headWeaknessBalance or coordination problems
94Cingulated Herniation - a Brain HerniationCingulated Herniation - aCingulate gyrus slips under falx cerebriUsually caused tumor or bleedNon life threatening
95Uncal or Lateral Herniation - b Brain HerniationUncal or Lateral Herniation - bUncus of temporal lobe slips through notch of tentorium and compresses the ipsilateral CN 3, brainstem, & vital centersLife threatening
96Central or Transtentorial Herniation - c Brain HerniationCentral or Transtentorial Herniation - cCaused by: downward pressure on mid structures of cerebrum or general cerebral edema which compresses the brainstemLife threatening – compresses RAS & vital centersAbnormal heart rhythms, disturbances or cessation of breathing, cardiac arrest, and death
97Extracranial Herniation - d Brain HerniationExtracranial Herniation - dOccurs with displacement of brain through a cranial defect.Usually Non-life threatening
98Infratentorial (subtentorial or Tonsillar) Herniation - e Brain HerniationInfratentorial (subtentorial or Tonsillar) Herniation - eDownward displacement of infratentorial structures through the foramen magnumLife threatening