rnsg 2432 enhanced concepts of adult health lisa randall, rn, msn, acns-bc
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RNSG 2432 Enhanced Concepts of Adult Health
Lisa Randall, RN, MSN, ACNS-BC
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
Cerebral function◦ Mental status◦ Speech◦ Eyes◦ Cranial nerves◦ Motor◦ Sensory◦ Reflexes
Consciousness◦ Arousal◦ Awareness
Lethargy◦ < alertness◦ < awareness◦ < thought process
Obtundation◦ << A/A◦ Clouding
Stupor◦ Deep sleeplike state◦ Vigorous stimulation
Coma◦ Unresponsiveness
PVS MCS
Unarousability Absence of sleep/wake cycles Inability to interact with the environment GCS =/< 8
Intermittent wakefulness Sleep-wake cycles No awareness of self or environment
http://youtu.be/Pl1IPTpHUHs
Altered consciousness Evidence of self or environmental
awareness is demonstrated
http://www.youtube.com/watch?feature=player_detailpage&v=HVGlfcP3ATI
Reticular Activating System (RAS) ◦ Reticular Formation ◦ Gray cells within brainstem extends into
thalamus Wakefulness Arousal Alertness
Lesion/injury to the RAS or cerebral cortex Metabolic disorders Anoxic injury Drugs Seizures
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
Edema Increased intracranial pressure
◦ Increased systolic BP ◦ Widening pulse pressure
Normal = 40 mmHg ◦ Decreased pulse rate ◦ Irregular respirations
Eyes
Spontaneous opening 4
Open to speech 3
Open to pain 2
Do not open 1
Verbal Response
Oriented 5
Confused 4
Inappropriate 3
Incomprehensible 2
None 1
Motor Response
Obeys commands 6
Localizes to pain Pushes your hand away
5
Withdraws from pain 4
Decorticate/flexion 3
Decerebrate/extension 2
None 1
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.
Mental status General appearance/behavior State of conciousness Mood and affect Thought content Intellectual capacity
Sensory: CN II - Optic ◦ Visual acuity
Motor: CN III - Oculomotor◦ PERRL◦ Direct/consensual ◦ EOMs (CN IV/VI)
http://www.youtube.com/watch?v=cuZXz92hd8g&feature=relate
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
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
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
Babinski's reflex◦ (+) great toe flexes
and the other toes fan out
Abnormal after the age of 2.
Hips and knees flex when the neck is flexed
Stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
Visual fields Dull vs. sharp
◦ Sensation same or different with eyes closed Face Hands Arms Abdomen Feet Legs
Brainstem compression◦ Yawning & sighing ◦ Cheyne-Stokes◦ Central neurogenic hyperventilation◦ Apneustic breathing◦ Cluster breathing ◦ Ataxic respirations
http://www.youtube.com/embed/CUaEwgfKOEc
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
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
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
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
◦ BG◦ Electrolytes/
Osmolality◦ ABGs◦ CBC◦ Liver function◦ Kidney function◦ Toxicology
◦ CT◦ MRI◦ EEG◦ Cerebral angiogram◦ TCD◦ LP
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
Vasoconstriction Decreased CSF CSF shunting Increased CSF reabsorption
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
NP Compensated Uncompensated
10mmHg 15mmHg 30mmHg
Blood 10%, CSF 10% Blood 5%, CSF 5% Blood 4%, CSF 4%
Stable Stiff ICP increases
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
Pressure needed for adequate blood flow to brain◦ CPP = MAP – ICP
Need higher MAP if ICP increased◦ 70-100 mmHg◦ <50 mmHg = ischemia◦ <30 mmHg = death
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
Au
tore
gula
tion
Arterial Blood Pressure - Brain & CS Fluid Compression = Actual Cerebral Blood Flow
Ed
ema,
CS
Flu
id, T
um
or
Changes in contents of cranial vault
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
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
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
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
Maintenance of airway and ventilation Endotracheal intubation Oxygenation Mechanical ventilation Fluid balance/Euvolemia Medications
Sedation, analgesia, neuromuscular blockade
Barbiturate coma Prophylactic anticonvulsant Mannitol/3% NaCl Lasix Atracrium Vasopressors Tylenol
Temperature control Electrolyte balance Proper positioning Adequate nutrition Ventriculostomy Paralytics Hypothermia Pentobarbital coma Craniectomy
LICOX ◦ PbtO2◦ Normal 37-47 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
Standing OrdersPer hospital policy
Neurological◦ Meningitis◦ Seizures◦ Cerebral salt wasting (CSW)◦ Syndrome of inappropriate antidiuretic hormone
(SIADH)◦ Hydrocephalus◦ Cerebral edema/Increased ICP
Increased secretion of ADH from abnormal stimuli
Results in water retention Hyponatremia
◦ Na+ excreted in urine
Decreased UOP Increased urine specific gravity Low serum osmo Hyponatremia Hypervolemia
Fluid restrictiion Replace sodium
◦ Democlocycline◦ Fludrocortisone◦ Hypertonic saline◦ Oral salt
Diuretics
Controversial Hyponatremia Failure of CNS to regulate Na+ reabsorption Increase in circulating atrial natriuretic
peptide (ANP)
Increased UOP Hyponatremia Normal to increased osmo Hypovolemia Increased urine specific gravity
Volume replacement Sodium replacement Reducing renal Na+ excretion
◦ Fludrocortisone◦ Urea
Parameter SIADH CSW
Serum Na+ Decreased Decreased
Serum osmolarity Decreased Decreased
Urine Na+ Increased Normal-increased
Urine OP Decreased Increased
Volume Normo/hypervolemic Hypovolemic
Body weight Increased Decreased
Cerebral edema◦ Vasogenic◦ Cytotoxic◦ interstitial
Hydrocephalus◦ Noncommunicating◦ Communicating◦ ICP
Production – choroid plexus;
Absorption – arachniod villi
Normal MRI Brain MRI Hydrocephalus
Irreversible coma◦ Persistent vegetative state
Locked-in Syndrome (not true coma)◦ Functioning RAS & cortex; pons level
interference◦ Aware, communicate with eyes◦ http://youtu.be/xWHnkFaxMxM
Brain death◦ Loss of all brain function- flat EEG, no blood
flow
A. Cingulate B. Uncal C. Central D. Extracranial E. Tonsillar
Cingulated Herniation (a)
Cingulate gyrus slips under falx cerebri
Usually caused tumor or bleed
Non life threatening
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
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
Infratentorial (subtentorial or Tonsillar) Herniation (e)
Downward displacement of infratentorial structures through the foramen magnum
Life threatening
Extracranial Herniation (d)
Occurs with displacement of brain through a cranial defect.
Usually Non-life threatening
http://youtu.be/dLMCwGmWvrw
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
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 15-
20mm Hg◦ C. clustering nursing activities to provide periods
of uniterrupted rest◦ D. routine suctioning to prevent accumulation of
respiratory secretions
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
VS/NVS ICP CPP MAP PbtO2 PaCO2 CVP Labs Imaging
Category status Advanced directives Prognosis Withdraw of care Palliative care End of life specialists SW/Chaplain
Varies according to underlying cause and pathologic process
GCS GOS Physical/mental disability
22 yo female Harvard law
student Horseback riding GCS 7
◦ Localized
Day 2◦ ICP◦ Hypothermia◦ Tracrium
Day 3◦ Flexion
AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. 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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