Increased Intracranial Pressure

Neurological Disorders Increased Intracranial Pressure (ICP) Conscious Confused Delirious 1. Overview a. Normal ICP: 5-15mmHg b. ICP can elevate due to trauma, hemorrhage, tumor, hydrocephalus, inflammation c. The cranial vault is rigid, increased ICP can limit cerebral perfusion, impeded CSF absorption and lead to herniation of brain tissue causing death 2. Points a. Assessment i. Levels of Consciousness Normal Assessment of LOC involves checking orientation: people who are able promptly and spontaneously to state their name, location, and the date or time are said to be oriented to self, place, and time, or "oriented X3". A normal sleep stage from which a person is easily awakened is also considered a normal level of consciousness. "Clouding of consciousness" is a term for a mild alteration of consciousness with alterations in attention and wakefulness. Disoriented; People who do not respond quickly with information about their name, impaired thinking location, and the time are considered "obtuse" or "confused". A confused and responses person may be bewildered, disoriented, and have difficulty following instructions. The person may have slow thinking and possible memory time loss. This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription), and infection. Disoriented; Some scales have "delirious" below this level, in which a person may be restlessness, restless or agitated and exhibit a marked deficit in attention. hallucinations, sometimes delusions Somnolent Sleepy Obtunded Decreased alertness; slowed psychomotor responses A somnolent person shows excessive drowsiness and responds to stimuli only with incoherent mumbles or disorganized movements. In obtundation, a person has a decreased interest in their surroundings, slowed responses, and sleepiness. 2 Stuporous Sleep-like state (not unconscious); little/no spontaneous activity People with an even lower level of consciousness, stupor, only respond by grimacing or drawing away from painful stimuli. Comatose Cannot be aroused; no response to stimuli Cannot be aroused; no response to stimuli ii. headache iii. Cushing's Triad 1. abnormal respirations 2. widening pulse pressure 3. reflex bradycardia iv. elevated temp v. pupilary changes vi. posturing vii. seizures viii. positive Babinski reflex b. Therapeutic Management i. monitory respiratory status ii. monitor pupil changes iii. avoid sedatives and CNS depressants iv. Hypocapnia (PaCO2 30-35 mmHg) will lead to cerebral vasoconstriction leading to decreased ICP v. monitor temperature vi. prevent shivering vii. decrease stimuli viii. monitor electrolytes ix. avoid Valsalva's maneuver x. Ventricular drain and ICP monitoring xi. Assess neuro status q 1-2 hours xii. elevate HOB to at least 30 degrees xiii. Osmotic diuretics and corticosteroids Stroke 1. Overview a. Neurological deficit caused by decreased blood flow to a portion of the brain b. May be ischemic or hemorrhagic c. Lack of blood flow greater than 10 minutes can cause irreversible damage 3 2. d. Risk factors: i. HTN ii. Diabetes iii. atherosclerosis iv. cardiac dysrhythmias v. substance abuse vi. obesity vii. oral contraceptives viii. anticoagulant therapy e. Diagnosed via: CT, MRI, cerebral arteriogram (hemorrhagic and late ischemic) Points a. Assessment i. contralateral manifestations (opposite side of stroke) ii. FAST 1. facial droop 2. arms - does one arm drift? 3. speech problems 4. time - call 9-1-1 iii. dependent on location 1. Aphasia - speech difficulty a. Expressive - understands but unable to communicate verbally b. Receptive - unable to comprehend spoke and written word c. Global - language dysfunction d. Interventions i. provide adequate time for client to respond ii. repeat names of individuals and objects frequently iii. use a picture board iv. provide only one instruction at a time 2. Apraxia - inability to perform tasks 3. Hemianopsia - blindness in half the vision field a. instruct client to turn head to capture the entire vision field b. approach client from unaffected side c. provide food and objects to unaffected side 4. Dysphagia - difficulty swallowing b. Therapeutic Management i. involve speech therapy ii. ischemic stroke 1. permissive hypertension 2. antithrombitic therapy 3. carotid endartecomy 4. thrombectomy 5. monitor neurological status 4 iii. hemorrhagic stroke 1. coiling or clipping of aneurysm 2. monitor neurological status iv. seizure precautions v. monitor level of consciousness vi. monitor neurological status vii. maintain quiet, calm environment viii. assess need for assistive devices ix. involve physical and occupational therapy Seizure Disorder 1. Overview a. Abnormal excessive discharge of electrical activity in the brain b. Types i. Generalized - both hemispheres 1. Tonic-clonic 2. absence 3. myoclonic 4. atonic ii. Partial - one hemisphere 1. simple partial 2. complex partial c. Risk factors i. genetics ii. trauma iii. tumors iv. toxicity v. infection vi. cerebral bleeding or swelling vii. acute febrile state d. Status epilepticus - persistent seizure activity with little or no break 2. Points a. Assessment i. assess for Aura (sensation that warns of impending seizure) ii. Postictal state (period after seizure): memory loss, sleepiness, impaired speech iii. assess type, onset, duration b. Therapeutic Management i. Maintain patent airway 1. turn client to side 2. have O2 and suction equipment available after the seizure 3. DO NOT force anything into the mouth during the seizure (including bite block) 5 ii. prevent injury 1. bed to the lowest position 2. padded side rails 3. loosen restrictive clothing 4. DO NOT try to restrain client iii. Document onset, preceeding events, duration, and postictal events iv. Medications 1. Anitepileptics 2. Diazepam, Lorazepam, phenobarbital are often given during seizure activity v. Educate client and family on importance of medication compliance vi. Educate family on care during seizure Parkinson's Disease 1. Overview a. Degenerative neurological disorder caused by atrophy of substantia negra leading to depletion of dopamine. This leads to termination of acetylcholine inhibition which causes symptoms. b. Dopamine plays a role in the inhibition of excitatory impulses. When this neurotransmitter is depleted acetylcholine is no longer inhibited. c. Slow, progressive disease. d. client becomes progressively debilitated and self-care dependent 2. Points a. Assessment i. bradykinesia: slow movements due to muscle rigidity ii. resting tremor iii. Pill rolling - tremors in hands and fingers iv. Akinesia v. blank facial expression vi. shuffling steps, stooped stance, drooling vii. dysphagia b. Therapeutic Management i. Assistive devices ii. involvement of speech, physical, and occupational therapy iii. monitor diet to insure proper caloric intake 1. increase fluid intake 2. high protein 3. high fiber iv. Assess ability to swallow prior to anything by mouth v. Use rocking movement to initiate movement vi. encourage client to ambulate multiple times a day vii. participate in active and passive range of motion activities 6 viii. avoid foods high in Vitamin B6 (blocks effects of antiparkinsonian drugs) ix. small, frequent, nutrient dense foods x. Medication therapy 1. dopaminergics, dopamine agonists, anticholinergics 2. goal is to increase the level of dopamine in the CNS 3. eventually drugs become ineffective Multiple Sclerosis 1. Overview a. Chronic, progressive demyelinization of the neurons in the CNS b. Remission and exacerbation c. Primarily ages 20-40 years old 2. Points a. Assessment i. fatigue ii. tremors iii. spasticity of muscles iv. bladder dysfunction v. decrease peripheral sensation (pain, temperature, touch) vi. visual disturbances vii. emotional instability b. Therapeutic Management i. No cure - supportive therapy ii. energy conservation iii. maintain adequate fluid intake 2000 mL/day iv. provide bowel and bladder training v. encourage activity independence vi. regulate temperatures on water heaters, baths, and heating pads vii. insure in home safety (rugs, cords, etc) Myasthenia Gravis 1. Overview a. Chronic progressive disorder of the PNS which affects transmission of nerve impulses b. Onset often caused by precipitating factors (stress, hormone disturbance, infection, trauma, temperature) c. Insufficient secretion of acetylcholine with excessive secretion of cholinesterase 2. Points a. Assessment i. weakness/fatigue ii. diplopia (double vision) and ptosis (drooping eyelid) iii. monitor respiratory status 7 1. swallowing, respirations, tachypnea, abnormal ABG, breath sounds, difficulty breathing iv. Cholinergic crisis: severe muscle weakness due to overmedication; cramps, diarrhea, bradycardia, bronchial spasm 1. Assessment a. N/V, diarrhea b. hypotension c. blurred vision 2. Intervention a. withhold medication b. administer antidote v. Myasthenic crisis: acute exacerbation of disease, sudden severe motor weakness, risk of respiratory failure, caused by insufficient medication dosage 1. Assessment a. increase pulse, respirations, bp b. anoxia and cyanosis c. bowel and bladder dysfunction 2. Intervention a. increase medication vi. Tensilon test 1. used to confirm diagnosis a. client at risk of vfib and cardiac arrest have atropine available b. Therapeutic Management i. monitor respiratory status ii. maintain suction and emergency equipment iii. insure proper medication iv. monitor feeding and insure proper nutrition 1. schedule medication 30-40 minutes prior to meals v. provide adequate eye care vi. instruct client to avoid temperature extremes, emotional stress, drugs, alcohol, and exposure to infection vii. educate on signs of cholinergic and myasthenic crisis Cram - Neurological Disorders 1. Glasgow Coma Scale Score 1 2 3 4 5 6 Eyes Does not open Opens to painful stimuli Opens to voice Opens spontaneously N/A N/A 8 Verbal Makes no sound Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented, converses normally N/A Motor Makes no movements Extension to painful stimuli Flexion to painful stimuli Withdraws to painful stimuli Localizes to pain Obeys commands 2. Hypothalamus a. regulates body temperature b. regulates response to sympathetic and parasympathetic nervous system c. produces hormones secreted by pituitary gland and hypothalamus 3. Pons a. regulates breathing 4. CT Scan a. assess for allergy to contrast, shellfish, iodine if dye is used b. provide adequate fluids to flush dye if used 5. MRI a. remove all metal objects from patients b. determine if client has a pacemaker - cannot complete MRI with pacemaker 6. Cerebral Angiography a. assess for allergies to dye b. maintain flat bed rest or at the position the physician orders c. assess insertion site for swelling, hematoma, and bleeding 7. Level of consciousness is the most essential indicator of neurological status 8. Pupil Assessment a. Pupils equal and react to light b. Pupil reacts slowly to light c. Dilated pupil (compressed cranial nerve III) d. Bilateral pupilary dilation, fixed (ominous) e. Bilateral pinpoint (pons damage) 9. Client position a. Decorticate i. flexes both arms on chest (toward CORd) ii. cortex damage b. Decerebrate i. extends arms and/or legs ii. brainstem lesion c. Flaccid i. no motor response to stimuli 10. Babinski test a. dorsiflexion of the big toe indicating neurologic damage 9 b. 11. Hyperthermia can increase cerebral O2 demands and lead to hypoxia a. initiate seizure precautions 12. Halo Sign a. CSF will separate from blood when placed on a white sterile background 13. Do not suction or blow nose with traumatic head injury 14. Diabetes insipidus results from inadequate secretion of ADH and can be manifested as copious amounts of urine output. This reflects damage to the pituitary gland. 15. Immobilize clients when spinal injury is suspected 16. Clean pin sites on halo traction devices daily a. Do not shower b. keep pin sites clean, assess skin, report any redness or swelling 17. Turn spinal patients using the log rolling technique 18. Trigeminal Neuralgia a. damage to fifth cranial nerve b. severe pain to cheeks, lips, gums c. extreme temperatures may d. client should avoid hot or cold foods and fluids 19. Bell's Palsy a. sudden weakness in the muscles on one half of face b. usually resolves within 6 months without treatment c. steroids and antivirals may be provided d. protect eyes from dryness e. chew food on unaffected side 20. Guillain-Barre Syndrome a. monitor respiratory status closely 21. West Nile Virus a. symptoms develop 3-14 days after being bitten by infected mosquito b. fever, headache, tremors, seizures, coma, vision loss c. DEET bug spray should be worn 22. Meningitis a. inflammation of the brain and spinal cord membranes due to infection by virus, bacteria, or fungus, protozoa 10 b. CSF is analyzed to determine diagnosis i. cloudy, ↑WBC, ↓Glucose c. Nuchal rigidity d. photophobia e. lethargy f. altered level of consciousness g. positive Kernig and Burdzinski's sign h. client should be placed in isolation i. administer analgesics and antibiotics j. initiate seizure precautions k. Assess for ↑ICP l. Transmission usually occurs in areas of population density and crowded living spaces