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Central Nervous System Disorders. Rita Carey- N ita. Meningitis . Meningitis Inflammation of the brain & spinal cord due to viral or bacterial infection Bacterial is more serious & spread by direct contact with discharge from infected person

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meningitis
Meningitis
  • Meningitis
    • Inflammation of the brain & spinal cord due to viral or bacterial infection
    • Bacterial is more serious & spread by direct contact with discharge from infected person
    • Viral is more common & rarely serious AKA aseptic meningitis
meningitis1
Meningitis
  • Pathophysiology
    • Most common bacteria include:
      • Neisseria meningitis
      • Streptococcus pneumoniae
      • Haemophilus influenza type B
    • The infection generally begins in another area such as the respiratory tract then travels to the blood & invades the CNS
    • The meninges become inflamed & there is an increase in intracranial pressure
    • Vessel occlusion & necrosis of brain tissue may occur
    • Cranial nerve function may be impaired temporarily or permanently
meningitis2
Meningitis
  • Prevention
    • Vaccination is available to prevent Hib & S. pneumoniae
    • Early diagnosis & prompt treatment of individuals in contact with diagnosed patient is imperative
meningitis3
Meningitis

Signs & Symptoms

  • Most common symptom: Headache
    • Caused by irritation of the dura mater & tension on blood vessels
  • High fever
  • Nuchal rigidity
  • Photophobia
  • Petechiae on skin & mucous membranes with meningococcal meningitis
  • Positive Kernig’s sign
  • Positive Brudzinski’s sign
  • Nausea & vomiting
  • Encephalopathy
  • Late signs:
    • Seizure
    • Lethargy
meningitis4
Meningitis
  • Complications
    • Need quick & effective treatment for positive resolution
    • Some patients have permanent neurological deficits while others recover completely
    • Some long term impairments include:
      • Blindness
      • Deafness
      • Seizures
      • Memory impairment
      • Learning disability
meningitis5
Meningitis
  • Diagnostic tests
    • Lumbar puncture
      • Viral:
        • clear CSF
        • normal glucose
        • normal to sl.  protein
        • no bacteria
        •  WBC count
      • Bacterial:
        • Turbid—cloudy
        • Massive WBC count
        • Identified by gram stain & culture
        •  glucose
        •  protein
meningitis6
Meningitis
  • Diagnostic Tests
    • Lumbar puncture with CSF analysis
    • CBC
    • C & S nose & throat
  • Done to determine complications
    • MRI
    • CT Scan
meningitis7
Meningitis
  • Therapeutic Interventions
    • Fatal if not treated promptly
    • Antibiotic therapy for bacterial meningitis
    • Symptoms management for both viral & bacterial
      • Decrease fever slowing to avoid shivering response
        • Antipyretics
        • Cooling blanket
      • Quiet dark environment to lessen stimulation
      • Analgesics for headache & neck pain
      • Corticosteroids & anti-inflammatory agents to decrease swelling
      • Anti-emetic to control nausea & vomiting
      • Safety in relation to seizures & agitation
      • Educate the family about symptoms & treatment
    • Isolation is required for patients with meningococcal meningitis to transmission to others
encephalitis
Encephalitis
  • Pathophysiology
    • Inflammation of the brain tissue
    • Neurological effect is dependent upon the area of nerve cell damage, necrosis or edema
    • Hemorrhage may occur with some types
    • Increased intracranial pressure with possible brain herniation may also occur
encephalitis1
Encephalitis
  • Etiology
    • Viruses are the most common cause
      • West Nile—mononucleosis—mumps
    • Herpes Simplex Virus Type 1 is most common noninsectborne viral cause
      • unsure but virus may become active due to stress—fever—infectious disease
    • Parasites
    • Toxic substances
    • Bacteria
    • Vaccines
    • Fungi
encephalitis2
Encephalitis
  • Signs & Symptoms
    • Headache & fever are the most common symptoms
    • Nausea
    • Vomiting
    • General malaise
    • Nuchal rigidity
    • Confusion
    • Decrease LOC
    • Seizure
    • Sensitivity to light
    • Ataxia
    • Abnormal sleep pattern
    • Tremors
    • Hemiparesis
  • Symptoms develop over several days
encephalitis3
Encephalitis
  • Herpes encephalitis:
    • Edema & necrosis in the temporal lobe
      • at times associated with hemorrhage
    • Causes increase in intracranial pressure
    • Can lead to herniation of the brain
  • If patient is comatose before treatment the mortality rate is 70%-80%
  • Death occurs in first 72 hours when edema is worst
encephalitis4
Encephalitis
  • Complications
    • Cognitive deficits
    • Personality changes
    • Seizures
    • Blindness
  • Diagnostic Testing
    • CT Scan
    • MRI
    • Lumbar Puncture with CSF analysis
      • CSF reveals  WBC count & protein & normal glucose & yellow color due to breakdown of RBC’s
    • EEG
encephalitis5
Encephalitis
  • Therapeutic Interventions
    • No treatment for insect borne encephalitis
    • Anticonvulsants
    • Antipyretics
    • Analgesics
    • Corticosteroids
    • Sedatives
    • Antiviral- acyclovior for herpes simplex
increased intracranial pressure
Increased Intracranial Pressure
  • Intracranial Pressure
    • The pressure exerted within the cranial cavity by the brain, blood & CSF
      • Any increase in one of the components without decrease in another results in increase ICP
    • Normal intracranial pressure is 0-15 mmHg
    • Fluctuates normally with changes in position—arterial pulsations—increases in intrathoracic pressure
  • Causes of increased intracranial pressure:
    • Brain injury—intracranial hemorrhage—brain tumor
  • Outcome & deficit is dependent on the degree of elevation & speed of increase in ICP
  • Early detection & intervention is imperative
increased intracranial pressure1
Increased Intracranial Pressure
  • The body will compensate:
    • CSF will be shunted to the subarachnoid space in the spinal column
    • The cerebral vessels will constrict decreasing the amount of blood in the brain
  • Only temporary & not effective for sudden & severe increases in ICP
increased intracranial pressure2
Increased Intracranial Pressure
  • Signs & Symptoms
    • Initial symptoms are
      • Restlessness—irritability—decreased level of consciousness
    • Hyperventilation causing vasoconstriction
    • Increasing temperature
    • Vomiting
    • Headache
    • Dilated pupil on affected side with progression of bilateral fixed & dilated pupils
    • Hemiparesis or hemiplegia
    • Decorticate then decerebrate posturing
    • Late signs include Cushing Triad:
      • Bradypnea—bradycardia—arterial hypertension creating widened pulse pressure
      • Interventions may not be successful at this point
increased intracranial pressure3
Increased Intracranial Pressure
  • Nursing interventions:
    • HOB 30 degrees
    • Avoid flexion of neck & hip
    • Administer antiemetics
    • Administer antitussives
    • Administer stool softeners
    • Minimal suctioning
    • Decrease noise & unnecessary stimuli
    • Provide rest periods
icp monitoring
ICP Monitoring
  • ICP Monitoring:
    • Detects early changes before symptomatic
    • Placement of catheter into ventricles of brain, parenchyma or subdural or subarachnoid space
    • Done at bedside or surgically
    • Scalp anesthetized & burr hole drilled into skull
  • External ventricle drainage
    • Catheter placed in the lateral ventricles
    • Allows for pressure monitoring
    • Drains CSF to reduce increase in ICP
    • Disadvantages:
      • Difficult insertion of catheter
      • Clotting of catheter by blood in CSF
icp monitoring1
ICP Monitoring
  • Subarachnoid Bolt
    • Tightly screwed bolt into burr hole after the dura has been punctured
    • Ease in placement
    • Disadvantages
      • Occlusion of sensor portion of bolt by brain tissue
      • Inability to drain CSF
  • Intraparenchymal monitor
    • Monitor is placed directly into brain tissue
    • Most accurate reflection of ICP
    • Disadvantages
      • Does not drain CSF
      • May become occluded by brain tissue
icp monitoring2
ICP Monitoring
  • Patients are generally in ICU
  • They are mechanically ventilated, pharmacologically paralyzed & sedated
  • Provided family with support & education
nursing implications for patients with infectious inflammatory neurological disorders
Nursing Implications for patients with infectious & inflammatory neurological disorders
  • Obtain history from patient or significant other
    • Ascertain any risk or events that could contribute
  • Thorough physical assessment with extensive neurological focus
    • LOC—pupillary reaction—orientation—muscle strength
  • Assess for signs & symptoms of  ICP
  • Monitor vitals
  • Assess pain level on scale 0-10 & provide analgesic as necessary
  • Keep HOB  30 degrees
  • Provide quiet dim environment
  • Decrease exposure to stimuli
  • Position for comfort, prevention of pressure ulcer & contractures
  • Monitor for safety
    • Seizure precaution
    • Decreased level of consciousness
    • Alteration in mental status
  • Educate & involve family in care
headaches
Headaches
  • Headaches are a common symptom of neurological disorders
  • Most are transient
  • Recurrent, persistent & increasing severity warrant further neurological evaluation
  • Types
    • Tension or Muscle Contraction
    • Migranes
    • Cluster
tension or muscle contraction headache
Tension or Muscle Contraction Headache
  • Tension or Muscle Contraction Headache
    • Persistent contraction of scalp, facial, cervical & upper thoracic muscles are cause
    • Cycle of muscle tension & muscle tenderness occurs
    • May or may not be accompanied by vasodilation of cerebral arteries
    • Associated with
      • PMS—anxiety—stress—depression
    • Symptoms develop gradually with radiation of pain from crown of head to base of skull
    • Variation of location & intensity
    • Pressure—aching—tight are words often used to describe headache
    • Treatment includes
      • Relaxation techniques—massage—nonnarcotic analgesics—counseling
migraine headaches
Migraine Headaches
  • Migraine Headaches
    • Caused by the cerebral vasoconstriction followed by cerebral vasodilation
    • May be triggered by
      • Trigeminal nerve stimulating release of substance P, a pain transmitter, into the vessels
      • Release of serotonin—norepinephrine—epinephrine
    • Aura may or may not occur
    • Hereditary tendency
    • Throbbing—viselike—pounding are terms used to describe
    • Noise & light tend to exacerbate
    • Triggers include
      • Noise—alcohol—bright light—specific food
migraine headaches1
Migraine Headaches
  • Two types:
    • Classic & common
  • Classic Migraine
    • Has prodromal phase
      • Visual disturbance—difficulty speaking—numbness & tingling
    • Headache follows accompanied by nausea & sometimes vomiting
    • Last hours to days
  • Common Headache
    • Does not have prodromal phase
    • Immediate onset of throbbing headache
migraine headaches2
Migraine Headaches
  • Treatment
    • Prophylactic or Acute
  • Prophylactic
    • Dietary restriction of precipitating food & beverages
    • Nifedipine (calcium channel blocker) & propranolol (beta-andrenergic) to control blood pressure & prevent vascular changes
    • Amitriptyline (tricyclic antidepressant)
  • Acute
    • Ergot (Cafergot) a vasoconstrictor is effective if taken within 30-60 minutes of onset
    • Imitrex & Zomig work at serotonin receptor sites & have vasoconstricting effect
cluster headaches
Cluster Headaches
  • Cluster headaches causes
    • Vascular disturbances—stress—anxiety—emotional distress
  • Occur in clusters that span from several days to weeks
  • Episodes may not occur for months to years
  • Alcohol worsens episodes
  • Throbbing—excruciating are terms used to describe
  • Unilateral affecting the nose—eye—forehead
  • Affected eye is bloodshot & teary
cluster headaches1
Cluster Headaches
  • Treatment is difficult & includes
    • Quiet dark environment
    • Cold compress
    • NSAIDS
    • Tricyclic antidepressant
  • Diagnosis
    • Based on patient’s history & symptoms
    • MRI—CT scan—EEG—arteriogram—cranial nerve testing—lumbar puncture to test CSF
      • may be done to rule out other causes
assessment of headache
Assessment of Headache
  • Assessment should include:
    • Rate pain on scale of 0-10
    • Describe the quality of pain?
    • Where is pain?
    • Does pain start in one place? Does it radiate?
    • What aggravate & alleviates pain?
    • When is it experienced?
      • PMS—emotional stress—tension
    • Any associated symptoms
      • Nausea—vomiting—bloodshot eyes
nursing interventions
Nursing Interventions
  • Quiet dark environment
  • Relaxation techniques & stress reduction
  • Identify precipitating factors through recording
    • Time of onset
    • Aggravating factors
    • Food eaten
    • Associated symptoms
  • Reduce or eliminate
  • Provide patient education about medication
seizure disorder
Seizure Disorder
  • Seizure
    • Sudden, abnormal & excessive electrical discharges from brain that can change motor or autonomic function, consciousness or sensation
    • Can occur at any time in life
    • Can occur at any time
    • May be a symptom of epilepsy or some other neurological disorder such as brain tumor or meningitis
  • Epilepsy
    • Chronic neurological disorder characterized by recurrent seizure activity
seizure disorder1
Seizure Disorder
  • Pathophysiology
    • Neuron membrane is instable
    • Instability allows for abnormal electrical discharge
    • Classified as:
      • Partial
      • Generalized
  • Partial
      • Begin on one side of cerebral cortex & sometimes spreads to the other hemisphere becoming generalized
  • Generalized involves both cerebral hemispheres
seizures
Seizures
  • Etiology
    • May be acquired or idiopathic
    • Causes include:
      • Brain injury—anoxia
    • Onset before 20 is idiopathic
    • New onset after 20 is usually caused by underlying neurological disorder
  • Signs & Symptoms
    • Depends on area of brain where seizure begins
    • Some people experience aura prior
    • If aura experienced it serves as warning of onset
partial seizure
Partial Seizure
  • Classic symptoms:
    • Repetitive—purposeful behaviors
    • Called automatisms
    • Dreamlike state while automatisms occurring
      • Lip smacking—picking at clothes—chewing—spitting—fondling self
    • Pt unaware of behaviors
  • Simple partial seizure if no lose of consciousness & less than 1 minute long
  • Complex seizure or psychomotor seizure if consciousness lost & lasts 2-15 minutes
partial seizure1
Partial Seizure
  • Origin
    • Parietal lobe—paresthesias on opposite side of body from seizure focus
    • Occipital lobe—visual disturbances
    • Motor cortex—involuntary movement in arm or hand to leg & face on opposite side of seizure focus
generalized seizure
Generalized Seizure
  • Generalized
    • Affects entire brain
    • Two types
      • Absence seizures
      • Tonic-clonic seizures
  • Absence seizures
    • AKA petit mal seizure
    • Occur primarily in children
    • Period of staring that last several seconds
tonic clonic seizure
Tonic-clonic seizure
  • Tonic-clonic
    • AKA grand mal seizures or convulsions
    • Aura & loss of consciousness may occur
    • Tonic phase:
      • 30-60 seconds
        • Rigidity—pupils fixed & dilated—hands & jaw clenched—period of apnea
    • Clonic phase:
      • Contraction & relaxation of all muscles in jerky rhythmic pattern
      • Extremities move forcefully causing possible injury if environment not clear
      • Incontinence
      • Biting of lip or tongue can occur
postictal period
Postictal Period
  • Postictal period:
    • Recovery period after seizure
  • Partial seizure:
    • postictal period last only few minutes
    • Disorientation noted
  • General seizure:
    • Postictal period may last 30 minutes to several hours
    • Deep sleep
    • Followed by headache—confusion—fatigue
  • Patient may realize they had seizure but not remember event
diagnostic tests
Diagnostic Tests
  • EEG
    • Most useful diagnostic test
    • Determines:
      • where in brain seizure start
      • Frequency & duration of seizure
      • Presence of asymptomatic seizures
  • Sleep deprivation & light stimulation may be used to evaluate seizure threshold
therapeutic interventions
Therapeutic Interventions
  • If there is a cause for the seizure then the focus is on treating cause
  • If there is no apparent cause the focus is on controlling the seizure activity
  • Anticonvulsant medications utilized
    • Start pt on one with dose increased until therapeutic with minimal side effects
    • If not controlled another medication is added
    • Renal & hepatic function are monitored
    • Drowsiness is common side effect so educated pt to avoid driving until effect of drug is known
    • Driving is contraindicated until seizures are controlled
    • Must wean off any seizure medication to avoid status epilepticus
surgical management
Surgical Management
  • Surgery may be required if medication is not effective
  • May have area of seizure resected if within nonvital

brain tissue

    • May reduce seizure activity or cure
  • If unable to identify focus area or if the focus is in vital area such as motor cortex or speech center surgery is not an option
emergency seizure care
Emergency Seizure Care
  • Main goal is to prevent injury
  • Seizure precautions:
    • Padded side rails
    • Call bell in reach
    • Assist with ambulation
    • Keep suction & airway at bedside
emergency seizure care1
Emergency Seizure Care
  • Nursing Care During Seizure:
    • Clear environment if seizure occurs & patient on floor
    • Loosen restrictive clothing
    • Turn patient on side to maintain airway & prevent aspiration
    • Do not force anything into airway once the seizure has started
    • Do not restraint patient
    • Monitor vitals if possible
    • Observe & document:
      • Behavior during
      • Which part of body involved
      • Progression of seizure
      • Length of seizure
emergency seizure care2
Emergency Seizure Care
  • After the seizure
    • Monitor vitals
    • Assess breathing
    • Suction if necessary
    • Rescue breathing or CPR if necessary
status epilepticus
Status Epilepticus
  • Status epilepticus
    • Seizure activity lasting at least 30 minutes without return to consciousness
    • Medical emergency requiring prompt intervention to prevent irreversible neurological damage
    • Main cause is abrupt cessation of anticonvulsant medication
emergent medical intervention
Emergent Medical Intervention
  • Need adequate oxygen so may be intubated & mechanically ventilated
  • Intravenous diazepam or lorazepam to stop seizure
    • Need to monitor resp depressive affects of these medications
  • Serum drug levels of anticonvulsants are reviewed & medication is adjusted to therapeutic level
  • If seizures continue:
    • Barbiturate coma induced with intravenous penobarbital
  • Last resort
    • Anesthesia or pharmacological paralysis requiring intubation, mechanical ventilation & management in ICU
emergent medical intervention1
Emergent Medical Intervention
  • Continuous EEG monitoring is done to determine seizure activity has stopped
  • A neuromuscular blockade will have to visible signs of seizure but continue to seize
psychosocial effects
Psychosocial Effects
  • Most patient’s with seizure control live normal productive lives
  • Patient may be embarrassed by seizure activity
    • Incontinence—involuntary movement—sounds made
  • Affects financial aspects
    • Denied insurance so need to pay out of pocket
    • Job opportunities may be limited due to job safety or transportation issue
  • Interpersonal relationships may suffer
    • Fear of possible seizure activity in front of friend or partner
    • Lower self esteem
nursing implementation
Nursing Implementation
  • Thorough neurological assessment
  • History of seizure
    • Type
    • Aura?
    • Patient knowledge of disease
  • Treatment
    • Importance of compliance with medication
    • Action, dose, schedule, side effects & of medication
  • Review drug levels to determine therapeutic level
traumatic brain injury
Traumatic Brain Injury
  • Pathophysiology
    • Trauma as a result of:
      • Hemorrhage
      • Contusion
      • Laceration of brain
      • Cells damage
    • Secondary effects include:
      • Cerebral edema
      • Hyperemia
      • Hydrocephalus
    • Effects range from none detected to vegetative state
traumatic brain injury1
Traumatic Brain Injury
  • Etiology
    • MVA constitutes large percentage
    • Falls
    • Sports injuries
    • Violence
  • Closed head injury or nonpenetrating injury
    • Rapid back & forth movement of brain
    • Causing bruising & tearing of brain tissue and vessels
    • Skull remains intact
  • Open head injury or penetrating injury
    • Break in the skull
  • Acceleration injury
    • Moving object strikes head
  • Deceleration injury
    • Head in motion hits stationary object
traumatic brain injury2
Traumatic Brain Injury
  • Acceleration-deceleration injury
    • Stationary head is hit by moving object & head strikes stationary surface
  • Rotational injury
    • Potential to cause shearing damage to brain—laceration—contusion
    • Caused by direct blow to head or side impact in MVA
    • Twisting of brain stem occurs affecting reticular activating system
    • Loss of consciousness occurs
    • Bruising & tearing of brain tissue at area of contact
types of brain injury
Types of Brain Injury
  • Concussion
    • Mild brain injury
    • If loss of consciousness, no more than 5 minutes
    • Headache—dizziness—nausea—vomiting
    • Amnesia of events before & after injury may occur
    • CT or MRI & exam show no evidence of injury to skull or dura
types of brain injury1
Types of Brain Injury
  • Contusion
    • Bruising of brain tissue
    • May include hemorrhage
    • May be multiple contusions depending on cause
    • Diffuse axonal injury is the result of severe contusions
    • Symptoms are dependent on area affected
      • Brainstem contusion affects LOC (transient or permanent)—respirations—pupils—eye movement—motor response to stimuli
      • Hypothalamic injury may cause rapid heart rate, resp rate, fever & diaphoresis
types of brain injury2
Types of Brain Injury
  • Subdural Hematoma
    • Acute or chronic
  • Acute subdural hematoma
    • Symptoms present in first 24 hours
    • Venous bleed
    • Accumulates in the dura & subarachnoid membranes
    • 24% of patients with TBI develop
    • Symptoms include:
      • Altered LOC—hemiplegia—extraocular movement—extremity weakness—dilated pupils—increase in ICP resulting in decrease in LOC
types of brain injury3
Types of Brain Injury
  • Chronic subdural hematoma
    • Affects elderly & alcoholics
    • Atrophy in brain tissue stretches veins between dura & brain
    • Minor fall or blow to head causes a venous rupture & bleed
    • Develops over weeks to months
    • Symptoms include
      • Forgetful—irritable—lethargic—headache
    • With increase of hematoma
      • Hemiparesis—pupillary changes
    • May delay treatment
types of brain injury4
Types of Brain Injury
  • Epidural Hematoma
    • 10% patient with severe brain injury develop
    • Collection of blood between the dura mater & skull
    • Arterial bleed
    • Hematoma develops rapidly & is large
    • Progressive course of symptoms
      • Loss of consciousness directly after injury
      • Regains consciousness & is coherent for brief period
      • Dilated pupil with fixed extraocular muscles on side of hematoma & less response
      • Patient becomes unresponsive
      • Seizure
      • Hemiparesis
    • Deterioration occurs rapidly
    • Need airway management
    • Need to decrease increased ICP
diagnostic tests1
Diagnostic Tests
  • CT scan
    • Fast & accessible
    • Easy to identify skull fracture than on MRI
  • MRI
    • Utilized later to determine the extent of brain tissue injury
  • Neuropsychological testing
    • Determines cognitive function
    • Issues with memory—judgment—learning—comprehension
    • Compensation strategies are suggested based on results
therapeutic interventions1
Therapeutic Interventions
  • Medical Management
    • Insert ICP monitor to measure ICP
    • Osmotic diuretic such as IV mannitol is administered if drainage of CSF is ineffective in reducing ICP then
    • Mechanical ventilation
      • Hyperventilation will help decrease ICP because of vasoconstrictive effect
        • Use with caution & only if other treatments ineffective because may cause ischemia in first 24 hours
    • High-dose barbiturate to induce therapeutic coma which will reduce the metabolic needs of brain during acute phase
    • Vasopressor may be required to maintain BP
    • Maintain normal body temperature as possible
    • Treated in ICU
complications with tbi
Complications with TBI
  • Brain Herniation
    • Uncontrolled edema as result of increased ICP causes displacement of brain tissue
    • Displacement affects function of herniated brain tissue
    • Places pressure on vital areas such as brain stem
    • Usually results brain death
      • May be candidate from organ donate
  • Diabetes Insipidus
    • Edema or direct injury affects posterior pituitary or hypothalamus
    • Inadequate release of ADH results in polyuria
    • Patient may experience polydipsia
    • Treat with fluid replacement & vasopressin to maintain fluid & electrolyte balance
complications of tbi
Complications of TBI
  • Acute Hydrocephalus
    • Cerebral edema can interfere with CSF circulation
    • Requires external ventricular drain followed by ventriculoperitoneal shunt as needed
  • Labile Vital Signs
    • Pressure or injury to brain stem affects the cardiac center—respiratory center—vasomotor center causing fluctuations in blood pressure, heart rate and respirations
    • Focus of treatment is control of ICP
complications of tbi1
Complications of TBI
  • Post Traumatic Syndrome
    • Complaints of headache—fatigue—difficulty concentrating—memory impairment—depression
    • May interfere with work, school & interpersonal relationships
    • Cognitive impairment with need for rehabilitation
    • Symptoms may take 3-12 months to resolve
  • Motor & Speech impairment may occur
    • Need intensive rehabilitative therapy to optimize recovery
complications of tbi2
Complications of TBI
  • Cognitive & Personality Changes
    • Changes in personality & cognition are difficult long term complication
    • May suffer short-term memory impairment
      • Affects learning new information & function at work or school
    • Impaired judgment puts them at risk for injury to self & others
    • Interferes with social functioning
    • Emotional lability
    • Loss of social inhibitions

**All of these symptoms have major effect on family**

    • May need counseling or support group
    • Patient my need cognitive therapy
care after acute phase of tbi
Care after Acute Phase of TBI
  • Once the patient is stable:
    • Assess neurological status frequently
      • Glasgow coma scale—pupillary response—muscle strength—vital signs
    • Assess for neurological deficits in order to implement therapy & interventions
    • Rehabilitation is necessary with extent depending on the deficits noted
    • Support & educate family as to expectations regarding changes in personality & function
brain tumors
Brain Tumors
  • Brain tumors
    • Neoplastic growths of the brain or meninges
    • Vague symptoms
      • Headache—visual disturbances—hemiparesis—seizures
  • Pathophysiology
    • Either compress or infiltrate brain tissue
    • May be primary site in CNS cells or metastasize from another location
      • If primary site they rarely metastasize but if they do it is to the spine
    • May be benign or malignant
    • Location is important factor
brain tumors1
Brain Tumors
  • Primary tumors
    • 80%-90% are primary
  • Intra-axial
    • arise from glial cells within the cerebrum—cerebellum—brain stem
    • Infiltrate & invade brain tissue
  • Extra-axial
    • Arise from the skull—meninges—pituitary gland—cranial nerves
    • Compressive effect on brain
brain tumors2
Brain Tumors
  • Secondary Brain tumors:
    • 10%-20% are secondary commonly spread via arterial circulation
    • If untreated causes increase in ICP causing death as opposed to primary site
signs symptoms
Signs & Symptoms
  • Signs & Symptoms
    • Directly related to location of tumor & rate of growth
    • Seizures
    • Motor & sensory deficits
    • Headaches
    • Visual disturbances
    • If pituitary involvement
      • Fluid volume changes
      • Abnormal growth
types of brain tumor
Types of Brain Tumor
  • Meningiomas are slow-growing tumors that are large before they present symptoms
  • Glioblastomamultiforme or metastatic tumors abruptly causes symptoms of seizure or hemiparesis
    • Glioblastoma are the most common & most aggressive type of brain tumor
  • Other tumors
    • Oligodendroglioma
    • Astrocytoma
    • Acoustic neuroma
diagnostic tests2
Diagnostic Tests
  • MRI
    • Clearest image
  • CT scan
    • Cost-effective
  • Angiogram
    • If tumor highly vascular or near close proximity to major vessels
  • MRA
    • Less invasive than angiogram
    • Inject contrast medium to visualize
  • Serum hormones
    • If pituitary involvement
therapeutic interventions2
Therapeutic Interventions
  • Surgical removal of whole or as much of tumor as possible
  • Medical treatment aimed at control of symptoms
    • Anticonvulsants for seizure
    • Steroids such as Decadron to decrease cerebral edema or headache
radiation therapy
Radiation therapy
  • External beam radiation
    • 5 days a week for 6 weeks
    • Hyperfractionated schedule would be twice a day for less time
  • Brachytherapy
    • delivers radiation directly to tumor
    • Small catheters implanted into tumor
    • Radioactive particles are inserted not catheters
    • Treatment lasts 3-5 days
    • Confined to room with minimal interaction because of radioactivity
  • Stereotactic radiosurgery
    • Technique that utilizes small amount of radiation directed at tumor from different angles
    • Metal frame is affixed to skull
    • Tumor is visualized within framework on CT or MRI
    • Computer plan is generated to direct radiation
    • Majority of radiation accumulates in tumor
chemotherapy
Chemotherapy
  • Chemotherapy
    • Requires very large doses of chemotherapy to penetrate blood-brain barrier
    • Not tolerated by other body systems
    • Chemotherapeutic substances may be placed in the cavity left to surgical resection
    • Mannitol may be administered to disrupt the blood-brain barrier & then deliver intra-arterial chemotherapy under general anesthesia
    • Gene therapy may also be used to kill malignant cells
complimentary therapies
Complimentary Therapies
  • May be last resort or another effort is other treatment are ineffective
  • Must weigh all options
  • Need to determine
    • If interferes with other treatment
    • Cost?
    • Side effects?
    • Research compiled?
    • Physicians opinion?
acute long term complications
Acute & Long-term Complications
  • Complication & symptoms of brain tumor may be hard to discern
    • Seizures—headaches—memory impairment—cognitive changes—ataxia
  • Created by treatment & symptoms of brain tumor
  • Hemiparesis & aphasia may result post-operative
  • Tumor may continue to grow in spite of treatment causing decline in function
    • Lethargy & unresponsiveness may occur followed by comatose & death
intracranial surgery
Intracranial Surgery
  • Cranial surgery is performed to remove mass lesion
  • Types:
    • Hematomas—tumors—arteriovenous malformations—contused brain tissue
  • May be performed to
    • elevate depressed skull fracture—remove foreign object—debridment—resection of seizure focus
intracranial surgery1
Intracranial Surgery
  • Craniotomy
    • Surgical opening into skull
    • Burr hole made with drill
  • Craniectomy
    • Removal of part of cranium
  • Cranioplasty
    • Repair of bone or use of prosthesis to replace bone following surgery
intracranial tumor surgery
Intracranial Tumor Surgery
  • Intracranial tumor surgery
    • Gross total resection of tumor
    • Called debulking
    • May leave viable tumor cells behind which may proliferate causing reoccurence
    • If entire tumor cannot be removed, surgeon removes as much as possible followed by chemotherapy or radiation
    • At times only a biopsy is obtained due to location, patient’s age, overall health status
      • Done under local or general anesthesia
      • Used to diagnose tumor & guide treatment
    • Usually done under general anesthesia but at times patient is awake & cooperative
preoperative care
Preoperative Care
  • Pre surgical laboratory testing
  • Anesthesia evaluation
  • Thorough neurological assessment for baseline
  • Educate patient & family by physician on disease process & surgery
    • Anxiety—cognitive impairment—education level may effect comprehension
    • Clarify & reinforce information provided
  • Allow patient & family to verbalize concerns
  • Provide honest & accurate information
  • Educate family as to what to expect post-operative
    • Shaved head—swollen face—possible periorbital bruising
postoperative care
Postoperative Care
  • Frequent neurological assessment
    • Q1h for first 24 hours
  • Assess the surgical site
    • Ensure dressing remains dry & intact
    • Drainage that is blood-tinged in center & yellow in a ring surrounding is indicative of CSF leak & must be reported to RN or physician immediately
    • Assess for signs of infection
  • Assess degree of immobility
  • Reposition q2 hours
    • avoiding operative site
    • Correct body alignment imperative
    • May use splints—braces—footboards to maintain alignment
  • ROM exercises
  • Consult PT/OT
  • Report any deterioration immediately
  • CT scan may be ordered in first 24 hours to assess cerebral edema
  • Patient usually requires ICU care