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Altered Cerebral Function and Increased intracranial pressure (ICP) Ashley Valentino MSN, BSN, RN updated Spring 2013. From the notes of Charlene Morris MSN, RN John Nation MSN, RN & Marnie Quick MSN, RN, CNRN. Head Injury.
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Altered Cerebral Function and Increased intracranial pressure (ICP)Ashley Valentino MSN, BSN, RNupdated Spring 2013 From the notes of Charlene Morris MSN, RN John Nation MSN, RN & Marnie Quick MSN, RN, CNRN
Head Injury • Head injury – a broad classification that includes any injury or trauma to _____, ______, or _______. • TBI is a serious form of head injury • 5.3 million live with disabilities resulting from TBI • MVC, falls most common cause • Other causes? • Males twice likely to sustain TBI than females • Head trauma= high potential for poor outcome** Deaths from trauma occur at what points? **Factors that predict poor outcome = ICP levels > than 20 mmHg, presence of intracranial hematoma, abnormal motor responses, GCS on arrival**
Glasgow Coma Scale 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.
Head Injury: TBI • GCS on arrival strong predictor of survival!! • GCS below ____ indicates only 30%-70% chance of survival • Majority of deaths occur immediately after injury - massive hemorrhage - shock ** Monitor neurological status; prompt surgical intervention critical in prevention of death**
Head Injury: Scalp Lacerations • External head trauma • Associated with profuse bleeding • Major complications: • Bleeding • Infection
Head Injury: Skull Fractures • Frequently occur with head trauma • Major complications = intracranial infections, hematoma, brain tissue damage • Characteristics: • linear vs. depressed • simple, comminuted, compound • open vs. closed Severity of skull fracture depends on? • TX – possible craniotomy if loose bone fragments • craniectomy if large amounts of bone destroyed
Head Injuries: Manifestations • Depends on location of fracture (Box 57-7) • Symptoms can evolve over course of several hours - Battle’s sign- what is this? - Rhinorrhea – patient teaching? - Otorrhea • If these occur, raise HOB & notify physician immediately!! ** Risk of _________ is high with a CSF leak ** - what will be administered? - Dextrostix, Tes-tape, halo - NG tube??
Head Trauma: Concussion • Minor diffuse injury • GCS 13-15 • change in LOC • may or may not lose total conciousness • Postconcussion syndrome - 2 wks – 2 months after injury - What s/s will you see? - What will we teach?
Diffuse Axonal Injury (DAI) • Results after mild, moderate, or severe TBI • Damage to cerebral hemispheres, basal ganglia, thalamus, and brainstem • axon swelling and disconnection • 12-24 hours to develop • Symptoms: - decreased LOC - increased ICP, global cerebral edema - what else will you see? *90% patients with DAI remain in vegetative state*
Focal Injury: Laceration • actual tearing of brain tissue • Can occur with depressed or open fractures with penetrating injuries • ** Tissue damage severe ** • surgical intervention impossible • Medical management – like what? • Intracerebral hemorrhage associated with cerebral laceration – poor prognosis! - Leads to increased ICP, expansion of hematoma
Focal Injury: Contusion • bruising of brain tissue; localized • minor to severe- GCS scale? • most associated with closed head injury • may contain areas of - hemorrhage, infarction, necrosis, and edema • occurs at fracture site • seizures common complication • Coup- countercoup injury (often noted) • brain moves inside skull • related to high impact injury • multiple contused areas
Focal Injury: Contusion • Prognosis depends on what? • May continue to rebleed • appear to “blossom” on CT scan - * worse neurological outcome ** • seizures common complication • anticoagulant use associated with ________, __________, and ___________. What should we assess for?
Focal Injury: Epidural Hematoma • results from bleeding between the _____ and inner surface of the skull • ** Neurological emergency!! ** • rapid surgical intervention • what S/S will you see? • associated with linear fracture • crosses major artery in dura • causes tear • can be venous or arterial in origin • Venous tear = develop slowly • arterial tear = rapidly developing, high pressure - often includes meningeal artery
Focal Injury: Subdural Hematoma • occurs from bleeding between the ______ and the _______ _____ of the ________. • usually results from injury to brain tissue and blood vessels • more common in older adults – why? • can be confused with dementia • usually venous in origin – develops? • sagittal sinus = source of most subdural hematomas • can be acute, subacute, and chronic
Focal Injury: Subdural Hematoma • Acute subdural hematoma • 24 – 48 hours after trauma • immediate deterioration – what will we see? • treatment? • Subacute subdural hematoma • 48 hr – 2 wk after trauma • alteration in mental status as hematoma develops • treatment? • Chronic subdural hematoma • > 20 days after injury • progressive alteration in LOC • TX = evacuation, membranectomy
Focal Injury: Inracerebral Hematoma • occurs from bleeding within brain tissue • usually in frontal and temporal lobes – why? • occurs in 16% of head injuries • the _______ and ______ of hematoma determines patients outcome
Diagnostic Tests • ______ is best diagnostic tool to evaluate for head trauma • Other studies: • MRI • PET • Transcranial Doppler – assess what? • Cervical Spine Xray
Treatments • ** Prevent secondary injury = manage elevated ICP; treat cerebral edema ** • timely diagnosis, surgery if necessary! • ** significant neurological impairment = surgical evacuation! ** • Burr holes – used in extreme emergency • followed by craniotomy • drain placed – to prevent what? • If extreme swelling expected = hemicraniectomy – why?
Planning: Overall Goals • maintain adequate cerebral oxygenation & perfusion • remain normothermic • achieve pain control, reduce anxiety • free of infection • attain maximal motor, cognitive, and sensory function
Nursing Interventions • Health promotion – like what? • ** Monitor for changes in neurological status ** • maintain cerebral perfusion and oxygenation • hemodynamic monitoring • be aware of coexisting injuries or conditions • Frequent Neuro checks • calm approach, reduce anxiety • maintain temp of 36 to 37 degrees C – cooling blanket? • sedation as necessary – prevent what? • administer antiemetics for nausea/vomiting – why?
Nursing Interventions • Provide patient/family support – spiritual care? • surgery consent • provide frequent status updates, open visitation • Home care • prevention of seizures • drug of choice? • assess nutritional status • speech therapy, OT, PT • assistance with financial aid, child care, social work • no driving, no drinking, no use of firearms • assist with role change (spouse to caregiver)
Brain Tumors • Can occur in brain or spinal cord • rarely metastasize outside CNS • contained by meninges • White males have highest incidence of malignant brain tumors • Primary vs. secondary • Secondary most common type • primary = arising from tissues within the brain • gliomas (glioblastoma, astrocytoma) • secondary = resulting from metastasis
Brain Tumors: Manifestations • Depend on _______ and ______ of tumor. • Headaches (common) • worse at night, may awake from sleep • dull, constant; throbbing • Seizures • common in gliomas • Nausea, vomiting – caused by what? • memory problems, personality changes • muscle weakness, sensory loss, aphasia • Hydrocephalus – leads to what? • **brain tumor left untreated = increased ICP, death**
Brain Tumors: Diagnostic Studies • Extensive history; comprehensive Neuro exam • New onset of seizures? • MRI, PET -detection of what? • CT = location of lesion • EEG • Why not lumbar puncture?? • Angiography – looks at what? • Computer guided stereotacitc biopsy – preliminary
Brain Tumors: Treatment • Goals: • identify tumor type, location • remove or decrease tumor mass • prevent/manage ICP • Surgical therapy • surgical removal = preferred treatment • partial vs. complete removal • reduces tumor mass, reducing ICP • Ventricular Shunt – risks? • tx for hydrocephalus; gradually put patient in upright position • catheter placed in lateral ventricle; tunneled through skin • drains CSF – drains into where?
Brain Tumors: Treatment • Radiation Therapy • follow-up measure after surgery • stereotactic radiosurgery – radiation precisely directed at a location in brain • radiation seeds- may be implanted into brain • complications?? • tx with Decardon, Solu-Medrol - how do these work? • Chemotherapy • nitrosoureas • Gliadel wafer – implanted at time of surgery • Ommaya reservoir • Temodar – 1st oral chemotherapeutic agent
Brain Tumors: Nursing Intervention • Goals: • maintain normal ICP • maximize neurological functioning • achieve pain control • patient/family aware of prognosis, long term implications • Provide support – end of life, palliative care? • Protect patient from self harm – how? • Prevent seizures/ seizure precautions • Encourage self care; mobility with supervision • Establish communication system • Assess nutritional status – dietary consult? TF?
Cranial Surgery: Types • Craniotomy • removal of bone flap; opening into dura to remove lesion • can be used to drain blood; relieve ICP • may have drain • after surgery, bone flap wired or sutured • Stereotactic Radiosurgery • often computer guided • precise location of specific area • used for biopsy, removal of small brain tumors, drainage of hematomas • * What is the advantage here? *
Cranial Surgery: Nursing Interventions • Goals: • return to normal consciousness • pain control, nausea • maximize neuromuscular functioning • rehabilitated to maximum ability • Acute Intervention • pre-operative teaching; provide support • post-operative teaching- what to expect ** Primary nursing goal post-op? ** • frequent neuro assessments x first 48 hours • monitor fluid & electrolytes – which one? • control pain and nausea – Phenergan?
Cranial Surgery: Nursing Interventions • Acute Intervention Continued • keep HOB 30-45 degrees – expect when? • assess dressing: drainage, color, odor? • * Notify surgeon immediately for increase in bleeding or if clear drainage is present!!! ** • If bone flap removed, do not place patient on operative side! • skin, mouth care • scalp care, assess for infection of incision • antiseptic soap or hospital policy
Cranial Surgery: Discharge • Encourage independence, maximize functioning • rehabilitation referral – case management • ST, OT, PT – will they need these at discharge? • Assess nutritional status • Patient/family support
Intro to Intracranial Pressure: • Skull is a closed box; 3 essential volume components • brain tissue – 78% • blood – 12% • cerebrospinal fluid (CSF) – 10% • What is Intracranial Pressure (ICP) ? • hydrostatic force measured in brain CSF compartment • a balance among 3 essential components maintains ICP
What factors influence ICP? • Changes in: • arterial pressure • venous pressure • intrabdominal or intrathoracic pressure • posture • temperature • blood gases – specifically which one? • * An increase or decrease in ICP depends on the ability of the brain to accommodate to changes *
Monro-Kellie doctrine: • Alexander Monro & George Kellie (18th century) • * Only applies to closed skull* • “ The three components must remain relatively constant within the closed skull structure” • “ If the volume of any 3 components increases, volume from another component will decrease; the total intracranial volume will not change” • compensatory adaptations? • What if compensatory adaptations fail?
How is ICP measured? • Measured in ventricles, subarachnoid space, subdural space, or brain tissue – using what? • ** Normal ICP = 5 – 15 mmHg ** • A sustained pressure above the upper limit is considered abnormal
Cerebral Blood Flow: • Cerebral blood flow (CBF) = amount of blood in ml passing through 100 g of brain tissue in __________ • universal CBF = 50ml/min per 100g brain tissue • ** Difference in blood flow between white matter and gray matter of the brain ** • gray matter faster blood flow (75ml/min) • white matter slower blood flow (25ml/min) • Maintenance CBF critical – what does the brain need?
How is CBF Regulated? • Brain regulates own CBF in response to metabolic needs • ____________ is the automatic adjustment in size of cerebral blood vessels to maintain constant blood flow • What is the purpose? • **Only effective in a person with MAP of 50mmHG – 150 mmHg ** • < 50 mmHg = CBF decreases; cerebral ischemia • What symptoms would you see? • > 150 mmHg = vessels maximally constricted
Regulating CBF • ___________ is the pressure needed to ensure adequate blood flow to brain • CPP = MAP- ICP • does not consider effect of cerebral vascular resistance • CPP = Flow x Resistance • increase in cerebral vascular resistance= impaired blood flow to brain • Normal CPP 60 – 100 mmHg
Transcranial Doppler • Used to measure what?
Regulating CBF • AS CPP decreases, autoregulation fails • leads to decrease in CBF • ** CPP < than 50 mmHg = ischemia, neuronal death ** • CPP < 30 mmHg = not compatible with life • ** Critical to maintain MAP when ICP elevated** • Which patient’s may need a higher CPP?
What affects CBF? • Cardiac, respiratory arrest • diabetic coma • systemic hemorrhage * When autoregulation lost, CBF influenced by BP, hypoxia, catecholamines *
What affects CBF? • C02, 02 hydrogen ions affect vessel tone • PaCO2 vasoactive agent - Increase in PaCO2= dilation - Decrease in PaCO2 = constriction • decrease in 02 tension = accumulation of lactic acid, increasing acidic environment • increased dilation occurs; autoregulation may be lost
Changes in Pressure • _________ is the expandability of the brain • Compliance = Volume/Resistance • Low compliance – small change in volume causes increase in pressure • Intracranial Pressure-volume curve • Stage 1 = total compensation • Stage 2 = at risk for increase in ICP • Stage 3 = great increase in ICP - Stage 4 = ICP rises to lethal levels