Dysfunction of the Brain Care of Critically Ill Patients with Neurologic Problems, Exams of Health sciences

Download Dysfunction of the Brain Care of Critically Ill Patients with Neurologic Problems and more Exams Health sciences in PDF only on Docsity! 1 Dysfunction Of The Brain Care Of Critically Ill Patients With Neurologic Problems . Subarachnoid hemorrhage Epidural hematoma Strokes Homonymous hemianopsia Transient Ischemic Attack 1. Warning signs that cause transient focal neurologic dysfunction resulting from a brief interruption in cerebral blood flow, possibly resulting from cerebral vasospasm or systemic arterial hypertension TIA: symptoms last a few minutes to 24 hours Can cause damage to the brain tissue Stroke (Brain Attack)-MEDICAL EMERGENCY a) Tx: Treat immediately to prevent neurological deficit & permanent disability b) BRAIN CANNOT STORE GLUCOSE OR OXYGEN c) Stroke occurs with a slow blood flow of 25 mL which causes aerobic metabolism - (normal 60-70mL/100g of brain tissue per minute). Ischemic—interruption in blood flow to the brain. Hemorrhagic—bleeding within or around the brain. Types of Strokes Types of Stroke a) Ischemic stroke b) Thrombotic stroke (CLOT) often preceded by transient ischemic attacks, ➢ causing a focal neurologic dysfunction. c) Embolic stroke a. History of hypertension, heart disease, atrial fibrillation, diabetes, obesity, and hypercoagulopathy are at risk of embolic stroke. d) Hemorrhagic stroke resulting from ruptured aneurysm, arteriovenous malformation Example: Subarachnoid hemorrhage Caused by severe 2 hypertension. 5 a) Sensory changes b) Homonymous hemianopsia c) Unilateral neglect is when a person is not aware of one side of his or her body. Homonymous hemianopsia When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient’s left side. d. Teach the patient that the left visual deficit will resolve. ANS: C During the acute period, the nurse should place objects on the patient’s unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect. DIF: Cognitive Level: Apply (application) REF: 1362 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity Homonymous hemianopsia A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client?a. Assess for bladder retention and/or incontinence.b. Listen to the client’s lungs after eating or drinking. c. Prop the client’s right side up when sitting in a chair.d. Rotate the client’s meal tray when the client stops eating. ANS: D This condition is blindness on the same side of both eyes. The 6 client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control. A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority? You Selected: • Risk for injury Correct response: • Risk for injury Explanation: Left homonymous hemianopsia causes loss of vision in half of the right visual field so clients cannot see past the midline without turning the head to that side, leaving the client at risk for injury. The client who has had a stroke may have impaired physical mobility, activity intolerance, and impaired verbal communication but these are not the priority according to Maslow’s hierarchy of needs. Dysphagia- Dysphagia is impairment in swallowing. It involves the oral and neck muscles and the gag reflex. Barium swallow to determine swallow abilities Tips to prevent aspiration: a) Tuck the chin with each swallow b) Turn the head toward the weak side to swallow c) Hold their breath while swallowing d) Sit in an upright position to swallow e) Tube feeds Emotions a) Be patient b) Reinforce what a person can do no what one can’t do. c) Embarrassment of the situation Elder abuse -Care giver stress: potential for abuse due to the situation that they are forced into. Emergent treatment a) Thrombolytic within 1 hour of presentation to ED. b) National Institute for Healthcare Stroke Scale (NIHSS) performed within 10 minutes of arrival to ED. 7 c) CT within 25 minutes of arrival to the ED d) Start 2 IVs o t-PA (class of drugs that includes ACTivase) o Monitor VS and neurological checks every 15 minutes for 2 hours then every 30 minutes for 6 hours and then every hour for 24 hours. o Admitted to the ICU for close monitoring o SBP less than 185 mmHg o Emergent treatment e) Heparin started at 800 to 1200 units per hour to maintain a PTT between one and a half to 2 x the baseline. Management of Arteriovenous Malformations a) Gamma radiation to produce fibrous thickening b) Closes off lesion c) Ionizing radiation Other AVM treatments clipping and coiling Rehabilitatio n Physiatrist Physical Therapist Occupational therapist Speech-language pathologist Social worker Psychologist Therapeutic recreational therapist Vocational rehab counselor Biomedical/rehab engineer Family physician Rehabilitation nurse Traumatic Brain Injury-Head injury occurs as a result of blow or jolt to the head such as ? a) Shaken baby syndrome b) Falls c) MVA d) Abuse firearms 10 ICP Cranial contents include: brain tissue, blood, and CSF Rigid skull ICP normal level of 10-15 mm Hg Leading cause of death from head trauma ICP increases cerebral perfusion decreases causing a) Tissue hypoxia = cerebral vasodilation b) Edema and a further increase in ICP Three types of edema: a) Vasogenic b) Cytotoxic c) Interstitial edema ICP ICP Types 11 1.Vasogenic is often seen in the adult. -It is an increase in the volume of brain tissue Fluid collection occurs in the white matter 2.Cytotoxic a) Hypoxic insult which causes a disturbance in cellular metabolism b) Brian is depleted of oxygen, glucose, and glycogen and converts to anaerobic metabolism c) Further increase in ICP 3.Interstitial edema- Elevated BP a) Acute brain swelling and is associated with: b) Elevated BP or increased CSF pressure What are the S/S of ICP: The opposite of Shock ICP Prior to the herniation 12 If the is no catheter to remove the extra accumulated blood = Suffer from Brain Herniation S/S : a) Shift in V/S b) Abnormal breathing c) Fixed and dilated pupils= NOT Good Patho Back of head = little hole where brain attaches to the spinal column (Valve) The shift it will cause pressure to the space onto the Brain stem Brain stem= Controls all autonomic functioning Hemorrhage Brain hematoma a) Primary with injury or arise later due to vessel damage b) Shearing force of trauma c) Potentially life threatening because they are space- occupying lesions and are surrounded by edema Three types 1. Epidural 2. Subdural 3. Intracerebral ICP 1. Epidural Hematoma-Arterial bleeding - NEUROSURGICAL EMERGENCY 15 Hydrocephalus Abnormal increase of CSF volume Impaired reabsorption of CSF at the arachnoid villi Blocks the outflow of CSF Patho- The ventricles inside the brain has CSF. The ventricle producing CSF gets trapped because does not have an exist route do to blood or brain tissue injury = causing ICP Brain Herniation- Pressure shift = late finding In the presence of ICP the brain tissue may shift and herniate downward a) Dilated non reactive pupils b) LOC c) Ptosis d) Changes in respirations Cheyne-Stokes respirations e) Pinpoint & non-reactive pupils, f) Potential hemodynamic instability ICP 16 Cont-Brain Herniation Uncal herniations-3rd Cranial Nerve pressure is one of the most clinically significant because it is life threatening. Shift of the temporal lobe know as uncus Pressure is placed on the third cranial nerve Late findings include: dilated & nonreactive pupils, ptosis, rapidly deteriorating LOC Central herniation is caused by a downward shift of the brainstem and the diencephalon s/s a) Cheyne-Stokes respirations b) pinpoint & non-reactive pupils c) potential hemodynamic instability Herniation Syndromes ICP Management of Head Injury 17 Nonsurgical Management of Head Injury a) At the scene a c-collar is placed to protect the spinal cord until the xray shows that the spinal cord is not injured. b) Can not be removed until cleared by doctor or radiology ABCs 1st Head trauma are treated as though they have cord injury until x-ray studies prove otherwise Assessment of vital signs –What should the nurse watch out for with head injury? a) Cushing’s triad: late sign b) Severe HTN with a widened pulse pressure( systolic is high and diastolic is not) and bradycardia (slow pulse) c) ICP increases pulse becomes thready, irregular, and rapid (can bounce between tachycardia and bradycardiac) d) Hypovolemic shock: hypotension & tachycardia e) Dysrhythmias Nursing Interventions for Brain injury -ICP Positioning- Interventions To : Help maintain ICP pressures down a) Avoid extreme flexion or extension of the neck to maintain the head in the midline( like no pillows but ok to roll towel for neck support. b) HOB elevated 30 -45 degrees c) Base head elevation on cerebral perfusion pressure- Ma d) Pulmonary ventilation and management of oxygen and carbon dioxide levels o Patient will be on the ventilator o Easier to manage based on ABG values Suctioning – Its dangerous on ICP patients N/I To prevent pneumonia /Suctioning a) If there is an order:1st -Lidocaine given endotracheally first to: may be used to suppress cough or gag reflex ( decreases icp) b) 2nd Hyperventilate before suctioning- to make sure oxygen saturation as high as possible prior to suctioning c) 3rd Then suction How many times ? the least as 20 Glucocorticoids( Steriod) Book says Not beneficial in ICP however it is still seen with treatment Mannitol and furosemide (Lasix) Mannitol (osmitrol) an osmotic diuretic is used to- treat cerebral edema by pulling water out of the extracellular space which helps with edematous brain tissue. o Manage out put –patient should have catheter to manage output N/I for Mannitol therapy o Effective in boluses o Better at a warm state- Cold can crystalized (cant be seen with naked eye that is why it needs to pulled with filter) – You can use sheet warmer o Make sure it does not have crystallization by using a filter o Mannitol is given IV through a filter in IV tubing or drawn up using a filter needle for IVP Furosemide (Lasix) is given with mannitol to prevent loop diuretic Furosemide(Lasix) – unlike mannitol( removes water from/through extracellular spaces) it works with the kidneys at loop of Henley for water to be released N/I : Assess Input and output Monitor for Electrolyte imbalances Opioids Morphine sulfate or fentanyl N/I Monitor respiration decrease- can cause ICP to increase Make sure to have naloxone (Narcan) available to reverse S/E of Opioids such as respiration decrease Both can be reversed by Narcan Sedatives: lorazepam (Ativan) and midazolam (Versed) also Diprovan Whenever you give a Paralytic you must have a sedative ICP Pharmacology Neuromuscular blocking agents-Paralytic ( give with a sedative) 21 Vecuronium bromide or cisatraciuium (Nimbex) Based on their mechanism of action, neuromuscular blocking agents are classified as either depolarizing or nondepolarizing. Depolarizing agent. o Succinylcholine is a short- acting Nondepolarizing agents are o Curare-long-acting o Pancuronium-long-acting o Atracurium -intermediate-acting o Vecuronium -intermediate-acting What are they for? • Neuromuscular blocking agents are used clinically to facilitate endotracheal intubation and to provide skeletal muscle relaxation S/E Analgesic and sedative effects- Pneumonia(especially with ventilated patients)is a side effect and as a treatment is avoided today Antiepileptic drugs to treat brain tissue that can be given IV Phenytoin (Dilantin) Acetaminophen and aspirin -Used to treat fever greater than 101 F Depends which is appropriate Medications to Put patients in a Barbiturate coma Disproven is newer drug Pentobarbital sodium (Nembutal, Novopentobarb) It works by: a) Decreasing the metabolic demands of the brain and cerebral blood flow, Stabilizes cell membranes b) Decreases the formation of vasogenic edema c) Produce a more uniform blood supply ICP- Pharmacology Cont- Medications to Put patients in a Barbiturate coma N/I a) Managed using hemodynamic assessment b) ICP monitoring 22 c) Electroencephalographic monitoring Complications: a) Decreased GI motility b) Cardiac dysrhythmias from hypokalemia c) Hypotension, d) Fluctuations in body temperature Surgical Management ICP monitoring devices Intraventricular catheter (IVC)- Small tube inserted into the anterior horn of the lateral ventricle of the nonodominant cerebral hemisphere. o What can it be used for? The physician can release pressure by removing fluid . Advantage: CSF can be drained & specimens can be obtained Other catheters? Epidural catheter-Transducer placed between the skull and the dura Subdural catheter- Placed under the dura mater Fiberoptic transducer-tipped- Placed in the subdural or subarachnoid space How is pressure monitored? Subarachnoid screw or bolt a) It is placed In the subarachnoid space for direct pressure measurements. b) It is Less invasive which- lowers risk for infection c) IT Cannot drain CSF- only for monitoring Pressure Craniotomy – Is done when it is difficult to manage ICP o May be performed in extreme instances of elevated ICP. Procedure- Remove a bone flap of the brain, store it and replace it once the swelling is down o Remove ischemic tissue or the tips of the temporal lobes o Allows expansion of brain tissue without further increasing ICP ICP Craniotomy-cont N/I: Be very careful with moving patient do to patient not having the bone flap available for protection ( all that is there is tissue and brain) Rancho Los Amigos Scale