Chapter 57 Nursing Management Acute Intracranial Problems Factors

Chapter 57 Nursing Management Acute Intracranial Problems

Factors That Affect ICP • • • Arterial pressure Venous pressure Intraabdominal and intrathoracic pressure Posture Temperature Blood gases-CO 2 levels

Fig. 57 -1

Intracranial Pressure • Regulation and maintenance of intracranial pressure – Normal intracranial pressure-total pressure exerted by the brain, blood, and CSF – Normal compensatory adaptations • Changes in CSF volume by altering absorption or production and displacement of CSF into spinal subarachnoid space • Alteration of blood volume • Tissue brain volume changes by distention of dura or compression of brain tissue • if skull is rigid- a pressure increase in one area will cause a decrease in the other two – Measuring ICP- 0 -15 mm HG

Intracranial Pressure (cont’d) • Cerebral blood flow – Autoregulation of cerebral blood flow • CPP- cerebral perfusion pressure (CPP= MAP-ICP) • Must have MAP of 50 mm HG. If ↓ 50 → cerebral ischemia. > 150 → can’t constrict any further – Pressure changes • Compliance= volume/pressure – Factors affecting cerebral blood flow • carbon dioxide- ↑ in Pa. Co 2 relaxes smooth muscle, dilates cerebral vessels, ↓ cerebrovascular resistance, and ↑CBF • ↓ O 2→ cerebrovascular dilation • Hydrogen ion- if O 2 not ↑ → ↑ lactic acid→acidosis→dilation

Increased Intracranial Pressure (cont’d) • Clinical manifestations – Change in level of consciousness – Changes in vital signs – Ocular signs – Decrease in motor function – Headache – Vomiting – Changes in the Glascow Coma Scale

Intracranial Pressure (cont’d) • Stages of pressure from 1 -5. • At stage 3 pt will exhibit signs of inc ICP= Ha, changes in LOC, or pupil response. • Stage 5 = widening pulse pressure, brady, decrease RR= known as Cushing’s triad, herniation

Increased Intracranial Pressure (cont’d) • Complications-inadequate cerebral perfusion and herniation • Diagnostic studies – CT without contrast • Measurement of ICP – Indications for ICP monitoring -Glascow Coma Scale<8, abnormal CT or MRI – CSF drainage-removing fluid to ↓ pressure – High risk of infection. – Normal CSF production is 20 -30 cc/hr and total volume is 90 -150.

Head Injury • Basilar skull fx – Battle’s sign-ecchymosis behind ears – Raccoon's eyes-periorbital ecchymosis – Cranial nerve deficit – Tear in dura with leakage of CSF

Head Injury • Two methods to test leaking fluid – Test CSF with Dextrostix for glucose – Halo sign- drip fluid onto a white padblood in center and yellow ring around blood. Remember brain injury opposite ecchymosis due to brain movement

Head Injury • Coup-contrecoup injury • Epidural-emergency tear in blood vessel – LOC at scene → brief lucidness →↓LOC – Surgery • Subdural hematoma-usually venous

Increased Intracranial Pressure (ICP) Fig. 57 -5. Decorticate and decerebrate posturing. A, Decorticate response. Flexion of arms, wrists, and fingers with adduction in upper extremities. Extension, internal rotation, and plantar flexion in lower extremities. B, Decerebrate response. All four extremities in rigid extension, with hyperpronation of forearms and plantar flexion of feet. C, Decorticate response on right side of body and decerebrate response on left side of body. D, Opisthotonic posturing. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Nursing Management: Increased Intracranial Pressure (ICP) Fig. 57 -11. Pupillary check for size and response. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

Diagnostic Tests • CT without contrast • PET • MRI

Nursing Management: Increased Intracranial Pressure (ICP) • Table 57 -9 • Nursing Implementation – Mannitol-osmotic diuretic to ↓ ICP – Acute intervention • • • Respiratory function-no coughing Fluid and electrolyte balance Monitoring ICP Body position-HOB 30 degrees Protection from injury-cluster interventions Psychologic considerations • Evaluation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Inflammatory Conditions of the Brain

Bacterial Meningitis • Etiology and pathophysiology- medical emergency- inflammation of meninges • Clinical manifestations – Stiff neck, HA, N/V, high fever, +Kernig’s, + Brunzinki’s, ↓ LOC (lethargy), photophobia – Complications-↑ ICP, residual neurological dysfunction • Diagnostic studies- LP- ↑protein, ↓glucose, purulent

Bacterial Meningitis Collaborative Care • Antibiotics started after collection of specimens • Slightly elevate head of bed • Dark room • Fever management • Isolation

Viral Meningitis CSF-↑protein, normal glucose, clear or purulent, lymphotycytosis