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Care of Critically Ill Patients with Neurologic Problems Dysfunction of the brain Care of Critically Ill Patients with Neurologic Problems,,.
Subarachnoid
hemorrhage Epidural
hematoma Strokes
Homonymous hemianopsia
Transient Ischemic Attack
- 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 - 70 mL / 100 g 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 hypertension.
Care of Critically Ill Patients with Neurologic Problems Example : AVM (aneurysm ) is an uncommon abnormality that occurs during embryonic development. During rupture : the patient describes as “the worst headache of my life”. Modifiable risk factors
1. Hypertension 2. Hypercholesterolemia 3. Atherosclerosis 4. Atrial fibrillation 5. Obesity 6. Smoking 7. Drugs and alcohol 8. Diabetes 9. Sickle cell anemia Nonmodifiable risk factors a) Age over the age of 65 b) Sex – men but women die more often c) Family history d) Stroke in the past history How is a Hemorrhagic Stroke Diagnosed? a) CT b) MRI-takes longer. c) MRA – takes longer. Vessels involved. Collateral circulation. d) Carotid ultrasound e) CBC f) BUN g) Creatinine h) Prothrombin time (PT) i) Partial prothrombin time (PTT) Neurologic Assessment Cognitive changes include; Aphasia- difficulty reading, writing, speaking There are 3 types Expressive aphasia (Boca's aphasia) cannot express what is to be said. Difficulty forming words. Dysarthria-slurring of speech Receptive aphasia (Wernicke’s aphasia) unable to understand what is being said or what is written. Global aphasia -both expressive and receptive aphasia Mobility
Care of Critically Ill Patients with Neurologic Problems 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
Care of Critically Ill Patients with Neurologic Problems
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) T hrombolytic within 1 hour of presentation to ED. b) National Institute for Healthcare Stroke Scale (NIHSS) performed within 10 minutes of arrival to ED.
Care of Critically Ill Patients with Neurologic Problems e) Alcohol & drugs Traumatic Brain injury Traumatic Brain Injury Those with moderate to severe head injuries are never the same as before the injury. a) Changes in cognition such as o memory loss o difficulty learning new information o Limited concentration. b) Personality alterations such as o Outbursts of temper and depression also may occur. o The become children o Social awkwardness o Sexually inappropriate Primary Brain Injury Open head injury occurs when there is a Skull fracture a. Skull is pierced by a penetrating object b. The Dura (underline structure) is violated, and exposure to outside contaminants occurs. Closed head injury is the result of blunt trauma; a. The integrity of the skull is not violated. b. The skull is still intact Secondary Injury- Not related to trauma however, it is the outcome of a primary brain injury - Result of an injury to the brain a. Hypoxia b. Cerebral edema c. Hypertension – response to increase perfusion d. Increased ICP e. Hypercapnia Basilar Skull Fracture Open injury- Occurs at the base of the skull a. Usually extends into the anterior, middle, or posterior fossa b. results in cerebrospinal fluid leakage from the nose or ears Battles sign- ( bruising behind the ear) Potential for hemorrhage, damage to cranial nerves, and infection
Care of Critically Ill Patients with Neurologic Problems
Raccoons eyes- Open injury
a) If bilateral, it is highly suggestive of basilar skull fracture , with a positive predictive value of 85%. Types of Closed Head Injuries a) No fracture b) Mild concussion o Shaky movement of the brain and may be mild or severe o Loss of consciousness for a short period of time – seconds to minutes Diffuse axonal injury –MVA a) Usually related to high-speed acceleration/decelerations as with MVA b) May present with immediate comas c) Most survivors need long-term care Contusion (coup and countercoup injury) Bruising of the brain tissue and is most commonly found at the site of impact ( coup injury ) or A line opposite the site of impact (countercoup injury) Types of Closed Head Injuries- Leads to bleeding Laceration a) Actual tearing of the cortical vessels which may lead to secondary hemorrhage and significant cerebral edema and inflammation b) More serious than a contusion
Care of Critically Ill Patients with Neurologic Problems
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
- 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
Care of Critically Ill Patients with Neurologic Problems 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
- Epidural
- Subdural
- Intracerebral **ICP
- Epidural Hematoma-Arterial bleeding** - NEUROSURGICAL EMERGENCY
Care of Critically Ill Patients with Neurologic Problems
1. Acute ( typically) Patients will have s/s within 48 hrs. After impact 2. Subacute Patients will have s/s within or after 48 hrs. to 2 weeks - Slowly worsening 3. Chronic- High Mortality Rate Patients will have s/s within or after 2 weeks to several months after injury - because patients are at home and do not realize the symptoms to seek md care 3. Intracerebral hemorrhage Subarachnoid hemorrhage- Intracerebral hemorrhage Accumulation of blood within the brain tissue caused by tearing of a) Small arteries and b) Veins in the subcortical white matter Subarachnoid hemorrhage is the most common type of Intracerebral hemorrhage ICP
Care of Critically Ill Patients with Neurologic Problems 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
Care of Critically Ill Patients with Neurologic Problems 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 1 st 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 : 1 st^ - Lidocaine given endotracheally first to: may be used to suppress cough or gag reflex ( decreases icp) b) 2 nd^ Hyperventilate before suctioning- to make sure oxygen saturation as high as possible prior to suctioning c) 3 rd^ Then suction How many times? the least as
Care of Critically Ill Patients with Neurologic Problems possible 1- 2 passes ICP Cont- Nursing Interventions for Brain injury -ICP
Care of Critically Ill Patients with Neurologic Problems 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)
Care of Critically Ill Patients with Neurologic Problems 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
