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2025 NR 341 WEEK 6 EDAPT STUDY NOTES COMPLEX
CARE
COMPLEX INTRACRANIAL – NEUROLOGICAL ALTERATIONS
Intracranial regulation is the body’s ability to control blood and cerebral spinal fluid flow throughout the brain and spinal cord. A delicate system of nerve fibers senses the increases and decreases in pressure and flow and adjusts to maintain homeostasis. Any type of injury or abnormality can cause an imbalance, requiring the nervous system to adjust. In some cases, adjustment isn’t possible, and the body requires outside intervention to bring the body back to its normal state. A client has a mean arterial pressure of 120 mm Hg with an intracranial pressure of 42 mm Hg. What is the calculated cerebral perfusion pressure? Cerebral perfusion pressure is the mean arterial pressure minus the intracranial pressure. For this client, the answer is 78 mm Hg. When intracranial pressure is significantly elevated, what symptoms might the nurse expect? Significantly elevated intracranial pressure leads to bradycardia, irregular respirations, and widening blood pressure measurements. This is also known as Cushing’s triad, and an indication of impending cerebral herniation. Bloody ear drainage suggests a skull fracture. Cold and clammy skin below the neck suggests symptoms of autonomic dysreflexia. The nurse reports that the client is experiencing a reduced level of consciousness. Which tool is used to measure and record the level of consciousness? The best tool to measure and record a client’s level of consciousness is the Glasgow coma scale (GCS).
The balance of cerebral spinal fluid and blood:
Intracranial pressure changes whenever brain tissue, cerebrospinal fluid, or blood pressures change. For small changes resulting from the changes of brain tissue, cerebrospinal fluid, or blood pressure, the body can compensate by increasing or decreasing blood pressure or changing the amount of flowing cerebral spinal fluid. This process is called intracranial regulation. Altered Intracranial Regulation When there are unexpected changes in mass, either due to space occupying tissue, or increased swelling from inflammatory response, the body can fail at intracranial regulation. This can occur slowly with a brain tumor, or quickly with
cerebral edema from inflammatory response or bleeding.
Research to discover how the different types of monitoring can impact survival and minimize damage in any client with altered intracranial regulation continues to bring new evidence to the bedside.
- This is inserted between the skull and dural tissue. This is the least invasive way to measure, but it cannot be used to drain excess CSF fluid.
Intracranial monitor:
Along with monitoring intracranial pressure, other measurements that may be used in complex environments measure brain information including:
- blood flow
- oxygenation
- metabolism
- continuous electroencephalographic monitoring
Spinal cord injury:
Injury to the spinal cord is another important neurological alteration addressed acutely in a complex health environment. The spinal cord can be bruised, punctured, or severed. Because the spinal cord runs from the top of the neck and ends between the first and second lumbar vertebrae, with further nerve roots going out to the ends of the extremities, any damage at any point of the spinal cause’s symptoms beyond the point of damage.
- If the spinal injury is in the neck, the respiratory system is affected.
Remember The effects vary based on the injury severity.
- If the injury occurs above the thoracic vertebrae T6, there can be cardiovascular signs including: - bradycardia - hypotension - the inability of veins and arteries to constrict - blood pressure changes associated with the position
- Spinal injury in the thoracic vertebrae can cause bowel and/or urinary problems, including: - urinary retention - constipation - paralytic ileus - fecal impaction
Spinal Nerves
- cervical nerves (cervic/o)
- thoracic nerves (thorac/o)
- lumbar nerves (lumb/o)
- sacral nerves (sacr/o)
- coccygeal nerve (coccyg/o) ACUTE SPINAL CORD INJURY: The location of a spinal cord injury determines the location of paralysis and the organs that are affected. Depending on the severity of the injury, a client can experience everything from complete paralysis (severed cord) to paresthesia, and temporary paralysis (bruised or partially severed cord). For example, injury at T6 or slightly high can minimally cause constipation to the gastrointestinal tract, or it could cause constipation, fecal impaction, abdominal bloating, fecal incontinence and/or paralytic ileus. This severity is dependent on injury, quality of care, and proactivity of bowel interventions.
C1-C3 Injury
High quadriplegia with inability to breath or cough
C4 Injury
High quadriplegia with significant respiratory affects
- Antiseizure drugs (suggests history of neurological symptoms/problems)
- Anticoagulants (potential for cerebral hemorrhage)
- Psychotropic drugs (neurological side effects)
- Serotonin inducing drugs (serotonin syndrome)
Dyslipidemia, concussion, and bacterial meningitis can all cause intracranial regulation
problems. Having a history of these helps the nurse understand those who may have a higher
risk for altered intracranial regulation.
A lumbar laminectomy indicates a potential spine issue. Because cerebral spinal fluid
flows through the spine, a surgery may cause scar tissue and disruption due to an
orthopedic problem.
Smoking increases the risk of cerebral vascular disease, and family history may put the client at
higher risk of cerebral vascular disease as well. These are pertinent details.
Symptoms of complex neurological problems:
Level of Consciousness Problems
- altered level of consciousness
- confusion
- altered memory and orientation Brain Connected Nerves Problems
- vision (blurred or double)
- hearing (unequal or absent)
- smell (absent)
- swallow or taste (difficulty or unable)
- neck or shoulder (muscle movement problems) Movement problem
- paralysis (unable to move)
- paresthesia (unable to feel, or may sense only a burning pain in a dermatome)
- reduced, absent, or hyper reflexes Pain
- headache (location, duration, and severity)
- extremity pain (nerves)
Airway Clearance and Gas Exchange
- difficulty breathing Elimination
- urinary retention or incontinence
- fecal retention or incontinence Reproduction
- erectile dysfunction
- anorgasmia Level of consciousness: Eye Opening Response Glasgow coma scale
- spontaneous—open with blinking at baseline, 4 points
- to verbal stimuli, command, speech, 3 points
- to pain only (not applied to face), 2 points
- no response, 1 point Verbal Response
- oriented, 5 points
- confused conversation, but able to answer questions, 4 points
- in appropriate words, 3 points
- incomprehensible speech, 2 points
- no response, 1 point Motor Response
- obeys commands for movement, 6 points
- purposeful movement to painful stimulus, 5 points
- withdraws in response, 4 points
- flexion in response to pain (decorticate posturing), 3 points
- extension in response to pain (decerebrate posturing), 2 points
- no response, 1 point Vital signs
Clients can have hypotension or hypertension, requiring antihypertensives or vasoconstrictors. Difficulty or Inability to Breathe Clients can have a loss of consciousness that involves the inability to maintain an airway, move their diaphragm, and expand their chest. This may often require artificial ventilation. Urinary Retention or Incontinence Clients can have the inability to urinate (which can lead to severe urinary retention and autonomic dysreflexia), or can cause urinary incontinence requiring catheterization. Bowel Retention or Incontinence Clients can have bowel retention which could lead to bowel obstruction, or they could experience fecal incontinence. They could require laxatives, stool softeners, or other bowel stimulation. Or they may need frequent bed changes or cleansing to protect them from skin breakdown. Jesse is admitted to the emergency department after a fall from a second- story balcony. He states that he is unable to move both lower extremities. His vital signs are stable, and he has had no urine output for the past 6 hours. Suddenly, he starts to experience symptoms of cold clammy skin from mid-chest down.
- Vitals^ signs: - T:^ 96.8ºF^ (36.0ºC) - BP:^ 145/ - P:^50 - R:^14 Which nursing action is most appropriate? The client’s symptoms are consistent with autonomic dysreflexia. Urinary catheterization with emptying of the bladder will likely improve this client’s symptoms. PRIMARY NURSING DIAGNOSIS: Primary alterations in intracranial regulation can lead to many nursing diagnoses, depending on the underlying pathophysiology of the condition. For example, a cerebral vascular accident (stroke) could lead to confusion, altered perfusion, and impaired mobility. A traumatic brain injury is more likely to lead to decreased intracranial adaptive capacity, impaired memory, acute confusion, and pain. Spinal cord injuries lead primarily to mobility and autonomic dysreflexia.
Remember! Consider airway, breathing, and circulation in any altered intracranial regulation environment.
Acute confusion - Assessment Cues
- disorientation, reduced alertness
Decreased intracranial adaptive capacity - Assessment Cues
- reduced level of consciousness (low Glasgow coma scale score)
- Cushing’s triad
- cranial nerve abnormalities
Secondary nursing diagnosis:
Regardless of the altered intracranial regulation, secondary results must always be monitored continuously. Secondary Nursing Diagnosis Assessment Cues Altered perfusion High blood pressure Reduced cardiac output Low blood pressure Impaired airway clearance No breathing, stridor Altered gas exchange Low oxygen saturation, and decreased respirations Constipation Reduced bowel movements or abdominal discomfort Urinary retention Distended bladder, reduced urination, and autonomic dysreflexia Incontinence (Bowel or bladder) Bowel or bladder leakage Altered tissue integrity Stasis ulcers and skin breakdown Secondary Nursing Diagnosis Assessment Cues
stimulation (TENS) unit as ordered. Reduced cardiac output
- Administer fluids as ordered. Administer blood pressure elevating
- medications. Altered gas exchange
- Administer oxygen as ordered.
- Administer ventilate if needed. Constipation
- Administer stool softeners.
- Increase fluid intake.
- Administer laxatives if needed and ordered. Below are potential evaluation criteria which can be used for each of the primary nursing diagnoses for a client with an altered intracranial regulation problem. Primary Nursing Diagnosis Nursing Evaluation Acute confusion The client is alert and oriented to person, place, time, and situation. Decreased intracranial adaptive capacity The Glasgow coma scale score is 15. Ineffective thermoregulation The client maintains an oral temperature between 97.8ºF (36.6ºC) a 99.8ºF (37.7ºC). Impaired memory The client can describe short- and long-term memories. Primary Nursing Diagnosis Nursing Evaluation
Autonomic dysreflexia The client has no symptoms of autonomic dysreflexia. Altered perfusion The client has no symptoms of decreased cerebral perfusion. Impaired mobility The client has normal reflexes, moves all extremities, maintains an balance, and has no paresthesia. Pain The client verbalizes a manageable pain level. Below are potential evaluation criteria which can be used for each of the secondary nursing diagnoses for a client with an altered intracranial regulation problem. Secondary Nursing Diagnosis Nursing Evaluation Altered perfusion Mean arterial pressure is maintained between 60 and 100 mm Hg. Reduced cardiac output Mean arterial pressure is maintained between 65 and 100 mm Hg. Impaired airway clearance A clear and open airway is maintained. Altered gas exchange Oxygen saturation is maintained above 92% with a respiratory rate between 12 and 20 breaths per minute. Constipation The client maintains a normal bowel routine. Secondary Nursing Diagnosis Nursing Evaluation Urinary retention Urine output remains above 30mL/hour with no residual urine in the bladder.
Remember! The highest priority is always airway, breathing, and circulation. Immobilizing clients to prevent secondary or extended injury to the area is essential. Remember! Assessing and treating infection should be a high priority when caring for a client with a spinal cord injury. Causes of Death for Clients With Spinal Cord Injury
- diseases of the respiratory system (21.4%)
- infective and parasitic diseases (12%)
- neoplasms (10.8%)
- heart disease (10.4%)
Acute care of spinal cord Injury:
Spinal cord injury may require treatment of the secondary effects of a severed cord. Complex intracranial regulation issues can often appear differently in the elderly population:
- Often it can be confused with age-related changes or new onset dementia as well.
- A thorough medical and medication history is important to identify potential causes of altered intracranial regulation that may not be seen in a younger client.
- Medications may alter blood clotting mechanisms.
- Certain activities can cause bleeding, such as cutting yourself shaving or going barefoot.
- In addition, unknown injuries, including unwitnessed falls involving head injuries could mean an underlying undiagnosed injury that could be life threatening. In younger populations, intracranial regulation problems are more likely to be caused by traumatic injuries or potential congenital problems. This can include:
- spina bifida
- cerebral palsy
- congenital malformations leading to hydrocephalus
These children live into adulthood and may have lingering chronic neurological issues or be susceptible to intracranial regulation changes that are unique to their condition. Birth history and childhood trauma are important assessment findings to review with the client. The nurse is caring for Angela Everheart, a 57-year-old female brought to the emergency department (ED). Review the electronic health record (EHR) and answer the question below. Click to specify the pertinent nursing assessment findings and Glasgow coma scale score: Angela’s Glasgow coma score is 4, based on the assessment that her eyes do not open, and she is verbally unresponsive to any stimuli. In addition, she is demonstrating “decerebrate posturing”. Also of concern is the unequal dilated pupil on the right side, widening systolic and diastolic blood pressure, bradycardia, and no respirations with an inability to obtain an oxygen saturation. Glasgow coma scale Eye Opening Response
- spontaneous—open with blinking at baseline, 4 points
- to verbal stimuli, command, speech, 3 points
- to pain only (not applied to face), 2 points
- no response, 1 point Verbal Response
- oriented, 5 points
- confused conversation, but able to answer questions, 4 points
- in appropriate words, 3 points
- incomprehensible speech, 2 points
- no response, 1 point Motor Response
- obeys commands for movement, 6 points
- purposeful movement to paintful stimulus, 5 points
- withdraws in response, 4 points
- flexion in response to pain (decorticate posturing), 3 points
- extension response in response to pain (decerebrate posturing), 2 points
- no response, 1 point The presence of 0 respirations indicates respiratory arrest. The signs of abnormal pupils (cranial nerve II), decreased Glasgow coma scale score, widening pulse pressure, and bradycardia suggest increased intracranial pressure.
Altered gas exchange
- Administer oxygen as ordered.
- Artificially ventilate. The correct order of high to low priority actions is:
- Reposition the head, neck, and jaw to open an airway.
- This action will establish an airway if the client is able to breathe on their own.
- Obtain an airway using the emergency equipment.
- If the client is unable to breathe, an emergent airway should be established.
- Artificially ventilate.
- After airway, ventilation should be started.
- Administer oxygen as ordered.
- Oxygenation comes after airway and ventilation.
- Administer blood pressure decreasing medications.
- Decreasing intracranial pressure is the next priority, medication will help.
- Elevate the head of the bed above 30 degrees.
- Gravity will help to a lesser degree to decrease intracranial pressure. The Arizona Department of Health received a $1 million dollar grant to implement strategies for reducing the number of spinal cord injuries in the state. In determining funding, which type of prevention should the public health nurse recommend that would affect most people? One third of all spinal cord injuries occur during motor vehicle crashes. Better speed reduction strategies and seat belt use could affect the largest number of people. Diving and motorcycle accidents cause only 6% of spinal cord injuries. Therefore, while new safety measures may help, it doesn't affect the greatest number of people. Same reason with the gun regulation. Nursing Actions Nursing Goal
- Administer stool softeners. The client maintains a normal bowel routine. Nursing Actions Nursing Goal
- Administer laxatives if needed and
ordered. The skin remains free of urinary or
- Provide bed padding and fecal moisture. frequent sheet changes.
- Administer barrier creams as ordered.
- Frequent turning and moving. The skin remains intact.
- Monitor daily weights.
- Maintain detailed input and output recording.
- Provide dietary consultation.
- Administer tube feedings. Albumin blood levels are maintained above 3.5 g/dl.
- Provide a cooling or warming blanket. The client maintains a temperature between 97.8ºF and 99.8ºF.
- Encourage active or passive range of motion exercises.
- Consult with physical therapy. The client maintains muscle mass.
