Critical Thinking Challenge – Case Study Critical Thinking Challenge – Case Study Critical, Exams of Nursing

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Neurology

NOVEMBER 2017

Increased Intracranial Pressure (ICP) Increased Brain Volume ◦ Common cause: cerebral edema ◦ Cytotoxic ◦ Intracellular swelling of neurons ◦ Hypoxia/hypo-osmolality ◦ Vasogenic ◦ Increased capillary permeability ◦ Tumors/meningitis Increased Blood Volume ◦ Loss of autoregulation ◦ Decreased oxygenation ◦ Hypercapnia ◦ Increased metabolic demands ◦ Obstruction of venous outflow Increased Cerebrospinal Fluid ◦ Hydrocephalus ◦ Blockage of normal flow ◦ Obstruction of normal reabsorption ◦ Excess production of CSF fluid

– Case Study

The nurse admits Mrs. S to the ED. She was found “down” in the bathroom by a relative. Initial vital signs include BP 110/60 mm Hg, HR 56 beats/min, RR 10 breaths/min, SpO 2 93%; temperature

° F. The patient is obtunded but moving all extremities to pain. Discuss components included in a thorough baseline neurological assessment. Discuss mental status assessment using the Glasgow Coma Scale. Discuss what the priority nursing assessment is in a patient with altered mental

Critical Thinking Challenge –

Case Study

Mrs. S is transferred to the ICU. Upon admission, the nurse completes a baseline neurological assessment. Vital signs include BP 100/50 mm Hg, HR 90 beats/min, RR 6-8 breaths/min and shallow, SpO 2 90% on 100% non-rebreather mask. The patient is unresponsive to voice and “localizes to painful stimuli.” ◦ Discuss changes in the patient’s status. Which assessment findings are critical? ◦ Discuss priority nursing care. ◦ Discuss neurological assessment findings related to Glasgow Coma Scale score.

Critical Thinking Challenge –

Case Study

One hour later, the nurse assesses Mrs. Stanley to be unresponsive to voice and notes flexion posturing of the extremities. The nurse also notes the patient to be having 10 second periods of apnea. The physician arrives 30 minutes later and places a right ventriculostomy. ◦ Discuss the patient’s neurological status/Glasgow Coma Scale score. ◦ What are the priority nursing interventions for this patient? ◦ What diagnostic tests would be of the highest priority to include in the patient’s plan of care?

Cerebral Perfusion Pressure

Dependent upon intracranial pressure and mean arterial pressure ◦ CPP = MAP – ICP Normal CPP = 50– Low CPP results in loss of autoregulation and hypoxic insult to brain tissue

Increased ICP – Nursing

Management

Goal to **maintain ICP<20mmHg and CPP< Space nursing care to allow for rest period in between Airway management Suctioning should be kept to a minimum HOB 30 degrees and neck in neutral position May turn client side to side but monitor ICP during and it should return to baseline within 5 minutes STRICT I & O

skull fractures) Pain and anxiety management

Increased ICP – Nursing

Interventions

Monitor for diabetes insipidus (DI) ◦ Polyuria ◦ Low urine specific gravity Monitor for SIADH ◦ Oliguria ◦ High urine specific gravity Avoid valsalva, coughing, sneezing, hypoxemia, and sudden arousal from sleep Avoid extreme hip flexion Protect client

Increased ICP – Medical

Management

ADEQUATE OXYGENATION Goal: PaO 2 > 80mm Hg Airway vigilance Mechanical ventilation Adequate hematocrit CARBON DIOXIDE MANAGEMENT PaCO 2 35-45 mm Hg Avoid hyperventilation

Increased ICP – Medical

Management

DIURETICS

Osmotic diuretics

◦ Reduce brain tissue volume ◦ Mannitol ◦ Hypertonic saline

Loop diuretics

◦ Reduce brain tissue volume ◦ Decrease CSF formation FLUID ADMINISTRATION Optimized fluid administration with isotonic solutions Strict intake/output Goal: serum osmolality less than 320 mOsm/L. Colloids or blood products to restore volume

Seizures

SEIZURES Abnormal electrical discharge in the brain ◦

Partial

◦ Simple partial ◦ Complex partial ◦

Generalized seizures

◦ pg. 9 th^ ed. 1420-

STATUS EPILEPTICUS Seizures in close proximity to each other ◦

Lasting longer than 30 minutes

◦ Two or more without

full recovery

Status Epilepticus

20–30 minutes of continuous seizure activity Consecutive seizures for 20–30 minutes without return of consciousness Causes: Known seizure disorder with medication noncompliance No history of seizures Toxic and metabolic events that damage cerebral cortex