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NR 341 WEEK 6 EDAPT 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.
NOTE:
Because the brain is a closed container, the worst complication of altered intracranial regulation is herniation. Herniation occurs when the pressure inside the skull is so severe it forces the brain stem through the hole in the bottom of the skull. Changes in the amount of brain tissue, cerebrospinal fluid, or blood can increase or decrease the intracranial pressure in the brain. When intracranial pressure goes up or down, the client can develop signs or symptoms of decreased brain perfusion, measured by cerebral perfusion pressure (CPP). In caring for clients with complex health:
- Advanced monitoring is used to closely measure intracranial pressures.
- Drains and other devices may be used to reduce this pressure through the drainage of cerebral spinal fluid.
- Intracranial pressure may be further reduced through the induction of a coma and artificial ventilation as well.
Intracranial pressure:
In complex health care environments, intracranial monitoring can be done with a catheter placed inside the skull. The continuous measurement determines possible elevated pressures or changes in brain temperature.
Remember the following normal range:
- Mean arterial pressure (MAP) is 70 to 100 mm Hg - Intracranial pressure (ICP) is 5 to 15 mm Hg - Cerebral perfusion pressure (CPP) is 60 to 80 mm Hg - Intraventricular Catheter: - This is the most accurate and is done with a flexible tube inserted into the lateral ventricle in the brain. This device can also be used to remove excess cerebral spinal fluid (CSF) to lower Intracranial pressure (ICP). - Subdural Screw (or Bolt) - This device can be inserted quickly and is composed of a hollow screw inserted through a hole drilled into the skull. The sensor reads the pressure in the subdural space. - Epidural Sensor
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
C6 Injury
Low quadriplegia with mild respiratory affects
T6 Injury
High paraplegia with cardiovascular and Gastrointestinal affects
L1 Injury
Low paraplegia with bladder affects
Altered intracranial regulation or other neurologic alterations can be related to different causes. Here are some cues from the client's history that may indicate regulation issues: Past Medical History
- Head injury (previous damage)
- Brain hematoma (epidural, subdural, or subarachnoid)
- Cerebral vascular accident (resulting in brain edema from dead brain tissue)
- Ruptured blood vessel in the brain (cerebral hemorrhage)
- Overproduction of cerebral spinal fluid (pseudotumor cerebri)
- Inflammation or infection in the meninges (lining of the brain and spinal cord)
- Vertebral fractures
- Osteoporosis
- Degenerative disc disease Past Surgical History
- Brain surgery (past damage or surgical changes)
- Spinal surgery (past symptoms related to) Family History
- Seizures
- Parkinson's
- Huntington's Chorea (genetic inheritance) Social History
- Prolonged anoxia (near drowning)
- Trauma (past head or spine injuries)
- Occupational exposure to toxins (lead or arsenic) Medications
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
- fever
- Cushing’s triad
- irregular breathing
- bounding bradycardia
- widening pulse pressure (systolic or diastolic) Brain Connected Nerves
- cranial nerve assessment
- Remember there are 12 pairs.
- I—smell
- II—pupillary constriction and dilation
- III, IV, and VI—ocular movement
- V and VII—facial movement and sensation
- VIII—hearing
- IX and X—vagal response, swallow, and palate rise
- XI and XII—shoulder and tongue movement Movement
- extremity and torso movement and strength
- extremity and torso sensation Airway Clearance and Gas Exchange
- respiratory rate
- oxygen saturation Elimination
- urinary retention or incontinence
- fecal retention or incontinence
- autonomic dysreflexia
Complex neurological changes:
When intracranial regulation is out of control, this can impact other
areas of the autonomic nervous system responsible for various bodily
functions. First review the impacted systems then review the case study
to see how they affect Phineas.
Impacted Systems of Altered Intracranial Regulation Blood Pressure Changes
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 Altered nutrition Inability to swallow Altered intracranial regulation can cause these primary issues.
- altered level of consciousness
- brain perfusion problems
- confusion
- memory problems
- temperature control problems As a result, these secondary issues can arise.
- bowel retention or incontinence
- breathing, airway, and oxygenation problems
- complications of immobility (muscle atrophy)
- complications of tissue integrity (skin breakdown)
- reduced nutrition intake
- urinary retention or incontinence Nursing Diagnosis Potential Nursing Actions Decreased intracranial adaptive capacity
- Elevate the head of the bed above 30 degrees.
- Administer diuretics as ordered.
- Administer corticosteroids as ordered. Ineffective thermoregulation
- Provide a cooling or warming blanket. Pain
- Administer pain medication as ordered.
- Use the transcutaneous electrical nerve
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. Incontinence (bowel or bladder) The skin remains free of urinary or fecal moisture. Altered tissue integrity The skin remains intact. Altered nutrition The albumin blood levels are maintained above 3.5g/dl.
How do most spinal cord injuries happen?
According to the National Spinal Cord Injury Statistics Center (2020), about 300– 400 people sustain a spinal cord injury every year. Almost three quarters of all injuries are caused by auto crashes, falls, gunshot wounds, and motorcycle crashes. Prevention should begin with safe driving practices, including improved speed enforcement and seat belts/airbags. Better use of safety gear when climbing or working at heights. Gun control and motorcycle safety are other areas of prevention that could help. This table shows a specific breakdown of causes. Cause% Auto crash32% Fall23.1% Gunshot wound15.2% Motorcycle crash6.1% Diving5.7% Medical complication2.9% Hit by falling/flying object2.7% Bicycle1.7% Pedestrian1.5% After injury, the most common causes of death are the following:
Remember! The highest priority is always airway, breathing, and circulation. Immobilizing clients to prevent secondary or extended injury to the area is essential. 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 Remember! Assessing and treating infection should be a high priority when caring for a client with a spinal cord injury.
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.
Nursing Diagnosis Potential Nursing Actions 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.
- Provide bed padding and frequent sheet changes.
- Administer barrier creams as ordered. The skin remains free of urinary or fecal moisture.
- 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.
