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Nr341 study guide exam 2, Study notes of Nursing

Chamberlain College of NursingNursing

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NR341 WEEK 6
THE BALANCE OF CEREBRAL SPINA FLUID AND BLOOD
Intracranial pressure
fluctuates whenever
brain tissue, cerebrospinal
fluid, or blood
pressure change. For small changes, 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. The amount of pressure required for the brain to work is
measured using cerebral perfusion pressure (CPP).
An
alteration
in intracranial regulation occurs when there are unexpected
changes in mass caused by either an increase in brain tissue (e.g., tumor) or
increased swelling from an inflammatory response. This can occur slowly
(e.g., brain tumor) or quickly (e.g., meningitis, bleeding).
Changes in the amount of brain tissue, cerebrospinal fluid, or blood can
increase or decrease intracranial pressure. When intracranial pressure goes
up or down, the client can develop signs or symptoms of decreased brain
perfusion. Special care is needed when caring for clients with altered cranial
regulations, including:
Advanced monitoring is used to measure intracranial pressures closely.
Drains and other devices may be used to reduce this pressure through
cerebral spinal fluid drainage.
Medications, artificial ventilation, and a medically induced coma are
additional ways in which alterations in alterations in intracranial regulation
can be managed.
Intracranial monitoring can be done in complex healthcare environments
with a catheter placed inside the skull. The continuous measurement
determines possible elevated pressures or changes in brain temperature.
Here are some common devices used to monitor and/or adjust intracranial
pressures:
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)
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NR341 WEEK 6

THE BALANCE OF CEREBRAL SPINA FLUID AND BLOOD

Intracranial pressure fluctuates whenever brain tissue, cerebrospinal

fluid, or blood pressure change. For small changes, 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. The amount of pressure required for the brain to work is measured using cerebral perfusion pressure (CPP).

An alteration in intracranial regulation occurs when there are unexpected

changes in mass caused by either an increase in brain tissue (e.g., tumor) or increased swelling from an inflammatory response. This can occur slowly (e.g., brain tumor) or quickly (e.g., meningitis, bleeding). Changes in the amount of brain tissue, cerebrospinal fluid, or blood can increase or decrease intracranial pressure. When intracranial pressure goes up or down, the client can develop signs or symptoms of decreased brain perfusion. Special care is needed when caring for clients with altered cranial regulations, including: Advanced monitoring is used to measure intracranial pressures closely. Drains and other devices may be used to reduce this pressure through cerebral spinal fluid drainage. Medications, artificial ventilation, and a medically induced coma are additional ways in which alterations in alterations in intracranial regulation can be managed. Intracranial monitoring can be done in complex healthcare environments with a catheter placed inside the skull. The continuous measurement determines possible elevated pressures or changes in brain temperature. Here are some common devices used to monitor and/or adjust intracranial pressures: 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 This is inserted between the skull and dura mater. This is the least invasive way to measure, but it cannot be used to drain excess CSF fluid. Here are normal measurement ranges for intracranial pressures:

  • Mean arterial pressure (MAP) is 70 to 100 mmHg
  • Intracranial pressure (ICP) is 5 to 15 mmHg
  • Cerebral perfusion pressure (CPP) is 60 to 80 mmHg 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. This results in death or severe brain damage. NURSING CARE: ALTERED INTRACRANIAL REGULATION HOB 30 degree Corticosteroids Diuretics Pain meds Stool softener/laxatives Acute Confusion
  • disorientation, reduced alertness Decreased Intracranial Adaptive Capacity
  • reduced level of consciousness (low Glasgow coma scale score)
  • Cushing’s triad
  • cranial nerve abnormalities Ineffective Thermoregulation
  • hyperthermia or hypothermia
  • Constipation
  • Paralytic ileus
  • Fecal impaction
  • If the spinal injury is in the neck, the respiratory system is affected.
  • 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 The spinal cord can be bruised, punctured, or severed. 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 spine causes symptoms beyond the point of damage.
  • If the spinal injury is in the neck, the respiratory system is affected.
  • 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 TRAUMATIC BRAIN INJURY Head injury includes trauma or injury to the scalp, skull, or brain. According to the Centers for Disease Control and Prevention (2022), there are about 176 traumatic brain injury-related deaths per day. Head injury can be caused

by blunt force trauma, including car or bicycle accidents, falls, workplace accidents, or violence. By understanding the basic mechanisms of homeostasis after a head injury, the nurse should be able to:

  • Describe the types of head injuries and the associated complications.
  • Review assessment techniques that suggest neurological injury or damage.
  • Analyze and prioritize signs and symptoms associated with an acute head injury.
  • Evaluate the outcomes of a client after a head injury.
  • Discuss the effects of head injury on vulnerable populations.
  • Describe health promotion and prevention strategies to reduce the size and severity of head injury. Blunt Force An object hitting the head but not penetrating it can cause a concussion, contusion, or lead to hemorrhage. The physics causing a contusion will produce another injury on the opposite side of the brain. This is called a coup-contrecoup injury. Penetrating Injury An object may penetrate the skin and scalp, causing a penetration injury. The object may go through the skull as well. Scalp Lacerations An object opening the skin layer but not penetrating the skull results in scalp laceration. NOTE: Scalp lacerations by themselves are not usually significant but suggest an underlying blunt force trauma injury which can be life- threatening. Skull Fractures Like any other bone, the skull can break. There are several different types of fractures. If the injury to the skull causes increased intracranial pressure, generally, the pressure (blood or cerebral spinal fluid) can be relieved through the opening caused by the fracture. Factors Indications Hardness of the object hit The harder the object, the higher the possibility of cerebral edema or more serious underlying injuries. Speed at impact It may indicate the severity of brain injury. Location of head strike Indicates where in a local area an injury may be. Resulting skull An open area in the skull may relieve pressure of an
  • risk-taking behavior : more likely to reinjure
  • abuse : unknown previous injuries may be found
  • drug addiction : neurological changes may occur due to drug withdrawal
  • contact sports : post-concussive syndrome may occur Medication
  • anticoagulants : clients on this medication are at high risk for hematomas and bad outcomes
  • anti-seizure drugs : clients may have a previous history of seizures and may be at a higher risk. ASSESSMENT OF HEAD INJURY: SKULL FRACTURES In an acute head injury, assessment should focus on the immediate injury and the potential for cerebral edema. Because of head injury severity, the assessment may be done in a more rapid sequence to identify urgent nursing actions that may be needed. Airway and blood pressure changes are often related to cerebral edema or cerebral hemorrhage. While these are secondary changes, they can be deadly if not caught. Remember! Look for secondary changes of cerebral edema or hemorrhage—airway, breathing, and circulation! Start cardiopulmonary resuscitation (CPR) if needed. Then, assess for: Skull Fractures
  • bleeding from the ears or nose with a positive halo sign
  • bruising behind the ears (Battle sign)
  • bruising around the eyes (raccoon sign)
  • indentations in the skull ASSESSMENT OF HEAD INJURY: HEMORRHAGE OR EDEMA Cerebral Hemorrhage or Edema
  • reduced level or loss of consciousness (Glasgow coma scale [GCS])
  • abnormal cranial nerve assessment
  • Cushing’s triad (irregular respirations, bradycardia with bounding pulse, and hypertension with wide pulse pressure) Cushing’s triad is a late sign of increased intracranial pressure and is a medical emergency. It is a sign of impending brainstem compression and death. ASSESSMENT OF HEAD INJURY: NECK OF SPINAL CORD INJURY Neck or Spinal Cord Injury
  • history of head injury with significant force
  • paresthesia or paraplegia of arms or legs
  • spine deformity or asymmetry MANAGEMENT OF HEAD INJURY Management of head injuries requires a collaborative approach. Actions to assist with intracranial adaptive capacity, ineffective tissue perfusion, and/or acute confusion include:
  • Head position : Keep the head in a neutral position to allow proper venous drainage. Elevating the head to 30 degrees or less can reduce intracranial pressure.
  • Antihypertensives : These may be given to reduce the mean arterial pressure in the body and brain. However, lowering the mean arterial too much can affect the central perfusion pressure.
  • Hyperventilation : This may be used to keep carbon dioxide levels low, as carbon dioxide is a potent vasodilator that can contribute to edema by increasing intracranial blood flow and pressure.
  • Inducing a coma : This may be used to rest the brain, reduce blood pressure and anxiety, and allow better control of carbon dioxide and oxygen levels. Intubation and ventilator management are required.
  • Diuretics : Diuretics reduce fluid levels from edema in the brain.
  • Steroids : Steroids reduce the inflammatory response and decrease brain edema.
  • Manage drainage devices : External ventricular drainage devices may be used to decrease intracranial pressure and increase central perfusion pressure. When caring for a client with a head injury, there are independent nursing functions that will assist in the management and care of the client.
  • Administer tube feedings : These deliver controlled and adequate nutrition to a client who may be unable to chew or swallow, which is helpful for clients with decreased levels of consciousness.
  • Document strict input and output : Track fluids coming in and going out of the body to better measure the effectiveness of diuretic therapy and nutritional status.
  • Monitor urine output : Measurement of urine output can be an alert to complications of head injury such as diabetes insipidus (DI) or syndrome of inappropriate antidiuretic hormone (SIADH).
  • Weigh daily : This is the best way to track daily increases or decreases in fluids. It is also helpful as many medication dosages are calculated by weight.

infection, intracranial events, metabolic disorders, and other medical disorders.

The prodromal phase occurs hours or days before a seizure and includes

clinical manifestations such as difficulty sleeping, anxiety, restlessness, irritability, or difficulty concentrating.

The aural phase occurs immediately before the ictal phase (seconds to an

hour) and can include clinical manifestations such as bowel/bladder incontinence, diaphoresis, loss of consciousness, pallor, flushing, cyanosis, or tachycardia.

The ictal phase is the time period of seizures and can include clinical

manifestations such as tonic, clonic, absence, or myoclonus activity.

The postictal phase occurs immediately after the seizure and may include

clinical manifestations such as an altered level of consciousness, lethargy, confusion, or headache. DIAGNOSIS STUDIES/MEDICAL MANAGEMENT Diagnosis:

  • Rule out – CBC, liver/kidney function, urinalysis
  • Lumbar puncture
  • CT, EG Medical management:
  • Meds
  • Surgery
  • Vagal nerve stim
  • Diet DX STUDIES: Initial Diagnosis
  • A complete blood count (CBC), serum chemistries, studies of liver and kidney functions, and urinalysis may be done to rule out metabolic disorders as the cause of seizures.
  • A lumbar puncture may be used to collect cerebral spinal fluid for analysis to rule out infection as the cause of seizures.
  • A computerized tomography (CT) scan or magnetic resonance imaging (MRI) may be used to rule out a structural lesion as the cause of seizures.
  • Electroencephalogram (EEG) abnormalities can help determine the type of seizure and pinpoint the seizure focus. An EEG is not definitive. For example, clients without seizure disorders can have abnormal EEG

results, or clients with a seizure disorder may have normal EEG results between seizures. Ongoing Monitoring For clients who are prescribed antiepileptic medication, serum drug levels are monitored. Therapeutic drug ranges are only used as a guide for therapy. It is possible clients can have a therapeutic effect (no seizure activity) and a subtherapeutic drug level. MEDICAL MGMT : Antiepileptic Drugs The goal of drug therapy is to prevent seizures with minimal drug side effects. If seizure control is not achieved with a single drug, the dosage or timing of administration may be changed or a second drug may be added.

  • The most common drugs to treat tonic-clonic and focal-onset seizures are phenytoin (Dilantin), carbamazepine (Tegretol), phenobarbital, and divalproex.
  • The most common drugs to treat generalized-onset nonmotor and myoclonic seizures include ethosuximide (Zarontin), divalproex, and clonazepam (Klonopin). Surgery For clients who are not responsive to drug therapy and who have a defined site of seizure origin, surgical resection of the area may be considered. Vagal Nerve Stimulation This can be used as an adjunct to drugs when an accessible focal point cannot be identified for surgical removal. The exact mechanism of action is unknown. Responsive Neurostimulation Continually monitors electroencephalogram (EEG) to detect abnormalities and deliver electrical stimulation as needed, similar to a cardiac pacemaker. Ketogenic Diet A special high-fat, low-carbohydrate diet helps control seizures in some people. Note: Seizure treatment is determined by the type of seizure. NURSING ACTION FOR A SEIZURE During:
  • Airway
  • Safety
  • IV access
  • Document activity