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Nur 265 Exam 3 Study Guide Well Elaborated And Latest Document
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Nur 265 Exam 3 Study Guide WellElaborated And Latest Document
Increased ICP (939-940, chart 941)
Normal ICP 10-15 mmHg, pressures >20 mmHg impair cerebral circulation
IICP is leading cause of death from head trauma in pts who reach the hospital alive.
Cerebral Perfusion Pressure (CPP)
o
Blood flow required to provide adequate oxygenation & glucose for brain metabolism
o
Maintenance above 70 mmHg
o
CPP= MAP-ICP
▪ MAP= (2xD) + S MAP NEEDS TO BE ATLEAST 80
3
Compensation
o
First Response – CSF is shunted or displaced into the spine (compliance)
o
Next – Reduction of blood volume in the brain (autoregulation)
o
As ICP continues to increase cerebral perfusion decreases leading to brain tissue ischemia, edema,
vasodilation then acidosis which causes further increases ICP
o
In edema remains untreated the brain may herniate into spinal canal – death from brain stem
compression
Assessment Findings
o
Changes in LOC – First sign of IICP is declining LOC & includes restlessness or confusion to Stuporous
▪ W/o glucose & 02, brain shuts down. Ex. Pt knew who you were in am & now don’t
remember
o
Headache – Quite environment may have photophobia so keep room lights very low.
o
Change in speech pattern – Aphasia, Slurred Speech
o
Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify
Dr
▪ Normal is 6 mm. Getting better if going back toward normal from dilated or constricted
▪ Uneven pupils tx as IICP until proven otherwise; pinpoint - brain stem (pons) dysfunction
o
Abnormal Posturing – Decorticate (flexion) or Decerebrate (extensor)
▪ Decorticate – arms drawn to core, legs straight
▪ Decerebrate – arms straight and stiff, pts rarely survive
o
Hyperthermia – followed later by hypothermia
▪ When hypothermic – BE CONCERNED, pressure on hypothalamus located next to brain stem
o
Cardiac & respiratory rate/rhythm changes
▪ Tachy first – Increased HR & RR before brady HR & RR
o
N/V – Common in IICP
o
Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia
▪ Late response & indicates severe IICP w/loss of autoregulation, Imminent death
▪ Systolic BP increases bc decreased blood flow to brain
▪ Pressure on Vagus nerve and brainstem = bradycardia
Managing IICP
o
Elevate HOB 30-45 degrees (unless contraindicated)
▪ If hypotension, elevate HOB where CPP >70
o
Maintain head in a midline neutral position
o
Avoid sudden and acute hip or neck flexion during positioning – Log roll pt
o
Avoid clustering of care (bath followed by linen change)
o
Coughing and suctioning increase ICP
o
Decrease cerebral edema – osmotic diuretics (mannitol) & fluid restriction
1
, ▪ Mannitol is hypertonic- pulling fluid into vascular space- will inc. fluid output & monitor BP
for HTN
▪ Furosemide used in adjunct to reduce incidence of rebound from mannitol. Helps reduce
edema & blood volume, decrease Na uptake by the brain, & decrease production of CSF at
choroid plexus.
o
LOW CSF using intraventricular drain system
o
Control fever w/antipyretics or cooling blanket – do not allow pt to shiver as will increase ICP
▪
▪
▪
▪
▪
▪ When febrile every cell in body needs more 02 and glucose
o
Oxygenation – Hyperventilate on a vent to decrease CO2 which causes vasodilation
o
Reduce cellular metabolic demands – barbiturates (-bital, -barbital) and/or sedation (coma)
2
, Traumatic Brain Injury (946-957)
Primary Brain Injury
o
Occurs at time of injury
o
Open – Head fractured or penetrated; Closed – Blunt trauma, shaken baby
o
Open Head Injuries
▪ Skull Fractures
Linear Fx – thin line on x-ray, no tx unless underlying brain tissue damaged
Depressed Fx – Brain damage from bruising (contusion), laceration from bone
fragments
Basilar skull Fx – Fx of bones of the base of skull & results in CSF leak from nose &
ears.
o
May not be seen on plain x-ray, R/F Infection w/ CSF leak
o
Manifested by bruises around eyes(raccoon eyes) or behind ears (Battle’s sign)
o
Has potential for hemorrhage if it damages the internal carotid
o
Closed Head Injuries
▪ Caused by blunt force trauma
▪ Contusion – Bruising to brain tissue @ site of impact (coup) or opposite (contercoup)
▪ Laceration – tearing of the cortical surface vessels, lead to secondary hemorrhage,
cerebral edema and inflammation
▪ Diffuse Axonal Injury (DAI) – Tissue of entire brain from high speed acel/decel MVC
Impaired cognitive functioning, results in disorganization, impaired memory
Severe will present with immediate coma, survivors require lone-term care
o
Classified as
▪ Mild – GCS 13-15 (concussion)
Blow to head, transient confusion, or feeling dazed or disoriented
Loss of consciousness for up to 30 min, loss of memory before and after accident
No evidence of brain damage, sx resolve w/i 72 hrs
Sx: HA, N/V, Fatigue, Foggy, Balance off, Irritable, Sad, Nervous, Emotional,
Visual probs
▪ Moderate – GCS 9-12
Loss of consciousness 30 min – 6 hrs w/ memory loss up to 24 hrs.
Short hospital stay to prevent secondary injury
Memory loss up to 24 hrs.
▪ Severe – GCS 3-8
Loss of consciousness >6 hrs
High risk for secondary brain injury from cerebral edema, hemorrhage, reduced
perfusion
Pupil changes, Bradycardia, Papilledema, HTN w/wide PP, Nuchal rigidity if CSF leak
o
Glasgow Coma Scale
▪ Score from 3-15; score 3-8 in a coma
▪ A change of 2 points requires immediate notification to HCP
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