Exam 3 Review FINAL.
45: NEUROLOGIC PROBLEMS
MONITORING FOR INCREASED INTRACRANIAL PRESSURE
• Most at risk for increased ICP resulting from edema during the first 72 hr. after onset of
a stroke
• May have worsening neuro changes starting within 24-48 after their
endovascular procedure from increased ICP
• Assess these pt. Q 1-4 hr.
CHART 45-6 KEY FEATURES
• Decreased LOC (lethargy to coma)
• Behavior changes: restlessness, irritability, and confusion
• HA
• N/V (may be projectile)
• Change in speech pattern/slurred speech:
o Aphasia
• Change in sensorimotor status:
o Pupillary changes: dilated and nonreactive (“brown pupils”) or constricted
and nonreactive
o Cranial nerve dysfunction
o Ataxia
• Seizures (usually within first 24 hr. after stroke)
• Cushing’s triad:
o Severe HTN
o Widened pulse pressure
o Bradycardia
• Abnormal posturing:
o Decerebrate
o Decorticate
>> INTERVENTIONS
• For increased ICP experiencing a stroke:
o Elevate HOB – sitting them up is very important
o O2 therapy (for O2 < 94%)
o Maintain head in midline, neutral position – promotes venous drainage from
the brain
1
,Exam 3 Review FINAL.
o Avoid sudden and acute hip or neck flexion during positioning
o Avoid the clustering of RN procedures – can elevate ICP even more
▪ Not for neuro pt.
o Hyperoxygenate before and after suctioning
o Provide airway management to prevent unnecessary suctioning and
coughing that can increase ICP
o Maintain quiet environment if pt. has a HA
o Keep the room lights low to accommodate and photophobia
o MT BP, heart rhythm, O2 sat, blood glucose, and body temp to prevent
secondary brain injury and promote positive outcomes after stroke
▪ MD usually like BP to be slightly elevated after a stroke (SBP = 140-150)
• CRITICAL RESCUE!! – Be alert for S/S of increased ICP in the head injury and report
any neuro deterioration to the MD or Rapid Response Team immediately!
o The 1st sign of increased ICP is a declining LOC
2
,Exam 3 Review FINAL.
TRAUMATIC BRAIN INJURY (TBI)
>>> PATHO
• Can lead to temporary and permanent
impairment in cognition, mobility,
sensory perception, and psychosocial
function
• Direct injury: blow directly to the head
• Indirect injury: force applied to another
body part with a rebound effect to the brain
• Sheared: rebound or rotated on the
brain stem
• Bruised: contusion of the brain
• Torn: laceration of the brain as it moves
across the inner surface of the cranial
• Acceleration injury: caused by n external force contacting the head, suddenly
placing the head in motion
• Deceleration injury: occurs when the moving head is suddenly stopped or hits
a stationary object
•
PRIMARY BRAIN INJURY
• Occurs at the time of injury -- Dives and hits head
• Can be focal or diffuse
o Focal: confined to a specific area of the brain and causes localized damage
that can often be detected with a CT scan or MRI
o Diffuse: damage throughout many areas of the brain
▪ Usually too small to detect with CT scan at first but cn worsen to
a detectable size
▪ MRI can see microscopic injuries
• Classified as open or closed
o Open: when the skull is fractured or pierced by a penetrating object
o Closed: the integrity of the skull stays intact
• Further defined as mild, moderate, or severe – usually determined by the Glasgow
coma scale immediately after resuscitation, presence of brain damage shown in CT
scan or MRI, estimation of force of the trauma, and S/S
3
, Exam 3 Review FINAL.
SECONDARY BRAIN INJURY
• Any processes that occur after the initial injury and worsen or negatively influence
pt. outcomes.
o Increased swelling due to primary brain injury
• Result form physiologic, vascular, and biochemical events that are an extension of
the primary injury.
o Most common secondary injuries result from hypotension and
hypoxia, intracranial HTN, and cerebral edema.
o Damage to the brain tissue occurs primarily because the delivery of O2 and
glucose to the brain is interrupted from cerebral edema and increasing
pressure.
> HYPOTENSION AND HYPOXIA
• Hypotension = MAP < 70
o r/t shock or clot formation
• Hypoxemia = PaO2 < 80
o r/t resp. failure, asphyxiation, or loss of airway and impaired ventilation
o leads to decreased cognition
• These restrict the flow of blood to vulnerable brain tissue
> INCREASED INTRACRANIAL PRESSURE
• Normal level of ICP = 10 – 15 mm Hg
• A sustained ICP of 20 is detrimental to the brain because neurons begin to die
• As a result of brain injury, the increase in the volume of one component must
be compensated for by a decrease in the volume of one of the other
components
o Cerebral edema
• The brain can compensate for increased ICP by sending blood volume into the sinuses
or jugular veins.
• Increased ICP is the leading cause of death from head trauma in pt. who reach
the hospital alive
o Happens when the brain can no longer compensate for the increased ICP
o As ICP increases, cerebral perfusion decreases, leading to brain tissue
ischemia and edema
o Brain herniation syndrome: when the brain is forced downward thru the
Forman of Monro
> HEMORRHAGE
• Causes a brain hematoma (collection of blood) or clot, may occur at the primary
4
45: NEUROLOGIC PROBLEMS
MONITORING FOR INCREASED INTRACRANIAL PRESSURE
• Most at risk for increased ICP resulting from edema during the first 72 hr. after onset of
a stroke
• May have worsening neuro changes starting within 24-48 after their
endovascular procedure from increased ICP
• Assess these pt. Q 1-4 hr.
CHART 45-6 KEY FEATURES
• Decreased LOC (lethargy to coma)
• Behavior changes: restlessness, irritability, and confusion
• HA
• N/V (may be projectile)
• Change in speech pattern/slurred speech:
o Aphasia
• Change in sensorimotor status:
o Pupillary changes: dilated and nonreactive (“brown pupils”) or constricted
and nonreactive
o Cranial nerve dysfunction
o Ataxia
• Seizures (usually within first 24 hr. after stroke)
• Cushing’s triad:
o Severe HTN
o Widened pulse pressure
o Bradycardia
• Abnormal posturing:
o Decerebrate
o Decorticate
>> INTERVENTIONS
• For increased ICP experiencing a stroke:
o Elevate HOB – sitting them up is very important
o O2 therapy (for O2 < 94%)
o Maintain head in midline, neutral position – promotes venous drainage from
the brain
1
,Exam 3 Review FINAL.
o Avoid sudden and acute hip or neck flexion during positioning
o Avoid the clustering of RN procedures – can elevate ICP even more
▪ Not for neuro pt.
o Hyperoxygenate before and after suctioning
o Provide airway management to prevent unnecessary suctioning and
coughing that can increase ICP
o Maintain quiet environment if pt. has a HA
o Keep the room lights low to accommodate and photophobia
o MT BP, heart rhythm, O2 sat, blood glucose, and body temp to prevent
secondary brain injury and promote positive outcomes after stroke
▪ MD usually like BP to be slightly elevated after a stroke (SBP = 140-150)
• CRITICAL RESCUE!! – Be alert for S/S of increased ICP in the head injury and report
any neuro deterioration to the MD or Rapid Response Team immediately!
o The 1st sign of increased ICP is a declining LOC
2
,Exam 3 Review FINAL.
TRAUMATIC BRAIN INJURY (TBI)
>>> PATHO
• Can lead to temporary and permanent
impairment in cognition, mobility,
sensory perception, and psychosocial
function
• Direct injury: blow directly to the head
• Indirect injury: force applied to another
body part with a rebound effect to the brain
• Sheared: rebound or rotated on the
brain stem
• Bruised: contusion of the brain
• Torn: laceration of the brain as it moves
across the inner surface of the cranial
• Acceleration injury: caused by n external force contacting the head, suddenly
placing the head in motion
• Deceleration injury: occurs when the moving head is suddenly stopped or hits
a stationary object
•
PRIMARY BRAIN INJURY
• Occurs at the time of injury -- Dives and hits head
• Can be focal or diffuse
o Focal: confined to a specific area of the brain and causes localized damage
that can often be detected with a CT scan or MRI
o Diffuse: damage throughout many areas of the brain
▪ Usually too small to detect with CT scan at first but cn worsen to
a detectable size
▪ MRI can see microscopic injuries
• Classified as open or closed
o Open: when the skull is fractured or pierced by a penetrating object
o Closed: the integrity of the skull stays intact
• Further defined as mild, moderate, or severe – usually determined by the Glasgow
coma scale immediately after resuscitation, presence of brain damage shown in CT
scan or MRI, estimation of force of the trauma, and S/S
3
, Exam 3 Review FINAL.
SECONDARY BRAIN INJURY
• Any processes that occur after the initial injury and worsen or negatively influence
pt. outcomes.
o Increased swelling due to primary brain injury
• Result form physiologic, vascular, and biochemical events that are an extension of
the primary injury.
o Most common secondary injuries result from hypotension and
hypoxia, intracranial HTN, and cerebral edema.
o Damage to the brain tissue occurs primarily because the delivery of O2 and
glucose to the brain is interrupted from cerebral edema and increasing
pressure.
> HYPOTENSION AND HYPOXIA
• Hypotension = MAP < 70
o r/t shock or clot formation
• Hypoxemia = PaO2 < 80
o r/t resp. failure, asphyxiation, or loss of airway and impaired ventilation
o leads to decreased cognition
• These restrict the flow of blood to vulnerable brain tissue
> INCREASED INTRACRANIAL PRESSURE
• Normal level of ICP = 10 – 15 mm Hg
• A sustained ICP of 20 is detrimental to the brain because neurons begin to die
• As a result of brain injury, the increase in the volume of one component must
be compensated for by a decrease in the volume of one of the other
components
o Cerebral edema
• The brain can compensate for increased ICP by sending blood volume into the sinuses
or jugular veins.
• Increased ICP is the leading cause of death from head trauma in pt. who reach
the hospital alive
o Happens when the brain can no longer compensate for the increased ICP
o As ICP increases, cerebral perfusion decreases, leading to brain tissue
ischemia and edema
o Brain herniation syndrome: when the brain is forced downward thru the
Forman of Monro
> HEMORRHAGE
• Causes a brain hematoma (collection of blood) or clot, may occur at the primary
4
