Care of Hospitalized Adult Patient with Changing Intracranial Dynamics : Care of Hospitalized Adult Patient with Changing Intracranial Dynamics Presented by:
Cathy Garcia, MSN, RN BC, CNA BS Opening : Opening http://classes.kumc.edu/son/nurs420/unit7/intracranialpressure.htm Intracranial Dynamics : Intracranial Dynamics Cranium is a closed vault.
No room for expansion. Mastery Concepts : Mastery Concepts The brain controls all body functions.
Nurses have an impact on patient outcomes.
Prompt intervention is key.
Autonomous, decision-making and collaborative interventions are required.
Addressing psychosocial needs are critical. Objectives : Objectives Prioritize nursing interventions.
Provide nursing actions for care.
Psychosocial components analyzed.
Patient/Family Teaching evaluated. : The brain controls all body functions. 3 Components of ICP : 3 Components of ICP Brain
Normal ICP – 0 to 15 Intracranial Dynamics : Intracranial Dynamics Monroe-Kelly Hypothesis
Any increase in one must be compensated for by a reduction in one of the others in order for ICP to be maintained. S/S of Increased ICP : S/S of Increased ICP I – Increasing pulse pressure (Or widening)
C – Changes (LOC, Respiratory, Speech, Seizures, HR)
P – Posturing, Pain (H/A), Puking (vomiting), Pupils (4 P’s) Why worry about rising ICP? : Why worry about rising ICP? Causes increased pressure in the skull.
No room in skull to allow for swelling.
Causes hydrocephalus and/or shift in brain tissues.
Can cause partial or complete brain herniation.
Brain herniation cannot be repaired.
Results in brain death. Cushing’s Triad : Cushing’s Triad Cushion
3 Tassels on Cushion
Widening pulse pressure
Late SIGN!!! CPP : CPP Cerebral perfusion pressure (CPP): pressure needed to ensure blood flow to the brain. Normal: 70-100 mmHg.
Less than 60 CPP is a bad day!!!
(Note: CPP in 70s with vasopressors and volume risk of ARDS) What does the nurse do? : What does the nurse do? ………….and why? : ………….and why? Nursing Implications: Positioning : Nursing Implications: Positioning Neck in neutral position
Trach ties/hard collars loosened/removed if possible
Elevate HOB 30 Degrees – not more, not less
Minimize movement – Knee gatch
Avoid exercise, coughing, suctioning and straining. (If intubated, hyperoxygenate - 2 passes only less than 10 secs. - hyperventilation not recommended - lowers CO2 causes vasoconstriction. Goal: PCO2 at 30 to 35 mm Hg.) Nursing Implications : Nursing Implications Sedate prn. (diprivan better than morphine. Patient even recovers from suctioning quicker.) Nursing Implications : Nursing Implications Mannitol (pulls fluid to intravascular space, too large does elderly can result in overexpansion of extracellular fluid and circulatory overload………water intoxication, heart failure) Contraindicated in anuria, pulmonary congestion, severe dehydration, renal disease, active intracranial bleeding. Nursing Implications : Nursing Implications Hypertonic saline for refractory IICP Nursing Implications : Nursing Implications Cerebral edema can damage the hypothalamus. (temperature regulation – hyperthermia causing vasodilation which increases ICP which increases O2 demands) Nursing Implications : Nursing Implications Administer norepinephrine. (increases in cerebral blood flow, for each step of CPP increase , augmenting peak mean flow velocity of the middle cerebral arteries, and slightly increasing ICP) (dopamine gives inconsistent increase in CPP) Nursing Implications : Nursing Implications Monitor BP trends.
(Hypotension: ischemia injury, hypoxia,
increasedPCO2 which results in vasodilation .) Nursing Implications : Nursing Implications Monitor fluid volume status. Goal:Euvolemia Nursing Implications : Nursing Implications Ventriculostomy zeroed q shift minimium………..(verify with other nurse, foramen of Monro -line between top of ear and outer canthus of eye)
Measure ICP. Nursing Implications : Nursing Implications Assessing for CSF leaks–old test glucose…..inaccurate; beta sub2 transferrin test: CSF specific marker proteins.
Halo test Some things work well…….and others just might work……so… : Some things work well…….and others just might work……so… Nursing Implications : Nursing Implications PEEP Nursing Implications : Nursing Implications Institute hypertension as ordered as a prevention/treatment for vasospasm in subarachnoid hemorrhage patients. NANDA’s: Which one? When? : NANDA’s: Which one? When? Ineffective Cerebral Tissue Perfusion : Ineffective Cerebral Tissue Perfusion Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level.
▪Decreased level of consciousness
▪Hemiparesis or hemiplegia
▪Neurologic deficits are absent.
▪Blood pressure is within ordered parameters. Ineffective Cerebral Tissue Perfusion : Ineffective Cerebral Tissue Perfusion NURSING INTERVENTIONS AND RATIONALE
1.Collaborate with physician regarding the administration of thrombolytic therapy to facilitate lysis of the clot and restoration of blood flow to affected area.
2.Monitor the patient for alterations in blood pressure, oxygenation, temperature, rhythm, and glucose levels.
3.Collaborate with physician regarding the administration of vasodilators for hypertension to maintain the patient's blood pressure within desired range. Use caution in lowering blood pressure because hypotension decreases cerebral blood flow Decreased Intracranial Adaptive Capacity : Decreased Intracranial Adaptive Capacity Decreased Intracranial Adaptive Capacity related to failure of normal intracranial compensatory mechanisms
Definition: Increases in ICP in response to a variety of noxious and nonoxious stimuli Decreased Intracranial Adaptive Capacity: Defining Characteristics : Decreased Intracranial Adaptive Capacity: Defining Characteristics ▪ICP >15 mm Hg, sustained for 15 to 30 minutes
▪Vomiting, with or without nausea
▪Decrease in Glasgow Coma Scale score of 2 or more points from baseline
▪Alteration in level of consciousness, ranging from restlessness to coma
▪Change in orientation: disoriented to time and/or place and/or person
▪Difficulty or inability to follow simple commands
▪Increasing systolic blood pressure of more than 20 mm Hg with widening pulse pressure
▪Bradycardia Decreased Intracranial Adaptive Capacity: Defining Characteristics : Decreased Intracranial Adaptive Capacity: Defining Characteristics ▪Irregular respiratory pattern (e.g., Cheyne-Stokes, central neurogenic hyperventilation, ataxic, apneustic)
▪Change in response to painful stimuli (e.g., purposeful to inappropriate or absent response)
▪Signs of impending brain herniation:
—Hemiparesis or hemiplegia
—Unequal pupil size (1 mm or more difference)
—Failure of pupil to react to light
—Disconjugate gaze and inability to move one eye beyond midline if third, fourth, or sixth cranial nerves involved
—Loss of oculocephalic or oculovestibular reflexes Decreased Intracranial Adaptive Capacity: Outcome Criteria : Decreased Intracranial Adaptive Capacity: Outcome Criteria ICP is less than or equal to15 mm Hg.
Cerebral perfusion pressure (CPP) is greater than 60 mm Hg.
Clinical signs of increased ICP as previously described are absent. Decreased Intracranial Adaptive Capacity: Nursing Interventions : Decreased Intracranial Adaptive Capacity: Nursing Interventions 1.Maintain adequate CPP.
•Collaborate with physician regarding the administration of volume expanders, vasopressors, or antihypertensives to maintain the patient's blood pressure within normal range.
•Implement measures to reduce ICP.
(a)Elevate head of bed 30 to 45 degrees to facilitate venous return.
(b)Maintain head and neck in neutral plan (avoid flexion, extension, or lateral rotation) to enhance venous drainage from the head.
(c)Avoid extreme hip flexion.
(d)Collaborate with the physician regarding the administration of steroids, osmotic agents, and diuretics and need for drainage of cerebrospinal fluid (CSF) if a ventriculostomy is in place.
(e)Assist patient with turning and moving self in bed (instruct patient to exhale while turning or pushing up in bed) to avoid isometric contractions and Valsalva maneuver. Decreased Intracranial Adaptive Capacity: Nursing Interventions : Decreased Intracranial Adaptive Capacity: Nursing Interventions 2.Maintain patent airway and adequate ventilation, and supply oxygen to prevent hypoxemia and hypercarbia.
3.Monitor arterial blood gas (ABG) values and maintain Pao2 >80 mm Hg, Paco2 at 25 to 35 mm Hg, and pH at 7.35 to 7.45 to prevent cerebral vasodilation.
4.Avoid suctioning beyond 10 seconds at a time; hyperoxygenate and hyperventilate before and after suctioning.
5.Plan patient care activities and nursing interventions around patient's ICP response. Avoid unnecessary additional disturbances, and allow patient up to 1 hour of rest between activities as frequently as possible. Studies have shown the direct correlation between nursing care activities and increases in ICP.
6.Maintain normothermia with external cooling or heating measures as necessary. Wrap hands, feet, and male genitalia in soft towels before cooling measures Decreased Intracranial Adaptive Capacity: Nursing Interventions : Decreased Intracranial Adaptive Capacity: Nursing Interventions —Possible decorticate or decerebrate posturingto prevent shivering and frostbite.
7.With physician's collaboration, control seizures with prophylactic and as-necessary (PRN) anticonvulsants. Seizures can greatly increase the cerebral metabolic rate.
8.Collaborate with the physician regarding the administration of sedatives, barbiturates, or paralyzing agents to reduce cerebral metabolic rate.
9.Counsel family members to maintain calm atmosphere and avoid disturbing topics of conversation (e.g., patient condition, pain, prognosis, family crisis, financial difficulties). Decreased Intracranial Adaptive Capacity: Nursing Interventions : Decreased Intracranial Adaptive Capacity: Nursing Interventions 10.If signs of impending brain herniation are present, implement the following:
Notify the physician at once.
Be sure head of bed is elevated 45 degrees and patient's head is in neutral plane.
Administer mainline intravenous (IV) infusion slowly to keep-open rate.
Drain CSF as ordered if a ventriculostomy is in place.
Prepare to administer osmotic agents and/or diuretics.
Prepare patient for emergency computed tomography (CT) head scan and/or emergency surgery Intracranial Dynamics : Intracranial Dynamics Cranium is a closed vault.
No room for expansion.