AH Exam 3 - Neuro
Terms in this set (127)
Normal ICP clinically
Normal ICP in average person
Compensatory mechanisms for increased ICP
- CSF production decreases, or CSF shifts into spinal cord
- Vasoconstriction causes blood volume to shift/decrease
- Brain shifts, aka HERNIATION!! (bad)
increased ICP happens when...
compensatory mechanisms FAIL! yikes
What mmHg is considered increased ICP?
ICP 20-25 mmHg for LONGER THAN 5 MINUTES
How does decreased cerebral perfusion affect CO2 levels?
CO2 levels increase!! Causing vasoDILATION and increases ICP even more
When does localized area ischemia occur??
When ICP reaches 20 mmHg
- (call the Dr!!)
Interventions for increased ICP
- HOB 30-45 degrees
- Head midline and straight
- Straighten knees
- Widening pulse pressure (aka increasing SBP)
- LOW HR
- Respiratory changes
- Cushing's is a late sign of iiCP
Early s/s of iiCP
LATE s/s of iiCP
Goal SBP for for iiCP
What is Mannitol?
- An osmotic diuretic
- Decreases the size of brain cells
- Used to decrease high ICP
- Used to decrease cerebral edema
- Monitor serum osmolarity and sodium levels to make sure you don't over diurese the pt!
- Usually given as a bolus, in grams
3% Hypertonic saline
- Used to decrease high ICP
- Usually given at a continuous rate
Mannitol and Hypertonic Saline Monitoring
- Serum osmolarity
- Na level
- Q6 Na labs
- Make sure you're not diuresing the pt too much
Goal Na level
Affect of steroids on cerebral edema caused by INJURY
Edema caused by injury does NOT respond to steroids.
Ideal body fluid status
Why would you avoid glucose IV solutions?
Glucose IV solutions can increase ICP even more, because body uses the glucose and so you are basically just giving them extra water.
What is CPP?
Cerebral perfusion pressure
*Lower than 50 is bad
How do you calculate the CPP?
MAP minus ICP
(MAP-ICP) = CPP
What is MAP?
MAP is your "driving pressure" to the brain
- Mean Arterial Pressure
How to fix a low CPP
Increase the MAP or
Decrease the ICP
How to increase MAP (up to like 80 is good)
- Give fluids
How to decrease ICP
- Drain CSF
- Manage Blood Pressure
- Diuretics (mannitol)
- HOB 30-45 degrees
- Head midline/straight
- Knees straight
What is an EVD?
External Ventricular Drain
(AKA: a ventriculostomy)
What is an EVD used for?
- Drain CSF
- Monitor ICP
- Sample CSF (instead of doing LPs)
- Give meds (abx)
Where should the EVD transducer be placed?
EVD transducer should be level with the temporal noch of the patient
Normal ICP waveform has...
3 humps per waveform (P1, P2, P3, and P1 is the tallest)
What changes in waveform indicates decrease brain compliance?
- Elevated P2 waveform or
- Plateau waveform (P1, P2, and P3 are all leveled out)
occurring on the same side of the body
Pupillary changes occur on what side of the brain?
The SAME SIDE as the injury
Motor changes occur on what side of the brain?
The OPPOSITE side of the injury
ICP monitor waveforms that indicate decreased complaince
- P2 higher than P1 and P3
- Plateau waves
Goal CO2 level in neuro patient
IN a neuro pt we want less than 35 but greater than 32!!
(A normal healthy pt range is 35-45)
What is a decompressive craniectomy?
Bone flap taken out/off and left off, to decrease ICP
What is a temporal lobectomy?
Temporal portion of the brain is removed! Done sometimes in CVA patients to remove infarcted area
What is the AEIOU & TIPS acronyms used for?
Other causes of altered LOC
What are other causes of altered LOC?
A - alcohol
E - endocrine/electrolyte
I - insulin
O - oxygen
U - uremia
T - trauma/tumor
I - infection/ICP
P - poisoning (drugs)
S - Seizures/Stroke/Syncope
What are "blown" pupils
Pupils that are fixed a DILATED
What can cause blown pupils?
- Atropine dilates
- Ophthalmology exams dilate
What is the gold standard for ischemic stroke diagnosis?
Possible scores of GCS
(Low is bad)
Max possible GCS for an intubated patient
- max 4 eye opening
- max 6 motor response
- max 1 for no verbal response
What does a "positive pronator drift" look like
arms out, palms up (supination), and one of the arms pronates or drops a little bit
What does a positive pronator drift indicate?
Poor blood flow to the brain
- make sure that drift did not exist previously, and if it did then make sure it does not get worse
Brain disorders that increase ICP
- Brain tumors
- Cerebral vasospasms
- Electrolyte imbalance
- Traumatic Brain Injury (TBI)
- Focal Brain Injury
General signs of meningeal irritation
- nuchal rigidity
- Brudzinski's sign
- Kernig's sign
2 types of meningitis
Viral or Bacterial
Which type of meningitis pt has to be in isolation?
Bacterial, until they've been on abx for 24 hours.
s/s of viral meningitis
malaise, HA, N/V
s/s of bacterial meningitis
fever, seizures, restless
What is encephalitis?
Inflammation of the brain or spinal cord parenchyma (nerve cells, glia)
Encephalitis is almost always.... ?
What is the 80-10-10 rule?
Our head is full of:
s/s of encephalitis are similar to what?
s/s of meningitis.
Hallmark signs of meningeal irritation
- Brudzinski's sign
- Kernig's sign
Interventions for bacterial meningitis
Interventions for viral meningitis
- treat symptoms
Interventions for encephalitis
- ANTIVIRALS (if viral), usually more viral
Edema associated with brain tumors is very susceptible to what kind of therapy?
what is "mass effect"?
effect of brain tumor putting pressure on tissue around it and CSF
How do they fix pituitary tumors?
"Trans sphenoidal pituitary tumor resection"
What is a trans sphenoidal pituitary tumor resection?
Poke a long needle through the sphenoid sinus
RN assessment priority for someone who had a trans sphenoidal pituitary tumor resection
- CSF leaks
- test fluid for glucose (= CSF)
What is a "global bleed"
Associated with subarachnoid hemorrhage that bleeds all over
What can cause a subarachnoid hemorrhage (SAH)?
Aneurysm or AVM
What is an AVM?
- usually innate
- no s/s until rupture
- men 18-24
- disorganized AV capillary bed
Where are subarachnoid aneurysms most likely to occur?
- in the circle of willis
(because of all the bifurcations/splits)
s/s of SAH
- dec LOC
- nuchal pain
- lots of pain
Common phrase stated by pt with SAH
"I have the worst HA of my life"
SAH PRE-rupture pain s/s
- Pain above & behind the eye
- localized HA
- Possible ptosis (eye drooping)
- EOM deficits
- possible diplopia
- dilated pupils
POST rupture SAH s/s
- "worst HA of my life"
- dec or loss of consciousness
- s/s of stroke, except not unilateral symptoms because bleeding all over (not focal)
- increased ICP
- Meningeal irritation
- cerebral edema
When do you use steroids to treat cerebral edema?
If edema is caused by brain tumor!!
Test done to DX where cerebral bleeding is coming from
If LP is done when someone has an SAH, what do you expect?
Blood in the LP fluid. (all 3 bottles)
Goal CSF level
Less than 20!
If an aneurysm of a patient is NOT secured, what do you want the BP to be?
kinda low, to prevent more bleeding
What part of your brain regulates temperature?
What is nimodipine? Why is it used for SAH
Calcium channel blocker
- crosses blood brain barrier
- NOT used here for blood pressure control
- acts on vessels that are "mad" because they are surrounded by blood
- prevents cerebral vasospasm and subsequent distal ischemia
What drug is used to prevent vasospasm in SAH?
Nimodipine - CCB
Why are anticonvulsants given with SAH?
Because SAH lowers the seizure threshold.
When do cerebral vasospasm usually occur
3-12 days after initial hemorrhage
Electrolyte imbalance in SAH
- Low sodium (cerebral salt wasting)
What is hydrocephalus?
blood in the ventricles after SAH
Tx for hydrocephalus
- Temporary ventric drain to decrease CSF
- Repeat LPs to rif excess fluid
- VP shunt for CHRONIC hydrocephalus (brain doesn't reabsorb the blood on its own)
What is a primary TBI
A change or damage to the cranium that we cannot control (as nurses), it was already there from an injury
TBIs are what type of injuries?
What is a secondary TBI?
- Occurs when you don't manage your patient correctly!!
- cerebral edema/ischemia
- lyte imbalance
Examples of primary TBIs
- contusions (bruises)
- skull fractures
- shear injuries
- penetrating injuries
TX for cerebral edema
mannitol or 3% NS
Epidural hematomas are usually associated with what?
temporal or parietal skull fractures
Type of bleeding seen with epidural hematoma (Focal brain injury)
ARTERIAL! - most commonly the middle meningeal artery
Rapid accumulation of blood and a rapid decline is seen with which TBI?
Subdural hematoma is what type of bleeding?
Type of injury associated with subdural hematoma
- such as an elderly person falling from standing
What is a intra-cerebral hematoma?
- Bruise/bleeding deep in the brain tissue
- hard to remove/stop
- usually just control or tx s/s
What is herniation syndrome?
when brain tissue starts to shift
- late sign of IICP
When brain tissue protrudes outside of the skull
What is central transtentorial herniation?
Diencephalon moves down the brain stem
Which herniation syndrome causes RAPID changes
Central transtentorial herniation
What is uncle herniation?
Uncus spills over the tentorium cerebelli
Common s/s of uncle herniation
ipsilateral pupil dilation that turns into unilateral dilation and then dilated, fixed pupils. (bad)
Brain death can be determined if there is:
- Irreversible cessation of circulatory and respiratory functions
- Irreversible cessation of all functions of the entire brain including the brainstem
Criteria for brain death
- GCS of 3
- No motor/reflex movements
- Dolls eyes
- pupils fixed/dilated
- no oculovestibular reflex
- flat eeg
How long do these criteria have to be met?
For at least 6 hours after onset of unresponsive coma
- and after other potential causes have been resolved!
Build up of CO2 in the body stimulates what to make you breath?
- who then tell the brain to take a spontaneous breath
Apnea test includes
- take pt off vent
- give blow by O2
- watch for spontaneous breath
- draw labs and check CO2 levels
Check ABGs for...
If pt IS ACTUALLY brain dead, ABGs after/during apnea test will show a PaCO2 of..
HIGHER than 60 or
- more than 20 above baseline
The time of your blood gas with CO2 >60 or 20 above baseline is considered...
time of death.
An organ donor's code status is what?
- they are on life support until organs are placed and an OR is scheduled
SBP, Core temp, PaCO2, and PO2 must be above what before declaring brain death?
SBP > 100
Core temp > 36C or >97F
PCO2 between 34-45
PO2 between 100-200
Pre Donor MGMT goals (SBP, MAP< Hgb, Hct, etc)
- SBP >100
- Map > 65
- adequate hydration
- Vasopressor support (Dopamine), used for polyuria too
- Hgb >8
- Hct > 24
- Glucose 70-150
- PaO2 - >100
- pH 7.35-7.45
- PEEP 5-8
- UO 30ml/hr and <300 ml/hr
- Temp 36-37.5 (96.8-99.5)
4 Immunosuppressants (prevent rejection) and
3 Prophylactic (prevent infection)
- sirolimus & everolimus
- sulfamethoxazole/ trimethoprim (bactrim)
- anti-rejection (attacks helper Tcells)
- used for liver & kidney transplants
- lifelong tx
- associated with new onset diabetes & htn
- MUST be Q12
- monitor blood levels
- BRAND NAME NECESSARY
- avoid grapefruit
- AVOID PREGNANCY
(defects & miscarriage)
- affects WBCs & plts
sirolimus & everolimus
- anti-rejection (stop Tcell prolif)
- anemia (esp in combo w/ mycophenolate)
- anti-inflam & immuno suppress
- dec dose over days
- s/s : incr BG, dec bone density , ulcers, hallucinations, wt gain
- infx prophylaxis
- prevent fungal thrush
- oral tid
- Don't eat or drink for 20 minutes after!!
- PO once daily
- sun sensitive
- alternative tx is pentamidine inhalation tx Qmonthly
- Prophylaxis viral
- PO daily
- dec WHBs, N/V/D
What meds prevent acid reflux and ulcers?
General side effects of transplant meds
Weight gain, high blood pressure, high glucose levels, high cholesterol/triglycerides
- don't use salt substitutes or have grapefruit.
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