Nursing Management: Acute Intracranial Problems Chapter 57 Overview Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Intracranial Pressure (ICP) Fig. 57-1. Components of the brain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Intracranial Pressure (ICP) Regulation and Maintenance of ICP Normal ICP Normal compensatory adaptations Cerebral Blood Flow Autoregulation of cerebral blood flow Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Intracranial Pressure (ICP) Table 57-1. Calculation of Cerebral Perfusion Pressure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

Intracranial Pressure (ICP) Cerebral Blood Flow, continued Pressure changes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

Intracranial Pressure (ICP) Fig. 57-2. Intracranial pressure-volume curve. (See text for descriptions of 1, 2, 3, and 4.) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Intracranial Pressure (ICP) Cerebral Blood Flow, continued Factors affecting cerebral blood flow Mechanisms of Increased ICP Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Intracranial Pressure (ICP) Fig. 57-3. Progression of increased intracranial pressure (ICP). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Intracranial Pressure (ICP) Fig. 57-4. Herniation. A, Normal relationship of intracranial structures. B, Shift of intracranial structures. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Intracranial Pressure (ICP) Cerebral Edema Vasogenic cerebral edema Cytotoxic cerebral edema Interstitial cerebral edema Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Increased Intracranial Pressure (ICP) Clinical Manifestations Change in level of consciousness Changes in vital signs Ocular signs Decrease in motor function Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Increased Intracranial Pressure (ICP) Fig. 57-5. Decorticate and decerebrate posturing. A, Decorticate response. Flexion of arms, wrists, and fingers with adduction in upper extremities. Extension, internal rotation, and plantar flexion in lower extremities. B, Decerebrate response. All four extremities in rigid extension, with hyperpronation of forearms and plantar flexion of feet. C, Decorticate response on right side of body and decerebrate response on left side of body. D, Opisthotonic posturing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Increased Intracranial Pressure (ICP) Clinical Manifestations, continued Headache Vomiting Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Increased Intracranial Pressure (ICP) Complications Diagnostic Studies Monitoring of ICP and Cerebral Oxygenation Indications for ICP monitoring Methods of measuring ICP Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Increased Intracranial Pressure (ICP) Fig. 57-6. Coronal section of brain showing potential sites for placement of ICP monitoring devices. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Increased Intracranial Pressure (ICP) Fig. 57-7. Intracranial pressure monitoring can be used to continuously measure ICP. The ICP tracing shows normal, elevated, and plateau waves. At high ICP the P2 peak is higher than the P1 peak, and the peaks become less distinct and plateau. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Increased Intracranial Pressure (ICP) Fig. 57-8. Ventriculostomy in place. CSF can be drained via a ventriculostomy when ICP exceeds the upper pressure parameter set by the physician. Intermittent drainage involves opening the three-way stopcock to allow CSF to flow into the drainage bag for brief periods (30 to 120 seconds) until the pressure is below the upper pressure parameters. ICP, Intracranial pressure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Increased Intracranial Pressure (ICP) Fig. 57-9. A, Leveling a ventriculostomy. B, CSF is drained into a drainage system. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Increased Intracranial Pressure (ICP) Table 57-4. Normal ICP Waveforms*. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Increased Intracranial Pressure (ICP) Monitoring of ICP and Cerebral Oxygenation, continued CSF drainage Cerebral oxygenation monitoring Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Increased Intracranial Pressure (ICP) Fig. 57-10. The LICOX brain tissue oxygen system involves a catheter inserted through an intracranial bolt (A). The system measures oxygen in the brain (PbtO2), brain tissue temperature, and intracranial pressure (ICP) (B). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Increased Intracranial Pressure (ICP) Collaborative Care Drug therapy Nutritional therapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Nursing Management: Increased Intracranial Pressure (ICP) Nursing Assessment Glasgow coma scale Neurologic assessment Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Nursing Management: Increased Intracranial Pressure (ICP) Fig. 57-11. Pupillary check for size and response. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

Nursing Management: Increased Intracranial Pressure (ICP) Fig. 57-12. Common abnormal respiratory patterns associated with coma. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Nursing Management: Increased Intracranial Pressure (ICP) Nursing Diagnoses Planning Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Nursing Management: Increased Intracranial Pressure (ICP) Nursing Implementation Acute intervention Respiratory function Fluid and electrolyte balance Monitoring ICP Body position Protection from injury Psychologic considerations Evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Types of Head Injuries Scalp lacerations Skull fractures Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Fig. 57-13. A, Raccoon eyes and rhinorrhea. B, Battle’s sign (postauricular ecchymosis) with otorrhea. C, Battle’s sign. D, Halo or ring sign (see text). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Types of Head Injuries, continued Head trauma Diffuse injury Diffuse axonal injury Focal injury Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Fig. 57-14. Coup-contrecoup injury. After the head strikes the wall, a coup injury occurs as the brain strikes the skull (primary impact). The contrecoup injury (the secondary impact) occurs when the brain strikes the skull surface opposite of the site from the original impact. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Complications Epidural hematoma Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Fig. 57-16. Epidural hematoma covering a portion of the dura. Multiple small contusions are seen in the temporal lobe. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Complications, continued Subdural hematoma Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Fig. 57-15. Locations of epidural, subdural, and subarachnoid hematomas. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Head Injury Complications, continued Intracerebral hematoma Diagnostic Studies and Collaborative Care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

Nursing Management: Head Injury Nursing Assessment Nursing Diagnoses Planning Nursing Implementation Health promotion Acute intervention Ambulatory and home care Evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Brain Tumors Types Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Brain Tumors Fig. 57-17. A, Glioblastoma. A large glioblastoma (G) arises from one cerebral hemisphere and has grown to fill the ventricular system. B, Meningioma. These two different sections from different levels in the same brain show a meningioma (M) compressing the frontal lobe and distorting underlying brain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Brain Tumors Clinical Manifestations and Complications Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Brain Tumors Fig. 57-18. Each area of the brain controls a particular activity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Brain Tumors Diagnostic Studies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Brain Tumors Collaborative Care Surgical therapy Ventricular shunts Radiation therapy and stereotactic radiosurgery Chemotherapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

Nursing Management: Brain Tumors Nursing Assessment Nursing Diagnoses Planning Nursing Implementation Evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Surgery Types Sterotactic surgery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Surgery Fig. 57-19. Stereotactic frame. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Cranial Surgery Types, continued Craniotomy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

Nursing Management: Cranial Surgery Nursing Assessment Nursing Diagnoses Planning Nursing Implementation Acute intervention Ambulatory and home care Evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

Inflammatory Conditions of the Brain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Brain Abscess Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Bacterial Meningitis Etiology and Pathophysiology Clinical Manifestations Complications Diagnostic Studies Collaborative Care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51

Nursing Management: Bacterial Meningitis Nursing Assessment Nursing Diagnoses Planning Nursing Implementation Health promotion Acute intervention Ambulatory and home care Evaluation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 52

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Viral Meningitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Encephalitis Clinical Manifestations and Diagnostic Studies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 54

Nursing and Collaborative Management: Encephalitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Rabies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 56