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Neurosensory: Altered Cerebral Function and Increased intracranial pressure (IICP) Marnie Quick, RN, MSN, CNRN
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Etilogy/Patho Altered Cerebral Function: Consciousness Dynamic state in that it fluctuates Continuum from awareness of self and environment to unawareness Consciousness to deep coma Caused by: lesions/injury to the reticular system or cerebral cortex Metabolic disorders
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Altered Cerebral Function: Arousal/cognition (LOC) Patho/assessment Reticular Activating System (RAS) meshwork of gray cell within brainstem/thalamus. Controls wakefulness, arousal and alertness. Cerebral cortex outer layer of gray cell bodies of brain. Controls cognition, thought process.
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Reticular Activating System (RAS)
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Altered Cerebral Function: Assessment of arousal/cognition (LOC) Observe individual’s behavior, call name Verbal response to person/place/time/event If unable- how responds to commands If unable- how responds to central pain stimuli
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Assessment of arousal/cognition (Respiratory and pupillary light reflex) Respiratory- changes occur as brainstem is being compressed Pupillary light reflex- Sensory: CN 2 Motor: 3 Note pupil size; darken room; shine light in and note reaction and size Direct/consensual
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Assessment Arosual/cognition (EOM’S) Eye movement- CN 3,4,6 In COMA- test EOM’s Oculocephalic reflex Doll’s eyes- Sensory- CN 8; Motor- CN 3,4,6 Good Dolls eyes: eyes move in opposite direction of head movement Bad/negative Dolls eyes: eyes do not move head turned
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Assessment arousal/cognition (Motor) Strength, symmetry and ability to move Order from best to worse: Purposeful Generalized response Posturing- flexion or extension Flaccid Planter Reflex- Babinski testing Meningeal signs- Brudzinski, nuchal rigidity
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Decorticate posturing- abnormal flexion Decerebrate posturing- abnormal extension
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Planter Reflex and Babinski testing
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Common manifestations/Complications Coma states and brain death Irreversible coma- persistent vegetative state Does not have functioning cerebral cortex Caused by anoxia or severe brain injury Sleep-wake cycles; chew/swallow/cough, no track Locked-in Syndrome (not true coma) Functioning RAS/cortex; pons level interference Aware, communicate with eyes Brain death Loss of all brain function- flat EEG, no blood flow
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Prognosis of individual with altered cerebral functioning Outcome varies according to underlying cause and pathologic process The longer the individual unconscious, the longer has absent Doll’s eyes; the poorer the cognitive recovery Residual mental problem typically outweigh the physical
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Altered Cerebral Function Therapeutic Interventions Diagnostic tests- to R/O & identify cause of altered cerebral function Medications- Isotonic IV; D50; treat narcotic overdose; fluid/electrolyte replacement; antibiotics Surgery- to remove cause Other- airway/vent; treat IICP; enteral feeding
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Nursing assessment specific to altered cerebral function Terms used to describe (p.1347) Description more important than term Health history- drugs/head injury/metabolic Physical exam- modify as individual cooperation Neuro Vital Signs (p.1299) Glasgow coma scale (p. 1299)
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Altered Cerebral Functioning: Pertinent Nursing problems Ineffective airway Risk for aspiration Risk for impaired skin integrity Impaired physical mobility Risk for imbalanced nurtition Ineffective coping- Family Home care
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Increased Intracranial Pressure (IICP) Normal Brain Monro-Kellie hypothesis Intracranial pressure:5-15 mmHg;60-180cm H2O Cerebral perfusion pressure: MAP-ICP=CPP; Normal: 80-100 mmHg; minimal blood flow 50; brain death 30 mmHg Autoregulation- cerebral arterioles change diameter to maintain CBF when ICP rises; need nomal range of MAP to occur; pressure (BP) and chemical (CO2) autoregulation
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Increased Intracranial Pressure Pathophysiology of intracranial hypertension Monro-Kellie hypothesis Cushing reflex- BP and Pulse Brain shifts- herniation syndromes Symptoms progress in relation to these physiological changes
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Increased Intracranial Pressure (IICP) Cerebral edema/hydrocephalus Cerebral edema- Increases the volume of brain tissue which can cause herniation Hydrocephalus- Noncommunicating Communicating
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Subarachnoid space with arachnoid villi
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Increased Intracranial Pressure (IICP) Brain Herniation Syndromes Cingulate herniation Central (transentorial) Uncal (lateral) Infratentorial herniation Extracranial herniation
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Brain herniation
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Normal brain and Herniation Syndromes
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Increased Intracranial Pressure Common manifestations/complications Result of compression of brain function Level of consciousness most important sign Second- pupil changes as 3 rd nerve is compressed Others- p.1355 Speed of IICP how fast cause develops Cushing reflex late sign Complication of IICP is permanent disability, coma, death
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Increased Intracranial Pressure (IICP): Therapeutic Interventions Diagnostic tests- to find cause; monitor hydration/O2 Medications Osmotic/loop diuretics; antipyretics; anticonvulsants; antiulcer; IV fluids; TPN; vasoactive drugs for MAP; barbiturate coma Hypothermia Surgery- remove cause; shunt/drain Mechanical ventilation ICP monitoring Other monitors- Jugular venous O2; partial pressure O2 in brain tissue
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Intraventricular and subarachnoid monitoring devices for IICP
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Intraventricular drainage system
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Increased intracranial pressure (IICP): Nursing assessment specific to IICP Health history- assess brain involvement Physical exam- Altered cerebral function assessment Frequency depends on potential IICP Early sign- change in LOC 3rd Cranial nerve compression Papilledema, projectile vomiting, vision changes, seizures (p. 1355) Late sign- Cushing VS changes– Know!
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Increased intracranial pressure (IICP): Pertinent Nursing Problems and Interventions Ineffective tissue perfusion: cerebral Assess/report sign IICP Adequate airway Promote venous drainage Control environment stimuli Plan nursing care Avoid Valsalva’s maneuver If bone flat out post op- assess Assess external shunts/drains
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