Grand Rounds Presentation

Grand Rounds Presentation

By Tiffany Myers

Core Measures

References

Outcomes / Goals

Patient Introduction

Temperature outside of therapeutic range should be corrected within one hour of onset.

A review of the use of therapeutic hypothermia in patients with elevated ICP concluded that a reduction of ICP was found in all studies.

Target temperature for therapeutic hypothermia:

32 - 34C or 89.6 - 93.2F

Sadaka and Veremakis (2012) .

Education about any visitation restriction should be provided on admission. Family visitation should be encouraged.

Studies indicate decreased patient anxiety, confusion, and agitation, decreased family anxiety, reduced cardiovascular complications, decreased length of stay, and increased overall quality of care

A study of auditory stimulation from familiar voices resulted in decreased ICP

If visitation is therapeutically contraindicated educate family on visitor lounges available

(McNett and Olsen, 2013)

Therapeutic hypothermia

Educate family on visitation

Pain management

Repositioning

American Association of Critical-Care Nurses. (2013). Assessing pain in the critically ill adult. Retrieved from: http://www.aacn.org/wd/practice/content/practicealerts/assessing-pain-critically-ill-adult.pcms?menu=practice

American Association of Critical-Care Nurses. (2011). Family presence: Visitation in the adult ICU. Retrieved from: http://www.aacn.org/wd/practice/content/practicealerts/family-visitation-icu-practice-alert.pcms?menu=practice

McNett, M., & Olson, D. (2013). Evidence to guide nursing interventions for critically ill neurologically impaired patients with ICP monitoring. Journal Of Neuroscience Nursing, 45(3), 120-123. doi:10.1097/JNN.0b013e3182901f0a

Rangel-Castillo, L., Gopinath, S., & Robertson, C. S. (2008). Management of intracranial hypertension. Neurologic Clinics. 26(2): 521-541. doi: 10.1016/j.ncl.2008.02.003

Sadaka, F., & Veremakis, C. (2012). Therapeutic hypothermia for the management of intracranial hypertension in severe traumatic brain injury: A systematic review. Brain Injury, 26(7/8), 899-908. doi:10.3109/02699052.2012.661120

Urden, L. D., Stacy, K. M., & Lough, M. E. (2012). Priorities in critical care nursing (6th ed.). St Louis, MO: Elsevier Mosby.

A 16 year old female in MVC was brought to Surgical Trauma Unit via Parkview Samaritan. The patient had a brain injury, broken ribs, lacerations to kidney, liver, spleen, stable pelvis fracture, and a ruptured bladder. Glasgow coma scale of 3.

Patient had an intracranial pressure (ICP) monitor and an anchored foley catheter. She was vented, sedated, and restrained for her safety. Only minor superficial injuries to the skin were present.

Increase hemoglobin

Decrease temperature

Pain control

Provide Comfort Measures

Prevent Complications

Patient should be adequately medicated 30 minutes prior to any interventions involving repositioning or transporting

Monitor ventilation and O2

Nutrition

Decreased brain swelling

Successful breathing trial

Discharge from ICU

Agitation and pain may significantly increase blood pressure and ICP

Adequate analgesia will reduce the requirements for sedation

Untreated pain can result in negative consequences impacting the patient’s functioning and quality of life

(Rangel-Castillo, Gopinath, & Robertson, 2008)

Patient should be repositioned every 2 hours

Repositioning prevents skin breakdown, promotes lung expansion, and reduces complications associated with immobility

Although repositioning may cause an initial increase in ICP, a study concluded that repositioning resulted in a statistically significant decrease in ICP after 5 minutes.

McNett and Olsen (2013)

Admission

Discharge

Handout

ICP Monitor

Assessment

0800 Day 2

Patient is resting with lights dimmed. Mother at bedside.

Vitals: HR 90, RR 16, BP 118/74, O2 98%, Temp 100.2

Urine output 125ml/hr, red tinged

ICP 6 mm Hg

Hgb 7.5 g/dL

When patient was turned onto right side, twitching of the right leg was noticed. ICP increased to 24 mm Hg but returned back normal after a few minutes

ICP monitors are devices that measure the intracranial pressure and are generally placed in any patient with concern for elevated ICP. Indication of ICP monitoring is mainly determined by Glasgow Coma Scale (<8).

Normal ICP is below 15 mmHg

Intracranial hypertension occurs when ICP is greater than 20 mmHg

Factors that increase ICP: head position, loud noises, restlessness, and stimulation

Symptoms: decreased level of consciousness, pupil changes, vomiting, headache, diminished brainstem reflexes and altered breathing patterns, and posturing

• Intracranial hypertension occurs with ICP above ________ mmHg.

• Early signs of increased ICP are decreased _________ ___ ______________,

____________ changes, vomiting and _____________ .

• Factors that increase ICP are ________ position, ________ ________, restlessness,

and _____________.

• Typical medications for patients with increased ICP are __________ diuretics, _____________,

______________, and _________________.

What should the nurse be concerned about?

What orders should the nurse anticipate?

(Urden, Stacy, & Lough, 2012)