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Neurologic System

DRMC PCU course - Neuro section
by

Sarah Fry

on 8 November 2016

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Transcript of Neurologic System

Neurologic System
Sarah Fry, MSN, RN
Neuro
Review

Protection
Autoregulation - process that ensures CBF despite changes to MAP in which vessels constrict and dilate to maintain adequate CBF.

Layers of the Brain - Meninges
Notice the vasculature
throughout the layers
Regions of the Brain
Supratentorium & Infratentorium
Cerebral Circulation
Functions of the Brain
Right sided injury
Emotional disturbances
Behavioral disturbances
Short attention span
Short term memory loss
Poor judgment
Spatial-perceptual disturbances
Left Sided Injury
Personality changes
Communication difficulty
Slow to action
Memory loss
Nerves and Spine
Neuro
Assessment
Level of Consciousness
Arousal & Awareness
Motor Function
Response
Symmetry
Coordination
Question:
In order to asses the patient's Trigeminal CN V, the nurse would do which of the following?
A: Ask the patient to shrug their shoulders.

B: Ask the patient to follow/track the penlight.

C: Test sensation on the face; forehead, cheek and jaw.

D: Ask the patient to smile and stick out their tongue.
http://www.strokecenter.org/wp-content/uploads/2011/07/NIH_Stroke_Scale_Booklet.pdf
NIH Stroke Scale
Stroke
Approximately 15-20% of all strokes
Ischemic
Its a perfusion problem!
Desired Outcomes:
Adequate brain perfusion
Recovery of neurological function
Prevention of complications
Prepare family for plan of care.
Hemorrhagic
Ischemic Strokes
Blood Pressure Parameters
Maintain normothermia
Current Standards:
non-tPA = SBP <200 mmHg or DBP <110 mmHg
with tPA = SBP <180 mmHg or DBP < 105 mmHg
Read your orders!!
Maintain Adequate glucose levels
HOB >30 degrees
Supplemental Oxygen
DVT Prophylaxis
Antiplatelets
(wait 24 hours if patient received t-PA)
Initiate PT, OT, ST
Physicians may treat with t-PA, carotid endarterectomy, interventional clot removal, or a combination.
Hemorrhagic Stroke
Blood Pressure Parameters
Maintain normothermia
Current Standards: SBP <140 mmHG
Read your orders!!
Maintain Adequate glucose levels
HOB >30 degrees
Supplemental Oxygen
DVT Prophylaxis
Initiate PT, OT, ST
Transfusions to correct coagulopathy
ICH, IVH
Core Measures
Core Measures, Ischemic Care Plan/Pathways
CORE MEASURES
Frequent Neuro checks
Question:
What is the purpose of placing stroke patients in semi-fowlers position (HOB 30 degrees)?
A: To allow for venous drainage

B: To prevent pressure ulcers

C: To prevent pneumonia
Intracranial Aneurysms
aSAH
Headache
CN deficits
Pain behind eye
Nausea/vomiting
Dizziness
Signs & Symptoms
Goals of Care
Minimize ischemia
Prevent complications
Prepare family
Anticonvulsant medications
Treatment
Neurosurgery - aneurysm clipping





Interventional - Coiling
Nursing Interventions
Same as hemorrhagic stroke with the following variations:
Target SBP <140 mmHg
READ YOUR ORDERS!!
Stool softeners to prevent straining
Calcium Channel Blocker (nimodipine) to prevent vasospasm
Magnesium Sulfate q4H
Hypertonic solutions (3% NaCl)
Frequent Na lab draws
Notify physician if >155
<30 mL/hr in PIV
Hypervolemia
Rebleeding
Potential Complications of
Intracranial Aneurysms
Most common during first 2 weeks before repair
Peak incidence 24-48 hours and 7-10 days after aSAH
Associated with significant mortality and morbidity
S/SX
Sudden severe headache
Nausea/vomiting
Neurologic deterioration
Management
Early repair after initial aSAH
Correct any coagulopathies
Potential Complications of
Intracranial Aneurysms
Vasospasm
Reduces cerebral blood flow leading to ischemia
Commonly occurs 3-14 days after rupture
Incidence & degree directly related to amount of blood in subarachnoid space
S/SX:
headache
ALOC
focal neurologic signs
Neurologic symptoms may not occur, could be subtle or dramatic
Management:
Calcium channel blocker
Triple H therapy (hypervolemia, hemodilution, hypertension)
Transcranial dopplers
Endovascular re-entry for stent
Potential Complications of
Intracranial Aneurysms
Hydrocephalus
Possible obstruction of CSF or impeding reabsorption of CSF
Onset delayed days or weeks
S/SX:
Decreased LOC
ataxia
headache
blurred vision
Nausea/Vomiting
Incontinence
Management:
Ventriclostomy
Transfer to ICU
Lumbar Drains
Arteriovenous
Malformations
Abnormal vascular network consisting of one or more direct connections between arteries and veins without an intervening capillary network.
Goals:
Obliteration without hemorrhage or tissue injury.
Minimize complications
Management:
If AVM ruptures - treatment is similar to aneurysm. Risk of vasospasm is slightly less than with ruptured aneurysm.
Treatment:
Radiosurgery
Craniotomy and microsurgery for resection
Embolization
Anticonvulsant medication
Neuromuscular Disorders
Myasthenia Gravis
Guillan-Barre Syndrome
Autoimmune affecting the peripheral nervous system
Triggered within ours or weeks of infection
Usually ascending flaccid paralysis
"rubbery legs"
deep aching
afebrile
Nursing Care
IVIg or Plasmapheresis (need dialysis access)
Respiratory management!
Turning Q2
HOB >30 degrees
Possible splints
Pain management
Speech therapy
Nutritional support
Chronic autoimmune
Defect in transmission of nerve impulses to muscles.
Weakness increasing with activity.
Drooping eyelids/facial expression
Dysphagia
Slurred speech
"Acute/Chronic inflammatory demyelinating polyneuropathy (AIDP)/(CIDP)"
(target 140-180 mg/dl)
Q15min x 2hrs; q30min x 4hrs; then per unit orders
With tPA: q15min x 2hrs; q30min x 6hrs; q1hr x 16hrs;
then per unit orders.
Core Measures
Question: Your post ischemic CVA patient's SBP is 95 mmHg. What should you do?
A: Document pressure, you are still within range of <200 mmHg.
B: Notify physician.
C: Administer labetalol 10 mg IV PRN.
Question: You arrive to your patients room for bedside report. What should be one of the first morning routines of a PCU nurse?
A: Administer the morning medications to get a head start.
B: Check the alarm parameters and adjust accordingly.
C: Check the care plan.
D: Document assessment findings before the morning rush.
Question: Your post-coil (day 10) aSAH patient has become confused and is complaining of a headache. You also notice that the blood pressure has decreased slightly. What appropriate intervention should you take?
A: Administer pain medication and reorient the patient.
B: Notify physician immediately.
C: Administer the Nimodipine early
D: Decrease the stimulation the patient is experiencing (dark, quiet room and rest).
Minimize environmental stimulation
Pupils
Don't get sued!
Sedation/analgesics
ALARMS, ALARMS, ALARMS!!!
Dysphagia Screening & NPO
BBB - Protection from toxic elements and organisms in the systemic blood system.
Ventricles & CSF - Fluid that cushions the brain and spinal cord. We make approximately 20 mL/hour. It is reabsorbed through the venous sinuses of the brain.
Monroe-Kellie Doctrine - when volume of one of three components of the brain (brain, blood, CSF) increases, the volume of one or both of the other must decrease or an increase in ICP occurs.
Brain Injuries
TBI
Primary Injury: Initial Insult
Secondary Injuries: delayed injury
hypoxia, ischemia, & neurotoxins
Concussion
Mild Brain Injury
Temporary neuro dysfunction caused by external force.
s/sx: vary (confusion, LOC, HA, memory loss)
Moderate to Severe Brain Injury
Contusion
Bruising to the brain
s/sx: dependent on size and location.
Skull Fractures
Linear & Comminuted
Most common
Depressed
Basal
Linear, Comminuted, Basal
Bleeds
Epidural Hematoma (EDH)
Laceration of dural arteries & veins
"Lucid Interval" followed by rapid deterioration
Acute Bleed
Commonly seen with skull fractures
Tx: surgery
Subdural Hematoma (SDH)
Bleeding between the dural and arachnoid layer
Most common type of bleed
Caused by tearing of veins
Acute, Subacute, Chronic
Tx based on size, and assessment factors
Medical management, drains, surgery
Traumatic Subarachnoid Hemorrhage (tSAH)
SAH
tSAH
Laceration of vessels in subarachnoid space
Medically managed
Intraventricular Hemorrhage & Intracerebral Hemorrhage (ICH)
Parenchymal Injuries from lacerations or contusions
Large deep cerebral vessel injury
* Parenchyma - function tissue of an organ
Diffuse Axonal Injury
Rotation & shearing injury of axons
Mild to severe
No treatment
Leads to long term cognitive disabilities and death
Intracranial Pressure (ICP)
Normal ICP 0-15 mmHg
Sustained ICP >20mmHg causes decreased CBF
Cerebral Perfusion Pressure (CPP)
CPP = MAP-ICP
Normal range 70-100mmHg
Pressure that drives cerebral blood flow

<iframe width="560" height="315" src="https://www.youtube.com/embed/v-1MQ0Cnbhs" frameborder="0" allowfullscreen></iframe>
Management of Increased ICP
Reduce Stimuli
Environmental
lights
sounds
temperature
Physical
positioning
restraints
Pain
shivering
Procedural
suction
coughing
Medical Management
Sedatives
risk of missing neuro changes
Osmotic Diuretics (mannitol)
filter straw
rapid bolus administration
keep Osmolality <320
Hypertonic Solution
3% NaCl - Q6H Na levels keep <150
23% NaCl - central line only, syringe pump administration
Decadron
blood glucose monitoring
Decompressive Craniectomy
s/sx of Increased ICP: dependent on location of exerted pressure
Early - change in LOC, CN changes (pupils, vomiting, "different" HA
Late - posturing, Cushing's Triad
Herniation
Removal of skull flap
Safety and care
Partial brain tissue oxygenation
Measurement possible through EVDs
Primary Injuries
Secondary Injuries
Cerebral Edema
Cytotoxic edema
results from hypoxic or toxic event damaging the cell's ability to pump water out of intracellular space.
Vasogenic edema
alteration in vascular permeability and disruption of the BBB resulting in increased extracellular space.
Seen in SAH, infection and masses.
Most common causes of secondary injury are hypoxia and hypotension
PbtO2
Regional CBF
Real-time tissue perfusion at capillary level
SjO2
jugular bulb venous oxygenation saturations
Ventriculostomy
A: Document the patient's LOC as "comatose".

B: Elicit a noxious stimuli, like nail bed pressure.

C: Document the patient's LOC as "unresponsive".
Question:
The patient will not open their eyes with verbal stimulation, what should be the nurses' next action?
Acute Brain Injury
Neurological
System

Seizures
causes
safety
assessment
EEGs
Pharmacology
Generalized Seizures
Partial Seizures
Whole body
bilateral symmetric
electrical discharges
LOC
amnesic effect
bilateral hemispheres
localized area
specific motor or sensory abnormalities
NO LOC
simple/complex
Status Epilepticus
Case Studies
Primary & Secondary Injury
Vertebral
Spinal cord
complete
incomplete
Spine Injuries
Neurogenic shock
T6 or above
disruption of the SNS
impulses from the brainstem are disrupted
Bradycardia, peripheral vasodilation below level of injury, hypotension
Spinal Shock
areflexia
not permanent
return of sensation leads to hyperreflexia and spasticity
Autonomic Hyperreflexia
noxious stimuli below level of SCI
bladder, constipation, fecal impaction, pressure ulcers
Sympathetic response triggered below level of injury leading to increased BP & HR causing a parasympathetic response above the level of injury
Complications: Cardio, GI, GU, Pulmonary, integumentary
https://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
Increased Brain, Cerebral Blood, Cerebrospinal Fluid
Management of carbon dioxide
Blood pressure management
Reduce metabolic demands
adequate Oxygenation
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