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Neurological Dysfuntion

Neurological Dysfuntion

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Published by jrose28rendon

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Published by: jrose28rendon on Dec 01, 2009
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03/30/2013

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Increased (ICP) Intracranial Pressure
Intracranial pressure
more than 15 mmHg
Brunner= Normal intracranial pressure 10-20mmHg
Monro-Kellie hypothesis: because of limitedspace in the skull, an increase in any one skullcomponent—brain tissue, blood, or CSF—willcause a change in the volume of the others
Compensation to maintain a normal ICP of 10to 20 mm Hg is normally accomplished byshifting or displacing CSF
With disease or injury, ICP may increase
Increased ICP decreases cerebral perfusion,causes ischemia, cell death, and (further)edema
Brain tissues may shift through the dura andresult in herniation
Autoregulation: refers to the brain’s ability tochange the diameter of blood vessels tomaintain cerebral blood flow during alterationsin the systemic blood pressure
CO
2
plays a role; decreased CO
2
results invasoconstriction, and increased CO
2
results invasodilatation
Pathophysiology
 The cranium only contains the brainsubstance, the CSF and the blood/bloodvessels
MONRO-KELLIE hypothesis- an increase inany one of the components causes achange in the volume of the other
Any increase or alteration in these structureswill cause increased ICP
Increased ICP from any cause decreasescerebral perfusion, stimulates furtherswelling(edema, and may shift brain tissuethrough openings in the rigid dura,resulting in hernation, a dire and afrequently fatal eventCompensatory mechanisms:
1. Increased CSF absorption
2. Blood shunting
3. Decreased CSF production
Decompensatory mechanisms:
1. Decreased cerebral perfusion
2. Decreased PO2 leading to brainhypoxia
3. Cerebral edema
4. Brain herniation
Decreased cerebral blood flow
o
Increased ICP significantly reducecerebral blood flow, resulting inischemia and cell death
o
Vasomotor reflexes are stimulatedinitially
à
systemic pressure rises tomaintain cerebral blood flow
à
slowbounding pulses and respiratoryirregularities
o
Increased concentration of carbondioxide will cause VASODILATION
à
 increased flow
à
increased ICP
Cerebral Edema
o
Abnormal accumulation of fluid in theintracellular space, extracellular spaceor both.
o
Edema can occur in gray, white orinterstitial matter.
Herniation
Results from an excessive increase inICP when the pressure builds up andthe brain tissue presses down on thebrain stem
Cerebral response to increased ICP
 The brain can maintain a steadyperfusion pressure if the arterialsystolic blood pressure is 50 to 150mm Hg and the ICP is less than 40 mmHg
Cushing’s response- is seen whencerebral blood flow decreasessignificantly. When ischemic vasomotor center triggers an increasein arterial pressure in an effort toovercome the increased ICP
Vasomotor center triggers rise in BP toincrease ICP
Sympathetic response is increased BPbut the heart rate is SLOW
Respiration becomes SLOW
CCP (cerebral perfusion pressure) isclosely linked to ICP
CCP = MAP (mean arterial pressure) –ICP
Normal CCP is 70 to 100
A CCP of less than 50 results inpermanent neuralgic damage
Manifestations of Increased ICP—Early
o
Changes in level of consciousness
o
Abnormal respiratory and vasomotorresponse
o
Any change in condition
o
Restlessness, confusion, increasingdrowsiness, increased respiratoryeffort, and purposeless movements hasneurologic significance
o
Stuporous, reactive only to loud andpainful stimuli (serious stage of braincirculation is probably taking place)
 
o
Pupillary changes and impaired ocularmovements(Pupillary changes- fixed,slowed response)
o
Weakness in one extremity or one side
o
Headache: constant, increasing inintensity, or aggravated by movementor straining
o
Vomiting
o
Comatose and abnormal motorresponse in the form of decortication(abnormal flexion of the upperextremities and extension of the lowerextremities), decerbration (extremeextension of the upper and lowerextremities) of flaccidity
Manifestations of Increased ICP—Late
o
Respiratory and vasomotor changes
o
VS: increase in systolic blood pressure,widening of pulse pressure, andslowing of the heart rate; pulse mayfluctuate rapidly from tachycardia tobradycardia and temperature increase
Cushing’s triad: bradycardia,hypertension, and bradypnea
o
Projectile vomiting
o
Hyperthermia
o
Abnormal posturing
Complications
o
Brain stem herniation: results from anexcessive increase in ICP in which thepressure builds in the cranial vault andthe brain tissue presses down on thebrain stem. Results in cessation of blood flow to the brain, leading toirreversible brain anoxia and braindeath.
o
Diabetes Insipidus: results odecreased secretion of ADHs/symp: excessive urineoutput, decreased urineosmolality and serumhyperosmolality
o
SIADH: is the result oincreased secretion of ADH. Pt.becomes vol. overloaded, urine outputdiminishes, and serum sodiumconcentration becomes dilute.
o
Nursing Process—Assessment of the PatientWith Increased Intracranial Pressure
o
Conduct frequent and ongoingneurologic assessment
o
Evaluate neurologic status ascompletely as possible
o
Glasgow Coma Scale
o
Pupil checks
o
Assess selected cranial nerves
o
 Take frequent vital signs
o
Assess intracranial pressure
o
Nursing interventions:
o
Maintain patent airway 
1.
Elevate the head of thebed 15-30 degrees- to promote venous drainage
2. assists in
administering100% oxygen
or controlledhyperventilation- to reducethe CO2 bloodlevels
à
constricts bloodvessels
à
reduces edema
3. Administer prescribedmedications- usually
Mannitol- to producenegative fluid balance
corticosteroid- to reduceedema
anticonvulsants-p toprevent seizures
4. Reduce environmentalstimuli
5. Avoid activities that canincrease ICP like valsalva,coughing, shivering, andvigorous suctioning
6. Keep head on a neutralposition. ACOID- extremeflexion, valsalva
7. monitor for secondarycomplications
Diabetes insipidus- outputof >200 mL/hr
SIADH
Medical Management:
o
Monitoring Intracranial Pressure andCerebral Oxygenation:
Ventriculostomy: a fine-bore catheter isinserted into a lateral ventricle,preferably in the non dominanthemisphere of the brain.
Use to drain blood from the ventricle.Continuous drainage of CSF unde pressure control is an effective method of treating intracranial hypertension.
Subarachnoid screw or bolt: is a hollowdevice that is inserted through the skull
 
and dura mater into the cranialsubarachnoid space. Attached to thepressure transducer and the output isrecorded on an oscilloscope.
Epidural monitor: uses a pneumatic flowsensor and functions without electricity.
Disadvantage: inability to withdraw CSF for analysis
Fiberoptic monitor: or transducer-tippedcatheter is an alternative standardintraventricular, subarachnoid andsubdural system.
o
Decreasing Cerebral Edema
Osmotic diuretics: such as mannitol maybe administered to dehydrate the braintissue and reduce cerebral edema. Act bydrawing water across intact membranes,thereby reducing the volume of the brainand extracellular fluid.
If brain tumor is the caused of theincreased ICP, corticosteroids(dexamethasone) help reduce the edemasurrounding the tumor.
Limiting overall fluid intake leads todehydration and hemoconcentration,which draws fluid across the osmoticgradient and decreases cerebral edema.
Lowering body temperature woulddecrease cerebral edema by reducingthe oxygen and metabolic requirementsof the brain, thus protecting the brainfrom continued ischemia.
o
Maintaining Cerebral Perfusion
Cardiac output is made using fluidvolume and inotropic agents such asdobutamine hydrochloride (Dobutrex)and norepinephrine bitartate (Levophed).
The effectiveness of the cardiac output isreflected in the CCP, which is maintained at greater than 70 mm Hg.
o
Reducing Cerebrospinal Fluid andIntracranial Blood Volume
CSF drainage is frequently performed,because the removal of CSF with aventriculostomy drain can dramaticallyreduce the ICP and restore CCP.
o
Controlling Fever
Fever increases cerebral metabolismand the rate at which cerebral edemaforms.
Administration of antipyreticmedications and use of hypothermiablanket
o
Maintaining Oxygenation
o
Reducing Metabolic Demands
Cellular metabolic demands may bereduced through the administration of high doses of barbiturates if the pt. isunresponsive to conventional tx.
Barbiturates decrease ICP and protect the brain is uncertain; administration of  pharmacologic paralyzing agents suchas propofol (Diprivan)
Cerebrovascular Accident/ ischemic stroke/ brainattack 
Sudden loss of function resulting fromdisruption of the blood supply to a part of thebrain.
Different types of stroke based on the caused
o
Large artery thrombotic stroke: caused byartherosclerosic plaques in the large bloodvessels of the brain. Thrombus formationand occlusion at site of the artherosclerosisresult in ischemia and infarction.
o
Small penetrating artery thrombotic stroke:also called
lacunar stroke
because of thecavity that is created after the death of theinfracted brain tissue
o
Cardiogenic embolic stroke: associated withcardiac dysrhythmias, usually atrialfibrillation. Embolic stroke can also beassociated with valvular heart dse andthrombi in the left ventricle.
o
Cryptogenic stoke: which have no cause
o
Strokes from other causes: illicit drug use,coagulopathie, migraine and spontaneousdissection of the carotid or vertebral artery.
Pathophysiology
o
Disruption of the cerebral blood flow due toobstruction of a blood vessel → initiates acomplex series of cellular metabolic eventsreferred to as the ischemic cascade Cerebral blood flow decreases to less than25 mL per 100g per minute → neurons areno longer maintain aerobic respirations mitochondria switch to anaerobic whichgenerates large amount of lactic acid,causing a change in the pH level → Neuronsincapable of producing sufficient quantitiesof ATP → the membrane pumps electrolytebalance begin to fail and the cell cease tofunction.
o
Early in the cascade an area of low cerebralblood flow, referred to as the penumbraregion, exist around the area of infarction. The penumbra region is a ischemic braintissue that may salvaged with timelyintervention.
o
 The penumbra area maybe revitalized byadministration of tissue plasminogenactivator.
Clinical Manifestations
o
Numbness or weakness of the face, arm, orleg, especially on one side of the body
o
Confusion or change in mental status
o
 Trouble speaking or understanding speech
o
Visual disturbances
o
Difficulty walking, dizziness, or loss of balance or coordination
o
Sudden severe headache

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