Solution Manual for Understanding the Essentials of

Critical Care Nursing : 0131722107

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Solution Manual for Understanding the Essentials of Critical Care Nursing : 0131722107

Perrin 1e IRM

Chapter 10 Care of the Patient with a Cerebral or

Cerebrovascular Disorder
RESOURCE LIBRARY

COMPANION WEBSITE

Case Study: The Patient with Patient with a Cerebral or Cerebrovascular Disorder

Nursing Care Plan

NCLEX Review Questions

Media Links

Media Link Applications

IMAGE LIBRARY

Figure 10-1 Functions of the lobes of the brain.

Figure 10-2 Cerebral Blood Flow.

Figure 10-3 Focal Symptoms that develop with damage to specific areas of the brain.

Figure 10-4 Aneurysm with clip.

Figure 10-5 Aneurysm with Guglielmi coils.

Learning Outcome 1
List the common manifestations of brain tumors and explain their causation.

Concepts for Lecture

1. Brain tumors classified as primary or metastatic.

2. Manifestations

a. Invasion of the brain parenchyma

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 b. Compression of brain tissue

c. Development of cerebral edema

d. Obstruction of flow of cerebrospinal fluid

PowerPoint Lecture Slides

1. Manifestations

• Invasion of the brain parenchyma

• Compression of brain tissue

• Development of cerebral edema

• Obstruction of flow of cerebrospinal fluid

2. Mechanisms cause symptoms related to the increased mass within the cranial cavity and the

increased intracranial pressure (IICP).

3. Clinical Manifestations of Brain Tumors:

• Headache

o Initial symptom 40% of people with a primary brain tumor

o 80% of people will complain of headache by the time of diagnosis

o Worse in the morning

o May worsen with coughing, exercise, or with a change in position

o Does not respond to usual headache remedies

4. Clinical Manifestations of Brain Tumors:

• Nausea and vomiting

o 30% of patients
 o May accompany headache

5. Clinical Manifestations of Brain Tumors:

• Drowsiness and visual disturbances

o Blurred, double vision, loss of peripheral vision occur in 25% of patients

• Swollen optic nerve

o Young children

o Slow-growing tumors

o Tumors in the posterior fossa

6. Clinical Manifestations of Brain Tumors:

• Mental and/or personality changes

o Problems with memory (especially short-term memory)

o Speech

o Communication and/or concentration changes to severe intellectual problems

o Confusion

o Changes in behavior, temperament and personality depending on where the tumor is

located

7. Clinical Manifestations of Brain Tumors:

• Seizures

o Result from tumor irritation of brain tissue

o Dependant on the location and type of the tumor

o Age of the patient

o Slow-growing tumors near the cerebral cortex (meningiomas)

▪ More likely in younger adults

 o May present as generalized convulsions with loss of consciousness

o Focal seizures, such as muscle twitching or jerking of an arm or leg, abnormal smells

or tastes, problems with speech, or numbness and tingling

Learning Outcome 2
Explain why glucocorticoids are administered to patients with brain tumors.

Concepts for Lecture

1. Glucocorticoids—mainstay treatment vasogenic cerebral edema

a. Decreasing swelling associated with brain tumors

2. Dexamethasone

PowerPoint Lecture Slides

1. Glucocorticoids Mainstay Treatment

• Effect vascular endothelial cell function and restore normal capillary permeability

• Glucocorticoid therapy with dexamethasone the standard treatment to decrease cerebral

edema

2. Glucocorticoid therapy with dexamethasone treatment

• Decreases tissue swelling

• Manages some signs and symptoms

o Headaches

o Seizures

▪ Focal

▪ Tonic clonic seizures

▪ Status epilepticus
 o Motor deficits

o Altered mental status

3. Dexamethasone: The Corticosteroid of Choice

• High potency

• Low mineralocorticoid effect that decreases sodium retention

• 48-hour half-life

• Side effects

Learning Outcome 3
Compare and contrast the care of patients with supratentoral, posterior fossa, and pituitary

tumors.

Concepts for Lecture

1. Supratentoral

a. Type of tumor

b. Age of patient

c. Surgical considerations

d. Nursing consideration

2. Posterior fossa

a. Type of tumor

b. Age of patient

c. Surgical considerations

d. Nursing consideration

3. Pituitary tumors
 a. Type of tumor

b. Age of patient

c. Surgical considerations

d. Nursing consideration

PowerPoint Lecture Slides

1. Types of Surgery

• Supratentoral

• Posterior Fossa

• Transphenoidal

2. Types of Tumors

• Supratentoral

o May be either a metastatic or a primary brain tumor

• Posterior Fossa

o Primary brain tumors often of cerebellum, perhaps of acoustic nerve

• Transphenoidal

o Pituitary tumors

3. Age of Patient

• Supratentoral

o Majority of adult tumors are

• Posterior Fossa

o 15–20% of adult and

 o 55–70% of pediatric tumors

• Transphenoidal

o 10% of adult tumors

4. Surgical Considerations

• Supratentoral

o Mapping may be used to avoid “eloquent” areas of the brain.

• Posterior Fossa:

o Small enclosed space near critical brain structures, including the brain stem,

cerebellum, and cranial nerves

• Transhpenoidal

o Approach is through the nose and sinuses.

o Pituitary sits on the optic chiasma.

5. Nursing Considerations

• Supratentoral

o Patients are usually positioned with their head of the bed elevated 30 degrees

postoperatively.

o Patients are not turned to the side of the tumor, if a large tumor has been removed.

o Assess at least Glasgow Coma Scale, pupils, strength, movement, and sensation in

extremities.

6. Nursing Considerations

• Posterior Fossa
 o Level of the head of patient’s bed varies by institution from flat to elevated 60

degrees.

o Prevent patient from pronounced flexion or extension of the neck post-op.

o Assess function of cranial nerves (V, VII, VIII, IX, and X).

o Evaluate coordination.

7. Nursing Considerations

• Transphenoidal

o Maintain head of the bed elevated 30 to 45 degrees.

o Provide a moustache dressing.

o Assess for CSF leakage on dressing.

o Discourage patient from sneezing and blowing nose.

o Assess for visual field defect.

o Assess pituitary function and identify presence of diabetes insipidus.

Learning Outcome 4
Summarize strategies used to prevent common complications post craniotomy.

Concepts for Lecture

1. Postsurgical complications

2. Four potentially serious complications

3. Systemic venous thromboembolism

4. Cerebrospinal fluid leaks

5. Meningitis

6. Seizures
7. Pain

a. Codeine phosphate

8. Strategies to prevent these common complications

9. Codeine phosphate

PowerPoint Lecture Slides

1. Strategies for prevention of:

• Venous thromboembolism (VTE)

o Pneumatic compression boots

o Graduated compression stockings

o Low dose heparin

2. Assessment

• Asymptomatic 80% of the time

• Leg discomfort

• Swelling

• Warmth

• Positive Homan’s sign

3. Risk factors

• Age older than 60

• Leg weakness

• Large tumor size

• Surgery lasting longer than 4 hours

 • Tumor histology

4. Cerebrospinal Fluid Leakages (CSF)

• Leaking from ear or nose

o Halo

• Headache

o More severe when upright

• Heal spontaneously or surgery

• Leak from Nose

• Leak from ear or surgical wound

• Potential to develop meningitis

5. Meningitis

• 9% of patients developed meningitis

• High mortality rate (nearly 30%)

• Aseptic technique

6. Manifestations of meningitis

• Fever

• Chills

• Increasing headache

• Neck stiffness

• Photophobia
7. Risk factors

• Postoperative external ventricular shunt

• Remote site infection

• Repeat operation

8. Seizures

• Partially dependant on the type of brain tumor

• Low-grade, slow-growing gliomas are most likely to develop seizures

• Between 30 and 70% of patients with brain tumors develop seizures

o 50% have tonic clonic seizures including status epilepticus

• Antiepilepsy prophylaxis

• Anticonvulsant medication

Learning Outcome 5
Compare and contrast the mechanisms of hemorrhagic and ischemic strokes.

Concepts for Lecture

1. Two major categories of CVA: hemorrhage and ischemia

2. Hemorrhagic is loss of blood flow due to rupture of cerebral vessels.

a. Causes

b. Symptoms

i. Severe headache

a. Outcomes

b. Treatments
3. Ischemic is the disruption of blood flow to part of the brain.

4. Subtypes

a. Thrombotic

b. Embolic

c. Hypoperfusion

d. Causes

e. Symptoms

f. Outcomes

g. Treatments

PowerPoint Lecture Slides

1. Cerebral Vascular Accident (CVA) is referred to as a brain stroke.

• Causes of CVA are classified as ischemic or hemorrhagic.

2. Hemorrhagic is loss of blood flow due to rupture of cerebral vessels, which accounts for 20%.

• Intracerebral hemorrhage (ICH)

o Bleeding of small arteries or arterioles directly into the brain

o Localized hematoma

o Progressive development of neurologic symptoms

• Causes Intracerebral hemorrhage (ICH)

o Hypertension

o Trauma

o Illicit drug use (particularly amphetamines and cocaine)

o Vascular malformations
 o Bleeding diathesis

4. Subarachnoid Hemorrhage (SAH)

• Rupture of aneurysm releases blood directly into the cerebrospinal fluid (CSF) under

arterial pressure

• Blood spreads rapidly within the CSF

• Immediate increase of intracranial pressure (ICP)

o Deep coma or death

• Sudden, severe headache

4. Ischemic is the disruption of blood flow to part of the brain and accounts for 80% of CVAs.

• Subtypes

o Thrombotic

▪ Thrombus formation in an artery causing a stroke due to decreased blood flow

▪ Artherosclerosis

5. Subtype: Embolic

• Particles result in blockage of arterial blood flow

• Originate from a source in the heart, aorta, or large vessels

• Onset of symptoms is abrupt and maximal

6. Causes of Embolic Hemorrhage

• Cardiac source

• Arterial source
 • Possible cardiac or aortic source based upon transthoracic and/or transesophageal

echocardiographic findings

• Unknown source

7. Subtype: Hypoperfusion

• General circulatory problem

• Decreased perfusion

o Cardiac arrest

o Arrhythmia

o Pulmonary embolism

o Pericardial effusion

o Bleeding

Learning Outcome 6
Describe emergent management of the patient with an ischemic stroke.

Concepts for Lecture

1. Time is of the essence.

2. Assessment

a. History

3. Neurologic examination

4. Stroke Scale

a. Visual

b. Motor

c. Sensory
 d. Cerebella

e. Inattention

f. Language

g. Level of consciousness (LOC)

PowerPoint Lecture Slides

1. Time Is of the Essence

NINDS has recommended the following time benchmarks for the potential thrombolysis

candidate:

Door to doctor 10 minutes

Access to neurologic expertise 15 minutes

Door to CT scan completion 25 minutes

Door to CT scan interpretation 45 minutes

Door to treatment 60 minutes

Admission to monitored bed 3 hours

2. Stroke Scale (NIHSS)

• Visual

• Motor

• Sensory

• Cerebella

• Inattention

• Language

• Level of consciousness (LOC)

3. Test as soon as possible following admission to the emergency department:

• Noncontrast brain CT or brain MRI

• Electrocardiogram (ECG) used to diagnose any cardiac dysrhythmias or MI.

• Complete blood count (CBC) including platelets (platelet count used to rule out

thrombotic thrombocytopenic purpura (TPP)

• Cardiac enzymes and troponin

• Electrolytes, urea nitrogen, creatinine (hyponatremia (Na less than 135 mEq/L) is found

in 10–40% of patients with subarachnoid hemorrhage)

4. Test Serum glucose

• Hypoglycemia can present with neurologic deficits mimicking stroke

• Severe hypoglycemia can cause neuronal damage

• Common in patients with acute ischemic stroke

• Associated with a poorer prognosis

5. Prothromin time (PT) and international normalized ratio (INR)—anticoagulant use is a

common cause of intracerebral hemorrhage

• Partial thromboplastin time (PTT)

• Oxygen saturation

6. Neuroimaging

• CT
 • MRI

• MRA

• CA

7. Other tests

• Carotid ultrasound

• TCD

• TTE/TEE

8. Collaborative Management

• ICU

• Airway patency and breathing pattern

o Prevent hypoxia, hypoventilation, and worsening cerebral injury

• Cardiovascular status (cardiac rhythm and rate, blood pressure)

o Detect signs of related acute cardiac ischemia

o Serious neurologic deficits

• Thrombolysis

• Invasive and surgical management

Learning Outcome 7
Compare and contrast intracerebral hemorrhage and subarachnoid hemorrhage.

Concepts for Lecture

1. Hemorrhage—rupture of a blood vessel resulting in too much blood in brain cavity
2. Intracerebral hemorrhage (ICH)

a. Up to 15% of hemorrhagic strokes

b. Mortality for ICH can exceed 50%

c. Hydrocephalus

d. Anticoagulant medications

3. Subarachnoid hemorrhage (SAH)

a. 4% of the population

b. Rupture of an aneurysm or an arteriovenous malformation (AVM)

i. 90% of intracranial aneurysms arise on the anterior (carotid) circulation

c. Common locations

d. Neurological assessment with grading of severity by the Hunt and Hess scale

4. Hunt and Hess Scale

PowerPoint Lecture Slides

1. Hemorrhage—rupture of a blood vessel resulting in too much blood in brain cavity

• Intracerebral hemorrhage (ICH)

o 15% of hemorrhagic strokes

o Mortality for ICH can exceed 50%

o Patients in intensive care units

o Hydrocephalusis a common complication

o Therapy is limited

2. Subarachnoid hemorrhage (SAH)

• Most common cause of bleeding is rupture of an aneurysm (AVM)

 • Occurs in about 4% of the population

• 10% of patients with SAH die before reaching hospitals

• 50% die within the first month.

• Usually repaired within 72 hours of hemorrhage to prevent rebleeding

o 90% of intracranial aneurysms arise on the anterior (carotid) circulation

• Common locations

o Anterior communicating artery

o Internal carotid artery at the posterior communicating artery origin

o MCA bifurcation

• Neurological assessment with grading of severity by the Hunt and Hess scale

3. Hunt and Hess Scale

• Grade 0—Unruptured aneurysm

• Grade 1—Asymptomatic or minimal headache and slight nuchal rigidity

• Grade 1A—No acute meningeal or brain reaction but with fixed neurologic deficit

• Grade 2—Moderate-to-severe headache, nuchal rigidity, no neurologic deficit other than

cranial nerve palsy

• Grade 3—Drowsiness, confusion, or mild focal deficit

• Grade 4—Stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity,

and vegetative disturbances

• Grade 5—Deep coma, decerebrate rigidity, and moribund appearance

4. Complications Following Rupture

 • Vasospasm

• Hydrocephalus

Learning Outcome 8
Describe the three most common complications following rupture of an aneurysm and

subarachnoid hemorrhage.

Concepts for Lecture

1. Ruptured aneurysms usually rebleed within the first day.

2. Two common complications following rupture:

a. Vasospasm

b. Hydrocephalus

PowerPoint Lecture Slides

1. Complications Following Rupture

• Vasospasm

• Hydrocephalus

Learning Outcome 9
Discuss screening for dysphagia in the stroke survivor.

Concepts for Lecture

1. Difficulty swallowing is dysphagia

2. Common post-stroke characteristic

3. Major risk factor for developing pneumonia

4. Increased risk of aspirating saliva and food

5. Screening assessment

PowerPoint Lecture Slides

1.

• Difficulty swallowing

• Major risk factor for developing aspiration pneumonia

• Increased risk of aspirating saliva or food

• Swallowing screening is necessary

CLASSROOM ACTIVITIES

Complete the following Table:

Hemorrhagic Ischemic Intracerebral Subarachnoid Brain

Stroke Stroke hemorrhage Hemorrhage Ischemia

CAUSES

SYMPTOMS

OUTCOMES

TREATMENTS
Solution Manual for Understanding the Essentials of Critical Care Nursing : 0131722107

Develop a complete nursing plan to care for a patient post craniotomy. Include potential

complications.

CLINICAL ACTIVITIES

- Select a patient admitted to the hospital with a diagnosis of ischemic stroke and write a

paper to describe the emergent management of that patient. Compare this patient’s actual

management to the management described in the textbook.

- Observe a craniotomy as a clinical assignment. Design a care plan for the care of the patient

in the first 24 hours post craniotomy.

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