Contemporary Medicines Slideshow Transcript
Slide 1: Critical Care Situations in Neurological Nursing Increased Intracranial Pressure Delirium CVA
Slide 2: Increased Intracranial Pressure: Skull as a “closed box” Brain tissue is 78% Intravascular blood is 12% Cerebrospinal fluid is 10 % About 1900 mL in adults Normally volume in = volume out
Slide 3: Normal ICP is 5-15 mmHg in pt. With HOB at 30 degrees. If sustained pressure above 20 mmHg herniation of the brain is likely, compressing the brainstem Body compensates for minor increases in ICP by increasing CSF absorption, decreased CSF production, as well as changing intracranial blood volume through increased venous outflow
Slide 4: Cerebral Perfusion Pressure: CPP This is the pressure of the blood flow into the cerebrum, which must be above 30 CPP = MAP - ICP Note the pressure-volume curve:
Slide 5: What are the factors that raise the ICP? Increased arterial blood pressure (note: MAP is the mean arterial pressure) Maximal constriction of vessels occurs at MAP of 150, maximal dilation at 50 Increased intra-abdominal and intrathoracic pressure (eg valsalva, cardiac) Posture (how high head is in relation to heart)
Slide 6: More factors that influence ICP Hyper and hypothermia Brain injury = swelling Low oxygen tension = cerebral vessel dilation Increased PaCO2 = cerebral vessel dilation Infection Masses Toxic substances in blood/brain tissue
Slide 7: Signs and Symptoms of Increased ICP Change in LOC: orientation, restlessness, clouded sensorium. Subtle or dramatic Change in Vital Signs: most important is watching for pattern. Cushing’s Triad (late sign): widening pulse pressure, bradycardia with full bounding pulse, and irregular respirations
Slide 8: More Signs and Symptoms Changes in pupil size, vision, symmetry, reactivity, as well as ocular and lid movement. Hemiparesis, or other changes in motor function Review decerebrate and decorticate posturing. Both serious, decerebrate is more ominous. Vomiting, headache.
Slide 9: Brief overview of treatment of Increased ICP Frequent assessment, with attention to subtle changes in LOC and neuro exam Very important to ACT EARLY when symptoms emerge, by the time symptoms are overt, pressure may be hitting the dangerous part of the curve. Maintain calm and non-stimulating environment (think: similar to “aneurysm precautions”) PaO2 at 100%, some physicians will aim for hyperventilatory state, some not. Do avoid
Slide 10: Increased ICP Care, continued Team will want to address the cause, and treat it whenever possible (discuss) Debate about use of sedation (discuss pros and cons, situational considerations) Diuresis: osmotic and loop diuretics, watch I & O, note SIADH as serious problem Corticosteroids
Slide 11: Even More ICP care Maintain normothermia Avoid skin breakdown Maintain nutrition (discuss why) Maintain adequate CPP with BP stable and fairly normo-tensive (physician may have specific boundaries in mind) Maintain ICP as near normal as possible, moniter it.
Slide 12: CVA: Epidemiology CVA affects over 730,000 people in US yearly One of the top 3 causes of death in US Costs us (in indirect and direct cost) about 41 billion yearly Incidence doubles after age 55, CVA affects more men than women, and African Americans are at a higher risk as well.
Slide 13: More Epidemiology About 50% Stroke victims in US die About ½ Strokes in US are associated with hypertension 85% strokes occur at home About 50% stroke victims travel to ED by ambulance
Slide 14: Risk Factors for CVA~Mostly Modifiable Use of Oral Hypertension Contraceptives Heart disease History of Migraine Diabetes Headache High cholesterol Elevated homocysteine Smoking Obesity and physical Alcohol and other inactivity drug use, esp Diet cocaine
Slide 15: Cerebrovascular Disease that Predisposes to Stroke Cerebral Vessel Abnormalities: arteriosclerosis, aneurysms, arteritis, hypertension*, vasoconstriction Blood Flow Abnormalities: Stenosis, thrombi, emboli Blood Property Abnormalities: coagulation problems, viscosity
Slide 16: CVA Symptoms Sudden onset of focal neurological deficits, the deficits relate directly to the area of the brain that is affected: visual, motor, sensory, speech most common Talk about stroke scales and their usefulness: NIH full and short scale, the LAPSS—why it matters
Slide 17: Mini NIHSS Facial assessment: able to smile, grimace, show teeth equal bilaterally? Extremity assessment: can hold affected arm up at 45 degrees for 10 seconds? Can hold affected leg up at 30 degrees for 5 seconds? Language: Speak clearly and appropriately?
Slide 18: Pathophysiology of Stroke Brain requires nearly constant supply of Oxygen and Glucose to function. Brain is about 2% of body mass, but uses about 20% of the blood pumped by your heart. Brain has little reserve Oxygen/glucose- therefore TIME IS BRAIN.
Slide 19: Ischemic Stroke (about 85%): Thrombus and Embolus (pictures) Densely ischemic central core: neuronal tissue undergoes rapid infarction Ischemic prenumbra: larger surrounding area that is compromised re circulation, but because of collateral circulation, tissue remains viable for a variable period of time (several hours)
Slide 20: Hemorrhagic Stroke: about 15% Hypertension, Aneurysm, malformed vessel, drug use are implicated Assessment findings alone are not definitive to differentiate. May find “worst HA ever, blood in CSF
Slide 21: Parts of the Brain and Deficits in CVA (oversimplified) Frontal Lobe: judgment, foresight, voluntary movement Parietal Lobe: Language comprehension Temporal Lobe: Hearing Occipital Lobe: Primary visual area Cerebellum: Coordination Brain Stem: Swallowing, breathing, heart rate, wakefulness
Slide 22: A Few More Broca’s Area: speech Wernicke’s Area: speech comprehension Sensory Cortex: pain, heat, and other sensations Motor Cortex : movement
Slide 23: Diagnosis in Stroke: Essential to be correct~treatment differs Physical Assessment CT scan is important Labs: may see elevated Evaluation needs to Hgb and Hct if stroke is be rapid. severe, EKG NURSE should be Blood sugar and patient advocate electrolytes and make sure Stroke mimics things are going on hypoglycemia, migraine, seizure time:Because time is brain.
Slide 24: Guidelines for Emergency Stroke Management On arrival: EKG, blood sugar, Vital signs Physician evaluation: 10 minutes Stroke team notification: 15 minutes CT scan : 25 minutes CT interpreted: 45 minutes Drug administration: 60 minutes Monitored bed: 3 hours
Slide 25: Most Common Nursing Diagnoses (not all) Self care deficits – all Immobility Situational Low Self Esteem Injury, risk for Aspiration, risk for & Impaired swallow Body temp, risk for imbalanced Communication, impaired Unilateral Neglect
Slide 26: Thrombotic or Embolic Stroke tPA Activase to dissolve Manage BP Goal: clot. 3 hour time window 140/80 to 150/90 and not for hemorrhagic If hypertensive stroke. 0.9 mg/kg up to labetrol used (20-40 90 mg. First 10% as mg over 2 min), or bolus, rest given over 60 minutes. sodium nitroprusside No ASA or heparin right now (discuss controversy)
Slide 27: Other Medications: ASA, heparin, anticonvulsants ASA, persantine: Heparin and low molecular weight Some studies find that heparin ASA given early prevents early recurrence of Some controversy in th/emb. research findings: the little decrease in Should be given if no thrombus or embolus clear diagnosis is may be canceled out by possible (even at home the increased risk of before coming in) intracranial bleeding. Anticonvulsants to Review the use of these prevent seizure (which drugs, including would compound injury appropriate lab values to monitor
Slide 28: Nursing Care Issues in Acute Treatment Keep temperature Assess for depression normal (discuss why) (common) Prevent aspiration and Keep patient calm-avoid choking while not abrupt increases in ICP starving the patient Aim for good CPP and Prevent and assess for ICP as close to normal thromboembolism as possible (discuss) Prevent seizures, seizure Neuro assessment, precautions report changes
Slide 29: Hemorrhagic Stroke Care Once this type of stroke is diagnosed, there are a few key differences in medical care. First, tPA, ASA, heparin, etc. are contraindicated (a main issue). Later, since 50% of hemorrhagic stroke victims go on to have a thrombotic or embolic stroke, they may be used with caution. Second, depending on the case, surgery may be indicated Third: a medication such as Amicar (an antifibrinolytic) may be used to facilitate a good clot at site of ruptured aneurysm
Slide 30: Nursing Care Consider many of the same issues as for thrombotic or embolic stroke—temperature, aspiration, blood pressure, preventing DVT (but without heparin!), maintaining blood glucose. Add aneurysm precautions Research suggests that organized stroke teams/units do a better job with some of these nursing care issues, and have better patient outcomes.
Slide 31: Aneurysm precautions Limit TV HOB up No very hot or cold Bedrest liquids Quiet No Valsalva Dark maneuver No caffeine Patient may be sedated with Limit visitors medication Rationale:
Slide 32: Prevention Issues Primary Prevention: work with public to facilitate limiting the modifiable risk factors prior to any illness developing Secondary Prevention: (early detection) Teach public that time is brain and symptoms of stroke to seek treatment for right away. Talk about ASA.
Slide 33: Tertiary Prevention ASA up to 300 mg/day, Carotid endarterectomy or persantine. (discuss especially useful if over research) 70% blockage Coumadin therapy esp if ACE inhibition person has A fib. (not Pravastatin or good if hemorrhagic Simvastatin to decrease stroke) hypercholesterol states Antihypertensive therapy Stop smoking Improve diet and exercise
Slide 34: Delirium: Basic Characteristics Disturbance of consciousness or cognition Usually reversible, with acute onset Usually secondary to some other condition or problem, such as intoxication, withdrawl, medical condition, severe stressors
Slide 35: Delirium: Assessment concerns Review MMS exam. In Ability to converse text. Level of Consciousness Scrutinize for underlying (alert, drowsy, causes stuporous, etc) Orientation to time (1st Illusions, hallucinations to go) (type, specific, timing) Orientation to place Awareness of own deficits Orientation to person (last to go) Distractability
Slide 36: Nursing Intervention: Delirium Do what is appropriate to eliminate cause, includes careful assessment Safety: falls, wandering, Ivs/ NGs pulled out easily, may strike out in fear Meet physiologic needs: nutrition, hydration, sleep, appropriate level of stimulation, pain relief Judicious use of antipsychotic,antianxiety meds
Slide 37: Communication with Confused Person Short questions, instructions, with no “big” words. Be patient. Check for comprehension, give instructions more than once, not in condescending manner Face to face, normal tone, good light No “honey” “dearie” etc
Slide 38: Reality Orientation with Confused Person Clocks, calendars, cues placed prominently. Talk about it. Names on doors, big. Familiar routine, structure, staff Verbal reorientation to PPT as a natural part of conversation Read text for more interventions!!
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