Neurological disturbances across the life diameter of blood vessels to

maintain cerebral blood flow

span
3. CO2 plays a role; decreased CO2
results in vasoconstriction, and
I. INCREASED INTRACRANIAL increased CO2 results in
PRESSURE vasodilatation
 The rigid cranial vault contains the
ff:

1. brain tissue (1,400 g),

2. Blood (75 mL), and
ICP and CPP
3. CSF (75 mL)
 CPP (cerebral perfusion pressure) is
 The volume and pressure of these
three components are usually in a closely linked to ICP
state of equilibrium and produce
the ICP  CPP = MAP (mean arterial
pressure) – ICP
 ICP is usually measured in the
lateral ventricles;  A CPP of less than 50 results in
 normal ICP is 10 to 20 mm Hg permanent neuralgic damage

• Monro-Kellie hypothesis: limited  The normal cerebral perfusion

space - increase in any skull pressure is 70 to 100 mm Hg
component - change in the volume
of the others Cushing’s response or Cushing’s
reflex
• Compensation to maintain a
normal ICP - normally - is seen when cerebral blood flow
accomplished by shifting or decreases significantly
displacing CSF
 A sympathetically mediated
• With disease or injury - ICP may response causes a rise in the
increase systolic blood pressure with a
widening of the pulse pressure and
• Increased ICP decreases cerebral cardiac slowing. This response,
perfusion, causes ischemia, cell which is mediated by the
death, and further swelling (edema sympathetic
)
 nervous system, is seen clinically
Compensation of the body on ICP as a rise in systolic blood
pressure,widening of the pulse
1. Brain tissues may shift through the
pressure, and reflex slowing of the
dura and result in herniation
heart rate. This is a sign requiring
2. Autoregulation: refers to the immediate intervention; however,
brain’s ability to change the perfusion may be recoverable if
treated rapidly.

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 MANIFESTATIONS OF INCREASED 5. Bilateral flaccidity occurs before
ICP—EARLY death.

1. Changes in level of consciousness 6. Loss of brain stem reflexes,

including pupillary, corneal, gag,
2. Any change in condition and swallowing reflexes, is an
ominous sign.
a. Restlessness, confusion,
increasing drowsiness, ASSESSMENT
increased respiratory effort,
and purposeless movements- 1. Conduct frequent and ongoing
decreased oxygen neurologic assessment

3. Pupillary changes and impaired 2. Evaluate neurologic status as

ocular movements- brain completely as possible
displacement
3. Glasgow Coma Scale
4. Weakness in one extremity or one
side- compression of the pyramidal 4. Pupil checks
tracts
5. Assess selected cranial nerves
5. Headache: constant, increasing in
6. Take frequent vital signs
intensity, or aggravated by
movement or straining - stretching 7. Assess intracranial pressure
of venous and arterial vessels in
the base of the brain 8. ICP MONITORING

MANIFESTATIONS OF INCREASED ICP DIAGNOSIS

—LATE
1. Ineffective airway clearance
1. Respiratory and vasomotor
2. Ineffective breathing pattern
changes
3. Ineffective cerebral perfusion
2. VS: increase in systolic blood
pressure, widening of pulse 4. Deficient fluid volume related to
pressure, and slowing of the heart fluid restriction
rate; pulse may fluctuate rapidly
from tachycardia to bradycardia 5. Risk for infection related to ICP
and temperature increase monitoring

a. Cushing’s triad: bradycardia, Collaborative Problems/Potential

hypertension, and bradypnea Complications

3. Projectile vomiting – pressure on 1. Brain stem herniation

the medulla
2. Diabetes insipidus
4. Hemiplegia or decorticate or
decerebrate posturing may 3. SIADH
develop as pressure on the brain
4. Infection
stem increases.
Planning Care for Increased ICP  Most common cause of brain
trauma is MVA
 Major goals may include:
 Group at highest risk group for
 Maintenance of patent airway brain trauma are males age 15 to
24
 Normalization of respirations
 Those younger than 5 years and
 Adequate cerebral tissue
the elderly are also at increased
perfusion
risk
 Respirations
PPathophysiology:
 Fluid balance

 Absence of infection

 Absence of complications

Interventions

 Frequent monitoring of respiratory

status and lung sounds

 Position with the head in neutral

position to promote venous
drainage

 Avoid hip flexion, Valsalva

maneuver, abdominal distention, or
other stimuli
Manifestations:
 Maintain a calm, quiet atmosphere
and protect patient from stress Depends upon the severity and location of
the injury
 Monitor fluid status carefully;
during acute phase, monitor I&O  Scalp wounds
every hour
– Tend to bleed heavily; scalp
 Use strict aseptic technique wounds are also portals for
infection
II. HEAD INJURY
 Skull fractures
 A broad classification that includes
injury to the scalp, skull, or brain – Usually have localized,
persistent pain
 Head injury is the most common
cause of death from trauma – Fractures of the base of the
skull

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  Bleeding from nose,  Pain and anxiety management
pharynx, or ears
 Nutrition
 Battle’s sign: ecchymosis
behind the ear

 CSF leak—halo sign—ring of

fluid around the blood stain
from drainage

Management:
[Link] INJURY
 Assume cervical spine injury until
this is ruled out  Closed brain injury (blunt trauma):
acceleration/ deceleration injury
 Therapy to preserve brain occurs when the head accelerates
homeostasis and prevent then rapidly decelerates, damaging
secondary damage brain tissue

– Treat cerebral edema  Open brain injury: object

penetrates the brain or trauma is
– Maintain cerebral perfusion;
so severe that the scalp and skull
treat hypotension,
are opened
hypovolemia, and bleeding;
monitor and manage ICP  Concussion: a temporary loss of
consciousness with no apparent
– Maintain oxygenation as well as
structural damage
cardiovascular and respiratory
function
 Contusion: more severe injury with
possible surface hemorrhage
– Manage fluid and electrolyte
balance
 Symptoms and recovery depend
upon the amount of damage and
associated cerebral edema

 Longer period of unconsciousness

with more symptoms of neurologic
deficits and changes in vital signs
Supportive measures:
 Diffuse axonal injury: widespread
 Respiratory support; intubation and axon damage in the brain seen
mechanical ventilation with head trauma; patient
develops immediate coma
 Seizure precautions and prevention
Intracranial bleeding
 manage reduced gastric motility
and prevent aspiration a. Epidural hematoma

 Fluid and electrolyte maintenance b. Subdural hematoma

 i. Acute and subacute intervention

ii. Chronic  Provide ongoing assessment and

monitoring is vital
c. Intracerebral hemorrhage and
hematoma  Maintain airway

Manifestations 1. Positioning to facilitate

drainage of oral secretions with
1. Altered level of consciousness
HOB usually elevated 30° to
2. Pupillary abnormalities decrease venous pressure

3. Sudden onset of neurological 2. Suctioning with caution

deficits and neurological changes;
3. Prevention of aspiration and
changes in sense, movement, and
respiratory insufficiency
reflexes
4. Monitor ABGs, ventilation, and
4. Changes in vital signs
mechanical ventilation
5. Headache
5. Monitor for pulmonary
Assessment: complications, potential ARDS

1. Health history with focus upon the 6. Monitor I&O and daily weights
immediate injury, time, cause, and
7. Monitor blood and urine
the direction and force of the blow
electrolytes, osmolality and
2. Baseline assessment blood glucose

3. LOC: Use Glasgow Coma Scale 8. Implement measures to

promote adequate nutrition

9. Implement strategies to
prevent injury

• Assess oxygenation

• Assess bladder and urinary

output

• Assess for constriction due to

dressings and casts

• Pad side rails

• Use mittens to prevent self-

injury; avoid restraints

4. Frequent and ongoing neurologic 10. Strategies to prevent injury

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 • Reduce environmental stimuli  Patient should be aroused and
assessed frequently
• Use adequate lighting to
reduce visual hallucinations Epidural Hematoma

• Implement measures to  Blood collection in the space

minimize disruption of sleep– between the skull and the dura
wake cycles
 Patient may have a brief loss of
• Provide skin care consciousness with return of lucid
state; then, as hematoma expands,
• Implement measures to increased ICP will often suddenly
prevent infection reduce LOC

 An emergency situation

11. Maintain body temperature  Treatment includes measures to

reduce ICP, remove the clot, and
• Maintain appropriate
stop bleeding—burr holes or
environmental temperature
craniotomy
• Use coverings: sheets, blankets
 Patient will need monitoring and
as per patient needs
support of vital body functions and
• Administer acetaminophen for respiratory support
fever
Subdural Hematoma
• Use cooling blankets or cool
 Collection of blood between the
baths; prevent shivering
dura and the brain
CONCUSSION
 Acute/subacute
 Patient may be admitted for
– Acute: symptoms develop over
observation or sent home
24 to 48 hours
 Observation of patients after head
– Subacute: symptoms develop
trauma; report immediately
over 48 hours to 2 weeks
– Observe for any changes in
– Requires immediate craniotomy
level of consciousness
and control of ICP
– Difficulty in awakening,
 Chronic
lethargy, dizziness, confusion,
irritability, and anxiety – Develops over weeks to months

– Difficulty in speaking or moving – Causative injury may be minor

and forgotten
– Severe headache
– Clinical signs and symptoms
– Vomiting
may fluctuate
 – Treatment is evacuation of the  Complex partial:
clot impairment of
consciousness
Intracerebral hemorrhage
2. Generalized seizures: involve the
 Hemorrhage occurs into the whole brain
substance of the brain
Specific Causes of Seizures
 May be due to trauma or a
nontraumatic cause  Cerebrovascular disease

 Treatment  Hypoxemia

– Supportive care  Fever (childhood)

– Control of ICP  Head injury

– Administration of fluids, 3. Hypertension

electrolytes, and
antihypertensive medications 4. Central nervous system infections

5. Metabolic and toxic conditions

– Craniotomy or craniectomy to
remove clot and control 6. Brain tumor
hemorrhage
7. Drug and alcohol withdrawal
 May not be possible due to
the location or lack of 8. Allergies
circumscribed area of
hemorrhage 9. Observe and document signs and
symptoms before, during, and after
seizure

[Link] 10. Seizure precaution for patient

safety and protection
 Abnormal episodes of motor,
sensory, autonomic, or psychic 11. Prevention of complications
activity (or a combination of these)
12. complication
 Resulting from a sudden,
STATUS EPILEPTICUS
abnormal, uncontrolled electrical
discharge from cerebral neurons  Status epilepticus (acute prolonged
seizure activity) is a series of
1. Partial seizures: begin in one part
generalized seizures that occur
of the brain
without full recovery of
 Simple partial: consciousness between attack
consciousness remains
 The term has been broadened to
intact
include continuous clinical or
electrical seizures lasting at least

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 30 minutes, even without neurologic deficit & worsens within
impairment of consciousness 2 days

Management CAUSES

 The goals of treatment are to stop  THROMBOSIS: most common in

the seizures as quickly as possible, elderly; results from obstruction
of a blood vessel; causes
 to ensure adequate cerebral ischemia, congestion, and
oxygenation, edema in the brain tissue; may
occur during surgery or MI
 Maintain the patient in a seizure-
free state. An airway and adequate  EMBOLISM: 2nd most common
oxygenation are established. If the cause of stroke – can occur at
patient remains unconscious and any age; history of RHD,
unresponsive, a cuffed endocarditis, post-traumatic
endotracheal tube is inserted. valvular disease, or myocardial
fibrillation, cardiac arrythmias;
 Intravenous diazepam (Valium),
it cuts off circulation by lodging
lorazepam (Ativan), or
in a narrow portion of an artery
fosphenytoin (Cerebyx) is given
causing necrosis & edema; if
slowly in an attempt to halt
septic may cause encephalitis
seizures immediately.
& abscess
 Other medications (phenytoin,
 HEMORRHAGE: 3rd most
phenobarbital) are given later to
common & may occur suddenly
maintain a seizure-free state
at any age; results from chronic
[Link] hypertension or aneurysms
causing sudden rupture of a
DEFINITION cerebral artery

 Also known as BRAIN ATTACK or COMPLICATIONS

CEREBROVASCULAR ACCIDENT
 Unstable blood pressure from loss
 A sudden impairment of cerebral of vasomotor control
circulation in one or more blood
vessels supplying the brain  Fluid imbalances

 Interrupts or diminishes oxygen  Malnutrition

supply causing necrosis in brain
 Infections: pneumonia
tissues
 Sensory impairment: vision
 Least severe: Transient Ischemic
problems
Attack (TIA) – results to temporary
interruption of blood flow  Altered level of consciousness

 Progressive Stroke / Stroke-in-  Aspiration

Evolution – begins with a slight
  Contractures  Angiography: pinpoints occlusion
or rupture site
 Pulmonary embolism
 Electro-encephalogram: localizes
 ASSESSMENT damaged area

 TIPS: TREATMENT

 If the left hemisphere is  Physical rehabilitation

affected: produces right sided
signs & symptoms;  Dietary & drug regimens to
decrease risk factors
 If the right hemisphere is
affected: produces left sided  Possible surgery: craniotomy,
signs & symptoms endarterectomy, extracranial-
intracranial bypass, ventricular
 Strokes causing cranial nerve shunting
damage produces signs of
cranial nerve dysfunction on  Medications:
the same side as the
hemorrhage  Tissue plasminogen activator:
clot dissolution (3 hours)
 Obtain family health history
 Anticonvulsants: prevent
 Neurologic examination seizures

 Motor function tests  Stool Softeners: prevent

straining & increasing ICP
 Vision testing
 Corticosteroids: minimize
 Sensory assessment associated cerebral edema

DIAGNOSTICS  Analgesics: relieve headache

 Computed tomography scan: INTERVENTIONS

hemorrhagic strokes, thrombotic
infarction after 48 to 72 hours  ACUTE PHASE:

 Magnetic resonance imaging:  Continued neurologic

ischemic or infarcted areas & assessment, respiratory
cerebral swelling support, continuous monitoring
of vital signs, careful
 Electrocardiogram: underlying positioning to prevent
heart disorders aspiration & contractures

 Carotid duplex: carotid artery  Maintain a patent airway and

stenosis oxygenation

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 Monitor vital signs and neurologic
status as necessary/ordered

 Watch out for signs of pulmonary

emboli (chest pains, SOB, dusky
color, tachycardia, fever, changed
sensorium)

 Maintain fluid & electrolyte balance

 Ensure adequate nutrition: check

for gag reflex before feeding

 Manage GI problems