RNSG 2432
Enhanced Concepts of Adult Health
Lisa Randall, RN, MSN, ACNS-BC
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Define and discuss altered cerebral function
and increased ICP
Analyze etiology and pathophysiology of
altered cerebral function
Discuss/illustrate signs and symptoms,
diagnostics, and treatment
Formulate nursing diagnoses that address
physical, psychosocial, and learning needs
Prioritize and evaluate nursing interventions
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Cerebral function
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Mental status
Speech
Eyes
Cranial nerves
Motor
Sensory
Reflexes
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Consciousness
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◦ Arousal
◦ Awareness
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Lethargy
◦ < alertness
◦ < awareness
◦ < thought process
Obtundation
◦ << A/A
◦ Clouding
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Stupor
◦ Deep sleeplike state
◦ Vigorous stimulation
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Coma
◦ Unresponsiveness
 PVS
 MCS
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Unarousability
Absence of sleep/wake cycles
Inability to interact with the environment
GCS =/< 8
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Intermittent wakefulness
Sleep-wake cycles
No awareness of self or environment
http://youtu.be/Pl1IPTpHUHs
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Altered consciousness
Evidence of self or environmental awareness
is demonstrated
Anatomy
http://www.youtube.com/watch?feature=player_detailpage&v=HVGlfcP3ATI
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Reticular Activating System (RAS)
◦ Reticular Formation
◦ Gray cells within brainstem extends into thalamus
 Wakefulness
 Arousal
 Alertness
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Lesion/injury to the RAS or cerebral cortex
Metabolic disorders
Anoxic injury
Drugs
Seizures
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LOC
Health history
◦ drugs/head injury/metabolic
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Physical exam
Vital signs
◦ Temperature
◦ Cushing’s reflex/triad
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Neuro Vital Signs
◦ LOC, Pupils, Strength/Movement, Sensation
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Glasgow coma scale
NIH Stroke Scale
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Edema
Increased intracranial pressure
◦ Increased systolic BP
◦ Widening pulse pressure
 Normal = 40 mmHg
◦ Decreased pulse rate
◦ Irregular respirations
Eyes
Spontaneous opening
Open to speech
Open to pain
Do not open
Verbal Response
Oriented
Confused
Inappropriate
Incomprehensible
None
4
3
2
1
5
4
3
2
1
Motor Response
Obeys commands
Localizes to pain
6
5
Pushes your hand away
Withdraws from pain
Decorticate/flexion
Decerebrate/extension
None
4
3
2
1
Range of possible scores = 3-15
A score of 13 to 14 indicates mild deficit. A score between
9 and 12 points to moderate deficit, and a score of 8 or less
indicates severe coma.
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Mental status
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General appearance/behavior
State of conciousness
Mood and affect
Thought content
Intellectual capacity
Sensory: CN II - Optic
◦ Visual acuity
Motor: CN III - Oculomotor
◦ PERRL
◦ Direct/consensual
◦ EOMs (CN IV/VI)
http://www.youtube.com/watch?v=cuZXz92hd8g&feature=relate
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Eye movement
CN III,IV,VI
Oculocephalic reflex
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Dolls eyes
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◦ Doll’s eyes
◦ Sensory CN VIII
◦ Motor CN III,IV,VI
◦ (+) opposite direction
◦ intact brain stem
◦ (-) no movement
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Trigeminal (V)
◦ Corneal reflex
◦ Sensory
◦ mastication
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Facial (VII)
◦ Expression
◦ Taste
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Glossopharyngeal
(IX)
◦ Gag/swallow
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Vagus (X)
◦ Gag/Swallow
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Acoustic (VIII)
Spinal Accessory
(XI)
◦ Shoulder shrug
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Hypoglossal (XII)
◦ TML
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Ability to move, strength, and symmetry
◦ Grips, arm strength, & drift
◦ Planter flexion, dorsiflexion, & leg strength
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Coordination
◦ Finger to nose, heel up and down shin
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Planter Reflex- Babinski testing
Meningeal signs- Brudzinski & Kernig’s sign
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Babinski's reflex
◦ (+) great toe flexes
and the other toes
fan out
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Abnormal after the
age of 2.
Hips and knees flex when the neck is flexed
Stiffness of the hamstrings causes an inability to straighten the leg
when the hip is flexed to 90 degrees.
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Visual fields
Dull vs. sharp
◦ Sensation same or different with eyes closed
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Face
Hands
Arms
Abdomen
Feet
Legs
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Brainstem compression
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Yawning & sighing
Cheyne-Stokes
Central neurogenic hyperventilation
Apneustic breathing
Cluster breathing
Ataxic respirations
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http://www.youtube.com/embed/CUaEwgfKO
Ec
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A patient with an intracranial problem does
not open his eyes to any stimulus, has no
verbal response except muttering when
stimulated, and flexes his arm in response to
painful stimuli. The nurse records the
patient’s GCS score as
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A. 6
B. 8
C. 9
D. 11
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The nurse recognizes the presence of
Cushing’s triad in the patient with
◦ A. increased pulse, irregular respiration, increased
BP
◦ B. decreased pulse, irregular respiration, increased
pulse pressure
◦ C. Increased pulse, decreased respiration, increased
pulse pressure
◦ D. decreased pulse, increased respiration,
decreased systolic BP
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CN III originating in the midbrain is assessed
by the nurse for an early indication of
pressure on the brainstem by
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A. assessing for nystagmus
B. testing the corneal reflex
C. testing pupillary reaction to light
D. testing for oculocephalic (doll’s eyes) reflex
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An unconscious patient with increased ICP is
on ventilatory support. The nurse notifies the
healthcare provider when arterial blood gas
(ABG) measurement results reveal a
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A. pH of 7.43
B. SaO2 of 94%
C. PaO2 of 50mm Hg
D. PaCO2 of 30mm Hg
◦ BG
◦ Electrolytes/Osmolali
ty
◦ ABGs
◦ CBC
◦ Liver function
◦ Kidney function
◦ Toxicology
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CT
MRI
EEG
Cerebral angiogram
TCD
LP
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Monro-Kellie hypothesis
◦ 80/10/10 rule
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Autoregulation
◦ Cerebral arterioles
◦ MAP (Mean arterial pressure)
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Perfusion depends on B/P and chemical (CO2)
Normal MAP is 70 to 100
< 60 - peripheral organs not perfused
< 50 – brain not perfused
Critical to maintain normal MAP with Increased ICP
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Vasoconstriction
Decreased CSF
CSF shunting
Increased CSF reabsorption
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Brain’s ability to tolerate an increase in
volume without an increase in pressure
Indications of decreased compliance:
◦ Sustained increase in ICP in response to stimuli
◦ Greater increases to non-noxious stimuli
NP
Compensated
Uncompensated
10mmHg
15mmHg
30mmHg
Blood 10%, CSF 10%
Blood 5%, CSF 5%
Blood 4%, CSF 4%
Stable
Stiff
ICP increases
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A slowly expanding mass is tolerated better
that a rapidly expanding mass
Brain tissue is compressible, but functional
impairment, possibly irreversible does occur
Location matters
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Pressure needed for adequate blood flow to
brain
◦ CPP = MAP – ICP
 Need higher MAP if ICP increased
◦ 70-100 mmHg
◦ <50 mmHg = ischemia
◦ <30 mmHg = death
Arterial Blood Pressure - Brain & CS Fluid Compression = Actual Cerebral Blood Flow
CPP
Danger of CPP
< 50 mmHg
MAP
50 to
150
mmHg
Normal ICP
0 to 15 mmHg
Edema, CS Fluid, Tumor
Autoregulation
70 to 100 mmHg
Increased ICP
> 20 mmHg
Increased MAP
needed to
perfuse brain
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Changes in contents of cranial vault
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Mass effect
◦ Tumor
◦ Blood clot
◦ Edema
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Increased CBF
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Increased blood flow
Increased PaCO2
Decreased PaO2
Vasodilators
Increased
intrathoracic
pressure
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Coughing
Straining
Suctioning
Peep
Impairment of
cerebral venous
drainage
◦ Positioning
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Changes in LOC
Worsening headache
Cognitive deficits
Pupillary changes
Increasing B/P with widening pulse pressure
Irregular respiratory patterns
Bradycardia
Seizures
Aphasia
Dysconjugate gaze
Hemiparesis or hemiplegia
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Health history- assess brain involvement
PE
◦ Altered cerebral function assessment
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Frequency depends on potential IICP
Early sign- change in LOC
3rd Cranial nerve compression
Papilledema
Projectile vomiting
Vision changes
Seizures
◦ Late sign- Cushing VS changes
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Ineffective tissue perfusion: cerebral
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Assess/report sign IICP
Adequate airway
Promote venous drainage
Control environment stimuli
Plan nursing care – avoid clustering care
Avoid Valsalva’s maneuver
If bone flap out post op- assess & position
Assess external shunts/drains
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Maintenance of airway and ventilation
Endotracheal intubation
Oxygenation
Mechanical ventilation
Fluid balance/Euvolemia
Medications
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Sedation, analgesia, neuromuscular blockade
Barbiturate coma
Prophylactic anticonvulsant
Mannitol/3% NaCl
Lasix
Atracrium
Vasopressors
Tylenol
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Temperature control
Electrolyte balance
Proper positioning
Adequate nutrition
Ventriculostomy
Paralytics
Hypothermia
Pentobarbital coma
Craniectomy
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LICOX
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Jugular venous bulb cath
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ICP Waveforms (P1, P2, & P3)
◦ PbtO2
◦ Normal 37-47 mmHg
◦ SjvO2
◦ Normal SjvO2 is 60% to 80%
◦ <50 to 55% of O2 in venous blood indicates impairment
of flow and brain taking out more O2 than normal
◦ P1 arterial pulse wave should be highest
◦ P2 is intracranial compliance – if higher than P1
compliance is compromised
◦ P3 is the venous pulsation and should be the lowest
P1 P2 P3
Standing Orders
Per hospital policy
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Neurological
Meningitis
Seizures
Cerebral salt wasting (CSW)
Syndrome of inappropriate antidiuretic hormone
(SIADH)
◦ Hydrocephalus
◦ Cerebral edema/Increased ICP
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Increased secretion of ADH from abnormal
stimuli
Results in water retention
Hyponatremia
◦ Na+ excreted in urine
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Decreased UOP
Increased urine specific gravity
Low serum osmo
Hyponatremia
Hypervolemia
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Fluid restrictiion
Replace sodium
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Democlocycline
Fludrocortisone
Hypertonic saline
Oral salt
Diuretics
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Controversial
Hyponatremia
Failure of CNS to regulate Na+ reabsorption
Increase in circulating atrial natriuretic
peptide (ANP)
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Increased UOP
Hyponatremia
Normal to increased osmo
Hypovolemia
Increased urine specific gravity
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Volume replacement
Sodium replacement
Reducing renal Na+ excretion
◦ Fludrocortisone
◦ Urea
Parameter
SIADH
CSW
Serum Na+
Decreased
Decreased
Serum osmolarity
Decreased
Decreased
Urine Na+
Increased
Normal-increased
Urine OP
Decreased
Increased
Volume
Normo/hypervolemic
Hypovolemic
Body weight
Increased
Decreased
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Cerebral edema
◦ Vasogenic
◦ Cytotoxic
◦ interstitial
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Hydrocephalus
◦ Noncommunicating
◦ Communicating
◦ ICP
Production – choroid plexus;
Absorption – arachniod villi
Normal MRI Brain
MRI Hydrocephalus
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Irreversible coma
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Locked-in Syndrome (not true coma)
◦ Persistent vegetative state
◦ Functioning RAS & cortex; pons level interference
◦ Aware, communicate with eyes
◦ http://youtu.be/xWHnkFaxMxM
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Brain death
◦ Loss of all brain function- flat EEG, no blood flow
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A. Cingulate
B. Uncal
C. Central
D. Extracranial
E. Tonsillar
Cingulated Herniation (a)
Cingulate gyrus slips under
falx cerebri
Usually caused tumor or
bleed
Non life threatening
Uncal or Lateral Herniation (b)
Uncus of temporal lobe
slips through notch of
tentorium and compresses
the ipsilateral CN 3,
brainstem, & vital centers
Life threatening
Central or Transtentorial Herniation (c)
Downward pressure
General cerebral edema
Brainstem compression
Compresses RAS & vital
centers
Abnormal heart rhythms,
disturbances or cessation of
breathing, cardiac arrest,
and death
Life threatening
Infratentorial (subtentorial or Tonsillar)
Herniation (e)
Downward displacement of
infratentorial structures
through the foramen
magnum
Life threatening
Extracranial Herniation (d)
Occurs with displacement of
brain through a cranial defect.
Usually Non-life threatening
Surgical Decompression
(Craniectomy)
http://youtu.be/dLMCwGmWvrw
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A patient has ICP monitoring with an
intraventricular catheter. A priority nursing
intervention for the patient is
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A. aseptic technique to prevent infection
B. constant monitoring of ICP waveforms
C. removal of CSF to maintain normal ICP
D. sampling CSF to determine abnormalities
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A patient has a nursing diagnosis of altered
cerebral tissue perfusion related to cerebral
edema. An appropriate nursing intervention
for the patient is
◦ A. avoiding positioning the patient with neck and
hip flexion
◦ B. maintaning hyperventilation to a PaCO2 of 1520mm Hg
◦ C. clustering nursing activities to provide periods of
uniterrupted rest
◦ D. routine suctioning to prevent accumulation of
respiratory secretions
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The earliest signs of increased ICP the nurse
should assess for include
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A. Cushing’s triad
B. unexpected vomiting
C. decreasing level of consciousness (LOC)
D. dilated pupil with sluggish response to light
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VS/NVS
ICP
CPP
MAP
PbtO2
PaCO2
CVP
Labs
Imaging
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Category status
Advanced directives
Prognosis
Withdraw of care
Palliative care
End of life specialists
SW/Chaplain
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Varies according to underlying cause and
pathologic process
GCS
GOS
Physical/mental disability
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22 yo female
Harvard law
student
Horseback riding
GCS 7
◦ Localized
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Day 2
◦ ICP
◦ Hypothermia
◦ Tracrium
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Day 3
◦ Flexion
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AANN Core Curriculum for Neuroscience Louis, MO.
Nursing, 4th Ed. 2004. Saunders. St.
Davis, F.A. (2001). Taber’s Cyclopedic Medical
Dictionary. F.A. Davis, Philadelphia.
Greenberg, Mark. (2006). Handbook of Neurosurgery.
Greenberg Graphics, Tampa, Florida.
Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L.
(2007).
Medical-Surgical Nursign. Assessment of
Management of Medical Problems. Mosby
Elsevier, St. Louis, Missouri
Silvestri, Linda. (2008). Comprehensive review for the
NCLEX-RN Examination. Saunders Elsevier, St.
Louis,
Missouri.