1Exam 3Nervous System Alterations•Brain metabolism – 15% of cardiac output•Cerebral glucose < 70 mg/dL = confusion•Cerebral glucose < 20 mg/dL = damage•Cerebral blood flow•Autoregulation – ensures perfusion to the tissues•Changes in BP•Changes in CO2•Alters cerebral blood volume with change in blood vessel sizeIntracranial Pressure-Components of ICP: brain tissue, blood, CSF fluid•Monro-Kellie doctrine•Increase in any one component requires a reduction in one or both ofother components to sustain normal ICP-Normal ICP: 5–15mmHg-Cerebral Perfusion Pressure (CPP)•Dependent upon ICP and MAP (CPP=MAP – ICP)•If CPP is inadequate, ischemia or infarction can occur-ICP 20mm Hg or greater for 5 minutes or longer can result in an increase in any one of thethree components:•Increased Blood Volume•Loss of Autoregulation•Decreased Oxygenation•Hypercapnia•Obstruction•Increased Brain Volume•Cerebral Edema•Increased Cerebrospinal Fluid•HydrocephalusIncreased ICP AssessmentEarliermanifestations of increased ICP:•Change in LOC – most reliable•Headache•Vomiting without nauseaLatermanifestations of increased ICP:•Deteriorating LOC•Cushing’s Triad – widening pulse pressure, bradycardia, and irregular respirations•Cheyne-Stokes respiration•Dilated pupils•Abnormal posturing – decorticate, decerebrate
2Increased ICP - Diagnostic TestsBlood/Urine•ABGs – acidosis, alkalosis•CBC – infection, hemoglobin•Coagulation profile – risk of bleeding, PTT/INR•Electrolytes – sodium and potassium•Serum osmolality – shrinking of the brain•Urinalysis and osmolality – renal damageRadiographic/Other•Computed tomography (CT) of the head – any bleeding, tumor•Magnetic resonance imaging (MRI) – detailed bleeding, tumor, lesion, aneurysm•EEG – EKG of the brain. Client remains still. Uses contrast dye. Allergies? Metformin?ICP MonitoringIndications: CSF score of 8 or less. For early identification and treatment of ICP.Purpose: records the pressure and shows the pictures of the wave forms and drainage of theCSFTransducer System: 3-way stopcock to monitor wave forms and leakage of CSF. Closed system.Nursing Management:-placement: aseptic technique-monitoring:Increased ICP Medical Management:Adequate Oxygenation•Goal: PaO2> 80mm Hg•Airway vigilance•Mechanical ventilationCarbon Dioxide Management•PaCO235-45 mm Hg•Avoid hyperventilationDiuretics•Osmotic (Mannitol) and loop diuretics (Furosemide)•Reduce brain tissue volume by removing sodium and water from injured brain cellsSteroids•DexamethasoneFluid Administration•Optimized fluid administration with isotonic solutions – maintain normal BP•Strict intake/output – monitor patient’s condition•Goal: serum osmolality less than 320 mOsm/L – ensure patient is hydratedBlood Pressure•Goal: MAP 70-90 mm Hg•CPP: at least 70 mm Hg•Avoid hypertension
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Traumatic brain injury
