Neuro Intensive Care Unit
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Transcript of Neuro Intensive Care Unit
NEURO INTE
NSIVE
CARE UNIT
AFTER CRANIOTOMYNursing Priorities• Accurately monitor and
record all vital signs and neurological signs
- Postoperative cerebral edema peaks between 48 and 68 hours following surgery.
- Patient may be lucid during first 24 hours, then experience a decrease in level of consciousness during this time
- Observe the patient closely at all times. Note GCS. Have family members remain with patient.
AFTER CRANIOTOMYNursing Priorities• Maintain body
temperature.
- Increases of body temperature in the neurosurgical patient may be due to cerebral edema around the hypothalamus.
- Place patient on hypothermia blanket, as ordered.
AFTER CRANIOTOMYNursing Priorities• Assess patient’s respiratory
status every 2 hours and as necessary for adventitious breath sounds.
• Maintain head of bed at 30ºelevation.
• Institute seizure precautions at patient's bedside (Tongue blade, airway) and observe for seizure activity.
AFTER CRANIOTOMY
Nursing Priorities• Administer
anticonvulsants as ordered. Monitor adverse effects. Monitor serum drug levels.
AFTER CRANIOTOMYDischarge Goals• Cerebral function
improved, neurological deficits resolving or stabilized
• Complications prevented or minimized
• Activities of daily living met by self or with assistance of others
AFTER CRANIOTOMYDischarge Goals• Family
acknowledgements reality of situation and involved in recovery program
• Condition, prognosis, complications and treatment regimen understood and available resources identified
• Plan in place to meet needs after discharge
MEDICATIONPost-Traumatic Brain Injury MedicationsAnti-convulsant/Anti-seizure
Anti-convulsant medications are used to suppress the rapid and excessive firing of neurons that start a seizure. Anti-convulsants can sometimes prevent the spread of a seizure within the brain and offer protection against possible excitotoxic effects that may result in brain damage.
Dilantin (phenytoin)
Valium (diazepam)
Diuretics
These drugs reduce the amount of fluid in tissues and increase urine output. Diuretics, given intravenously to people with traumatic brain injury, help reduce pressure inside the brain.
Mannitol
Pain Management:
Pain management medications are used to control pain stemming from TBI, and the symptoms and effects related to the injury.
NSAIDs:
Aspirin (ASA)
Midol (ibuprofen)
Post-Craniotomy MedicationsSteroids
These will be given to you to decrease post-operative brain swelling. These medications might elevate your blood sugar so be cautious and check your blood sugar regularly if you are a diabetic. Increased blood glucose will increase brain swelling.
Anti-seizureThese medicines (Dilantin, Phenobarb, Tegratol) will decrease your chance of post-operative seizures. Please take as directed.
AUTONOMIC DYSREFLEXIA• Monitor blood pressure and
pulse every 2-5 minutes until the patient has stabilized
• Use an antihypertensive agent with rapid onset and short duration while the causes of AD are being investigated if the blood pressure is at or above 150 mm Hg systolic. The most commonly used agents are nifedipine and nitrates
• The patient should be placed in the highest sitting position possible with legs lowered
AUTONOMIC DYSREFLEXIA• Any clothing or leg straps
considered tight or restrictive should be loosened or removed.
• Check the bladder - Irrigation of a catheter should be done slowly and gently
• In the absence of bladder distention, examine the rectum for the presence of stool
AUTONOMIC DYSREFLEXIA• A digital rectal examination
should be conducted following the application of a local anaesthetic to reduce rectal stimulation
• If there is poor response to treatment and/or if the cause of the AD has not been identified, send the patient to the emergency room (ER) for monitoring, maintenance of pharmacologic control of blood pressure, and investigation of other possible causes of the AD. Remember to document the episode of AD.
NCPN
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INEFFECTIVE TISSUE PERFUSION RELATED TO FLUID EXCESS
SECONDARY TO POST-OPERATIVE PROCEDURE
INTERVENTIONS:
Independent:• Determine factors related to
individual situation, cause for come or decreased cerebral perfusion and potential for increased ICP
• Monitor vital signs: BP, noting onset of and continuing systolic hypertension and widening pulse pressure; observe for hypotension in multiple trauma client
• Monitor and document neurological status frequency and compare with baseline: GCS during the first 48hrs
• Evaluate pupils, noting size, shape, equality, and light reactivity
INEFFECTIVE TISSUE PERFUSION RELATED TO FLUID EXCESS
SECONDARY TO POST-OPERATIVE PROCEDURE
• Monitor intake and output (I&O). Weigh as indicated. Note skin turgor and status of mucous membranes.
• Assess higher functions, including speech, if client is alert
• Position head slightly (20-30 ®) elevated as tolerated
• Prevent straining at stool or holding breath
• Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity
INEFFECTIVE TISSUE PERFUSION RELATED TO FLUID EXCESS
SECONDARY TO POST-OPERATIVE PROCEDURE
Collaborative
• Maintain patients on supplemental oxygen via mechanical ventilator as indicated
• Administer isotonic IV fluids
• Administer diuretics such as mannitol and Fusosemide – lasix as ordered
ACUTE PAIN RELATED TO POST-OPERATIVE PROCEDURE
INTERVENTIONS: Independent
assess contributing factors to pain (noise, wrong positioning, environment)
provide comfort measures such as repositioning the client in a comfortable position and providing a hot or cold compress
encouraged adequate rest periods assist in self-care activities as
tolerated provide calm and quiet
environment
Collaborative administer medications as ordered
by physician (analgesics, etc.)
INEFFECTIVE BREATHING PATTERN RELATED TO SPINAL CORD INJURY
INTERVENTIONS:
Independent
Auscultate chest to evaluate presence
or character of breath
sounds/secretions
Observe rate and depth of respiration
Suction Airway as needed
Elevate Head of Bed if appropriate
Monitor pulse O2
Administer 4L of O2 as ordered by the
physician
MEDICAL
SURGICAL U
NIT
HEALTH INSTRUCTIONS• Provision of information about TBI
• Education provided to patients and their support
system about the nature and common
manifestations of TBI is a critical aspect of
intervention. Communication of health information
from providers helps manage patient expectations
and can prevent the development of TBI symptoms
and/or reduce their duration, number, and severity.
HEALTH INSTRUCTIONS• Supervision
• Due to concerns of safety, some patients will be instructed to have
supervision. This will mean that they would need a responsible adult
to be with them at all times.
• Mood Changes
Inform relative for irritability and emotional changes of the patient.
Some people show emotions more easily after a brain injury. Some
may even get violent. This behavior does not necessarily mean that
they are feeling a deep emotion, but can occur because the brain is
not regulating emotions to the same extent as before the injury.
HEALTH INSTRUCTIONS• Healthy Rest
• Getting a good night’s sleep has to do with many factors, and is also a
treatment for insomnia. Also instruct patient to avoid exerting physical
and mental effort.
• Physical Therapy
• Instruct patient that they may need the help of a Physical
Rehabilitation Therapists to aid in restoring and maintaining function,
slowing disease progression, and improving quality of life.
• Speech Therapy
• Inform patient and relative about speech therapy. Some patients may
have problems in speech occurring after a TBI.
MEDICATIONAntibiotic
Prophylactic antibiotics are given to prevent infection. Bacterial meningitis is the most common complication of post operative craniotomy.
Vancomycin
Penicillin
Cefotaxime
Anti-emetic
Craniotomy surgery can irritate and inflame a patient's brain matter. This can cause patients to experience brain swelling complications after brain surgery. Brain swelling causes fluid to abnormally accumulate within the skull. Affected patients may experience severe headaches, dizziness, nausea or vomiting.
Droperidol
POSSIB
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OMPLIC
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AFTER D
ISCHARGE
POSTTRAUMATIC SEIZURES
POSTTRAUMATIC SEIZURES
Approximately 5-10% of individuals with traumatic brain injury (TBI) experience new- onset seizures.
The risk is greatest in the first two years after injury and gradually declines thereafter.
All types of seizures may occur as a result of trauma, but the most frequent are focal or partial complex seizures. Generalized complex seizures (which are commonly called "grand mal' seizures) occur in approximately 33% of cases.
It is not completely understood what physiological mechanisms cause seizures after injury, but early seizures are thought to have different underlying processes than late ones.
Late seizures are thought to indicate permanent changes in the brain's structure and to imply epilepsy.
Factors that may result in seizures that occur within two weeks of an insult include the presence of blood within the brain; alterations in the blood brain barrier; excessive release of excitatory neurotransmitters such as glutamate; damage to tissues caused by free radicals; and changes in the way cells produce energy.
Late seizures are thought to be the result of epileptogenesis, in which neural networks are restructured in a way that increases the likelihood that they will become excited, leading to seizures
PREVENTION
Medications used to prevent seizures include valproate, phenytoin, and phenobarbital. It is recommended that treatment with anti-seizure medication be initiated as soon as possible after TBI.
DEEP VEIN THROMBOSIS
DEEP VEIN THROMBOSIS
Deep vein thrombosis (DVT) is common in persons with TBI,
with an incidence as high as 54%. In patients with TBI, risk
factors for DVT include immobility, lower extremity fracture,
paralysis, and disruption in coagulation and fibrinolysis.
Complications of DVT include pulmonary embolism (PE) and
recurrence. Because DVT can result in PE, it can be critical.
Given the rapid decline in pulmonary function when a PE
has completely occluded the pulmonary capillary system,
sudden death may be the first clinical sign. Other clinical
signs of PE include shortness of breath, chest pain, and
pulmonary crackles; these are usually present with small
emboli.
The most recognized risk factor for venous thromboembolism are venostasis, initial damage of the vessel wall, and a hypercoagulable state.
Patients with a severe brain injury are commonly immobilized for periods of time as a result of the fractures they experience in their extremities or spine. The incidence of DVT appears to be impacted by length of stay in the ICU.
Patients involved in trauma that does not specifically involve vessel injury are still at increased risk of thromboembolism, suggesting a trauma-induced hypercoagulable state. Therefore persons who have sustained a TBI appear to be at increased risk of developing venous thromboembolism.
PREVENTION
Prophylaxis for DVT should be started as soon as possible.
Use of elastic compression stockings
Warfarin
HETEROTROPHIC OSSIFICATION
Heterotopic ossification is described as ectopic bone formation in the soft tissue surrounding the joints. In TBI, the incidence of heterotopic ossification is 11-76%, with a 10-20% incidence of clinically significant heterotopic ossification.
Heterotopic ossification generally causes joint pain and decreases range of motion (ROM).
In decreasing order of frequency, heterotopic ossification
occurs in the hips, knees, elbows, shoulders, hands, and
spine.
Risk factors associated with the development of heterotopic
ossification after TBI are a posttraumatic coma lasting longer
than 2 weeks, limb spasticity, and decreased mobility.
The risk of heterotopic ossification is greatest during the first
3-4 months after injury.
The pathophysiology of HO is not well understood. HO forms through a
typical process beginning with the formation of osteoid to full calcification
within a matter of weeks. Over the next few months, the calcified osteoid
remodels into well-organized trabecular bone at which point it is
considered to have matured. Several months after the initial trauma,
these patients develop paraarticular and intramuscular bone formation
and experience restricted range of motion, pain and ankylosis.
The bony lesion has been found to have a high metabolic rate, with a rate
of bone formation more than three times greater than that of normal bone
and an osteoclastic density of more than twice the number of osteoclasts
found in normal bone.It is believed that there is a neurogenic factor
contributing to HO, although this mechanism is not yet understood.
Circulating factors promoting heterotopic ossification may be
present in head injured patients. In one animal study, the
serum from patients with head injuries has been shown to
promote mitogenesis and cell division in a rat osteoblast cell
culture model.
Many studies have shown enhanced osteogenesis in patients
sustaining traumatic brain injury (TBI). Accelerated fracture
healing and heterotopic ossifications are well-known
phenomena in these patients.
PREVENTIONRange of motion exercises
Nonsteroidal anti-inflammatory medications (NSAIDs)
Low-dose radiation
Warfarin
Etridonate disodium
NCPM
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IMPAIRED PHYSICAL MOBILITY RELATED TO
POST-OPERATIVE PROCEDURE
INTERVENTIONS
• Ensure the patient’s safety. Always keep the side rails up
• Turn patient every 2 hours to prevent pressure ulcers
• Perform Range of Motion Exercise.
• Discuss the proper usage of assistive devices and its functions
• Ensure that the patient always have a relative present for any need
for assistance.
• Provide emotional support for the patient.
IMPAIRED VERBAL COMMUNICATION RELATED TO ALTERATION IN CNS INTERVENTIONS
Independent
• Establish rapport simply by listening carefully and attending to the patient’s verbal and non verbal expressions
• Assess patient’s readiness to participation to alternative means of communication
• Encourage patient to express his thoughts via nonverbal movements like eye blinking, the picture board, computer or anything that is available to which the patient prefers to use
• Always speak to the patient in a calm voice
• Allow patient to complete what he’s saying
• Provide encouragement and reassurance to the patient at all times when they are attempting to communicate
Collaborative
• Refer to speech therapist
NAUSEA RELATED TO INCREASED INTRACRANIAL PRESSURE
INTERVENTIONS: Assess contributing factors to nausea.
Administer anti-emetic drugs.
Provided instructions to the patients
on appropriate food and fluid choices,
and encourage frequent
intake of clear liquids in small
amounts.
Caution them not to drink excessive
amounts of carbonated beverages,
such as soft drinks
Administer Mannitol.