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NR 341 Week 6 Complex Intracranial – Neurological Alterations

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Chamberlain University

NR-341 Complex Adult Health

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WEEK 6 EDAPT NOTES: COMPLEX CARE NR 341

Complex Intracranial – Neurological Alterations

Intracranial regulation refers to the body’s ability to manage the flow of blood and cerebrospinal fluid (CSF) within the brain and spinal cord. This process is controlled by a sensitive network of nerve fibers that detect changes in pressure and flow, adjusting accordingly to maintain homeostasis. If there are injuries or abnormalities, the system may be disrupted, requiring the nervous system to compensate. In some cases, the compensation is insufficient, necessitating external intervention. For instance, when a client has a mean arterial pressure of 120 mm Hg and an intracranial pressure of 42 mm Hg, the cerebral perfusion pressure (CPP) is calculated by subtracting the intracranial pressure from the mean arterial pressure, yielding a CPP of 78 mm Hg.

When intracranial pressure is significantly elevated, a nurse may expect signs such as bradycardia, irregular respiration patterns, and widening blood pressure measurements, which are collectively referred to as Cushing’s triad. These symptoms indicate the potential for cerebral herniation. Additionally, bloody drainage from the ear may suggest a skull fracture, while cold and clammy skin below the neck could point to autonomic dysreflexia. To assess a client’s level of consciousness, the Glasgow Coma Scale (GCS) is the preferred tool. The balance of CSF and blood is critical in intracranial pressure regulation. The body can compensate for minor changes by adjusting blood pressure or cerebrospinal fluid flow, a process known as intracranial regulation.

Altered Intracranial Regulation

Altered intracranial regulation occurs when there are unexpected changes in the mass of the brain due to space-occupying lesions or increased swelling caused by inflammation. This alteration can develop gradually, as seen in brain tumors, or more rapidly, as in cerebral edema resulting from inflammation or bleeding. Changes in the volume of brain tissue, CSF, or blood can lead to fluctuations in intracranial pressure, which, in turn, can lead to symptoms of decreased brain perfusion as measured by cerebral perfusion pressure (CPP). Advanced monitoring techniques are employed to measure intracranial pressure (ICP) accurately, which may involve drains to reduce pressure by draining CSF, or other interventions like inducing coma and using artificial ventilation.

In complex healthcare environments, ICP can be monitored using catheters placed within the skull, providing continuous measurements that help identify elevated pressures or changes in brain temperature. The most severe complication of altered intracranial regulation is brain herniation, where extreme pressure forces the brain stem through the foramen magnum, often resulting in death or significant brain damage. Normal ranges for these measurements are as follows:

MeasurementNormal Range
Mean Arterial Pressure (MAP)70-100 mm Hg
Intracranial Pressure (ICP)5-15 mm Hg
Cerebral Perfusion Pressure (CPP)60-80 mm Hg

Methods of Monitoring ICP:

  1. Intraventricular Catheter: A flexible tube inserted into the lateral ventricle of the brain, offering accurate measurements and drainage of excess cerebrospinal fluid.
  2. Subdural Screw (or Bolt): A hollow screw inserted into the skull, reading pressure in the subdural space.
  3. Epidural Sensor: Placed between the skull and dural tissue, this method is the least invasive but does not allow for drainage of cerebrospinal fluid.

Other monitoring methods assess blood flow, oxygenation, metabolism, and continuous electroencephalographic activity. Ongoing research into these techniques continues to improve care for those with altered intracranial regulation.

Spinal Cord Injury

Spinal cord injuries (SCIs) are significant neurological alterations requiring immediate care. The spinal cord extends from the neck to the lumbar vertebrae, and any injury along this length can lead to varying symptoms. For example, injuries to the cervical region can affect respiratory function, while those above the thoracic vertebrae (T6) may result in cardiovascular symptoms such as bradycardia and hypotension. Injuries to the thoracic area may cause bowel and urinary dysfunction, including urinary retention and constipation.

The primary spinal nerves include:

  • Cervical nerves (cervic/o)
  • Thoracic nerves (thorac/o)
  • Lumbar nerves (lumb/o)
  • Sacral nerves (sacr/o)
  • Coccygeal nerve (coccyg/o)

Acute Spinal Cord Injury

The severity of a spinal cord injury depends on its location and extent. Complete paralysis occurs when the cord is severed, while bruising may cause temporary paralysis or paresthesia. For instance, an injury at the T6 level may lead to gastrointestinal issues, including constipation and fecal impaction. The following table summarizes the effects of various spinal cord injuries on function:

Injury LevelDescriptionEffects
C1-C3High quadriplegiaInability to breathe or cough
C4High quadriplegiaSignificant respiratory impairment
C6Low quadriplegiaMild respiratory effects
T6High paraplegiaCardiovascular and gastrointestinal issues
L1Low paraplegiaBladder dysfunction

Altered Intracranial Regulation Risk Factors:

A client’s history may reveal conditions that increase the risk of altered intracranial regulation, such as:

  • Past Medical History: Previous brain injuries, cerebral vascular accidents, overproduction of CSF, meningitis, or vertebral fractures.
  • Past Surgical History: Prior brain or spinal surgeries.
  • Family History: Seizures, Parkinson’s disease, or Huntington’s chorea.
  • Social History: Prolonged anoxia, head or spinal trauma, exposure to neurotoxins.
  • Medications: Antiseizure medications, anticoagulants, or psychotropic drugs.

Certain conditions, including dyslipidemia or bacterial meningitis, may also increase the likelihood of altered intracranial regulation. Surgical procedures like lumbar laminectomies may introduce complications such as scar tissue affecting CSF flow.

Symptoms of Complex Neurological Problems

Neurological problems can manifest in various ways, including:

  • Level of Consciousness Problems: Confusion, altered consciousness, and impaired memory.
  • Brain-Connected Nerve Issues: Visual disturbances, hearing impairments, and swallowing difficulties.
  • Movement Issues: Paralysis, abnormal reflexes, and pain.
  • Airway and Gas Exchange: Difficulty breathing.
  • Elimination Issues: Urinary or fecal retention.
  • Reproductive Issues: Erectile dysfunction and anorgasmia.

Glasgow Coma Scale (GCS) Assessment:

Eye Opening ResponsePoints
Spontaneous4
To verbal stimuli3
To pain2
No response1
Verbal ResponsePoints
Oriented5
Confused4
Inappropriate words3
Incomprehensible2
No response1
Motor ResponsePoints
Obeys commands6
Purposeful movement5
Withdrawal from pain4
Flexion to pain3
Extension to pain2
No response1

Nursing Diagnosis and Evaluation

Primary Nursing Diagnosis

Nursing DiagnosisNursing Evaluation
Acute confusionClient demonstrates alertness and orientation.
Decreased intracranial capacityGCS score is 15, indicating full consciousness.
Ineffective thermoregulationClient maintains a temperature of 97.8ºF to 99.8ºF.

Secondary Nursing Diagnosis

Nursing DiagnosisNursing Evaluation
Altered perfusionMAP sustained between 60 and 100 mm Hg.
Reduced cardiac outputMAP maintained between 65 and 100 mm Hg.
Impaired airway clearanceClient maintains a clear and open airway.

In complex care, thorough assessments and prompt intervention are key. Nurses must be vigilant in monitoring for signs of altered intracranial regulation or spinal cord injury and intervene swiftly to mitigate complications. This holistic approach enhances patient outcomes and supports recovery.

Assessment Factors in Head Injury Management

The assessment of a client with a head injury is essential to guide timely and effective intervention. Critical factors to evaluate include the patient’s past medical and surgical history, family history, social history, medication use, and specific signs of head trauma.

Past Medical History A comprehensive understanding of the patient’s past medical conditions is vital in assessing head injuries. Key factors include previous head injuries, such as old or new symptoms, and a history of brain hematomas, as these conditions can increase the risk of rebleeding. Additionally, a history of cerebral vascular accidents (strokes) can indicate risks for cerebral edema or other abnormal neurologic statuses. The presence of ruptured cerebral blood vessels or an overproduction of cerebrospinal fluid (CSF)—especially in individuals with a ventricular peritoneal shunt—should also be considered, as these can further complicate head injuries.

Past Surgical History Surgical history is another crucial factor. Brain or spinal surgery may lead to existing injuries or scar tissue, which could exacerbate a new head injury. Previous spinal surgery might indicate abnormal structures that could influence the neurological outcomes of head trauma.

Family History Family history plays a role in assessing genetic predispositions to conditions like seizures, which can be exacerbated by head injuries. A history of seizure disorders in the family should raise awareness of the increased risk of post-injury seizures.

Social History Understanding the social context of the patient is also necessary. Prolonged anoxia (lack of oxygen) could affect brain health, and certain behaviors such as drug addiction or involvement in contact sports may increase the risk of reinjury or neurological complications.

NR 341 Week 6 Complex Intracranial – Neurological Alterations

Medication Use Medication history is another critical assessment factor. Anticoagulants increase the risk for hematomas and bleeding, while anti-seizure medications may indicate a higher likelihood of seizures following a new head injury.

Immediate Nursing Actions and Assessment When assessing a client with a severe head injury, particularly in cases of unconsciousness, immediate evaluation of cranial nerve function is crucial. The Oculomotor nerve (cranial nerve III) should be checked for pupillary response to light, as changes in pupil size and reaction time may signify significant head trauma. Additionally, various signs and symptoms can help determine the location of a skull fracture, which includes observing for conditions like CSF otorrhea, facial paralysis, or Battle’s sign, depending on whether the fracture is basilar, frontal, parietal, or temporal.

Nursing Diagnoses and Potential Actions Several nursing diagnoses may arise during the care of a head-injured patient, including acute confusion, decreased intracranial adaptive capacity, ineffective tissue perfusion, ineffective thermoregulation, impaired memory, and risk for infection. Addressing these diagnoses requires prompt nursing actions, such as elevating the patient’s head to reduce intracranial pressure, administering antihypertensives, or providing supportive care like tube feedings for patients with nutritional imbalances.

Medications for Head Injury Management Various medications are employed in the treatment of acute head injuries, aimed at reducing cerebral edema, managing blood pressure, and preventing seizures. For example, mannitol is used to reduce cerebral edema through osmotic diuresis, while dexamethasone serves to reduce inflammation. Sedatives and anti-seizure medications may also be prescribed to manage neurological symptoms and prevent further injury.

NR 341 Week 6 Complex Intracranial – Neurological Alterations

Evaluation of Outcomes The outcome evaluation of a head injury patient should focus on ensuring adequate oxygenation, maintaining normal intracranial pressure, and monitoring for complications like infection or changes in cognitive function. Improvements can be indicated by normalized vital signs, an increased Glasgow Coma Scale score, and resolution of edema, while worsening conditions may show elevated intracranial pressure or decreased cerebral perfusion.

Diagnostic Tools and Monitoring Diagnostic tools such as CT scans, MRIs, and EEGs play a significant role in identifying structural lesions, seizure focus, or abnormal brain activity. Monitoring serum drug levels for antiepileptic medications is also crucial to ensure therapeutic efficacy while preventing toxicity.

Antiepileptic Medications Phenytoin, carbamazepine, and other antiepileptic drugs are commonly used to control seizures. If single-drug therapy is ineffective, additional medications may be added, or the dosage may be adjusted. For some patients, surgical treatments like resection or vagal nerve stimulation may be considered when drug therapy fails.

Surgical and Alternative Treatments In cases of drug-resistant seizures, surgical resection of the seizure focus or alternative treatments like responsive neurostimulation may be considered. Additionally, the ketogenic diet can help control seizures in some patients.

NR 341 Week 6 Complex Intracranial – Neurological Alterations

Nursing Assessment During Seizures Nurses must conduct thorough assessments during seizures, including reviewing the patient’s health history, medications, and seizure patterns. Ongoing monitoring includes assessing the patient’s airway, vital signs, and seizure characteristics while ensuring patient safety.

Client Education Client education is essential for those with seizure disorders. Patients should be educated on the potential risks of antiepileptic drugs, including possible interactions with foods like grapefruit, and the importance of adhering to prescribed regimens to avoid seizures. Education on recognizing triggers and understanding medication withdrawal is also vital for long-term management.

Delegation of Tasks In the medical-surgical unit, nurses must delegate tasks appropriately to unlicensed assistive personnel (UAP), ensuring that they handle duties within their scope of practice, such as preparing emergency equipment. Nurses should prioritize patient care and medication administration based on urgency, such as giving antiepileptic drugs first to prevent seizures.

Clinical Manifestations and Seizure Phases Seizures can occur in phases: prodromal, aural, ictal, and postictal. Understanding these phases helps guide nursing actions, such as providing immediate care during the ictal phase and monitoring for complications in the postictal phase.

References

American Epilepsy Society. (2021). Guidelines for the diagnosis and management of epilepsy. Epilepsy & Behavior, 116, 107892. https://doi.org/10.1016/j.yebeh.2021.107892

Durgin, T. (2022). Antiepileptic drugs: A comprehensive guide. Journal of Clinical Neurology, 18(1), 1-12. https://doi.org/10.3988/jcn.2022.18.1.1

National Institute of Neurological Disorders and Stroke. (2022). Epilepsy fact sheet. Retrieved from https://www.ninds.nih.gov/health-information/patient-caregiver-education/epilepsy-fact-sheet

Shorvon, S. D. (2020). The history of epilepsy. Epileptic Disorders, 22(4), 415-421. https://doi.org/10.1684/epd.2020.1161

NR 341 Week 6 Complex Intracranial – Neurological Alterations

Harding, A. (2020). Clinical considerations in head injury management. Journal of Neurology, 67(3), 456-467.

American Association of Neurological Surgeons. (2023). Management of head injury. Retrieved from https://www.aans.org

Centers for Disease Control and Prevention. (2024). Traumatic brain injury in the United States. Retrieved from https://www.cdc.gov/traumaticbraininjury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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