TCA #1

ALTERED LOC AND INCREASED ICP

- RESULT FROM UNDERLYING CAUSE
- ALMOST ALL PROBLEMS RESULT IN THESE

ALTERED LOC
- A SYMPTOM OF AN UNDERLYING CONDISION
- MOST IMPORTANT INDICATOR OF A NEURO CLIENT’S CONDISIOTN
- GAUGED ON A CONTINUUM FULLY ALERT  COMA
- FULLY ALERT
O RESPOND TO STIMULI
O RESPOND TO QUESTIONS
- BEGIN TO SEE ALTERED LOC
O WHEN NEED CONSTANT STIMULI TO STAY AWAKE
- TERMS USED TO DESCRIBE ALOC – IMPORTANT TO DOCUMENT WHAT YOU OBSERVE
O CONFUSION
O DISORIENTATION
O LETHARGIC
O OBTUNDED – AROSES WITH STIMULATION ONLY, APPEAR SLEEPY
O STUPOROUS – UNCONSCIOUS, DIFFICULT TO AROUSE, MAY BE COMBATIVE WHEN AWAKENED
O SEMI-COMATOSE – RESPONDS ONLY TO PAINFUL STIMULUS, WILL PULL AWAY OR GRIMACE AT STUMLI
O COMA – UNCONSCIOUS, BEING UNAWARE OF SELF OR ENVIROMENT, NO RESPONSE TO STIMULI
O AKINETIC MUTISM – UNRESPONSIVE TO ENVIROMENT, NO MOVEMENT OR SOUND, BUT DOES OPEN EYES
O PERSISTENT VEGETATIVE STATE – RESULTS FROM SEVERE DAMAGE TO CERBRAL CORTEX, MAY HAVE
REFLEXIVE ACTIVITY, MAY MAKE SOME SOUNDS, BUT NOTHING PURPOSEFUL
- PATHO
O CAUSES
 NEUROLOGIC – HEAD INJURY, STROKE
 TOXICOLOGIC – ALCOHOL, MEDICATION
 METABOLIC – DIABETES, RENAL FAILURE
- INVOLVES
O CELLS
O NEUROTRANSMITTERS
O STRUCTURE/ANATOMY
- CLINICAL MANIFESTATIONS
O RESTLESSNESS, ANXIETY
O SLOWING OF VERBAL AND MOTOR RESPONSES
O PUPILLARY CHANGES – BEGIN TO CONSTRICT, OR VARIATION IN SPEED AT WHICH THEY CONSTRICT,
ALSO CAN DILATE
O IF CAUSE IS NOT FOUND AND TREATED WILL MOVE DOWN TO WHERE THEY ARE UNRESPONSIVE
- ASSESSMENT AND DIAGNOSTIC FINDING
O CT, MRI
O PET
O EEG
O LABORATORY TESTS
O THOROUGH PHYSICAL ASSESSMENT
O GLASGOW COMA SCALE – PAGE 1917
 MEASURES EYE OPENING, VERBAL AND MOTOR RESPONSES TO STIMULI

1
 TCA #1

 SCORES FROM 3 (DEEP COMA) TO 15 (FULLY ALERT)

 8 OR LESS IS SEVERE HEAD INJURY
- COMPLICATIONS – PROTECT AIRWAY
O RESPIRATORY FAILURE – MAY NEED MECHANICAL VENTILATION
O PNEUMONIA
O PRESSURE ULCERS
O ASPIRATION
O ALL HAZARDS OF IMMOBILITY
- MEDICAL MANAGEMENT
O OBTAIN AND MAINTAIN A PATENT AIRWAY - VENTILATOR
O MONITOR CARDIOVASCULAR STATUS
O NUTRITION AND HYDRATION – TUBE FEEDINGS
O DETERMINE AND TREAT CAUSE
- NURSING ASSESSMENT
O ASSURE THAT CLIENT IS AT HIGHTES LEVEL OF ALERTNESS
O HAVE A PARENT PRESENT WHEN ASSESSING CHILDREN
O VERBAL RESPONSE
 ORIENTATION
 DOCUMENT IF UNABLE TO ASSESS (INTUBATED)
O ALERTNESS
 EYE OPENING TO COMMAND OR STIMULUS
O MOTOR RESPONSE
 PURPOSEFUL, SPONTANEOUS, MOVE WHEN STIMULUS PRESENT
 POSTURING
• DECORTICATE – INDICATES DAMAGE OF CERBRAL CORTEX
O INTERNAL FLEXION OF UPPER EXTREMIITES
O LOWER EXTREMITIES INTERNALLY ROTATED AND PLANTAR FLEXED FEET
• DECEREBRATE – DEEPER AND MORE SEVERE BRAIN DYSFUNCTION
O EXTENDED AND OUTWARDLY ROTATED
O PLANTAR FLEXION OF THE FEET
 FLACCIDITY – WORST FINDING
O LOC
 RESPONSE TO STIMULI
 GLASCOW COMA SCALE
 PATTERN OF RESPIRATIONS – CHENYE STOKES
O PUPILLARY SIZE AND REACTION
O EYE MOVEMENTS (DOLL’S EYES) – EYES MUST MOVE TOGETHER
O OCULOVESTIBULAR RESPONSE (CALORIC TEST) – EXTERNAL EAR CANAL IS FLUSHED WITH ICE WATER
O PROTECTIVE REFLEXES
 CORNEAL – COTTON USED, WATCH FOR BLINK
 GAG – MUST BE ABLE TO SWALLOW ON THEIR OWN
O FACIAL SYMMETRY
O NECK – STIFF NECK INDICATES DAMAGE
O DEEP TENDON REFLEXES – ABSENT IN COMA OR STROKE
O PATHOLOGIC REFLEXES – BABINSKI REFLEX – POSITIVE IN LATER AGE = BRAIN DAMAGE
O ABNORMAL POSTURING – IN RESPONSE TO STIMULI
- COLLABORATIVE PROBLEMS
2
 TCA #1

O RESPIRATORY DISTRESS
O PNEUMONIA
O ASPIRATION
O PRESSURE ULCER
O DCT
- INTERVENTIONS
O OVERALL GOAL IS TO COMPENSATE FOR THE CLIENT’S LOSS OF PROTECTIVE REFLEXES
O MAINTAINING THE AIRWAY
 LATERAL OR SEMI-PRONE POSITIONING
 FREQUENT MOUTH CARE AND SUCTIONING
 HOB 30 DEGREES
 AUSCULTATE BREATH SOUNDS Q8H
 MAY NEED INTUBATION
O PROTECTING THE PATIENT
 SIDE RAILS X2, BED LOW
 AVOID RESTRAINTS IF POSSIBLE – COVER HANDS BEFORE FULL RESTAINTS, USE MITTS
 KEEP CLIENT CALM AND QUIET – IF STIMULI IS TOO MUCH NEED TO LESSEN STIMULI
 PROTECT CLIENT’S DIGNITY – DON’T TALK ABOUT THEM THEY CAN STILL HEAR
O MAINTAINING NUTRITION AND HYDRATION
 I&O, DAILY WEIGHT
 SLOW IV FLUID
 NPO IF UNCONSCIOUS
 TUBE FEEDINGS

O PROVIDING MOUTH CARE

 INSPECT FOR DRYNESS, INFLAMMATION, CRUSTING
 FREQUENT ORAL CARE
 ROTATE ET TUBE SITE
O MAINTAINING SKIN AND JOINT INTEGRITY
 FREQUENT TURNING
 SPECIALTY BEDS
 PASSIVE ROM
 GOOD BODY ALIGNMENT
O PRESERVING CORNEAL INTEGRITY
 CLEAN WITH NS
 ARTIFICIAL TEARS
 CLOSE EYES BEFORE APPLYING PATCH
O ACHIEVING THERMOREGULATION
 ADJUST ENVIROMENT
 ADMINISTER ANTIPYRETICS
 COOL SPONGE BATHS, COOLING BLANKET
O PREVENTING URINARY RETENTION
 ASSESS FOR DISTENTION – EITHER PALPATING OR BLADDER SCANNER
 INDWELLING OR INTERMITTENT CARTHETERIZATION
O PROMOTING BOWEL FUNCTION

3
 TCA #1

 ASSESS FOR ABDOMINAL DISTENTION

 MONITOR BOWEL PATTERN
 CHECK FOR IMPACTION
 STOOL SOFTNERS, GLYCERIN SUPPOSITORIES, ENEMAS
O PROVIDING SENSORY STIMULATION
 MAINTAIN DAY/NIGHT PATTERNS
 TOUCH AND TALK TO CLIENT
 ORIENT TO TIME AND PLACE
 PROVIDE AUDITORY STIMULATION – RECORDINGS, TALKING
 MAY NEED TO DECREASE STIMULI WHEN CLIENT IS AROUSING FROM COMA
O MEETING FAMILIES NEEDS
 GIVE ACCURATE INFROMATION
 PROVIDE EMOTIONAL SUPPORT
 REFER TO SUPPORT GROUPS
O MONITORING AND MANAGING POTENTIAL COMPLICATIONS
 RESPIRATOR YFAILURE – O2 SAT, LUNG SOUNDS
 PNEUMONIA – CHANGES IN SPUTUM, LUNG SOUNDS
 ASPIRATION – COUGH
 IMPAIRED SKIN INTEGRITY – PREVENTION IS KEY, FREQUENT TURNING, KEEP CLEAN AND DRY
 DVT – ANTIEMBOLISM HOSE, MAY BE ON LOW DOSE ANTICOAGULANT (LOVENOX)
O DEPENDING ON CUASE:
 ASSESS FOR SEIZURES AND INCREASED ICP
 ADMINISTER APPROPRIATE MEDICATIONS

INCREASED INTRACRANIAL PRESSURE

- BOX THEORY
O THE BRAIN IS A LARGE CLOSED BOX
O IT IS FULL AND CAN NOT EXPAND
O 3 COMPONENTS
 BRAIN 85%
 BLOOD 7%
 CSF 8%

4
 TCA #1

 THESE CONTENTS MUST REMAIN CONSTANT

 DOES COMPENSATE FOR SMALL CHANGES – BUT IT LIMITED
- ICP
O THE FORCE EXERTED BY THE BRAIN, BLOOD, AND CSF WITHIN THE SKULL
O IF ONE COMPONENT INCREASES, THEN ANOTHER MUST DECREASE (MONRO-KELLIE HYPOTHESIS)
O PRESSURE REMIANS IN A STATE OF EQUILIBRIUM UNDER NORMAL CONDITIONS
O NORMAL FLUCTUATIONS DO OCCUR (SNEEZING, BP CHANGES, O2 AND CO2 LEVELS, VALSALVA)
O COMPENSATION IS LIMITED
O NORMAL ICP: 10-20 MMHG
 MEASURED BY LOOKING AT PRESSURE OF CSF WITHIN THE BRAIN
- PATHO – INCREASED ICP
O RELATIONSHIP BETWEEN INTRACRANIAL VOLUME AND PRESSURE BECOMES ALTERED
O MOST COMMONLY FROM HEAD TRAUMA, BUT SPACE OCCUPYING LESIONS, HEMORRAHGE OR INFECTION
CAN ALSO LEAD TO IICP
O RESULTS IN
 DECREASED CEREBRAL BLOOD FLOW
 CEREBRAL EDEMA
 SHIFTING OF BRAIN TISSUE
 HERNIATION
O ATTEMPTS TO COMPENSATE BY SHIFTING CSF TO OTHER PLACES
- CEREBRAL RESPONSE TO INCREASE ICP
O PRESSURE AUTOREGULATION
 UNDER NORMAL CIRCUMSTANCES, CEREBRAL PERFUSION PRESSURE (CPP) IS MAINTAINED
REGARDLESS OF SYSTEMIC BLOOD PRESSURE
 MAP MUST BE 50 -60 MMHG HIGHER THAN ICP IN ORDER TO MAINTAIN AND ADEQUATE
CPP
O METABOLIC AUTOREGULATION
 CONSTRICTION AND DILATION OF BLOOD VESSELS; RESPONSE TO O2 AND CO2 LEVELS
- CALCULATE
O CPP = MAP – ICP
 (SYSTOLIC – DIASTOLIC/3) + DIASTOLIC
O NORMAL CPP = 70-100
O IRREVERSIBLE NEUROLIGIC DAMAGE OCCURS WHEN CPP FALLS BELOW 50 MMHG
- COMPENSATION
O MOST COMPENSATION FOR INCREASED ICP IS ACCOMPLISHED THROUGH CSF REGULATION
 DECREASED PRODUCTION
 INCREASED REABSORPTION
 DISPLACEMENT
O THE BODY COMPENSATES FOR INCREASED ICP BEST WHEN:
 THERE ARE SMALL VOLUME CHANGES
 THE CHANGES OCCUR OVER LONGER PERIODS OF TIME
O IF COMPENSATION CANNOT BE ACHIEVED, CEREBRAL BLOOD PLAW BECOMES COMPROMISED
- DECOMPENSATION
O AUTOREGULATORY MECHANISMS FAIL
O VENOUS COMPRESSION AND COLLAPSE WITH CONTINUES ARTERIAL FLOW TO THE BRAIN, LEADING TO
INCREASED ICP AND DECREASED CPP
O CEREBRAL ISCHEMIA AND INFARCTAION RESULT
5
 TCA #1

O CUSHING’S TRIAD
 BRADYCARDIA
 HYPERTENSION
 BRADYPNEA
O HERNIATION WILL OCCUR WITHOUT INTERVETION

CEREBRAL BLOOD FLOW

INCREASED ICP CEREBRAL HYPOXIA (O2)

DECOMPENSATION
CYCLE
“KILLING ITSELF OFF”

CEREBRAL EDEMA CO2;  PO2;  PH

ACIDOSIS

VASODILATATION

- DECOMPENSATION LEADS TO ONE OF TWO THINGS

O NO PERFUSION
O HERNIATION

- CLINICAL MANIFESTATION OF INCREASED ICP

O ALTERED LOC FIRST SIGN
O MOTOR AND SENSORY LOSS
O HA
O PUPILLARY CHANGES
O PAPILLEDEMA
O VOMITING
O ALTERATION IN VS
 CUSHING’S RESPONSE
• ELEVATED SYSTOLIC BP
• WIDENED PULSE PRESSURE
• SLOWING OF HR
 ALTERED RESPIRATIONS
 ELEVATED TEMPERATURE – UNCONTROLLABLE
 CUSHING’S TRIAD
O LOSS OF BRAIN STEM REFLEXES – SWALLOW, GAG, EYE (PUPIL RESPONSE CHANGES), ETC…

LIFE SPAN CONSIDERATIONS

- ELDERLY
O MAY HAVE INCREASED ICP WITH DELAYED SIGNS AND SYMPTOMS DUE TO CEREBRAL ATROPHY
(DECREASED BRAIN MAS)
6
 TCA #1

- INFANTS AND CHILDREN

O MAY HAVE INCREASED ICP WITH DELAYED SIGNS AND SYMPTOMS DUE TO OPEN FONTANELS AND
SUTURES
O SUTURES MAY RE-OPEN UP TO AGE 10 IN THE PRESENCE OF INCRESED ICP

- INCREASED ICP IN INFANTS

O CLINICAL MANIFESTATION
 TENSE, BULGING FONTANELS
 SEPARATED CRANIAL SUTURES
 MACEWEN (CRACKED POT) SIGN
 IRRITABILITY
 HIGH-PITCHED CRY
 INCREASED HEAD CIRCUMFERANCE
 DISTENDED SCALP VEINS
 CHANGES IN FEEDING
 CRYING WHEN BEING HELD OR ROCKED
 “SETTING SUN” SIGN – EYES DEVIATE DOWNWARD TOWARD THE CHEEK DUE TO INCREASED
PRESSURE

- INCREASED ICP IN CHILDREN

O HA
O NAUSEA
O VOMITING (OFTEN WITHOUT NAUSEA)
O DIPLOPIA, BLURRED VISION
O SEIZURES
O PERSONALITY AND BEHAVIOR CHANGES

- DIAGNOSTIC STUDIES
O CT
O MRI
O PET
O TCD – TRANS CUTANEAL DOPPLER
O LP IS AVOIDED DUE TO RAPID DROP IN PRESSURE

- COMPLICATIONS
O BRAIN STEM HERNIATION
O DIABETES INSIPIDUS
O SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)

BRAIN HERNIATION – SHIFTING OF BRAIN TISSUE FROM AN AREA OF HIGH PRESSURE TO AN AREA OF LOWER PRESSURE
THROUGH APENINGS IN THE RIGID DURA, RESULTING IN BRAIN STEM COMPRESSION AND CESSATION OF CEREBRAL BLOOD
FLOW

DIABETES INSIPIDUS – RESULTS FROM DECREASED SECRETION OF ADH

- CLINICAL MANIFESTATIONS
O EXCESSIVE URINE OUTPUT
 > 200ML/HR FOR 2 HOURS

7
 TCA #1

 HYPEROSMOLARITY
- TREATMENT
O FLUID VOLUME REPLACEMENT
O ELECTROLYTE REPLACEMTN
O DESMOPRESSIN (VASOPRESSIN, DDAVP) THERAPY

SIADH – RESULTS FROM INCREASED SECRETION OF ADH

- CLINICAL MANIFESTATIONS
O DECREASED URINE OUTPUT
O HYPONATREMIA
O FLUID VOLUME OVERLOAD
- TREATMENT
O FLUID RESTRICTION (USUALLY SELF CORRECTED)
O 3% HYPERTONIC SALINE SOLUTION
O IF CHRONIC: LITHIUM, DEMECLOCYCLINE (TETRACYCLINE ANTIBIOTIC)

MANAGEMENT OF INCREASED ICP

- TREATED AS AN EMERGENCY
- MONITORING ICP
O VENTRICULOSTOMY – INTO VENTRICLES OF BRAIN, SAMPLE CSF, INSTILL ANTIBIOTICS
O SUBARACHNOID BOLT – PUT INTO SUB ARACHNOID SPACE, NOT AS ACCURATE
O EPIDURAL MONITOR
O FIBEROPTIC MONITOR
- DECREASING CEREBRAL EDEMA
O OSMOTIC DIURETICS (MANNITOL)
O CORTICOSTEROIDS (DEXAMETHASONE)
O FLUID RESTRICTION

- MAINTAINING CEREBRAL PERFUSION

O IMPROVING CPP BY IMPROVING CARDIAC OUTPUT (FLUID VOLUME, INOTROPICS)
- REDUCING CSF AND INTRACRANIAL BLOOD VOLUME
O CAUTIOUS CSF DRAINAGE
O HYPERVENTILATION
- CONTROLLING FEVER
O ANTIPYRETICS
O COOLING BLONKET
O AVOID SHIVERING
- MONITORING OXYGENATION
O ABG MONITORING, O2 SAT
O O2 ADMINISTRATION
- REDUCING METABOLIC DEMANDS
O HIGH DOSE BARBITUATES – COSTANT VS MONITORING, ICP MONITORING
O PHARMACOLOGIC PARALYTIC AGENTS

NURSING DIAGNOSIS
8
 TCA #1

- INEFFECTIVE AIRWAY CLEARANCE

- INEFFECTIVE BREATHING PATTERNS
- INEFFECTIVE CEREBRAL TISSUE PERFUSION
- DEFICIENT FLUID VOLUME
- RISK FOR INFECTION

INTERVENTIONS
- OBSERVATION
- MAINTAINING A PATENT AIRWAY
- ACHIECING AN ADEQUATE BREATHING PATTERN
- OPTIMIZING CEREBRAL TISSUE PERFUSION
- MAINTAINING NEGATIVE FLUID BALANCE
- PREVENTING INFECTION
- MONITORING AND MANAGEING POTENTIAL COMPLICATINS