Lewis: Medical-Surgical Nursing, 8

th
Edition
Chapter 57: Nursing Management: Acute ntracranial !ro"lems
#e$ !oints % !rinta"le
N&'AC'ANAL !'ESS('E
Intracranial pressure (ICP) is the hydrostatic force
measured in the brain cerebrospinal fuid (CSF) compartment.
Normal ICP is the total pressure exerted by the three components
within the sull! brain tissue" blood" and CSF.
If the #olume of any one of the three components
increases within the cranial #ault and the #olume from another
component is displaced" the total intracranial #olume" and
therefore" pressure" will not chan$e.
Normal ICP ran$es from % to &' mm ($) a sustained
pressure abo#e the upper limit is considered abnormal.
Cerebral Blood Flow
Cerebral blood fow (C*F) is the amount of blood in
milliliters passin$ throu$h &%% $ of brain tissue in & minute.
+hrou$h a process nown as autore$ulation, the brain has
the ability to re$ulate its own blood fow in response to its
metabolic needs despite wide fuctuations in systemic arterial
pressure.
+he cerebral perfusion pressure (CPP) is the pressure
needed to ensure blood fow to the brain. ,s the CPP decreases"
autore$ulation fails and C*F decreases" which can lead to
ischemia and neuronal death.
Compliance is the expandability of the brain. -ith low
compliance" small chan$es in #olume result in $reater increases
in pressure.
NC'EASE) N&'AC'ANAL !'ESS('E
Increased ICP is a [Link]$ situation that results
from an increase in any or all of the three components (brain
tissue" blood" CSF) within the sull.
/le#ated ICP is clinically si$ni0cant because it diminishes
CPP" increases riss of brain ischemia and infarction" and is
associated with a poor pro$nosis.
ICP may rise because of head trauma" stroe" subarachnoid
hemorrha$e" brain tumor" infammation" hydrocephalus" or brain
tissue dama$e from other causes.
Cerebral edema is an important factor contributin$ to
increased ICP. +here are three types! #aso$enic" cytotoxic" and
interstitial. 1ore than one type may occur in the same patient.
+he clinical manifestations of increased ICP can tae many
forms" dependin$ on the cause" location" and rate at which the
pressure increase occurs. +he earlier the condition is reco$ni2ed
and treated" the better the patient outcome.
Complications of ICP include chan$es in the le#el of
consciousness" chan$es in #ital si$ns" dilation of pupils" decline
in motor function" headache" and #omitin$.
+he ma3or complications of uncontrolled increased ICP are
inade4uate cerebral perfusion and cerebral herniation.
ICP monitorin$ is used to $uide clinical care when the
patient is at ris for or has ele#ations in ICP. It may be used in
patients with a #ariety of neurolo$ic insults" includin$
hemorrha$e" stroe" tumor" infection" or traumatic brain in3ury.
+he 5$old standard6 for monitorin$ ICP is the
#entriculostomy" in which a speciali2ed catheter is inserted into
the ri$ht lateral #entricle and coupled to an external transducer.
7ther de#ices now allow for an indirect assessment of cerebral
oxy$enation and perfusion.
-ith the #entricular catheter and certain 0beroptic
systems" it is possible to control ICP by remo#in$ CSF. +he le#el
of the ICP at which to initiate draina$e" amount of fuid to be
drained" hei$ht of the system" and fre4uency of draina$e are
ordered by the physician.
+he $oals of collaborati#e care are to identify and treat the
underlyin$ cause of increased ICP and to support brain function.
o 1aintenance of a patent airway is critical in
supportin$ brain function in the patient with increased ICP
and is a primary nursin$ responsibility.
o 8ru$ therapy plays an important part in the
mana$ement of increased ICP. ,n osmotic diuretic"
corticosteroids" and barbiturates may be prescribed*
o 1etabolic demands" such as fe#er and pain" which
contribute to increased ICP" must be controlled.
o ,ll patients must ha#e their nutritional needs met"
re$ardless of their state of consciousness or health.
+he 9las$ow Coma Scale is a 4uic" practical" and
standardi2ed system for assessin$ the de$ree of impaired
consciousness that should be used durin$ nursin$ assessment.
7ther components of the neurolo$ic assessment include cranial
ner#e assessment) pupil e#aluation for si2e" shape" mo#ement"
and reacti#ity) and motor and sensory testin$.
+he o#erall nursin$ $oals are that the patient with
increased ICP will maintain a patent airway" ha#e ICP within
normal limits" demonstrate normal fuid and electrolyte balance"
and ha#e no complications resultin$ from immobility and
decreased le#el of consciousness.
Nursin$ care for the patient with increased ICP re#ol#es
around the dia$noses of decreased intracranial adapti#e
capacity" ris for ine:ecti#e cerebral perfusion" and ris for
disuse syndrome.
+he patient with increased ICP and a decreased le#el of
consciousness needs protection from self.in3ury. Confusion"
a$itation" and the possibility of sei2ures increase the ris for
in3ury.
+EA) N,('-
Head injury is a broad term used to describe any trauma to
the scalp" sull" or brain.
Scalp lacerations are an easily reco$ni2ed type of external
head trauma. *ecause the scalp contains many blood #essels
with poor constricti#e abilities" the ma3or complications
associated with scalp laceration are blood loss and infection.
Sull fractures fre4uently occur with head trauma. +here
are se#eral ways to describe sull fractures! (&) linear or
depressed) (;) simple" comminuted" or compound) and (<) closed
or open.
o +he manifestations may #ary dependin$ on the
location of the fracture.
o +he ma3or potential complications associated with
fractures are intracranial infections and hematoma" as well
as menin$eal and brain tissue dama$e.
(ead trauma" or brain in3uries" are cate$ori2ed in a #ariety
of ways!
o In di:use or $enerali2ed in3ury (e.$." concussion"
di:use axonal) dama$e to the brain cannot be locali2ed to
one particular area of the brain" whereas a focal or
locali2ed in3ury (e.$." contusion" hematoma) occurs in a
speci0c area of the brain.
o In3ury can be classi0ed as minor (9CS &<.&')"
moderate (9CS =.&;)" and se#ere (9CS <.>).
, concussion is a sudden transient mechanical head in3ury
with disruption of neural acti#ity and a chan$e in the le#el of
consciousness (?7C) and is considered a minor head in3ury.
, contusion, a ma3or head in3ury" is the bruisin$ of the
brain tissue within a focal area. , contusion may contain areas of
hemorrha$e" infarction" necrosis" and edema and fre4uently
occurs at a fracture site.
*leedin$ complications associated with head in3uries may
include an epidural hematoma" a subdural hematoma" and
intracerebral hematoma.
C+ scan is considered the best dia$nostic test to e#aluate
for craniocerebral trauma because it allows rapid dia$nosis and
inter#ention in the acute settin$. 1a$netic resonance ima$in$
(1@I)" positron emission tomo$raphy (P/+)" and e#oed potential
studies may also be used.
+he most important aspects of nursin$ assessment are
notin$ the 9CS score" assessin$ and monitorin$ the neurolo$ic
status" and determinin$ whether a CSF lea has occurred.
+he o#erall nursin$ $oals are that the patient with an acute
head in3ury will maintain ade4uate cerebral oxy$enation and
perfusion) remain normothermic) achie#e control of pain and
discomfort) be free from infection) and attain maximal co$niti#e"
motor" and sensory function.
1ana$ement at the in3ury scene can ha#e a si$ni0cant
impact on the outcome of the head in3ury. +he $eneral $oal of
acute nursin$ mana$ement of the head.in3ured patient is to
maintain cerebral oxy$enation and perfusion and pre#ent
secondary cerebral ischemia.
+he ma3or focus of nursin$ care for the brain.in3ured
patient relates to increased ICP. (owe#er" there may be other
speci0c problems that re4uire nursin$ inter#ention" such as
hyperthermia" pain" and impaired physical mobility.
7nce the condition has stabili2ed" the patient is usually
transferred for acute rehabilitation mana$ement to prepare the
patient for reentry into the community. 1any of the principles of
nursin$ mana$ement of the patient with a stroe are
appropriate.
.'AN &(M/'S
*rain tumors can occur in any part of the brain or spinal
cord. +umors of the brain may be primary, arisin$ from tissues
within the brain" or secondary, resultin$ from a metastasis from a
mali$nant neoplasm elsewhere in the body.
*rain tumors are $enerally classi0ed accordin$ to the
tissue from which they arise. +he most common primary brain
tumors ori$inate in astrocytes and these tumors are called
gliomas.
Anless treated" all brain tumors e#entually cause death
from increasin$ tumor #olume leadin$ to increased ICP. *rain
tumors rarely metastasi2e outside the central ner#ous system
(CNS) because they are contained by structural (menin$es) and
physiolo$ic ([Link]) barriers.
, wide ran$e of possible clinical manifestations" dependin$
on the location and si2e of the tumor" are possible. (eadache is a
common problem and sei2ures are common in $liomas and brain
metastases.
,n extensi#e history and a comprehensi#e neurolo$ic
examination must be done in the worup of a patient with a
suspected brain tumor. , new onset sei2ure disorder may be the
0rst indication of a brain tumor.
Sur$ical remo#al is the preferred treatment for brain
tumors. @adiation therapy is commonly used as a [Link]
measure after sur$ery. +he e:ecti#eness of chemotherapy has
been limited by diBculty $ettin$ dru$s across the [Link]
barrier" tumor cell hetero$eneity" and tumor cell dru$ resistance.
+he o#erall nursin$ $oals are that the patient with a brain
tumor will maintain normal ICP" maximi2e neurolo$ic functionin$"
achie#e control of pain and discomfort" and be aware of the lon$.
term implications with respect to pro$nosis and co$niti#e and
physical functionin$.
C'ANAL S('0E'-
+he cause or indication for cranial sur$ery may be related
to a brain tumor" CNS infection (e.$." abscess)" #ascular
abnormalities" craniocerebral trauma" sei2ure disorder" or
intractable pain.
8ependin$ on the location of the patholo$ic condition" a
craniotomy may be frontal" parietal" occipital" temporal" or a
combination of any of these.
Stereotactic sur$ery uses precision apparatus (often
computer $uided) to assist the sur$eon to precisely tar$et an
area of the brain.
+he o#erall $oals are that the patient with cranial sur$ery
will return to normal consciousness" achie#e control of pain and
discomfort" maximi2e neuromuscular functionin$" and be
rehabilitated to maximum ability.
+he primary $oal of care after cranial sur$ery is pre#ention
of increased ICP. Fre4uent assessment of the neurolo$ic status of
the patient is essential durin$ the 0rst C> hours.
+he rehabilitati#e potential for a patient after cranial
sur$ery depends on the reason for the sur$ery" the postoperati#e
course" and the patientDs $eneral state of health. Nursin$
inter#entions must be based on a realistic appraisal of these
factors.
N1LAMMA&/'- C/N)&/NS /1 &+E .'AN
.'AN [Link]
*rain abscess is an accumulation of pus within the brain
tissue that can result from a local or a systemic infection. 8irect
extension from ear" tooth" mastoid" or sinus infection is the
primary cause.
+he manifestations of brain abscess are similar to those of
menin$itis and encephalitis.
,ntimicrobial therapy is the primary treatment for brain
abscess. 7ther manifestations are treated symptomatically.
.AC&E'AL MENN0&S
1enin$itis is an acute infammation of the menin$eal
tissues surroundin$ the brain and the spinal cord. *acterial
menin$itis is considered a medical emer$ency.
1enin$itis usually occurs in the fall" winter" or early sprin$"
and is often a result of #iral respiratory disease. 7lder adults and
persons who are debilitated are more often a:ected than is the
$eneral population.
Fe#er" se#ere headache" nausea" #omitin$" and nuchal
ri$idity (nec sti:ness) are ey si$ns of menin$itis.
+he most common acute complication of bacterial
menin$itis is increased ICP.
-hen a patient presents with manifestations su$$esti#e of
bacterial menin$itis" a blood culture should be done. 8ia$nosis is
usually #eri0ed by performin$ a lumbar puncture with analysis of
the CSF.
-hen menin$itis is suspected" antibiotic therapy is
instituted after the collection of specimens for cultures" e#en
before the dia$nosis is con0rmed.
Nursin$ care for the patient with bacterial menin$itis
re#ol#es around the nursin$ dia$noses of decreased intracranial
adapti#e capacity" ris for ine:ecti#e cerebral perfusion"
hyperthermia" and acute pain.
*ecause menin$ococcal menin$itis is hi$hly conta$ious"
patients re4uire respiratory isolation until the cultures are
ne$ati#e.
,fter the acute period has passed" the patient re4uires
se#eral wees of con#alescence before normal acti#ities can be
resumed.
2'AL MENN0&S
+he most common causes of #iral menin$itis are
entero#iruses" arbo#iruses" human immunode0ciency #irus" and
herpes simplex #irus ((SE).
Eiral menin$itis usually presents as a headache" fe#er"
photophobia" and sti: nec. +here are usually no symptoms of
brain in#ol#ement.
Eiral menin$itis is mana$ed symptomatically because the
disease is [Link]$. Full reco#ery from #iral menin$itis is
expected.
ENCE!+AL&S
/ncephalitis" an acute infammation of the brain" is a
serious" and sometimes fatal" disease.
/ncephalitis is usually caused by a #irus. 1any di:erent
#iruses ha#e been implicated in encephalitis" some of them
associated with certain seasons of the year and endemic to
certain $eo$raphic areas. +ics and mos4uitoes transmit
epidemic encephalitis.
Si$ns of encephalitis appear on day two or three and may
#ary from minimal alterations in mental status to coma. Eirtually
any CNS abnormality can occur.
Collaborati#e and nursin$ mana$ement of encephalitis"
includin$ -est Nile #irus infection" is symptomatic and
supporti#e. In the initial sta$es of encephalitis" many patients
re4uire intensi#e care.
'[Link]
@abies is $enerally transmitted #ia sali#a from the bite of
an infected animal) it can also be spread by scratches" mucous
membrane contact with infected secretions" and inhalation of
aerosoli2ed #irus into the respiratory tract.
*ecause rabies is nearly always fatal" mana$ement e:orts
are directed at pre#entin$ the transmission and rapid
postexposure prophylaxis to pre#ent the onset of the disease.