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How do you calculate Cerebral Perfusion Pressure? (CPP)
MAP= (1 systolic + 2 diastolic)/3
- MAP-ICP (monitor surgically placed in head)=CPP
- CPP>50 is normal
Measured in mm Mercury
- If BP 145/90 and ICP is 18, what is CCP?
- Answer: 60
Nursing care plans for craniotomy pt.
- Risk for altered tissue perfusion related to:
- Ineffective individual coping related to:
- The client will have decreased anxiety related to:
- Risk for altered thought process related to:
- Anticipatory grief related to:
- Risk for safety related to:
- Risk for discomfort related to:
Come up with some interventions...
What is subarachnoid hemorrage?
- Most commonly caused by TBI, intracranial aneurysms and AVMs
- Saccular (berry) aneurysms are most common & development
- --hastens with HTN, atherosclerosis, aging and stress
- --usually found in anterior circle of willis
Pathophys of SAH
- Media thins and connective tissue replaces smooth muscles
- Vasospasm causes ischemia and infarction seems related to volume of blood degradation
SnSs of SAH?
- Usual very sudden onset with sudden severe HA, projectile vomiting, then loss of consciousness
- Generalized seizures may occur
- S&S of meningeal irritation (nuchal rigidity [whole spine goes stiff when lifted by head], photophobia, back pain)
- S&S relate to the artery in spasm
- MCA: hemiparesis, dysphagia
- ACA: incontinence, faulty problem solving
- PCA: hemianopia
- Review ignoral (neglect of a side of body or limb) and heminopsia (part of visual field is completely ignored.
How do you diagnose SAH?
- Best diagnostic is CT angiographyBlood in CSF
- Most frequently seen at 7th day post hemorrhage
- 80% have enough blood to be appreciated with non-contrast CT. Other 20% will not, so might be missed.
Therapeutic goas for SAH?
- Maintain CPP (vasopressors, hemodynamics monitored, prevent ischemias from hypotension)
- Control ICP
- Minimize vasospasm (treat HTN,Hypervolemia and Hemodilution)
- Manage hydrocephalus (drains may be placed)
- Manage arrhythmias (monitor electrolytes and rhythm)
- Prevent re-bleeding
What treatments are available for SAH?
- Possible surgeries:
- --Endovascular therapies
- --Aneurysm clip (“time bomb”)
- AVMs: tangle of arteries/veins malformation. Impossible to detangle. Present like SAH when it bleeds.
- --Massive lesions that tangle veins and arteries
- --Usually in brain or spinal column
- --When bleeds, present like SAH
- --Can present with “circulatory steal”
- --Usually require surgical resection, now developing radiographic approaches to controlling AVMs
- --Care is similar to SAH with outcomes, interventions
What are some etiologies of Neurotraumas?
Associated with space occupying lesion, infarction, CSF flow issue, abscess,elevated pCO2,decreased pO2
SnSs of neurotrauma
- Subtle change in LOC (restlessness,confusion, irritability)
- Change in GCS
- HA, N/V, Diplopia, changes in PERRLA
- Cushing's triad: massive increased SBP, widened pulse pressure, bradycardia
- Cheyne stokes respirations, apneustic (loss of respirations) or ataxic breathing (labored, uncoordinated breathing). Messy breathing.
What should you know about cranial herniation?
- Always a medical emergency
- Herniation through open skull fractures
- Central herniation (rapid change in LOC with hyperventilation (early))
- Uncal herniation (lateral pressure on temporal lobe) has pupils that are unreactive to light with stupor and resp changes
- Infratentorial (Tonsillar) herniation is classic foramen magnum herniation with Cushing's triad and change in LOC
Outcomes and nursing interventions for cranial trauma/hemorrhage?
- Decrease ICP
- Mannitol (review this one)
- CPP/ICP monitoring
- Prevent complications
- Barbiturate coma combined with...
- ...NMB (neuromuscular blockage) agents. Done to preserve the brain and to slow blood flow to smooth muscle.
- Nursing Care
Assessments for neuro/trauma?
- VS, especially RR and pattern
Independent nursing interventions for neuro/trauma pt.
- Positioning: with szr, may want to place pt on floor because they'll end up there anyway.
- F&E/I&O (DI, then you're dry)
- Body Temp
- Monitor VS, LOC, ICP, CPP
- Nutrition: becomes a problem when pt cannot feed themselves or loses gag reflex-->npo.
- Prevent complications