Neurological disturbances across the life
maintain cerebral blood flow
span
I. INCREASED INTRACRANIAL
PRESSURE
 The rigid cranial vault contains the
ff:
1. brain tissue (1,400 g),
2. Blood (75 mL), and
3. CSF (75 mL)
 The volume and pressure of these
three components are usually in a
state of equilibrium and produce
the ICP
 ICP is usually measured in the
lateral ventricles;
 normal ICP is 10 to 20 mm Hg
• Monro-Kellie hypothesis: limited
space - increase in any skull
component - change in the volume
of the others
• Compensation to maintain a
normal ICP - normally
accomplished by shifting or
displacing CSF
• With disease or injury - ICP may
increase
• Increased ICP decreases cerebral
perfusion, causes ischemia, cell
death, and further swelling (edema
)
Compensation of the body on ICP
1. Brain tissues may shift through the
dura and result in herniation
2. Autoregulation: refers to the
brain’s ability to change the
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diameter of blood vessels to
3. CO2 plays a role; decreased CO2
results in vasoconstriction, and
increased CO2 results in
vasodilatation
ICP and CPP
 CPP (cerebral perfusion pressure) is
closely linked to ICP
 CPP = MAP (mean arterial
pressure) – ICP
 A CPP of less than 50 results in
permanent neuralgic damage
 The normal cerebral perfusion
pressure is 70 to 100 mm Hg
Cushing’s response or Cushing’s
reflex
- is seen when cerebral blood flow
decreases significantly
 A sympathetically mediated
response causes a rise in the
systolic blood pressure with a
widening of the pulse pressure and
cardiac slowing. This response,
which is mediated by the
sympathetic
 nervous system, is seen clinically
as a rise in systolic blood
pressure,widening of the pulse
pressure, and reflex slowing of the
heart rate. This is a sign requiring
immediate intervention; however,
perfusion may be recoverable if
treated rapidly.
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 MANIFESTATIONS OF INCREASED
ICP—EARLY
1. Changes in level of consciousness
2. Any change in condition
a. Restlessness, confusion,
increasing drowsiness,
increased respiratory effort,
and purposeless movements-
decreased oxygen
3. Pupillary changes and impaired
ocular movements- brain
displacement
4. Weakness in one extremity or one
side- compression of the pyramidal
tracts
5. Headache: constant, increasing in
intensity, or aggravated by
movement or straining - stretching
of venous and arterial vessels in
the base of the brain
MANIFESTATIONS OF INCREASED ICP
—LATE
1. Respiratory and vasomotor
changes
2. VS: increase in systolic blood
pressure, widening of pulse
pressure, and slowing of the heart
rate; pulse may fluctuate rapidly
from tachycardia to bradycardia
and temperature increase
a. Cushing’s triad: bradycardia,
hypertension, and bradypnea
3. Projectile vomiting – pressure on
the medulla
4. Hemiplegia or decorticate or
decerebrate posturing may
develop as pressure on the brain
stem increases.
5. Bilateral flaccidity occurs before
death.
6. Loss of brain stem reflexes,
including pupillary, corneal, gag,
and swallowing reflexes, is an
ominous sign.
ASSESSMENT
1. Conduct frequent and ongoing
neurologic assessment
2. Evaluate neurologic status as
completely as possible
3. Glasgow Coma Scale
4. Pupil checks
5. Assess selected cranial nerves
6. Take frequent vital signs
7. Assess intracranial pressure
8. ICP MONITORING
DIAGNOSIS
1. Ineffective airway clearance
2. Ineffective breathing pattern
3. Ineffective cerebral perfusion
4. Deficient fluid volume related to
fluid restriction
5. Risk for infection related to ICP
monitoring
Collaborative Problems/Potential
Complications
1. Brain stem herniation
2. Diabetes insipidus
3. SIADH
4. Infection
Planning Care for Increased ICP  Most common cause of brain
trauma is MVA
 Major goals may include:
 Group at highest risk group for
 Maintenance of patent airway brain trauma are males age 15 to
24
 Normalization of respirations
 Those younger than 5 years and
 Adequate cerebral tissue
the elderly are also at increased
perfusion
risk
 Respirations
PPathophysiology:
 Fluid balance

 Absence of infection

 Absence of complications

Interventions

 Frequent monitoring of respiratory

status and lung sounds

 Position with the head in neutral

position to promote venous
drainage

 Avoid hip flexion, Valsalva

maneuver, abdominal distention, or
other stimuli
Manifestations:
 Maintain a calm, quiet atmosphere
and protect patient from stress Depends upon the severity and location of
the injury
 Monitor fluid status carefully;
during acute phase, monitor I&O  Scalp wounds
every hour
– Tend to bleed heavily; scalp
 Use strict aseptic technique wounds are also portals for
infection
II. HEAD INJURY
 Skull fractures
 A broad classification that includes
injury to the scalp, skull, or brain – Usually have localized,
persistent pain
 Head injury is the most common
cause of death from trauma – Fractures of the base of the
skull

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  Bleeding from nose,  Pain and anxiety management
pharynx, or ears
 Nutrition
 Battle’s sign: ecchymosis
behind the ear

 CSF leak—halo sign—ring of

fluid around the blood stain
from drainage

Management:
III.BRAIN INJURY
 Assume cervical spine injury until
this is ruled out  Closed brain injury (blunt trauma):
acceleration/ deceleration injury
 Therapy to preserve brain occurs when the head accelerates
homeostasis and prevent then rapidly decelerates, damaging
secondary damage brain tissue

– Treat cerebral edema  Open brain injury: object

penetrates the brain or trauma is
– Maintain cerebral perfusion;
so severe that the scalp and skull
treat hypotension,
are opened
hypovolemia, and bleeding;
monitor and manage ICP  Concussion: a temporary loss of
consciousness with no apparent
– Maintain oxygenation as well as
structural damage
cardiovascular and respiratory
function
 Contusion: more severe injury with
possible surface hemorrhage
– Manage fluid and electrolyte
balance
 Symptoms and recovery depend
upon the amount of damage and
associated cerebral edema

 Longer period of unconsciousness

with more symptoms of neurologic
deficits and changes in vital signs
Supportive measures:
 Diffuse axonal injury: widespread
 Respiratory support; intubation and axon damage in the brain seen
mechanical ventilation with head trauma; patient
develops immediate coma
 Seizure precautions and prevention
Intracranial bleeding
 manage reduced gastric motility
and prevent aspiration a. Epidural hematoma

 Fluid and electrolyte maintenance b. Subdural hematoma

 i. Acute and subacute
ii. Chronic
c. Intracerebral hemorrhage and
hematoma
Manifestations
1. Altered level of consciousness
2. Pupillary abnormalities
3. Sudden onset of neurological
deficits and neurological changes;
changes in sense, movement, and
reflexes
4. Changes in vital signs
5. Headache
Assessment:
1. Health history with focus upon the
immediate injury, time, cause, and
the direction and force of the blow
2. Baseline assessment
3. LOC: Use Glasgow Coma Scale
4. Frequent and ongoing neurologic
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intervention
 Provide ongoing assessment and
monitoring is vital
 Maintain airway
1. Positioning to facilitate
drainage of oral secretions with
HOB usually elevated 30° to
decrease venous pressure
2. Suctioning with caution
3. Prevention of aspiration and
respiratory insufficiency
4. Monitor ABGs, ventilation, and
mechanical ventilation
5. Monitor for pulmonary
complications, potential ARDS
6. Monitor I&O and daily weights
7. Monitor blood and urine
electrolytes, osmolality and
blood glucose
8. Implement measures to
promote adequate nutrition
9. Implement strategies to
prevent injury
• Assess oxygenation
• Assess bladder and urinary
output
• Assess for constriction due to
dressings and casts
• Pad side rails
• Use mittens to prevent self-
injury; avoid restraints
10. Strategies to prevent injury
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 • Reduce environmental stimuli  Patient should be aroused and
assessed frequently
• Use adequate lighting to
reduce visual hallucinations Epidural Hematoma

• Implement measures to  Blood collection in the space

minimize disruption of sleep– between the skull and the dura
wake cycles
 Patient may have a brief loss of
• Provide skin care consciousness with return of lucid
state; then, as hematoma expands,
• Implement measures to increased ICP will often suddenly
prevent infection reduce LOC

 An emergency situation

11. Maintain body temperature  Treatment includes measures to

reduce ICP, remove the clot, and
• Maintain appropriate
stop bleeding—burr holes or
environmental temperature
craniotomy
• Use coverings: sheets, blankets
 Patient will need monitoring and
as per patient needs
support of vital body functions and
• Administer acetaminophen for respiratory support
fever
Subdural Hematoma
• Use cooling blankets or cool
 Collection of blood between the
baths; prevent shivering
dura and the brain
CONCUSSION
 Acute/subacute
 Patient may be admitted for
– Acute: symptoms develop over
observation or sent home
24 to 48 hours
 Observation of patients after head
– Subacute: symptoms develop
trauma; report immediately
over 48 hours to 2 weeks
– Observe for any changes in
– Requires immediate craniotomy
level of consciousness
and control of ICP
– Difficulty in awakening,
 Chronic
lethargy, dizziness, confusion,
irritability, and anxiety – Develops over weeks to months

– Difficulty in speaking or moving – Causative injury may be minor

and forgotten
– Severe headache
– Clinical signs and symptoms
– Vomiting
may fluctuate
 – Treatment is evacuation of the
clot
Intracerebral hemorrhage
 Hemorrhage occurs into the
substance of the brain
 May be due to trauma or a
nontraumatic cause
 Treatment
– Supportive care
– Control of ICP
– Administration of fluids,
electrolytes, and
antihypertensive medications
– Craniotomy or craniectomy to
remove clot and control
hemorrhage
 May not be possible due to
the location or lack of
circumscribed area of
hemorrhage
IV.SEIZURES
 Abnormal episodes of motor,
sensory, autonomic, or psychic
activity (or a combination of these)
 Resulting from a sudden,
abnormal, uncontrolled electrical
discharge from cerebral neurons
1. Partial seizures: begin in one part
of the brain
 Simple partial:
consciousness remains
intact
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 Complex partial:
impairment of
consciousness
2. Generalized seizures: involve the
whole brain
Specific Causes of Seizures
 Cerebrovascular disease
 Hypoxemia
 Fever (childhood)
 Head injury
3. Hypertension
4. Central nervous system infections
5. Metabolic and toxic conditions
6. Brain tumor
7. Drug and alcohol withdrawal
8. Allergies
9. Observe and document signs and
symptoms before, during, and after
seizure
10. Seizure precaution for patient
safety and protection
11. Prevention of complications
12. complication
STATUS EPILEPTICUS
 Status epilepticus (acute prolonged
seizure activity) is a series of
generalized seizures that occur
without full recovery of
consciousness between attack
 The term has been broadened to
include continuous clinical or
electrical seizures lasting at least
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 30 minutes, even without
impairment of consciousness
Management
 The goals of treatment are to stop
the seizures as quickly as possible,
 to ensure adequate cerebral
oxygenation,
 Maintain the patient in a seizure-
free state. An airway and adequate
oxygenation are established. If the
patient remains unconscious and
unresponsive, a cuffed
endotracheal tube is inserted.
 Intravenous diazepam (Valium),
lorazepam (Ativan), or
fosphenytoin (Cerebyx) is given
slowly in an attempt to halt
seizures immediately.
 Other medications (phenytoin,
phenobarbital) are given later to
maintain a seizure-free state
V.STROKE
DEFINITION
 Also known as BRAIN ATTACK or
CEREBROVASCULAR ACCIDENT
 A sudden impairment of cerebral
circulation in one or more blood
vessels supplying the brain
 Interrupts or diminishes oxygen
supply causing necrosis in brain
tissues
 Least severe: Transient Ischemic
Attack (TIA) – results to temporary
interruption of blood flow
 Progressive Stroke / Stroke-in-
Evolution – begins with a slight
neurologic deficit & worsens within
2 days
CAUSES
 THROMBOSIS: most common in
elderly; results from obstruction
of a blood vessel; causes
ischemia, congestion, and
edema in the brain tissue; may
occur during surgery or MI
 EMBOLISM: 2nd most common
cause of stroke – can occur at
any age; history of RHD,
endocarditis, post-traumatic
valvular disease, or myocardial
fibrillation, cardiac arrythmias;
it cuts off circulation by lodging
in a narrow portion of an artery
causing necrosis & edema; if
septic may cause encephalitis
& abscess
 HEMORRHAGE: 3rd most
common & may occur suddenly
at any age; results from chronic
hypertension or aneurysms
causing sudden rupture of a
cerebral artery
COMPLICATIONS
 Unstable blood pressure from loss
of vasomotor control
 Fluid imbalances
 Malnutrition
 Infections: pneumonia
 Sensory impairment: vision
problems
 Altered level of consciousness
 Aspiration
  Contractures
 Pulmonary embolism
 ASSESSMENT
 TIPS:
 If the left hemisphere is
affected: produces right sided
signs & symptoms;
 If the right hemisphere is
affected: produces left sided
signs & symptoms
 Strokes causing cranial nerve
damage produces signs of
cranial nerve dysfunction on
the same side as the
hemorrhage
 Obtain family health history
 Neurologic examination
 Motor function tests
 Vision testing
 Sensory assessment
DIAGNOSTICS
 Computed tomography scan:
hemorrhagic strokes, thrombotic
infarction after 48 to 72 hours
 Magnetic resonance imaging:
ischemic or infarcted areas &
cerebral swelling
 Electrocardiogram: underlying
heart disorders
 Carotid duplex: carotid artery
stenosis
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 Angiography: pinpoints occlusion
or rupture site
 Electro-encephalogram: localizes
damaged area
TREATMENT
 Physical rehabilitation
 Dietary & drug regimens to
decrease risk factors
 Possible surgery: craniotomy,
endarterectomy, extracranial-
intracranial bypass, ventricular
shunting
 Medications:
 Tissue plasminogen activator:
clot dissolution (3 hours)
 Anticonvulsants: prevent
seizures
 Stool Softeners: prevent
straining & increasing ICP
 Corticosteroids: minimize
associated cerebral edema
 Analgesics: relieve headache
INTERVENTIONS
 ACUTE PHASE:
 Continued neurologic
assessment, respiratory
support, continuous monitoring
of vital signs, careful
positioning to prevent
aspiration & contractures
 Maintain a patent airway and
oxygenation
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 Monitor vital signs and neurologic
status as necessary/ordered

 Watch out for signs of pulmonary

emboli (chest pains, SOB, dusky
color, tachycardia, fever, changed
sensorium)

 Maintain fluid & electrolyte balance

 Ensure adequate nutrition: check

for gag reflex before feeding

 Manage GI problems