Increased Intracranial Pressure

l    Pathophysiology

–    Intracranial space consists of brain tissue and extracellular fluid

–    Skull non-distensible cavity

–    If volume of one of constituents of intracranial cavity increases, reciprocal decrease in one or both of others

–    Pressure rises when volume added exceeds compensatory capacity


l    Normal intracranial pressure = 10-20 mm Hg

–    Responds to changes in B/P, respiratory cycle, isometric contractions, cough, Valsalva

l    > 20 = life-threatening event

–    As ICP rises, relationship between volume and pressure changes; small increases in volume can change ICP significantly


l    Etiology

–    Increases in brain volume

l   Mass lesions

l   Cerebral edema

–    Cytotoxic edema – Intracellular swelling of neurons due to hypoxia and hyperosmolality
–    Vasogenic – Break down of blood-brain barrier so osmotically active substances leak into interstitial area and draw water from intravascular system. Head injuries, brain tumors, abscesses


l    Etiology

–    Cerebrovascular alterations

l   Venous outflow obstructions

–    Neck positions compress jugular vein and inhibit venous return, cause central venous engorgement, increase IICP. Mechanisms that increase intrathoracic or intraabdominal pressure
–    Fluctuations in blood pressure
–    Vasodilation

l   Increases in CSF fluid



l    Clinical Manifestations

–    Decreased level of consciousness (Categories of Consciousness, p. 276, Box 16-1)

l   Earliest sign of IICP is lethargy

l   Other early indicators are slowing speech and delay in response

l   Any sudden change in condition is significant


l    Clinical Manifestations

–    Decreased motor ability

l   Decortication – Internal rotation and flexion of upper extremities, plantar flexion of feet, extension and internal rotation of lower extremities

l   Decerebrate – Extension and outward rotation of upper extremities and plantar flexion and extension of lower

l   Flaccidity with loss of reflexes


l    Clinical Manifestations

–    Decreased cranial nerve function

l   Any changes in pupillary size, shape, or reactivity ominous

l   In unconscious client, pupils most sensitive sign of deterioration

–    Changes in vital signs

l   Cushing’s Triad – Bradycardia, Systolic hypertension with widening pulse pressure, bradypnea


l    Clinical Manifestations

–    Papilledema

l   Common in intracranial tumors and may be first sign

l   Early changes do not cause visual acuity problems; may be detected only with ophthalmic exam

l   Prolonged pressure causes optic atrophy and severely diminished visual acuity

l   Swelling of optic disc


l    Clinical Manifestations

–    Increasing headache

l   Constant, increasing, aggravated by movement or straining, frontal or occipital

–    Blurred vision

–    Seizure activity

l   Common in intracranial tumors


l    Clinical Manifestations

–    Vomiting

l   Recurrent and projectile, not related to meals, may have significant nausea; occurs late in IICP

–    Nuchal rigidity

–    Lateralizing signs

l   Neurological findings only on one side of body

l   Help localize lesion to one side of brain

l   Emergency – may herald herniation


l    Management (Table 61-2, p. 1864)

–    Immediate goal

l   Reduce size of brain by decreasing cerebral volume, CSF fluid volume, or blood volume while maintaining cerebral perfusion

–    Mechanisms

l   Osmotic diuretics (Mannitol)

–    Effects occur within 20 minutes; does not cross intact blood-brain barrier; observe for rebound IICP; 0.25-1 gm/kg IV; monitor body wt, F&E balance; Monitor CVP; foley


l    Mechanisms

–    Corticosteroids

l   Decreases cerebral edema in brain tumors

l   Reduce CSF production, stabilize blood-brain barrier and cell membranes -> overall improvement of neuronal function

l   Most common is Decadron

l   Needs to be weaned off


l    Mechanisms

–    Restrict fluids

l   Goal to maintain intravascular volume without adding free water

l   Strict I&O

l   CO maintained to provide adequate perfusion to brain

l   Effectiveness reflected in cerebral perfusion pressure (CPP)

–    CPP = MAP – ICP
–    Ideally > 80 mm Hg


l    Mechanisms

–    Drain CSF

l   Ventriculostomy – Pliable catheter inserted into lateral ventricle on nondominant side

–    Monitoring device and treatment modality
–    Flawless aseptic technique
–    Can remove CSF intermittently or continuously
–    Removal of even small amount will dramatically decrease ICP


l    Drain CSF

–    Subarachnoid bolt

–    Epidural monitor

–    Fiberoptic catheter


l    Mechanisms

–    Hyperventilation

l   Decreased PaCO2 causes vasoconstriction and decreased CBF -> decreased ICP

l   Maintained at 25-30 mm Hg

l   Short term control

l   PaO2 between 90 and 100 mm Hg


l    Mechanisms

–    Temperature control

l   Cerebral metabolic rate directly proportional to body temperature

l   Persistent fluctuations and/or hypothermia or hyperthermia in conjunction with head injury grave prognostic sign

l   Antipyretic medications, cooling blanket

l   Monitor temperature closely and observe for shivering


l    Mechanisms

–    Reduce cellular metabolic demands

l   Patency of airway important

l   Sedatives and/or neuromuscular blocking agents if ICP monitor

l   Control seizure activity

–    Dilantin:  15-18 mg/kg; not to exceed 50 mg/min
–    Valium: 5-10 mg bolus at 2 mg/min
–    Barbiturates (Pentobarbital & thiopental) when not responsive to conventional therapy


l    Mechanisms

–    Reduce cellular metabolic demands

l   Paralyzing agents; CV monitoring; endotracheal intubation; mechanical ventilation; ICP monitoring; arterial pressure monitoring

l   Lidocaine through ETT or IV

–    Blunts ICP spikes to stimulation
–    Prophylactic administration of Lidocaine before ET suctioning widely practiced


l    Nursing Process

–    Assessment

l   LOC

–    Lethargy and change in LOC first signs; restlessness
–    Glasgow Coma Scale

l   Vital signs

–    Late sign
–    Cushing’s Triad
–    If major circulation begins to fail, pulse and resp. increases and T inconsistently increases


l    Assessment

–    Headache

–    Pupillary changes

l   Check pupil reaction, size, conjugate (paired; working together) or dysconjugate

–    Vomiting


l    Nursing interventions

–    Achieve cerebral tissue perfusion

l   Elevate HOB 30-45 degrees with head in neutral position

l   Cervical collar if needed to keep head neutral

l   Avoid extreme hip flexion

l   Avoid Valsalva maneuvers – ask client to exhale when being moved or turned

l   Avoid isometric exercises that increase SBP

l   Preoxygenate and hyperventilate prior to suctioning


l    Nursing interventions

–    Achieve cerebral tissue perfusion

l   Space nursing interventions

l   Avoid emotional distress and frequent arousal from sleep

l   Note abdominal distension

l   Avoid high levels of PEEP


l    Nursing interventions

–    Achieve airway clearance

l   Suction to maintain patent airway

l   Hyperoxygenation for suctioning

l   Nasal drainage may indicate dural tear; suctioning of nares contraindicated

l   Auscultate lung fields

l   No close mouth coughing

l   Elevate HOB


l    Nursing interventions

–    Attain normal respiratory pattern

–    Attain fluid balance

l   Monitor skin turgor, mucous membranes, serum and urine osmolality

l   Monitor IVF carefully

l   Observe for CHF and pulmonary edema if giving Mannitol

l   Good oral hygiene, monitor VS, monitor I&O


l    Nursing interventions

–    Attain normal urine and bowel elimination

l   Test urine for specific gravity and glucose

l   Indwelling catheter

l   Monitor UOP every 2-4 hours; output of > 200 ml/hr over two consecutive hours may = diabetes insipidus

l   Monitor bowel sounds; abd. Distension

l   Test stools for occult blood


l    Nursing interventions

–    Hyperventilation

l   PaCO2 ranged from 25-30 mm Hg

–    Temperature control

l   Prevent hyper- or hypothermia

–    B/P control

l   High range normal essential for adequate perfusion pressure; too high may increase ICP; sedation and antihypertensives


l    Nursing interventions

–    Seizure control

–    Monitor for complications

l   Brain herniation

l   Cushing’s stress ulcer

l   Diabetes insipidus

–    Severe polyuria followed by polydipsia
–    UOP more than 9 L/day and urine osmolality of < 100 mOsm/kg after dehydration or water restriction test require ADH replacement (desmopressin/DDAVP)


l    Nursing interventions

–    Monitor for complications

l   Syndrome of Inappropriate Secretion of ADH (SIADH)

–    High levels of ADH that result in oliguria in the absence of normal physiologic stimuli for its release
–    Pituitary surgery, ectopic tumors that secrete ADH

Monitoring ICP

l    Indicated when ICP > 20 mm Hg

l    Mean ICP readings taken at end of respiratory cycle and before inspiration

l    Purposes

–    Identify increased pressure early

–    Quantitate degree

–    Initiate appropriate therapy; monitor effectiveness

–    Access CSF for sampling and drainage

Monitoring ICP

l    Devices

–    Ventricular catheter

l   Lateral ventricle of nondominant cerebral hemisphere

l   ICP monitoring and drainage of CSF

l   High risk for infection

l   Most accurate

Monitoring ICP

l    Devices

–    Subarachnoid screw

l   Subarachnoid space

l   Pressure readings and drainage of fluid

l   High risk of infection

–    Epidural

l   Between skull and dura mater

l   ICP monitoring only

l   Less risk of infection, but less accurate readings

Monitoring ICP

l    Devices

–    Intraparenchymal Fiberoptic Prob

l   Nondominant brain tissue and measures brain tissue pressure

l   Ventricle, subarachnoid space, subdural space, brain parenchyma, or under bony flap

Monitoring ICP

l    Pressure waves

–    A waves

l   Plateau waves/ 50-100 mm Hg

l   Advanced intracranial hypertension

l   Generally last 15-20 minutes

l   Sharp increase in ICP of 30-69 mm Hg

l   Plateaus for 2-20 minutes and returns to baseline

l   May increase in amplitude and frequency before S&S of ICP seen clinically

Monitoring ICP

l    Waves

–    B waves

l   < 50 mm Hg; correspond to respirations

l   Warning of potential risk of IICP

l   Sharp, rhythmic oscillations with sawtooth appearance that occur every 30 sec to 2 minutes

l   Frequently precede A waves

Monitoring ICP

l    Pressure waves

–    C waves

l   Small waves (16-20 mm Hg)

l   Correlate to changes in BP and respirations

l   Lack clinical significance

l   Occur every 4-8 minutes

Monitoring ICP

l    Nursing implications

–    Management of A waves directed at reduction of high pressure and prevention of other plateau waves

–    Closed systems to avoid contamination and infections

–    Strict aseptic technique when handling system

–    Inspect insertion site for signs of infection

–    Check all connections for leaks

Monitoring ICP

l    Nursing implications

–    Transducer zeros at particular reference point, usually 1 inch above ear in supine client

–    Ensure tubing long enough but not too long

–    Be careful to prevent kinks in tubing

–    Flush catheter if readings dampen

Monitoring ICP

l    Nursing implications

–    If inaccurate readings

l   Check for leaks in system

l   Differences in height of transducer and device

l   Kinks

l   Client performing Valsalva maneuver

l   Obstruction in system

Brain herniation syndromes

l    Herniation = Protrusion of brain tissue from its normal compartment

l    Syndromes

–    Cingulate

l   Lateral shift of tissue so frontal lobes of cerebrum compressed

l   Cerebral artery compression -> ischemia and congestion, edema, IICP, change in LOC and mental status

l   Non life-threatening but can lead to others

Brain Herniation

l    Syndromes

–    Central or Transtentorial

l   Downward shift of one or both cerebral hemispheres

l   Early indication is rapid change in LOC

l   Changes in respiratory patterns: Cheyne-Stokes -> central neurogenic hyperventilation -> apneustic -> ataxic -> apnea

l   Small, reactive pupils -> dilated, fixed

l   + Babinski -> Decorticate -> Decerebrate

l   Brain stem dies: Absent Doll’s eyes and cold caloric

Brain Stem Herniation

l    Syndromes

–    Uncal or lateral transtentorial

l   Lateral and downward shift of brain tissue, usually temporal

l   Pupils sluggish -> unresponsive first in ipsilateral pupil then in contralateral pupil

l   Decreasing LOC

l   Cheyne-Stokes respirations -> central neurogenic hyperventilation

l   Decorticate -> decerebrate

Brain Stem Herniation

l    Syndromes

–    Tonsillar

l   Downward shift through foramen magnum

l   Compresses medulla and upper portion of spinal cord

l   Manifestations progress rapidly

–    Erratic changes in BP, pulse rate, breathing
–    Decreased LOC
–    Arched still neck
–    Quadriparesis

Brain Herniation

l    Always an emergency

l    Signs and symptoms

–    Assessment

l   Glasgow Coma Scale standardized tool for assessing client – Actual numbers less meaningful than trend in scores

l   LOC:  Any change early sign of neurological deterioration


Brain Herniation

l    S&S

–    Sensorimotor – Spontaneous movement, muscle strength, muscle tone, coordination

l   Responses may include localizing, withdrawing or posturing, flaccidity

l   Compare L and R sides and upper and lower extremities

l   Abnormal postures

–    Hemiplegia – One side of body stops moving spontaneously

Brain Herniation

l    S&S

–    Assessment

l   Abnormal postures

–    Decorticate – Cortical, subcortical, or diencephalon lesion
l   Flexion of upper extremities and extension with internal rotation of lower
–    Decerebrate – Midbrain or pons lesion
l   Jaw clenched, extremities fully extended, plantar extension, forearms pronated, wrist and fingers flexed
–    Babinski – Major pathological DTR. Sign of upper motor neuron lesion and damage to corticospinal tract

Brain Herniation

l    S&S

–    Sensorimotor function

l   Orientation and awareness

l   Ability to follow commands

l   Appropriate responses are those that do not elicit random or reflex responses

–    Show me your thumb, stick out your tongue

Brain Herniation

l    S&S

–    Sensorimotor

l   Acceptable noxious stimuli

–    Shaking arm
–    Pinching inner aspect of arm or leg
–    Nail bed pressure
–    Trapezius pinch
–    Supraorbital pressure

l   Not acceptable

–    Sternal rub, nipple twisting or pinching

Brain Herniation

l    S&S

–    Respiratory patterns

l   Cheyne-Stokes: Rhythmic crescendo and decrescendo of rate and depth of respiration; brief periods of apnea

l   Central neurogenic hyperventilation: Deep, rapid respirations without periods of apnea

l   Apneustic: Prolonged inspiratory and/or expiratory pause of 2-3 sec

l   Cluster breathing: Cluster of irregular, gasping breaths separated by long periods of apnea

Brain Herniation

l    S&S

–    Respiratory patterns

l   Ataxic: Irregular, random pattern of deep and shallow respirations with irregular apneic periods

–    Eye function

l   Pupils: Size, shape, equality, and light reflex. Inequality of > 1 mm pathological sign

l   Direct and consensual light reflex: Rate of response important

Brain Herniation

l    Vital signs

–    Changes occur late in course

–    Initially assess q 15 minutes, temp. q 2 hr

–    Trends in VS and respiratory pattern analyzed

l    Head-to-toe progression

–    LOC deteriorates before any other neurological changes; monitor closely for subtle changes

Stages of Central Herniation

l    4 stages: Decreased LOC; nuchal rigidity, HA, small reactive pupils -> fixed dilated pupils; Cheyne-Stokes; cardiac dysrhythmias; decerebrate or decorticate posturing -> flaccid

Reflex testing

l    Doll’s eyes reflex (Oculocephalic)

–    Contraindicated before C-spine cleared

–    Hold eyelids of comatose client open and briskly turn head to one side and then the other. Observe eye movement

–    Normal if eyes deviate to opposite direction when head is turned

–    Abnormal if deviates in different directions

–    Absent if no deviation


l    Ice Water caloric test (Oculovestibular reflex)

–    Tests brain stem function and more reliable

–    Not done in conscious client

–    HOB elevated 30 degrees and 30-50 cc ice water quickly injected into ear

–    Slow phase – eyes move toward instilled ear

–    Quick phase – eyes make quick corrective action opposite instilled ear



l    Ice water caloric test

–    Showing brain stem integrity

–    Abnormal response indicative of severe brain stem injury

–    Dysconjugate or no response = little or no brainstem function

–    Contraindicated if CSF leak or perforated tympanic

–    Ominous sign

Uncal Herniation


Status Epilepticus

l    Seizure activity of 30 minutes or more duration, usually without return of consciousness

l    Emergency condition

l    Causes

–    Insufficient level of anticonvulsant drugs – most common

–    Metabolic disturbances

Status Epilepticus

l    Causes

–    Infections

–    Structural CNS lesions

–    Familial predisposition

Status Epilepticus

l    Management

–    Goals to stop seizures within 20 minutes

–    Valium 2 mg/min for total of 30 mg or Ativan IV bolus for rapid control

–    Maintain seizure free

–    Ensure adequate cerebral oxygen

l   Maintain clear airway, prevent aspiration by positioning and suctioning, provide adequate oxygenation

Status Epilepticus

l    Management

–    Assess client constantly; even when seizures controlled may be unconscious for while

–    High risk for injury: Seizure precautions

l   Padding siderails, keeping bedrails up, placing suction equipment at bedside, keep bed at lowest level

–    Sensory-perceptual alteration

l   Keep room quiet and dark in post-icteral period; stimulation may cause more seizures

Status Epilepticus

l    High risk for ineffective individual coping

–    Provide client verbal and written information about medications; explain importance of taking medications regularly

–    Explain care during seizures

–    Help identify factors that precipitate seizures and ways to avoid these factors

Head Injuries

l    Any trauma to scalp, skull, or brain

l    Scalp lacerations: Common, can be associated with skull fractures so palpate for depressed skull fracture; very vascular

Skull Fractures

l    Types

–    Linear – Most common; bedrest and close monitoring

–    Comminuted – Bone fragmented into many pieces; craniotomy

–    Depressed – Outer table depressed below inner table of surrounding intact skull. May be epileptogenic, may have CSF leak, scalp bruising and tenderness

Skull Fractures

l    Types

–    Compound – Depressed fracture with added problems of hemorrhage and avenue for infection to enter the cranial vault; examine dura for tears and cranioplasty

l    Clinical manifestations

–    Depend on amount and distribution of brain injury

Skull Fractures

l    Manifestations

–    Base of skull

l   Hemorrhage from nose,pharynx, ears, conjunctiva

l   Battle’s sign – Ecchymosis over mastoid

l   CSF from ears and nose

l   Raccoon’s eyes – periorbital ecchymosis from extension of linear fracture into base of skull

l   Spontaneous closure of dural tear in 7-10 days if no infection and bony edges don’t trap dura between them

Skull fractures

l    Diagnostic Eval

–    Neurological exam

–    CT – cornerstone of evaluation for head injuries

–    MRI

–    Cerebral angiography

Skull fractures

l    Management

–    Nondepressed – Close observation

–    Depressed – Surgical intervention

–    Base of skull – Check for CSF leak; keep nasopharynx and external ear clean with plug of sterile cotton or sterile cotton pad; no sneezing or blowing nose; HOB elevated 30 degrees; NVC and VS frequently; no nasal suctioning; abx; surgical intervention if persistent


l    Temporary loss of neurological function from which there is complete recovery

l    Period of unconsciousness from several seconds to an hour.

l    May cause dizziness and spots in front of eyes to complete loss of consciousness

l    Retrograde amnesia; post-traumatic amnesia


l    Presents with HA, dizziness, N & V. No break in dura or skull; no visible damage on CT

l    Observation

l    Postconcussion Syndrome: Develop immediately after orientation or within few days

–    HA, visual disturbances, nervousness, dizziness, confusion, gait abnormalities, poor memory, decreased info processing


l    Bruising of brain tissue with potential for development of areas of necrosis, hemorrhage, edema

l    Symptoms more marked

l    Gradually returns to normal; residual HA and vertigo


Epidural Hematoma

l    Blood in epidural space between dura and skull

l    Tear of middle meningeal artery

l    Altered LOC -> lucidity that can last 12 hours-> confusion, irritability; increasingly severe HA; deterioration of LOC

l    Hallmark is pupil fixed and dilated on side of lesion

l    Vomiting, possible seizures, hemiparesis

Epidural hematoma

l    Rapid onset

l    Management – Extreme emergency

–    Burr holes through skull, removing clot, controlling bleeding

–    Dx made with CT

–    Careful, ongoing assessment

–    Lower ICP with hyperventilation

Subdural hematoma

l    Collection of blood between dura and underlying brain; surface vein torn

l    Slow process in frontal or temporal lobes

l    Causes

–    Brain trauma, falls, bleeding tendencies, aneurysms, acceleration/deceleration, rotational forces

Subdural hematoma

l    Types

–    Acute – Occurs within 24-48 hours; serious complication

l   Similar manifestations to acute epidural hematoma with slower onset

l   Often associated with moderate or severe brain injury

l   May remain unconscious or have variable LOC

l   Usually has a HA

l   Irritable and confused and lapse into coma or have fluctuating LOC

Subdural hematoma

l    Acute

–    Subtle changes in LOC and development of lateralizing changes

–    Mortality 50% if associated with injuries to other body systems

Subdural hematoma

l    Subacute – Occur from 2 days to 2 weeks later

–    Onset slower and more subtle manifestations

–    Suspected in clients who fail to regain consciousness after head trauma

–    Clinical symptoms similar to acute

Subdural hematoma

l    Chronic – Occur 2 weeks to several months later

–    Most common in elderly and alcoholic clients

–    Intermittent severe HA, alternating focal neurological signs, personality changes, mental deterioration, focal seizures, ipsilateral pupil dilation with sluggish reaction to light, papilledema

–    Tx: surgical evacuation of clot

Nursing process

l    Ineffective airway clearance

–    Maintain adequate oxygenation; elevate HOB, monitor ABGs, monitor ventilation, guard against aspiration

l    Fluid volume deficit

–    Daily weights, check skin turgor, monitor I&O

Nursing Process

l    Altered nutrition

–    NGT feedings when stabilized unless discharge of CSF from nose; elevate HOB; check residuals; calorie count

l    High risk for violence

–    As emerges from coma, increased agitation; assess adequate oxygenation and no bladder distention; padded side rails; hands in mitts; avoid restraints; avoid opiates that decrease respirations

Nursing Process

l    High risk for violence

–    Minimize environmental stimuli; provide adequate lighting; do not disrupt sleep-wake cycle

l    Altered thought processes

–    Memory deficits, decreased ability to focus and sustain attention to task, decreased ability to process information, slow thinking, perceiving, communicating, reading, and writing

Nursing Process

l    Altered thought processes

–    Collaborative team work; neuropsychologist plans program and initiates treatment or counseling; redevelop ability to devise new problem-solving strategies

–    Ideal coma stimulation program – Single stimulation activity lasting no more than 10-30 minutes per session, 3-4 times per day

Nursing Process

l    Potential ineffective family coping

–    Dealing with physical and emotional deficits, altered relationships, changes in temperments, behavior, and personality

–    Provide adequate and honest information

–    Encourage setting well-defined, mutual, short-term goals

–    Support groups

Nursing Process

l    Self-care deficit

–    Perform ROM exercises; provide proper alignment; encourage to do as much for self as possible; rehabilitation focus

l    Impaired verbal communication

–    Broca’s area = expressive aphasia

l   Speech produced with much effort, poorly articulated, slow, nonfluent

Nursing Process

l    Impaired verbal communication

–    May be able to say 2-3 words clearly, commonly profanity and used often

–    May have agraphia, dysarthria, apraxia

–    Muscles weakened, uncoordinated, not sequenced in movement

–    Be supportive of frustration and accepting of behaviors; allow longer response time; do not supply words; accept incorrect words

Nursing Process

l    Impaired verbal communication

–    Wernicke’s area = receptive aphasia

–    Unable to comprehend the spoken or written word

–    Speech flows, rhythmic, and articulate but makes no sense

–    Speech rehab ASAP; face client when speaking; simple sentences and common words; speak slowly and distinctly; decrease distractions, noise

Brain Tumors

l    Primary – Benign or malignant tumors originating in brain

l    Secondary – Tumors developing from malignancies in other parts of the body

Brain Tumors

l    Classifications

–    Benign or malignant

–    Location

l   Primary intracranial intracerebral tumors

–    Glioma (50%)
l   Grade I and II usually benign and occur in younger
l   Grade III and IV malignant
l   Astrocytoma – Most common – presents usually with seizure followed by mental status changes – Partial resection and XRT gives ? 5 years

Brain Tumors

l    Classifications

–    Location

l   Glioblastoma Multiforme – Most common and most lethal CNS cancer. Debulking, chemo, XRT may decrease ICP. 5-18 months from onset of clinical symptoms

l   Primary Intracranial Extracerebral

–    Meningioma – Complete resection possible with excellent prognosis. Partial resection + XRT gives 2+ years
–    Acoustic neuroma – CN VIII, hearing loss, dizziness, tinnitus; excellent outcome with surgery

Brain Tumors

l    Location

–    Pituitary tumors

l   Slow growing tumors; usually benign

l   Manifestations: Visual field defects, irregular or absent menstrual cycles, infertility, decreased libido, impotence, decreased body hair, decreased production of pituitary-stimulating hormones

l   Dx by test blood for stimulating hormones

l   Diabetes Insipidus fairly common sequelae of pituitary surgery – IV Pitressin or inhalation of DDAVP

Brain Tumors

l    Clinical Manifestations

–    Headache, vomiting, papilledema significant indicators

–    Headaches – Often severe in frontal or occipital region; intermittent, increasing in duration, intensified by change in posture or straining; recurrent severe HA in client previously free of them or recurrent HA in a.m., increasing in frequency and severity

Brain Tumors

l     Clinical Manifestations

–     N&V – Late symptom; not related to meals; marked nausea

–     Papilledema – May be first sign of intracranial tumors; may cause client to seek help

–     Seizures – focal or generalized; often first indication of tumors

–     Dizziness and vertigo; mental status changes

–     Localized manifestations depending on area involved

–     Little relationship between size of tumor and intensity of symptoms

Brain Tumors

l    Management

–    Neurosurgery: Debulking, palliation, prolonged and improved lifespan, better effects of other treatment modalities, accurately diagnosing tumors

l   Stereotactic Radiosurgery: Application of ionizing beams of radiation focused with help of intracranial guiding devices

l   Craniotomy

l   Transsphenoidal Hypophysectomy – Performed through anterior upper gum or nose; nose packed to control bleeding; head elevated; mouth care; replacement hormones

Brain Tumors

l    Management

–    Stereotactic Radiation Therapy: Scanning device that creates 3-dimensional map of tumor; used for implantation of radioactive isotopes, needle biopsy, incision and aspiration. Laser to vaporize tumor

–    XRT – Surgically implanted radioactive nuclide in tumor


Brain Tumors

l    Management

–    Chemotherapy: Considered after complete XRT course, after surgical debulking in combination with XRT, for tumor recurrence. Corticosteroids

–    Immunotherapy – Bone marrow harvesting prior to chemotherapy with autologous infusion 1-2 days after chemotherapy; autologous infusion of lymphocytes intraoperatively with glioblastoma; interferon and interleukin-2 effective

Brain Tumors

l    Nursing

–    Pre-operatively

l   Explain procedures; encourage open communication with family; watch use of narcotics; prophylactic steroids and antibiotics

–    Post-operatively

l   Continuously assess neuro status and VS; use of diuretics and CSF drainage devices

l   Cardiac monitor

Brain Tumors

l    Post-op

–    Positioning – If client neurologically unstable and ICP elevation > 20 mmHg, avoid procedures that require flat position; support head during elevation; avoid sharp hip flexion

l   Supratentorial surgery: Elevate 30 degrees

l   Intratentorial: Most common flat without HOB elevated

l   Posterior fossa: Side lying with pillow under head for support


Brain Tumors

l    Post-op

–    Drainage: Inspect dressing and underlying linens for bleeding or CSF leak

l   Assess character, estimated amount and document prolonged “oozing”; increased risk of infection and managed by abx and bedrest

–    Monitor labs, particularly electrolytes (glucose, sodium, K, osmolality, and Hct)

Brain Tumors

l    Post-op

–    Ventilation

l   Assess respiratory parameters frequently to avoid hypercapnia and ensure maximal oxygenation

l   Arterial lines and pulse ox

l   Maintain airway patency but do not suction through nose

l   Monitor ABGs

l   Mechanical hyperventilation

Brain Tumors

l    Medications

–    Osmotic diuretics and steroids

–    Phenytoin prophylactic to manage seizures

–    Antacids or histamine-blockers to prevent stress ulcer

–    Acetaminophen or codeine for pain relief


Brain Tumors

l    Post-op

–    Prevent complications

l   Increased ICP

l   Cerebral edema

l   Hematomas

l   Shock

l   Hydrocephalus

l   Respiratory

l   Infection

Brain Tumors

l    Post-op

–    Seizures

–    Achieving self-acceptance

–    Client home education

Spinal Cord Injuries

l    Mechanisms of injury

–    Blunt

–    Penetrating

–    Associated factors

–    Nontraumatic etiologies

Spinal Cord Injuries

l    Management

–    Goal to prevent further injury and to observe for symptoms of progressive neurological deficits

–    Pharmacotherapy

l   Corticosteroids – High dose methylprednisolone

l   Histamine blockers – Reduce risk of gastric and intestinal bleeding

Spinal Cord Injuries

l    Management

–    Hypothermia

–    Respiratory measures – Oxygen to maintain high oxygen level. Caution to avoid flexing or extending the neck

–    Surgical stabilization

l   Advantage is allows earlier mobilization and decreases complications

l   Fusion, decompression, rod insertion, bone grafting

Spinal Cord Injuries

l    Management

–    Manual stabilization

l   Traction

–    Halo device
–    Tongs
–    Braces


l    ABCs

l    Neurological exam – Accurate assessment of motor, sensory, and reflex function

–    Motor

l   Assess for strength, ROM against resistance

l   Evaluate and compare each side

l   Flexion and extension of joints

l   Ask client to spread fingers, squeeze hand, move toes


l    Neurological exam

–    Sensory

l   Exact point where normal sensation felt

l   Terms

–    Anesthesia – Absence of normal sensation
–    Analgesia – Decreased sensation of pain
–    Hypoesthesia – Reduced sensation
–    Hyperesthesia – Exaggerated sensation


l    Neurological exam

–    Sensory

l   Cotton swab for sensation; pin prick for pain

l   Begin distal and work proximal

l   Proprioception tested by moving big toes and thumbs up and down and asking client to confirm position

–    Reflex

l   DTRs

l   Peripheral reflexes


l    Neurological Exam

–    Spinal shock (Abates in 3-6 weeks)

l   Immediate response to cord transection

l   Complete loss of skeletal muscle function, bowel and bladder tone, sexual function and autonomic reflexes

l   Muscles innervated by the cord segment below the level of lesion become completely paralyzed and flaccid; absent DTRs; no perspiration

l   Assumes environmental temperature; bradycardia; hypotension

Diagnostic Tests

l    X-rays and CT scan

l    Search for injuries especially of head and chest

l    EKG monitoring


l    Promote adequate breathing

–    Observe for impending respiratory failure; ABGs

–    High-flow oxygen; pulse ox

–    Lesion C4 or above – mechanical ventilation; T6 or above assistance with secretions

–    Prevent vaso-vagal response with suctioning

–    Lesion T12 or above at risk for atelectasis and pneumonia


l    Promote adequate breathing

–    Chest PT and quad-assisted coughing; exercises to increase strength of muscles

–    Adequate humidification and hydration

–    Assess for signs of respiratory infection


l    Promote mobility

–    Proper body alignment

–    Monitor B/P with position changes

–    PROM exercises


l    Maintain skin integrity

–    Position changes every 2 hours

–    Inspect skin carefully

–    Keep skin clean and dry

–    Encourage client/family participation

–    ROM exercises


l    Maintain urinary elimination

–    Immediately after injury, bladder atonic

–    No sensation of bladder distention

–    Intermittent catheterization or temporary foley

–    Record I&O, voiding pattern, residual urines, quality of urine, unusual feelings


l    Improve bowel function

–    Paralytic ileus – NGT

–    Bowel activity usually returns in first week

–    High-calorie, high-protein, high fiber diet

–    Stool softeners

–    Bowel program ASAP


l    Providing comfort measures

–    Tongs or calipers

l   Assess for signs of infection; pressure problems

–    Halo traction

l   Slight HA around skull pins for several days

l   Clean and observe for signs of infection

l   Inspect skin under vest

l   Do not wet liner of vest or use powder


l    Monitor for complications

–    Thrombophlebitis

l   Measure circumference of thighs and calfs

l   Anticoagulation once head and other injuries R/O

l   ROM exercises, support stockings, adequate hydration

l   At risk for up to 3 months



l    Complications

–    Orthostatic hypotension

l   For first 2 weeks after SCI, BP unstable and low

l   Common in clients with lesion above T7

l   Close monitoring before and during position changes

l   Vasopressors for severe vasodilation problems

l   Thigh-high elastic stockings or SCD

l   Tilt tables help with transition


l     Autonomic Hyperreflexia

–     Acute emergency

–     Occurs only after spinal shock resolved

–     Severe, pounding HA; paroxysmal hypertension; profuse sweating; nasal congestion; facial flushing; bradycardia

–     Lesions above T6

–     Stimulated by distended bladder, distended bowel, stimulation of skin, distention or contraction of visceral organs


l    Place immediately in sitting position to lower BP

l    Empty bladder immediately

l    Examine rectum for fecal mass when sx subside

l    Remove stimulus

l    Ganglionic blocking  agent (Apresoline) IV


l    Label medical record about risk

l    Instruct client on preventive and management measures

l    Instruct any client with lesion above T6 event can occur many years after initial injury