Module 3 Blueprint Increased ICP Glasgow coma scale EYES Spontaneous 4 To voice 3 To pain 2 None 1 VERBAL Oriented 5 Confused

4 Inappropriate words 3 Incomprehensible sounds 2 None 1 MOTOR Obeys command 6 Localized pain 5 Withdraws from pain 4 Flexion (decorticate) 3 Extension (decerabrate) 2 None 1 Glasgow Coma Scale pointers 15 is fully alert 7 or less is comatose book says 8 or less is generally accepted as indicating a severe head injury Score of 0 does not exist a dead person will score 3 MOTOR ~ be able to distinguish btw 4 & 5 MOTOR ~ 3 flexion is corticated posturing is where they bring to core; 2 extension is cerebrate posturing which is opposite of corticated HESI HINT Use of the Glasgow coma scale eliminates ambiguous terms to describe neurologic status such as lethargic, stuporous, or obtunded. Dolls phenomenon Tests occulocephalic reflex ~ Dr performs, not nurse; think of eyes of baby dolls fixed to look straight; pt will be told to focus on something

1 Intact occulocephalic eyes deviate to opposite direction in which head is turned Abnormal eyes remain midline & move with the head Abnormal indicates brain stem injury If pt has cervical spine injury or even just a suspected, do not attempt Pathophysicology 3 components of brain brain tissue, blood, CSF Monroe-Kellie hypothesis - volume of any one of the 3 contents of the skull changes the volume of the other 2 contents Cushings response is seen when cerebral blood flow significantly. When eschemic, the vasomotor center triggers and in arterial pressure in an effort to overcome the ICP. S/S: Early sign is change in LOC HA d/t pressure N/V Changes in VS drastic changes or significantly ICP Cushings triad Cushings triad systolic BP with widening of pulse pressure, bradypnea, bradycardia, NURSING ALERT The earliest sign of ICP is a change in LOC. Slowing of speech and delay in response to verbal suggestions are the other early indicators. HESI HINT Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate ICP HESI HINT CSF leakage carries the risk of meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual signs of ICP may not occur. Management

 blood volume cerebral edema volume CSF Done by Restricting fluids Controlling fever cellular metabolic demands Administration of osmotic diuretics & corticosteroids Draining CSF Hyperventilating pt HESI HINT If temperature elevates, take quick measures to it since fever cerebral metabolism and can cerebral edema. HESI HINT Safety features for immobilized client: Prevent skin breakdown with frequent turning Maintain adequate nutrition Prevent aspiration with slow, small feedings or NG feedings Monitor neurological signs to detect the first signs that intracranial pressure may be Provide ROM exercises to prevent deformities Prevent respiratory complications frequent turning and positioning for optimal drainage. HESI HINT Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, convert bleeding, or cerebral anoxia. Do not over-sedate, and report any symptoms of restlessness. Medical management Surgical removal of cause clot, tumor, etc...

2 Osmotic diuretics ~ Manitol which removes fluid from normal brain tissue with little effect on edematous tissue because of blood/brain barrier (this allows more space & Lasix may be used in conjunction), glycerol, urea cerebral edema Steroids ~ Ex Decadron edema with tumors in areas that are edematous around tumors complications are immunosuppression, BS (pt on sliding scale insulin), GI bleeding (tagment, protonix, nexium), risk of infection CSF drainage ~ catheter in ventrical to remove CSF bur hole in scull Mechanical ventilation ~ controlled hyperventilation to induce respiratory alkalosis which then causes cerebral vasoconstriction reduces volume of blood and volume of CSF Temperature control ~ fever cerebral metabolism & rate that edema occurs High dose barbiturate therapy ~ if not resolved by other measures; cerebral resistance therefore cerebral blood flow basically allowing less blood flow to get to head means less volume in head Use of narcotics are contraindicated; NEVER give morphine to pt with ICP narcotics can ICP, Morphine affects pupil size and accurate size cant be obtained on assessment; Codeine be prescribed for HA r/t ICP Maintain patent airway with suctioning hyperoxygenate prior; airway obstruction will ICP Position ~ HOB elevated & keep head in neutral alignment gravity enhances venous return & turned head impedes venous return No straining ~ BM ICP so pt on stool softeners; NO valsalva maneuver; Do not allow them to help repostition bc it will cause them to push and facilitate valsalva maneuver have pt exhale while turning or moving them up in bed to prevent Monitor IVs to prevent fluid overload

NI

3 Passive ROM active ROM will cause I CP NURSING ALERT The body temperature of an unconscious pt is never taken by mouth. Rectal or tympanic (if not contraindicated) temperature measurement is preferred to the less accurate axillary temperature. Posturing Decorticate ~ abnormal flexion; arms, wrist, fingers flexed & arms abducted; legs fully extended & internally rotated with plantar comes to the core Decerebrate posturing ~ stiff arms extended & adducted, hands hyperpronated, wrist & fingers flexed, plantar flexion of feet outward rotation from the body Headaches Symptom not a disease Temporomandibular Joint Pain (TMJ) unilateral facial pain pain can be referred to upper part of face as well as down into neck usually caused by malocclusion, trauma, arthritis, bruxism (teeth grinding) Temporal Arteritis (Cranial arteritis) inflammation of the walls of the temporal (cranial) arteries S/S: pain, fatigue, wt los, fever & malaise; heat, redness, & tenderness over involved artery specific S/S of this kind of HA d/t the inflammation visual disturbances or blindness may result from ischemia of involved structures Tx analgesics for comfort & steroids for inflammation Migraine Complex S/S, characterized by periodic and recurrent attacks of sever HA Caused by VASCULAR disturbance that occurs more commonly in women and has strong familial tendency

HESI HINT TRY NOT to use restraints; they only restlessness. narcotics since they mask level of responsiveness.

AVOID

HESI HINT Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired persons require total care. HESI HINT Pts with an altered state of consciousness are fed by enteral routes since the likelihood of aspiration with oral feedings is great. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 mL residual in adults usually indicates poor gastric emptying and the feeding should be held. HESI HINT Paralytic ileus is common in comatose clients. Gastric tube aids in gastric decompression. HESI HINT Any client or bedrest/immobilization must have ROM exercises often and very frequent position changes. Do no leave the client in any one position for longer than 2 hours. Any positions that venous return is dangerous, i.e., sitting with dependent extremities for long periods. NURSING ALERT If the pt begins to emerge from unconsciousness, every measure that is available and appropriate for calming and quieting the pt should be used. Any form of restraint is likely to be countered with resistance, leading to self-injury or to a dangerous in ICP. Therefore, physical restraints should be avoided if possible; a written prescription must be obtained if their use is essential for the pts well-being.

Onset: childhood, adolescence, puberty occurs more often when major change in pace or schedule such as holidays, stress, first job can have one from having time off from work from the let down/change in pace Pain is unilateral Causative factors: vasoconstriction of arteries followed by vasodilation stretches nerve ending in vessel walls causing pain S/S: aura something signals the attack is coming on, lasts about 30 min visual disturbances (light flashes, commonly not verbalized though), N/V, photophobia, numbness & tingling in face & hands Lasts for hours or days; until very intense Recovery: sleep, photophobia, wet cloth on face, be alone Precipitating factors: o Foods tyramine, monosodium glutamate, milk products or nitrates Tyramine ~ cheese, chocolate, coffee, sausages, hot dogs, canned meats Tyramine in foods with vasoactive monamine BP ~ pickles foods, wines o Sun glare, weather changes causing sun to seem brighter, noise, bright lights o Birth control, Nitro vasodilator o Mental & emotional excitement can not do welll with certain changes in life; dont give surprise b-day party to o Fatigue, hunger, smoking, alcohol TX: o Prevent relaxation techniques, diet (avoid foods that cause it), quiet & dark rooms o Ergotamine preps: effective is taken early on must be taken 3060 min prior to full blown HA (during aura) vasoconstrictor

4 not used for HTN bc it is vasoconstrictor Ergotamine tartate: acts on smooth muscle, causing prolonged vasoconstriction of cranial blood vessels SE:parasthesias of fingers & toes d/t vasoconstriction; N/V, weakness in legs d/t vasoconstriction, muscle pain in extremities, bradycardia contraindicated: cardiac pts, HTN, PVD, impaired renal function, pregnancy Cafergot: combo of ergotamine and caffeine Imitrex: abords HA before it gets fullblown Zomig o Meds to prevent Inderal 40 mg tid-qid: beta blocker remember not to abruptly dc Sansert 2 mg BID or TID: rarely used d/t SE (blood dyscrasias) and the drug holidays that the pt has to take q6 months for 1-2 months prevents retroperitoneal fibrosis and pleuropulmonary and cardiac fibrosis Cluster HA Vascualr HA seen more during spring or fall More frequent in men No warning symptoms Come in clusters one to eight per day each attack last 15 min - 3 hrs Unilateral pain Sudden onest & subsides abruptly Usually localized around eye Eyes & nose might run Occurs mainly at night & wakes person up This person will be up pacing floor vs migraine who wants to be left alone TX: eliminate the factors that cause it same as migraine

5 Cluster VS Migraine No aura Has aura No vomiting Vomiting Rarely nausea Nausea Affect more men Affects more women No menstrual relationship Menstrual cycles can trigger Only neurological deficit is ocular Neurological deficits sympathetic paralysis Pt up pacing floor Dark, quiet room, alone, asleep Frequency is greater Frequency not as often Nocturnal attacks more frequent Waking hours normally Serotonin does not at the onset serotonin occurs during HA Tension HA Muscle contraction HA Caused by: result of sustained contraction of the mujscles of the neck and scalp, face & upper back Prolonged state of contraction causes blood supply to the muscle to become diminished and metabolic wastes begin to accumulate S/S: steady constant feeling of pressure in back of neck, forehead, & temple; pt c/o feeling like a brick/wt is on head TX: remove souce of stimuli; analgesics, Tylenol, muscle relaxants, moist heat, massage CVA Any functional abnormality of the CNS caused by a pathologic condition of the individual cerebral vessels or of the cerebrovascular system; includes any of the vessels which furnish blood to the brain if any portion of brain has disturbed blood flow Onset: any age; usually elderly; children with sickle cell Risk factors: modifiable and non-modifiable Pathological causes of CVAs o Cerbral thrombosis o Cerebral embolism o Cerebral ischemia o Cerebral hemorrhage Epidural Subdural Subarachnorid Intracerebral Anatomy of skull form outside to inside Skin skull epidural (above dura) dura mater subdura (below dura) arachnoid subarachnoid (below arachnoid) pia mater brain (grey matter & white matter) Meninges ~ fibrous connective tissue that cover the brain and spinal cord; provide protection, support, and nourishment Meningeal layers: dura mater arachnoid pia mater Cerebral thrombosis Blood clot occluding vessel that is supplying that area of the brain with blood Slowly developing pathological process Can occur over mins, hrs, days, or months not usually abrupt though May be preceded by prodromal warning such as parasthesias Mary mentioned that migraine is preceded by prodromal warning also and also parasthesias S/S: paresis ( strength & mobility of extremity), aphasia (language function); Can occur at rest or 1 hr after arising or after unusual fatigue Usually does not develop abruptly Associated with TIA Major causes: atherosclerosis S/S: conciousness may or may not be lost; HA uncommon at onset; may c/o dizziness, possible seizures The ischemia from the clot leads to edema in that area of the brain; since it is slowly occurring; symptoms may not be initially d/t the thrombosis in that particular area it occurs over time; as time goes the area of brain that is deprived of oxygenation will start to swell edeam occurs

Area of brain effected will give you the symptoms

HESI HINT Atrial flutter/fibrillation has a high incidence of thrombus formation following arrhythmia d/t turbulence of blood flow through all valves/heart chambers. Cerebral embolism Can be fat or blood Can occlude vessel totally or partially Usually lodges in the middle cerebral artery branches of the carotid carotid is larger so clot does not occlude and it keeps going until it reaches smaller vessels Can orriginate from heart A-fib pts (from stagnant blood in heart) or pulmonary (from infection or bedrest) Occurs rapidly Not related to activity Usually no prodromal signs maay have HA, but basically have no warning sign that this is occuring S/S & prognosis: Depends on area & how much tissue Cerebral ischemia (TIA) Insufficiency of blood supply to the brain Mainly d/t [atheromatous] constriction of the arteries supplying the brain Most common manifestation is TIA TIA: transient impairment of blood flow comes and goes o Temporary o Symptoms usually resolve completely without permanent damage o Commonly a sudden loss of motor, sensory, or visual funcion o Lasting few seconds or min or hrs, but no longer than 24 hrs

6 o Red flag: warning sign for impending stroke, advanced atherosclerosis something is going on & can become severe o TX: antiplatelet aggregation (presantine, aspirine) & possibly anticoagulants Cerebral hemorrhage General info Bleed in brain Rapid development Occurs during activity valsalva, straining, anything that the intrathoracic pressure that can raise the arterial pressure S/S: result from the compression of cranial nerves or brain tissue o Blood escaping compresses & displaces brain tissue o Frequently asymptomatic until vessel breaks and then o C/O severe HA o As blood escapes into brain tissue the pt will experience nuchal rigidity (neck stiffness) the blood on the nerves or affecting the meninges is very irritating o Dizziness; visual disturbances diplopia or loss of vision; hemoplegia or hemoparesis; seizures o Clot will form just like in cut and blood left in tissues will reabsorb clot will be reabsorbed/dissolved rebleed even up to a week after o The pt may not experience many S/S until the rebleed then they will get severe S/S Preceding events: o Severe occipital HA with nuchal rigidity HA in back of neck Mary discussed pt coming in with severe HA and ruling out migraine d/t location and then said that if BP was then you know it is not good o BP, vertigo, syncope, parasthesias in extremities, epistaxis usually d/t BP, retinal hemorrhage Types of cerebral hemorrhages Epidural (extradural) hemorrhage

Occurs outside dura mater d/t head injury (usually) middle meningeal artery has ruptured if not tx with in a few hours of incident they have little chance of survival d/t rapid pressure on brain tissue from the bleeding Subdural hemmorrage o Involves small vessels o Acute, subacute, and chronic o Chronic seen a lot in elderly takes a longer period of time for a hematoma to form in this area of brain to cause pressure on the brain o Pts with chronic subdural hemorrhages may have them for months without showing any S/S o Mary gave an example of elderly pt falling a couple of months prior Intracerebral hemorrhage o Usually arterial BP (usually) o S/S: depends upon the area of the brain that is involved as well as the amount of bleeding; Rapid onset, severe HA, nuchal rigidity, N, vertigo, loss of conciousness o NI: Keep pt quiet and inactive it can occur with activity Subarachnoid hemorrhage o Causes: trauma, hypertension, malformation of arterial/venous system (AVM congenital) o The rupture is usually preceded by some degree of physical strain o S/S: sudden shooting pain in back of eye & sudden shooting HA, N, nuchal rigidity, loss of conciousness o HA is explosive o If LP was done on this pt they would find blood in the CSF Diagnostic studies for CVA Performed to differentiate btw the types/causes of the CVA o o o o

7 Pt hx when did it start, do they have any other problems Neuro exam baseline to check for further deterioration; continuously done, can predict affected areas of brain, and prognosis Skull series (X-ray of skull/brain scan) see if there is fx/trauma EKG cardiac vs cerebral LP usually not done bc can not be done if evidence of ICP brain stem herniation or rebleeding can occur d/t the rapid release of pressure from the ICP MRI CT initial diagnostic test, should be done emergently for prompt tx (esp if candidate for tpa); differentiates type ischemic vs hemorrhagic tx based on the type o shows location and size of lesion; affected and/or possibly affected areteries, veins, adjoining vessels, and vascular branches predicts deficits pt will exhibit PET EEG ~ brain wave test; done with the things that stick on head Interventions of CVA Diuretics to edema & ICP o Manitol osmotic diuretic; Lasix can be used as adjunctive therapy o NI to check effectiveness of diuretics Urinary output ~ at least 30 mL/hr should be more Possitive effects to neuro exam Antiplatelet aggregates o ASA o Presantine 50-75 mg TID o Ticlid o Plavix NURSING ALERT Wrong pg # given but mary said When you get your pts hx during assessment make sure you ask about herbal remedies. GINKO &

GARLIC potentiate bleeding time. So if you give an ASA or anything of that nature, your anticoagulants; you need to know what else the pt is taking, like herbal remedies as well. Basically they will bleeding time. Anticoagulants o Heparin & coumadin TPA o Criterial protocols must rule out active bleed Surgical intervention for ischemic strokes Carotid endarterectomy remove plaque/atherosclerosis/thrombus to prevent ischemia from the occlusion Post op care from endarterectomy Important, especially during first 24 hours Keep head in neutral position o Keep incision intact o Do not want to prevent venous return HOB Neuro assessment VS & hand grips o VS o Hand grips contraleteral weakness weakness on opposite side Monitor operative side for edema or hematoma Nursing assessment after a sever cerebral hemorrhage Classic picture of what you will see if somebody is having/just had a cerebral hemorrhage Pt unconscious Face is brick red Difficulty in breathing Contralateral paralysis Cheek will blow out on paralyzed side during expiration d/t forcefulness from the difficult respirations BP Slow, full, bounding pulse The longer they are comatose the poorer the prognosis Acute care of CVA d/t cerebral hemorrhage

Complete bedrest possible Head in neutral position venous return Prevent valsalva maneuver (straining) intrathoracic pressure BP arterial pressure 3 main causes of death d/t hemorrhagic stroke Pneumonia Rerupture of aneurism Brain herniation ICP Clinical manifestations of CVA Baseline data: VS & neuro (Glasgow) Perceptual Disturbances: parietal & temporal lobe (optic tract) visual disturbances o Homonymous hemianopsia: loss of half of visual field (not entire eye, only half of each eye) temporary or permanent; Loss of vision will be on SAME side of paralysis Neglect to one side of body Difficulty judging distances Eat only half of food if they only eat 50% will be unusual looking food on the side of visual loss will not be seen and thus ignored turn plate around Seizure activity: can cause seizures prophylactic anticonvulsants Emotional lability: unpredictable; exaggerated use distraction (change subject) when behavior becomes exaggerated Agnosia: incapable of importing information in various senses o Visual identify colors o Auditory problems identifying auditory stimuli they can hear it, but cant identify where it is coming from and what it is o Olfactory identifying smells

8 to keep pt as quiet and inactive as

9 o Tactile cant identify what they are touching hard time identifying textures, shapes, etc o 1 2 3 4 5 CRANIAL NERVE Olfactory Optic Oculomotor Trochlear Trigeminal ASSESSMENT Identify smells with eyes closed Snellen chart; visual fields 3,4,6 ocular rotation, conjugate movements, nystagmus. Papillary reflexes, inspect eyelids for ptosis Cotton to forehead, cheeks, jaw. Rotate btw sharp & dull in same places sensitivity to superficial pain. If incorrect responses, test temperature sensation. Symmetry while smiling, whistles, eyebrows, frowns, tightly closes eyelids Whisper or watch-tick test. Weber, rinne Swallow, differentiate sugar vs salt Gag reflex, hoarseness in voice, swallow, AH uvula Shrug shoulders, head side-to-side Stick tongue out, move it side-to-side Affected Area Occipital Temporal Parietal Affected Area Temporal Parietal-Occipital Frontal Frontal

HESI HINT Type of Aphasia Dysarthria: Dyshpasia: Aphasia: Agraphia: Alexia: Dysphagia:

inability to perform purposeful movements in the absence of motor problems Difficulty articulatin Impairment of speech and verbal comprehension Loss of the ability to speak Loss of the ability to write Loss of the ability to read Dysfunctional swallowing

6 7 8 9 10 11 12

Abducens Facial Acoustic Glossopharyngeal Vagus Spinal accessory hypoglossal Type of Agnosia Visual Auditory Tactile Type of Aphasia Auditory-Receptive Visual-Receptive Expressive Speaking Expressive writing

Use short sentences when communicating with pt who has had a stroke dont give too many options (keep instructions & questions very simple) Prevention of longterm complications Assess movement relieve pressure Prevent external rotation of hip Prevent clawlike contracture deformity Prevent footdrop Bladder control Assess sensations Maintain Skin integrity Speech therapy to regain communication Brain Tumor Biphasic age distribution peak 5-8 & 55-60 Males slightly higher risk Children more likely to develop tumors of the cerebellum cerebellum s/s imbalance & ataxia 90% of all tumors in adults are about tentorium

10 Classified based on tissue origin, location, & relation to the brain TISSUE ORIGIN Neural Connective Meninges Blood vessels Glands SUPRATENTORIAL Cerebrum Adults HOB INTRINSIC Originated inside brain Rapid growing Malignant (most) TERMINOLOGY Neuroma Glioma Meningio Angio Adenoma INFRATENTORIAL Cerebellum Children Supine

EXTRINSIC Originated outside brain Slow growing Benign (most) Usually encapsulated May or may not be Can be removed if too removed much pressure Most common tumor to metastasize to the brain is lung CA followed by breast CA

11 RIGHT-SIDED VISION VS Left-sided paralysis Spatial perceptual deficits: Inability to judge distance, size, position Inside from outside of clothing Wheelchair running into frame of door Buttoning clothes wrong Lipstick crooked One sided neglect hemianopsia Reading left side of words can be dropped women might be seen as men Impulsive behavior they will go too fast: teach small segments & get them to demonstrate or repeat it back to you If pt is getting up they might try to walk before they have their balance and then end up falling When learning something new they might rush to the next step and not learn it Unaware of neurologic deficits Euphoric; Distractable May be alert & oriented LEFT-SIDED Right-sided paralysis Unable to discriminate words and letters Reading problems Deficits in right visual field

BEHAVIOR

Slow, cautious, & disorganized These pts need frequent feedback Dont give too many options (keep instructions & questions very simple) Anxious Quick anger and frustration Dysarthria: articulation muscles impaired Aphasia may not be hard of hearing just can communicate information; they hear, process it, but cant respond you do not have to raise your voice Receptive aphasia receiving Expressive aphasia speaking Global aphasia receptive & expressive Agraphia No deficit

MEMORY HEARING

LANGUAGE

Disoriented Cannot recognize faces

Loses ability to hear tonal variations

No deficit

12 Assessment Take complete hx o From pt o From family they may have seen something pt cant see personality or behavioral changes S:S: common to all o ICP: HA, nausea, Projectile vomiting, cushings triad (bradycardia, BP with widening pulse pressure (systolic hypertension), braypnea) o Focal disturbances: slight change in LOC seizure activity HESI info Mary pointed out as 2 classic differentiate from Migraine o HA more severe upon awakening o Vomiting not associated with nausea Tumors based on tissue origination Neuroma (Acoustic) o Involve cranial nerves o Benign o Intrinsic o S/S: involves # VIII hearing & balance vertigo, staggering, loss of coordination; as tumor grows it compresses # V pain on same side of face o Prognosis: can be completely removed, but because # V is involved they can have facial paralysis; they can also have deafness on the side with lesion Glioma o Neoplasm of connective tissue o Common brain CA o Always intrinsic o Infiltrating filtrates throughout brain tissue o Can not be completely removed because it is not ncapsulated o Bulk can only be removed, but brain tissue comes with o TX: surgery, chemo, radiation o Not curable, Reoccurring o Two main types Astrocytomas Graded 1-4; 4 more malignant & faster growing 1 less malignant & slow grawing Medullablastomas Rapidly growing Children in brainstem (age 6-10) Seeds through CSF Most commonly in cerebellum Meningioma o Tumors that cover lining of brain o Extrinsic usually encapsulated cant spread & can be removed o Slow growing o S/S: HA; depending on pressure put on tissue they may have other symptoms like seizure o Prognosis: this is one you would rather have; completely removed if needed; cured after removal o Not reoccurring Angioma ~ Hemangioma ~ Hemangioblastoma ~ angioblasoma o Tumor of immature blood vessels o S/S: ICP HA, vertigo, nystagmus, + Rhomberg where they tilt toward side of lesion o Prognosis is good; they can remove entire lesion Adenoma ~ pituitary o Can or pituitary function o Anterior lobe GH, TSH, LSH, ACTH o Posterior lobe ADH o Hyperpituitarism

Accelerates growth when GH secretion d/t tumor children will have giantism & adults will have acromegally Cushings syndrome from ACTH d/t tumor moon face, buffalo hump, BS, obesity o Hypopituitarism Adiposity & loss of sexual function Loss of libido, sterility, impotence, amenorrhea Loss of vision pressure on optic nerve Primary symptom that these pt have is when they talk about HA they will describe it as bifrontal HA not on one side; across entire front of head o TX: transphenoid hypophysectomy Incision into maxillary gingival Go up nasal cavity to remove tumor Postop Mustache dressing Mouth breathing (not nose) No blowing nose, coughing, sneezing ICP d/t tissue manipulation & edema Diabetes insipidus transient (temporary) post-op Foley, urine looks like H20 & 3-10 L/day tx with ADH Vasopressin Symptoms according to site/location LOBE Function S/S Frontal Personality, mood, Impaired judgement, slowness language center of thought, obscene language (never used before), expressive aphasia Temporal Short-term memory Hemianopsia Parietal Sensory Parasthesias, hypoasthesias, hyperesthesia or sensitivity to touch

Occipital Cerebellar

Visual Balance

13 Impairment, homonymous hemianopsia Unstady gait, fall toward side of lesion, intentional tremor (have tremor when reaching for object), + Rhomberg, neg finger to nose, nystagmus, HA in suboccipital area

Prognosis of Brain tumor If untreated leads to death from either ICP or brain damage. Intracranial surgery Pre-op intracranial surgery Tell pt what to expect post-op o O2 o Suction o IV o Art lines o Frqnt neuro check & VS o Cranial dressing and drain o Foley o Transfusions o Periorbitol edema & ecchymosis looks like they were punched in eyes o Leg exercises o Deep breathing Baseline neuro assessment to determine conditions needing intervention post-op Steroids brain edema Prophylactic dilantin Surgeries Craniectomy o Portion of skull removed to accomadate cerebral edema by allowing expansions for inoperable tumor

o Do NOT position pt on operative side no skull to protect brain Cranioplasty o Repair of cranial defect d/t cosmetic defect or done to protect brain o NI Observe dressing for bleeding & CSF leakage Observe dressing for tightness, indicating edema Do NOT allow pt to lie on portion of head where skull has been removed Take precausions to not accidently hit the head Do NOT remove dressing without an order strict aseptic technique Craniotomy o Surgical opening of skull to gain access to intracranial structures (monitors for ICP bur hole) o Supratentorium adults, cerebrum o Infratentorium children, cerebellum HESI HINT Craniotomy preoperative medications: Corticosteroids to reduce swelling Agents and osmotic diuretics to reduce secretions (atropine, robinul) Agents to reduce seizures (Dilantin) Prophylactic antibiotics Transphenoidal hypophysectomy approach o Monitor for ICP d/t edema o Pituatary surgery o Incision in maxillary gingival upper lip btw gums and lip; go up through the nasal passage o Tumor is packed with muscle or fat from thigh/lower abdomen

o o o o

14 Nasal cavities packed with Vaseline gauze and ointment Upper gums sutured Moustache dressing under nose to hold the packing in place NI: High fowlers Vasopressin & steroids No nasopharyngeal suctioning Mouth breathing No nose blowing, sneezing, or coughing No tooth brush Post-op complications Diabetes insipidus Hypothyroidism Hypoglycemia CSF leak

Post-op intracranial surgery Monitor for signs of ICP Establish & maintain adequate airway and ventilation Maintain body alignment after supratentorial o HOB 30 (45) o Position pt on side or back o If tumor was large do not turn on the side it was on displacement from gravity o Neutral head positon; no neck flexion venous return ICP o Pillow under head & shoulders not just neck o When repositioning do not let pt help to prevent valsalva have pt exhale Maintain body alignment after infratentorial o Supine HOB flat o Position from side to side o Head in neutral position esp when turning

o When repositioning do not let pt help to prevent valsalva have pt exhale Assess surgical dressing o CSF leakage if clear use dextrose strip it will be + for glucose; if bloody look for halo sign (clear/yellow) HOB, Diamox formation of CSF o Excessive bleeding o Do not change dressing until ordered o Ventricular drainage Monitor elimination avoid circulatory overload Provide pt comfort o HA for 24-48 d/t stretching/irritation of nerve of the scalp Activites to avoid bending over, coughing, sneezing; valsalva, vomitting Surgery complications Meningitis o D/T Infection Blood in the subarachnoid space Prolonged use of intracranial monitoring devices 2/3d post surgery o S/S Headache, chills, fever, irritability, nuchal rigidity, soreness of skin & muscles, cells in CSF, + Kernigs, + Brudzinski, delirium, convulsion o PI Strict aseptic technique Prophylactic antibiotics Seizures o Greater risk with supratentorial o NI: padded side rails, side rails up, dilantin prophylactic Stress ulcers pepcid, protonix Diabetes insipidus

15 o Hypothalamus and pituitary gland area surgery edema interferes with production of ADH excessive output o TX: fluid and vasopressin Seizures Divided into 2 major classes Generalized Person loses conciousness for a few sec to a min, no warning or aura associated Tonic-clonic (Grand Mal) o Most common o Loss of conciousness o Tonic phase stiffening of body o Clonic phase Jerking of extremities o Excessive salivation o Bite tongue or cheeks o Incontinence o After seizure muscle soreness, tired, sleep for hours o May not for normal for several hours to days after o No memory of seizure Petit Mal (Absent) o Usually only children o Rarely continues beyond adolesecence o Brief staring spell that lasts only a few sec can go unnoticed o Can have 100 or more episodes in a day o May experience twitching in facial muscles o Typical of kids that come home from school with note from teacher saying that they are staring out into space, they are not paying attention, and their grades are slipping Partial Begin in a specific region of cortex

16 Confined to one side of brain and remain partial or focal in nature or may spread to involve entire brain Simple motor Jacksonian simple partial seizures o Only a finger or hand may shake or mouth may jerk uncontrollably o May talk unintelligibly o May be dizzy o May experience unusual or unpleasant sights, sounds, odors, or tastes o No loss of conciousness o Rarely last longer than minute Complex symptom psychomotor Complex partial o Involves temporal lobe o Person either remains motionless or moves automatically (automatisms) either way it is inappropriate movement for the time and place o May experience emotions of fear, anger, elation, or irritability. o Person does not remember the episode with it is over o Lipsmacking o Automatisms are picking at clothes, fumbling with objects, walking away (during conversations) Status epilepticus Most serious Continous No conciousness between seizures Problem is lack of O2 to brain brain damage can result Severe injury or death can happen d/t trauma head injury from falling, drowning in tub, sever burn TX: IV Valium, Ativan, Cerebyx administered slowly to stop seizures Dilantin, phenobarbital are administered later to maintain seizure free state Diagnostic Studies Aimed at determining type, frequency, and severity, and factors that precipitate them. o Labs, EEG, CT, etc to determine cause of seizure Management Look at 2192 and picture pt on side with O2 and suction setup. Pads, o2, suction when pt has hx of seizures Maintain privacy of pt Ease pt to floor if possible Protect head with pad Loosen constrictive clothing Push furniture out of way If pt in bed, remove pillows and raise side rails If aura precedes, insert oral airway to reduce the possibility of pt biting tongue or cheek do not put anything in their mouth during the seizure; can only be done prior or after Do not restrain pt Put pt on side with head flexed forward allows tongue to fall forward and facilitates drainage of saliva and mucua. Use suction to clear secretion O2 After keep pt on side Make sure airway is patent After grand-mal, usually a period of confusion Short apneic period may occur during or immediately after a generalized seizure Pharmacological management Maintain seizure free state must be at a therapeutic level Periodic serum therapeutic levels taken usually every 6 months Dilantin side effects gingival hyperplasia, drowsiness

17

18 Meningioma Neuroma (Acoustic) Crainial VIII (hearing & balance) Grows & compresses V (Acoustic & Facial) Intrinsic Benign Gliomas Astrocytomas Meduloblas tomas Connective tissue Most commonly in cerebellum Forms a cyst The tumor itself remains a little nodule in the cyst wall Hemangioma (hemangioblasoma angioblastoma) Immature blood vessels Adenoma

Location

Covering of brain

Adults cerebrum Children cerebellum

Pitutitary Tumor of ductless gland

Originated Benign VS malignant Growth

Extrinsic Benign

Always intrinsic Usually malignant Malignant Highly Grade 4 most malignant malignant Gades 1&2 ~ Rapid slow Grades 3&4 ~ rapid Any Frqntly in children Female to male 2:1 Not curable; can never remove all of tumor; When removed brain tissue comes with it d/t being infiltrating

Slow

------------

Age Sex Prognosis

30-60 Females greater Can be completely removed Not recurring After removal they are cured Depends on location

------------------------

Any

Good; they can remove entire lesion

S/S

Vertigo, staggering loss of

ICP HA, vetigo, mystagmus, + rhomberg

function

function

19 HA usually coordination Pain on side of face Facial paralysis & deafness tilt toward side of lesion of GH Hyperpituittar ism Children: gigantism Adults acromegaly Cushing;s syndrome ACTH: moon face, buffalo hump, BS Infiltrating

Encapsulated Encapsulated VS Infiltrating