Cerebral Edema,Herniation and Nursing intervention

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Cerebral Edema
-    Is an increase in the water content of the brain tissue. When cerebral edema occurs as a result of trauma, hemorrhage, tumor, abscess or ischemia, an increase in ICP occurs.
Herniation
-    When the pressure exerted by a mass in the brain is not equally divided, result in shifting or herniation of the brain from one compartment of high pressure to one of lower pressure.Clinical Manifestations

 

-    Change in level of consciousness is the most sensitive and important indicator of neuro status
-    Early signs may be nonspecific: restlessness, irritability, generalized lethargy
-    Determine the level of stimulus needed to arouse the patient (verbal, touch, shaking?)
-    Content of consciousness: orientation
-    Speech: clear, coherent, slurred, distorted, aphasic, incomprehensible sounds, no effort to speak
-    Report changes immediately.
-    Changes in vital signs-
-    Increasing systolic blood pressure
-    Widening pulse pressure
-    Bradycardia
-    Pulse slowing and is bounding
-    Irregular respiratory pattern
-    May also have a change in temperature
-    Ocular signs
-    Pupil changes are from pressure on third cranial oculomotor nerve result in dilation of pupil
-    Pupils become sluggish, unequal.  This is because of brain shift.  May also be pressure on other cranial nerves
-    A fixed, unilaterally dilated pupil indicates herniation of the brain
-    Motor ability is controlled by nerve tracks originating in the frontal lobes of the brain.
-    Distortion of brain tissue along these pathways can cause motor dysfunction.
-    Patient may exhibit localization to painful stimulus or withdraw from it.
-    Motor strength and tone are assessed in all 4 extremities.
-    Decorticate posturing now called abnormal flexion,
-    Decerebrate posturing now called abnormal extension.
-    Decrease in motor function
-    May have hemiparesis or hemiplegia
-    May see posturing – either decorticate or decerebrate
-    Decerebrate – more serious from damage in midbrain and brainstem
-    Decorticate – from interruption of voluntary motor tracts
-    Headache
-    From compression on the walls of cranial nerves, arteries and veins
-    Straining and movement makes worse
-    Vomiting
-    NOT preceded by nausea- “unexpected”
-    May be projectile

Diagnostic Tests
-    CT
-    MRI
-    Cerebral angiography
-    EEG
-    No lumbar puncture if there is ICP because sudden release of pressure can cause brain to herniate
-    ABG’s – keep O2 at 100% and PCO2 as related to ICP (25-35)

Drug Therapy
-    Mannitol – Rapid short acting diuretic that decreases ICP.  Decreases total brain water content
-    Watch fluids and electrolytes closely (I and O and labs)
-    Don’t give in cases of renal failure or if serum osmolality increased
Drug Therapy
-    Barbiturates – causes decrease in metabolism and ICP.  Causes reduction in cerebral edema and blood flow to brain.
-    Skeletal muscle paralyzers may be used (Pavulon)
-    Antiseizure drugs – Dilantin
-    Loop diuretics – reduce blood volume and tissue volume
Nutrition
-    Fluid balance is controversial
-    Give saline either .45% or normal saline – not glucose to help prevent additional cerebral edema
-    Watch sodium if on Mannitol – may need to give additional salt.
-    Also may need additional free water if dehydrated – watch I and O closely.
Nursing Interventions
-    Airway and respiratory – suction only as needed and for 10 seconds at a time, only 2 passes.  Give 100% O2 prior to suctioning.
-    Avoid abdominal distention – may need NG tube to decompress stomach
-    Sedate with care – if not on a ventilator, use sedation that will not interfere with respiration or mask any neuro changes
*    Posture and head position
•    Avoid jugular vein compression
-    Head should be in neutral position
-    Cervical collars should not be too tight
•    Elevation of the head and trunk may improve jugular venous return.
-    Keep head in alignment to prevent cutting off venous flow from the head
-    Don’t elevate knees – this will increase intrathoracic pressure
-    Turn gently from side to side – if turning raises ICP, client will need to stay on back
-    If client is posturing frequently during care, will need to sedate first and then do only one thing at a time.  Minimize stimulation
-    These clients can become agitated and aggressive – avoid over stimulating them
-    Restraining them will make them MORE AGITATED and RAISE THEIR ICP!
-    NO TV IN ROOM
-    Keep room darkened if needed
-    Hyperventilation (PaCO2 < 35 mmHg) works by decreasing blood flow and should be reserved for emergency treatment and only for brief periods
-    May need eye drops to moisten eyes
-    Client may benefit from rehab to help him adapt and progress
-    Keep body temperature within normal limits
-    Do not use ice on client
-    Prevent infection
-    Protect from injury
-    Avoid factors that increase ICP
-    Psychological support

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