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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