NR 341 Week 6 Complex Intracranial – Neurological Alterations
NR-341 Complex Adult Health
WEEK 6 EDAPT NOTES: COMPLEX CARE NR 341
Complex Intracranial – Neurological Alterations
Intracranial regulation refers to the body’s ability to manage blood and cerebrospinal fluid flow within the brain and spinal cord. This is governed by a sensitive system of nerve fibers that detect variations in pressure and flow, adjusting accordingly to maintain homeostasis. Injuries or abnormalities can disrupt this balance, necessitating adjustments by the nervous system. In some cases, these adjustments are insufficient, requiring external intervention to restore normal function. For example, if a client has a mean arterial pressure of 120 mm Hg and an intracranial pressure of 42 mm Hg, the cerebral perfusion pressure is calculated as the mean arterial pressure minus the intracranial pressure, yielding a cerebral perfusion pressure of 78 mm Hg.
When intracranial pressure is significantly elevated, a nurse may anticipate symptoms such as bradycardia, irregular respiration patterns, and widening blood pressure measurements, collectively known as Cushing’s triad. These symptoms can indicate the risk of impending cerebral herniation. Furthermore, bloody drainage from the ear may indicate a skull fracture, while cold and clammy skin below the neck may suggest autonomic dysreflexia. To assess a client’s level of consciousness accurately, the Glasgow Coma Scale (GCS) is the preferred tool. The balance of cerebrospinal fluid and blood is crucial, as intracranial pressure changes when there are alterations in brain tissue, cerebrospinal fluid, or blood volume. The body can compensate for minor changes by adjusting blood pressure or cerebrospinal fluid flow, a process known as intracranial regulation.
Altered Intracranial Regulation
Altered intracranial regulation can arise when there are unexpected changes in mass due to space-occupying lesions or increased swelling from an inflammatory response. This condition may develop gradually, as seen in brain tumors, or rapidly, as in cases of cerebral edema caused by inflammation or bleeding. Changes in the volume of brain tissue, cerebrospinal fluid, or blood can lead to fluctuations in intracranial pressure, which can, in turn, result in symptoms of decreased brain perfusion, as measured by cerebral perfusion pressure (CPP). In managing clients with complex health issues, advanced monitoring techniques are employed to measure intracranial pressures accurately. This may involve the use of drains and other devices to reduce pressure by draining cerebrospinal fluid or inducing coma and artificial ventilation to lower intracranial pressure.
In complex healthcare environments, monitoring intracranial pressure can be achieved through the placement of a catheter within the skull, providing continuous measurements that help identify elevated pressures or changes in brain temperature. Notably, the most severe complication of altered intracranial regulation is herniation, which occurs when extreme pressure inside the skull forces the brain stem through the foramen magnum, leading to severe outcomes such as death or significant brain damage. Normal ranges for these measurements are as follows:
- Mean arterial pressure (MAP): 70 to 100 mm Hg
- Intracranial pressure (ICP): 5 to 15 mm Hg
- Cerebral perfusion pressure (CPP): 60 to 80 mm Hg
There are several methods for monitoring intracranial pressure, including:
- Intraventricular Catheter: A flexible tube inserted into the lateral ventricle of the brain, providing accurate measurements and allowing for the drainage of excess cerebrospinal fluid.
- Subdural Screw (or Bolt): A hollow screw inserted through a drilled hole in the skull, which reads the pressure in the subdural space and can be quickly installed.
- Epidural Sensor: Placed between the skull and dural tissue, this is the least invasive method but does not allow for drainage of cerebrospinal fluid.
Alongside monitoring intracranial pressure, other metrics that may be assessed in complex situations include blood flow, oxygenation, metabolism, and continuous electroencephalographic monitoring. Research into the efficacy of different monitoring techniques continues to enhance patient care for those with altered intracranial regulation.
Spinal Cord Injury
Spinal cord injuries are critical neurological alterations that require immediate attention in complex healthcare environments. The spinal cord can suffer from bruising, punctures, or severing. Since the spinal cord extends from the neck down to the first and second lumbar vertebrae, damage at any point can lead to symptoms extending beyond the injury site. For example, injuries in the cervical region can affect respiratory function, while damage above the thoracic vertebrae (T6) can result in cardiovascular symptoms such as bradycardia, hypotension, and impaired vascular response. Injuries at the thoracic level may cause bowel and urinary dysfunction, including urinary retention and constipation.
The specific spinal nerves include:
- Cervical nerves (cervic/o)
- Thoracic nerves (thorac/o)
- Lumbar nerves (lumb/o)
- Sacral nerves (sacr/o)
- Coccygeal nerve (coccyg/o)
Acute Spinal Cord Injury
The severity and location of a spinal cord injury dictate the extent of paralysis and the organs affected. Depending on the injury’s severity, clients may experience complete paralysis (if the cord is severed) or temporary paralysis and paresthesia (in cases of bruising). For instance, an injury at the T6 level may lead to gastrointestinal issues like constipation, fecal impaction, and abdominal bloating, contingent on the injury’s specifics, the quality of care provided, and proactive bowel management.
The following table summarizes the impact of various spinal cord injuries on function:
| Injury Level | Description | Effects |
|---|---|---|
| C1-C3 | High quadriplegia | Inability to breathe or cough |
| C4 | High quadriplegia | Significant respiratory impairment |
| C6 | Low quadriplegia | Mild respiratory effects |
| T6 | High paraplegia | Cardiovascular and gastrointestinal issues |
| L1 | Low paraplegia | Bladder dysfunction |
Altered intracranial regulation or other neurological changes can stem from various causes, as indicated by specific cues from the client’s history:
Past Medical History:
- Previous head injury
- Brain hematomas (epidural, subdural, or subarachnoid)
- Cerebral vascular accidents leading to brain edema
- Ruptured cerebral blood vessels
- Overproduction of cerebrospinal fluid (pseudotumor cerebri)
- Meningeal inflammation or infection
- Vertebral fractures
- Osteoporosis
- Degenerative disc disease
Past Surgical History:
- Previous brain surgeries
- Previous spinal surgeries
Family History:
- Seizures
- Parkinson’s disease
- Huntington’s chorea
Social History:
- Prolonged anoxia (near drowning)
- Past trauma to the head or spine
- Occupational exposure to neurotoxins
Medications:
- Antiseizure medications indicating a history of neurological issues
- Anticoagulants posing a risk for cerebral hemorrhage
- Psychotropic medications with neurological side effects
- Serotonin-inducing drugs linked to serotonin syndrome
Conditions such as dyslipidemia, concussions, and bacterial meningitis can also disrupt intracranial regulation. A history of these conditions alerts nurses to patients at higher risk for altered regulation. Surgical procedures like lumbar laminectomies can introduce complications, potentially creating scar tissue that affects cerebrospinal fluid flow. Additionally, smoking may elevate the risk of cerebrovascular diseases, and a family history of such diseases could heighten the client’s risk as well.
Symptoms of Complex Neurological Problems
Level of Consciousness Problems:
- Altered consciousness
- Confusion
- Impaired memory and orientation
Brain-Connected Nerve Issues:
- Visual disturbances (blurred or double vision)
- Hearing impairments (unequal or absent hearing)
- Anosmia (loss of smell)
- Dysphagia or dysgeusia (swallowing or taste difficulties)
- Impaired neck or shoulder movement
Movement Issues:
- Paralysis (inability to move)
- Paresthesia (loss of sensation or abnormal sensations)
- Abnormal reflexes
Pain Symptoms:
- Headaches (considering location, duration, and intensity)
- Extremity pain
Airway Clearance and Gas Exchange:
- Breathing difficulties
Elimination Issues:
- Urinary retention or incontinence
- Fecal retention or incontinence
Reproductive Issues:
- Erectile dysfunction
- Anorgasmia
Level of Consciousness Assessment
The Glasgow Coma Scale (GCS) evaluates a client’s level of consciousness through eye-opening, verbal, and motor responses:
Eye Opening Response:
- Spontaneous: 4 points
- To verbal stimuli: 3 points
- To pain only: 2 points
- No response: 1 point
Verbal Response:
- Oriented: 5 points
- Confused conversation: 4 points
- Inappropriate words: 3 points
- Incomprehensible speech: 2 points
- No response: 1 point
Motor Response:
- Obeys commands: 6 points
- Purposeful movement to pain: 5 points
- Withdrawal from pain: 4 points
- Flexion to pain: 3 points
- Extension to pain: 2 points
- No response: 1 point
Vital Signs:
- Fever
- Cushing’s triad
- Irregular breathing patterns
- Bradycardia
- Widening pulse pressure
Brain-Connected Nerve Assessment:
- Comprehensive evaluation of cranial nerves, including:
- I: Olfactory (smell)
- II: Optic (vision)
- III: Oculomotor (eye movement)
- IV: Trochlear (eye movement)
- V: Trigeminal (facial sensation, mastication)
- VI: Abducens (eye movement)
- VII: Facial (facial expressions, taste)
- VIII: Vestibulocochlear (hearing, balance)
- IX: Glossopharyngeal (taste, swallowing)
- X: Vagus (autonomic functions)
- XI: Accessory (shoulder movement)
- XII: Hypoglossal (tongue movement)
Assessment Techniques:
- Measure vital signs
- Perform a detailed neurological assessment
- Observe pupil size and reactivity
- Assess limb strength and movement
- Evaluate sensory responses
- Examine the abdomen for signs of distension or discomfort
In summary, careful assessment and monitoring are essential in managing complex care clients, particularly those experiencing altered intracranial regulation or spinal cord injuries.
Primary Nursing Diagnosis and Evaluation
| Primary Nursing Diagnosis | Nursing Evaluation |
|---|---|
| Acute confusion | The client demonstrates alertness and orientation to person, place, time, and situation. |
| Decreased intracranial adaptive capacity | The Glasgow Coma Scale score is 15, indicating full consciousness. |
| Ineffective thermoregulation | The client maintains an oral temperature ranging from 97.8ºF (36.6ºC) to 99.8ºF (37.7ºC). |
| Impaired memory | The client is able to articulate both short- and long-term memories. |
| Autonomic dysreflexia | The client shows no symptoms of autonomic dysreflexia. |
| Altered perfusion | There are no indications of decreased cerebral perfusion in the client. |
| Impaired mobility | The client exhibits normal reflexes, moves all extremities, maintains balance, and reports no paresthesia. |
| Pain | The client communicates that their pain level is manageable. |
Secondary Nursing Diagnosis and Evaluation
| Secondary Nursing Diagnosis | Nursing Evaluation |
|---|---|
| Altered perfusion | Mean arterial pressure is sustained between 60 and 100 mm Hg. |
| Reduced cardiac output | Mean arterial pressure is maintained between 65 and 100 mm Hg. |
| Impaired airway clearance | The client maintains a clear and open airway. |
| Altered gas exchange | Oxygen saturation levels remain above 92%, with a respiratory rate between 12 and 20 breaths per minute. |
| Constipation | The client adheres to a normal bowel routine. |
| Urinary retention | Urine output is consistently above 30 mL/hour, with no residual urine detected in the bladder. |
| Incontinence (bowel or bladder) | The client’s skin remains dry and free of urinary or fecal moisture. |
| Altered tissue integrity | The client’s skin remains intact and free of lesions. |
| Altered nutrition | Albumin blood levels are consistently above 3.5 g/dL. |
According to the National Spinal Cord Injury Statistics Center (2020), approximately 300–400 individuals sustain spinal cord injuries annually. Nearly three-quarters of these injuries stem from motor vehicle accidents, falls, gunshot wounds, and motorcycle accidents. Preventive measures should emphasize safe driving practices, including enhanced speed enforcement and the consistent use of seat belts and airbags. Additionally, increased safety gear usage when working at heights and improvements in gun control and motorcycle safety are vital areas for prevention.
Causes of Spinal Cord Injury
| Cause | Percentage (%) |
|---|---|
| Auto crash | 32 |
| Fall | 23.1 |
| Gunshot wound | 15.2 |
| Motorcycle crash | 6.1 |
| Diving | 5.7 |
| Medical complication | 2.9 |
| Hit by falling/flying object | 2.7 |
| Bicycle | 1.7 |
| Pedestrian | 1.5 |
Post-injury, the primary causes of mortality in clients with spinal cord injuries include:
- Diseases of the respiratory system (21.4%)
- Infective and parasitic diseases (12%)
- Neoplasms (10.8%)
- Heart disease (10.4%)
In acute care settings for spinal cord injuries, it is crucial to address the secondary effects of the injury. The top priorities always include maintaining airway, breathing, and circulation. Clients must be immobilized to prevent further damage to the spinal cord.
Elderly patients may present complex intracranial regulation issues that can be confused with age-related changes or new-onset dementia. Therefore, a comprehensive medical and medication history is vital for identifying potential causes of altered intracranial regulation that may be less apparent in younger clients. Medications can interfere with blood clotting mechanisms, and certain activities, such as shaving or walking barefoot, pose risks for bleeding. Unwitnessed falls may also suggest underlying injuries that could be life-threatening.
NR 341 Week 6 Complex Intracranial – Neurological Alterations
In younger populations, intracranial regulation problems are often due to traumatic injuries or congenital issues such as spina bifida, cerebral palsy, or congenital malformations that lead to hydrocephalus. These individuals may experience chronic neurological problems as they age. Birth history and any childhood trauma are essential factors to review with the client.
For instance, Angela Everheart, a 57-year-old female brought to the emergency department (ED), presented with a Glasgow Coma Scale score of 4. This score is based on assessments indicating that her eyes do not open and she is verbally unresponsive. Additionally, she exhibited “decerebrate posturing” and had an unequal dilated pupil on the right side. Other concerning signs included widening systolic and diastolic blood pressure, bradycardia, and absent respirations with an inability to obtain an oxygen saturation reading.
Glasgow Coma Scale Eye Opening Response:
- Spontaneous: opens with blinking at baseline (4 points)
- To verbal stimuli, command, speech (3 points)
- To pain only (not applied to face) (2 points)
- No response (1 point)
Verbal Response:
- Oriented (5 points)
- Confused conversation but able to answer questions (4 points)
- Inappropriate words (3 points)
- Incomprehensible speech (2 points)
- No response (1 point)
Motor Response:
- Obeys commands for movement (6 points)
- Purposeful movement to painful stimulus (5 points)
- Withdraws in response (4 points)
- Flexion in response to pain (decorticate posturing) (3 points)
- Extension response in response to pain (decerebrate posturing) (2 points)
- No response (1 point)
The absence of respirations suggests respiratory arrest. Signs of abnormal pupils, decreased Glasgow Coma Scale scores, widening pulse pressure, and bradycardia may indicate increased intracranial pressure. Autonomic dysreflexia is closely associated with skin assessment changes in spinal cord injury patients, sharing symptoms with neurogenic shock. An epidural hematoma represents an emergency that can develop within 24 hours of a head injury.
Nursing Diagnosis and Potential Actions
| Nursing Diagnosis | Assessment Cues | Potential Nursing Actions |
|---|---|---|
| Decreased intracranial adaptive capacity | Reduced level of consciousness, cranial nerve abnormalities | Elevate the head of the bed above 30 degrees, hyperventilate, assist with cerebrospinal fluid catheter insertion and drainage. |
| Altered perfusion | Mean arterial pressure inconsistencies | Administer blood pressure-lowering medications. |
| Impaired airway clearance | Compromised breathing | Reposition the head, neck, and jaw to ensure airway patency; prepare suction equipment and emergency airway supplies. |
| Altered gas exchange | Low oxygen saturation and decreased respiration | Administer oxygen as prescribed; prepare for artificial ventilation. |
The sequence of nursing actions, prioritized from high to low, includes:
- Repositioning the head, neck, and jaw to open the airway.
- Obtaining an airway using emergency equipment if the client cannot breathe independently.
- Initiating artificial ventilation.
- Administering oxygen as prescribed.
- Administering medications to reduce blood pressure.
- Elevating the head of the bed above 30 degrees to aid in decreasing intracranial pressure.
The Arizona Department of Health has allocated a $1 million grant aimed at implementing strategies to reduce spinal cord injuries statewide. Public health nurses should recommend preventative measures that will benefit the largest demographic. Given that one-third of spinal cord injuries occur due to motor vehicle accidents, advocating for enhanced speed reduction strategies and increased seat belt usage would likely impact the greatest number of individuals. In contrast, diving and motorcycle accidents account for only 6% of spinal cord injuries, indicating that while new safety measures may help, they would not affect as many people. The same rationale applies to gun regulation.
Nursing Goals and Actions
| Nursing Goal | Nursing Actions |
|---|---|
| Maintain normal bowel routine | Administer stool softeners as needed. |
| Maintain skin integrity | Use barrier creams, provide bed padding, and ensure frequent sheet changes. |
| Maintain normal nutrition | Monitor daily weights, keep detailed intake and output records, provide dietary consultations, and administer tube feedings as necessary. Albumin levels must remain above 3.5 g/dL. |
| Regulate body temperature | Provide a cooling or warming blanket to maintain a temperature between 97.8ºF and 99.8ºF. |
| Promote mobility and muscle strength | Encourage active or passive range of motion exercises and consult with physical therapy. |
Head Injury Considerations
Head injuries are frequent occurrences in the United States, typically resulting from blunt force trauma due to automobile accidents, falls, workplace injuries, or violence. Cerebral contusions can lead to increased intracranial pressure due to cerebral edema. A basilar skull fracture allows blood and edema to escape outside the skull, whereas a spinal cord injury may cause localized edema but is less likely to elevate intracranial pressure. Scalp lacerations are external injuries that do not penetrate the brain but may indicate underlying blunt force trauma.
Coup-contrecoup injuries occur due to rapid deceleration
forces resulting in brain damage. Traumatic brain injuries can result in significant deficits, including memory impairment and loss of balance. Injury severity is classified using the Glasgow Coma Scale, which provides a reliable assessment of conscious awareness.
Head Injury Assessment and Nursing Considerations
At the scene of the incident, Sally experienced a brief loss of consciousness, after which she regained the ability to communicate without issues. However, within an hour, her condition deteriorated as she became increasingly drowsy and less responsive to inquiries. She vomited once and complained of a headache. Given Sally’s symptoms, an epidural hematoma is the most likely diagnosis. This condition typically presents with a loss of consciousness, followed by a lucid interval, after which the individual’s consciousness declines. Symptoms associated with an epidural hematoma may include headaches, nausea, and vomiting. In contrast, a subdural hematoma usually leads to a gradual decline in consciousness over 24 to 48 hours, while a concussion generally does not involve loss of consciousness. Intraventricular hemorrhage often results in focal neurological symptoms such as paralysis. For any patient with a head injury, a thorough assessment is essential to identify additional factors that might influence the severity of the injury and the challenges related to recovery.
Assessment Factors
To effectively assess a client with a head injury, it is critical to consider the following factors:
| Category | Assessment Factors |
|---|---|
| Past Medical History | – Previous head injuries (old/new symptoms) – Brain hematoma history (risk of rebleeding) – History of cerebral vascular accidents (cerebral edema or abnormal neurologic status) – Ruptured cerebral blood vessels (risk of rebleeding) – Overproduction of cerebrospinal fluid (CSF) or presence of a ventricular peritoneal shunt |
| Past Surgical History | – Brain surgery (potential for aggravation of existing injury or scar tissue) – Spinal surgery (previous abnormalities) |
| Family History | – Seizure history (higher seizure risk with new head injury) |
| Social History | – Prolonged anoxia (comparison with prior assessments) – Risk-taking behaviors (increased risk of reinjury) – History of abuse (possible undisclosed injuries) – Drug addiction (neurological changes due to withdrawal) – Participation in contact sports (risk for post-concussive syndrome) |
| Medication | – Anticoagulants (increased risk for hematomas and complications) – Anti-seizure medications (higher seizure risk in clients with a seizure history) |
The assessment of a client with a head injury should prioritize im