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53 Cards in this Set
- Front
- Back
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How do you calculate CPP (Cerebral Perfusion Pressure)?
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CPP = MAP - ICP
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What is CPP (Cerebral Perfusion Pressure) needed for?
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1. Blood flow
2. Oxygen - brain uses 20% of body's O2 |
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What is a normal ICP (Intracranial Pressure)?
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0 - 15 mmHg
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Name the 3 things that affect ICP
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1. Brain
2. Blood 3. CSF |
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Explain the Monroe Kellie Doctorine
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If the volume in any one of the three components increases within the cranial vault and the volume from another component is displaced, the total intracranial volume will not change.
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If the MAP (Mean arterial pressure) drops what happens to the vessels in the brain?
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vasodilate
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If the MAP (mean arterial pressure) increases, what happens to the vessels in the brain?
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vasoconstric (Autoregulation)
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What is the formula for calculating MAP (mean arterial pressure)?
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MAP = SBP + (2 X DBP) / 3
120/80 120 + (2 X 80) / 3 = 93 |
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What is the normal pressure of CPP (cerebral perfusion pressure)?
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70-100 mmHg
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What occurs when the CPP (cerebral perfusion pressure) drops below 50 mmHg?
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ischemia, cell death
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What occurs when the CPP (cerebral perfusion pressure) drops below 30 mmHg?
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not compatible with life
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What is a normal MAP (mean arterial pressure)?
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>= 90
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Name 4 devices to measure ICP (intracranial pressure).
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1. Ventricular Catheter - drains CSF directly from the ventricle
2. Intraparenchymal (Lycox) - placed into the brain tissue 3. Subarachnoid bolt - drains CSF between the arachnoid and dural space 4. Epidural catheter - threaded into the epidural space (lease invasive, less chance of infection) A patient will usually have 2 of the above. Ventricular and intraparenchymal. |
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An intraventricular drain must be level with what body part?
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the patient's ear
if too high, CSF will drain back into the brain. If too low, CSF will drain too fast |
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If a patient has a Low MAP what 2 things should you consider?
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1. Volume status
2. Effectiveness of contractility |
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If a patient has a High ICP what 2 things should you consider?
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1. Swelling
2. Metabolism / O2 consumption |
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MAP = 96
ICP = 10 CPP = 86 Is the problem MAP or ICP? |
Neither, both are within normal limits
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MAP = 96
ICP = 30 CPP = 66 What's the problem? |
Increased ICP - does the patient have swelling or a metabolism / O2 consumption problem?
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MAP = 80
ICP = 15 CPP = 65 What is the issue? |
Low MAP = check patient's volume status and contractility
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Osmolality normal range is?
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270 - 295
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An osmolality > 295 means what?
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Hypovolemic
There are more particles than plasma "the higher, the dryer" |
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How do you treat a patient with a low volume/low MAP?
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Give volume! duh
Hespan - volume expander Bolus of fluid |
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List 2 interventions to reduce swelling, when treating High ICP
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1. Give Osmotic Diuretic - Mannitol
2. Drain CSF |
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What medications can be given when there is a metabolism issue associated with High ICP?
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Morphine / Ativan
Neuromuscular blockers Barbiturates |
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Evaluating CCP
CPP = MAP - ICP MAP - ICP (80-15) = CPP of 65 1. Is the PROBLEM MAP or ICP? 2. What is the VOLUME STATUS? -CVP 6, UO 100mL past 2 hrs, OSMO 275 |
1. MAP low, ICP normal...MAP is the problem.
2. Volume status is within normal limits. CONTRACTILITY PROBLEM. Start Vasopressor like Dopamine. |
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Another CCP problem...
MAP 80 ICP 15 CPP? Is the problem MAP or ICP? What is the volume status? CVP 2, UO 20mL past 2 hrs, Osmo 320, Na 147, BUN 28. What to do??? |
CPP = 65
Problem is MAP CVP (2) low, normal is 0-2 UO is low, should be 30mL/hr Osmo is high, normal 270-295 Na is high, normal 135-145 BUN is high, normal is 8-18 Volume issue, need to give 250 NS. Pt is dehydrated |
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Evaluating CPP...
Your MAP is normal Your ICP is High Check the volume... CVP 6; UO 60mL past 2hrs, Osmo 280. What to do? |
Increased ICP be from swelling or increased metabolism/O2 consumption...
The volume levels are all normal... Give Mannitol...this will drain CSF If the hydration status is adequate, it's ok to dehydrate a little. |
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Evaluating CPP...
Normal MAP High ICP Volume status? CVP 1; UO 20mL past 2 hours, Osmo 320. What to do? |
Drain CSF...maybe give sedative to decrease metabolism if restless (could drop MAP)
*don't give a diuretic, could increase the pressure |
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What do; mass lesions, head injuries, brain surgery, cerebral infections, vascular insults (cva), and toxic or metabolic encephalopathies have in common?
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They all cause Cerebral Edema (Increased ICP)
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What are the 3 sections of the Glasgow Coma Scale?
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1. Eyes Open
2. Best Verbal Response 3. Best Motor Response |
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What is the highest possible score on the Glasgow Coma Scale?
Is this good or bad? Why? |
Highest score is 15
Good Means your eyes open spontaniously, A&Ox3 and conversant, and obey motor commands. |
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At what score on the Glascow Coma Scale would you be considered in a coma?
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GCS of 8 or less
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Define coma...
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Inability to speak, obey commands or open eyes when a verbal or painful stimulus is applied.
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What signs would you observe with CN 3 compression?
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1. An ipsilateral (same-side) reaction
2. Sluggish 3. One pupil larger than the other 4. Full dilation **This is a surgical emergency! |
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The previous nurse charted "pt Dolls Eyes present" ... What does this mean?
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When the patient's head is turned the pupils don't move in the opposite direction.
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Your patient presents with ipsilateral dilation and/or contralateral motor weakness. Which surgical emergency does this describe?
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Herniation
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True or False
When assessing for pronator drift that patient's eyes remain open and keeps the palms of his hands down. |
FALSE!!
Eyes closed, palms up, if the drift, you crazy fool. :-) |
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Your patient is laying in bed with her arms twisted outward and feet extended. Which posturing position does this describe?
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Decerebrate.
*When the hands are turned out they look like "E"...lots of "E's" in decerebrate. |
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What does a decorticate posture look like?
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The arms are bend towards the "cor", feet flexed.
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Which posture would indicate a more serious damage: decorticate posturing or decerebrate posturing?
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Decerebrate posture may be indicative of a more serious damange to the mid-brain.
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What are the 3 sections of Cushing's Triad?
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1. Increased Systolic BP with Widening Pulse Pressure
2. Slow bounding heart rate 3. Irregular respiratory pattern |
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What is meant by "Widening Pulse Pressure?
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When the difference between Systolic and Diastolic pressure increase
ie: 120/80 = PP of 40; 180/80 = PP of 100 (bad) |
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Collaborative Management for Altered Cerebral Perfusion includes.... (choose all that apply)
1. Maintain patent airway (possible intubation) 2. Prevent hypoxia / hypercapnea 3. ABG Goals: 100% and PCO2 35-45 4. Suction secretions 5. NG tube to prevent abdominal distention 6. Treat pain, anxiety, and fear with Morphine, Ativan, Diprivan...Neuromuscular blockade |
All are correct. I'm not clever enough to make any up.
2. You want to prevent hypoxia / hypercapnia because too much H+ ions will increase blood flow to the brain causing swelling (secondary damage) |
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Why would you try to prevent hypercapnia in your patient with increased ICP?
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Increased pCO2 -->respiratory acidosis -->produces increased H+ ions -->vasodilation. The brain is already swollen, it can't accommodate dilated blood vessels too.
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Why maintain PaO2 of 100%?
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1. Provides O2 at the cellular level
2. Helps meet the brain's metabolic demands |
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What independent interventions could you do for your patient with Altered Cerebral Perfusion related to IICP?
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1. Cluster / Limit your care activities. Don't go in and out of the room several times.
2. Provide a quiet, non-stimulating environment. Keep the lights dim, decrease noise. |
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The doctor orders Mannitol for your patient with IICP. Why?
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Mannitol is an Osmotic Diuretic. It decreases ICP in two ways.
1. Initially there is a plasma-expanding effect that reduces the Hct and blood viscosity, thereby increasing CBF and cerebral oxygen delivery. 2. A vascular osmotic gradient is created that moves fluid from the tissues into the blood vessels. ICP is reduced by a decrese in the total brain fluid content. **Fluid and electrolyte status must be monitored when osmotic diuretics are used. Mannitol may be contraindicated if renal disease is present and if serum osmolality is elevated* |
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The MD orders a barbiturate medication for your patient. What would you observe on an EEG?
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Barbiturates are a last effort medication for the patient with IICP. They will cause flattened wave forms on an EEG.
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Your patient has an order for a stool softener. Is it a good idea to administer it?
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HELL YEAH!!!
You don't want the patient to strain. |
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Which is better for your patient regarding nutrition: enteral or parenteral feedings?
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Enteral feedings are absorbed better by the body and there is a decreased risk for infection.
Parenteral feedings have an increased risk for infection because of the high levels of glucose. You also would need to change the tubing daily. Who has time for all that? Seriously :-) |
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The patient with increased ICP is in a hypermetabolic state that increases his/her needs for glucose to provide the necessary fuel for metabolism of the injured brain. How soon should nutritional replacement begin and how much?
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Enteral or Parenteral feedings should begin within 3 days of injury. Replace 140% of nutritional needs. Maintain normovolemia.
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Your patient has an increased urinary output related to a decrease in antidiuretic hormone secretion and could potentially become dehydrated. What's wrong? What to do?
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Diabetes Insipidus.
You'd want to replace fluids to maintain an equal intake and output |
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Your patient has SIADH (syndrome of inappropriate antidiuretic hormone). What is this doing to his urine output and sodium levels?
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SIADH causes a decreased urine output; therefore diluting all elect
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