NCM 118: Responses to Alterations/Problems and its

Pathophysiologic Basis in Life-Threatening

Conditions, Acutely Ill/Multi-Organ Problems, High
Acuity and Emergency Situation

Responses of Altered Perception

MARK ANTHONY M. SERGIO, RN MAN

• Perception • Being able to both recognize environmental stimuli and actions in response to these stimuli.
• Altered perception • defined as a change in the amount of patterning of incoming stimuli, accompanied by a
diminished, exaggerated, distorted, or impaired response to such stimuli.

I. ASSESSMENT
• Common complaints:
o Headaches
o Motor disturbances
o Seizures
o Sensory deviations
o Altered level of consciousness (LOC)

Health history
• To collect a thorough health history, gather details about the patient’s current state of health, previous health
status, lifestyle, and family health. Basically, asking for subjective data with the use of your Gordon’s.
1. Current state
• Able to answer appropriately?
2. Previous health
3. Lifestyle
• Diet
• Exercise
• Work environment
4. Family health Information
• Heredofamilial diseases
• Take note: A patient with neurologic impairment may have trouble remembering. If members of the patient’s
family or close friends are available, include them in the assessment process. They may be able to correct the
details of the patient’s health history.

NEUROLOGICAL ASSESSMENT
A. MENTAL STATUS

• Glasgow Coma Scale (GCS) - used to describe the patient’s baseline mental status and detect and
interpret changes in the level of consciousness.

• GCS Score:
o 15- best response
o 8 or less – coma
o 3 – unresponsive
B. SPEECH
• Dysarthria - difficult or unclear speech
Ask the patient to do the following:
o Me me me (to test the lips)
o la-la-la (to test the tongue
o ga ga ga (to test the pharynx)
• Dysphasia - Deficiency in speech or comprehension
1. Receptive aphasia – ask the patient to follow a command (Wernicke’s aphasia); You can hear what people
say or see words on a page, but you have trouble making sense of what they mean.
2. Expressive aphasia (Broca’s aphasia) - you know what you want to say, but you have trouble saying or
writing your thoughts
3. Paraphasia (mild): substitutes a close word for the right one. (e.g. saying “dat” instead of “hat” or
“tephelone” instead of “telephone.”)

C. PUPILLARY REACTION
• Size – the average diameter of the pupil is 3 to 4mm
• Shape – Round
• Equality of the pupils – the pupils are normally equal in size. Difference in pupil size is called anisocoria
• Pupillary reaction to light – normally the pupils constrict briskly when exposed to light; assessment should be
made in darker room to facilitate observing pupillary reaction.
• PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation
D. MOTOR STRENGTH
• Presence or absence of muscle power
• Asking the client to squeeze the hand or fingers or move their legs
• Assessing the patient’s ability to flex or extend the extremities against resistance.

E. SENSORY FUNCTION
• Touch, pain, temperature, and position.

F. CRANIAL NERVE TESTING

• reveals valuable information about the condition of the CNS, especially the brain stem.
• assess both sensory and motor functions
QUICK FACTS:

1. ASSESS THE BRAIN STEM

a. Oculocephalic
• the head is briskly turned from side to side with the head held briefly at the end of each turn.
• Normal: the eyes appear to move opposite to the movement of the hand
• Abnormal response: With an abnormal (doll’s eye) response, the eyes appear to move passively in the same
direction as the head, indicating the absence of reflex.

b. Oculovestibular
• first determine that the patient has an intact tympanic membrane and a clear external ear canal.
• cold water is irrigated into the external ear canal through a small catheter
• Normal: the eyes deviate toward the side being irrigated with cold water
• Abnormal responses: - If the patient is conscious to some degree, there may be nystagmus (involuntary,
rapid movement of the eyeball) with rapid jerking of the eyes away from the side being irrigated.
- In a normal, conscious individual, as little as 10 mL of ice water may produce such a response and may
also cause nausea.
- In a comatose patient with an intact brain stem, the eyes tonically deviate toward the stimulated ear. Absence of
eye movement suggests a brain stem lesion
G. CEREBELLAR FUNCTION
• Coordination and movement
• Proprioception, or kinesthesia, is the sense that lets us perceive the location, movement, and action of parts
of the body
o Moving the toes or fingers up and down or side and asking the patient what position it is in.
o Let patient locate nose, ears, etc. while eyes closed

• Tandem test or heel toe test - Note whether the patient can sit and stand without support. If appropriate,
observe as the patient walks across the room, turns, and walks back.

• Romberg test - evaluate cerebellar synchronization of movement with balance.

o Let patient stand barefooted. Feet together. Hands on the side.
o Note his ability to maintain balance with both eyes open and then closed.
o Positive Romberg’s Test = (+) Cerebellar
Ataxia - Inability to maintain an erect posture over 60 seconds with eyes closed. (Falls in less than 60 seconds)
H. REFLEXES
• are involuntary contraction of muscles or muscle groups in response to a stimulus.
• Classified as Deep Tendon Reflex and Superficial Reflex
b. Superficial Reflex
• Corneal reflex (blink reflex) – touch cornea with cotton swab

• Pharyngeal reflex (gag reflex) - touching the roof of the mouth, the back of the tongue, the area around the
tonsils, the uvula, and the back of the throat; causes the patient to gag (make sure patient did not recently eat since
it may cause vomiting)
• Cremasteric reflex elicited when the inner part of the thigh is stroked. This action causes the testicles to lift
IMAGING STUDIES
1. CT Scan (Computed tomography)
• used to detect brain contusion, brain calcifications, cerebral atrophy, hydrocephalus, inflammation, space-
occupying lesions (tumors, hematomas, edema, and abscesses), and vascular anomalies.
• The images provide cross-sectional views of the brain, distinguishing differences in tissue densities of the
skull, cortex, subcortical structures, and ventricles.

NURSING CONSIDERATIONS:
• Confirm that the patient isn’t allergic to iodine or shellfish.
• A review of relaxation techniques for claustrophobia
• If with contrast medium, tell the patient that it’s injected into an existing I.V. line or that a new line may be inserted
a period of fasting (usually 4 hours) is required prior to the study
• Evaluation of Renal function – due to injection of dye; this needs to be excreted
• Feel flushed or notice a metallic taste in his mouth when the contrast medium is injected. • educating the
patient about the need to lie quietly throughout the procedure.

2. MRI (Magnetic resonance imaging)

• More accurate than CT scan
• provides superior contrast of soft tissues, sharply differentiating healthy, benign, and cancerous tissue and clearly
revealing blood vessels.
• Useful for studying the CNS because it can reveal structural and biochemical abnormalities associated with such
conditions.
NURSING CONSIDERATIONS:
• Confirm that the patient isn’t allergic to the contrast medium.
• If with contrast medium, tell the patient that it’s injected into an existing I.V. line or that a new line may be inserted.
• Tell the patient that procedure may last for 1 ½ hours and must remain still for intervals of 5 to 20 minutes
• Instruct the patient to remove all metallic items.
• Asses for tattoos. Tattoos sometimes have metal particles (like iron) in the ink, which can interact with the
magnetic and radio waves of an MRI and become irritated.
• Explain that the test is painless, but that the machinery may seem loud and frightening and the tunnel
confining.
• Provide sedation, as ordered, to promote relaxation during the test.
• After the procedure, increase the I.V. flow rate, as ordered, or encourage the patient to increase his fluid intake
to flush the contrast medium from his system.

3. PET Scan (positron emission tomography)

• provides colorimetric information about the brain’s metabolic activity.
• used to reveal cerebral dysfunction associated with tumors, seizures, TIA, head trauma, Alzheimer ’s
disease, Parkinson’s disease, MS, and some mental illnesses.
• Can be used to evaluate the effect of drug therapy and neurosurgery.
NURSING CONSIDERATIONS:
• Provide reassurance the scan doesn’t expose the patient to dangerous levels of radiation.
• Explain that insertion of an I.V. catheter may be required.
• Instruct the patient to lie still during the test

4. Cerebral Angiography
• an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery.
• used to determine vessel patency, identify presence of collateral circulation, and provide detail on vascular
anomalies that can be used in planning interventions.

NURSING CONSIDERATIONS:
• Confirm that the patient isn’t allergic to iodine or shellfish
• Preprocedure testing should include evaluation of renal function (GFR) and potential risk of bleeding (PT, aPTT
and platelet count). Notify the practitioner of abnormal results.
• Instruct the patient to lie still during the procedure.
• Explain that he’ll probably feel a flushed sensation in his face as the dye is injected.
• Maintain bed rest.
• Monitor the catheter injection site for signs of bleeding.
• As ordered, keep a sandbag over the injection site.
• Monitor the patient’s peripheral pulse in the arm or leg used for catheter insertion and mark the site of the pulse
for reference.
• Unless contraindicated, encourage the patient to drink more fluids. • Monitor the patient for neurologic
changes.
• Monitor for adverse reactions to the contrast medium, which may include restlessness, tachypnea and
respiratory distress, tachycardia, facial flushing, urticaria, and nausea and vomiting.

OTHER STUDIES:
5. EEG (electroencephalogram)
• It provides an assessment of cerebral electrical activity.
• It is useful for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome. • The EEG is also
used in marking a determination of brain death

NURSING CONSIDERATIONS:
• Explain that a technician applies paste and attaches electrodes to areas of skin on the patient’s head and neck
after these areas have been lightly abraded to ensure good contact. Inform patient that hair might be shaved
for the test.
• Instruct the patient to remain still during the test.
• Discuss what the patient may be asked to do during the test, such as hyperventilating for 3 minutes or
sleeping, depending on the purpose of the EEG.
• After the test, use acetone to remove any remaining paste from the patient’s skin.
6. Lumbar Puncture
• The test may be performed to obtain CSF for examination, to measure and reduce CSF pressure, to
determine the presence or absence of blood in the CSF, and to administer medications intrathecally (into the
spinal canal at the lumbar subarachnoid space)
• The needle is usually inserted into the subarachnoid space between the L3-L4 or L4-L5 (most commonly
used)
7. ICP Monitoring
• Sterile procedure
• neurosurgeon inserts a ventricular catheter or subarachnoid screw through a twist-drill hole created in the
skull. Both devices have built-in transducers that convert ICP to electrical impulses displayed as waveforms,
allowing constant monitoring.
• Normal: Balanced pressure between the cranium and spinal cord
o Range: 0-15 mmHg

NURSING CONSIDERATIONS
• Assess the patient’s clinical status and monitor routine and neurologic vital signs every hour or as ordered.
• Inspect the insertion site at least every 24 hours for redness, swelling, and drainage
• Calculate cerebral perfusion pressure (CPP) hourly.
o To calculate CPP, subtract ICP from mean arterial pressure (MAP).
SBP (systolic blood pressure)
DBP (diastolic blood pressure)
o MAP= SBP+2(DBP)/3
o CPP= ICP-MAP

CRITICAL THINKING! What procedure should NOT be done if ICP is increased? LUMBAR PUNCTURE
• cranium will not adjust, if LP is done, the brain will detect that it’s another exit to decompress= spinal cord may exit
on the LP site or blood or CSF leakage)
• MONITOR ICP before lumbar puncture
MAP= SBP+2(DBP)/3
Example: BP= 102/70mmHg
70x2=140
140+102=242
242/3=80.66 or 81 (normal MAP is between 70 and 100 mmHg)

CPP=MAP-ICP
BP-102/70 ICP=13
81-13=68 (normal CPP 60 to 80 mm Hg)
8. Jugular Venous Oximetry
Jugular venous oximetry is a method of analyzing the balance between oxygen supply and demand to the brain.
The oxygen saturation of blood draining from the brain into the jugular bulb is continuously measured providing an
indirect measure of oxygen extraction by the brain.
Normal jugular venous oxygen saturation (SJVO2) ranges between 60 and 90%. A decline to below 50% is
considered indicative of cerebral ischaemia.
9. Partial Brain Tissue Oxygenation Monitoring
Brain tissue oxygen monitoring is performed in patients with, or at high risk of, cerebral ischemia and/or hypoxia. It
is used for measurement and continuous monitoring of regional brain tissue oxygenation for prevention and
detection of secondary brain injury. Monitoring of brain tissue oxygen provides important information relative to the
delivery of oxygen to cerebral tissue of the injured brain.
10. None-Invasive Transcranial Doppler
Transcranial Doppler (TCD) ultrasound provides rapid, noninvasive, real-time measures of cerebrovascular
function. TCD can be used to measure flow velocity in the basal arteries of the brain to assess relative changes in
flow, diagnose focal vascular stenosis, or to detect embolic signals within these arteries
11. Near Infrared Spectroscopy

NIRS-derived regional cerebral oxygen saturation (rSO 2) is an indirect marker of cerebral venous oxygenation and
has been shown to correlate with jugular bulb venous saturation (SjO 2). Deoxygenated blood and the remaining
oxygen flows through the internal jugular veins to return to the heart. Therefore, the measurement of SjO 2 helps
establish the balance between cerebral blood flow (CBF) and metabolic requirement (CMRO2), giving an indication
of the use of oxygen by the brain. Accordingly, when oxygen demand increases, brain extracts a greater amount of
oxygen, resulting in decreased jugular venous oxygen saturation. NIRS-derived regional tissue oxygen saturation
(green probe) analyzes the oxygen concentration in cerebral microcirculation, which is predominantly from venous
oxygenation. Jugular bulb venous saturation (blue probe) analyzes the remaining oxygen concentration that flows
from the venous sinuses to the internal jugular vein. Both are indirect measurements of how much oxygen is being
used by the brain. Brain tissue oxygenation tension (yellow probe) analyzes the dissolved oxygen within the cerebral
plasma that diffuses across the blood brain barrier (BBB).
COMMON RELATED DISORDERS:
1. SPINAL CORD INJURY
• Caused by trauma from head or neck such as in vehicular and diving accidents, falls, and bullet shot wounds,
less often from tumors within the spinal cord or outside of the cord that compresses it.
• The real danger with spinal injury is spinal cord damage due to cutting, pulling, twisting, and compression. Spinal
cord injury can occur at any level, and the damage it causes may be partial or involve the entire cord.

TYPES OF SPINAL CORD INJURY:

1. Concussion without direct trauma to the cord
2. Compression, contusion, or laceration of the cord
3. Hemorrhage into the cord subs (hematomyelia)
4. Compression of the blood supply to the cord

INCOMPLETE SPINAL CORD INJURY

• the sensory or motor fibers or both are preserved below the lesions
• classifies according to spinal cord damaged: central, lateral, anterior or peripheral
COMPLICATIONS OF SCI
1. Spinal Shock
• Also known as muscular flaccidity
• Loss of function which is inflicted at the time of injury or the loss of autonomic, reflex, motor, and sensory
activity below the level of the cord lesion.
• If there is injury to the lumbar spine, below it, there will be flaccidity

Signs of spinal shock include:

• Flaccid paralysis
• Loss of deep tendon and perianal reflexes
• Loss of motor and sensory function.

MANAGEMENT:
• Maintain your ABCs
• Spinal stabilization
• Rehabilitation

2. Neurogenic shock
• an abnormal vasomotor response that occurs secondary to disruption of sympathetic impulses from the brain
stem to the thoracolumbar area.
• It causes temporary loss of autonomic function below the level of injury and leads to cardiovascular changes
Signs of neurogenic shock include:
• Orthostatic hypotension
• Bradycardia
• inability to sweat below the level of injury

MANAGEMENT:
• maintain ABCs
• treat with atropine for bradycardia
• keep the MAP greater than 80 or 85 for SCI
• treat with fluids for hypotension

3. Autonomic Dysreflexia
• An exaggerated sympathetic response that occurs in clients with T6 injuries or higher
• Response is seen after spinal shock occurs when a stimulus cannot ascend the spinal cord (example:
urge to void or abdominal discomfort)

Symptoms:
• Increased BP
• Pounding headache
• Profuse sweating
• Nasal congestion
• Bradycardia
• Flushed, clammy, goosebumps
MANAGEMENT:
• Elevate HOB and remove offending stimulus
• Assess BP q 2 to 3 minutes while assessing for stimuli that initiated response; remove stimulus
immediately when found.
• With severe hypertension unresolved by removing the offending stimulus, notify the physician and administer
antihypertensive as ordered.

DIAGNOSTIC PROCEDURE FOR SCI:

• Spinal X-rays
• Myelography
• CT scan and MRI
• Neurologic evaluation

MANAGEMENT FOR SCI:

• Immediately stabilize the patient’s spine.
• Perform a neurologic assessment to establish a baseline and continually reassess neurologic status for
changes.
• Assess respiratory status closely (manage ABCs)
• Auscultate breath sounds and check secretions as necessary.
• Monitor oxygen saturation levels.
• Assess cardiac status at least q hour INITIALLY
o If px becomes hypotensive, give vasopressors
• Assess GI status closely for signs of ulceration or bleeding. Be alert for paralytic ileus
o Anticipate use of NG tube for insertion and low intermittent suction for decompression of stomach
o Assess abdominal distention and auscultate for bowel sounds and report if diminished or absent since
paralytic ileus usually happens 72 hours after SCI
• Monitor intake and output for fluid imbalance.
• Insert an indwelling urinary catheter as ordered.
• Begin measures to prevent skin breakdown due to immobilization.
• Repositioning
• Skin and eye care
• Monitor the patient for deep vein thrombosis and pulmonary embolism.
o No massaging of calf or legs
• Begin rehabilitation as soon as possible.

2. CEREBRAL ANEURYSM
• a weakness in the wall of a cerebral artery causes that area of the artery to dilate or bulge.
• The most common form is the berry aneurysm a saclike outpouching in a cerebral artery.

CAUSES
• Congenital defect
• Degenerative process
• Combination of both • Trauma
Types:
✓ Rupture causes a subarachnoid hemorrhage, in which blood spills into the space normally occupied by CSF.
Sometimes blood can spill into brain tissue wherein a clot can cause increased ICP and brain damage
Grading
Severity of symptoms vary from patient to patient depending on the site and amount.

DIAGNOSTIC EXAMS
• Cerebral angiography
• CT scan, CTA, or MRA
• PET scan
• Transcranial doppler sonography
MANAGEMENT: During the initial treatment after hemorrhage, follow these steps:
• Establish and maintain a patent airway.
• Position the patient to promote pulmonary drainage and prevent upper airway obstruction. If intubated,
preoxygenate with 100% oxygen before suctioning.
• Impose aneurysm precautions to minimize the risk of rebleeding and avoid increased ICP.
• Administer a stool softener.
o For unruptured aneurysms, Valsalva maneuver may cause it to rupture
• Monitor LOC and vital signs frequently. Avoid rectal temperatures.
• Determine the CPP.
• Accurately measure intake and output
• Be alert for danger signs that may indicate an enlarging aneurysm:
rebleeding, intracranial clot, increased ICP, or vasospasm, including decreased LOC, unilateral enlarged pupil,
onset or worsening of hemiparesis or motor deficit, increased blood pressure, slowed pulse rate, worsening of
headache or sudden onset of a headache, renewed, or worsened nuchal rigidity, and renewed or persistent
vomiting.
• TTS (turn to sides) q2H to prevent skin breakdown
• If the patient has facial weakness, assist during meals. If he can’t swallow, insert an NG tube, as ordered. Give
all tube feedings slowly.
4. HEAD INJURY
• is any traumatic insult to the brain that causes physical, intellectual, emotional, social, or vocational
changes.
• either open or closed
• Primary injury is defined as the consequence of direct contact to the head/brain during the instant of initial
injury, causing extracranial focal injuries
• Secondary injury evolves over the ensuing hours and days after the initial injury and results from
inadequate delivery of nutrients and oxygen to the cells.
• In children ages 6 months to 2 years (less control of the head, just learned how to walk) and elderly adults
(may be frail and unable to walk without assist) are most at risk for head injury
TYPES:
Concussion
• Characterized as a blow to the head hard enough to make the brain hit the skull, but not hard enough to
cause a cerebral contusion; causes temporary neural dysfunction.
• Recovery is usually complete within 24 to 48 hours.
• Repeated injuries have a cumulative effect on the brain

SIGNS AND SYMPTOMS

• Short-term loss of consciousness
• Vomiting from localized injury and compression
• Anterograde and retrograde amnesia
• Irritability or lethargy from localized injury and compression
• Behavior out of character due to focal injury
• Complaints of dizziness, nausea, or severe headache due to focal injury and compression

DIAGNOSTICS
• Computed tomography (CT) scan or magnetic resonance imaging (MRI)
Contusion
• bruising of brain tissue; more serious than concussion
• It’s most common in 20- to 40-year-olds.
• Most result from arterial bleeding where blood commonly accumulates between skull and dura.
• Blood commonly accumulates between skull and dura.
• Injury to middle meningeal artery in parietotemporal area is most common and is typically accompanied
by linear skull fractures in temporal region over middle meningeal artery.

SIGNS AND SYMPTOMS

• Severe scalp wounds from direct injury
• Labored respiration and loss of consciousness secondary to increased pressure from bruising
• Drowsiness, confusion, disorientation, agitation, or violence from increased intracranial pressure (ICP)
associated with trauma
• Hemiparesis related to interrupted blood flow to the site of injury
• Decorticate or decerebrate posturing from cortical damage or hemispheric dysfunction
• Unequal pupillary response from brain stem involvement
DIAGNOSTICS
• CT scan – show changes in tissue density, possible displacement of surrounding structures, and evidence of
ischemic tissues, hematomas, and fractures
• Lumbar puncture – with CSF analysis may reveal increased pressure in blood, do not perform if ICP is
increased
• EEG recordings – directly over the contusion reveals progressive abnormalities by appearance of high amplitude
theta and delta waves

Epidural hematoma
• Injury is directly beneath the site of impact when the brain rebounds against the skull from the force of a
blow, when the force of the blow drives the brain against the opposite side of the skull, or when the head is
hurled forward and stopped abruptly
• Brain continues moving and slaps against the skull (acceleration), then rebounds (deceleration). Brain may
strike bony prominences inside the skull (especially the sphenoidal ridges), causing intracranial hemorrhage
or hematoma that may result in tentorial herniation.

SIGNS AND SYMPTOMS

• Brief period of unconsciousness followed by a lucid interval varying from 10–15 minutes to hours or, rarely,
days
• Severe headache
• Progressive loss of consciousness
• intracranial hypertension
• Respirations, initially deep and labored, becoming shallow and irregular as brain stem is impacted
• Contralateral motor deficits reflecting compression of corticospinal tracts that pass through the brain stem
• Ipsilateral pupillary dilation
• Seizures possibly from high ICP
• Continued bleeding leading to progressive neurologic degeneration

DIAGNOSTICS
• CT scan or MRI

Subdural Hematoma
• Meningeal hemorrhage results from accumulation of blood in subdural space
• It may be acute, subacute, and chronic: unilateral or bilateral.
• It’s usually associated with torn connecting veins in cerebral cortex; rarely from arteries.

DIAGNOSTICS
• CT scan, X-rays, and arteriography reveal mass and altered blood flow in the area, confirming a hematoma.
• CT scan or MRI reveals evidence of masses and tissue shifting
• Lumbar puncture - CSF is yellow and has relatively low protein (chronic subdural hematoma)
Intracerebral Hemorrhage
• Bleeding within the brain tissue itself
• Traumatic or spontaneous disruption of cerebral vessels in brain parenchyma cause neurologic deficits,
depending on site and amount of bleeding.

SIGNS AND SYMPTOMS

• Unresponsive immediately or experiencing a lucid period before lapsing into a coma
• Possible motor deficits and decorticate or decerebrate responses
DIAGNOSTICS
• CT scan or cerebral arteriography.
• CSF pressure is elevated, and the fluid may appear bloody or xanthochromic (bilirubin in CSF)

Skull Fracture
TYPES:
1. Linear fractures occur when the bone splits, but doesn’t move out of position. Linear fractures tend to heal of
their own accord with proper medical supervision.
2. Depressed (or “ping-pong”) fractures occur when the break forces the skull downward, like an
indentation.
3. Diastatic fractures lie across the line of a skull suture, pushing the bony plates apart. (infant skulls are
vulnerable for this)
4. Basilar fractures are defined by their location. Fracture in the base of the skull. Any break below the
neurocranium fits into this category including fractures in the eyes socket, nose bones, ear bones, or back of the
occipital bones
SIGNS AND SYMPTOMS
• Discontinuity and displacement of bone structure
• Motor sensory and cranial nerve dysfunction
• Racoon’s eyes, anosmia and pupil abnormalities
• CSF rhinorrhea, CSF otorrhea
• Hemotympanum – blood in the ears
• Battle’s sign – bruising at the back of the ear
• Signs of medullary dysfunction
• Halo sign – seen in your CSF, put CSF in a gauze and there will be a halo

MANAGEMENT
• Initially, monitor vital signs and neurologic status
• Maintain a patent airway.
• Assess hemodynamic parameters to aid in evaluating CPP.
• Observe the patient closely for signs of hypoxia or increased ICP,
• Monitor for signs of brain atrophy.
• Carefully observe the patient for CSF leakage.
• Position the patient so that secretions drain properly.
• Monitor intake and output frequently to maintain fluid balance.
• Institute seizure precautions as necessary.
• Prepare the patient for craniotomy as indicated.
• Monitor wounds for signs and symptoms of infection.
• Explain all procedures and treatments to the patient and his family.
• Urge the patient with a cerebral contusion not to cough, sneeze, or blow his nose because these activities can
increase ICP.

TREATMENT
• Evacuation of a hematoma
• Craniotomy
• Cleaning and debridement of any wounds associated with skull fractures
• Diuretics such as mannitol (only diuretic that will cross the brain) and corticosteroids
• Analgesics such as acetaminophen
• Anticonvulsants
• Respiratory support
• Prophylactic antibiotics
5. STROKE
 The main cause of ischemic stroke is atherosclerosis, or fatty deposits (plaque) that line the vessel walls. Fatty
deposits can cause two types of obstruction:
 Cerebral thrombosis is a thrombus (blood clot) that develops at the site of fatty plaque within a blood vessel that
supplies blood to the brain.
 Cerebral embolism is a blood clot that forms in the heart or large arteries of the upper chest or neck, or at
another location in the circulatory system. Part of the blood clot breaks loose, enters the bloodstream and travels
through the brain’s blood vessels until it reaches vessels too small to let it pass. A main cause of embolism is an
irregular heartbeat called atrial fibrillation. It can cause clots to form in the heart, dislodge and travel to the brain.

 Hemorrhagic Stroke results from a weakened vessel that ruptures and bleeds into the surrounding brain. The
blood accumulates and compresses the surrounding brain tissue. The two types of hemorrhagic strokes are
subarachnoid hemorrhage and intracerebral hemorrhage.
Subarachnoid hemorrhage (SAH) occurs when a blood vessel on the surface of the brain ruptures and bleeds into
the space between the brain and the skull. Intracerebral hemorrhage (ICH) occurs when a blood vessel bleeds
into the tissue deep within the brain.
SIGNS AND SYMPTOMS
• Weakness of face and extremities on one side.
• Mental Changes
• Slurring of speech
• Visual disturbance
• Difficulty in walking, dizziness and coordination
• Sudden severe headache

MANAGEMENT:
• Maintain patent airway
• Monitor for cardiac arrythmias
• Anticipate the need for ET intubation and mechanical ventilation
• Monitor LOC frequently (at least every 15 to 30 minutes initially then hourly as indicated)
• Monitor hemodynamic status
• Elevate HOB 25 to 30 degrees or low fowler’s
• Monitor for seizures
o If cerebral edema is suspected, maintain ICP position for adequate cerebral perfusion, but low enough to
avoid your brain herniation
• Give antiplatelets, tissue plasminogen activator (tPA) - it breaks up the blood clots that block blood flow to your
brain. A healthcare provider will inject tPA into a vein in your arm. This type of medicine must be given within 3
hours after stroke symptoms start.
• TTS (turn to sides) q2H
• Anti-embolism stockings or intermittent sequential compression devices
• Passive ROM to prevent muscle atrophies
• Monitor for GI problems – increase fiber diet
• Provide meticulous eye and mouth care
• Maintain communication with patient, if aphasic, set up a simple method of communicating
• Provide psychological support

Mechanical Treatment to Remove the Clot:

A mechanical thrombectomy removes a clot in eligible patients with a large vessel occlusion, or LVO. In this
procedure, doctors use a wire-cage device called a stent retriever. They thread a catheter through an artery in
the groin up to the blocked artery in the brain. The stent opens and grabs the clot. Special suction tubes may
also remove the clot.

The procedure:
• Is usually done within six hours of the onset of acute stroke symptoms but can be done up to 24 hours after
symptoms begin if imaging tests show undamaged brain tissue.
• May include Alteplase IV r-tPA treatment in eligible patients.