Rafael Joseph P.

Lardizabal April 27, 2020

NCENH04 NCB

1. Explain the physiological mechanism that maintain normal intracranial pressure.

The rigid cranial vault contains brain tissue this is 1,400 grams, blood that is seventy five
mL, and Cerebro Spinal Fluid this is 75 mL. The quantity and pressure of these three additives
are normally in a state of equilibrium and convey the Intra Cranial Pressure (ICP). Intra Cranial
Pressure is typically measured within the lateral ventricles; Normal Intra Cranial Pressure is 10
to twenty mmHG. Increased Intra Cranial Pressure is a syndrome that affects many patients
with acute neurologic conditions. This is due to the pathologic situations that regulate the
relationship among intracranial extent and strain. Although the improved intracranial strain is
most usually related to head injury, it also can be visible as a secondary effect in other
conditions. Increased intracranial pressure from any motive decreases cerebral perfusion,
stimulates further swelling or edema and shifts brain tissue via openings in the rigid dura,
resulting in herniation, a horrible, regularly fatal event.
As brain tissue swells in the rigid skull, numerous mechanisms attempt to catch up
on the growing intracranial pressure. These
mechanisms encompass auto regulation and decrease the manufacturing flow and waft or
pause cerebrospinal fluid. Auto regulation refers to the brain's capacity to alternate the diameter
of its blood vessels routinely and automatically and to maintain a consistent cerebral
blood drift during changes in systemic blood pressure
As Intra Cranial Pressure rises, compensatory mechanisms within the brain work to
preserve blood flow and prevent tissue damage. The brain can maintain a consistent perfusion
pressure when the arterial systolic blood stress is fifty to one hundred fifty mmHg and intra
cranial pressure as much less than forty mmHg. The cerebral perfusion stress is calculated with
the aid of subtracting the intra cranial strain from the mean and arterial pressure. As Intra
Cranial Pressure rises, however, and the automobile regulatory mechanism of the mind is
overwhelmed, cerebral perfusion stress can rise to extra than one hundred mmHg or fall to
much less than fifty mmHg. A medical phenomenon regarded as "Cushing's response" or
Cushing;s reflex is visible whilst cerebral blood flow decreases significantly. When ischemic, the
vasomotor center triggers an upward thrust in arterial strain in an effort to conquer the improved
intra cranial pressure. A sympathetically mediated response reasons a rise in the systolic blood
stress with a widening of the pulse pressure and cardiac slowing. This response, which is
mediated by means of the sympathetic nervous system, is seen clinically as a rise in systolic
blood pressure, widening of the pulse pressure, and reflex slowing of the coronary heart rate.
At a sure quantity or pressure, the brain's capacity to auto regulate becomes ineffective
and decomposition begins. When this occurs, the affected person exhibits considerable
changes in mental status and vital signs. Bradycardia, hypertension, and bradypnea associated
with this deterioration or decline are referred to as Cushing's triad, a serious, dire sign. At this
point, herniation of the mind stem and occlusion of the cerebral blood flow occur if therapeutic
intervention isn't always initiated. Herniation refers to the transferring of brain tissue from an
area of excessive strain to a place of lower stress
The herniated tissue exerts strain at the brain region to which it has herniated or shifted,
interfering with the blood that deliver in that location. Cessation of cerebral blood flow
consequences in cerebral ischemia and infarction and brain death
2. Describe the common etiologies, clinical manifestations and collaborative care of the
patient with increased intracranial pressure

The common etiologies are:

1. Infections- Some examples of infections that cause increase in intra cranial pressure are:

a. Encephalitis is an acute inflammation of the brain typically resulting from both a viral
infection or because of the body's own immune machine mistakenly attacking the brain tissue.

b. Meningitis is a contamination of the membranes that protect the spinal cord and brain.
When the membranes end up infected, they swell and press at the spinal cord or brain. This can
reason life-threatening problems. Meningitis symptoms strike all of sudden and worsen quickly.

2. Tumors- Cancers that spread from the lungs, skin, breast or other parts of the body are more
likely to cause increased Intra Cranial Pressure. Increased ICP can also develop if
other cancers or their treatments cause an obstruction in CSF pathways, leading to CSF not
flowing normally,

3. Stroke- An example is a hemorrhagic stroke this is when blood from an artery starts bleeding

into the brain. This happens whilst a weakened blood vessel bursts and bleeds into the
encompassing brain. Pressure from the leaked blood damages brains cells, and, as a result, the
damaged area is not able to work properly.

4. Brain aneurysm- Is a bulge or ballooning in a blood vessel inside the brain. It often looks as if
a berry is on a stem. A brain aneurysm can leak or rupture, inflicting bleeding into the brain

5. Seizures- Seizures in general, increase ICP temporarily in patients who are undergoing

invasive EEG monitoring with subdural grids

6. Hydrocephalus- Is the accumulation of cerebrospinal fluid in the brain cavities

7. Hypertensive brain injury- Is when uncontrolled high blood pressure leads to bleeding in the
brain

8. Hypoxemia- Is a deficiency of oxygen in the blood

Clinical manifestations:

-Impaired neural functions, clinical changes in LOC and then followed by abnormal respiratory
and vasomotor responses.
-Restlessness, confusion, or increasing drowsiness, lead to neurologic significances. These
maybe from the compression of the brain due to the swelling of a hemorrhage or edema.
-Patient becomes stuporous, at this point serious problems in the brain are arising. As
neurologic function continues to lower, the patient may become comatose and might exhibit
abnormal motor responses (decortication decerebrations or flaccidity) Dilated pupils, coma and
respirations, this may lead to death.
Collaborative care:

1. Monitoring ICP
-The purposes of intra cranial pressure monitoring are to pick out increased pressure early in its
course (earlier than cerebral harm occurs) to quantify the degree of elevation, to
initiate right treatment, to gain access to CSF for sampling and drainage, and to assess the
effectiveness of the treatment rendered.

a. A ventriculostomy (ventric) is a device that drains surplus of cerebrospinal fluid from

the head. It is likewise used to degree the pressure in the head referred to as intracranial
pressure. The device is made up of a small tube, drainage bag, and monitor. It is a
neurosurgical process that involves making a hole within a cerebral ventricle for drainage. It is
most normally done on those with hydrocephalus. It is executed through surgically penetrating
the skull, dura mater, and mind such that the ventricle of the brain is accessed.

b. The subarachnoid bolt has been used considerably and for the purpose to reveal
intracranial strain in numerous conditions. It is based on a hollow screw inside the skull whose
tip projects via the dura into the subarachnoid space. Pressure is monitored isovolumetrically by
way of connecting the screw to a transducer.

c. An epidural monitor uses a pneumonic glide sensor that functions on a nonelectrical

basis. This pneumatic epidural ICP monitoring system has a low incidence of contamination or
infection and problems or difficulties and appears to examine pressures accurately. One
downside of the epidural catheter is the incapability to withdraw CSF for analysis
d. A fiber optic monitor, or transducer-tipped catheter, is turning into a extensively used
alternative to traditional intraventricular, subarachnoid, and subdural systems. The miniature
transducer reflects stress changes, which can be converted to electrical signals in an amplifier
and displayed on a virtual monitor. This catheter may be inserted into the ventricle,
subarachnoid space, subdural space, or mind parenchyma or underneath a bone flap. If
inserted into the ventricle, it may additionally be used alongside a CSF drainage device.
2. Decreasing cerebral edema
Osmotic diuretics are given to dehydrate the brain tissue and reduce cerebral edema.
They act by way of drawing water throughout intact membranes, thereby lowering the extent of
brain and extracellular fluid. An indwelling urinary catheter is typically inserted to screen urinary
output and to control the resulting diuresis, An affected person receiving osmotic diuretics,
serum osmolality need to be determined to asses hydration status, Corticosteroids help reduce
the edema surrounding brain tumors while a brain tumor is the motive of expanded ICP.
Another approach for decreasing cerebral edema is restricting fluid intake. Lowering
body temperature will lower cerebral edema, reduce oxygen and metabolic necessities of the
brain, and protect the mind from continued ischemia. If body metabolism can be reduced via
decreasing body temperature the collateral circulation in the brain may be able to provide okay
blood deliver to the brain
3. Maintaining Cerebral Perfusion
The cardiac output can be manipulated to offer adequate perfusion to the brain.
Improvements in cardiac output are made to the usage of fluid extent and inotropic agents
inclusive of dobutamine hydrochloride. The effectiveness of every cardiac output is reflected
within the cerebral perfusion pressure, which is maintained at extra than seventy mmHg. A
decreased cerebral perfusion pressure indicates that the cardiac output is inadequate to
preserve okay cerebral perfusion
4. Reducing CSF and intracranial blood volume
CSF drainage is often performed because the elimination of CSF with a ventriculostomy
drain may also dramatically reduce ICP and restore cerebral perfusion pressure, Excessive
drainage may additionally end result to crumble of the ventricles, when not practiced with
caution. Reduction of PaCO2 may bring about hypoxia, ischemia, and a growth in cerebral
lactate level. Maintaining the PaCO2 at 30-35 mmHg can be beneficial. Hyperventilation is
indicated in patients whose ICP is unresponsive to standard therapies.
5. Controlling fever
Preventing a temperature elevation is vital due to the fact that fever will increase
cerebral metabolism and the rate at which cerebral edema forms.
Strategies to reduce temperature are: administration of antipyretic medications, as
prescribed and use of a cooling blanket. The patient's temperature is monitored closely because
shivering can also cause increase ICP
6. Maintaining oxygenation
Arterial blood gases ought to be monitored to make sure that systemic
oxygenation stays optimal. Hemoglobin saturation can also be optimized to offer oxygen
more efficaciously at the mobile level.
7. Reducing Metabolic Demands
Cellular metabolic needs can be reduced thru the management of high doses of
barbiturates whilst the affected person is unresponsive to traditional treatment. Barbiturates are
central nervous depressants. They reduce the activity of nerves causing muscle relaxation.
They can lessen breathing, heart rate, and blood pressure. All barbiturates affect gamma-
aminobutyric acid (GABA), a neurotransmitter (chemical) that nerves use to speak with one
another.
Pentobarbital, thiopental, and propofol are most common high dose barbiturate therapy
Administration of pharmacologic paralyzing agents. These patients can't move,
therefore, lowering metabolic needs and resulting in a decrease in cerebral oxygen demand.
Although paralyzed, sufferers are unable to report feelings, so, sedation and analgesia are
given.
Patients who're being given excessive doses or barbiturates and/or pharmacologic
paralyzing agents should be monitored continuously.
 Some serial neurologic assessments on the patients are incapability to do because of
using barbiturates or paralyzing agents, so other monitoring gear or tools are used like ICP,
blood pressure, Respiratory charge, Heart charge and response to ventilator therapy.
8. Trends in neurologic monitoring
Cerebral tracking is the measurements of venous oxygen saturation in the jugular bulb.
Venous jugular desaturations can mirror early cerebral ischemia, alerting the clinician previous
to a rice in ICP.
3. Describe the collaborative and nursing management care of the patient with increased
intracranial pressure.

1. Maintaining a patent airway

The patency of the airway is assessed. Secretions obstructing the airway ought to be suctioned
with care, because brief elevations of Intra Cranial Pressure occur with suctioning. The affected
person is hyperoxygenated before and after suctioning to keep good oxygenation.
Hypoxia resulting from bad oxygenation results in cerebral ischemia and edema. Coughing is
discouraged because it is able to strain that also ends in increase in Intra Cranial Pressure. The
lung fields are auscultated at least every eight hours to determine the presence of adventitious
sounds or any areas of congestion. Position the affected person and elevate the head of
the bed may aid in clearing the secretions and as well as enhancing the drainage of the brain
2. Achieving an adequate breathing pattern
An affected person should be monitored constantly for breathing irregularities. Increased strain
on the frontal lobe or deep mid-line parts may result in Cheyne-Stokes respiration, and strain
within the mid brain may motive hyperventilation. If hyperventilation therapy is considered
suitable to lower ICP, the nurse collaborates with the respiratory therapist in tracking the PaCO2
of the patient. Repeated assessments of the affected person are made so that development or
deterioration may be noted immediately. If affected person's situation deteriorates, put together
for surgical interventions.
3. Optimizing cerebral tissue perfusion
Proper positioning enables to reduce ICP. The elevation of the head of the bed is from 0-60
degrees to useful resource in venous drainage unless otherwise prescribed. Flexion, extension
or intense movements of the neck are avoided due to the fact compression or distortion of the
jugular veins will increase ICP, also severe hip flexion or movements are averted because it
causes increase in intra-abdominal and intra thoracic pressures that may lead to elevation of
ICP. Do now that to not do valsalva maneuver too because it may lead to increase in ICP. Stool
softeners are given. Emotional pressure and common arousal from sleep are averted. A calm
environment and surrounding is maintained. Other environmental stimuli that may lead to
elevation in ICP are kept at a minimal.
4. Maintaining negative fluid balance
The administration of various osmotic and loop diuretics is a part of the remedy to lessen ICP.
Corticosteroids are used to reduce cerebral edema, and fluid restriction Skin turgor, mucous
membranes, and serum and urine osmolality are monitored to assess fluid status. If fluid are
given via intravenously, the drops ought to be gradual and with an intravenous pump to save
you from fast administration and to avoid over hydration. For patients who're undergoing
dehydrating procedures, the nurse ought to screen the essential symptoms and check fluid
extent status. An indwelling urinary catheter is likewise inserted to allow evaluation of the renal
function and fluid status. Careful oral care should be completed too, because it not applying this,
this may cause dehydration. Frequent mouth rinsing, lips lubrication can also help promote
comfort.
5. Preventing infection
When ICP is increased, risk for infection is greatest when monitored via intraventricular
catheter. The dressing over the ventricular catheter must be kept dry because we all know
something that is wet can attract bacteria and is conducive for bacterial growth. Aseptic
technique should always be followed when handling and changing these types of tubes. The
nurse should also monitor the catheter because leaks can lead show loose connections and
may lead to contamination.

6. Monitoring and managing potential complications

Brain herniation is the primary complication of increased ICP, and this may lead to death. Our
nursing management should be focused in discovering early sings of increasing ICP because
medical interventions or managements are usually profitless once later signs and symptoms
develop.

7. Detecting early indications of increasing ICP

The nurse should assess and not hesitantly report the following signs and symptoms
Disorientation, restlessness, increased respiratory effort, weak movements and mental
confusion, because these are the early signs of elevating ICP. Pupillary changes and impaired
extraocular movements may also change due to the brain cells being abstracted by the increase
of ICP. Weakness in one side of the body occurs because of increasing ICP compresses the
pyramidal tracts. Constant headache that increases in intensity and is aggravated when moving
occurs too because of venous and arterial vessels of the brain are being moved by the increase
in ICP
8. Detecting Later signs of increased ICP
LOC continues to deteriorate or lower or movements becomes less. Bradypnea and
Bradycardia arise, as to hypertention and hyperthermia. Altered respiratory patterns then later
develop, including Cheyne-Stokes breathing. This is a rhythmic waxing and waning of rate and
depth of respirations with brief periods or apnea. Vomiting may also be a problem. And loss of
brain stem reflexes with pupillary, corneal, gag and swallowing reflexes become an ominous
sign

9. Monitoring ICP
ICP monitoring is closely monitoring for continuous elevation or significant rise over the
baseline. Vital signs are assessed when ICP increase is noted. Strict aseptic technique is
always used when touching or handling or moving any part of the monitoring system. Plus, the
insertion site is inspected for signs of infection. The connections from the monitor to the patient
are all checked for leaks. Whenever technology is associated with patient management or care,
the nurse or any medical worker must be certain that the technology used is functioning well
and proper. Informed consent or proper information to the family of the patient should be given
in full detail on what the technology is for and for its goals. Keen observations should always be
done.

10. Monitoring for secondary Complications

The nurse should also assess for complications like diabetes insipidus and SIADH. Input and
output should be closely monitored. When one of these arises, the nurse should do preventive
or assistive measures like fluid replacement for diabetes insipidus and for SIADH, fluid
restriction.
4. Differentiate types of head injury by mechanism of injury and clinical manifestations

TYPE OF BRAIN INJURY MECHANISM OF INJURY CLINICAL

MANIFESTATIONS
1. CONCUSSION Direct impact or hit to the Headache, loss of memory
Head injury that has a head is the most common. A and confusion
temporary loss of neurologic ball thrown at you, or an If the frontal love, brain tissue
function with no usual object that is in motion or is affected or hit, the patient
structural damage to the when you hit your head in the might exhibit weird or bizarre
brain wall or fall on the ground. irrational behaviors, therefore
Direct hit or a blast injury may lead to temporary
Blunt injury amnesia or disorientation
Grade 1 Concussion Blunt Injury -Transient confusion, no loss
of consciousness, mental
status problems resolve in
not less than 15 minutes
Grade 2 Concussion Blunt Injury -Transient Confusion, mental
status last more than 15
Grade 3 Concussion Blunt Injury minutes
-Loss of consciousness
lasting from seconds to
minutes
2. CONTUSION Severe acceleration- Loss of consciousness with
Moderate to severe head deceleration force. Speeding stupor and confusion.
injury, brain is bruised and car with sudden stop. Soreness, Persistent
damaged. Usually located in Blunt trauma Headache, Nausea and
the anterior part of the head Vomiting, convulsions or
in the frontal and temporal seizures, Dilation of one or
lobes, near the or around the both of the eyes. Neurologic
sylvian fissure, usually orbital deficit without hematoma
areas. formation, hemorrhage into
the tissue that varies in size
surrounding the edema.
Hemorrhage and edema
usually peak after or from
eight teen to thirty-six hours.
Temporal contusions are
always or more often
associated with hemorrhage
and destruction or destroying
of the reticular activating
fibers altering arousal
3. Diffuse Axonal Injury(DAI) Traumatic brain injury. Disorientation or
It occurs while the brain Prolonged traumatic coma. confusion, headache, nausea
unexpectedly shifts in the Usually after a motor vehicle or vomiting, drowsiness or
skull as a harm or injury is crash fatigue, trouble sleeping,
occurring. Widespread sleeping longer than normal,
shearing and rotational forces loss of balance or dizziness.
that produce harm all through
the brain to axons in the
cerebral hemispheres, copus
callosum and mind stem. The
mind is sheared as the hastily
and speeds up and slows
down within the hard bone of
the cranium or skull

4. Intracranial Hemorrhage Physical trauma or head Clinical manifestations

Takes place when a blood injury. Blunt injury. Bleeding depend on which vital areas
vessel in the cranium is inside the head or skull were affected and how and
ruptured or leak. Rapidly where the head was injured
developing hematoma can be Sudden weakness, tingling,
fatal, even if it is small. or paralysis in the face, arm,
or leg, severe headache,
trouble swallowing, trouble
with vision in one or both
eyes, loss of balance and
coordination, dizziness.
A. Epidural Hematoma Physical trauma or head Restless, agitated, and
It is bleeding that occur in injury. Blunt injury. Bleeding confused then becomes
the distance between tough inside the head or skull coma. Suddenly, signs of
outer membrane protecting herniation appear, dilation or
the brain or dura mater and a pupil or paralysis of an
the skull that causes a extremity.
rupture in the middle
meningeal artery.
B. Subdural Hematoma Blunt trauma.  Headache, nausea,
It is bleeding that occur in confusion, personality
the distance the dura and the change, decreased level of
brain. Caused by a rupture of consciousness, speech
small vessels that connect
difficulties, change in
the subdural space. Some
subdural hematomas stop mental status, impaired
and resolve spontaneously, vision or double vision.
others require surgical
drainage
-Acute Subdural Hematoma Blunt injury from contusions. Headache, nausea,
Are less than 72 hours confusion, weakness,
old and are hyperdense seizures, and incontinence.
compared with the brain on Hemiparesis and decreased
computed tomography scans level of consciousness are
. common
-Subacute Subdural Blunt injury from contusions.
Hematoma
The subacute phase begins
3-7 days after acute injury
-Chronic Subdural Minor head injury, Blunt Headaches, nausea,
Hematoma trauma vomiting, trouble walking,
Develop over the course of impaired memory,
weeks and are problems with vision,
hypodense compared with seizures, trouble with
the brain. Most frequent in speech.
older adults due to brain
atropy—Aging.

C. Intracerebral Hemorrhage Increase blood flow in the  Sudden

Bleeding in the brain itself tingling, weakness,
parenchyma of the brain. numbness, paralysis,
Caused by bleeding within severe headache, difficulty
the brain tissue itself. with swallowing or vision,
Somehow related to or is loss of balance, difficulty
associated to stroke. understanding, speaking,
reading, or writing, and a
C. Intracerebral Hematoma Penetrating trauma. Gun change in LOC, stupor,
Common in brain injuries shot, stab or penetration of a lethargy, sleepiness, or coma
that is when force is exerted sharp object.
to the head.
5. Describe the collaborative and nursing care and nursing management of the patient
with a head injury.
Treatment of head injury includes: seizure prevention, ventilatory support, fluid and electrolyte
maintenance, pain and anxiety management and nutritional support.
The nursing interventions or nursing managements for a patient who experienced a head injury
are extensive and diverse, priorities are set for nursing interventions depending on the type of
head injury, anticipating and giving of needs and assessing for complications and initiating or
giving rehabilitation

1. Monitor the neurologic functions. Regularly assess the level of consciousness because
change level of consciousness changes mean that there are other changes in the vital signs
and neurologic signs. Glasgow Coma Scale is used to asses LOC, based on the criteria for eye
opening, verbal responses and motor responses to verbal and nonverbal commands and
physical stimuli. In addition to the Glasgow Coma Scale, The size and equality and reaction to
light are also assessed, because a pupil that is poorly responding may indicate hematoma, and
if two pupils are fixed dilated, this may indicate serious damage to the brain stem. These are
checked because the patient with a head injury may develop abnormalities and focal neurologic
deficits like: aphasia, memory loss, seizures and epilepsy.
2. Changes in LOC are an indicative sign for deterioration in a patient with a head injury,
monitoring of vital signs are still important to assess the intracranial status. Checking of vital
signs is important because the patient may experience: bradycardia, increase in systolic blood
pressure, widening of pule pressure. When brain compression happens, rapid respirations may
occur and lowering of the blood pressure and the pulse will gradually slow. Checking of the
temperature is vital because hyperthermia increases the metabolic needs of the brain and may
indicate brain damage. Tachycardia and arterial hypotension shows that there is bleeding in a
different part of the body
3. Motor function is also checked by frequently or from time to time checking the patient's
movements, the ability of the patient to raise and lower the extremities, the strength of hand
gripping and pedal push at periodic intervals. If the patient doesn't show good or positive
outcomes about these, the patient is then assessed through a painful physical stimuli. Abnormal
responses of the motor aspects of the patient may be associated to poor prognosis
4. One of the most important nursing interventions or goals in facing a patient that has or had a
brain injury is maintaining and adequate airway, because hypoxia may lead to neurologic deficit.
Keep an unconscious patient with the head elevated about 30 degrees to facilitate in drainage
of secretions. Suctioning is also done, monitoring of arterial blood gases to assess ventilation,
monitor for pulmonary complications such as acute respiratory distress syndrome and/or
pneumonia
5. Head injury that follows a brain injury may increase in metabolic and hormonal dysfunctions.
Monitoring of serum electrolyte levels are important most especially in patients having osmotic
diuretics. Head injuries may be accompanied by problems in sodium regulation so the blood and
urine electrolytes and osmolality are checked. A record of daily weight is maintained.
6. Adequate nutrition is promoted because a head injury results in increase in calorie
consumption and nitrogen excretions, protein is what the body looks for following a head injury.
And give nutritional therapy because it showed that outcomes of head injuries are improved.
Usually, parenteral nutrition or enteral feedings are administered via nasogastric tube or
nasojejunal tube.
7. Providing comfort for a patient that had a head injury in vital because providing comfort can
help ease what the patient is feeling. Also, the nurse should assess the patient's oxygenation,
and bladder should not be distended. Avoid using opioids as means controlling restlessness
because these medications may lower respiration and constrict the pupils and may lead to
unresponsiveness. Nurses should also minimize environmental stimuli through keeping the
room at with minimal noise and limiting visitors to promote comfort. Provide adequate lighting
because too much or no light might lead to visual hallucinations. Minimize disruption when
patient is asleep. Bed bath and moisturize the patient so the patient’s skin doesn't get irritated.
We should also maintain skin integrity. We should turn the patient every 2 hours and provide
skin care every 4 hours
8. Always maintain a good body temperature and check for other signs and symptoms because
a head injury sometimes may lead to the damage of the hypothalamus, irritation from the
hemorrhage or infection. The temperature is assessed or checked every four hours. When
temperature rises, acetaminophen is given or cooling blankets as prescribed. If an infection
arises, antibiotics are given.
Early teaching usually focuses on reinforcing information given to the family or relatives about
the patient's condition or problem and prognosis. As the patient's status and expected
outcomes can change over time, family teaching may focus on interpretation and explanation of
changes in patient’s physical and psychological needs or responses. If the patient is able to go
home, health teaching will mostly focus on the possible complications that might occur. The
patient and family or specific others are instructed about the side effects of the medications
given and the importance of continuing to take them as prescribed
Rehab of a patient with a head injury always begins at the time the injury happened. The patient
is encouraged to do rehabilitation programs after discharge because improvement in his or her
status may continue for more than three years after the injury. Depending on the status, the
patient is still encouraged to do normal activities of daily living but gradually. During the acute
and rehabilitation phase of care, needs, issues and problems are the focus of health teachings.
The nurse or health care provider should emphasize health promotions and proper care to the
injured site
6. Compare the types, clinical manifestations, collaborative care of patients with brain
tumors.

Primary brain tumors is an intracranial lesion that occupies the space within or in between the
skull. This brain tumor usually arise or come from the cells and structures inside he brain itself.
Secondary brain tumors or metastatic brain tumors, these usually develop outside of the brain
and if this happens, usually 20 percent to 40 percent of the patients with cancer occur. Causes
of primary brain tumors are unknown.
1. GLIOMAS
-This, glial tumor is the most common type of brain neoplasm. Usually this kind of tumor can
spread by infiltrating or penetrating the surrounding neural connective tissue and this usually or
most often cannot me totally removed without causing substantial damage to the vital
structures.
Clinical manifestations:

-Headache. nausea or vomiting, confusion or a decline in brain function, memory loss,

personality changes or irritability, difficulty with balance, urinary incontinence, vision problems,
such as blurred vision, double vision or loss of peripheral vision, peech difficulties, seizures.

SUBTYPES
-Astrocytomas are the most common type of glioma and Oligodendroglial tumors are also a type
of glial tumor which is usually 20 percent of gliomas. The difference of astrocytomas and
oligodendrogliomas are hard to distinguish, but from the past researches, oligodendrogliomas
are a lot more sensitive to chemotherapy than astrocytomas.
-Glioblastoma is an aggressive kind of cancer which could occur in the brain or spinal cord.
Glioblastoma manifest from cells referred to as astrocytes that assist nerve cells.
-Ependymoma is a sort of tumor that can form within the brain or spinal cord. Ependymoma
begins in the ependymal cells inside the brain and spinal cord that line the passageways
wherein the fluid (cerebrospinal fluid) that nourishes your brain flows.

Clinical manifestations:
Astrocytoma:
Persistent headaches, double or blurred vision, vomiting, loss of appetite, changes in mood and
personality, changes in ability to think and learn, new seizures, and speech difficulty of gradual
onset.
Ependymomas
Cause weakness in the part of the body controlled by the nerves that are affected by the tumor.

Glioblastoma
-Worsening headaches, nausea, vomiting and seizures.
 Oligodendrogliomas
Seizures and headaches. Weakness or disability can occur in the part of the body that's
controlled by the nerve cells affected by the tumor

2. MENINGIOMAS

-This usually or most often than not represent 20 percent of every primary brain tumors. This
is a common encapsulated tumor of the arachnoid cells on the meninges. These tumors are
slow growing and often occur in areas proximal to the venous sinuses.

Clinical manifestations:
It depends on which part of the brain it hit

-Changes in vision, such as seeing double or blurriness, headaches, especially those that are
worse in the morning, hearing loss or ringing in the ears, memory loss, loss of smell, seizures,
weakness in your arms or legs, language difficulty

3. ACOUSTIC NEUROMAS

- This kind of tumor is usually seen in the eighth cranial nerve, this cranial nerve serves as the
one responsible for hearing and balance (ears). This may grow very slow and get very big or
increase size before it can be easily diagnosed.

Clinical manifestations:

-Loss of hearing, tinnitus, and episodes of vertigo and staggering gait, loss of balance. Painful
sensations on the face.

4. PITUITARY ADENOMAS

- These kinds of tumors or type are between eight and twenty percent of every brain tumor

Clinical manifestations:

-Not all pituitary tumors cause symptoms but the usual is hormonal changes (hyper or
hypofunction of the pituitary gland),
-When pressure is seen in this, it produces headache, visual dysfunction, hypothalamic
disorders, increased ICP, and the enlargement and erosion of the sella turcica.
-The hormonal effects of this tumor are: prolactin secreting adenoma, growth hormone
 secreting pituitary adenoma that produce acromegaly in adults, and adrenocorticotropic
hormone or ACTH producing pituitary adenoma. In females, they usually get amenorrhea or
galactorrhea. In male they most often get impotence and hypogonadism. Sometimes, obesity
occurs and increase fat in the face, supraclavicular and abdominal areas. Hypertension also
occurs

5. ANGIOMAS

- This type of tumor are masses that are composed largely of abnormal blood vessels. These
are usually seen in or on the surface of the brain. These usually occur in the cerebellum,
mostly eighty-three percent of the time. Due to thin walls of the blood vessels this can cause
stroke.

Clinical manifestations:

Nausea, vomiting, abdominal discomfort, loss of appetite, feeling of fullness in the

abdomen.

GENERAL CLINICAL MANIFESTATIONS:

-Increasing ICP because of the gradual compression in the brain
-Headache, though not always felt, it usually worsens in the morning or when
straining or sudden movements.
-Vomiting isn’t because of food intake, but due to vagal centers in the medulla/
-Visual disturbances because papilledema is usually present
-Localized symptoms:
-hemiparesis, seizures and mental status changes.
-sensory and motor abnormalities, visual problems, cognition and
language disturbance.
-emotional, mental personality changes occur

COLLABORATIVE CARE
There are multiple treatments for patients with brain tumor like:
-Chemotherapy and external-beam radiation therapy. Radiation therapy is the most
common treatment for brain tumors.
-Brachytherapy is the surgical implantation of radiation to deliver high doses at a short
distance.
-IV autologous bone marrow transplantation is usually used for patients that do
chemotherapy and radiation therapy
-Corticosteroids are given to reduce cerebral edema.
-Photodynamic therapy is a therapy that still convers healthy brain tissue.
7. Discuss the nursing management of the patient with a brain tumor

The nurse should assess and check the patient for possible complications of the brain
tumor. The nurse should administer medications as prescribed, health teaching about
nutrition, proper positioning, rest and comfort are given. The nurse should assist in activities in
daily living so the cognitive functions and motor functions can also be assessed. Providing
oral care and hygiene as to avoid parotitis. Assessing of the level of consciousness because
altered level of consciousness may lead to urinary retention.

The patient with a brain tumor may be at an increased chance for aspiration due to a
cranial nerve dysfunction. Prior the operation, the gag reflex and capacity and ability to
swallow food and fluids are evaluated. In patients with faded gag response, care consists of
teaching the affected person to direct meals and fluid closer to the unaffected side, having the
patient take a seat upright to eat, offering a semi soft diet, and having suction readily available
at the bed side. Functions of the gag reflex should be reassessed right or after the operation
because adjustments can and may also occur. The effects of increased intra cranial pressure
caused by the tumor are assessed by the nurse. The nurse must carry out neurologic checks,
the nurse ought to monitor critical signs, the nurse should also check the vital signs, the nurse
has to also keep a neurologic flow chart to evaluate if situation is worsening or lightening up.
Nursing interventions to prevent rapid increase in intra cranial pressure are done, and the
nurse orients or explains to the patient importance of person, time and place. Patients need
adjustments in cognition because of the lesion or tumor require frequent reorientation, with the
help of the nurse and the use of orienting gadgets like photographs, a calendar, a clock and or
lists of stuff, family members and friends. Supervision and help with self-care, and ongoing
monitoring and injury prevention are done. Patients that experience seizures are cautiously
monitored and is covered from harm and away from injury.

The effects of increased intra cranial pressure caused by the tumor are assessed by the
nurse. The nurse should perform neurologic checks, the nurse should monitor vital signs, the
nurse should also maintain a neurologic flow chart to assess if condition of worsening or not,
Nursing interventions to prevent rapid increase in intra cranial pressure, and the nurse orients
or explains to the patient when necessary to person, time and place. Patients with changes in
cognition caused by the lesion or tumor require frequent reorientation and the use of orienting
devices like photographs, a calendar, a clock and or lists of stuff. Supervision and assistance
with self-care, and ongoing monitoring and injury prevention. Patients with seizures are
carefully monitored and is protected from injury

Post operatively, the nurse should assess the patient’s level of consciousness, assess
bowel sounds and educate the patient about goals and reiterating the importance of rest as it
may trigger possible complications. The nurse should also explain or teach the patient’s
guardian or family members about taking care of the head. The nurse should also emphasize
the importance of giving and taking in meds and safety should always be provided. After a few
hours when the patient is awake, orientation about time and place. Proper care to wound
should be given

The common problem seen after a cranial surgery is a periorbital edema, because fluid
drains to the dependent periorbital area when the patient is positioned prone during an
operation. So prior the operation the patient and the family members should be informed that
one of both eyes may be edematous post operation. Post operation, we should apply ice as it
may aid in lowering the edema. Assist in communication techniques like saying when you're in
the room as to not aggravate the patient. And make sure that the first post-operative change
of the dressing should be done by the neurosurgeon. And the patient is observed for the
effects of increase intra cranial pressure.

The patient is encouraged to verbalize any feelings or concerns regarding the change in
appearance, as there will be the baseline of support that the nurses will give. Proper
information given to the patient is vital as to not lead to misconceptions. Allow patient to
interact with his or her family and friend can really help reduce anxiety and stress and it may
increase the patient's self-worth. Encourage the patient's watchers to visit the patient more
often than not because it will give the patient self-hope while recovering

The nurse should always assess the patient as to be sure that possible complications do
not arise like bleeding, increase ICP, hypovolemic shock, infection, and more. To know if there
is an increase in ICP, the nurse will note blood pressure elevation and lowering of the pulse
with respiratory failure. If complications happen the patient is brought back to the operating
room for removal of blood clots and/or other problems.

It is important to rehydrate the patient after a long period of him or her not getting any
fluids at all. So, usually after 24 hours of the operation, the nurse should give the patient fluids
and to not give more complications. The nurse should also assess the gag and swallowing
reflexes before giving of orals. If a patient that have a posterior fossa tumor cannot swallow,
so alternate routes are used. Assess also for nausea and vomiting as the diet evolves.
Patients that went through brain tumor surgery their serum glucose are measured every
four to six hours. H2 blockers are prescribed to suppress gastric acid. Monitor the patient for
bleeding and gastric pain. Fluid replacement is done to a patient that is experiencing diabetes
insipidus.
 One of the most important nursing interventions to a patient who just undergone cranial
surgery is infection control. So, when handling the dressings, drainage systems, and IV lines
of the patient, aseptic technique is always used. Always asses and monitor the patient for
signs and symptoms of infection because any of the sites maybe infected.

Preventing seizures is essential after a cranial surgery because it can give a lot more of
complications, Administering a prescribed antiseizure medication prior to and after the
operation may prevent a seizure. Status epilepticus may happen after a craniotomy and
maybe because of hematoma or ischema.

Multiple complications usually occur in between the 1st and first 2 weeks. In order to
avoid any complications, the patient’s watcher and/or nurses should see to it that they assist is
changing the patient’s position every 2 hours, the suction secretions, prophylaxis, the removal
of the catheter, early ambulation and skin and oral hygiene.
8. Describe the nursing management of the patient undergoing cranial surgery.

Pre operation
A baseline act, pre-operative assessment is always compared to the post-operative status and
the time of the start of recovery. Many assessments are done and some are:
First thing's first is to check or assess the level of consciousness and the patient's ability
to respond to stimuli and that the nurse should point out any neurologic deficits. The neurologic
deficits seen are: Paralysis, Visual dysfunction, and alterations in personality or speech, and
bladder and bowel disorders. Also the nurse should check the patient's motor strength or ability
to move the upper and the lower extremities and have it recorded.
The nurse should assess the patient's general health status, like: how the patient
prepared for the surgery, the physical, emotional and mental status of the patient. The
neurological needs of the patient are assessed because this can be of foot help on how the
patient will cope up post operatively. If the patient has motor problems or paralysis, trochanter
rolls are applied to the extremities, the feet are on a foot board. If a patient is able to ambulate
or move around, he or she is encouraged to do so. If the patient has problems with
communicating, writing materials, bedpan, a glass of water, or play music to improve the
patient's communication. All these nursing interventions, interacting with the patient may lower
his or her level of anxiety, fear and post-operative complications.
The preparation of the patient and his or her family members include education them about
what is to be expected during and after surgery. In other words, preparation.
Post operation
The first thing to do is to remove the hair with clippers and the surgical site is to be
prepared, but usually in the operating room so the chance of infection is lowered. Second, an
indwelling catheter is inserted as to monitor the urinary output, but this is in the operating room.
Third, the patient will be given a central and arterial line for fluid administration and to monitor
any pressures during the operation. Fourth, instructing that a head dressing will be applied after
the operation and that it may impair hearing, but temporarily. Fifth, the vision may be because
eyes are swollen shut. Sixth, if there is a tracheostomy tube or endotracheal tube in place, the
patient will not be able to speak until the tube is removed, so communication will be a problem.
Lastly, the family is encouraged to continue giving the patient his or her needs because
neurological problems or the cognitive state of the patient makes him unaware of his
surroundings, making it another problem, so support should be given.
After a intracranial surgery, an elevation of the temperature can occur. Injury to the
hypothalamus can happen during the operation and when this happens, fever arises, it should
be taken care of immediately because it ay alter the function of the brain during operation. The
nurse should monitor the patient's temperature, when the patient experiences hyperthermia, you
should remove the blankets and administer antipyretics as prescribed. Hypothermia happens
when the operation is taking longer than expected, rectal temperatures are taken.
A patient is vulnerable to have impaired gas exchange and pulmonary infections during
a neurosurgery because of the patient's immobility, that's why the patient should reposition the
patient every two hours to help mobilize the pulmonary functions and secretions. When the
patient recovers and gains consciousness, teach the patient to do deep breathing exercises,
use of incentive spirometry and coughing. Also, increase the humidity of oxygen delivery may
help loosen secretions
9. Differentiate among the primary causes, collaborative care and nursing management
of brain abscess, meningitis and encephalitis.

BRAIN ABSCESS
-Rare in immunocompetent people. Most likely, those who are immunosuppressed they are the
ones who are usually infected by this.

Primary causes: -Usually when a brain tissue gathers infections from the outside.
-Usual causative agent of brain abscess is bacteria.
-Adults who are immunocompetent and have otitis media and
rhinosinusitis are common problems that lead to abscesses.
-Due to a penetration to the head, or like a intracranial surgery, or
piercing of the tongue, the patient may produce an abscess.
-Organisms that like to do hematologic spread to get to the brain and go
through the lungs, gums, tongue, or heart, or wound, or sometimes a
intra-abdominal infection may easily cause brain abscess.
-When you are immunocompromised, you can get brain abscess through
different pathogens.
Collaborative Care: -Treatment is usually after the controlling of the increasing of intra cranial
pressure, abscess draining, and giving the patient an antimicrobial
therapy right at the abscess.
-Many doses of antibiotics given though IV are administered to the patient
to penetrate the blood-brain barrier and reach the abscess.
-The antibiotic medication to be used is based on what the outcome of the
culture and sensitivity testing is, and what the causative agent.
-Ceftriaxone is usually started at first and will adjust nalang based on
what kind the causative agent is.
-A sterotactic CT-guided aspiration will be used in order to drain the
abscess and recognize the causative agent.
-To help reduce the inflammatory cerebral edema, corticosteroids are
given as when the patient shows an elevation of neurologic problems.
-Antiseizure meds are given to prevent seizures too
Nursing Management:-Performing neurologic checks to see if the symptoms are needed for
more and stronger interventions.
-When the medication is given to the patient, don’t forget to document the
reaction to the medication
-Aggressively check the blood glucose level and serum potassium levels
of the patients
-Insulin or electrolyte replacement may be administered or given to return
the said levels to normal range
-Of course, provide safety. An injury maybe because of lowered LOC or
falls.
Meningitis
-Inflammation of the meninges, these cover and protect the brain and the spinal cord

Primary causes: -Bacterial, viral and fungal infection comprise of the major causes of
meningitis.
-Bacteria causes septic meningitis. Streptococcus pneumoniae and
Neisseria meningitides, bacterial meningitis are the ones who are mostly
the cases when handling patients with bacterial meningitis in adults.
-Viral or secondary or secondary to cancer, causes aseptic meningitis,
when the immune system is low. Most common causative agent for this
ate the enteroviruses.
Collaborative care: -Outcomes depend on how early the antibiotics are given and how it
crosses the blood-brain barrier into the subarachnoid space to stop the
multiplication of the bacteria.
-Usually Penicillin G is combined with a cephalosporin, administered via
IV, within 30 minutes of hospital arrival is administered to the patient
-Dexamethasone can be a very beneficial supplement therapy when
treating acute bacterial meningitis and pneumococcal meningitis when it
is administered 15 to 20 minutes before the 1st dose of antibiotics.
-Dexamethasone also improves the outcomes in adults the lowers the risk
of gastrointestinal bleeding.
-Fluid volume expanders are used to treat dehydration and shock.
Phenytoin is given to treat seizures.
Nursing management:-Infection control for 24 hours after the giving of the antibiotic therapy
(droplet precautions)
-The nurse assists in pain management because the patient experiences
overall body aches and neck pain
-The nurse assists when giving resto a patient and the room is darkened.
-The nurse implements interventions or management to lower the
increased temperature.
-Making sure that the patient is hydrated.
-Neurologic monitoring
-Continue to check the vital signs
-If there is elevation of ICP, pulse oximetry and abg values are used to
assess if respiratory support is needed
-Insert endotracheal tube and mechanical ventilation as to maintain an
adequate oxygenation.
-IV fluid replacement when needed as prescribed, although care is given
to prevent fluid overload
-Providing the patient with safety is important because an injury may
complicate how the patient is feelings.
-The nurse prevents complications by continuing on monitoring the
patient and giving the needs.
Encephalitis
-This is an acute inflammatory process that happens to the brain tissue. Encephalitis have two
types: HSV-1 and HSV-2. Usually HSV-1 affects children and adults. HSV-2 affects the
neonates who acquire the disease from their mom’s at new born, because the mom’s may have
an active genital herpes infection.

Primary cause: -Viral infection (herpes simplex virus)

Collaborative care: -Antiviral agents are given (acyclovir or ganciclovir). These two are the
medication of choice for encephalitis.
-Early giving of antiviral medications improve the prognosis associated
with the patient’s HSV-1.
-Continuation of medications for 3 weeks should help prevent relapse.
-To help prevent crystallization of the medication in the urine, slow IV
administration over an hour is done.
-As to the patient having a history of renal insufficiency, the usual dose of
acyclovir is lowered.
Nursing management: -Assessing of the neurologic functions of the patient is important as to
see the progression of the disease.
-To reduce possible headache, comfort measures are given like: lowering
of the lights, limiting noise and visitors. When taking care of the patient,
pupunta lang dun ng minsanan as to not disturb the patient that much and
administering analgesics
-Opioid analgesic medications may cover neurologic symptoms so they’re
used cautiously.
-Providing safety to the patient because they might be prone to seizures
and altered LOC
The nurse should educate the patient’s family to help reduce anxiety
-Monitoring vital signs is important as to see if complications are arising.
-Monitor blood chemistry test results and urinary output to check to make
sure that there is no presence of renal complications.
REFERENCES:

https://www.healthline.com/health/increased-intracranial-pressure#causes-and-risk-factors
https://www.mayoclinic.org/diseases-conditions/ependymoma/cdc-20350144
https://www.mayoclinic.org/diseases-conditions/pituitary-tumors/symptoms-causes/syc-
20350548
Brunner and Suddarth’s Textbook of Medical Surgical Nursing 12TH edition
Brunner and Suddarth’s Textbook of Medical Surgical Nursing 13th edition