July 20, 2023 • 16 mins
Ever wondered how the Glasgow Coma Scale impacts patient prognosis? Or why outdated methods in feedings could be detrimental for patient care? With Dr. Hobbock as our guide, we untangle these subjects and more in a comprehensive look at the neurologic system in nursing. Together, we debunk ambiguous terms in measuring altered states of consciousness, advocating for the specificity of the Glasgow Coma Scale. We also underscore the importance of regular vitals and go in-depth into the risks of aspiration for patients and methods to prevent it.
As we shift gears, we put the spotlight on the pivotal role of correct processes for feedings and the need to check the placement of an enteral tube. Dr. Hobbock illustrates why old-school methods are no longer reliable and the pressing need for accurate techniques. We further explore the potential complications of immobility and preventive measures. Wrapping up, we dive into monitoring vital signs, recognizing increased intracranial pressure, and the role of constant communication in patient care. Join us on this journey, filled with essential insights and actionable tips, a must-listen for all nursing enthusiasts and healthcare professionals.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hey and welcome to Nursing with Dr Hobbock.
Today's going to be a longerepisode because we're going to
dive into the neurologic system.
The first thing that we'regoing to talk about is the
Glasgow Coma Scale.
You should be familiar withthis scale.
You should have a good idea ofit, if not, have it memorized.
It's going to measure eyeopening either spontaneously to
(00:23):
verbal commands to pain or noresponse.
It measures motor responses toa verbal command, to painful
stimuli.
Do they localize with pain,flex or withdrawal?
Do flex or posturing ordecorticate Extensive posturing,
which is discerabit, or noresponse, and then a verbal
response.
Does the patient respond to youoriented and converse?
(00:47):
Are they disoriented butconversing?
Are they using inappropriatewords, incomprehensible sounds
or no response?
Something to keep in mind isthe maximum total for the
Glasgow Coma Scale is 15.
The minimum is 3.
7 or less indicates coma.
7 or less indicates a coma.
(01:07):
The lower the score, the lessconscious the patient is.
The higher the score, thebetter.
People who have scores greaterthan 8 usually have a better
prognosis for recovery.
Let's talk about altered statesof consciousness.
While we're talking about thisGlasgow Coma Scale, you're going
to use the Glasgow Coma Scaleto measure altered states of
(01:30):
consciousness.
It's much more specific thanambiguous terms like somnolent,
obtunded.
We kind of want to avoidstuporous lethargic.
Those are ambiguous, they'renot very, very specific.
This Glasgow Coma Scale is muchmore specific, so make sure
that you're familiar with itwhen you're doing an assessment
(01:51):
for someone with an alteredlevel of consciousness.
You also want to do, of course,regular vital signs Heart rate,
blood pressure, sp2.
Sometimes it's an oxygenproblem, sometimes it's a
perfusion problem.
There could be a lot of thingsgoing on.
So we want to make sure we getas many assessment pieces as we
can.
So get your tools out Pupilsize, limb movement.
(02:13):
Of course, our vital signs.
You want to check skinintegrity, corneal integrity.
We want to check for bladderfullness.
This is a big one to keep inmind for altered level of
consciousness or patients withspinal cord injury.
We want to check that bladderfor fullness.
We're going to put anindwelling catheter in if we
have to or do straight casts,whatever is ordered.
(02:34):
We want to make sure we'relistening to lung sounds and
cardiac sounds, cardiac statusand of course you're going to
want to find out is this normalfor this patient?
Talk to family or a secondarysource to find out.
These patients are at high riskfor aspiration.
So we typically are going tofeed them enterally or
parenterally, so we might see afeeding tube, and we need to
(02:58):
remember the correct process forfeedings.
Number one checking placement ofan enteral tube via oscultation
.
You know those old schoolnurses told you to put your
stethoscope on the patient'sbelly and push some air in.
That doesn't work.
There's plenty of research tosupport that.
That is not affected.
(03:19):
It doesn't tell you if the tubeis in the right place.
Don't use it.
You want to use observation andPH strips, so if your facility
doesn't have those, advocate forthem.
The gold standard is X-ray, somake sure there's an X-ray on
file that shows you the tube isin the right place.
We don't get an X-ray everytime we check the patient though
.
So when we get ready to go doany kind of insertion of
(03:45):
anything into an enteral tubemedications, feedings you want
to check placement and you'regoing to do that by aspirating
gastric contents, checking thePH of those contents, and then
you want to make sure that youare checking residual if you're
doing enteral feedings.
Residual is the residue, theleftovers, the amount that's
left after the patient has beena certain period of time.
(04:07):
Usually there's an order thattells you how often to check
residuals.
My experience it's like everyfour hours or I would check them
whenever I'm going to accessthe tube.
What you're going to do isaspirate everything out of the
tube that you can.
If you have to use a graduatedcylinder to hold those contents,
if there's a hundred or more,or whatever your facility policy
(04:28):
is, that indicates that we maynot have good gastric emptying.
So checking placement is withPH, checking gastric emptying is
with that gastric residual.
Now it's really important foryou to put that gastric residual
back.
Number one is partiallydigested.
Number two it's got acid in it.
If you take all that acid awayfrom your patient, what's going
(04:48):
to happen?
Alkylosis.
So put all that back in thereand follow your facility policy
on notifying the provider.
We want to make sure that weunderstand that if the patient
is comatose, a lot of the timesthey're going to experience
paralytic ileus, meaning thatthe intestines are not moving.
So we're not going to do anykind of insertion, any feeding
(05:09):
or anything if there's no bowelsound.
So you're always going to checkbowel sounds before you access
a tube.
If the patient has paralyticileus, we're probably using a NG
tube for gastric decompression.
So it's going to be to usuallylow intermittent suction when
our patient has an altered levelof consciousness.
You have to make sure that youare working to prevent all of
(05:32):
those side effects orcomplications of immobility.
You're doing range of motionevery four hours.
You're turning the patient atminimum every two.
Remember the two hours is aminimum mark.
If you can turn them every hourthat's way better.
I like to coordinate with myaids or my unlicensed assistive
personnel that they go in everytwo hours.
I go in every two hours and westagger it so that we can get
(05:54):
that patient moved around everyhour.
I guarantee this patient is atrisk just because of their
condition and so two hours maybe too long.
We want to try to get themturned as much as we can.
If you anticipate that there'sgoing to be intubation or if
there's a problem with theairway, insert an oral airway or
of course you're going to calla rapid response and that'll all
(06:15):
get taken care of.
We're going to monitor PO2 andPCO2.
We want to make sure that weare keeping these patients NPO.
If your patient has a suddenchange in level of consciousness
, npo is the way to go.
We don't want to put anythingin their mouth and then aspirate
.
So make sure that you'rekeeping them NPO and we're going
to do mouth care every fourhours on patients who are NPO
(06:36):
because we want to keep thatarea clean.
Of course we want to make surethat we're recording intake and
output and then, to avoid thosecomplications, turn on our
patients range of motion, maybeadvocate for sequential
compression devices or elasticcompression stockings because we
want to prevent those DVTs.
(06:57):
Urinary Calculi is acomplication of immobility.
So in making sure that they'regetting enough fluid intake,
either gastric, po or IV, makingsure we're checking that urine
specific gravity to see if it'shigh, making sure we're keeping
an eye on intake and output overa 24-hour period and if
possible, apply splints like forfoot drop to prevent that, to
(07:20):
prevent wrist drop.
You'll coordinate with yourprovider for those things.
Keeping an eye on our vitalsigns is going to be important
because we're also monitoringpotentially for increased
intracranial pressure.
Any change in heart rate thatgoes down below 60 or above 100
could indicate that we want tomake sure that we're keeping an
eye on blood pressure.
The blood pressure is going upor we have a widening pulse
(07:43):
pressure.
Remember that that can indicateincreased ICP.
Any temperature abnormalitiescould indicate the patients
getting worse.
You can monitor theirtemperature.
We want to make sure that we arecontinuing to use the Glasgow
Coma Scale to measure the levelof consciousness and we're
keeping an eye on those pupils,preventing injury.
Of course, we're always keepingthe bed in low position, side
(08:05):
rails up at all times.
Make sure that you are pattingthose rails, that the patient is
a safety risk or a seizure risk, and we want to be really
careful about monitoring forover sedation because that can
impact our vital signs and ourassessment, disguise worsening
conditions.
Make sure that you're keepingan eye on that.
Whenever you're touching apatient with an altered state of
(08:27):
consciousness it doesn't matterhow deep they are You're
talking to them, you're tellingthem what you're doing,
constantly talking to thepatient.
Even if you think they'retotally in a coma, you're still
going to talk to them and letthem know what you're doing, let
them know that you're going totouch them, let them know you're
doing a bath.
Whatever it is you're doing, westill want to make sure that
(08:49):
we're doing hygiene.
Grooming, bathing, oral hygieneis going to be super important
Wash their hair, provide nailcare If they need it.
We want to make sure that weare checking their eyes for
coronal injury.
If the eyes are not able to, ifthe patient's blink reflex is
gone, you want to make sure theeyes stay closed and we're going
to keep those irrigated, maybewith sterile solution that's
(09:11):
prescribed, or instilling anointment in their eyes, whatever
is ordered by the provider.
So keep those things in mindfor your altered level of
consciousness.
Next, let's talk about traumaticbrain injury or head injuries.
We have a head injury, which isany traumatic damage to the
head.
You can have an open traumaticbrain injury.
(09:32):
Of course this is where we'vegot a fracture in the skull, or
penetration by an object, orclosed Closed is more serious
because we can have swelling orbleeding inside the brain,
inside the skull, and thatdoesn't give the skull, doesn't
give it all, and that canincrease intracranial pressure,
which can then cause a decreasein actual blood flow to the
(09:54):
brain because those capillariesand stuff arteries get
compressed.
The biggest concern that you'regoing to have, the worst
complication, is going to beincreased intracranial pressure,
which we've already addressedjust a little bit ago.
Things that you're going tokeep an eye on are going to be
their symptoms, sounconsciousness, disturbances in
(10:15):
consciousness.
They may have vertigo,confusion, delirium.
They may be disoriented.
This should sound very familiarbecause we're going to use the
Glasgow Coma Scale here tomeasure the patient's worsening
or improvement.
Hopefully.
Change in level ofresponsiveness is the most
important symptom of increasingintracranial pressure.
(10:38):
Again, that's that change inlevel of responsiveness.
So if you have any kind ofchange in a patient who's had a
head injury, you're going towant to report that stat.
Even subtle changes likerestlessness, irritability or
confusion that's worsening ornew, that can indicate that
increased ICP.
Again, we're watching pulse forelevation or decrease, watching
(11:01):
blood pressure if it's going upor if there's a widening pulse,
pressure, temperature rise.
We want to make sure we controlthat if we can.
We may see headache, vomiting,pupillary changes.
We want to keep an eye on those.
Seizures.
Ataxia, abnormal posturing thisis where that decerebrate or
decorticate comes in.
Any leaking of cerebral spinalfluid, either through the nose
(11:23):
or the ear remember that we cantell that by the halo sign or
it's got glucose in it.
Normal mucus does not.
Hematomas may be something thatwe see and if a patient has a
CSF leak that can actually keepthem from demonstrating those
normal signs of increased ICP,they may not occur.
(11:44):
Want to keep an eye out forthose things.
Ct MRI scan is going to showeither an epidural or subdural
hematoma.
If it requires surgery, we mayget an EEG to measure for
seizure activity and what you'regoing to do as the nurse.
You're going to monitor oxygen,p02, pco2.
We're looking for hypoxia orhypercapnia.
We want to make sure that we'repositioning the client
(12:04):
semi-prone or lateral recumbentto help prevent aspiration,
especially if they're vomiting.
We'll make sure you'repreventing those complications
of immobility.
I'm not going to go over thoseagain.
We heard those just a littlebit ago.
We're going to do neurologicvital signs frequently and if we
have any signs of deteriorationwe're going to notify the
provider right away.
(12:25):
We want to avoid anything that'sgoing to increase endocrinial
pressure.
So, changing bed position,extreme hip flexion, suctioning,
endotracheal suctioning,compression of the jugular veins
you want to make sure you keepthe head straight in that
natural position, not turn toone side or the other.
A coughing, vomiting, straining, no val salvas those can all
increase endocrinial pressure.
(12:46):
If the patient has atemperature increase, you want
to make sure that you address itright away.
Whatever is ordered usuallyit's acetaminophen or Tylenol we
want to get that into thepatient a cooling blanket if
needed, because an increase intemperature is going to increase
cerebral blood flow, which isgoing to cause an increase in
ICP, especially if it's alreadyhappening.
(13:07):
So we want to make sure thatwe're not doing that.
Now there is such a thing as anintercranial monitoring system.
This is a catheter that'sinserted into the lateral
ventricle and there's a sensorthere placed on the dura, or a
screw into the subarachnoidspace that's attached to a
pressure transducer.
We want to make sure that wenotify the provider stat of
anything over 20 millimeters.
(13:28):
Mercury no-transcript.
We might be giving somemedications hyper-osmotic agents
and diuretics to dehydrate thebrain excuse me, dehydrate the
brain or to prevent cerebraledema.
Manitol is one of the big ones,urea is another one.
Steroids we might be givingdexamethasone or
methylprednisolone.
Sodium succinate Barbituratesare actually gonna reduce brain
(13:51):
metabolism and systemic BP, andthose are things that we're
gonna keep an eye on, of course,in taking out putty.
It's gonna be really important,especially if they're on
osmotic diuretics.
We may have a passivehyperventilation on a ventilator
that's gonna lead torespiratory alkalosis which is
gonna cause cerebralbasoconstriction.
And then we're gonna continueour seizure precautions.
(14:15):
They may order phenitoin justas a prophylactic for seizures,
and then we wanna make sure thatwe're talking to the patient
about post-traumatic syndromeheadaches, vertigo, emotional
instability, inability toconcentrate, impaired memory.
They could have post-traumaticepilepsy or even post-traumatic
neurosis or psychosis.
So that is traumatic braininjury and we'll move on to
(14:40):
spinal cord injury next.
Thanks for hanging out with metoday on Nursing with Dr Hobbock
.
I hope you enjoy.
I'll see you next time withspinal cord injuries.
Hey and welcome to Nursing with Dr Hobbock.
Today's going to be a longerepisode because we're going to
dive into the neurologic system.
The first thing that we'regoing to talk about is the
Glasgow Coma Scale.
You should be familiar withthis scale.
You should have a good idea ofit, if not, have it memorized.
It's going to measure eyeopening either spontaneously to
(00:23):
verbal commands to pain or noresponse.
It measures motor responses toa verbal command, to painful
stimuli.
Do they localize with pain,flex or withdrawal?
Do flex or posturing ordecorticate Extensive posturing,
which is discerabit, or noresponse, and then a verbal
response.
Does the patient respond to youoriented and converse?
(00:47):
Are they disoriented butconversing?
Are they using inappropriatewords, incomprehensible sounds
or no response?
Something to keep in mind isthe maximum total for the
Glasgow Coma Scale is 15.
The minimum is 3.
7 or less indicates coma.
7 or less indicates a coma.
(01:07):
The lower the score, the lessconscious the patient is.
The higher the score, thebetter.
People who have scores greaterthan 8 usually have a better
prognosis for recovery.
Let's talk about altered statesof consciousness.
While we're talking about thisGlasgow Coma Scale, you're going
to use the Glasgow Coma Scaleto measure altered states of
(01:30):
consciousness.
It's much more specific thanambiguous terms like somnolent,
obtunded.
We kind of want to avoidstuporous lethargic.
Those are ambiguous, they'renot very, very specific.
This Glasgow Coma Scale is muchmore specific, so make sure
that you're familiar with itwhen you're doing an assessment
(01:51):
for someone with an alteredlevel of consciousness.
You also want to do, of course,regular vital signs Heart rate,
blood pressure, sp2.
Sometimes it's an oxygenproblem, sometimes it's a
perfusion problem.
There could be a lot of thingsgoing on.
So we want to make sure we getas many assessment pieces as we
can.
So get your tools out Pupilsize, limb movement.
(02:13):
Of course, our vital signs.
You want to check skinintegrity, corneal integrity.
We want to check for bladderfullness.
This is a big one to keep inmind for altered level of
consciousness or patients withspinal cord injury.
We want to check that bladderfor fullness.
We're going to put anindwelling catheter in if we
have to or do straight casts,whatever is ordered.
(02:34):
We want to make sure we'relistening to lung sounds and
cardiac sounds, cardiac statusand of course you're going to
want to find out is this normalfor this patient?
Talk to family or a secondarysource to find out.
These patients are at high riskfor aspiration.
So we typically are going tofeed them enterally or
parenterally, so we might see afeeding tube, and we need to
(02:58):
remember the correct process forfeedings.
Number one checking placement ofan enteral tube via oscultation
.
You know those old schoolnurses told you to put your
stethoscope on the patient'sbelly and push some air in.
That doesn't work.
There's plenty of research tosupport that.
That is not affected.
(03:19):
It doesn't tell you if the tubeis in the right place.
Don't use it.
You want to use observation andPH strips, so if your facility
doesn't have those, advocate forthem.
The gold standard is X-ray, somake sure there's an X-ray on
file that shows you the tube isin the right place.
We don't get an X-ray everytime we check the patient though
.
So when we get ready to go doany kind of insertion of
(03:45):
anything into an enteral tubemedications, feedings you want
to check placement and you'regoing to do that by aspirating
gastric contents, checking thePH of those contents, and then
you want to make sure that youare checking residual if you're
doing enteral feedings.
Residual is the residue, theleftovers, the amount that's
left after the patient has beena certain period of time.
(04:07):
Usually there's an order thattells you how often to check
residuals.
My experience it's like everyfour hours or I would check them
whenever I'm going to accessthe tube.
What you're going to do isaspirate everything out of the
tube that you can.
If you have to use a graduatedcylinder to hold those contents,
if there's a hundred or more,or whatever your facility policy
(04:28):
is, that indicates that we maynot have good gastric emptying.
So checking placement is withPH, checking gastric emptying is
with that gastric residual.
Now it's really important foryou to put that gastric residual
back.
Number one is partiallydigested.
Number two it's got acid in it.
If you take all that acid awayfrom your patient, what's going
(04:48):
to happen?
Alkylosis.
So put all that back in thereand follow your facility policy
on notifying the provider.
We want to make sure that weunderstand that if the patient
is comatose, a lot of the timesthey're going to experience
paralytic ileus, meaning thatthe intestines are not moving.
So we're not going to do anykind of insertion, any feeding
(05:09):
or anything if there's no bowelsound.
So you're always going to checkbowel sounds before you access
a tube.
If the patient has paralyticileus, we're probably using a NG
tube for gastric decompression.
So it's going to be to usuallylow intermittent suction when
our patient has an altered levelof consciousness.
You have to make sure that youare working to prevent all of
(05:32):
those side effects orcomplications of immobility.
You're doing range of motionevery four hours.
You're turning the patient atminimum every two.
Remember the two hours is aminimum mark.
If you can turn them every hourthat's way better.
I like to coordinate with myaids or my unlicensed assistive
personnel that they go in everytwo hours.
I go in every two hours and westagger it so that we can get
(05:54):
that patient moved around everyhour.
I guarantee this patient is atrisk just because of their
condition and so two hours maybe too long.
We want to try to get themturned as much as we can.
If you anticipate that there'sgoing to be intubation or if
there's a problem with theairway, insert an oral airway or
of course you're going to calla rapid response and that'll all
(06:15):
get taken care of.
We're going to monitor PO2 andPCO2.
We want to make sure that weare keeping these patients NPO.
If your patient has a suddenchange in level of consciousness
, npo is the way to go.
We don't want to put anythingin their mouth and then aspirate
.
So make sure that you'rekeeping them NPO and we're going
to do mouth care every fourhours on patients who are NPO
(06:36):
because we want to keep thatarea clean.
Of course we want to make surethat we're recording intake and
output and then, to avoid thosecomplications, turn on our
patients range of motion, maybeadvocate for sequential
compression devices or elasticcompression stockings because we
want to prevent those DVTs.
(06:57):
Urinary Calculi is acomplication of immobility.
So in making sure that they'regetting enough fluid intake,
either gastric, po or IV, makingsure we're checking that urine
specific gravity to see if it'shigh, making sure we're keeping
an eye on intake and output overa 24-hour period and if
possible, apply splints like forfoot drop to prevent that, to
(07:20):
prevent wrist drop.
You'll coordinate with yourprovider for those things.
Keeping an eye on our vitalsigns is going to be important
because we're also monitoringpotentially for increased
intracranial pressure.
Any change in heart rate thatgoes down below 60 or above 100
could indicate that we want tomake sure that we're keeping an
eye on blood pressure.
The blood pressure is going upor we have a widening pulse
(07:43):
pressure.
Remember that that can indicateincreased ICP.
Any temperature abnormalitiescould indicate the patients
getting worse.
You can monitor theirtemperature.
We want to make sure that we arecontinuing to use the Glasgow
Coma Scale to measure the levelof consciousness and we're
keeping an eye on those pupils,preventing injury.
Of course, we're always keepingthe bed in low position, side
(08:05):
rails up at all times.
Make sure that you are pattingthose rails, that the patient is
a safety risk or a seizure risk, and we want to be really
careful about monitoring forover sedation because that can
impact our vital signs and ourassessment, disguise worsening
conditions.
Make sure that you're keepingan eye on that.
Whenever you're touching apatient with an altered state of
(08:27):
consciousness it doesn't matterhow deep they are You're
talking to them, you're tellingthem what you're doing,
constantly talking to thepatient.
Even if you think they'retotally in a coma, you're still
going to talk to them and letthem know what you're doing, let
them know that you're going totouch them, let them know you're
doing a bath.
Whatever it is you're doing, westill want to make sure that
(08:49):
we're doing hygiene.
Grooming, bathing, oral hygieneis going to be super important
Wash their hair, provide nailcare If they need it.
We want to make sure that weare checking their eyes for
coronal injury.
If the eyes are not able to, ifthe patient's blink reflex is
gone, you want to make sure theeyes stay closed and we're going
to keep those irrigated, maybewith sterile solution that's
(09:11):
prescribed, or instilling anointment in their eyes, whatever
is ordered by the provider.
So keep those things in mindfor your altered level of
consciousness.
Next, let's talk about traumaticbrain injury or head injuries.
We have a head injury, which isany traumatic damage to the
head.
You can have an open traumaticbrain injury.
(09:32):
Of course this is where we'vegot a fracture in the skull, or
penetration by an object, orclosed Closed is more serious
because we can have swelling orbleeding inside the brain,
inside the skull, and thatdoesn't give the skull, doesn't
give it all, and that canincrease intracranial pressure,
which can then cause a decreasein actual blood flow to the
(09:54):
brain because those capillariesand stuff arteries get
compressed.
The biggest concern that you'regoing to have, the worst
complication, is going to beincreased intracranial pressure,
which we've already addressedjust a little bit ago.
Things that you're going tokeep an eye on are going to be
their symptoms, sounconsciousness, disturbances in
(10:15):
consciousness.
They may have vertigo,confusion, delirium.
They may be disoriented.
This should sound very familiarbecause we're going to use the
Glasgow Coma Scale here tomeasure the patient's worsening
or improvement.
Hopefully.
Change in level ofresponsiveness is the most
important symptom of increasingintracranial pressure.
(10:38):
Again, that's that change inlevel of responsiveness.
So if you have any kind ofchange in a patient who's had a
head injury, you're going towant to report that stat.
Even subtle changes likerestlessness, irritability or
confusion that's worsening ornew, that can indicate that
increased ICP.
Again, we're watching pulse forelevation or decrease, watching
(11:01):
blood pressure if it's going upor if there's a widening pulse,
pressure, temperature rise.
We want to make sure we controlthat if we can.
We may see headache, vomiting,pupillary changes.
We want to keep an eye on those.
Seizures.
Ataxia, abnormal posturing thisis where that decerebrate or
decorticate comes in.
Any leaking of cerebral spinalfluid, either through the nose
(11:23):
or the ear remember that we cantell that by the halo sign or
it's got glucose in it.
Normal mucus does not.
Hematomas may be something thatwe see and if a patient has a
CSF leak that can actually keepthem from demonstrating those
normal signs of increased ICP,they may not occur.
(11:44):
Want to keep an eye out forthose things.
Ct MRI scan is going to showeither an epidural or subdural
hematoma.
If it requires surgery, we mayget an EEG to measure for
seizure activity and what you'regoing to do as the nurse.
You're going to monitor oxygen,p02, pco2.
We're looking for hypoxia orhypercapnia.
We want to make sure that we'repositioning the client
(12:04):
semi-prone or lateral recumbentto help prevent aspiration,
especially if they're vomiting.
We'll make sure you'repreventing those complications
of immobility.
I'm not going to go over thoseagain.
We heard those just a littlebit ago.
We're going to do neurologicvital signs frequently and if we
have any signs of deteriorationwe're going to notify the
provider right away.
(12:25):
We want to avoid anything that'sgoing to increase endocrinial
pressure.
So, changing bed position,extreme hip flexion, suctioning,
endotracheal suctioning,compression of the jugular veins
you want to make sure you keepthe head straight in that
natural position, not turn toone side or the other.
A coughing, vomiting, straining, no val salvas those can all
increase endocrinial pressure.
(12:46):
If the patient has atemperature increase, you want
to make sure that you address itright away.
Whatever is ordered usuallyit's acetaminophen or Tylenol we
want to get that into thepatient a cooling blanket if
needed, because an increase intemperature is going to increase
cerebral blood flow, which isgoing to cause an increase in
ICP, especially if it's alreadyhappening.
(13:07):
So we want to make sure thatwe're not doing that.
Now there is such a thing as anintercranial monitoring system.
This is a catheter that'sinserted into the lateral
ventricle and there's a sensorthere placed on the dura, or a
screw into the subarachnoidspace that's attached to a
pressure transducer.
We want to make sure that wenotify the provider stat of
anything over 20 millimeters.
(13:28):
Mercury no-transcript.
We might be giving somemedications hyper-osmotic agents
and diuretics to dehydrate thebrain excuse me, dehydrate the
brain or to prevent cerebraledema.
Manitol is one of the big ones,urea is another one.
Steroids we might be givingdexamethasone or
methylprednisolone.
Sodium succinate Barbituratesare actually gonna reduce brain
(13:51):
metabolism and systemic BP, andthose are things that we're
gonna keep an eye on, of course,in taking out putty.
It's gonna be really important,especially if they're on
osmotic diuretics.
We may have a passivehyperventilation on a ventilator
that's gonna lead torespiratory alkalosis which is
gonna cause cerebralbasoconstriction.
And then we're gonna continueour seizure precautions.
(14:15):
They may order phenitoin justas a prophylactic for seizures,
and then we wanna make sure thatwe're talking to the patient
about post-traumatic syndromeheadaches, vertigo, emotional
instability, inability toconcentrate, impaired memory.
They could have post-traumaticepilepsy or even post-traumatic
neurosis or psychosis.
So that is traumatic braininjury and we'll move on to
(14:40):
spinal cord injury next.
Thanks for hanging out with metoday on Nursing with Dr Hobbock
.
I hope you enjoy.
I'll see you next time withspinal cord injuries.
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