NEURO CEREBRAL

INCREASED ICP – Increased intracranial pressure

 Disequilibrium and increase pressure in the cranial vault
 Brain tissue (1400g)
 Blood (75mL)
 CSF (75mL)
Normal ICP- 0-10mmHg (limit of 5-15)

RF
 Head injury
 Brain tumors – because of metaplasia
 Subarachnoid hemorrhage
 Encephalopathies – hepatic failure

Monro-kellie hypothesis/doctrine
 kapag may sumobra or nagkulang = ICP
 the sum of volumes of brain, cerebrospinal fluid (CSF) and intracerebral blood is constant
 75mL

Inflammation= Vasodilation= increase in hydrostatic pressure leading to edema

Swelling= lalaki ang brain= tataas ang pressure
Conflict in the carotid artery=
*In initial phase of ICP, mag cocompensate ang brain which is cushing’s response. = increase in venous
return- bababa ang SBP, widening of pulse pressure and cardiac slowing. (normalize)

Manifestations Increased in ICP

 LOC, dizziness, bradycardia, projectile vomiting, chenne stokes,
 Cranial nerve 9= projectile vomiting

CLINICAL SIGNS
Impairement of the neural function
 Changes in LOC, confusion, drowsiness stuporous leads to comatose
 Headache, projectile vomiting
 Restlessness
 Abnormal motor response, flaccidity

COMPLICATIONS
 Respiratory irregularities
 Brainstem herniation
 Medulla tinamaan= put client in mechanical ventilation
 Diabetes insipidus
 SIADH
DX
 History and clinical features
 Neurologic assessment
 GCS

Laboratory:
 Serum and electrolytes, ABGs

Diagnostics:
 Imaging studies: CT, MRI, PET, Cerebral angiography
 Monitoring studies: Transcranial Doppler, eletrophysiologic monitoring (to monitor the pressure
and brain waves)
 Size

PHARMACOLOGIC MX
 Loop diuretics edema
 Furosemide
 Osmotic diuretics for cerebral edema
 Mannitol
 Corticosteroids to decrease inflammatory response
 Dexamethesone
 Inotropic agents to promote perfusion, pampalakas ng tibok ng puso therefore delivering
oxygen to the brain
 Dobutamine
 norepinephrine
 Sedatives/High dose barbiturates to decrease metabolic demands/ to stop brain activity
 pentobarbital
 Phenobarbital
 Thiopental
 Propofol
 dexmedettomide
 Antipyretics for fever

MEDICAL MANAGEMENT
 IV therapy: hypertonic (3% NaCl)
 Enteral/Parenteral nutrition
 Intubation + mechanical ventilation
 Arterial pressure monitoring
 Cardiac monitoring

SURGICAL MX
 Intraventicular catheter (ventriculostomy) bubutasin csf to drain
 Subarachnoid bolt bound to decompress excessive tissue
 Epidural/ subdural catheter draining of csf
 Fiberoroptic transducer-tipped catheter for monitoring the pressure of the brain and brain
waves
 Intracranial pressure to monitor brain waves
 Waveforms
  Craniotomy burholing
 Craniectomy removal part of the skull (supratentorial sa gilid, infratentorial sa baba likod)
 Cranioplasty ibabalik na yung skull
 Transphenoidal approach for visualization. sphenoid bone ang daan

NURSING MANAGEMENT

Perioperative care
 Imaging studies
 Anticonvulsants to prevent seizure activity
 Phenytoin
 levetiracetam
 Anxiolytics during seizure
 Diazepam
 Lorazepam
 Corticosteroids for inflammation
 Dexamethasone
 Hyperosmotic agents to decrease ICP
 Mannitol
 Furosemide

Nursing Care
 Preoperative assessments
 Patient and family education
 Ambulation and assistive devices
 Writing materials or picture cards
 Shower prior to the procedure
 Central or arterial line

Post operative
 Endotrachial tube (client is intubated)
 Intensive care and monitoring

Nursing care
 V/S and NVS (frequent)
 Supratentorial: back or side = supine or side lying position (unoperated side)
 Infratentorial: flat on one side = side lying position (turn the patient right left right left to
prevent pressure ulcer)
 Turning q2h (turn as a unit)
 Temperature regulation
 Improve gas exchange: yawning, sighing, DBE
 Modes of communication (speech therapy)
 Verbalize feelings, grooming (use of turban)
 Support system
For transphenoidal approach

Nursing care
 V/S and NVS (frequent)
 Visual assessment to check if there is nerve damage of the optic nerves
 + nasal packing
 Oral care and warm saline gargle
 Cool mist vapour
 X bending over, straining it would increase ICP and CSF leakage in the nose
 WOF: hematoma

Complications:
 Increased ICP
 Bleeding
 CSF drainage
 Hypovolemic shock
 Fluid and electrolyte imbalance
 DI/SIADH
 Infections
 Seizures

NURSING MANAGEMENT FOR PATIENTS WHO HAS ICP

 Neurologic status monitoring
 V/S and NVS 30 minutes if critical, every 1-2 hours if not
 Airway patency and breathing
 Elevate head of bed
 Gentle suctioning
 Hyperventilation therapy to increase oxygen concentration to prevent hypoxia
 Cerebral tissue perfusion
Postion: neutral/midline, 30-45 degrees HOB to prevent increase ICP
 Cervical collar
 X extreme neck/hop rotation, flexion
 Use rotating beds, turning sheets
X valsalva maneuver
 High fiber diet
 Stool softeners, enema
 Instruct to exhale during movement
 Stress relief measures
 Calm atmosphere
 Decrease environmental stimuli
 X emotional stress, frequent arousal
 Fluid balance
 Monitor urine output and osmolality
 Accuarate IVF regulation via infusion pumps
 Indwelling catheters
 Oral hygiene and petroleum
  Infection prevention
 Aseptic technique
 Check, maintain drainage system
 Observe output (cloudiness)

SEIZURE DISORDERS
 Abnormal motor, sensory, autonomic or psychic activity d/t sudden excessive discharge from
cerebral neurons
 Due to sudden or excessive discharge of electrical impulse of electrical neurons
 Decrease in oxygen demand or impairment on cerebral metabolism

TYPES OF SEIZURES
 General seizures- Rapidly bilateral distributed networks
 Focal – within one hemisphere of the brain
 Unknown- epileptic spasms – cells are the problem
 Unclassified- incomplete data to be classified

DIFFERENT TYPES OF SEIZURES BASED ON MANIFESTATIONS

 Grand mal
 known as tonic-clonic seizures
 tonic- causes spasm of the muscle
 clonic- jerking
 buong katawan nanginginig
 Peti mal
 Blank stare
 Jacksonian
 Tonic hands moving to the body
 Sa kamay nagsisimula at pwedeng kumalat sa katawan meron din sa kamay lang
 Complex
 Psychogenic = irritability (sumisigaw, ano ano sinasabi, they talk in different types of
language)

RF
 Genetic
 Cerebrovascular disease
 Hypoxemia
 Fever (childhood) CONVULSION
 Head injury
 Hypertension
 CNS infection
 Metabolic and toxic conditions
 Brain tumor
 Drug and alcohol withdrawal
 Allergies
PATHOPHYSIOLOGY
Decrease oxygen – tataas ang carbon dioxide – bababa energy sa brain – cellular power failure – failure
of sodium potassium pump – hyperexcitability – increased neural impulse – seizures – tataas muscle
activity – increased oxygen demand – metabolic acidosis – cell swelling – mawawala function ng GABA –
prolonged neural irritability – seizure for 5 minutes or more – status epilepticus (DEADLY)

CLINICAL SIGNS
 Involuntary jerking of fingers, hands, mouth
 Dizziness, talking unintelligently
 Unpleasant sights, sounds, odor or taste
 Intense rigidity (generalized seizures)
 Alternating contraction and relaxation (tonic-clonic)
 Epileptic cry
 Tongue is chewed
 Urine and fecal incontinence
 Decrease LOC

After 1-2 minutes:

 Relaxes in deep coma

After seizure episode (postictal state):

 Hard to arouse and sleep for hours
 Confused
 Headache, sore muscle. Fatigue

Focal seizures
 Motor or non-motor symptoms
 Impairment of consciousness and awareness

DX
 Assessments: History and clinical features

Diagnostics:
 MRI to see if the patient is at risk for seizures
 Microelectrodes
 Telemetry
 Single photon emission CT (SPECT) also to see if at risk for seizure

 Electroencephalogram (EEG) records electrical acitivity in the brain through electrode

placement.
Nursing care:
 No anticonvulsants (24-28 hrs)
 No stimulants (coffee, smoking)
 + lubricant, collodion glue
NURSING MANAGEMENT DURING SEIZURE
 + Aura
 Provide privacy and ease patient
 Protect head with a pad
 Loosen constrictive clothing, remove glasses
 Environmental safety
 X attempt to open jaw or insert anything
 X restrain px
 Position: one side with head flexed, bed in lowest position
 Hook to oxygen support
 Suction (if available) ready na dapat para after seizure suction agad
 Time the seizure occurrence
 DOC- diazepam (during)

AFTER SEIZURE:
 Side lying position w/ padded side rails up
 Ensure an open airway / oxygen support
 Suction secretions
 Reorient the px when awake
 Assist px in a comfortable position
 Document the occurence
 Monitor for recurrence
 Seizure precautions
 Maintenance drug: anticonvulsant, phenytoin (dilantin) for 2 weeks to effect

EPILEPSY
 Syndrome characterized by unprovoked
 Recurring seizures
 2 unprovoked seizures more than 24hrs

RF
 Primary
 Idiopathic (unknown)
 Hereditatry
 Secondary (caused by other factors)
 Birth trauma, asphyxia neonatorum
 Congenital malformations
 Head injury
 Infections
 CO and lead poisoning
 Fever
 Circulatory and metabolic
 Drug , alcohol

CLINICAL SIGNS
 Same as seizures
PHARMACOLOGIC MX
 Anticonvulsants
 Phenytoin
 Gabapentin
 Carbamazepine
 Levetiracetam
 Phenobarbital
 Valporate
WOF: withdrawal, toxicity (activated charcoal to neutralize) Or diuretics or enemas.
Phenytoin (dilantin) most common manifestation for toxicity is GINGIVAL HYPERPLASIA OR GINGIVITIS.

SURGICAL MX
 Microsurgical techniques
 EEG with depth electrodes
 Vagal nerve stimulator (VNS)
 Responsive neurostimulation (RNS)
*These are for monitoring device only. For controlling, we rely in pharmacologic mx.

NURSING MX
 Seizure precaution and management
 Px ‘s adherence
 Px and family cooperation
 Periodic monitoring
 Prevention of triggers (stress)
 Regular and moderate routine
 Ketogenic: high fat, CHON, low CHO
 Exercise and rest
 X food stimulants, sleep deprivation
 X photic stimulation
 Oral care (phenytoin) –gingival hyperplasia
 Coping strategies: counselling and recreation
 Medical ID bracelet

STATUS EPILEPTICUS
 Acute prolonged seizure activity
 Generalized seizures without full recovery of consciousness between attacks
 Continuous clinical or electrical seizures lasting at least 5-30 minutes
DISTURBANCES IN CEREBRAL FUNCTION

ALTERED LOC
 Px is not oriented, does not follow commands or needs persistent stimuli to achieve alertness.

Coma
 Clinical state of unarousable unresponsiveness nonpurposeful painful stimuli and brain reflexes
may be present.
 No response

Akinetic mutism
 Unresponsive to environment to environment with no voluntary movement.
 No movement

Persistent Vegetative state

 Resumes sleep-wake cycle after coma but no cognitive, affective mental function.
 EEG to diagnose –beta until delta waves only.

Minimally conscious state

 PVS w/ inconsistent but reproductive signs of awareness.
 Lumuha
 Inangat yung daliri or yung ibang part ng katawan

Locked-in syndrome
 Lesion in pons with paralysis and inability to speak but with vertical eye movement and lid
elevation.
 Eye movement
 Cannot speak
 Paralyzed
 Gumigising natutulog
 Sumasara mata bumubukas
 RF
 Neurologic
 Head injury, stroke
 Toxicologic
 Drug, alcohol intoxication
 Metabolic
 Hepatic/kidney injury, DKA

CLINICAL SIGNS
*Depend on what state in the continuum
 + alterations in GCS (4 eye, 5 verbal, 6 motor)
 Sluggish to fixed pupil reaction (minimal response of the pupil)
 Behavioural changes (irritability, agitation)
 Coma

LEVEL OF CONSCIOUSNESS
 Alert (conscious) – awake, awareness
 Lethargy (mild) – decreased in alertness
 Obtundation (moderate) – further decrease in alertness, decrease in response time
 Stupor (severe) – deep sleep, arousal but w/ elevated stimulations (responds to pain only)
 Coma (unconscious) – deep sleep, unresponsive

COMPLICATIONS
 Respiratory distress or failure problem in the medulla or pons
 Pneumonia px who has altered in loc are at risk for pnuemonia
 Aspiration, dyphagia, lack of
 Pressure ulcer since there are impairment in mobility
 Contractures due to stasis, immobility

DX
 Hx and clinical features
 Neurologic assessments:
 Mental status
 Cranial nerve function
 Cerebellar function check for balance and gait
 Reflexes
 Motor and sensory function
GCS

Laboratory:
 Blood glucose (CBG, FBS, RBS, HBA1C)
 Serum electrolytes, ammonia, liver function (AST/ALT), BUN/creatinine osmolality, PT,PTT,
ketones
 ABGs

Diagnostics:
 CT, MRI, PET
 Electroencephalography measures brain waves

MEDICAL MX
 Oxygen support: oral/nasal intubation (unconscious), tracheostomy (worsen) kapag a decrease
in respirations
 Intravenous therapy to support the imbalance of electrolytes
 Central venous pressure monitoring
 Feeding tubes or gastrostomy

NURSING MX
 Maintain airway
 + secretion accumulation
 Elevate HOB at least 30 degrees
 Lateral or semi prone
 Suctioning w/ oral hygiene
 Chest physiotherapy w/ postural drainage to ensure evacuation of secretions
 Protecting patient
 Padded and raided side rails
 Secure invasive lines and equipment
  X environmental irritants, damp bed/dressing
 Fluid balance and nutrition
 Assess hydration status
 IV therapy regulation
 Enteral feeding
 Mouth care
 Meticulous oral care
 Thin coat of petroleum pag may dry lips
 Switch ET sides
 Solution: Chlorhexidine
 Skin integrity
 Regular turning every 2hrs
 X dragging, pulling force use soft layers or cotton pads
 Correct body position
 Passive ROM if client is immobile
 Assistive device: foam boots, trochanter rolls
 Maintain body temperature
 Hypothermia blankets and cool baths
 Adjust room temperature
 Antipyretics as prescribed
 Prevent urine retention
 Monitor urine output
 Intermittent catheterization
 External catheters/absorbent pads
 Bladder training programs
 Promote bowel function
 Dietary promotion
 Stool softeners, enema lactulose 30mL
 Glycerin suppositories kapag di na nag effect ang stool softeners
 Restoring health
 Sensory activities (talk,touch)
 X negative comments
 Read a book, radio, television
 Frequent rest and quiet times
 Allow experience on missed events
*The last to be eliminated is hearing sensory
 Family needs
 Considerate time, assistance and support
 Reinforce, clarify information
 Involve in care and support decision-making
 Listen and encourage verbalization
 Monitor and manage complications
 Vital signs every 1-2 hours – NVS (GCS, papillary reaction, muscle strength)
 Monitor status
 Refer and respond to complications
NEURO TRAUMA

HEAD INJURY
 Broad classification encompasses any damage to the head as a result of trauma.

TRAUMATIC BRAIN INJURY

 Results of an external force and is of sufficient magnitude to interfere with daily life and
prompts seeking treatment.

TYPES OF TBI
 PRIMARY INJURY
 Consequence of direct contact to the head/brain during the initial injury
 Motorcycle accidents
 Within 24 hours

 SECONDARY INJURY
 Hours days after injury resulting from inadequate delivery of nutrients and oxygen d/t
intracranial metabolic process
 Hours to days before it develop

RF
 Falls
 Vehicular accidents
 Struck by objects
 Assaults
Age: 0-4; 15-19; 65 yrs old
Sex: M > F

SCALP INJURY
 Minor isolated trauma resulting in abrasion, contusion, laceration or hematoma beneath the
layers of tissue of the scalp (subgaleal hematoma).
 Emergency: avulsion (tearing aways) natapyas yung scalp

DX
 Physical examination

Management:
 Irrigation (risk for infection) PNSS
 Suturing

SKULL FRACTURE
 Break in the continuity of the skull caused by forceful trauma
 Open fracture (basag bone, open skin)
 Close fracture (intact skin pero may fracture sa loob)
DIFFERENT TYPES OF SKULL FRACTURES
 Simple (linear)
 Break in the continuity of the bone
 Crack
 1 line

 Comminuted
 Splintered or multiple fracture line
 Maraming fracture line
 Durog

 Depressed fracture
 Forceful downward displacement (splintered to embedded to skull tissue)
 Lumubog
 Dumikit sa skull tissue

 Basal
 Base of the skull that can transverse to frontal paranasal sinus or temporal bone
 Can extend to frontal to temporal (pababa)

CLINICAL SIGNS
+ persistent, localized pain

 Basal skull fracture

 Hemorrhage of nose, pharynx, ears
 Blood under conjunctiva
 Ecchymosis over mastoid (also known as battle sign)
 CSF otorrhea (ear)
 CSF rhinorrhea (nose)

DIAGNOSTICS
 CT, MRI
*suspect for associated brain injury

MEDICAL MX
 *Close observation
 Nondepressed fractures
 Surgical not required
 Depressed fractures
 Skull elevation and debridement within 24hrs

BRAIN INJURY

 Blunt traumatic brain injury (closed)

 Head accelerates then rapidly decelerates or collides with another object
 No opening through skull and dura
 Penetrating traumatic brain injury (open)
 Object penetrates the skull, enters the brain and damages soft brain tissue
  Blunt trauma that the scalp, skull and dura

UNDER BRAIN INJURY there is:

FOCAL BRAIN INJURY

 Direct location/specific location where the brain injury actually occurred.

Types of focal brain injury:

 1. Contusion
 Brain is bruised and damage in a specific area d/t severe acceleration-deceleration force or
blunt trauma
 Mas malala yung impact sa opposite side kung saan tumama ang ulo

CLINICAL SIGNS:
Depend upon size, location and extent of surrounding cerebral edema
+ decrease in LOC: stupor, confusion
Hemorrhage, edema within 18-36 hrs

COMPLICATIONS:
 Increased ICP
 Herniation syndrome
 Deep contusions: hemorrhage
 Reticular activating fiber (arousal)

 2. Intracranial hemorrhage
 Epidural hematoma:
 Blood accumulation in the epidural space (between skull and dura matter)
CAUSE: skull fracture resuting to rupture of middle meningeal artery

CLINICAL SIGNS:
 + brief decrease LOF w/ lucid interval of consciousness
 Compensation: rapid CSF abosorption
 Decrease intravascular volume

COMPLICATIONS:
 Increase ICP: restless, agitated, confused = coma
 Herniation: focal neurologic deficits
 + fixed dilated pupils
 Paralysis
 Respiratory arrest

MEDICAL MX:
 ICP management
 Elevation of the head 30 degrees
 Avoid valsalva maneuver
 Assisted ventilation
SURGICAL MX:
 Burr holes
 Craniotomy
 Drain insertion

 2. Intracranial hemorrhage
 Subdural hematoma
 Blood accumulation in the subdural space (between dura matter and brain)
CAUSE: trauma, coagulopathies, ruptured aneurysm

CLINICAL SIGNS:
 Acute SDH
Cause: major head injury – contusion, laceration
S/sx: - rapid change in LOC
 Papillary signs
 Hemiparesis (paralyzed kalahati ng katawan)

 Chronic SDH
Cause: minor head injury, aging – brain atrophy
S/sx: - intermittent severe headache
 Alternating focal neurologic signs, seizures
 Personality changes, mental detoriation

MEDICAL MX
 Increased ICP management
 Intensive monitoring

For Acute SDH

 Immediate craniotomy
 Evacuation of clot

For Chronic SDH

 Multiple burr holes
 Craniotomy
 Evacuation of clots

 3. Intracerebral hemorrhage
 Bleeding in the parenchyma of the brain

RF
 Head injuries by force
 Systemic hypertension
 Aneurysm rupture
 Vascular anomalies
 Intracranial tumors
 Bleeding disorders: leukemia, haemophilia, aplastic anemia, thrombocytopenia
 Anticoagulant therapy
CLINICAL SIGNS
 Insidious onset
 + neurologic deficit followed by headache

SURGICAL MANAGEMENT
 Craniotomy
 Craniectomy

DIFFUSE BRAIN INJURY

1. Concussion
 Temporary loss of neurologic function with no apparent structural damage to brain

RF
 Blunt trauma
 Acceleration-deceleration force
 Direct blow
 Blast injury

CLINICAL SIGNS
 Frontal lobe: bizarre irrational behaviour
 Temporal lobe: temporary amnesia or disorientation
 + decrease LOC, worsening headache, dizziness
 Abnormal pupil response, vomiting
 Slurred speech, numbness and weakness
 Irritability, seizures
 Repeated concussive incidents
 Leads to Chronic traumatic encephalopathy
 Personality changes
 Memory impairment
 Speech and gait disturbance

2. Diffuse axonal injury

 Damage of the brain (axons, cerebral hemisphere, corpus callosum, brainstem) d/t
widespread shearing and rotational forces
 Mismong sa brain ang problema
CAUSE: prolonged traumatic trauma

CLINICAL SIGNS:
 Immediate coma
 Decorticate and decerebrate posturing
 Cerebral edema
DX
Assessment:
 History and clinical features
 Neurologic Assessment

Diagnostics:
 CT, MRI, PET Scans
 Cervical spine x-rays
*pag merong brain injury si client, rule out spinal cord injury also.

MEDICAL MX FOR HEAD INJURIES:

 Emergency management
- Suspect spinal cord injury
- Transport using spine board
- Cervical collar
 Goals:
- Preserve rain homeostasis
- Prevent secondary injury
- Stabilize respiratory and cardiovascular function
 Intensive care unit
 ICP monitoring management
- Elevate head of bed
- Maintain normal blood volume
 Supportive measures
- Ventilator support
- Seizure precautions
- Fluid and electrolyte maintenance
- Nutritional support
- Pain and anxiety

BRAIN DEATH:
 Cardinal signs
- Coma
- X brainstem reflexes (deep tendon reflex’s)
- Apnea (absence of breathing)

PHARMACOLOGIC MX
 Anticonvulsants
- Phenytoin
 Benzodiazepines (decrease workload of the brain, sedative)
- Lorazepam
- Midazolam
 Citicoline to increase cerebral perfusion 1g through IV push
 Stool softeners to decrease valsalva maneuver
- Laxatives
- Enemas
SURGICAL MX
 Evacuation of blood clots
 Debridement
 Elevation of depressed fracture
 Suture scalp lacerations
*DOC for cerebral edema- Mannitol to decrease edema in the brain. Usually taken with corticosteroids
(prednisone, SONE drugs) to decrease inflammation in the brain.

NURSING MX
 Maintain airway
- If client is unconscious drainage of oral sections
- Head of bed 30 degrees
- Effective suctioning
- Aspiration precaution
- ET, MV, PPEP
- Good oral hygiene
- Monitor ABGs
 Monitor neurologic function
- Level of consciousness
- GCS and NVS
- Papillary reactions
 Vital signs
- Monitor in frequent intervals
- Denotes increased ICP
- Increase systolic BP
- Decrease heart rate widened pulse pressure (cushing reflex)
 Motor function
- Observe spontaneous movements
- Comparing strength:
Upper: squeeze finger’s
Lower: hand on soles of the feet
- Motor response to pain
 Fluid and electrolyte balance
- Monitor: serum, urine osmolality
- Risk: HypoNa+ hypergly
- Monitor intae and output
- IV: hypertonic to release edema
 Adequate nutrition
- Early initiation
- Enteral or parenteral nutrition
 Maintain body temp
- Every 2-4hrs
- Cooling devices
- Acetaminophen
- WOF: shivering
  Prevent injury
- + Restlessness
- Assess for bladder distention
- Use padded side rails
- X opioids
- Decrease environmental stimuli
- Lubricating skin with oil emollients
- External sheath catheters
 Skin integrity
- Assist in turning and moving
- Turning/reposition every 2hrs
- Skin care every 4hrs
 Improve sleeping pattern
- Group nursing care activities
- Decrease environmental noise
- Dimmed room
 Managing complications
- Systemic hypertension
Increase IV fluids + vasopressors
- Post traumatic seizures
Immediate: within 24 hrs
Early: 1-7 days
Late: 7 days after
Seizure precautions

CONTROLLING ICP IN SEVERE BRAIN INJURY

 Elevate the head of bed
 Head and neck in neutral position
 X valsalva maneuver
 Maintain body temp
 Pa02 > 90 mmHg
 Mainatin fluid balance: 3% PNSS
 Avoid noxious stimuli
 Administer sedation (propofol, dexmethedomidine)
 Maintain CPP 5-70 mmHg
*pag may secretion si client pero bawal mag suction, do chest physiotherapy or abdominal thrust.

 Patient coping
- Refer to the neuropsychologist
- Counselling
- Cognitive rehab activities
- Sensory stimulation (watching tv)
- Behavioural modification
- Reality orientation
- Computer training programs
 Family coping
- Assess status and difficulties
- Discusss changes/ progress of the px
 - Accurate and honest information
- Family counselling, support groups
- Assist decision-making and permit organ donation

NGT INSERTION

ASSESSMENT (FOR INSERTION)

 Identify the indication and the need for NGT insertion
- Ex. Patient who undergone surgery. Bawal sila ngumuya.
- Upper GI bleeding such as ulcerations in the stomach
- Unconscious
- Gastric gavage and lavage
 Check for hx of nasal surgery or deviated septum
 Assess patency of nares
 Determine ability to swallow and presence of gag reflex
 Assess knowledge status of the px

PURPOSES OF NGT
 To administer tube feeding (gastric gavage) – administration of solution to the GI tract
 To provide suction and prevent gastric distention/to decompress – to evacuate the blood clots
 To lavage the stomach (gastric lavage)
 To instill medication
*you cannot crash enteric coated drugs

PHYSICIAN INSERTS THE NGT IN CASES OF:

 Patients with alteration in LOC
 Clients w/ oral or esophageal abnormalities
 Post oral surgery px
 Clients with gastric hemorrhage
 Pre and post gastric surgery clients

EQUIPMENTS
 NGT 9usual sizes: F 16, 18 Adult; F 10, 12, 14 Pedia
 Clean gloves
 Glass of distilled water w/ straw
 Asepto syringe or bulb yringe
 Non-allergic tape 1” wide
 Water soluble lubricant
 Paper towel or bib cloth
 Stethoscope
PROCEDURE
 Verify doctor’s order for NGT insertion
 Introduce yourself and very client’s identity
 Explain the procedure to the client
 Gather all necessary equipment
 Provide client privacy
 Place the client in a high fowler’s position and lower side rails – if it’s contraindication, semi
fowler’s position can do
 Perform hand hygiene. Put on gloves
 Prepare the tube (check the packaging; color, appearance, size) open packaging and place it in
your dominant hand. Use the tube to mark-off the distance from the tip of the patient’s nose
and then to the earlobe to the xyphoid process. – to ensure the length will reach the px stomach
 Lubricate the tip of the tube w/ a water soluble lubricant – for easy passageway and avoid
trauma or injury
 Insert the tube into the nostril w/ its natural curvature (downward)
 Ask the px to hyperextend the neck and gently advance the tube towards the nasopharynx – for
better visualization and smooth procedure
 Direct the tube along the floor of the nostril towards the ear on that side with slight pressure
 If the tube meets resistance, withdraw the tube. Relubricate and insert in the other nares – if
both have resistance, withhold and wait then try again.
 Once the client reaches the oropharynx, ask the client to tilt head forward (flexion) and
encourage to drink or swallow
 Advance tube for 5-10 cm with each swallow, until desired length is inserted.
 Verify correct placement of the tube
- Check pH aspirate
- Instill 30mL of air observe for gurgling sounds
- Confirm tube placement using radiographic scan (most accurate)
 If improper placement, withdraw tube gently, let client rest and repeat procedure.
 Secure tube by taping it into to the bridge of nose and bring split ends around the tubing and
back up over the nose
 Clamp and secure end of the tube. Either clip on clothing or head part of the bed.
 Place the client in a comfortable position and raise side rails
 Remove gloves, perform hand hygiene and dispose waste materials
 Document type of tube, laterality of nostril, tube condition and px’s response.
*For the silicone, put it in the fridge for a couple of minutes for easier insertion. (pinapatigas)
*for the normal tube, warm the tube first for it to become soft. (pinapalambot)
*check the pulse of the px

ASSESSMENT (FOR FEEDING)

 Identify the indication and need for NGT feding
 Assess knowledge status
 Assess px status
 Assess px for food allergies
 Assess abdomen for distention and abnormality
*NGT is administered every 4 hours. 8am,12pm,4pm,8pm,12am,4am -6x
EQUIPMENT
 Clean gloves
 Distilled water
 Asepto syringe or bulb syringe
 Paper towel
 Stethoscope
 Prescribed formula or feeding solution

PROCEDURE
 Verify doctor’s order for NGT insertion
- Verify caloric reqs of client
- How frequent the administration of NGT
- What type of feeding
- Nutritional components
- For instances, blendered egg white
 Introduce yourself and very client’s identity
 Explain the procedure to the client
 Gather all necessary equipment
 Take client v/s – to know baseline status of px
- If bradycardic or hypotensive, withhold the feeding. Call the physician.
 Place the client in a high fowler’s position and lower side rails – if it’s contraindication, semi
fowler’s position can do
 Perform hand hygiene. Put on gloves
 Clamp the tube. Para walang pumasok na air (attach in the px clothing or head of the bed)
Attach bulb syringe. Place stethoscope over epigastric area. Unclamp muna then Instill air and
observe for gurgling sound. Aspirate contents. 20-30 okay lang. more than 60-100 aspirate is
left, withhold the feeding.
 Clamp the tube and remove plunger/bulb. Before removing the plunger, you kink the tube para
walang pumapasok na air.
 Flush the tube with 30mL distilled water (luke warm)
 Obtain formula (type, amount, temp)
 Gently pour formula into NG tube while releasing clamp from tube.
- Usually the normal feeding/formula for the px is 250-300mL
- Wag punuin kasi baka umubo sip px tatalsik. ¾ will do.
 Let it flow via gravity at a prescribed rate. Raise or lower to adjust. Observe for discomfort such
as nausea and vomiting, abdominal cramping, abdominal pain.
*if the px cannot tolerate the feeding (naduwal, nasuka, nag cause ng distention) – refer to the
attending physician.
*pag gusting mabilis ang pagbaba ng formula/feeding, itaas lang. Ibaba kung gusto bumagal.
*pag viscous mabagal talaga.
*If there is debris (buo-buo) pwedeng ipinodt pindot para ma-melt but never push.
*Aspirate = residual volume = ibalik then withhold the feeding since meron pang laman.
 Once the feeding has consumed, you kink it again then flush the tube once feeding tube is
drained. – to dissolve any form of debris. Prevents clotting in the tube.
 Once the flushing is done, clamp the tube then remove syringe and clamp tube. Secure the tube.
 Place in a comfortable position of atleast 30 minutes. Raise side rail. – prevent digestion of the
solution and prevent aspiration.
 Dispose equipment. Remove gloves and perform hand hygiene.
  Monitor signs of abdominal distress.
 Document type of feeding and patient’s response.

MEDICATIONS BY FEEDING TUBES

Important consideration:
 Can an ordered tablet be crushed and delivered through tubes?
- YES but not enteric coated.
 Will interactions between the drug and the feeding solution degrade nutrient components, alter
the drug’s bioavailability or clog the tube?
- POSSIBLE. Observe for drug to drug interactions.
 Will the medication change the osmolality or pH in the feeding system or cause GI intolerance,
nausea and vomiting, cramping and diarrhea?
- POSSIBLE. Drug the study. Take note of the feeding or different medications that is being
administered to the px.

REMOVING A NASOGATRIC TUBE

PROCEDURE
 Verify doctor’s order. Introduce self. Identify px. Explain the procedure. Perform hand hygiene.
Wear gloves. Provide privacy. Make sure that the gastric drainage has deceased since the tube
was inserted.
 Auscultate the px’s bowel sounds for 2 to 5 mins.
 Sk if the px has paased flatus
 Observe for abdominal distention
 Note whether the px can tolerate small amounts of ice chips or if he is experiencing nausea and
vomiting.
 Remove the adhesive tape securing the tube to the client’s nose. Unpin the tube form the
client’s gown.
 Suggest that the client to keep the eyes closed while withdrawing the tube. – For comfort. It will
easen up the anxiety of the px
 Instill 50 mL of air through the tube (optional)
 Clamp the tubing or kink your fingers. DO NOT remove NGT if client cannot tolerate clamping.
 Ask the client to take deep breath and hold it while you steadily and quickly remove the tube.
- Possible that the epiglottis will move making the patient to vomit.
 Dispose of the tube in a bag or paper towel
 Provide tissues for the px to blow the nose and offer mouthwash if desired. ORAL CARE
 Document removal of the tube, client’s response and amount of fluid drained.
AUTOIMMUNE

GBS: GULLAIN BORRE SYNDROME - ASCENDING PARALYSIS

CAUSE: Idiopathic – autoimmune (infection) – attacks the nerve – destroys myelin sheath – it starts of
lower extremity – paresthesia (burning or tingling sensation, numbness) – progressive upward paresis –
paralysis – easy fatigue – paralysis of the phprenic nerve – problems in the diaphragm – respiratory
paralysis. –

DX
 Hx of infection
 IGM
 O2 sat/ ABGs

MX
 Promote safety
 Range of motion exercise
 Diet = liquid diet
 Respiratory mx
- Oxygen therapy (high dose 6-10 liters per minute)
- Insertion of ET tube and mechanical ventilation
 Antibiotics
- DOC: Piptazo
 Support mx
- Vitamin B complex (neural enhancer or neural support)
 Steroids – to stop immune response
 Plasmapharesis – to remove anti bodies
 Decrease stress

MS: MULTIPLE SCLEROSIS – DESCENDING PARALYSIS

Tracheostomy

CAUSE: Idiopathic – Autoimmunity (existence of previous infection) – attack the neurons – myelin
sheath – upper extremities – problems in muscle control – facial muscle abnormality – facial paralysis –
facial droop – mastication problems; magkakaroon ng dysphagia– bababa sa internal organs – problems
in urinary system – problems in the sphincter – incontinence – respiratory inactivity – pneumonia –
laringgo spasm –

DX
 Check for hx of infection
 Immunoglobulin M – to indicate autoimmunity
 02 sat and ABGs

MX
 Safety
 Range of motion exercises
 Diet = liquid diet
  Can administer NGT as long as client can still swallow (much better)
 Respiratory
- Oxygen therapy
- ET tube or mechanical ventilation
- Tracheostomy (safer) if there is already laryngospasm
 Immunosuppresants
- Steroids (prednisone)
 Infection = Antibiotics (piptazo)
 Decrease stress

MG: MYESTENIA GRAVIS

CAUSE: Idiopathic – autoimmunity (existing infection) – attacks the ACH preceptors (muscle movement)
– block the ACH entrance – mawawala action potential – muscle paresis – muscle paralysis – immobility
– fatigue

DX
 Check on the available ACH
- Perfrom tensilon test
- Binibigay by giving anticholinesterase drug
- Positive pag nagkaron ng muscle improvement/contraction
- Igm

MX
 Ensure safety
 Range of motion exercises; to prevent muscle atrophy
 Immunosuppressants: STEROIDS (prednisone)
 Plasmapharesis

PHARMA MX
 Anti-colinesterase
- Neostigmine effect is 4-6 hrs
- Pyridostigmine effect is 12 hors
 Antibiotics if there is pre-existing infection
- Piptazo

PARKINSON’S DISEASE
 Problem in dopamine
 Distraction of your substancia nigra of the basal ganglia
 Loss of dopamine
 The more na gumagalaw the na nangininig (TREMORS)

CAUSE: Idiopathic – autoimmunity – basal ganglia – obsruction of the substantia nigra – loss of
dopamine – loss of inhibitory effects – leads to tremors – lead to pill rolling of the hands – activity
intolerance – ataxia – gait – speech chewing – facial muscle = PROBLEMS
DX
 MRI, CT SCAN

MX
 Diet = Soft diet (aspiration precaution)
 Range of motion exercises; for those na kaya pa
 Safety of the client

PHARMA MX
 Amatadine – it will slow down the progression of the disease
 DOC:
- Levodopa
- Carbidopa
 Vit. B6 – it inhnaces the levodopa and carbidopa

STROKE

CEREBROVASCULAR DISEASE (CVD)

 Abnormality of the central nervous system that occurs when the blood supply to the brain is
disrupted.
 Decrease in blood supply leading to cerebral hypoxia (decrease in level of oxygen)

TYPES OF CVD

1. TRANSIENT ISCHEMIC ATTACK (TIA)

 Temporary ischemia/blockage
 Neurologic deficit lasting 1-2 hours (motor, sensory, visual function)
 Obstruction

2. ISCHEMIC STROKE
 Stroke or brain attack
 Sudden loss of function resulting from disruption of the blood supply to a part of the
brain
Different type of ischemic stroke:
1. Large artery thrombotic strokes
 Atherosclerotic plaques in the large blood vessels
 Started in part of circle of willis

2. Small penetrating artery thrombotic stroke also known as “lacunar stroke”

 Affects one or more vessels

3. Cardiogenic embolic strokes

 Originate from the heart and circulate to the cerebral vasculature (cardiac
dysrhythmias)
 Blood clot na napunta sa brain

4. Cryptogenic strokes
  No known cause

5. Other causes
 Drug use, (cocaine), coagulopathies, migraine/ vasospasm, spontaneous dissection

RF
 Asymptomatic carotid stenosis
 Atrial fibrillation
 Diabetes (accelerated atherogenesis)
 Dyslipidemia *fasting of lipid profile; 10-12 hours; fbs; 8-10 hours; 10 hours pag sabay –
These can diagnose CVD and Cardiovascular disorders
 Excessive alcohol/tobacco consumption
 Hypercoagulable states
 Hypertension
 Migraine
 Obesity
 Sedentary lifestyle
 Sleep apnea

HEMMORHAGIC STROKE
 Loss of function due to bleeding into the brain tissue, the ventricles or the subarachnoid space
 Dumugo, sumabog yung vessel causes bleeding in the brain
 Increase in ICP

Different types of HS
1. Primary intracerebral hemorrhage; bleeding in the brain tissue/rupture in the blood vessel
2. Secondary cerebral hemorrhage; other causative factor (aneurysm, napalo, nauntog)
3. Subarachnoid hemorrhage; bleeding in the space between the skull and brain

RF
 Hypertension
 Cerebral atherosclerosis
 Brain tumors
 Medications: anticoagulants, amphetamines
 Arteriovenous malformations
- Abnormality in embryonal development leading to tangled and veins.
- It is a congenital problem
 Intracranial aneurysm
- Dilation of cerebral artery as a result of weakness of the wall
- Common: circle of willis
 Unknown
 Atherosclerosis
 Congenital defect
 Hypertensive vascular disease
 Head trauma
 Aging
CLINICAL SIGNS OF SCHEMIC STROKE
Depend on the location of the lesion, size of area, amount of collateral blood flow
 + alterations in GCS (eye,verbal,motor)
 Numbness and weakness of face, arms, legs
 Confusion or change in mental status
 Speech disturbances – frontal lobe problem
 Sensory and motor disturbances
 Sudden severe headache

 Motor deficits
- Loss of voluntary control
- Flaccid or decrease DTRs
- Hemiplegia vs. Hemiparesis
- Ataxia: unsteady gait
- Dysarthria: difficulty forming words
- Dysphagia

 Verbal deficits
- Expressive aphasia; alam sasabihin pero hindi alam pano sasabihin
- Receptive aphasia; wernicke’s are affected (temporal lobe) – problems in understanding.
Naririnig nip x pero hindi naiintindihan.
- Global (mixed) -both

 Visual deficits
- Homonymous hemianopsia
- Diplopia: double vision
- Loss of peripheral vision

 Sensory deficits
- Paresthesia
- Loss of proprioception
- Agnosia: loss of ability to recognize objects

 Cognitive deficits
- Memory loss
- Decreased attention span
- Impaired concentration
- Poor reasoning, judgement, comprehension

 Emotional
- Loss of self control
- Emotional lability; walang pake
- Changes in behaviour
- Decrease tolerance to stress
- Fear, hostility, anger
- Feeling of isolation
CLINICAL SIGNS FOR HEMORRHAGIC STROKE
+ sudden severe headache = ruptured in the brain
 Intracerebral hemmorhage
- Nausea and vomiting
- Early sudden change in LOC; causing of hypoxia
- Seizures (common manifestation)

 Intracranial hemmorhage
- Nuchal and spinal rigidity; panful back and neck
- Visual disturbances
- Tinnitus, dizziness
- Hemipharesis

Complications:
 Rebleeding or hematoma expansion
 Vasospasm 7-10 days
 Acute hydrocephalus
 Seizures

DX
 Assessment
- Hx and clinical features

 Diagnostics
- Plain cranial CT (<25mins. –to prevent secondary injuries of the brain)
- MRI, ECG, Doppler studies
- CT angiography - visualization
- Lumbar puncture; location: L4 & L5

NURSING MANAGEMENT
 PERIOPERATIVE CARE
CT SCAN: Cerebral Angiography (eschemic stroke)
Nursing Care:
- Check BUN, creatinine; excretion of the dye (iopanidol); 30 minutes prior to the CT scan pag
MRI naman, Gadiodamide
- + well hydrated = clear fluids prior para mag spread
- Peripheral pulses are marked
- Educate on possible warm sensation
- Through cannula intravenously
Medical mx:
Emergency Mx
- Acute stroke team= “stroke code”
- Diagnostics within 25 minutes
- National institutes health stroke scale (NIHSS) 0-42
- Frequent neurologic assessment (NVS) – every hour
-GCS, muscle strength upper and lower, pupillary reflex
PHARMACOLOGIC MX
 Anticoagulants – prevent blood clot
- Warfarin for A.Fib nursing consideration: monitor PT/PTT, INR 0.5-1-5
- Dabigatran
- Apixaban
- Endoxaban
- Rivaroxaban

 Antiplatelets – blood clot

- Aspirin
- Clopidogren
*DO NOT MIX THESE TWO, HINDI SABAY BINIBIGAY.

 Psychostimulants – it increases cerebral perfusion

- Citicholine

 Antihypertensives + diuretics
 Statins – for hyperlipidemia
*If the client has cerebal edema, we can administer osmotic diuretic, mannitol.
- Check client’s blood pressure. Di pwede ibigay pag hypotensive.

 Thrombolytic Theraphy (for eschemic stroke only)

Treat by dissolving clots
- Given within 3 hours from attack
- Within 60 minutes upon ER
- Intra-cranial ang administration
- Recombinant t-PA 0.9 mg/kg (max. 90 mg)
- 10% = bolus x 1 min.
- 90% = 1 hour infusion
Nursing care:
 Cardiac monitoring; V/S
 NO anticoagulant for 24hrs.
 Non-invasive
 Monitor for bleeding

Medical mx:
For non t-PA candidates due to unknown onset of stroke
- Anti-coagulants: Heparin, LMW heparin (enoxaparin, subQ once a day for 3-5 days only)
- Osmotic diuretics (mannitol)
- Oxygen theraphy (02sat >95%)
*if client manifest respiratory depression during the attack, intubte the px and hook to
mechanical ventilation.
- Intubation + MV
- Hemodynamic monitoring
SURGICAL MX
 Carotid endarterectomy (CEA)
 Carotid artery stenting (CAS)
*to remove plaque
 Hemicraniotomy; half of the skull bubuksan tapos tatangalin yung blood clot or the affectation.

MEDICAL MX FOR HEMORRHAGIC STROKE

 Frequent neurologic assessment
 Oxygen therapy (ET to MV)
 Maintaining hemodynamic status
 IV: hypertonic solutions – humahatak ng fluid and electrolytes
 CSF drainage: ventricular catheters
 Pnuematic compression devices

 TRIPLE-H Theraphy
- Hypervolemia
- Arterial hypertension
- Hemodilution

 IF THE PROBLEM IS DUE TO EXCESSIVE anticoagulants

- Correct INR w/ FFP or vit. K
- Hemodialysis
- Oral activated charcoal
- Prothrombin complex concentrates
- Recombinant activated factor VIII

 To decrease bleeding
- Give low molecular weight heparin
- Unfractioned heparin

PHARMA MX
 Calcium channel blockers to decrease vasospasms
- Nimodipine
 Psychostimulants
- Citicholine
 Antihypertensives
- Nicardipine (continuous infusion)
- Labetalol
- Hydrazaline
Goal: 140mmHg
 Phenytoin – use to control seizures
 Mannitol

SURGICAL MX
 Craniotomy – if there is hemorrhage
 Ligature or clipping – if there is aneurysm
 Interventional Neurodiology (we put coils, embolic agents or stent)