Neuro question

[elthia]

This doesn't quite fit in neuro intensive care, so I'll ask here.

I had a pt with a brain tumor that was causing hydrocephalus, and was compressing the cerebellum and brainstem, and had cerebral edema, on neuro checks q4 hours, and on decadron q4 hours. Pt alert/confused, PERRLA, BP and P were elevated from baseline, MD aware.

I placed the pt on seizure precautions, wrote nursing orders to have room kept dimly lit and as noise free as possible, Spoke with nurse supervisor, who advised HOB be kept low due to the fact the tumor was occluding the ventricles, pt continually sitting up in bed. Pt did not have a ICP monitor or a shunt, no way to measure ICP.

Went home, did some research, called work and told them to keep head of bed elevated per my nursing references it would help decrease ICP, cerebral edema.

A coworker implied that I was over reacting.

what would you have normally done??

[hrtprncss]

transfer to icu to r/o herniation but first insertion of icp to monitor level and possible administration of mannitol prn. hob high and head straight to drain excess fluid and decrease cerebral edema.

[fireflyLPN]

All in all, I think you did a good job. Besides the advice that was already given I would see about getting an order for Accuchecks. Where I work it is protocol to do Accuchecks when the pt is on Decadron.

[elthia]

transfer to icu to r/o herniation but first insertion of icp to monitor level and possible administration of mannitol prn. hob high and head straight to drain excess fluid and decrease cerebral edema.

MD didnt' want to transfer to ICU, supposedly they are to discuss end of life issues today with the family.

[hrtprncss]

oh if you're thinking about palliative or hospice care, end of life discussion with family, i assume you have a dnr order already just in case the patient doesn't go into full herniation. well i guess just do supportive care and you're doing what you're supposed to be doing.

[papawjohn]

Hey Y'all

Ms Hrtprncss (I cheated and looked this time ) gets my vote. The 'neuro position' is HOB up 45degrees and head straight (not tilted over onto a shoulder or twisted around to the side). This promotes drainage from the venous side of the cerebral circulation.

Papaw John

[hrtprncss]

papawjohn stop following me lol j/k

[CritterLover, BSN, RN]

there is actually pretty differing viewpoints on the hob up/hob down positions in pts at risk for/with elevated icps.

where i have worked as an rn, we have always kept the hob elevated for pts with elevated icps/brain injuries, for the reasons stated: to promote venous drainage from the brain, and decrease swelling. we would have been *shot* there had the hob been less than 45 degrees (unless it was a sci pt, as well).

however, i went to nursing school out west. there, we were taught to keep the hob at a fairly low angle, 30 degrees or less. the rationale for this was to keep the blood perfusing the brain. the thought was that by elevating the hob, you made it more difficult to perfuse the brain, especially if the icp was elevated as well. we were taught at that time that elevating the hob was "old" and that newer research was showing it didn't work.

i no longer work with neuro patient much, but am told by my collegues who do that they are still elevating the hob (in the hospital where i used to work.)

i'm not sure which is correct according to current research, but wanted to mention what i had been taught.

(by the way, the instructor for that part of the course was a apn who worked in a major trauma center with a group of neurosurgeons).

[elthia]

oh if you're thinking about palliative or hospice care, end of life discussion with family, i assume you have a dnr order already just in case the patient doesn't go into full herniation. well i guess just do supportive care and you're doing what you're supposed to be doing.

No, the patient was FULL CODE at the time, but they didn't want to send him to the ICU, which is why I think I was freaking out. There were no ICU beds left, and all the ICU pt's were on vents or need cardiac monitoring/pacing so no one to "trade" my patient for. I usually only handle general med patients with a good mix of palliative care thrown in.

[fungirl]

No, the patient was FULL CODE at the time, but they didn't want to send him to the ICU, which is why I think I was freaking out. There were no ICU beds left, and all the ICU pt's were on vents or need cardiac monitoring/pacing so no one to "trade" my patient for. I usually only handle general med patients with a good mix of palliative care thrown in.

Elthia, you were right by telling your fellow coworkers to have the hob up. I work in a trauma icu, which most trauma patients have coexisting head injuries. Protocol for head injuries is for hob up 30 degrees, if no contraindications, such as sci. Also, if your doing seizure precautions on a pt. you may worry of aspiration, and once again the hob should be up. The reason for the hob up is because the brains venous system has no valves and this assists it to drain. You might also look up cushing's triad, a group of symptoms that suggest an increasing icp and impending herniation. Also protocol is to keep sbp less than 160. All in all you alerted the doctor and that was the right thing to do!!!

[elthia]

Elthia, you were right by telling your fellow coworkers to have the hob up. I work in a trauma icu, which most trauma patients have coexisting head injuries. Protocol for head injuries is for hob up 30 degrees, if no contraindications, such as sci. Also, if your doing seizure precautions on a pt. you may worry of aspiration, and once again the hob should be up. The reason for the hob up is because the brains venous system has no valves and this assists it to drain. You might also look up cushing's triad, a group of symptoms that suggest an increasing icp and impending herniation. Also protocol is to keep sbp less than 160. All in all you alerted the doctor and that was the right thing to do!!!

well, I don't think a herniation was impending, at least not when I left. His pulse was up from baseline, pupils equal, respers regular. But I guess I just hate it when there are too many pt's going south at the same time, and one has a condition that I never really have handled before.

Had two others going south at the same time this one came to the floor, and only one other RN.

[ADDnurse]

Fungirl you are right in your treatment when trying to prevent a supratentorial herniation but with a posterior fossa tumor the problem you face is subtentorial herniation, and the HOB should be flat. If you raise the head of the bed you can cause shunting of the CSF which causes the ICP above the blockage to suddenly decrease thereby inducing a subtentorial herniation(the pressure below is not caused by excessive CSF but the mass effect of the tumor and accompanying edema) which because of the sudden nature of the incident does not always present with Cushings triad. The only treatment is surgical decompression of the posterior fossa.

Thanks