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If a bone flap was removed to allow more room for the brain to swell, it's very possible there is an area with no protection to the brain tissue itself. This procedure is often resevered as a "last ditch" measure for hydrocephalus refractory to other treatments (shunt, mannitol, etc.) I have heard this commonly, (albeit inappropriate) called "mush head." The nurse is responsible for protecting the area, much as you would the fontanels in an infant.

I wasn't implying anything and my post certainly wasn't directed towards you. Just trying to add my perspective as an experienced neurosurgery nurse and educate those that are new or unfamiliar with that particular scenario. Additionally, the propofol drip can be turned down, but if you're titrating to sedation and the sedative effects are not therapeutic when the MAP rises sufficiently to support ideal CPP, then it may be necessary to try an alternative drug for sedation. Good luck with your Doctorate.

I agree that propofol is a far superior drug for providing sedation in ICU patients under most circumstances, however it should be noted that some patients experience a sustained drop in blood pressure that limits its use, particularly if they have increased ICP. For those who are unfamiliar, it is exceedingly important to maintain cerebral perfusion pressure, usually greater than 60-70 mmHg, in a patient with high ICP. The formula is: (MAP) - (ICP) = CPP

In my experience, barbituate comas are still used, but only as a last ditch effort for cerebral hypertension (not hydrocephalus) refractory to other treatments, such as mannitol in addition to what Gwenith stated. Barbituate comas have some very negative side effects, such as pneumonia, paralytic ileus and severe skin breakdown Additionally its use delays brain death testing, as the drug must be out of the system entirely before testing can be initiated. Pentobarb is fat soluable and takes days to clear. I have seen patients come out of barbituate comas and survive, but their quality of life is questionable (trached, pegged, in a nursing home). The majority of patients I've seen have died, either from complications or the progression of brain death.

As a former Neuro ICU nurse and a current PACU nurse, I hope I can offer some well-rounded advice: 1. Tell your staff that neuro patients and EVDs are not that scary and with a little training, they can care for this population with confidence. 2. Find out if any of your staff nurses have neuro experience. If so, she will probably have the aptitude to learn new information quickly and become a resource person. 3. Review the Glasgow Coma scale and have your nurses practice pupil checks. These are the two main things most neurosurgeons want to know first. 4. Talk with your anesthesia personnel about post-op meds, especially narcotics. Neurosurgeons typically prefer that their patients are not heavily sedated so they can determine if neurologic deficits have improved or worsened with surgery.

I've been working weekends only in ICU for close to 2 years now. The plan at my hospital pays us for 80 hours in 2 weeks when we only work 60 (3 days one week, 2 the next). The majority of people that do it are parents with young children and students. Our policy requires that nurses must have at least a year in ICU before going to weekends and the reason for that is you have to be prepared to work indenpendently quite well. As stated before, you don't have as much ancillary staff and usually get unfamiliar patients due do lack of scheduled surgeries, etc. We have a lot more codes on the weekend as well, mainly because we don't have the critical care docs in the unit and the attendings aren't around either. It seriously hinders your social life, though. Be prepared to have to turn down many social engagements, weekend trips, etc. If you can live with that, you'll be fine. Spend some time getting your confidence built up with your skills and then go for it.

Erin, I had the exact same problems working nights that you described and after a year, I told my manager that I either had to get on days or I was going to have to leave. I just couldn't physically do it and I think that there are some of us whose biological clocks can't tolerate all the switching around. The only thing I can suggest if you want to tough it out is to make sure that you work all your nights together, taking a short nap before your first shift begins and only sleeping until noon or so the day after your last shift. That was the only way nights were even remotely tolerable for me. Good luck!

Having worked both ER and ICU, I have to say that paying diff to ICU and not ED is certainly unfair. I also have to agree with the part of the argument that most all hospital nurses work very hard and each area has differing aspects of the job that are difficult or challenging. That being said, how about those of you who work at facilities with a clinical ladder? Is that a more fair way of rewarding nurses for their knowledge base, experience and skills specific to their practice? I wouldn't know because my hospital doesn't pay critical care diff, nor do we have a clinical ladder.

We haven't experienced a shortage recently, but our peak aneurysm season is over and we've had far more crani for tumor and head injuries lately, so I haven't been giving as much Nimodipine. As for Nicardipine, I attended a presentation last summer by a neurosurgery fellow from Pitt, and he had conducted a study indicating that Nicardipine is as effective as Nimodipine at preventing vasospasm. Of course we still use Nimodipine, as I'm sure it's much less expensive.

Rach, Because this woman was still conscious, I would assume that she was put on a morphine gtt or some other comfort measures were taken to ensure that she would have as peaceful death as possible. I'm sorry you were so freaked out, but consider that this woman had talked with her family prior to becoming so ill and this was what she wanted. It sounds like her prognosis was extremely poor (liver failure is horrible) and she and her family chose to spend those last hours of her life together.

Good thinking NurseyBaby - that's why we make sure the EVD is leveled properly every hour and with any movement of the patient. Also you wouldn't want to LP a patient with a suspected or confirmed spinal cord injury because it's very important to maintain alignment until the spine has been surgically fixated. To answer your question about charting Glasgow, you do it like this: GCS=15 (E=4, V=5, M=6) or whatever your assessment reveals.

Bluesky, Sorry about the old bat projecting her misery onto you. Just ignore her as best you can and see if you can get one of your co-workers to swap assignments with you. Try to do it when you're going to be working several nights in a row so you can keep your assignment. You could also try getting to work a little early and telling her that management wants you to have a more complex assignment and she needs to change you to patients X and Y instead of A and B. If she refuses, write your manager a note on the spot and give specific examples of what she says. Don't ever worry about trying to get her approval because you won't. Every unit I've worked in has one just like her - worked there since they laid the foundation, holier-than-thou, know-it-alls that seemingly gets away with everything. Hang in there and maybe she'll retire soon.

Greetings Paul! Here in the USA, you can come right out of nursing school and work in the ICU, with a training period that varies from 3 to 6 months. ICU here is highly specialized and units are generally broken down by specialty like neurosurgery, cardiothoracic surgery, general medicine/pulmonary, trauma, etc. We do utilize respiratory therapists, and they typically manage your vents, extubate patients that have successfully weaned, maintain O2 flow rates, and draw ABGs. ICU nursing in the US is very stressful, largely because more and more patients are moved into the ICU to die, therefore we often care for extremely sick people with little to no chance of survival (often referred to as futile care).

I've seen DNI patients stay on Bipap as long as a week, but IMO it seems like torture. Just watching a tachypnic patient trying to blow off CO2 on one of those things is exhausting. Longer-term use of bipap also results in some freaky ABGs.

Great answer CritterLover! I might add that Nipride is extremely potent and any sort of "accidental" bolus, even a really small one, could bottom out the patient's pressure, and trust me, you do not want to ever have to code someone in the scanner.