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Increased ICP (939-940, chart
Nur 265 Exam 3 Study Guide Latest
Update 2023 Guatanteed A+.Top
Ranked
(^) Normal ICP 10-15 mmHg, pressures >20 mmHg impair cerebral circulation (^) IICP is leading cause of death from head trauma in pts who reach the hospital alive. (^) Cerebral Perfusion Pressure (CPP) o (^) Blood flow required to provide adequate oxygenation & glucose for brain metabolism o (^) Maintenance above 70 mmHg o (^) CPP= MAP-ICP ▪ MAP=^ (2xD) +^ S^ MAP^ NEEDS^ TO^ BE^ ATLEAST^80 3 (^) Compensation o (^) First Response – CSF is shunted or displaced into the spine (compliance) o (^) Next – Reduction of blood volume in the brain (autoregulation) o (^) As ICP continues to increase cerebral perfusion decreases leading to brain tissue ischemia, edema, vasodilation then acidosis which causes further increases ICP o (^) In edema remains untreated the brain may herniate into spinal canal – death from brain stem compression (^) Assessment Findings o (^) Changes in LOC – First sign of IICP is declining LOC & includes restlessness or confusion to Stuporous ▪ W/o glucose & 02, brain shuts down. Ex. Pt knew who you were in am & now don’t remember o (^) Headache – Quite environment may have photophobia so keep room lights very low. o (^) Change in speech pattern – Aphasia, Slurred Speech o (^) Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify Dr ▪ Normal^ is 6 mm. Getting better if going back toward normal from dilated or constricted ▪ Uneven^ pupils tx as IICP^ until proven otherwise;^ pinpoint^ - brain stem (pons) dysfunction o (^) Abnormal Posturing – Decorticate (flexion) or Decerebrate (extensor) ▪ Decorticate – arms drawn to core, legs^ straight ▪ Decerebrate^ – arms straight and^ stiff, pts rarely survive o (^) Hyperthermia – followed later by hypothermia ▪ When hypothermic – BE CONCERNED,^ pressure on hypothalamus located next to brain stem o (^) Cardiac & respiratory rate/rhythm changes ▪ Tachy^ first^ –^ Increased^ HR^ &^ RR^ before^ brady^ HR^ &^ RR o (^) N/V – Common in IICP o (^) Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia ▪ Late^ response & indicates severe IICP^ w/loss of autoregulation, Imminent death ▪ Systolic BP^ increases^ bc decreased blood flow to brain ▪ Pressure^ on^ Vagus^ nerve^ and^ brainstem^ =^ bradycardia (^) Managing IICP o (^) Elevate HOB 30-45 degrees (unless contraindicated) ▪ If^ hypotension,^ elevate^ HOB^ where^ CPP^ >
o (^) Maintain head in a midline neutral position o (^) Avoid sudden and acute hip or neck flexion during positioning – Log roll pt o (^) Avoid clustering of care (bath followed by linen change) o (^) Coughing and suctioning increase ICP o (^) Decrease cerebral edema – osmotic diuretics (mannitol) & fluid restriction ▪ Mannitol is hypertonic- pulling fluid into vascular space- will inc. fluid output & monitor BP for HTN ▪ Furosemide used in adjunct to reduce incidence of rebound from mannitol. Helps reduce edema & blood volume, decrease Na uptake by the brain, & decrease production of CSF at choroid plexus. o (^) LOW CSF using intraventricular drain system o (^) Control fever w/antipyretics or cooling blanket – do not allow pt to shiver as will increase ICP ▪ ▪ ▪ ▪ ▪ ▪ When^ febrile every cell in body^ needs more 02 and glucose o (^) Oxygenation – Hyperventilate on a vent to decrease CO2 which causes vasodilation o (^) Reduce cellular metabolic demands – barbiturates (-bital, -barbital) and/or sedation (coma)
▪ Epidural^ Hematoma^ –^ Arterial^ bleeding^ between^ dura^ and^ inner^ skull,^ from^ fx^ of temporal bone (^) Have “lucid intervals” – Pt awake & talking then momentary unconsciousness ▪ Subdural^ Hematoma^ –^ Venous^ bleeding^ into^ space^ beneath^ dura^ &^ above arachnoid (^) From laceration of brain tissue, bleeding is slower than epidural, Highest mortality rate (^) Acute SDH – w/i 48 hrs after impact (^) Subacute SDH – 48 hrs – 2 weeks (^) Chronic SDH – 2 weeks to several months ▪ A^ loss of consciousness from an epidural or subdural hematoma is a neurological emergency! o (^) Hydrocephalus – abnormal increase in CSF volume ▪ Caused^ by^ impaired^ reabsorption^ or^ blockage^ with^ outflow^ of^ CSF,^ leads^ to^ IICP o (^) Brain Herniation ▪ Uncus-^ dilated^ non-reactive^ pupils,^ ptosis,^ decreased^ LOC ▪ Central^ –^ Down^ shift^ brain^ stem^ –^ Cheyne-Stokes,^ Pinpoint^ & nonreactive pupils, hemodynamic instability. NOTIFY PHYSICIAL IMMEDIATELY (^) Secondary Brain Injury o (^) Any process that occurs after the initial injury and worsen or negatively influences patient outcomes.
▪ While trying to recover from initial event, something else happens (ex:
meningitis)
o (^) Most common result from hypotension, hypoxia, IICP, & cerebral edema ▪ Damage^ to brain tissue due to delivery of^ O2 and glucose to brain is interrupted ▪ Low^ blood flow and hypoxemia contribute to cerebral edema o (^) Hypotension & Hypoxia ▪ hypotension^ (MAP^ <70),^ hypoxia^ (PaO2^ <80) ▪ Hypotension^ may^ be^ from^ shock^ &^ hypoxia^ from^ resp.^ failure,^ loss^ of^ airway,^ or impaired ventilation o (^) Increased Intracranial Pressure (IICP) ▪ See^ Increased ICP^ section above o (^) Hemorrhage ▪ Begins at moment of impact & potentially life threatening (^) Etiology o (^) Young males, play more sports, take more risks when driving (MVC), consume more alcohol o (^) Falls most common in older adults. (^) Assessment/Interventions o (^) Hx – Did pt lose consciousness? Drug or alcohol consumption? All screened for abuse/neglect o (^) Physical ▪ First^ priority^ is^ assessment^ of^ ABCs^ -^ Report^ any^ sign^ of^ respiratory^ problems immediately! ▪ Suspect^ neck injury until proven otherwise, stabilize w/ C-Collar and backboard (^) Skin breakdown & pressure ulcer formation are concern with spine board & c-collar (^) Once board removed, spinal precautions maintained until HCP indicates it is safe o (^) (1) Bedrest; (2) No neck flexion with a pillow or roll; (3)No thoracic or lumbar flexion w/HOB elevation (reverse T acceptable); (4) Manual
control of C spine anytime collar removed; (5) Log roll ▪ Prevent^ secondary^ brain^ injury^ –^ O2^ &^ lowering^ ICP,^ Vent^ if^ needed,^ do^ not^ want CO2 to rise as it causes vasodilation & IICP. o (^) Vital Signs ▪ Monitor^ VS Q 1-2 hrs –^ May be hypotensive or hypertensive (IV^ fluids to maintain above 90) ▪ Central^ fever caused by hypothalamic damage – no sweating, high, last days-weeks (^) Responds better to cooling (sponge bath, cool air) (^) Fever from any cause is associated w/higher mortality rates ▪ Cushing’s^ Triad^ –^ HTN,^ Wide^ PP,^ &^ Bradycardia^ –^ late^ sign^ of^ IICP^ and^ indicates imminent death ▪ Hypotension^ and^ tachycardia^ indicate^ hypovolemic^ shock o (^) Neuro ▪ GCS ▪ Most^ important^ variable^ to^ assess^ w/any^ brain^ injury^ is^ LOC ▪ Dec or change in LOC is first sign of deterioration (behavior changes, restlessness, disorientation) ▪ Assess^ pupils (^) Pinpoint - & nonresponsive – Brainstem dysfunction @ level of ponds (^) Asymmetric, loss of light reaction, unilateral or bilateral dialed – herniation o (^) Late signs of IICP – severe HA, N/V, seizures, papilledema - always sign of IICP ▪ Motor response - Decorticate or Decerebrate posturing o (^) Psychosocial ▪ Personality^ changes^ –^ temper^ outbursts,^ depression,^ risk-taking,^ denial,^ talkative, outgoing o (^) Therapeutic Hypothermia ▪ Rapidly cool pt to 89.6 – 93.2 for 24-48 hrs after primary injury to reduce brain metabolism and reduce secondary brain injury. o (^) Mechanical ventilation ▪ Maintain^ PaCO2^ at^35 to^38 to^ prevent^ IICP^ from^ vasodilation^ from^ CO ▪ Maintain^ PaO2^ between^ 80-100^ to^ prevent^ secondary^ injury ▪ Lidocaine^ given IV or endotracheally to suppress^ cough reflex; coughing increases ICP
▪ Close attention on neuro to detect early rebleeding or migration of the clip.
Changes in cognition or new focal neurologic deficits must be communicated urgently to the surgeon. o Coil: with stent assist; with balloon assist ▪ Detachable coils placed under fluoroscopy to occlude aneurysm w/o interrupting main vessel flow.
▪ Due^ to rebleeding risk,^ avoid drugs^ that^ interfere with the clotting during recovery ▪ Re-evaluation^ at^ 3,^ 6,^ and^12 months^ w/neurosurgeon^ to^ evaluate^ effectiveness ▪ Frequent neurologic assessments in first 24 hrs post procedure to detect intracranial bleeding. (^) Flow diversion o (^) Shifting blood flow away from the vessel defect, resulting in a thrombosed (clotted) aneurysm over 5-6 mon o (^) Full embolization takes 5-12 months, ongoing monitoring by the neurosurgery ▪ Teach^ pt^ to^ avoid^ strenuous^ activity^ or^ situations^ that^ create^ HTN^ while^ the^ prolonged embolization occurs (^) Liquid polymer embolization o (^) AVMs only, used prior to surgical litigation or to tx small AVMs
o may not provide definitive treatment
▪ Perform^ frequent^ neuro^ assessment in^ the^24 hours post-op^ to^ detect early^ signs^ of bleeding (^) Stereotactic Surgery o (^) Microwave or radio beams are directed to the defective vessels to obliterate the defect. o (^) Swelling around beam site may alter neurologic status o (^) Inform neurosurgeon of ant deterioration in consciousness or new focal weakness or sensory changes. Brain Tumor (957-962) (^) Complications o (^) Cerebral edema/brain tissue inflammation o (^) IICP o (^) Neurologic deficits o (^) Hydrocephalus o (^) Pituitary dysfunction – pressure causing SIADH or DI (^) Symptoms of a Brain Tumor o (^) HA- more severe on awakening in the AM o (^) N/V o (^) Visual changes, diplopia o (^) Seizures, Aphasia o (^) Loss of balance or dizziness o (^) Weakness or paralysis in one part or one side of the body o (^) Changes in mentation or personality o (^) Difficulty thinking, speaking, or articulating o (^) Papilledema (swelling of the optic disc) indicating IICP (^) Diagnosis o (^) CT, MRI, & Skull films conducted first; identifies size, location, and extent of tumor. o (^) EEG, Lumbar puncture, brain scan, and PET scan for further information ▪ To^ prevent^ brain^ herniation,^ LP^ not^ performed^ if^ pt^ has^ signs^ of^ IICP (^) Interventions o (^) Drugs – Chemo alone or in combo w/radiation & surgery, & w/tumor progression – control tumor growth ▪ Oral^ Drugs^ –^ lomustine,^ temozolomide,^ procarbazine,^ methotrexate,^ and^ vincristine (IV) ▪ Analgesics^ –^ Codeine^ &^ acetaminophen are given^ for HA ▪ Dexamethasone^ to^ control^ cerebral^ edema ▪ Phenytoin^ or^ other^ antiepileptic^ drugs^ to^ prevent^ or^ treat^ seizure^ activity ▪ PPIs^ to^ prevent^ stress^ ulcers o (^) Stereotactic Radiosurgery ▪ Alternative^ to traditional surgery ▪ Ionized radiation with radioisotope cobalt-60, w/o damaging surrounding healthy tissue ▪ Tx^ takes less than an hour and only requires overnight hospitalization ▪ Not^ invasive,^ lower^ risk^ than^ craniotomy,^ rapid^ recovery
o (^) Provide reassurance that the surgeon will spare vital parts of brain while removing tumor o (^) Check that the pt has not had alcohol, tobacco, anticoagulants, or NSAIDS for at least 5 days b4 surgery o (^) NPO status for at least 8 hrs b4 surgery (^) Post-Operative Care o (^) Focus is to monitor pt to detect changes in status & prevent or minimize complications (IICP) o (^) Assess neurologic and VS @ 15-30 min for the first 4-6 hrs then Q 1 hr. If pt stable for 24 hrs checks decrease to Q 2-4 hrs. o (^) Immediately report new neurologic deficits – Dec LOC, motor weakness or paralysis, aphasia, dec sensation, & reduced pupil reaction to light. Personality changes (agitation, aggression) can indicate worsening status o (^) Periorbital edema and ecchymosis of one or both eyes is normal, tx w/cold compress o (^) Irrigate affected eye w/warm saline solution or artificial tears to improve pt comfort. o (^) Record I&O for the 1st (^) 24 hrs & anticipate fluid restriction to 1500 mL a day if there is pituitary involvement o (^) Do NOT reposition pt on the operative site o (^) Supratentorial surgery – elevate HOB 30 degrees, avoid extreme hip or neck flexion & midline neutral position to prevent IICP o (^) Infratentorial (Brainstem) craniotomy – Flat and side-lying, alternating sides Q2 for 24- hrs. ▪ Pt^ to remain NPO for 24 hrs due to edema around medulla causing vomiting and aspiration. o (^) Check head dressing @ 1-2 hrs & mark, small or moderate amount expected (30-50 mL Q 8hrs) ▪ Report^ saturated^ head^ dressing^ or^ drainage^ >^ 50mL/8hrs^ immediately^ to surgeon! o (^) Drugs Given routinely ▪ Antiepileptic drugs, H2 Blockers or PPIs for stress ulcer prophylaxis, and glucocorticoids (dexamethasone) to reduce intracranial edema ▪ Acetaminophen^ for^ fever^ or^ mild^ pain (^) Preventing Post-op Complications o (^) IICP ▪ Severe^ HA,^ dec^ LOC,^ restlessness,^ irritability,^ &^ dilated^ or^ pinpoint^ pupils^ slow to react or nonreactive o (^) Hydrocephalus – caused by obstruction of the normal CSF pathway from edema ▪ HA,^ decreased^ LOC,^ irritability,^ blurred^ vision,^ urinary^ incontinence o (^) Subdural or Epidural Hematoma ▪ Severe^ HA, rapid^ dec in LOC,^ progressive neurologic deficits,^ & herniation o (^) Respiratory complications ▪ Atelectasis, PNA, & neurologic pulmonary edema^ (sx same as pulmonary edema but not associated w/cardiac problem) o (^) Wound Infections ▪ Pts^ w/hx^ of^ DM,^ long-term^ steroid^ use,^ obesity,^ and^ previous^ infections ▪ Pt^ may or may^ not be febrile, wound^ reddened and puffy o (^) Meningitis o (^) Hyponatremia - from fluid overload from SIADH or steroids (weakness, change in LOC & confusion) ▪ UOP^ <20^ mL/hr,^ decreased^ serum^ Na^ due^ to^ dilutional^ effect ▪ Conivaptan^ and^ tolvaptan^ for^ severe^ hyponatremia^ < o (^) Hypernatremia – Caused by meningitis, dehydration, or DI (muscle weakness, restlessness, extreme thirst, and dry mouth). Untreated can lead to seizures. ▪ Suspect DI if pt voids lg amounts of very dilute urine w/inc serum osmolarity & electrolyte concentration. Urine specific gravity <1.005, urine osmolarity dec ▪ May^ need vasopressin if UOP^ >6L/24 hrs,^ desmopressin for long term replacement o (^) Cerebral Salt Wasting (CSW) ▪ Primary^ cause^ of^ hyponatremia^ in^ neurosurgical^ pts. ▪ Hyponatremia,^ dec^ serum^ osmolarity,^ and^ dec^ blood^ volume ▪ Vasopressin^ and^ ANF^ levels^ differentiate^ CSW^ and^ SIADH
▪ Tx^ w/ replacement of Na and isotonic fluid volume (^) Community Based Care/IDC o (^) Managed at home if possible, if have hemiparesis make sure home is accessible and safe o (^) Rehab if needed, psychologist, dietitian (if radiation or chemo) o (^) Teach seizure precautions as can have risk for up to 1 year after surgery
o (^) LP for analy sis of CSF, CT scan b4 LP if pt has signs of IICP ▪ Br oa d sp ec tr u m an ti bi oti c gi ve n b re su lts ar e ba ck or if de la y in ob tai ni ng C SF o (^) CSF Findi ngs ▪ Ba ct eri al
- Cloudy, INC WBCs, INC protein, DEC glucose, CSF pressure elevated ▪ Viral^ –^ Clear,^ INC^ WBCs,^ INC^ Protein,^ Normal^ Glucose,^ Normal^ or^ elevated^ CSF pressure
(^) Interventions o (^) Antibiotics started right after LP w/C&S due to high mortality rate o (^) Most important –Neurologic checks & VS Q 4 hrs ▪ Monitor^ for neuro changes that indicate IICP^ (dec LOC) o (^6) th (^) cranial nerve defect (inability to move the eyes laterally) indicate hydrocephalus ▪ IICP,^ urinary^ incontinence^ (from^ IICP)^ also^ can^ indicate^ hydrocephalus o (^) Seizure precautions o (^) Decrease environmental stimuli ▪ Quite,^ turn down lights, bed rest, HOB 30 degrees o (^) Mannitol and antiepileptic drugs for ICP tx o (^) People who were in close contact w/pt w/N. meningitides (meningococcal meningitis) need prophylaxis ▪ Rifampin(also^ H influenza), ciprofloxacin, or ceftriaxone o (^) Vascular assessment Q 4 hrs for early detection of thrombosis as gangrene can develop quickly o (^) Standard precautions for all EXCEPT for bacterial (N. Meningitides & H. Influenzae) who get droplet ▪ 3 feet^ away^ if^ no^ mask.^ Need^ mask^ and^ gloves^ w/I^3 feet^ of^ pt.^ Teach^ to^ visitors^ too Encephalitis (865-867) (^) Inflammation/infection of the brain tissue & surrounding meninges from virus, bacteria, fungus or parasite (Malaria) (^) Viral encephalitis is the most common o (^) West Nile virus and many other viruses can cause disease
Organisms enter body through oral/respiratory route or animal/insect bites, replicate &
destroy brain cells (^) Organisms invade brain tissue, replicate & destroy the cells (^) Unlike meningitis it does NOT cause exudate (pus) formation (^) White matter destroyed, leads to hemorrhage, edema, necrosis (cell death) and dev. Of small launae (hollow cavities), wide spread edema, & IICP. Death from herniation. (^) Herpes simplex virus type 1 encephalitis most common in North America, pts have hx of cold soars (^) Amebic found tin warm fresh water and enter nasal mucosa of people swimming in ponds or lakes, or in soil (^) Assessment o (^) Typical sx – high fever, N/V, and stiff neck o (^) Other Sx ▪ Changes in mental status (agitation), Motor dysfunction (dysphagia),^ Focal (specific) neurologic deficits, Photophobia, Phonophobia, Fatigue, Sx of IICP (dec LOC), Joint pain, HA, Vertigo o (^) Assess LOC w/GCS, more extensive changes mental status than w/meningitis ▪ Confusion,^ irritability,^ and^ personality^ and^ behavior^ changes^ (especially^ from herpes) o (^) S/S meningeal irritation – nuchal rigidity & motor changes (mild weakness to hemiplegia)Parkinson’s sx, myoclonic jerks, increased DTR and seizures o (^) In severe cases the pt may have IICP from cerebral edema, hemorrhage, & necrosis of tissue. Monitor for widened pulse pressure, bradycardia and irregular respirations (Cushing’s Triad – late sign of increase ICP) (^) D x o^ LP – Clear fluid w/ INC protein, INC WBCs, & NORMAL Glucose o (^) CT scan b4 LP to prevent herniation (^) Interventions/Management o (^) Drugs ▪ Acyclovir^ or^ Vidarabine–^ antiviral^ drug^ for^ tx^ of^ herpes^ encephalitis ▪ NSAIDS^ for sx relief o (^) Maintain patent airway to prevent PNA or atelectasis which leads to further brain hypoxia o (^) Turn, cough deep breath Q2h; Assesse VS and neuro Q2 hr o (^) Perform deep tracheal suction even with presence of increased ICP is
o (^) Prevention of West Nile Virus ▪ Insect^ repellant^ with^ DEET
▪ Vaccines for equine encephalitis
Myasthenia Gravis (MG) (917-923) (^) Autoimmune disease that worsens with exercise and improves with rest. (^) Loss of Acetylcholine receptors in the neuromuscular junctions (^) Some cases have hyperplasia (abnormal growth) of the thymus gland due to a thymoma (thyroid tumor) (^) Initially pts present with reports about vision from disturbances of the ocular muscles (^) Signs and Symptoms o (^) Progressive muscle weakness that worsens w/repetitive use and improves w/rest o (^) Dysphagia, Poor posture, Ocular palsies, Fatigue ▪ Increased^ r/f lung infections from aspiration of foods, fluids, or saliva o (^) Ptosis (drooping eyelid), diplopia, flat affect, tendency for the mouth to hang open, drooling o (^) Respiratory weakness and compromise o (^) Loss of bowel & bladder function o (^) Muscle aches, Paresthesias, dec sense of smell or taste o (^) Smile transformed into a snarl o (^) Weight loss from difficulty chewing and swallowing and regurgitation of fluids through the nose. o (^) More difficulty eating after talking o (^) Voice weaker or nasal twang after extended conversations o (^) Consciousness NOT altered (^) D x o^ Immediately confirmed by pt response to cholinergic drugs o (^) Endrophonium (Tensilon) Test & Neostigmine (Prostigmin) Test ▪ Inhibits^ the^ breakdown^ of^ Ach ▪ Pt^ w/ MG will show IMPROVEMENT ▪ Atropine^ antidote o (^) EMG – Electromyography helps confirm the dx (^) Medical Management/Treatments o (^) Pyridostigmine(Mestinon) – Cholinesterase Inhibitor drug, prevent decrease of Ach ▪ Take^45 min^ to^1 hr^ before^ meals(to^ prevent^ aspiration)^ with^ a^ snack,^ to^ alleviate^ GI distress ▪ Keep^ meds^ and glass^ H2O at^ bedside if^ you^ are week^ in the^ am ▪ Set^ timer^ (watch) to^ take^ meds^ on time,^ post drug^ schedule so^ others know^ it. ▪ Plan^ strenuous activities when drug peaks ▪ Avoid^ drugs^ containing^ Mag,^ morphine,^ hypnotics^ or^ sedatives^ to^ avoid^ increased weakness o (^) Plasmapheresis – antibodies removed from plasma to dec sx, for short-term mgmt of an exacerbation o (^) Immunosuppressants – corticosteroids, methotrexate, rituximab o (^) IV immunoglobulin (IVIG) – for acute management or long-term mgmt. for disease refractory to other tx o (^) Thymectomy ▪ Have w/i 2 years of onset, not always immediately effective, some may have no change at all ▪ Immediately^ b4 surgery^ give^ pyridostigmine^ to keep pt stable during surgery ▪ Antibiotics^ given^ immediately^ b4^ or^ during^ surgery.
▪ Sterile technique for wound care ▪ Observe^ for signs of pneumothorax or Hemothorax (^) Sudden SOB, Chest pain
o (^) Respiratory therapist to improve gas exchange o (^) Physical and Occupational therapists to assist w/mobility, self-care and energy conservation o (^) Dietitian, Speech therapy, & occupational therapy to plan meals Guillain Barre Syndrome (GBS) (913-917) (^) Acute inflammatory demyelinating polyneuropathy that affects the peripheral nervous system causing motor weakness & sensory abnormalities (^) Sx begin in the legs and ascend to arms and upper body – ascending paralysis, increasing in intensity
(^) More common in males peaking after age 55 (^) Some pts require intubation (^) Healing occurs in reverse (^) Results from o (^) Bacterial infection (Campylobacter jejuni) o (^) Viral infections (Influenza, Epstein-Barr, and cytomegalovirus) o (^) Live vaccines 1-3 weeks prior to sx o (^) Trauma, surgery (^) Stages o (^) Acute or initial (1-4 weeks) – Onset of first sx and ends when no further deterioration occurs o (^) Plateau (several days to 2 weeks) o (^) Recovery Stage (gradually over 4-6 mon, up to 2 y) – Re-myelination and axonal regeneration (^) Signs and Symptoms o (^) Ask pt to describe sx in chronological order o (^) Motor–ascending symmetric muscle weakness to flaccid paralysis, falls, clumsiness ▪ Dec^ DTR’s,^ Respiratory^ compromise,^ Loss^ of^ bowel^ &^ bladder^ control,^ &^ Ataxia o (^) Sensory – Paresthesias & Pain (cramping) o (^) Cranial nerve – Facial weakness, Dysphagia, Diplopia & Difficulty speaking o Autonomic manifestations – Labile BP (low or poor control), Cardiac dysrhythmias (tach), Tachycardia o Does NOT affect level of consciousness, cognition, or pupillary constriction or dilation o PARALYSIS IS ONLY TEMPORARY! (^) Interventions o (^) Priority is airway management as inability to maintain an airway is a high risk ▪ Monitor^ closely^ for^ s/s^ respiratory^ distress^ (dyspnea,^ air^ hunger,^ adv^ breath sounds, dec O2 sat, & cyanosis), rate rhythm and depth Q 1-2 hrs. Decline in mental status indicated hypoxia ▪ Keep^ intubation^ equipment^ at^ bedside (^) Dec in vital capacity to < 15-20 mL/kg & inability to clear secretions – need to intubate ▪ Monitor^ ABGs o (^) Implement aspiration precautions – HOB 45 degrees, test for dysphagia b4 restarting oral anything, suction o Tx w/either plasmapheresis or IV immunoglobulin (IVIG) – no benefit in combining them ▪ 1 st^ - IVIG is safer and immediately available, doesn’t need shunt access (^) Complications range from mild discomfort ( chills, mild fever, myalgia, and HA) to major complications ( anaphylaxis, aseptic meningitis, retinal necrosis, acute renal failure) ▪ NO steroids used ▪ Plasmapheresis (^) Need a shunt – check for patency (bruit & thrill) Q 2 hrs & Keep double dog clamps bedside o (^) Report loss of thrill or bruit, uncontrolled bleeding & redness, drainage or swelling (^) Monitor electrolytes b4 & after tx, anticipate Ca replacement (^) Diphenhydramine or corticosteroid as premedication when urticarial (skin react) present b (^) R/f coag depletion, CBC & coag panel b4 & after tx (^) R/f Infection from immunoglobulin depletion, v/s w/temp 3x daily (^) Monitor fluid status during tx and 2x in 1 st (^) hr after tx (^) Colloid substitute of albumin after if needed, NO FFP o (^) Cardiac monitor due to r/f dysrhythmias o (^) HTN tx w/ BB (-olol) or nitroprusside (vasodilator for HTN) o (^) Hypotension tx w/ IV fluids and putting pt in supine position (unless in resp distress) or Atropine o (^) Encourage max independence, active or passive ROM exercises daily
