NCM 118L/ 119L (Related Learning Experience) Day 3-Activity

NCM 118L/ 119L
(Related Learning Experience)
Day 3- ACTIVITY
October 18-20, 2021 Rotation
Name: Villanueva, Nicole P.

Year/Section/Group No.: N4A/Group 4
Clinical Instructor: Ma’am Precy Lantin, RN, MAN
Case Analysis
NICU Cases
CASE STUDY PROGRESS
J.R. is transported to radiology for a CT, where he is found to have a large epidural hematoma on the
right with a hemispheric shift to the left. He will be taken straight to the operating room (OR) for
evacuation of the hematoma. While in route from the CT scan to the OR, the physician instructs the
respiratory therapist to initiate hyperventilation of the patient to “blow off more CO2.
After J.R.'s surgery he is admitted to the neurological intensive care unit (NICU)
11. What is the rationale for this action?

- Hyperventilation can be used short-term to get a critically high ICP down stat. CO2 is a potent
vasodilator, by blowing off CO2 through hyperventilation, it lower CO2 leading to arterial
vasoconstriction. This lowers cerebral blood flow, cerebral blood volume and ICP.
12. While he is in surgery, J.R.'s family arrives at the ED with their faith healer. They ask that
their faith healer anoint J.R. and pray over him. What should the nurse say?
- I would be comforting and ask the procedure to the family and then in a calm manner why
they wouldn’t be allowed to enter the operating room. I would then offer an alternative and
encourage praying for him from afar and possibly after the operation and anointing JR with
the prayer healer.
13. What assessment indicators will be closely monitored in J.R.?
- Assessment indicators will be closely monitored in JR would be:
● Continuous neuro checks (esp. PERRLA- pupil, equal, round, reactive to light and
accommodation, cough/gag reflex, corneal reflex)
● CSF drainage - amount, color, consistency
● Vitals
● ABG's
● I&O
● Monitor for O2 toxicity r/t high FiO2
● Watch for further temperature increases
● Assess ICP for response to treatment
● volume of the blood and the patients weight
14. J.R. has ICP monitoring in place with an intraventricular catheter. Nursing interventions
related to J.R.'s care while the catheter is in place include: (Select all that apply.)
Nursing interventions related to J.R.'s care while the catheter is in place include the following:
a. Continuously monitoring the ICP waveforms.
Three waveforms — A, B, and C — are used to monitor intracranial pressure (ICP). A waves are an
ominous sign of intracranial decompensation and poor compliance. B waves correlate with changes
in respiration, and C waves correlate with changes in arterial pressure.
b. Using aseptic technique when setting up the device.
Insertion of an ICP monitoring device requires sterile technique to reduce the risk of central nervous
system (CNS) infection. Setting up equipment for the monitoring systems also requires strict asepsis.
c. Maintaining a cerebral perfusion pressure of 60 mm Hg.
The normal Cerebral Perfusion Pressure (CPP) is 60-80 mmHg. A decrease in the CPP suggests that
the gradient required to push blood towards the brain is not being maintained. This can cause brain
ischemia from reduced cerebral blood flow. The goal for maintaining the CPP is to ensure that the
CPP is high enough to perfuse the brain; while preventing excessive CPP elevations that might
worsen any cerebral edema.
d. Leveling the transducer even with the foramen of Monroe.
Ensuring that the transducer is level to the foramen of Monro is crucial to interpreting the accuracy
of any obtained values. The foramen of Monro is generally considered to be the optimal reference
point because it aligns most closely with the center of the head. Patients may change position or the
head of bed may be raised or lowered. Even a change of a few centimeters will affect the accuracy of
the readings.
Errors in positioning the transducer:

● Too far above the FOM will lead to a falsely low ICP measurement and insufficient drainage of
CSF – in this case intracranial hypertension would go undetected and untreated.
● Too far below the FOM will lead to a falsely high ICP measurement and excessive drainage of
CSF – with subsequent collapsing of the ventricles with perhaps blockage of the system and
unnecessary other treatment.
15. List four medication classifications that NICU nurses could use to decrease or control increased ICP
and the rationale for using each.
➢ Diuretics: Osmotic Diuretics (Mannitol®) helps to draw water from the brain cells and into the plasma.
Loop Diuretics (Lasix®, Bumex®) decrease ICP by removing Na+ and water from injured brain cells
and decreasing CSF formation. Watch for electrolyte imbalance with the use of these drugs.
➢ Corticosteroids: Decadron® is the most commonly used corticosteroid used to reduce cerebral edema;
however, research on its effects on decreasing ICP alone yields mixed results. Watch for electrolyte
disturbances along with hyperglycemia and immunosuppression.
➢ Anticonvulsants: Because of the increased risk for seizure activity of brain injury patients, antiepileptic
agents such as Dilantin® and Tegretol® are used to help increase the threshold of excitation among
neurons, which decreases seizure risk. Watch for ataxia and lethargy along with gingival hyperplasia
with prolonged Dilantin® use. Dilantin® is given IV through a filtration device and the patient must be
monitored closely for heart block.
➢ Antihypertensives: Hypotension causes a decrease in cerebral blood flow, which leads to cerebral
ischemia. HTN > 160 mm Hg can lead to cerebral ischemia as a result of cerebral vessel compression.
Antihypertensives such as Beta-Blockers, Ca-Channel Blockers, and ACE-Inhibitors can decrease
overall BP. Watch for bradycardia and hypotenstion as an adverse effect.
16. Explain at least eight independent nursing interventions and the rationale for each that would be used to
prevent increased ICP in the first 48 postoperative hours.
1. Perform neurological assessments hourly

➢ Monitor and report any early signs and symptoms of increasing ICP, which can be done by
regularly attending to neurological observations on the patient.
2. Elevate HOB 15-30°
➢ To reduce the pressure from increasing further. Researchers discovered that head elevation to 30
degrees significantly reduced ICP in the majority of the 22 patients without reducing cerebral
perfusion pressure and cerebral blood flow.
3. Monitor neurological responses to any activity that increases ICP
➢ Certain activities like suctioning, chewing, coughing, use of bedpan, and abnormal breathing
patterns may exacerbate/increase ICP. Continual monitoring is necessary to prevent increased
ICP
4. Maintain the head in a neutral position (midline).
➢ Head elevation above 30 degrees should be avoided in all cases. In most patients with
intracranial hypertension, head and trunk elevation up to 30 degrees is useful in helping to
decrease ICP, providing that a safe CPP of at least 70 mmHg or even 80 mmHg is maintained.
5. Avoid extreme hip flexion, straining with stool, breath-holding exercises.
➢ Hip flexion can increase intra-abdominal and thoracic pressure which can increase ICP. Valsalva
maneuver causes sudden expulsion of blood from the thoracic vessels into the carotid vessels
causing a rise in the intracranial pressure (ICP), altering the brain perfusion. The altered
pressures are further transmitted to the spinal cord.
6. Observe strict fluid restrictions (as ordered by MD, ARNP, or PA).
➢ It is well known that fluid restriction, if pursued to excess (hypovolemia), may result in episodes
of hypotension, which can increase intracranial pressure (ICP) and reduce cerebral perfusion
pressure, and the consequences can be devastating.
7. Do NOT suction for more than 15 seconds at a time, utilize hyperoxygenation before and after the
procedure.
➢ It's important to ensure utilizing an effective technique, and that never suction longer than a few
seconds—most guidelines recommend less than 15 seconds. In some patients, suctioning may
also stimulate the vagus nerve, triggering hypoxia and bradycardia.
8. Assess the client's vital signs and notify the physician for any abnormal changes.
➢ Patient assessment should include hourly monitoring for signs and symptoms associated with
changing ICP, or more frequently as the clinical situation warrants. Notify the physician
immediately if ICP exceeds established parameters. If no parameter is specified, notify the
physician if ICP is >20 mmHg or CPP falls outside of the 50-70 mmHg range (Thompson,
2012).
/Prof. P. Lantin

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NCM 118L/ 119L

(Related Learning Experience)

Name: Villanueva, Nicole P.

11. What is the rationale for this action?

b. Using aseptic technique when setting up the device.

c. Maintaining a cerebral perfusion pressure of 60 mm Hg.

d. Leveling the transducer even with the foramen of Monroe.

Errors in positioning the transducer:

1. Perform neurological assessments hourly

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