This details the critical care nurse's role in caring for a patient with severe traumatic brain injury, managing ICP and brain oxygenation. Ties in closely with Orem's self-care deficit theory for nursing.

1. A Case Study Presentation by Elisa Rubio Brigham Young University-Idaho

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6. Also called “activities of daily living” (ADLs)

7. these self-care requisites are interrelated

8. and usually a lower need must be fulfilled

9. before an upper need can attended to.

10. This pyramid can help nurses make decisions

11. about priorities for nursing diagnoses.

12. (George, 2002, p. 128) Each of these healthcare requisites has associated needs and abilities.

13. (George, 2002, p. 128) Patient abilities Patient needs In a healthy individual, a balance exists between the patient’s self-care needs and the patient’s abilities to fulfill his own self-care needs. Health (balance) When the patient’s needs increase, as in the case of illness, and/or his abilities decrease… Each of these healthcare requisites has associated needs and abilities.

14. Patient needs Patient abilities Self-care deficit A self-care deficit exists, creating the need for NURSING. (George, 2002, p. 128)

15. Patient needs Patient abilities During the assessment phase, the nurse examines the patient’s abilities. During the diagnosis phase, the nurse must examine the patient’s needs and evaluate the degree self-care deficit. During the planning phase, the nurse takes this information and decides what support and how much support to give the patient in order to restore balance. Nursing support Nursing support Implementation involves putting the plan into play (or actually supporting the patient) (George, 2002, p. 128)

16. Patient needs Patient abilities Nursing support The evaluation phase involves verifying that the self-care deficit is resolved, or ensuring that a balance exists with nursing assist. (George, 2002, p. 128)

17. Severe Traumatic Brain Injury

22. Intracranial pressure (ICP) -measured with ventriculostomy in healthy brain tissue. Ideally 0-15 mm Hg. Must keep below 20 mm Hg to avoid secondary brain injury (Hill, 2006) As described before, is increased in any case that the brain is unable to compensate for increases in one of the components of the intracranial vault. Cerebral perfusion pressure (CPP)- the difference between the MAP and the ICP. May be managed by increasing BP or decreasing ICP. “Autoregulation of cerebral blood flow is impaired in the injured brain, resulting in further ischemic damage if the cerebral perfusion is not maintained above a critical threshold” (Krell, 2004). Should be maintained at about 60 mm Hg. Avoid too high or too low levels. CPP=MAP - ICP

23. Partial pressure of brain tissue oxygen (PbtO 2 )- A recent advancement in monitoring, this is an objective and direct measurement of oxygenation to brain tissue since ICP is not always directly related to oxygenation. Measured with LICOX monitor inserted into injured brain tissue. Must be above 20 mm Hg. “… the measurement of ICP and CPP alone does not accurately reflect the tissue oxygenation in injured brain” (Littlejohns, Bader & March, 2003)

24. Bispectral Index (BIS) monitoring gives a numeric value to reflect electrical activity in the brain. This correlates to the level of sedation. By monitoring this on patients, particularly neuro patients, the level of sedation can be objectively measured to ensure neither under nor oversedation (Franges, 2006). Another useful tool for measuring level of sedation is to monitor the burst/ suppression ratio on a simple EEG reading. Medications can be titrated to maintain a desired ratio depending on the patient’s needs. A decreased sedation goal can help maintain a stable ICP. BURST BURST suppression

25. While the BIS and the EEG are used to monitor level of sedation , the Train of Four (TOF) test is used to monitor the degree of neuromuscular block . A series of four electrical impulses are delivered to a small muscle in succession. The nurse observes the muscle for twitching. If the patient is blocked adequately, a typical ratio is 2 twitches to 4 signals. 1 twitch 2 twitches To view illustration again, click ← , then ->

26. Nursing: The Juggling Act Particularly in the case of a patient with STBI, the critical care nurse is constantly evaluating and re-evaluating as she/he intervenes, making adjustments to interventions as required. Implementation Evaluation To view illustration again, click ← , then ->

27. Interventions to reduce ICP are aimed at either decreasing blood flow, decreasing brain tissue or decreasing CSF. The annotations on the following protocol help to encourage critical thinking through each rationale for the given intervention

32. The following insert, taken from an article in the Journal of Neuroscience Nursing, is also intended to help the nurse critically think through interventions. The categories describe two reasons for decreased PbtO 2 :Increased demand and decreased delivery of oxygen. Associated possible etiologies are listed. Under the arrows are suggestions for reversing the etiologies.

33. Disclaimer: This photograph is not of the actual patient from the case study. Mr. L

34. Mr. L. was a victim of a single car rollover MVA. He had sustained some pulmonary contusions and lacerations, as well as a C6 fracture and head injury. Mr. L. was unconscious and decorticate posturing upon EMS arrival. The patient had undergone placement of a ventriculostomy and LICOX monitor to monitor and manage ICP and PbtO 2 . Due to the difficulty of controlling these values initially, the patient was placed in a drug-induced coma. Consequently, the patient was being monitored with a simple EEG and bispectral index monitor (BIS) in order to assess his degree of coma, to avoid over or undersedation.

41. 2. The physician’s perspective of the person’s health A good way to get this information is to speak with the physician or read the progress notes. Orem’s Step 1: Assessment (From the progress notes: ) “This has been a difficult day [for the patient… and] I have had several conferences with the family that he is probably approaching the peak of his cerebral edema and that his prognosis remains guarded, but there is little else to change here.”

42. Laboratory tests and analysis of results

43. We are keeping close tabs on the CO 2 level. It is important in ICP because it is related to vasoconstriction. When the CO 2 level is low, the blood vessels constrict, reducing blood flow and thus pressure to the brain (Urden et al., 2006). We are managing this value by the set mechanical ventilatory respiratory rate and we want the CO 2 low--as low as 25-30 n a patient with intracranial hypertension as long as PbtO 2 is adequate. (Urden et al., 2006). The HCO 3 is attempting to compensate for the alkalotic CO 2 by going acidotic (decreasing). This is a good thing because, although we want the CO 2 low, we want the pH to remain within normal limits, so compensation is to our advantage. Due to the decreased CO 2 that we are desiring and the compensation of the HCO 3 , the patient has a … Mild Compensated Respiratory Alkalosis (Urden et al., 2006, p. 776-777) 604-607) The base deficit of -2.1 also indicates that the metabolic system is attempting to correct by creating an acidotic state. PaO 2 is “high” due to supplemental oxygen administration. Date/time Test Value Normal Interpretation 10/14 0348 ABG pH 7.41 7.36-7.44 Normal PCO 2 36 38-52 mm Hg sl low PO 2 112 65-80 mm Hg High, supp O 2 HCO 3 22 23-30 mEq/L Slightly low BE -2.1 -3.0-3.0 Normal

44. Up until today, we were using a 7% normal saline (highly hypertonic) solution on this patient in an effort to draw fluid from the cerebral interstitial space by osmotic pressure. This has a tendency to increase the serum sodium. After these values was viewed by the physician, the 7% NS was discontinued. Increases in serum chloride level are usually associated with increases in other electrolytes (in this case, sodium). With sodium, plays a major role in serum osmolality. (Urden et al., 2006, p. 797-798) As they are both cations, sodium and potassium are in constant competition in the body. To preserve electrical neutrality, when serum sodium is elevated, serum potassium is decreased and vice versa. This potassium level is likely decreased secondary to hypernatremia. Both sodium and chloride contribute to this high osmolality. To a degree, high osmolality is desired to draw fluid from the interstitial brain tissue in order to reduce ICP. As we can see, the value has decreased since the 7% NS was discontinued early this morning. Date/time Test Value Normal Interpretation 10/14/08 0345 Na 166 136-145 mEq/L Sig high K 3.3 3.5-5.1 mEq/L Sl low Cl 133 100-110 mEq/L High 10/14/08 0345 Serum osmolality 342 275-295 mmol/kg High 10/14/08 1001 335 improved

45. Increased AST might be due to alcohol consumption or possibly to trauma to the liver during the accident. It may or may not be related to the present illness. Remember that protein and albumin increase oncotic pressures in the blood vessels. When these values are low, fluid leaks into the interstitial spaces, including brain tissue, increasing the brain tissue component of the intracranial vault, resulting in increased ICP. Continued attention to nutrition with possible protein supplements and albumin infusions might be helpful to increase these values and reduce third spacing. (Kee, 1999, p. 69) A great deal of ICU patients have low protein and albumin levels secondary to their increased protein consumption for healing and decreased protein intake. Date/time Test Value Normal Interpretation Total Protein 5.5 6.4-8.2 g/dL Low Albumin 1.4 3.4-5.0 g/dL Low AST 35 8-28 units/L Sl high

46. The patient’s sputum was positive for staph aureus. A respiratory infection is definitely enough to increase the white blood count. This patient has been placed on Vancomycin. The differential shift indicates that the infection is not new, since the immature neutrophils (bands) are not actively multiplying. (Cook, 1999; Glauser, 2005) Date/time Test Value Normal Interpretation WBC 15.3 4-10.5 K/mm 3 High WBC diff Segs 82 47-76 % High Bands 5 0-4% High

47. Despite major trauma, this patient has not had a blood transfusion since his admission six days ago. These values are low but stable since admit. The patient is not actively bleeding, but likely had some bleeding at the time of the accident, which caused these numbers to be low. Keep in mind that these values are important to us because changes in Hct will affect oxygen carrying capacity, and, in turn, will effect oxygenation to tissue such as to the brain. A blood transfusion may not be a bad idea. This value indicates the size of the RBC’s. It is slightly high. In the presence of a normal MCV, usually indicates iron deficiency, which may also have contributed to our low hct/hgb/RBC. (Kee, 1999) We’re interested in keeping the patient supplied with iron, since it plays significant role in hemoglobin formation, and therefore the oxygen-carrying capacity of the blood. Perhaps iron supplementation would be appropriate. Date/time Test Value Normal Interpretation RBC 3.38 4.4-5.9 m/mm 3 Low Hgb 10 13.5-17.5 g/dL Low Hct 29.8 39.8-52.2 % Low RDW 15.9 11.5-14.5 % High

48. Orem’s Step 1: Diagnosis What needs does this patient have? Patient needs 5. The patient’s requirements for self-care.

51. Since our patient’s abilities are extremely limited and his needs are significantly increased, according to Orem’s nursing systems, our patient requires the help of a “ wholly compensatory nursing system” at this point. Patient needs (George, 2002, p. 131) Patient abilities

55. During the Planning phase, the nurse decides what support is needed and how much. We have already selected goals, now we will think through some interventions that will help us reach our goals. We’ll discuss some of the interventions performed during the shift, taken from the Critical Care Protocol on previous slides. ----------- --------- --------- --------- ----------- --------- --------- --------- ----------- --------- --------- --------- Critical Care Protocol Nursing Support

56. Nursing Support To ensure adequate cerebral perfusion : Monitor ICP and CPP continuously using ventriculostomy Monitor and maintain MAP to achieve desired CPP by: Monitor CVP and administer fluids as necessary to keep MAP adequate to achieve desired CPP If CVP > 10 and CPP remains low, increase MAP by titrating levophed drip Maintain open CSF drainage to 15 mm Hg from ventriculostomy

57. To achieve adequate cerebral tissue oxygenation: Continuously monitor PbtO2 with LICOX monitor Maximize oxygen supply/delivery by: Maintain therapeutic vasodilation by adjusting respiratory rate to CO2 25-30 as long as ICP <20 Adjust FiO2 and PEEP to maximize oxygenation to tissues. Monitor H/H to keep Hct above 33% and transfuse PRBC if required

58. Minimize oxygen demand by: Monitor and maintain core temperature at less than 96.5 O F using continuous intravenous fluid cooler. Titrate propofol and thiopental to BIS 10-20 and EEG BSR 3/5 to maintain coma and reduce metabolic rate. Maintain paralysis, titrate atracrium to Train of four 2/4 Premedicate/bolus with propofol prior to noxious activities (e.g. bathing, suctioning) to reduce reactions which would increase ICP or oxygen demand.

59. Nursing Support

60. Nursing Support

61. Medications with Rationale

69. Nursing Support Fentanyl Propofol Atracrium besylate Thiopental Dilantin Norepinephrine Insulin drip

70. Nursing Support

71. Nursing Support

72. Patient needs Patient needs Patient abilities Nursing support Patient abilities Nursing support

76. Patient needs Patient abilities Nursing support Patient needs Patient abilities Nursing support Hooray!

87. Click True or False. Increasing the respiratory rate can help reduce ICP, but it may also cause a decrease in PbtO2. FALSE TRUE Increasing the respiratory rate on the ventilator results in decreased levels of CO 2 as the patient “blows it off”. Decreased CO 2 leads to vasoconstriction. (I like to think of it as the CO 2 is directly related to the diameter of the vessel). Since vasoconstriction reduces blood flow to the brain, the ICP will go down, but with decreased perfusion, the PbtO 2 may suffer as well.

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