chapter 56 acute intracranial problmes fall...

Fall 2019 - Spring 2020

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SENSORY &REGULATORY NEEDS: NEUROLOGICAL

1 Fall 2019 - Spring 2020

SENSORY &regulatory needs: Neurological

•  Alzheimer’s Disease •  Delirium •  Guillain-‐Barre Syndrome •  Increased Intracranial Pressure

•  Mul<ple Sclerosis •  Parkinson’s Disease •  Seizure •  Spinal Cord Injury •  Stroke •  Trauma<c Brain Injury

•  Intracranial Regula<on

•  Cogni<on •  Mobility •  Perfusion •  Sensory Percep<on

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Acute Intracranial Problems

•  Head Injury •  Inflammatory Brain Disorders •  Increased Intracranial Pressure (ICP)

Acid-‐Base Balance Cogni<on Mobility Oxygena<on Perfusion Safety Stress and Coping *What concept is involved? *What nursing physical assessments are involved?



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Concepts Related to Intracranial Regula<on Concept RelaDonship To Intracranial

RegulaDon Nursing ImplicaDons

Acid-‐Base Balance

éCO2 èvasodila<onèéICP •  Assess LOC, act immediately to decreased ICP

•  Underlying cause determines treatment

Cogni<on Altera<ons in intracranial regula<on can lead to impaired cogni<ve func<on, ranging from mild confusion to lack of consciousness.

•  Assess LOC •  Assess VS •  Underlying cause ( fall, seizure,

disease) determines treatment

Mobility Pa<ents will have different needs based on the underlying pathology. A pa<ent who is comatose will need passive ROM exercises, whereas on with éICP should have s<mula<on kept at a minimum to avoid further increase in ICP.

•  Assess LOC •  Assess VS in response to

interven<ons •  Consider involving PT/OT to

minimize any deficits, if appropriate


Concepts Related to Intracranial Regula<on (con’t) Concept RelaDonship

To Intracranial RegulaDon

Nursing ImplicaDons

Oxygena<on êLOC may result in êrespira<ons

•  Assess airway and respira<ons •  An#cipate: airway support. A nasopharyngeal airway may

be sufficient for pa<ents who are drowsy but arousable. Pa<ents with more serious altera<ons in consciousness may require and oropharyngeal airway or endotracheal intuba<on and mechanical ven<la<on

Safety Pa<ents may be awake and coopera<ve or confused or comba<ve. Pa<ents with seizures may uninten<onally put themselves at risk for injury.

•  Assess LOC •  Iden<fy e<ology of any decrease in LOC. If SPO2 is low,

O2 may help with confusion •  Reorient o\en as appropriate •  Be aware of poten<al drug side effects or drug-‐drug

interac<ons that could harm the pa<ent •  Educate the pa<ent/family about care and preven<on of

future episodes as appropriate (teach pa<ent with sports-‐related concussion about helmet use).


Concepts Related to Intracranial Regula<on (con’t) Concept RelaDonship

To Intracranial RegulaDon

Nursing ImplicaDons

Stress and Coping

Neurologic disorders are o\en sudden, some<mes life threatening, and always life altering

•  Allow the pa<ent and family <me to process situa<on

•  Answer ques<ons and assess reac<on to situa<on •  Consider referral to a psychologist, support group,

or clergy as appropriate



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Head Injury •  Any trauma to (closed vs. open) –  Skull –  Scalp –  Brain

•  Traumatic brain injury (TBI)* •  Location determines manifestations

•  Most common causes •  Falls •  MVA

•  Other causes •  Firearm-‐related

injuries •  Assaults •  Sports-‐related

trauma •  Recreational

injuries •  War-‐related

injuries


Diagnostic Studies •  CT scan (+ whole body)

–  Best diagnostic test to determine craniocerebral trauma

•  Serum panel –BMP, CBC, Coags, T&S, T&C, UA, Drug/ETOH screen –what do these labs prepare the patient for?

•  MRI, PET •  Transcranial Doppler studies •  Cervical spine x-‐ray •  ↑ or ↓Blood glucose level •  ↑ ICP


Types of Head Injuries •  Skull Fractures (recall types

of fracture) – Complications •  Infections •  Hematoma •  Tissue damage

– Basilar skull fracture*

Scalp Lacerations Scalp is highly vascular → Profuse bleeding Major complications – blood loss and infection



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Types of Head Injuries Diffuse (generalized): •  Concussion

–  Brief disruption in LOC –  Retrograde amnesia –  Headache –  Short duration –  May result in postconcussion

syndrome

•  Diffuse Axonal Injury –  Widespread axonal damage –  Decreased LOC –  Increased ICP –  Decortication, decerebration –  Global cerebral edema

Focal (localized): •  Lacerations –tearing of brain tissue

–  With depressed and open fractures and penetrating injuries

–  Intracerebral hemorrhage –  Subarachnoid hemorrhage –  Intraventricular hemorrhage

•  Contusions –bruising of brain tissue –  Associated with closed head injury –  Can cause hemorrhage, infarction, necrosis,

edema –  Can re-‐bleed –  Monitor for seizures –  Potential for increased hemorrhage if on

anticoagulants •  Cranial nerve injuries

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Complications of Head Injuries Epidural Hematomas •  Bleeding between the dura and the inner

surface of the skull •  Venous origin slow; Arterial origin rapid •  Initial period of unconsciousness •  Brief lucid interval followed by decrease in

LOC •  Headache, nausea, vomiting •  Neurologic emergency –requires rapid

evacuation Subdural Hematoma •  Bleeding between dura mater and arachnoid

layer of meninges •  Injury to brain tissue and blood vessels •  Most common source are Veins that drain

brain surface into sagittal sinus –slow onset •  Can also be arterial

Intracerebral Hematoma •  Bleeding within brain tissue

If bleeding or cerebral edema persist in any of these head injuries what is the priority problem?

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The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed? a.  Prone with the head turned to the right side b.  High-‐Fowler’s position with the legs elevated c.  Supine position with the head on two pillows d.  Side-‐lying with the head elevated 30 degrees

Audience Response Question

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Head Injury

Deaths occur at three points in time after injury:

1.  Immediately after the injury –why?

2.  Within 2 hours after the injury –why?

3.  3 weeks after the injury –why?

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Interprofessional Care Emergency Treatment

•  Patent airway •  Stabilize cervical spine –  Assume neck injury

•  Oxygen •  IV access •  Intubate if GCS <8 •  Control external

bleeding •  Remove patient’s

clothing

•  Maintain patient warmth

•  Ongoing monitoring •  Anticipate possible

intubation •  Administer fluids

cautiously –why?

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Interprofessional Care •  Concussion and contusion

–  24 hour observation and management of ICP

•  Skull fractures – Conservative treatment –  Surgery if depressed

•  Subdural and epidural hematomas –  Surgical evacuation

•  Craniotomy, burr-‐holes •  Craniectomy if extreme swelling

–  Cranioplasty later •  Drug therapy – Mannitol – Hypertonic saline

Treatment principles: •  Prevent secondary

injury •  Timely diagnosis •  Surgery if necessary

²  Compare and contrast outcomes for a young patient without a PMH, and an older patient with co-‐morbidities. Is there one that may potentiate complications of head injury?

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Nursing Process 1st Level Assessment 2nd Level

SDmuli Nursing Diagnosis

Goal/Expected Outcomes

Nursing IntervenDons

EvaluaDon

Subjec<ve: If head trauma severe, subjective data deferred, must utilize astute physical assessment skills, or ask others who are present Headache, mood/behavior changes, impaired judgment, aphasia, dysphasia Objec<ve: Altered LOC, pupil dysfunction, lacerations, contusions, abrasions, hematoma, battle’s sign periorbital edema and ecchymosis, otorrhea, exposed brain, rhinorrhea impaired gag reflex altered/irregular respirations cushing’s triad, vomiting bowel and bladder incontinence uninhibited sexual expression seizures cranial nerve deficit(s) motor deficit, palmar drift, paralysis, spasticity Posturing Rigidity or flaccidity Ataxia

Pathophysiology : •  Concussion/

contusion •  Skull fractures •  Subdural/

epidural hematoma

•  Risk for ineffective cerebral tissue perfusion

•  Hyperthermia •  Impaired

physical mobility

•  Anxiety •  Potential

complication: éICP

as manifested by: 1. 2. 3.

Goal: • Cerebral oxygenation and perfusion • Normothermic • Control pain and discomfort • Free of infection • Adequate nutrition • Maximal cognitive, motor, and sensory function Expected Outcomes: 1. 2. 3.

1. 2. 3. 4. 5. 6.

•  Maintain normal cerebral perfusion pressure

•  Achieve maximal cognitive, motor, and sensory function

•  Experience no infection or hyperthermia

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Nursing Implementation –HEAD INJURY: SUBDURAL/EPIDURAL HEMATOMA

Nonsurgical –a small bleed on initial CT, repeat CT scan shows no change in size of bleed = 24 observation (recall age, PMH)* •  Monitor for increased ICP •  Monitor for changes in neurologic status every 1-‐2 hour – What does this involve? – Thoughts about admission order medications?

Acute Care •  Maintain cerebral

perfusion •  Prevent secondary

cerebral ischemia Patient and family teaching of diagnosis, treatment plan, rationale for interventions

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Surgical evacuation needed: –  Major focus of nursing care relates

to increased ICP –  Respiratory support –  Measures for patients leaking CSF

•  Head of bed elevated •  Loose collection pad under nose/over

ear •  No sneezing or blowing nose •  No NG tube ; No nasotracheal

suctioning –  Nutritional support –  Bladder & bowel support –  Measures for immobilized patients –  Analgesics, antiemetics, antiseizure,

antibiotics –  Eye problems –  Hyperthermia

Preoperative –patient/family consent Postoperative –general principles of post-‐operative nursing care Patient and family teaching of diagnosis, treatment plan, rationale for interventions

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•  Motor and sensory deficits •  Communication issues •  Memory and intellectual functioning

•  Nutrition •  Bowel and bladder management

•  Seizure disorders •  Mental and emotional difficulties

•  Family participation and education

Ambulatory Care –acute rehabilitation once medically cleared Progressive recovery

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Inflammatory Brain Disorders Inflammatory conditions of

the brain and spinal cord: •  Brain abscesses •  Meningitis •  Encephalitis

Caused by: • Bacteria, viruses, fungi, and chemicals (e.g., contrast media used in diagnos<c tests, blood in the subarachnoid space)

• CNS infec<ons may occur via the bloodstream

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Inflammatory CondiDon of the

Brain

EDology and Pathophysiology Clinical ManifestaDons Treatment

Brain abscess •  Pus within brain tissue from a local or systemic infection

•  Streptococci •  Staphylococcus aureus

•  Headache, fever, n/v •  Symptoms reflect local area

of abscess

•  Antimicrobial therapy •  Symptomatic treatment

for other manifestations •  May need to be drained or

removed if drug therapy is not effective = Incision and drainage (I&D)

Bacterial meningi<s –medical emergency

•  Acute inflammation of meningeal tissue surrounding brain and spinal cord

•  Streptococcus pneumoniae •  Neisseria meningitidis

•  Organisms enter CNS through upper respiratory tract or bloodstream

•  May enter through skull wounds or fractured sinuses

•  Inflammatory response •  ↑ CSF production •  Purulent secretions spread to other

areas of brain through CSF •  Cerebral edema and increased ICP

become problematic

•  Fever, severe headache, n/v •  Nuchal rigidity •  Photophobia •  ↓ LOC •  Signs of ↑ ICP •  Seizures occur in 1/3 of all

cases •  Headache worsens •  Vomiting and

irritability may occur

•  An<bio<cs (ampicillin, penicillin, vancomycin, ce\riaxone)

•  Cor<costeroids (dexamethasone) •  Fever management •  Dehydra<on •  Respiratory isola<on •  Minimize environmental

s<muli •  Seizure precau<ons

Viral meningi<s •  Most common causes are enterovirus, arbovirus, HIV, and HSV

•  Most often spread through direct contact with respiratory secretions

•  Headache, fever (moderate or high), photophobia, and stiff neck

•  Usually no symptoms of brain involvement

•  Treat with antibiotics after obtaining diagnostic sample but before receiving test results

•  Symptomatic management

•  Disease is self-‐limiting •  Full recovery expected 21 Fall 2019 - Spring 2020


8

Diagnostic Studies –BACTERIAL MENINGITIS

•  CT scan, MRI •  Blood culture •  X-‐rays of skull Diagnosis verified by: Lumbar puncture –analysis of CSF

•  Consent •  Proper positioning

•  Specimens of secretions are cultured to identify causative organism

•  Gram-‐stain to detect bacteria •  Neutrophils are predominant WBC

in CSF Rapid diagnosis crucial •  Patient usually critical when

health care is initiated •  Antibiotic therapy instituted

before diagnosis is confirmed –what type?

•  Respiratory isolation until cultures negative

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Complica<ons of Bacterial Meningi<s •  ↑ ICP

–  Major cause of altered mental status

•  Residual neurologic dysfunction –  Cranial nerves III, IV, VI, VII, or VIII

can become dysfunctional –  Sequelae varies by cranial nerve

•  Optic nerve (CN II) compressed by ↑ ICP

•  Ocular movements affected with irritation to nerves III, IV, and VI –  Ptosis –  Unequal pupils –  Diplopia

•  CN V irritation –  Sensory loss and loss of corneal

reflex •  Inflammation of CN VII

–  Facial paresis •  Irritation of CN VIII

–  Tinnitus, vertigo, deafness –  Hearing loss may be permanent

•  Hemiparesis, dysphagia, hemianopsia

•  Suspect the following if above do not resolve –  Cerebral abscess, subdural

empyema, subdural effusion, or persistent meningitis

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Nursing Management Acute Care –BACTERIAL MENINGITIS

•  Fever management –  Fever increases cerebral edema and the

frequency of seizures –  Neurologic damage may result from

high, prolonged fever •  Hydration status

–  Compensate for diaphoresis in replacement fluids

•  Therapeutic blood levels of antibiotics •  Respiratory isolation •  Provide relief for head and neck pain •  Darkened room and cool cloth over

eyes for photophobia •  Minimize environmental stimuli

–  Mental distortion and hypersensitivity are typical

–  Convey caring and unhurried gentleness while providing efficient care

•  Safety precau<ons –seizure, falls

Initial/ongoing assessment should include •  Vital signs • Neurologic assessment •  Fluid intake and output •  Evaluation of lungs and skin

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Nursing Management Ambulatory Care –BACTERIAL MENINGITIS

•  Provide for several weeks of convalescence

•  Increase activity as tolerated –  Stress adequate nutrition –  Encourage adequate rest and sleep

•  Progressive ROM exercises and warm baths for muscle rigidity

•  Ongoing assessment for recovery of vision, hearing, cognitive skills, motor and sensory abilities

•  Tend to signs of anxiety and stress of family and caregivers

Patient will: •  Demonstrate

appropriate cognitive function

•  Be oriented to person, place, and time

•  Maintain body temperature within normal range

•  Report satisfaction with pain control

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A pa<ent with increased ICP is posi<oned in a lateral posi<on with the head of the bed elevated 30 degrees. The nurse evaluates a need for lowering the head of the bed when the pa<ent experiences which clinical manifesta<on? a.  Ptosis of the eyelid b.  Unexpected vomi<ng c.  A decrease in motor func<ons d.  Decreasing level of consciousness

Audience Response Question

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Increased Intracranial Pressure (ICP) Skull has three essential components:

1.  Brain tissue 2.  Blood 3.  Cerebrospin

al fluid (CSF)

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Diagnostic Studies

•  CT scan / MRI / PET •  Cerebral angiography •  ICP and brain tissue oxygenation measurement

•  Doppler and evoked potential studies •  EEG •  NO lumbar puncture –why?

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Increased Intracranial Pressure (ICP)

•  If one component increases, another must decrease to maintain ICP

•  Normal ICP 5 to 15 mm Hg –  Elevated if >20 mm Hg sustained

•  Normal compensatory adaptations: –  Changes in CSF volume –  Changes in intracranial blood volume

–  Changes in tissue brain volume •  Ability to compensate is limited –  If volume increase continues, ICP rises → decompensation

Factors that influence ICP: •  Arterial pressure •  Venous pressure •  Intraabdominal and

intrathoracic pressure

•  Posture •  Temperature •  Blood gases (CO2

levels)

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CEREBRAL BLOOD FLOW •  Pressure changes

– Compliance is the expandability of brain

–  Impacts effect of volume change on pressure

– Compliance = Volume/Pressure

•  Factors affecting cerebral blood vessel tone – CO2 – O2 – Hydrogen ion concentration

Definition: •  Amount of blood in mL

passing through 100 g of brain tissue in 1 minute

•  About 50 mL/min per 100 g of brain tissue

Autoregulation : •  Adjusts diameter of blood

vessels

•  Ensures consistent CBF •  Only effective if mean arterial

pressure (MAP) 70 to 150 mm Hg

Cerebral perfusion pressure (CPP):

•  Normal is 60 to 100 mm Hg

•  <50 mm Hg is associated with ischemia and neuronal death

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11

Increased Intracranial Pressure (ICP) Stages of increased ICP: •  Stage 1: Total

compensation •  Stage 2: ↓

Compensation; risk for ↑ICP

•  Stage 3: Failing compensation; clinical manifestations of ↑ ICP (Cushing’s triad –irregular respirations, widening pulse pressure, bradycardia)

•  Stage 4: Herniation imminent → death

Fall 2019 - Spring 2020 31

CEREBRAL EDEMA Vasogenic cerebral edema (tumors, abscesses, toxins) •  Most common type •  Occurs mainly in white matter

•  Fluid leaks from intravascular to extravascular space

•  Continuum of symptoms → coma

•  ↑ Extravascular fluid in brain

•  Variety of causes (e.g. lesions, head injuries, toxic/metabolic encephalopathy)

Three types of cerebral edema:

1.  Vasogenic 2.  Cytotoxic 3.  Interstitial

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CEREBRAL EDEMA

Cytotoxic cerebral edema (lesions, trauma, SIADH) •  Disruption of cell

membrane integrity •  Results in cerebral

hypoxia or anoxia •  Fluid shift from

extracellular to intracellular

Inters<<al cerebral edema (hydocephalus) •  Usually result of hydrocephalus

•  Excess CSP produc<on, obstruc<on of flow, or inability to reabsorb

•  Treat with ventriculostomy or shunt

Fall 2019 - Spring 2020 33


12

Clinical ManifestaDons-‐ ICP

•  Headache –  Often continuous –  Worse in the morning

•  Vomiting –  Not preceded by nausea –  Projectile

•  Ocular signs –  Compression of oculomotor nerve –  Unilateral pupil dilation –  Sluggish or no response to light –  Inability to move eye upward –  Eyelid ptosis

•  Other cranial nerves –  Diploplia, blurred vision, EOM

changes

•  Change in level of consciousness, GCS

•  Flattening of affect → coma

•  Change in vital signs •  Cushing’s triad •  Change in body

temperature

Fall 2019 - Spring 2020 34

Clinical Manifestations

•  ↓ In motor function (strength, response) –  Hemiparesis/hemiplegia –  Pronator drift –  Raise foot off bed, bend

knees –  Motor response to pain –  Decerebrate posturing

(extensor) •  Indicates more serious

damage

–  Decorticate posturing (flexor)

Fall 2019 - Spring 2020 35

Potential Placements of ICP Monitoring Devices

Guides clinical care Indications: •  Glasgow Coma Scale of

≤8 •  Abnormal CT scans or

MRI Measurement of ICP •  Ventriculostomy •  Catheter inserted into

lateral ventricle •  Coupled with an

external transducer

Fall 2018 36


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Ventriculostomy in Place

Fall 2018 37

External vs. Internal Ventriculostomy (VP Shunt)

Management of ICP and Monitoring Devices

•  Prevent and monitor for infection

•  Measure as mean pressure •  Waveform should be recorded –  Normal, elevated, and plateau waves

•  Can control ICP by removing CSF (with ventricular catheter)

•  Intermittent or continuous drainage

•  Careful monitoring of volume of CSF drained is essential

•  Prevent infection and other complications

Treat underlying cause •  Adequate oxygenation

•  PaO2 > 100 mm Hg

•  PaCO2 35-‐45 mm Hg

•  Intubation •  Mechanical

ventilation •  Surgery

Fall 2019 - Spring 2020 38

Interprofessional Care –ICP DRUG THERAPY

•  Mannitol (Osmitrol) – Plasma expansion – Osmotic effect

•  Hypertonic saline – Moves water out of cells and into blood

•  Corticosteroids – Vasogenic edema

•  Antiseizure medications •  Antipyretics •  Sedatives •  Analgesics •  Barbiturates

Iden<fy 3 items of concern to assess and monitor for with regards to each drug therapy?

Fall 2019 - Spring 2020 39


14

Interprofessional Care –ICP NUTRITIONAL THERAPY

•  Hypermetabolic and hypercatabolic state ↑ need for glucose – Enteral or parenteral nutrition –how do you know which one?

– Early feeding (within 3 days of injury)

– Keep patient normovolemic –  IV 0.9% NaCl preferred over D5W or 0.45% NaCl –why?

It has been one week in the ICU since your pa<ent suffered a trauma<c brain injury. The prognosis looks to be a very long recovery. What long term “support” will you an<cipate in order for this pa<ent to be moved out of the ICU and into the process for rehabilita<on?

Fall 2019 - Spring 2020 40

Nursing Management Acute Care –ICP

•  Respiratory function –  Maintain patent airway –  Elevate head of bed 30 degrees –  Suctioning needs –  Minimize abdominal distention –  Monitor ABGs –  Maintain ventilatory support

•  Pain and anxiety management –  Opioids –  Propofol (Diprivan) –  Neuromuscular blocking agents –  Benzodiazepines

•  Fluid and electrolyte balance –  Monitor IV fluids –  Daily electrolytes –  Monitor for DI or SIADH

Monitor and minimize increases in ICP and optimize CPP:

•  HOB elevated appropriately

•  Prevent extreme neck flexion

•  Turn slowly •  Avoid coughing,

straining, Valsalva •  Avoid hip flexion

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Nursing Management Acute Care –ICP

•  Minimize complications of immobility

•  Protection from self-‐injury – Judicious use of restraints; sedatives

– Seizure precautions – Quiet, nonstimulating environment

•  Psychologic considerations •  Long term airway and nutrition protections: – Tracheostomy – PEG

Fall 2019 - Spring 2020 42

chapter 56 acute intracranial problmes fall...

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