-Transphenoidal hypophysectomy- nasal packing, don’t brush teeth, don’t increase abdominal pressure, assess nasal drainage for glucose and halo sign. Leak= rest, HOB less then 30 degree, decrease stimulation. Risk of meningitis and DI.
-DI- getting rid of pure water. LOW(DILUTE) URINE (lower urine osmilatity), high serum osm. Specific gravity low, hypernatremia. Restrict water and sodium. Give hypotonic fluids. Cerebral Hemorrhage. Dehydration
-SIADH- keeping sodium and water. Concentrated urine (high urine osmilatity), low serum osm. High specific gravity, hyponatremia. NS/hypertonic. Cerebral Edema. Fluid overload.
-Ventriculostomy is the only one that can drain
-Right and left internal carotids and right and left vertebral arteries feed ipsilateral side of the brain. If vessel is damaged (aneurysm, bleeds), contrlater nerro deficits if vessel damage is in the cerebrum, ipsilater if vessel damage is in cerebellum; circle of Willis- anastamosis of vessels at base of brain provides collateral circulation, common site of aneurysms.
- Increase cerebral blood flow- high PaCO2/low pH, low Pa02/sats, low blood pressure. Hyperventilation to lower PAC02 to vasoconstict the erebral blood vessels and to decrease blood flow to the brain.
-Monroe-Kellie hypothesis: Brain, blood flow, and CSF. We alter the blood flow and CSF. Not the brain. We can dilate and constrict blood flow. We can also remove CSF.
-BBB: helps to filter out toxic chemicals to the brain. Lipids, water, ammonia, glucose, carbon dioxide, oxygen. The BBB does not let all medications pass that may be helpful to the brain.
- 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, and 5 sacral vertebrae.
-Cranial Nerves: vagus nerve (X) Swallowing movements and saliva secretion. Gag and swallow reflexes. Sensation in the pharynx and larynx, as well as taste on posterior 1/3 of tongue. Also, autonomic innervation of heart,lungs, esophagus, and stomach.. CN IX(glossopharyngeal) damage-intracranial tumor of infection. CN XII- hypogloassal stick tounge out. Motor, tounge movement. Observe tounge, stick it out, tounge against cheek
- Normal glascow 3-15. 7 to 8 in a coma. Not complete especially with spinal cord injury.
-papilledema in the head injured client is a sign of increased ICP, 6 cardinal fields, earliest sign of ICP is LOC, surrounds, orientation. Drugs that cause dialation: anticholinergics, atropine, scapolmine, nurcarinic antagonist.

- Oculovestibular testing also evaluates CNs III and VI, along with CN VIII. The physician instills iced saline solution into the ear canal and observes for nystagmus (involuntary rapid eye movements). In a normal response, the eyes show conjugate movement and nystagmus in the direction of the irrigated ear, indicating an intact brain stem. Absence of nystagmus is an abnormal response signifying a decrease in consciousness with severe brain stem injury. The oculovestibular test is contraindicated in patients with ruptured tympanic membranes or otorrhea; results may be false-positive in patients who are on ototoxic drugs (including phenytoin) or who have Ménière’s disease
-Brudesinski’s- meningial irritation. Lay flat, raise head, flexion of knees and pelvis if positive.
-Hypereflexia is a reaction of the ANS hyporeflexia is a reaction of the PNS. Cerebral angiography- dye to visualize vessels.
- sciatica- weakness, numbness, and tingling in the legs.
-MS- numbness or weakness, partial or complete loss ofvision, double vision, tingleing, pain, electric schock sensations, tremor, fatigue, dizziness
-ALS- difficulty lifting front part of foot and toes, weakness in legs, feet or angles, hand weakness, slurring, muscle cramps. No cognitive changes. Starts in feet and then extends.

MEDS:
Propofol- hyperventilation causes vasodilation which decreases ICP S/E bradycardia and hypotension. Rapid onset 60 seconds. Nursing priorities: monitor for respiratory depression, apnea, bradycardia, and hypotension. Treat bradycardia with atropine. Must taper slowly. Must use strict aseptic technique. Change tube every 12 hours. Risk of fat embolism and infection. Lowers blood pressure. Maintenance of sedation. Continuous drip.
Manitol- lowers ICP. Increase osmolatity (275-295 normal) check serum osm for theurepeutic, dumps into vascular, need to have functioning heart and liver. Complications: fluid overload, CHR-CRRT, LOC, neuro, pupils, ICP, electrolytes, Bun/creatinine, hourly output
Amacar- increases clotting, used for bleeding, antifebrin, TPA opposite, unsafe, uneffective if rebleed.
Solumedral- given to spinal cord injuries patient. Increase the risk of walking again.
Heparin/Coumadin- thin blood. Does not do anything to existing clot.
Ninotop- CCB decrease vasospasm and decreased B/P, 21 days. Dizziness, lightheadedness, flushing, swelling in feet and ankles, rash, allergic reaction
Simvastatin- decreases total cholesterol HA, N/V
Plavix- antiplatelet

Started in increase in volume (brain, blood, CSF) complicance (adjustment to correct increase in other) influences (much much time, size of intercranial departments) slow developing is more compliance. When ICP increases and CPP decreases, theres a decrease in cerebral blood flow. In return/response decrease in PaO2, increase in PaCo2 and a decrease in pH. All of these will increase cerebral vasodialation and worsen the ICP. Increases in ICP that are greater then 20 minutes for 5 minutes or longer, leads to brain herniation. Risk factors: Brain volume: cerebral edema, or intracerebral mass. Blood flow: impaired autoregulation (below 50 and above 150 MAP- lose ability) decrease cerebral oxygenation hypoxia hypercapnia, (suctioning) increased 02 demand and delivery, hyperthermia, cluttering of activities, pain, REM, physical activity, stimulation, seizure*, impaired venous outflow.

Loc is most important and first indicator. In unconscious it is pupils. Loc and orientation decreased first, then pupils, then vital signs. LOC- restlessness, orientation, lethargy. Later: deep coma. Headache with blood, cerebral edema. Vitals are good early then cushing triade. Blown pupil are a late irreversible sign of brain death. Not usually vomiting. Temperature regulation is lost later because we lose the ability to regulate later. Brain herniation is with later (reversabile) respiration-cheystokes, pulse (late bradycardia). Need to pick up early to be corrected. Late signs are pt with die or significate loss of function.

Positioning: decrease risk of cerebral blood flow changes neutral head (supine or side) avoid anything around the neck, avoid flexion, extension of head and hips. No straining sneezing cough. Elevation 15 to 30 degrees. No pillow. Consider the MAP. If HOB is moved to 30 degrees with low MAP it will decrease CCP and increase ICP. And underperfusion! Flat if unstable. Body alignment-log roll-look at ICP if baseline CCP doesn’t come turn back. Gental touch are okay. Vasava is bad. No cough, sneezing. Suctioning increased ICP. Administerd lidocain prior, 100 02 before, 10 seconds, no more then 2 passes. Space interventions. Do not cluster.
Secondary brain injury-did not happen initially. Hypoxia increases cerebral blood flow, lower pH, anerobic energy. PAC, swan ganz.
PAO2=100 not 60. Aggrevily treat hypoxia, CO2 cause vasodialater (increase blood flow increases ICP)-ABGS, hyperventilation. MAP hypertension is safer, treat hypotension. Want MAP between 70 and 80. Fluids, colloids, NS* or 3% decrease cerebral edema. Never hyponutremic and give hypotonic=DEADLY. Vasopressors (lephod, neo, dobamine) EKG, art, MAP, resp, temp, PA catth, cardiac output. MAINTAIN MAP! GLASCOW LESS THEN 8, ICP monitor