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Who You’ll Hear
Kati Kleber, MSN RN– Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.
Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.
Elizabeth Mills, BSN RN CCRN – highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center.
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Neuro Wise - A Crash Course for New Neuro Nurses from FreshRN® is your one-stop ultimate resource and online course, crafted specifically for brand new neuro nurses. If you want to get ahead of the game so instead of merely surviving orientation, you’re thriving all the way through from day one to day done - this is the course for you.
What You’ll Learn
- Medications
- Diagnostics
- Surgeries and Procedures
- Monitoring
- Encouragement
We continue our journey through neurocritical care nursing!
Medications
tPA – discussed in Neuro Nurse Tips, Part I
Mannitol – osmotic diuretic, given to decrease ICP
- Increasing the plasma osmolality to pull fluid off of the brain, into the intravascular space, and out of the bed
- The cells actually shrink because they were “swollen” – this “shrinks” them back down to their normal size
- You’re increasing cardiac output; increasing urine output
- You’re putting more fluid into the vessels
- Watch patients with existing fluid overload issues (like congestive heart failure)
- Watch electrolytes
- Basic metabolic panel (BMP), serum osmolality
- Know holding parameters
- If the serum Osmo is too high, you can have cellular death because they’re shrinking too much which can ultimately cause more edema… there’s an inflammatory process that occurs when cells die
- Normal serum Osmo 275-285 (may differ between, typically holding if it gets to 320
- Watch for kidney issues – intrarenal vasoconstriction can occur
- Know sodium and how quickly it trends up; we expect it to rise but we don’t want a sudden drastic increase – you may have a holding parameter for the sodium as well
- Give it through a filter set or draw it up with a filter needle – hurts like hell if you don’t
- I would draw up with a blunt needle and give with a filter set because it’s faster
- Whatever you do – FILTER it
- Mannitol crystallizes and can get cloudy; don’t give it if it’s cloudy/crystallized
Hypertonic saline (3%) – treat hyponatremia and/or cerebral edema
- Essentially saltwater
- Most likely need a central venous catheter
- FreshRN Podcast related episode: Central Venous Catheters 101
- Resource: Safety of Continuous Peripheral Infusion of 3% Sodium ChlorideSolution in Neurocritical Care Patients from the American Journal of Critical Care
- Places now give 23% hypertonic saline; the physician must administer
- Monitor labs and hemodynamics closely
- If you’re drawing labs on a patient receiving a continuous infusing – PAUSE THE DRIP before drawing labs and draw them from a different lumen if possible.
- This can significantly impact the lab result and is easily overlooked
- Nicardipine, Norepinephrine, Neosynephrine are some examples
- KNOW THESE if you’re working in a neurocritical care unit
- Consider the disease process when giving PRN BP meds
- For example, if the patient has a hemorrhagic stroke and needs consistently blood pressure control, a Nicardipine drip at a low dose would offer more consistent/level blood pressure than intermittent dosing of a PRN IV push med (like 20 mg Hydralazine) when the BP spikes again
- If a patient is hemodynamically unstable and requiring vasoactive med, get a central line sooner than later
- If your patient is on a drip to keep their blood pressure UP, do not give their scheduled antihypertensive medications (if any). Clarify holding parameters or temporarily hold them (after clarifying with the physician) while the patient is on the medication to increase the blood pressure.
- Double-check drips, dosings, titrating, why, and wean
- Consider other meds the patient is getting while vasoactive meds are getting and the impact they may have on the blood pressure medication
- For example, many antiepileptics will lower blood pressure
Antiplatelets / anticoagulants
- Typically many patients with a hemorrhagic stroke are on a blood thinner
- Know if they’re on any; when it was last taken and the dose
- Reversal agents
- Examples: Fresh frozen plasma (FFP), Kcentra, vitamin K
- Educate the family on why it’s being reversed; this can be especially challenging when they’ve been told by their physician for years how important their blood thinner is and now they’re not getting it
- If you have a mechanical valve who had a hemorrhagic stroke, they will be taken off their blood thinner – you must recognize the big risks with this
- Cardiology and neurology will be working together to figure out what’s best because they’re stuck between a rock and a hard place (risk of another hemorrhagic stroke, or risk of an ischemic stroke or pulmonary embolism due to the mechanical valve)
Antiepileptics
- Know your indications
- If you have Lorazepam ordered for seizures, do not give it for agitation. Call and get another order
Diagnostics
- MRI vs. CT
- Related FreshRN Podcast Episode – Diagnostics
- EEG – electroencephalogram
- Most likely due to seizure activity
- Educating family/patient is critical
- Families think that an EEG will tell you very detailed aspects of brain function (what they can/cannot understand, if they can hear and understand what’s going on around them, etc.)
- It shows the electrical activity, not the structure
- Think of it like an ECG shows the electrical activity of the heart and an echocardiogram shows the structural components while an EEG shows the electrical activity of the brain and a CT/MRI shows the structures
- Continuous versus spot EEG
- Just because you
- Don’t document if you see the patient having a seizure; you can’t say definitively say someone is having a seizure without the EEG to confirm it
- Chart “rhythmic twitching” or whatever it is that you see
- The children’s book we talked about, was written by a nurse, to explain to his kid what he does working as a nurse: Daddy, the Amazing Nurse! By Donald Jacobsen, RN
- Brain death testing
- EEG, apnea testing, cold caloric testing
Surgeries/Procedures
Thrombectomy
- Neurovascular procedure; similar to a heart cath but in the brain
- A catheter placed through the femoral artery up to the brain, administer contrast, so they can identify the clot and remove it to open up a blocked artery in the brain
- Only done for large vessels – so think any artery in the Circle of Willis
- This is done when there is a clear indication for it because it is an invasive procedure with very real risks; most patients have had a CTA first
- Video animation of a thrombectomy:
- https://www.youtube.com/watch?v=7TcUoBQqkac
- Please note, that this shows only 1 device and was published in 2013. He states that they use tPA or this procedure. Now, both can be done to the same patient to perfuse the brain.
- Remember your post-procedure care; similar to a patient who just had a cardiac cath with a femoral approach (lay flat for 6 hours, pressure and monitoring insertion site, watch for a hematoma/retroperitoneal bleeds)
Craniotomy
- Removing part of the skull to get to the brain to do something (remove a tumor, clip an aneurysm, remove a hematoma, and many more reasons)
- Typically incisional pain is not necessarily all up in my brain pain – not as many pain receptors in the brain so it’s not as painful as other surgeries
Craniectomy
- Removing part of the skull and leaving it off to allow room for edema
- Can be stored in a freezer or in the patient’s abdominal cavity
New articles we discussed
External ventricular drains
- Draining CSF and/or blood to relieve pressure
- Drains via gravity, so it must be leveled correctly
- Similar to an arterial line
- Anatomical landmark – foramen of Monro
- Tragus or lateral canthus
- MUST follow precisely – a change of head of the bed can be fatal
- Educate families and other healthcare team members not to move the head of bed without checking with the nurse
- Can be hooked up to ICP monitoring
Monitoring
ICP monitoring
- 7-15 mmHg = normal
- 20+ mmHg = uh… you need to do something
- Can be done with an EVD or a bold
Cerebral perfusion pressure (CPP)
MAP-ICP = CPP
- Basically, the blood pressure of the brain
- You want to maintain CPP, even in the event of increased intracranial pressure because you want to ensure the brain is getting the blood flow it requires otherwise additional damage/compromise can occur
- 60-70 typically good
- 50 or less, you are going to have brain issue because the brain is not being adequately perfused with blood
- Just because the CPP is high doesn’t mean it’s great either
- May have other issues like ARDS
- It’s a balancing act
Body temp
- This is so important guys!
- For every degree of increase in body temp, the increase in oxygen demand increases 10%
- Aggressively treat fevers
- Know your orders!
- Neuro changes can occur with increased body temp
- If you’ve got neuro changes, check a body temp to see if it’s increased. This could explain your neuro changes.
- Combination of Fever, Neurological Injury Strongly Linked to Poorer Outcomes
Encouragement
- This is a lot of information
- Get better each day
- Stick with it
- If you’re not sure, pull another set of eyes in to look at the patient
- There are no stupid questions
- Join your professional organizations
- American Nurses Association, American Association of Neuroscience Nurses ,
- American Association of Critical-Care Nurses
More neuro resources
- FreshRN Podcast episodes specifically related to neuro:
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