ICU PROCEDURES: Neurological Monitoring

by | Sep 13, 2024 | Nurse Article | 0 comments

ICU PROCEDURES: Neurological Monitoring

ICU Procedures: Chest Tube Management – Nursing Management

Chest tubes are inserted into the pleural space to remove air, fluid, or blood and to restore normal intrapleural pressure, enabling full lung expansion. Nursing management of a chest tube is crucial to ensure patient safety, prevent complications, and ensure the chest tube is functioning properly.

Indications for Chest Tube Insertion:

  1. Pneumothorax: Air in the pleural space causing lung collapse.
  2. Hemothorax: Blood in the pleural space.
  3. Pleural Effusion: Excess fluid in the pleural space.
  4. Empyema: Pus in the pleural space due to infection.
  5. Post-surgery: Following thoracic surgery or trauma to prevent fluid or air accumulation.

Nursing Management:

1. Initial Assessment:

  • Vital Signs: Monitor heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature.
  • Respiratory Assessment: Assess breath sounds, respiratory effort, and oxygen needs. Look for signs of respiratory distress such as dyspnea, cyanosis, and use of accessory muscles.
  • Pain Management: Administer prescribed analgesics to minimize discomfort from the chest tube insertion.

2. Monitoring the Chest Tube System:

  • Drainage System Components:
    1. Water Seal Chamber: Acts as a one-way valve, allowing air or fluid to exit but preventing air from re-entering the pleural space.
    2. Suction Control Chamber: Controls the amount of suction applied to the chest tube.
    3. Collection Chamber: Where fluid or air accumulates after being drained from the pleural space.
  • Key Points to Monitor:
    1. Drainage:
      • Monitor the amount, color, and consistency of drainage.
      • Record the drainage every 1-2 hours initially, then as needed.
      • Report sudden increases (>100 mL/hour) or changes in drainage characteristics (e.g., bright red, purulent) immediately.
    2. Water Seal:
      • Tidal fluctuations (rise and fall of water in the water-seal chamber) should correspond with the patient’s breathing pattern. Absence of tidaling could indicate obstruction, re-expansion of the lung, or disconnection.
      • Bubbling in the water-seal chamber: Intermittent bubbling is expected in pneumothorax patients. Continuous bubbling may indicate an air leak.
    3. Suction:
      • Ensure the suction control chamber is set to the prescribed level (usually between -20 cm H₂O).
      • Monitor for gentle bubbling in the suction chamber if suction is applied.

3. Maintaining the Chest Tube System:

  • Ensure proper positioning:
    • Keep the drainage system below chest level at all times to prevent backflow of fluid into the pleural space.
  • Check tubing:
    • Ensure the tubing is not kinked, looped, or compressed, as this could impair drainage.
    • Avoid clamping the chest tube unless ordered by a physician (e.g., during tube removal or checking for an air leak).
  • Secure the chest tube:
    • Ensure the chest tube dressing is clean, dry, and occlusive to prevent air from entering the pleural space.
    • Tape all connections to prevent accidental disconnection.

4. Patient Positioning and Mobilization:

  • Encourage ambulation: If permitted, ambulation can help improve lung expansion and drainage.
  • Frequent Position Changes: Turning, coughing, and deep breathing exercises should be encouraged to help re-expand the lung and promote drainage.
  • Positioning: Patients can be positioned semi-Fowler’s to promote lung expansion and drainage.

5. Pain Management:

  • Assess pain regularly and administer analgesics or other pain control measures as needed. Pain can inhibit deep breathing and effective lung expansion.
  • Encourage deep breathing and coughing exercises, using incentive spirometry to help prevent atelectasis.

6. Recognizing and Managing Complications:

  • Air Leaks:
    • Identified by continuous bubbling in the water seal chamber.
    • Check all connections for tightness and securement.
    • Notify the physician if the air leak is persistent or worsening.
  • Tube Dislodgement:
    • If the chest tube is accidentally dislodged, cover the insertion site with a sterile occlusive dressing and tape it on three sides to allow air to escape and prevent tension pneumothorax. Notify the physician immediately.
  • Infection:
    • Monitor the insertion site for signs of infection (redness, warmth, swelling, drainage). Use sterile technique during dressing changes and report any signs of infection to the healthcare team.
  • Subcutaneous Emphysema:
    • This occurs when air leaks into the subcutaneous tissue, resulting in swelling and crepitus around the insertion site. Notify the physician if this is detected.
  • Tension Pneumothorax:
    • If the patient shows signs of sudden respiratory distress, hypotension, tracheal deviation, or absence of breath sounds, it may indicate a tension pneumothorax, a medical emergency. The chest tube system should be checked for patency and the physician notified immediately.

7. Chest Tube Removal:

  • Criteria for Removal: Once the underlying condition is resolved, and the chest tube drainage is minimal (<100 mL in 24 hours), the chest tube may be removed.
  • Procedure:
    1. Premedicate the patient for pain.
    2. The physician will clamp the chest tube and remove the tube, often while the patient performs the Valsalva maneuver (forced expiration).
    3. Apply an airtight dressing over the insertion site.
  • Post-removal Monitoring: Monitor the patient closely for signs of respiratory distress or recurrence of the original issue (e.g., pneumothorax).

Key Nursing Responsibilities:

  • Monitor drainage: Regular assessment of the drainage system is vital for detecting changes in the patient’s condition.
  • Maintain patency: Ensure the tubing and collection system are functioning properly to avoid complications like reaccumulation of air or fluid.
  • Patient education: Inform the patient about the importance of deep breathing and coughing, and what to expect with the chest tube in place.
  • Documentation: Keep accurate records of drainage, respiratory status, and any changes in the patient’s condition.

Effective chest tube management is critical for recovery, and vigilant nursing care can help prevent complications and ensure successful outcomes in patients requiring this intervention.

Indications for Neurological Monitoring:

  1. Traumatic Brain Injury (TBI)
  2. Stroke (Ischemic or Hemorrhagic)
  3. Post-neurosurgery
  4. Increased Intracranial Pressure (ICP)
  5. Seizure Disorders
  6. Comatose States
  7. Neuromuscular Diseases (e.g., Guillain-Barré syndrome, Myasthenia Gravis)

Neurological Monitoring Techniques:

  1. Intracranial Pressure (ICP) Monitoring
    • Involves measuring pressure inside the skull to detect increases that may harm brain tissue.
    • ICP values >20 mmHg indicate increased ICP and require immediate intervention.
  2. Cerebral Perfusion Pressure (CPP)
    • Calculated as the difference between mean arterial pressure (MAP) and ICP (CPP = MAP – ICP). CPP should be maintained above 60-70 mmHg to ensure adequate brain perfusion.
  3. Glasgow Coma Scale (GCS)
    • Assesses level of consciousness based on eye, motor, and verbal responses.
    • Scored from 3 (deep coma) to 15 (fully alert). A GCS of ≤8 indicates severe brain injury.
  4. Pupil Assessment
    • Checks for pupil size, shape, equality, and reactivity to light (PERRLA – Pupils Equal, Round, Reactive to Light and Accommodation).
    • Non-reactive or unequal pupils may indicate increasing ICP or brainstem damage.
  5. Cranial Nerve Assessment
    • Evaluates cranial nerve function to detect any deficits related to neurological injury.
  6. Electroencephalogram (EEG)
    • Monitors brain wave activity, especially in patients with seizures or altered mental status.
  7. Transcranial Doppler (TCD)
    • Used to monitor cerebral blood flow velocity, especially in patients with vasospasm after subarachnoid hemorrhage.

Nursing Management in Neurological Monitoring:

1. Assessment:

  • Glasgow Coma Scale (GCS):
    • Assess GCS regularly (e.g., hourly or as ordered) and monitor for any decrease in score, which may indicate neurological deterioration.
  • Pupil Check:
    • Assess pupils for size, symmetry, and reactivity to light. Document any changes (e.g., sluggish response, fixed dilated pupils).
  • Vital Signs:
    • Regularly monitor blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation.
    • Monitor for Cushing’s Triad (bradycardia, hypertension, irregular breathing), which is a sign of increased ICP.
  • Motor and Sensory Function:
    • Assess the patient’s ability to move and feel sensations in all extremities, including checking for symmetry in muscle strength and response to stimuli.
  • Intracranial Pressure (ICP):
    • If ICP monitoring is in place, check the device and ICP readings frequently. ICP should be <20 mmHg.

2. Monitoring for Complications:

  • Increased ICP:
    • Signs include headache, vomiting (without nausea), altered consciousness, irregular breathing, papilledema, and posturing (decerebrate or decorticate).
  • Seizures:
    • Monitor for seizure activity, especially in post-traumatic or post-surgical patients.
    • Maintain seizure precautions (e.g., side rails up, padded bed, suction ready).
  • Cerebral Perfusion Issues:
    • Ensure adequate cerebral perfusion by maintaining CPP ≥60 mmHg. Adjust fluids, vasopressors, or ICP treatment as ordered.
  • Hydrocephalus:
    • Monitor for signs of hydrocephalus (e.g., altered LOC, visual disturbances), especially in patients with ventricular drains.

3. Interventions for Increased ICP:

  • Positioning:
    • Keep the head of the bed elevated to 30 degrees to promote venous drainage from the brain.
    • Maintain the patient’s head in a neutral position, avoiding neck flexion or excessive rotation, which may increase ICP.
  • Control Ventilation:
    • Hyperventilation can be used cautiously to lower PaCO₂ and decrease ICP temporarily by causing cerebral vasoconstriction. Monitor arterial blood gases (ABGs) closely.
  • Sedation and Analgesia:
    • Administer prescribed sedation and pain relief to prevent agitation, coughing, or straining, which can increase ICP.
  • Fluid Management:
    • Maintain fluid balance; avoid both dehydration and fluid overload. Administer hypertonic saline or mannitol to draw fluid out of the brain tissue in cases of increased ICP.
  • Temperature Control:
    • Maintain normothermia (36-37°C). Hyperthermia can increase cerebral metabolism and ICP, so antipyretics or cooling measures may be required.

4. Seizure Management:

  • Anticonvulsants:
    • Administer antiepileptic medications as prescribed, and monitor for effectiveness.
  • Seizure Precautions:
    • Keep suction equipment and oxygen at the bedside. Pad the side rails, and ensure the patient has easy access to a call bell if alert.

5. Nursing Care for ICP Devices:

  • Intraventricular Catheter (Ventriculostomy):
    • Regularly check for proper functioning of the drainage system.
    • Monitor for signs of infection at the insertion site and observe the CSF for changes in color or consistency (e.g., blood-tinged, cloudy, or foul-smelling fluid).
  • Monitor Drainage:
    • Record CSF drainage amounts and maintain proper level settings to avoid over-drainage or under-drainage.

6. Medication Management:

  • Mannitol: An osmotic diuretic used to reduce brain swelling by drawing water out of brain tissue.
  • Hypertonic Saline: Helps reduce cerebral edema by pulling fluid into the intravascular space.
  • Barbiturates: Sometimes used to induce a coma to decrease brain metabolism and ICP.
  • Vasopressors: To maintain adequate MAP and CPP.

7. Preventing Secondary Brain Injury:

  • Maintain Oxygenation: Ensure adequate oxygen supply by using mechanical ventilation or supplemental oxygen if necessary. Keep PaO₂ >60 mmHg and SpO₂ >92%.
  • Manage Blood Pressure: Avoid hypotension (which can reduce cerebral perfusion) and hypertension (which can increase ICP).
  • Prevent Hyperthermia: Use cooling blankets or antipyretics to control elevated body temperature, which can increase brain metabolism.

Complications to Watch for:

  1. Brain Herniation: A life-threatening condition where brain tissue shifts due to increased ICP.
    • Signs: Sudden loss of consciousness, irregular breathing, dilated pupils, abnormal posturing.
  2. Seizures: Can occur due to cerebral irritation or injury.
  3. Cerebral Edema: Worsening swelling in the brain can lead to increased ICP and poor outcomes.
  4. Infections: Particularly meningitis in patients with invasive monitoring devices.
  5. Secondary Brain Injury: Hypoxia, hypotension, or hypercapnia can further damage the brain.

Nursing Considerations:

  • Communication: Regularly update the healthcare team regarding any changes in neurological status.
  • Documentation: Accurately record all neurological assessments, ICP readings, medication administration, and patient response to interventions.
  • Patient and Family Education: Explain procedures and treatment plans to the patient and family, offering support and resources.

Conclusion:

Nursing management of neurological monitoring in the ICU is a complex, ongoing process that requires frequent assessments, monitoring for complications, and timely interventions. The goal is to ensure adequate cerebral perfusion, reduce ICP, and prevent secondary injury, which is critical to improving patient outcomes in critically ill patients.