Chapter 61 management of patients with neurologic dysfunction
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Chapter 61 Management of Patients With Neurologic Dysfunction. Altered Level of Consciousness (LOC). Level of responsiveness and consciousness is the most important indicator of the patient's condition LOC is a continuum from normal alertness and full cognition (consciousness) to coma

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Chapter 61 Management of Patients With Neurologic Dysfunction

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Chapter 61 management of patients with neurologic dysfunction

Chapter 61Management of Patients With Neurologic Dysfunction


Altered level of consciousness loc

Altered Level of Consciousness (LOC)

  • Level of responsiveness and consciousness is the most important indicator of the patient's condition

  • LOC is a continuum from normal alertness and full cognition (consciousness) to coma

  • Altered LOC is not the disorder but the result of a pathology

  • Coma:unconsciousness, unresponsiveness, and inability to arouse


Altered level of consciousness loc cont

Altered Level of Consciousness (LOC) (cont.)

  • Akinetic mutism: unresponsiveness to the environment, the patient makes no movement or sound but sometimes opens eyes

  • Persistent vegetative state: patient is devoid of cognitive function but has sleep–wake cycles

  • Locked-in syndrome: patient is unable to move or respond except for eye movements due to a lesion affecting the pons


Nursing process assessment of the patient with altered loc

Nursing Process—Assessment of the Patient With Altered LOC

  • Verbal response and orientation

  • Alertness

  • Motor responses

  • Respiratory status

  • Eye signs

  • Reflexes

  • Postures

  • Glasgow Coma Scale

  • See Table 61-1


Chapter 61 management of patients with neurologic dysfunction

Decorticate Posturing

Decerebrate Posturing


Nursing process diagnosis of the patient with altered level of consciousness

Nursing Process—Diagnosis of the Patient With Altered Level of Consciousness

  • Ineffective airway clearance

  • Risk of injury

  • Deficient fluid volume

  • Impaired oral mucosa

  • Risk for impaired skin integrity and impaired tissue integrity (cornea)

  • Ineffective thermoregulation

  • Impaired urinary elimination and bowel incontinence

  • Disturbed sensory perception

  • Interrupted family processes


Collaborative problems potential complications

Collaborative Problems/Potential Complications

  • Respiratory distress or failure

  • Pneumonia

  • Aspiration

  • Pressure ulcer

  • Deep vein thrombosis (DVT)

  • Contractures


Nursing process planning the care of the patient with altered loc

Nursing Process—Planning the Care of the Patient With Altered LOC

  • Goals include:

    • Maintenance of clear airway

    • Protection from injury

    • Attainment of fluid volume balance

    • Maintenance of skin integrity

    • Absence of corneal irritation

    • Effective thermoregulation

    • Accurate perception of environmental stimuli

    • Maintenance of intact family or support system

    • Absence of complications


Interventions

Interventions

  • A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care; protection includes maintaining the patient’s dignity and privacy

  • Maintain an airway

    • Frequent monitoring of respiratory status including auscultation of lung sounds

    • Position the patient to promote accumulation of secretions and prevent obstruction of upper airway: HOB elevated 30°, lateral or semiprone position

    • Provide suctioning, oral hygiene, and CPT


Maintaining tissue integrity

Maintaining Tissue Integrity

  • Assess skin frequently, especially areas with high potential for breakdown

  • Turn patient frequently; use turning schedule

  • Carefully position patient in correct body alignment

  • Perform passive range of motion

  • Use splints, foam boots, trochanter rolls, and specialty beds as needed

  • Clean eyes with cotton balls moistened with saline

  • Use artificial tears as prescribed

  • Implement measures to protect eyes; use eye patches cautiously as the cornea may contact patch

  • Provide frequent, scrupulous oral care


Interventions1

Interventions

  • Maintain fluid status

    • Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O

    • Administer IVs, tube feedings, and fluids via feeding tube as required: monitor ordered rate of IV fluids carefully

  • Maintain body temperature

    • Adjust environment and cover patient appropriately

    • If temperature is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to blow over patient to increase cooling

    • Monitor temperature frequently and use measures to prevent shivering


Promoting bowel and bladder function

Promoting Bowel and Bladder Function

  • Assess for urinary retention and urinary incontinence

  • May require indwelling or intermittent catherization

  • Initiate bladder-training program

  • Assess for abdominal distention, potential constipation, and bowel incontinence

  • Monitor bowel movements

  • Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated

  • Diarrhea may result from infection, medications, or hyperosmolar fluids


Sensory stimulation and communication

Sensory Stimulation and Communication

  • Talk to and touch the patient and encourage the family to talk to and touch the patient

  • Maintain normal day–night pattern of activity

  • Orient the patient frequently

  • A patient aroused from coma may experience a period of agitation; minimize stimulation at this time

  • Initiate programs for sensory stimulation

  • Allow family to ventilate and provide support

  • Reinforce and provide consistent information to family

  • Provide referral to support groups and services for the family


Increased intracranial pressure icp

Increased Intracranial Pressure (ICP)

  • Monro-Kellie hypothesis: because of limited space in the skull, an increase in any one skull component—brain tissue, blood, or CSF—will cause a change in the volume of the others

  • Compensation to maintain a normal ICP of 10 to 20 mm Hg is normally accomplished by shifting or displacing CSF

  • With disease or injury, ICP may increase

  • Increased ICP decreases cerebral perfusion, causes ischemia, cell death, and (further) edema


Increased intracranial pressure cont

Increased Intracranial Pressure (cont.)

  • Brain tissues may shift through the dura and result in herniation

  • Autoregulation: refers to the brain’s ability to change the diameter of blood vessels to maintain cerebral blood flow

  • CO2 plays a role; decreased CO2 results in vasoconstriction, and increased CO2 results in vasodilatation


Brain with intracranial shifts

Brain With Intracranial Shifts


Icp and cpp

ICP and CPP

  • CCP (cerebral perfusion pressure) is closely linked to ICP

  • CCP = MAP (mean arterial pressure) – ICP

  • Normal CCP is 70 to 100

  • A CCP of less than 50 results in permanent neuralgic damage


Manifestations of increased icp early

Manifestations of Increased ICP—Early

  • Changes in level of consciousness

  • Any change in condition

    • Restlessness, confusion, increasing drowsiness, increased respiratory effort, and purposeless movements

  • Pupillary changes and impaired ocular movements

  • Weakness in one extremity or one side

  • Headache: constant, increasing in intensity, or aggravated by movement or straining


Manifestations of increased icp late

Manifestations of Increased ICP—Late

  • Respiratory and vasomotor changes

  • VS: increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate; pulse may fluctuate rapidly from tachycardia to bradycardia and temperature increase

    • Cushing’s triad: bradycardia, hypertension, and bradypnea

  • Projectile vomiting


Manifestations of increased icp late cont

Manifestations of Increased ICP—Late(cont.)

  • Further deterioration of LOC; stupor to coma

  • Hemiplegia, decortication, decerebration, or flaccidity

  • Respiratory pattern alterations including Cheyne-Stokes breathing and arrest

  • Loss of brain stem reflexes: pupil, gag, corneal, and swallowing


Nursing process assessment of the patient with increased intracranial pressure

Nursing Process—Assessment of the Patient With Increased Intracranial Pressure

  • Conduct frequent and ongoing neurologic assessment

  • Evaluate neurologic status as completely as possible

  • Glasgow Coma Scale

  • Pupil checks

  • Assess selected cranial nerves

  • Take frequent vital signs

  • Assess intracranial pressure


Icp monitoring

ICP Monitoring


Intracranial pressure waves

Intracranial Pressure Waves


Location of the foramen of monro for calibration of icp monitoring system

Location of the Foramen of Monro for Calibration of ICP Monitoring System


Licox catheter system

LICOX Catheter System


Nursing process diagnosis of the patient with increased intracranial pressure

Nursing Process—Diagnosis of the Patient With Increased Intracranial Pressure

  • Ineffective airway clearance

  • Ineffective breathing pattern

  • Ineffective cerebral perfusion

  • Deficient fluid volume related to fluid restriction

  • Risk for infection related to ICP monitoring


Collaborative problems potential complications1

Collaborative Problems/Potential Complications

  • Brain stem herniation

  • Diabetes insipidus

  • SIADH

  • Infection


Nursing process planning the care of the patient with increased intracranial pressure

Nursing Process—Planning the Care of the Patient With Increased Intracranial Pressure

  • Major goals may include:

    • Maintenance of patent airway

    • Normalization of respirations

    • Adequate cerebral tissue perfusion

    • Respirations

    • Fluid balance

    • Absence of infection

    • Absence of complications


Interventions2

Interventions

  • Frequent monitoring of respiratory status and lung sounds and measure to maintain a patent airway

  • Position with the head in neutral position and HOB elevation of 0° to 60° to promote venous drainage

  • Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP

  • Maintain a calm, quiet atmosphere and protect patient from stress

  • Monitor fluid status carefully; during acute phase, monitor I&O every hour

  • Use strict aseptic technique for management of ICP monitoring system


Intracranial surgery

Intracranial Surgery

  • Craniotomy: opening of the skull

    • Purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, and control hemorrhage

  • Craniectomy: excision of a portion of the skull

  • Cranioplasty: repair of a cranial defect using a plastic or metal plate

  • Burr holes: circular openings for exploration or diagnosis, to provide access to ventricles, for shunting procedures, to aspirate a hematoma or abscess, or to make a bone flap


Supratentorial approach for cranial surgery

Supratentorial Approach for Cranial Surgery


Infratentorial approach for cranial surgery

Infratentorial Approach for Cranial Surgery


Transsphenoidal approach for cranial surgery

Transsphenoidal Approach for Cranial Surgery


Burr holes

Burr Holes


Preoperative care medical management

Preoperative Care—Medical Management

  • Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies

  • Medications are usually given to reduce risk of seizures

  • Corticosteroids, fluid restriction, hyperosmotic agents (mannitol), and diuretics may be used to reduce cerebral edema

  • Antibiotics may be administered to reduce potential infection

  • Diazepam may be used to alleviate anxiety


Preoperative care nursing management

Preoperative Care—Nursing Management

  • Obtain baseline neurologic assessment

  • Assess patient and family understanding of and preparation for surgery

  • Provide information, reassurance, and support


Postoperative care

Postoperative Care

  • Postoperative care is aimed at detecting and reducing cerebral edema, relieving pain, preventing seizures, and monitoring ICP and neurologic status

  • The patient may be intubated and have arterial and central venous lines


Nursing process assessment of the patient undergoing intracranial surgery

Nursing Process—Assessment of the Patient Undergoing Intracranial Surgery

  • Careful, frequent monitoring of respiratory function, including ABGs

  • Monitor VS and LOC frequently; note any potential signs of increasing ICP

  • Assess dressing and for evidence of bleeding or CSF drainage

  • Monitor for potential seizures; if seizures occur, carefully record and report them

  • Monitor for signs and symptoms of complications

  • Monitor fluid status and laboratory data


Nursing process diagnosis of the patient undergoing intracranial surgery

Nursing Process—Diagnosis of the Patient Undergoing Intracranial Surgery

  • Ineffective cerebral tissue perfusion

  • Risk for imbalanced body temperature

  • Potential for impaired gas exchange

  • Disturbed sensory perception

  • Body image disturbance

  • Impaired communication (aphasia)

  • Risk for impaired skin integrity

  • Impaired physical mobility


Collaborative problems potential complications2

Collaborative Problems/Potential Complications

  • Increased ICP

  • Bleeding and hypovolemic shock

  • Fluid and electrolyte disturbances

  • Infection

  • Seizures


Nursing process planning the care of the patient undergoing intracranial surgery

Nursing Process—Planning the Care of the Patient Undergoing Intracranial Surgery

  • Major goals may include:

    • Improved tissue perfusion

    • Adequate thermoregulation

    • Normal ventilation and gas exchange

    • Ability to cope with sensory deprivation

    • Adaptation to changes in body image

    • Absence of complications


Maintaining cerebral perfusion

Maintaining Cerebral Perfusion

  • Monitor respiratory status; even slight hypoxia or hypercapnia can affect cerebral perfusion

  • Assess VS and neurologic status every 15 minutes to one hour

  • Implement strategies to reduce cerebral edema; cerebral edema peaks in 24 to 36 hours

  • Implement strategies to control factors that increase ICP

  • Avoid extreme head rotation

  • Head of bed may be flat or elevated 30° according to needs related to the surgery and surgeon’s preference


Interventions3

Interventions

  • Regulate temperature

    • Cover patient appropriately

    • Treat high temperature elevations vigorously; apply ice bags, use hypothermia blanket, and administer prescribed acetaminophen

  • Improve gas exchange

    • Turn and reposition the patient every 2 hours

    • Encourage deep breathing and incentive spirometry

    • Suction or encourage coughing cautiously as needed (suctioning and coughing increase ICP)

    • Humidify oxygen to help loosen secretions


Interventions cont

Interventions (cont.)

  • Sensory deprivation

    • Periorbital may impair vision, so announce your presence to avoid startling the patient; cool compresses over eyes and HOB elevation may be used to reduce edema if not contraindicated

  • Enhance self-image

    • Encourage verbalization

    • Encourage social interaction and social support

    • Pay attention to grooming

    • Cover head with turban and later with a wig


Interventions cont1

Interventions (cont.)

  • Monitor I&O, weight, blood glucose, serum, urine electrolyte levels, osmolality, and urine specific gravity

  • Preventing infections

    • Assess incision for signs of hematoma or infection

    • Assess for potential CSF leak

    • Instruct patient to avoid coughing, sneezing, or nose blowing, which may increase the risk of CSF leakage

    • Use strict aseptic technique

  • Patient teaching for self-care


Seizures

Seizures

  • Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons

  • Classification of seizures: see Chart 61-3

    • Partial seizures: begin in one part of the brain

      • Simple partial: consciousness remains intact

      • Complex partial: impairment of consciousness

    • Generalized seizures: involve the whole brain


Specific causes of seizures

Specific Causes of Seizures

  • Cerebrovascular disease

  • Hypoxemia

  • Fever (childhood)

  • Head injury

  • Hypertension

  • Central nervous system infections

  • Metabolic and toxic conditions

  • Brain tumor

  • Drug and alcohol withdrawal

  • Allergies


Plan of care for a patient experiencing a seizure

Plan of Care for a Patient Experiencing a Seizure

  • Observation and documentation of patient signs and symptoms before, during, and after seizure

  • Nursing actions during seizure for patient safety and protection

  • After seizure care, prevent complications

  • See Chart 61-4


Guidelines for seizure care

Guidelines for Seizure Care


Headache

Headache

  • Also called cephalgia, it is one of the most common physical complaints

  • Primary headache has no known organic cause and includes migraine, tension headache, and cluster headache

  • Secondary headache is a symptom with an organic cause such as a brain tumor or aneurysm

  • Headache may cause significant discomfort for the person and can interfere with activities and lifestyle


Assessment of headache

Assessment of Headache

  • A detailed description of the headache is obtained

  • Include medication history and use

  • The types of headaches manifest differently in different persons, and symptoms in one individual may also may change over time

  • Although most headaches do not indicate serious disease, persistent headaches require investigation


Assessment of headache cont

Assessment of Headache (cont.)

  • Persons undergoing a headache evaluation require a detailed history and physical assessment with neurological exam to rule out various physical and psychological causes

  • Diagnostic testing may be used to evaluate the underlying cause if the neurologic exam is abnormal


Nursing management of headache pain

Nursing Management of Headache—Pain

  • Provide individualized care and treatment

  • Prophylactic medications may be used for recurrent migraines

  • Migraines and cluster headaches require abortive medications instituted as soon as possible with onset

  • Provide medications as prescribed

  • Provide comfort measures

    • Quiet, dark room

    • Massage

    • Local heat for tension


Nursing management of headache teaching

Nursing Management of Headache— Teaching

  • Help patient identify triggers and develop preventive strategies and lifestyle changes for headache prevention

  • Provide medication instruction and treatment regimen

  • Implement stress reduction techniques

  • Implement nonpharmacologic therapies

  • Provide follow-up care

  • Encourage healthy lifestyle and health promotion activities


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