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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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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
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
  • 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
  • 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
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
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
  • 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
  • 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
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
  • 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
  • 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
  • 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