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Neurology. Management of Patients with Neurological Dysfunction Chapter 61. Nursing management. Ineffective airway clearance r/t alt. LOC HOB h Lateral/semi-prone Suctioning Hyper-oxygenate Chest physiotherapy Postural drainage Auscultate Intubation Mech. vent. Nursing management.

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neurology

Neurology

Management of Patients with Neurological Dysfunction

Chapter 61

nursing management
Nursing management
  • Ineffective airway clearance r/t alt. LOC
    • HOB h
    • Lateral/semi-prone
    • Suctioning
      • Hyper-oxygenate
    • Chest physiotherapy
    • Postural drainage
    • Auscultate
    • Intubation
    • Mech. vent
nursing management3
Nursing management
  • Risk of injury r/t i LOC
    • Padded side-rails
    • Lines & equipment
    • Restraints
    • Dignity
      • Privacy
      • Speak to pt
nursing management4
Nursing management
  • Deficient fluid volume r/t NPO
    • P Skin turgor
    • P Mucous membranes
    • I&O
    • P labs
question
Question?
  • Which of the following lab values is most useful in assessing dehydration?
    • K+
    • Na+
    • Hematocrit
    • BUN
    • Urine specific gravity
question6
Question?
  • What affect does dehydration have on a pt BUN level?
    • Increase
    • Decrease
question7
Question?
  • What affect does dehydration have on a pt. Hematocrit level?
    • Increase
    • Decrease
nursing management8
Nursing management
  • Impaired oral mucous membranes r/t mouth breathing etc.
    • P for dryness, inflammation, crusting
    • Oral care q8h
    • Lips
    • Move endotracheal tube each day (rt–lf–rt)
nursing management9
Nursing management
  • Alt. in nutrition, less than body requires
    • NGT/GT
    • HOB h
question10
Question?
  • Mrs. Jones has an NGT and has 2 medication that need to be given at 12:00 pm. Can the nurse crush the meds and give them at the same time?
    • Yes
    • No
  • Each med is given separate and flush with 20-30 ml of water after each dose
question11
Question?
  • How do you measure for NGT tube placement?
  • From the tip of the nose  ear lobe  xyphoid process
  • From the tip of the nose  ear lobe  xyphoid process + 6 inches
  • From the ear lobe  tip of the nose  xyphoid process
  • From the ear lobe  tip of the nose  xyphoid process + 6 inches
question12
Question?
  • What is the most effective way to check NGT placement?
  • Inject 20 cc of air and listen for gurgle
  • Aspirate stomach contents
  • X-ray
question13
Question?
  • Mrs. Nop had an NGT placed 7 days ago and is tolerating feeding well. You are assigned to give her a 250 bolus feeding of Ensure. How should you make sure the NGT is in the stomach and not the lung?
  • Inject 20 cc of air and listen for gurgle
  • Aspirate stomach contents
  • X-ray
  • None of the above are necessary
nursing management14
Nursing management
  • Risk for impaired skin integrity r/t immobility
    • Reg. turning
      • X drag
    • ROM
    • Splints
      • Foam boats
    • Beds
nursing management15
Nursing management
  • Impaired tissue integrity of cornea r/t I corneal reflex
    • Clean
      • Cotton-ball & normal saline
    • Cold compress
      • i edema post-op
    • Eye patch warning!
nursing management16
Nursing management
  • Ineffective thermoregulation r/t damage to hypothalamic center
    • Minimal bedding
    • Anti-pyretic
    • Cool sponge bath
    • Fan
    • Hypothermic blanket
nursing management17
Nursing management
  • Impaired urinary elimination (incontinence or retention)
    • Scan bladder
    • Retention  Foley
    • P S&S of infection
      • Fever
      • Cloudy urine
nursing management18
Nursing management
  • Bowel incontinence
    • Bowel sounds
    • Abd girth
    • Monitor BM
      • Frequency
      • Consistency
nursing management19
Nursing management
  • Disturbed sensory perception
    • Touch
    • Talk
    • Orient
    • Familiar sounds (tape player)
      • Favorite TV/radio
    • When arousing from coma 
      • i stimuli
nursing management20
Nursing management
  • Interrupted family processes r/t health crisis
    • Grief process
what s your advice
What’s your advice?
  • While assessing the patency of a central line for an unresponsive, terminally ill patient, I was startled when the patients wife said to me, “this isn’t how it was suppose to be. He’s just a year away from retirement, and we had wonderful plans to travel across the country.” I didn’t know what to say except, “I’m sorry.” I’d like to do better if this situation come up again. What should I have said?
small group questions
Small Group Questions
  • What is the priority nrs dx for a patient with alt. LOC?
  • Describe cerebral blood flow during suctioning.
  • How can a nrs best assess for dehydration?
  • Give 5 nrs interventions for a patient at risk for injury & for impaired joint and skin integrity.
increased intracranial pressure
Increased Intracranial Pressure
  • Rigid vault
  • Contains 3 components
    • Brain tissue
    • Blood
    • CSF
  • Normal ICP 10-20 mmHg
i icp
I-ICP
  • Minor changes in ICP
    • Straining
    • Coughing
    • Sneezing
    • Posture
    • BP
i icp25
I-ICP
  • Etiology of I-ICP
    • Head injury
    • Stroke
    • Inflammatory process
    • Intra-Cranial surgery
i icp26
I-ICP
  • I-ICP Cycle
    • I-ICP 
    • i cerebral perfusion 
    • Ischemia 
    • Further edema 
    • Herniation (shift brain tissue) 
    • Deathmosis
i icp27
I-ICP
  • h PaCO2 
  • Cerebral vasodilatation 
  • h cerebral blood flow 
  • h-ICP
  • i PaCO2 
  • Cerebral vasoconstriction 
  • i cerebral blood flow 
  • i-ICP
i icp28
I-ICP
  • Cerebral edema
    • Abn. h of fluid 
    • h brain tissue volume 
    • I-ICP
i icp29
I-ICP
  • Compensation
    • Bodies attempt to i ICP
    • Cushing’s response
      • Widening PP
      • Bradycardia
  • Decompensation
    • Ischemia
    • Infarction
what is the earliest s s of i icp
What is the earliest S&S of I-ICP?
  • Hyporeflexia
  • Paresethesia
  • Visual distrubance
  • Altered level of consciousness
  • Motor slowing
  • Pupils fixed
i icp31
I-ICP
  • Early S&S
    • #1 Alt LOC
      • h restlessness or confusion
    • H/A
    • Pupillary changes
    • Weakness on one side
i icp32
I-ICP
  • Late S&S
    • Stupor  coma
    • Pulse & Resp
      • i
      • Erratic (Cheyne-stoke, ataxic, Biot’s)
    • BP & Temp
      • h
    • Projectile vomiting
i icp33
I-ICP
  • Late S&S
    • Decorticated posturing
    • Decerebrate posturing
    • Loss of protective reflexes
where did it go
Where did it go?
  • What goes first?
    • Orientation to time
    • Orientation to person
    • Response to verbal stimuli
    • Response to painful stimuli
    • Protective reflexes
i icp35
I-ICP
  • Ominous sign!
  • Grave sign!
complications of i icp
Complications of I-ICP
  • Herniation
  • Diabetes Insipidus
  • SIADH
i icp management
I-ICP Management
  • Monitor ICP
    • Ventricular catheter
    • Sub-arachnoid screw
3 goals of i icp management
3 goals of I-ICP management
  • i edema
  • i CSF volume
  • i Cerebral blood volume
i icp management40
I-ICP management
  • Decrease Edema
    • Osmotic diuretic
      • Mannitol/Osmitrol
        • I&O
        • Indwelling catheter
        • P via serum osmolality
i icp management41
I-ICP management
  • Decrease edema
    • Corticosteroids
      • Dexamethasone /Decadrone
        • S/E
          • Hyperglycemia
          • GI bleed
        • Give with
          • Antacids / Tums
          • Histamine H2 receptor blockers / Tagamet (cimetidine)
i icp management42
I-ICP management
  • Decreasing edema
    • Fluids
      • i
    • HOB
      • h
    • Body temperature
      • Lower
        • i cerebral edema
        • i metabolism
i icp management43
I-ICP management
  • Decreasing CSF
    • Drain CSF
      • Via lumbar puncture
      • Not too much 
      • Ventricles collapse
i icp management44
I-ICP management
  • Decrease cerebral blood flow
    • O2
      • Hyperventilate 
      • Vasoconstriction
      • Hgb levels
    • Control fever
      • Anti-pyretics
      • Cooling blanket
      • X shivering  I-ICP
i icp management45
I-ICP management
  • Decrease cerebral blood flow
    • Decrease metabolic demand
      • Induce coma
        • Phenobarbital
      • Paralyzing agents
        • Monitor cardiac
        • Vent
        • Monitor ICP
        • monitor Arterial pressure
        • Monitor serum barbituate levels
i icp management46
I-ICP management
  • Decrease cerebral blood flow
    • Decrease metabolic demand
      • Prevent Seizures
        • Phenytoin / Dilantin
        • Diazepam / valium
        • Monitor serum levels
      • Prevent infections
    • Control BP
i icp nursing management
I-ICP Nursing Management
  • Maintain patent airway
  • Optimizing cerebral tissue perfusion
    • Position
      • HOB h
      • Head neutral position
      • Avoid extreme hip flexion
    • X valsalva maneuver  I-ICP
      • Stool softeners
      • X emena
      • Suctioning
i icp nursing management48
I-ICP Nursing Management
  • Optimizing cerebral tissue perfusion
    • Calm atmosphere
    • Space nursing tasks
    • Minimal stimuli
  • Monitor ICP
intracranial surgery
Intracranial surgery
  • Craniotomy:
    • Opening the skull surgically to gain access to intracranial structures
intracranial surgery50
Intracranial surgery
  • Burr hole
    • Circular opening made in the skull by a drill
intracranial surgery51
Intracranial surgery
  • Craniectomy
    • An excision of a portion of the skull
intracranial surgery52
Intracranial surgery
  • Cranioplasty
    • Repair of a cranial defect by means of a plastic or metal plate
intracranial surgery53
Intracranial surgery
  • Transsphenoidal
    • Through the nasal sinuses to gain access to the pituitary gland
intracranial surgery54
Intracranial surgery
  • Pre-op
    • Diagnostic procedures
      • CT scan
      • MRI
      • Cerebral angiography
    • Anticonvulsants
      • Phenytoin / Dilantin
    • Corticosteroids
      • Dexamethasone / Decadron
intracranial surgery55
Intracranial surgery
  • Pre-op
    • Fluids
      • Restricted
    • Diuretics
      • Mannitol
      • Furosemide / Lasix
    • i Anxiety
      • Diazepam / Valium
intracranial surgery56
Intracranial surgery
  • Pre-op
    • Antibiotics
    • Shave head
    • Indwelling catheter
    • Warn pt about post-op environment
    • Baseline neuro check
intracranial surgery57
Intracranial surgery
  • Post-op
    • Continue Pre-op meds
    • Reduce cerebral edema
      • Mannitol
      • Dexamethasone
    • Relieve pain
      • Acetaminophen / Tylenol
      • Codeine
      • Morphine sulfate
slide58
Which of the following would be of concern while assessing the ABG’s of a patient post-op craniotomy?
  • PaO2 105
  • Hypoxemia
  • Hypercapnia
  • Hypercarbia
  • Hypocapnia
intracranial surgery59
Intracranial surgery
  • Post-op
    • Prevent seizures
      • Phenytoin / Dilantin
      • Diazepam / valium
      • Monitor serum levels
    • Monitor ICP
    • Edema peaks 24-36 hrs post-op
    • Temp control
intracranial surgery60
Intracranial surgery
  • Post-op
    • Periorbital edema / ecchymosis
    • Enhancing self image
      • Verbalize frustration
      • Cover head with turban
      • Wig until hair grows
seizures
Seizures
  • Definition
    • Abnormal motor, sensory autonomic or psychic activity resulting from sudden excessive discharge from cerebral neurons
what is epilepsy
What is Epilepsy?
  • disorder
  • briefly interrupts the normal electrical activity of the brain
  • too many neurons fire at one time
  • "electrical storm" 
  • seizure
seizures63
Seizures
  • Classification
    • Partial
        • Seizure that begins in one part of the brain
      • Simple
        • Repetitive purposeless behavior
        • Dreamlike state
        • No loss of consciousness
        • Duration: < 1 minute
        • I.e. talking unintelligibly, dizziness, hand shake, picking at clothes, chewing, smacking lips, spitting, fondling self
seizures64
Seizures
  • Classification
    • Partial
      • Simple
      • Complex
        • Repetitive purposeless behavior
        • Loss of consciousness
        • Lasts 2-15 minute
        • Not aware of behavior
seizures65
Seizures
  • Classification
    • Generalized
        • Seizure that involves electrical discharges in the whole brain
      • Absence Seizure
        • Occurs must often in children
        • Period of staring
        • Duration: several seconds
      • Tonic-Clonic Seizure
seizures66
Seizures
  • Classification
    • Generalized
      • Tonic-Clonic Seizure
        • (grand mal seizure)
        • Tonic – rigidity
        • Clonic – contraction and relaxation of all muscles  jerky, rhythmic
seizures67
Seizures
  • Possible Etiology
    • Underlying cause is electrical disturbance  emitting of abnormal, recurring, uncontrolled electric discharge
      • Idiopathic origin
      • Head injury
      • Hypoglycemia
      • Brain tumor
      • Infection
      • Anoxia
seizures68
Seizures
  • Clinical manifestations
    • Prodromal phase
      • Vague emotional changes
      • Minutes – hours before seizure
seizures69
Seizures
  • Clinical manifestations
    • Prodromal phase
    • Aura
      • Brief sensory experience
      • Precedes seizure by a few seconds
      • Usually the same aura each time
seizures70
Seizures
  • Clinical manifestations
    • Prodromal phase
    • Aura
    • Loss of consciousness
      • May or may not occur
    • Seizure activity
seizures71
Seizures
  • Seizure activity
    • Tonic Phase
      • Duration: 30-60 sec
      • Rigidity  fall
      • Pupils fixed & dilated
      • Hands and jaws clenched
      • Stop breathing
    • Clonic phase
seizures72
Seizures
  • Seizure activity
    • Clonic phase
      • Contraction & relaxation of all muscles, jerky rhythmic fashion
      • Incontinent
      • Frothing at the mouth
      • Dyspnea
      • Epileptic cry
      • Tongue chew
      • Lasts 1-2 minutes  subsides
seizures73
Seizures
  • Characteristics
    • Post-seizure / postictal
      • Recover period
      • Deep sleep
      • Confused
seizures74
Seizures
  • Medical management
    • Anticonculsants
      • Caramazepine / Tegretol
        • S/E
          • Severe rash
          • Blood dyscrasias
          • Hepatitis
      • Clonazepam / Klonopin
        • S/E
          • Hepatotoxicity
          • Behavioral changes
seizures75
Seizures
  • Anticonculsants
    • Phenytoin / Dilantin
      • S/E
        • Gum hyperplasia
        • Rash
        • Nystagmus
        • Blood dyscrasias
        • PG  cleft palate
seizures76
Seizures
  • Anticonculsants
    • Valproate / Depakene
      • S/E
        • Hepatotoxicity
        • Blood dyscrasias
        • Skin rash
    • Diazepam / Valium
    • Phenobarbital / Luminal
      • S/E
        • Drowsiness
        • Rash
        • h pain
seizures77
Seizures
  • Nrs Management w/ anticonvulsants
    • Do not stop abruptly  seizures
    • Monitor levels
    • Take regularly
    • Inform of all meds
    • Alcohol only in moderation
seizures78
Seizures
  • Before Seizure
    • At risk for injury
      • Padded side rails
      • Suction machine in room
      • Loose clothing
      • Know aura
seizures79
Seizures
  • Fear r/t possibility of a seizure
    • Take meds routinely
    • ID triggers
      • Stress
      • New environment
      • Menstruation
      • Fever
      • Sleep deprivation
      • Alcohol
seizures80
Seizures
  • Fear
    • Avoid photic stim
      • Bight flickering lights
      • TV
      • Wear dark glasses
    • Regular routine
    • Wear ID band
seizures81
Seizures
  • Ineffective coping
    • Embarrassed
    • Feel rejected, avoided, discriminated
    • Frequently lonely  psych problems
    • Driving restrictions
seizures82
Seizures
  • Knowledge deficit
    • Take meds daily
    • records of meds & seizures
    • Drug levels routine
    • Avoid activities requiring alertness after meds
    • Showers or bath?
      • Shower!
    • Exercise
    • Sleep
seizures83
Seizures

During a seizure

  • Safety
    • Ease to floor
    • Protect the head
    • Turn to side
    • Loosen clothing
    • In bed?
      • Remove pillow
      • Side rails up
    • Do not
      • pry open mouth
      • Insert anything in mouth
      • restrain
    • Stay with pt
  • Support patient
    • Privacy
seizures84
Seizures
  • Observe & document
    • Circumstance (before)
    • Aura?
    • 1st
    • Movement
    • Area
    • Pupils
    • Automatisms
    • Incontinent
  • Duration
  • Unconsciousness
  • Weakness
  • Dysphasia
  • Post seizure behavior
seizures85
Recovery positionSeizures
  • After a seizure
    • Document
    • At risk for
      • Hypoxia
      • Vomiting
      • Aspiration
seizures86
Seizures
  • Nursing care
    • Side lying
    • Bed low
    • Padded side rails
    • i stimulation
      • Dim lights
      • Noise i
    • VS
    • Check mouth
    • Clean pt
    • Allow to “sleep it off”
status epilepticus
Status Epilepticus
  • Defines
    • Prolonged seizure activity
    • Series of generalizes seizures w/o full recovery btw attacks
  • Medical emergency
status epilepticus88
Status Epilepticus
  • Affects
    • Metabolic demand
    • Respiration
    • Anoxia
    • Brain damage
status epilepticus89
Status Epilepticus
  • Medical Management
    • Goal
      • Stop seizure activity
      • Airway
  • Rx of choice
    • Diazepam
      • Valium
status epilepticus90
Status Epilepticus
  • Dx
    • Blood studies
      • Electolytes
      • Glucose
      • Phenytoin level