Chapter 61

Management of Patients With Neurologic Dysfunction

1

Altered Level of Consciousness (LOC) LOC: is apparent in the patient who is not oriented, does not

follow commands, or needs persistent stimuli to achieve a state of alertness.

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, unarousable unresponsiveness Akinetic mutism: unresponsiveness to the environment, makes no

movement or sound but sometimes opens eyes Persistent vegetative state: devoid of cognitive function but has sleep-

wake cycles Locked-in syndrome: inability to move or respond except for eye

movements due to a lesion affecting the pons

Nursing Process: The Care of the Patient with Altered Level of Consciousness—Assessment

Assess verbal response and orientation Alertness Motor responses Respiratory status Eye signs Reflexes Postures Glasgow Coma Scale

QuestionThe body temperature of an unconscious patient

is never taken by which route?

A. Axillary

B. Mouth

C. Rectal

D. Tympanic

AnswerB

The body temperature of an unconscious patient is never taken by mouth. Rectal or tympanic (if not contraindicated) temperature measurement is preferred to the less accurate axillary temperature.

Decorticate and Decerebrate Posturing

Abnormal posture response to stimuli. (A) Decorticate posturing, involving adduction and flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. (B) Decerebrate posturing, involving extension and outward rotation of upper extremities and plantar flexion of the feet.

Nursing Process: The Care of the Patient with Altered Level of Consciousness— Diagnoses

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 Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Deep vein thrombosis (DVT) Contractures

Nursing Process: The Care of the Patient with Altered Level of Consciousness— Planning

Goals may 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 A major nursing goal is to compensate for the patient's

loss of protective reflexes and to assume responsibility for total patient care. Protection also includes maintaining the patient’s dignity and privacy.

Maintaining an airway Frequent monitoring of respiratory status including

auscultation of lung sounds Positioning to promote accumulation of secretions

and prevent obstruction of upper airway—HOB elevated 30°, lateral or semiprone position

Suctioning, oral hygiene, and Chest Physiotherapy

Maintaining Tissue Integrity Assess skin frequently, especially areas with high potential for breakdown Frequent turning; use turning schedule Careful positioning in correct body alignment Passive ROM Use of splints, foam boots, trochanter rolls, and specialty beds as needed Clean eyes with cotton balls moistened with saline Use artificial tears as prescribed Measures to protect eyes; use eye patches cautiously as the cornea may

contact patch Frequent oral care

Interventions Maintaining 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.

Maintaining 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 Assess for urinary retention and urinary

incontinence May require indwelling or intermittent

catherization 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 Talk to and touch patient and encourage family to

talk to and touch the patient Maintain normal day night pattern of activity Orient the patient frequently Note: When arousing from coma, a patient may

experience a period of agitation; minimize stimulation at this time

Programs for sensory stimulation Allow family to ventilate and provide support Reinforce and provide and consistent information to

family Referral to support groups and services for family

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

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

Elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies

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

Brain tissues may shift through the dura and result in herniation CO2 plays a role; decreased CO2 results in vasoconstriction,

increased CO2 results in vasodilatation

Increased Intracranial Pressure

QuestionIs the following statement True or False?

The earliest sign of increasing ICP is a change in LOC.

AnswerTrue

The earliest sign of increasing ICP is a change in LOC. Slowing of speech and delay in response to verbal suggestions are other early indicators.

Manifestations of Increased ICP: Early Changes in LOC Any change in condition

Restlessness, confusion, increasing drowsiness, increased respiratory effort, 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 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; temperature increase Cushing’s triad: bradycardia, hypertension, bradypnea

Projectile vomiting Further deterioration of LOC; stupor (reacting only to loud

or painful stimuli) to coma Hemiplegia, decortication, decerebration, or flaccidity Respiratory pattern alterations including Cheyne-Stokes

breathing and respiratory arrest Loss of brainstem reflexes—pupil, gag, corneal, and

swallowing

Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Assessment Frequent and ongoing neurologic assessment Evaluate neurologic status as completely as

possible Glasgow Coma Scale Pupil checks Assessment of selected cranial nerves Frequent vital signs Assessment of intracranial pressure

ICP Monitoring

Intracranial Pressure Waves

Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Diagnoses

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 Complications Brainstem herniation Diabetes insipidus SIADH Infection

Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Planning

Major goals may include: Maintaining a Patent Airway Achieving an Adequate Breathing Pattern Preventing Infection Optimizing Cerebral Tissue Perfusion Maintaining Negative Fluid Balance Absence of complications

Interventions Frequent monitoring of respiratory status and lung sounds and

measures to maintain a patent airway (suction is contraindicated) Position with head in neutral position and elevation of HOB 0–

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; every hour I&O during acute

phase Use strict aseptic technique for management of ICP monitoring

system

Intracranial Surgery Craniotomy: opening of the skull

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

Craniectomy: excision of portion of skill Burr holes: circular openings for exploration

or diagnosis, to provide access to ventricles or for shunting procedures, to aspirate a hematoma or abscess, or to make a bone flap

Burr Holes

Preoperative Care: Medical Management Preoperative diagnostic procedures may include CT

scan, MRI, angiography, or transcranial Doppler flow Medications are usually given to reduce risk of

seizures Corticosteroids, fluid restriction, hyperosmotic agent

(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 Obtain baseline neurologic assessment Assess patient and family understanding of

and preparation for surgery. Provide information, reassurance, and support

Postoperative Care Postoperative care is aimed at detecting and

reducing cerebral edema, relieving pain, preventing seizures, monitoring ICP, and neurologic status.

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

Nursing Process: The Care of the Patient Undergoing Intracranial Surgery— Assessment

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 these Monitor for signs and symptoms of complications Monitor fluid status and laboratory data

Nursing Process: The Care of the Patient Undergoing Intracranial Surgery—Diagnoses

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 Complications Increased ICP Bleeding and hypovolemic shock Fluid and electrolyte disturbances Infection Seizures

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

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 Monitor respiratory status; even slight hypoxia or

hypercapnia can effect cerebral perfusion Assess VS and neurologic status every 15 minutes to

every hour Strategies to reduce cerebral edema; cerebral edema

peaks 24–36 hours 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 preference

Interventions Regulating temperature

Cover patient appropriately. Treat high temperature elevations vigorously; apply ice

bags, use hypothermia blanket, administer prescribed acetaminophen.

Improving gas exchange Turn and reposition every 2 hours. Encourage deep breathing and incentive spirometry. Suction or encourage coughing cautiously as needed

(suctioning and coughing increase ICP). Humidification of oxygen may help loosen secretions.

Interventions Sensory deprivation

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

Enhancing self-image Encourage verbalization. Encourage social interaction and social support. Attention to grooming. Cover head with turban and, later, a wig.

Interventions

Monitor I&O, weight, blood glucose, serum and urine electrolyte levels, and 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 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 seizuresPartial 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 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 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 to prevent complications

Nursing Care After the Seizure Keep the patient on one side to prevent aspiration.

Make sure the airway is patent. There is usually a period of confusion after a grand

mal seizure. A short apneic period may occur during or

immediately after a generalized seizure. The patient, on awakening, should be reoriented to

the environment. If the patient becomes agitated after a seizure, use

calm persuasion and gentle restraint.

Nursing Care During a Seizure Provide privacy and protect the patient from curious

onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.)

Ease the patient to the floor, if possible. Protect the head with a pad to prevent injury (from striking

a hard surface). Loosen constrictive clothing. Push aside any furniture that may injure the patient during

the seizure. If the patient is in bed, remove pillows and raise side rails.

Nursing Care During a Seizure If an aura precedes the seizure, insert an oral airway to reduce

the possibility of the patient's biting the tongue or cheek. Do not attempt to open jaws that are clenched in a spasm or

to insert anything. Broken teeth and injury to the lips and tongue may result from such an action.

No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions.

Status Epilepticus Status epilepticus (acute prolonged seizure

activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks