neurological med surg

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 61

Management of Patients With Neurologic Dysfunction

Chapter 61

Management 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, 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

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


QuestionQuestion

The body temperature of an unconscious patient is never taken by which route?

A.Axillary

B.Mouth

C.Rectal

D.Tympanic


AnswerAnswer

B

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 Posturing Decerebrate Posturing


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

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 ComplicationsCollaborative 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

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


InterventionsInterventions

• 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 CPT


Maintaining Tissue IntegrityMaintaining 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, scrupulous oral care


InterventionsInterventions• 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 FunctionPromoting 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 CommunicationSensory 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

• With disease or injury ICP may increase

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

• 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, increased CO2 results in vasodilatation

Increased Intracranial PressureIncreased Intracranial Pressure


Brain with Intracranial Shifts Brain with Intracranial Shifts


QuestionQuestion

Is the following statement True or False?

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


AnswerAnswer

True

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.


ICP and CPPICP and CPP

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

• CCP = MAP (mean arterial pressure) – ICP

• Normal CCP is 70–100

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


Manifestations of Increased ICP: EarlyManifestations 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: LateManifestations 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 to coma

• Hemiplegia, decortication, decerebration, or flaccidity

• Respiratory pattern alterations including Cheyne-Stokes breathing and arrest

• Loss of brainstem reflexes—pupil, gag, corneal, and swallowing


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

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 MonitoringICP Monitoring


Intracranial Pressure WavesIntracranial Pressure Waves


Location of the foramen of Monro for calibration of ICP monitoring systemLocation of the foramen of Monro for calibration of ICP monitoring system


LICOX Catheter SystemLICOX Catheter System


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

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



• Brainstem herniation

• Diabetes insipidus

• SIADH

• Infection


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

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

• Major goals may include:

– Maintenance of patent airway

– Normalization of respirations

– Adequate cerebral tissue perfusion

– Respirations

– Fluid balance

– Absence of infection



InterventionsInterventions• Frequent monitoring of respiratory status and lung

sounds and measures to maintain a patent airway

• 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 SurgeryIntracranial Surgery

• Craniotomy: opening of the skull

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

• Craniectomy: excision of portion of skill

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

• 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


QuestionQuestion

What is the purpose of burr holes in neurosurgical procedures?

A.Make a bone flap in the skull.

B.Aspirate a brain abscess.

C.Evacuate a hematoma.

D.All of the above.


AnswerAnswer

D

The purpose of burr holes in neurosurgical procedures is to

make a bone flap in the skull, aspirate a brain abscess, and

evacuate a hematoma.


Burr HolesBurr Holes


Preoperative Care: Medical ManagementPreoperative 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 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 ManagementPreoperative Care: Nursing Management

• Obtain baseline neurologic assessment

• Assess patient and family understanding of and preparation for surgery.

• Provide information, reassurance, and support


Postoperative CarePostoperative 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

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

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



• Increased ICP

• Bleeding and hypovolemic shock

• Fluid and electrolyte disturbances

• Infection

• Seizures


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

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



Maintaining Cerebral PerfusionMaintaining 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


InterventionsInterventions• 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.



• Sensory deprivation

– Periorbital 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.



• 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


SeizuresSeizures

• 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

– 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 SeizuresSpecific 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 SeizurePlan 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


HeadacheHeadache

• AKA cephalgia

• 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 HeadacheAssessment 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.

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

• Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam.


Nursing Management of Headache: PainNursing Management of Headache: Pain

• Provide individualized care and treatment

• Prophylactic medications may be used for recurrent migraines

• Migraines and cluster headaches requires 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: TeachingNursing Management of Headache: Teaching

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

• Medication instruction and treatment regimen

• Stress reduction techniques

• Nonpharmacologic therapies

• Follow-up care

• Encouragement of healthy lifestyle and health promotion activities

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