week 6
TRANSCRIPT
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Etiology
Degenerative Neurologic Disorders
Seizure Disorders
Disorder of consciousness
Direct damage/trauma• Concussions• Contusion • Laceration
Increased intracranial pressure
Intracranial Tumors
Alteration in Neural Regulation
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Diagnostic Procedures
Skull Films
Spine Films
Computerized Axial Tomography Scan (CAT Scan)
Electroencephalography (EEG)
Electromyography (EMG)
Nerve Conduction Velocity (NCV)
Cerebral Angiography (Arteriogram)
Lumbar Puncture
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Diagnostic Procedures
Myelography
Magnetic Resonance Imaging (MRI)
Pneumoencephalography
Ventriculography
Positive Emission Tomography
Single photon emission computed tomography
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Diagnostic Procedures
Noninvasive carotid flow studies
Transcranial Doppler
Evoked Potentials (Auditory and Visual)
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Diagnoses Taxonomy
Ineffective airway clearance related to upper airway obstruction by tongue and soft tissues and inability to clear respiratory secretions
Potential fluid volume deficit related to inability to ingest fluids, dehydration from osmotic therapy
Altered oral mucous membranes related to mouth breathing, absence of pharyngeal reflexes and inability to ingest fluids
Potential impairment of skin integrity related to immobility or restlessness
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Diagnoses Taxonomy
Impaired tissue integrity of cornea related to diminished or absent of corneal reflex
Potential hyperthermia related to potential damage to hypothalmic center
Altered urinary eliminations (incontinence or retention ) related to unconscious state
Altered bowel elimination (incontinence or retnetion related to unconscious state
Altered family process related to sudden crisis of unconsciousness
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Pharmacologic Management
Mannitol -an osmotic diuretic, to reduce cerebral edema by inducing diuresis
Lasix (furosemide)-a diuretic to reduced cerebral edema
Decadron (dexamethasone) -a corticosteroid to reduce cerebral edema by anti inflammatory effect
Alteration in Neural Regulation
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Surgical Management
Craniotomy - is the surgical opening of the skull to gain access to intracranial structures, remove tumors, relieve
intracranial pressure, evacuate a blood clot or stop hemorrhage.
Craniectomy – is the excision of a portion of the skull
Cranioplasty –is the repair of a cranial defect by means of a plastic or metal plate
Thymectomy – is the removal of thymus glands
Alteration in Neural Regulation
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Surgical Management
Rhizotomy- surgical severing of a nerve root.
Plasmapheresis – is an adjunctive therapy for clients with refracoty
Alteration in Neural Regulation
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Complications
Intracranial bleeding and hematoma
Cerebral edema
Infections
Seizures
Cranial nerve dysfunction
Alteration in Neural Regulation
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Assessment
• Mental status
- Orientation to: people, time and place
- Memory
>> Immediate recall >> Recent memory >> Remote memory
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Assessment• Level of consciousness - Level 1 : Conscious , Cognitive , coherent - Level 2 : Confused, Drowsy,
lethargic obtunded, somnolent - Level 3 : Stuporous - Level 4 : Light coma and Deep coma
• Glasgow Coma Scale (GCS)
- Eye opening - Best Verbal Response - Best Motor l Response
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
• Sensory Function - stereognosis the ability to perceive sensory stimuli - agnosia - inability to perceive sensory stimuli
• Motor function - Apraxia - inability to perform fine motor activities - Agraphia - is inability to write - Atraxia is uncoordinated movement, characterized by wide- base stance and swaying manner of walking - General appearance of muscles - Muscle power , tone and volume - Movemen
>> Bradikinesia is slow muscle
movement not associated with weakness >> Akenisia is absence of muscle movement
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management• Motor function
- Coordination
- Station and gait
• Reflex Testing - superficial reflexes
• Pupilliary reflex PERRLA ( pupils equal, round, reactive to light, accommodation)
• Corneal reflex
• Biceps reflex
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
• Triceps reflex
• Patellar reflex
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management• Abdominal reflex • Cremasteric reflex • Anal reflex • Ankle reflex
• Babinski reflex
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management - deep tendon reflexes
- Reflexes to assess meningeal irritation >> Kernigs Sign
>> Brudzinki’s reflex
- Oculovestibular Reflex or Caloric Ice Water test
- Oculocephalic Reflex or Dolls eye phenomenon
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
• Cranial Nerve testing - I Olfactory - II Optic - III Oculomotor - IV Trochlear - V Trigeminal - VI Abducens - VII Facial - VIII Acoustic - IX Glossopharyngeal - X Vagus Nerve - XI Spinal Accessory - XII Hypoglossal
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
• Language and Speech
• Bladder and Bowel Functioning
• Intracranial Pressure
- Restlessness - Headache - Vomiting - Diplopia - Decrease in level of
consciousness - Vital signs changes
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
• Pupillary Changes - Aniscura - Pinpoint pupils - Fixed, dilated pupils - Papilledema
• Lateralizing Signs
• Brain Stem Function Impairment
- Doll’ s Eye sign - Decortication - Decerebration
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management• Brain Stem Function Impairment
- Doll’ s Eye sign
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management• Brain Stem Function Impairment - Decortication
Decerebration
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Managing Increased Intracranial Pressure• Position the patient on semi-fowlers• Adequate oxygenation• Safety• Rest• Avoid factors that increase ICP
» Nausea and vomiting» Sneezing/ coughing» Valsalva maneuver » Over suctioning» Restraints» Rectal examination» Enema» Flexion of waist, hip, neck
(bending or stooping)
• Control hypertension• Restrict fluid intake to 1200 to 15000
mls/ day
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Maintaining Effective Airway • Place the patient in semi prone
position or lateral position
• Keep airway free of secretions – Insert oral airways if tongue is
paralyzed or is obstructing .– Prepare for insertion of cuffed
endotracheal tube – Employ oxygen therapy as prescribed – Evaluate pulses (radial, carotid, apical
and pedal)
• Measure blood pressure
• Maintain circulation, support the blood pressure and treat life threatening cardiac dysrhythmias.
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Attaining and Maintaining Fluid balance Electrolyte
• Monitor prescribed intravenous fluids
• Use hyperaliminentation feedings
• Initiate nasogastric feedings
• Measure urinary output and specific gravity
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Maintain Healthy Oral Mucous Membrane
• Remove dentures
• Inspect patient’s mouth for dryness, inflammation
and presence of crusting
• Clean the mouth with prescribed solution every 2 hours
• Apply lip emollient
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Maintaining Skin Integrity• Keep the skin clean, dry and free of
pressure.
• Clip the patients nail to prevent excoriation
• Turn the patient from side to side on a regular
• Reposition carefully after turning
• Put all extremities through range of motion exercises at least 4 times daily,
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Maintaining Corneal Integrity
• Protect the eyes from corneal irritation.
• Make sure the patient’s eye is not rubbing
against the bedding if blinking and corneal reflexes are absent
• Prepare for temporary tarsorraphy
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Reducing Fever
• Look for possible sites of infections
• Control persistent elevations of temperature
• Cool room to 18.3 degree Celsius.
• Remove bedding over the patient except light sheet
• Employ cool water sponging and an electric fan blowing over the patient to increase surface cooling
• Consider use of hypothermia blanket if hyperthermia is of neurogenic in origin.
• Esophageal or other core temperature is monitored continually
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Promoting urinary elimination
• Palpate over the patient’s bladder at interval
• Insert an indwelling urethral catheter for short term management
• Use intermittent bladder catheterization for retention as soon as possible
• Monitor for fever and cloudy urine, inspect the urethral orifice for suppurative discharge
• Initiate a bladder training program as soon as consciousness is regained
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Promoting Bowel Function
• Observe for constipation
• Stool softener may be prescribed and given with tube feeding
• Glycerin suppository may be prescribed
• Monitor for diarrhea
• Perform rectal examination if fecal impaction is suspected
• Use commercial fecal collection bags and meticulous skin care if patient has fecal incontinence.
• Auscultate for bowel sounds, measure abdominal girth with a tape measure to detect abdominal distention.
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Other Nursing Interventions • Use every sensory avenue to stimulate
the patient
• Use physical touch and reassuring voice tone
• Encourage family to talk in a meaningful way the patient even when he is not responding.
• Orient patient to people, time, place and situation
• Have adequate room lighting to prevent hallucination as patient regain consciousness
• Be aware of the varying phases of restlessness
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Other Nursing Interventions
• Provide social contacts and environmental enrichment
• Be aware that the patient after regaining consciousness
• Give an explanation of what has happened
• Permit the patient to asks questions
Alteration in Neural Regulation
Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and
Coordination
Alteration in Neural Regulation
Nursing Management
Evaluation• Maintain clear airway, cough up
secretions
• Attains/maintains adequate fluid volume status, absence of clinical signs of dehydration
• Has intact healthy appearing oral mucous membrane
• Absence of skin breakdown
• Absence of trauma to cornea
• Temperature within acceptable range
• Demonstrates bladder continence
• Maintaining normal bowel function