Transcript Airgas template

Chapter 61
Management of Patients With
Neurologic Dysfunction
Copyright © 2008 Lippincott Williams & Wilkins.
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
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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
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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
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Decorticate Posturing
Decerebrate Posturing
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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
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Collaborative Problems/Potential
Complications
• Respiratory distress or failure
• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures
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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
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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 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
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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
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Interventions
• 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
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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
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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
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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
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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
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Brain With Intracranial Shifts
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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
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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
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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
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Manifestations of Increased ICP—Late
(cont.)
• Further deterioration of LOC; stupor to coma
• Hemiplegia, decortication, decerebration, or
flaccidity
• Respiratory pattern alterations including CheyneStokes breathing and arrest
• Loss of brain stem reflexes: pupil, gag, corneal,
and swallowing
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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
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ICP Monitoring
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Intracranial Pressure Waves
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Location of the Foramen of Monro for
Calibration of ICP Monitoring System
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LICOX Catheter System
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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
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Collaborative Problems/Potential
Complications
• Brain stem herniation
• Diabetes insipidus
• SIADH
• Infection
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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
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Interventions
• 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
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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
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Supratentorial Approach for
Cranial Surgery
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Infratentorial Approach for
Cranial Surgery
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Transsphenoidal Approach for
Cranial Surgery
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Burr Holes
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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
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Preoperative Care—Nursing Management
• Obtain baseline neurologic assessment
• Assess patient and family understanding of and
preparation for surgery
• Provide information, reassurance, and support
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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
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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
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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 Copyright
physical
mobility
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Collaborative Problems/Potential
Complications
• Increased ICP
• Bleeding and hypovolemic shock
• Fluid and electrolyte disturbances
• Infection
• Seizures
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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
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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
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Interventions
• 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
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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
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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
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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 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
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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
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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
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Guidelines for Seizure Care
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Headache
• 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
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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
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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
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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
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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
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