Transcript Neurological Assessment

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 sleepwake 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
Question
The body temperature of an unconscious patient
is never taken by which route?
A. Axillary
B. Mouth
C. Rectal
D. Tympanic
Answer
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 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
Increased Intracranial Pressure






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
Question
Is the following statement True or False?
The earliest sign of increasing ICP is a change in
LOC.
Answer
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.
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.
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
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 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