Transcript Airgas template

Management of
Neurologic Dysfunction
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The Neurologic System
• Central nervous system controls the body’s
vital functions
• Relies on structural integrity for support and
homeostasis
– Structural disruptions (eg, stroke, tumor)
• Relies on the body’s ability to maintain a
homeostatic environment
– Homeostatic disruptions (eg, toxins, lyte
imbalance)
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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
– Cause may be neurologic, toxicologic or metabolic
– Initial changes may be subtle
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Nursing Process—Assessment of
the •Patient
With
Altered
LOC
Verbal response and orientation
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Alertness
Motor responses
Respiratory status and pattern
Eye signs
Reflexes
Postures
Glasgow Coma Scale
– Eye opening, verbal and motor response
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Glascow Coma Scale
EYE OPENING
None 1 = Even to supra-orbital pressure
To pain 2 = Pain from sternum/limb/supra-orbital pressure
To speech 3 = Non-specific response, not necessarily to command
Spontaneous 4 = Eyes open, not necessarily aware _______
MOTOR RESPONSE
None 1 = To any pain; limbs remain flaccid
Extension 2 = Shoulder adducted and shoulder and forearm internally rotated (DECEREBRATE)
Flexor response 3 = Withdrawal response or assumption of hemiplegic posture (DECORTICATE)
Withdrawal 4 = Arm withdraws to pain, shoulder abducts
Localizes pain 5 = Arm attempts to remove supra-orbital/chest pressure
Obeys commands 6 = Follows simple commands _______
VERBAL RESPONSE
None 1 = No verbalization of any type
Incomprehensible 2 = Moans/groans, no speech
Inappropriate 3 = Intelligible, no sustained sentences
Confused 4 = Converses but confused, disoriented
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Oriented 5 = Converses and oriented________
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Decorticate
Posturing
Decerebrate
Posturing
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Nursing Process—Diagnosis of
the Patient With Altered Level of
Consciousness
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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
• Goals include:
LOC
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Maintenance of clear airway (this is priority)
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
• 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 (PRIORITY)
– 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
position
– Provide suctioning, oral hygiene, and CPT
– Monitor ability patient’s to maintain airway and manage
secretions
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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
• Implement measures to protect eyes
• 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, 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
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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
• Reinforce and provide consistent information to
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
• Decreased cerebral blood flow
– Systemic BP rises to maintain cerebral flow
• Occurs w/ low HR and irregular respiration
– CO2 plays a role; decreased CO2 results in
vasoconstriction, and increased CO2 results in
vasodilation
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Increased Intracranial
Pressure
• Cerebral Edema
– Defined as an abnormal accumulation of fluid in
the brain tissue
– As the brain swells, body attempts to
compensate for increased ICP
• Autoregulation (blood vessels)
• Decreased CSF production
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Brain With Intracranial Shifts
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ICP and CPP
• CPP (cerebral perfusion pressure) is
closely linked to ICP
• CPP = MAP (mean arterial pressure) – ICP
• Normal CPP is 60 to 100
• A CPP of less than 50 results in permanent
neurolgic damage
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Manifestations of Increased
ICP—Early
• Changes in level of consciousness (FIRST)
• 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:
– Cushing’s triad: bradycardia, hypertension
(with widened pulse pressure), and
bradypnea
• 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
Cheyne-Stokes breathing and arrest
• Loss of brain stem reflexes: pupil, gag,
corneal, and swallowing
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Increased Intracranial
Pressure
• Diagnostic studies
– CT, cerebral angiogram, MRI, direct pressure
measurement (via ventriculostomy)
• Complications
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Inadequate cerebral perfusion
Brain stem herniation
Diabetes insipidus
SIADH
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Increased Intracranial Pressure
Collaborative Care
– Monitoring ICP
• Usually with ventriculostomy for ICP monitoring
– Decreasing cerebral edema
• Osmotic diuretics
• Corticosteroids
– Controlling fever
– Cerebral oxygenation
– Maintaining cerebral perfusion
• Maintaining systemic BP and increasing CO
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Increased Intracranial Pressure
– Reducing metabolic cellular demands
• Sedation (propofol most common)
• Barbiturate coma
– Reducing CSF and IC blood volume
• Ventriculostomy - CSF drainage
• Hyperventilation as short term measure only for refractory
increased ICP
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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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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 tissue perfusion, cerebral
• Ineffective airway clearance
• Ineffective breathing pattern
• Deficient fluid volume related to fluid
restriction
• Risk for infection related to ICP monitoring
• Impaired physical mobility
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Nursing Process—Planning for
Patient With Increased
Intracranial Pressure
• Major goals may include:
– Maintenance of patent airway
– Normalization of respirations
– Adequate cerebral tissue perfusion
– Fluid balance
– Absence of infection
– Absence of complications
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Interventions
• Frequent monitoring of respiratory status, LOC, lung
sounds and measure to maintain a patent airway
• Position with the head in neutral position and HOB
elevation 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 sterile technique for management of ICP
monitoring system
• Monitor for signs/symptoms of infection
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Interventions
• Monitor for early signs of increased ICP
– LOC change, pupillary/EOM changes, weakness, HA
• Monitor for late signs of increased ICP
– LOC deteriorates, Cushing’s triad, vomiting, posturing,
loss of reflexes
• Monitor ICP if indicated
• Monitor for secondary complications
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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
• 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 (phenytoin)
• Corticosteroids, fluid restriction, hyperosmotic
agents (mannitol), and diuretics may be used to
reduce cerebral edema
• Antibiotics may be administered to reduce
potential infection
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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,
ventriculostomy
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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 tissue perfusion
• Disturbed sensory perception
• Body image disturbance
• Impaired communication (aphasia)
• Risk for impaired skin integrity
• Impaired 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:
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Improved cerebral 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 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 withCopyright
turban
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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
• Monitoring for increased ICP and bleeding
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Seizures
• Uncontrolled, paroxysmal electrical
discharge of neurons in the brain that
disrupts normal function
• Classification of seizures: see table 59-6
– 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
• Includes tonic-clonic, absence
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Specific Causes of Seizures
• Head trauma
• Drug -related processes
• Infectious processes
• Intracranial events
• Metabolic imbalances
• Medical disorders
• Other
• Table 58-8
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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
– Eg, aura, type of movements, pupils, incontinence,
changes in consciousness, cognitive
• Nursing actions during seizure for patient safety
and protection
• See handout; table 59-12 for home teaching
• After seizure care, prevent complications
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Epilepsy
• Acondition in which a person has
spontaneously recurring seizures
– Classified by patterns of clinical features, including
onset, family history and seizure type
– Idiopathic or secondary
• Causes
– Include idiopathic, birth trauma, head injury,
infectious disease, toxins, circulatory problems,
brain tumor, abcess, congenital malformations,
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• Diagosis
Epilepsy
– History and physical exam
– Electroencephalogram
– Video recording of seizures
• Treatment
– Pharmacologic (treat, not cure)
• Review epilepsy meds - table 59-9
– Surgical management
• For cessation or reduction of seizures (see table 5910)
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Guidelines for Seizure Care
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Status Epilepticus
• Acute prolonged seizure activity; a series of
generalized seizures that occur without full recovery
of consciousness between attacks
• Generally lasts longer than 30 minutes
• Heavy metabolic demand may result in interference
with respiration and hypoxia of the brain
• Medical management is aimed at stopping the
seizures
– Airway
– IV lorazepam, diazepam for abrupt cessation
– Phenytoin or fosphenytoin for maintenace of seizure-free
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state; phenobarbital in extreme cases
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Headache
• Also called cephalgia
• 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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Headache
• Migraine
– Characterized by periodic and recurrent
attacks of severe HA lasting 4-72 hours
– Throbbing pain
– Most common in women , 25-55 years
– Familial tendency
– Subtypes
• May be with or without aura
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Headache
• Migraine
– Triggers include menstrual cycles, bright light, stress,
sleep deprivation, medications, foods (MSG, tyramine,
nitrites, milk products, red wine, chocolate)
– Phases
• Prodrome (60%)
• Aura (30%)-neurologic symptoms correspond to cerebral
vasoconstriction
• Headache-severe, throbbing; may have N/V, photophobia; 4-72
hours
• Recovery-exhaustion, muscle aches
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Headache
• Migraine Treatment
– Abortive - relief of HA in progress
• Includes NSAIDS, opiods, triptans (serotonin receptor
agonists) , ergotamine preparations (table 59-3)
– Prevention
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Avoidance of triggers
Beta blockers
Antiepileptics
Calcium channel blockers
Antidepressants
Botox
Relaxation therapy
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Headache
• Tension-type headache
– Chronic, mild to moderate in intensity, most common
type
– May last days-weeks-months
– Muscular origin vs. neurovascular origin
– Characterized by steady pressure that usually begins
in the forehead, temples, or neck
– Treated symptomatically: heat, massage, analgesics,
muscle relaxants
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Headache
• Cluster headache
– Severe form of vascular headache; may be
precipitated by ETOH, vasodilators, nitrites,
histamines
– Described as sharp, stabbing, intense
– Far more common in men
– Treatment
• Abortive may include 100% oxygen x 15 minutes,,
triptans, NSAIDS, opioids
• Preventive therapy may include beta blockers,
ergotamine, lithium, naproxen
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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 and teaching
• Migraines and cluster headaches require
abortive medications instituted as soon
as possible with onset
• Provide medications as prescribed
• Provide comfort measures
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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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