Management of Patients with Neurologic Dysfunction
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
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
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
Decorticate
Decerebrate
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
Collaborative Problems/Potential Complications Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Deep vein thrombosis (DVT) Contractures
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
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
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
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
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
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
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
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
Brain With Intracranial Shifts
Brain Herniation with increased ICP
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
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
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
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
Doll’s eyes movement
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
ICP monitoring
Intracranial Pressure Waves
Location of the Foramen of Monro for Calibration of ICP Monitoring System
Collaborative Problems/Potential Complications Brain stem herniation Diabetes insipidus SIADH Infection
Patient With Increased Intracranial Pressure Major goals may include: Maintenance
of patent airway
Normalization Adequate
of respirations
cerebral tissue perfusion
Respirations Fluid
balance
Absence
of infection
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
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
Supratentorial Approach for Cranial Surgery
Infratentorial Approach for Cranial Surgery
Transsphenoidal Approach for Cranial Surgery
Burr Holes
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
Preoperative Care—Nursing Management Obtain baseline neurologic assessment Assess patient and family understanding of
and preparation for surgery Provide information, reassurance, and
support
Preoperative Care—Nursing Management 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
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
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
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 physical mobility
Collaborative Problems/Potential Complications Increased ICP Bleeding and hypovolemic shock Fluid and electrolyte disturbances Infection Seizures
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
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
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
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
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
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
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
Tonic-clonic contractions
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
Guidelines for Seizure Care
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
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
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
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
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
Types of IC Hematomas