CRITICAL CA

RE CHALLEN
GES
3.BRAIN STEM
4.CEREBELLUM

4 LOBES

1. Frontal – judgement
2. Temporal – comprehension; stock memory
3. Parietal – distance, temperature and pain
4. Occipital – vision (dizziness and blurring of vision)

SPINAL CORD

Basic part
1. sensory – things that receives the messages.
2.motor – will deliver messages.(pain)
3. connector – that’s link the two.

2
ASSESSMENT
Why is it important?
a. To establish baseline neurological assessment to note deviat
ons and trends which part of the brain that tells /control your
awareness. “retcullar actvatng system”.
b. Detect changes in the neurologic status of the patent.
c. Minimize loss of functon from neurologic deficits.
d. Determine effects of neurologic dysfuncton on ADL.
e. Compare data from previous assessment to the present.

3
PARAMETERS TO BE USE OF NEUROLO
GICAL ASSESSMENT
History taking
Vital signs
LOC
a. Alert – oriented to person, tme & place.
b. lethargic- patent sleep most of a tme but responded upon calling upon his/her name.
c. Abtended – sleep most of a tme but responded by apply painful stmuli or by shoutng after ap
plying to pain and back to sleep.
d. Drowsy/ stupor – to painful stmuli
e. semi-coma – flex or extend by applying pain
f. Coma – no response to all even in painfull stmuli.
Pupillary assessment
size 2-3mm
Equality
Reacton
Note ! If narcotcs is given the pupil size is constricted.
AtSO4 –Dilates the pupils
paracetamol – constricted
pons is damaged pin point
bilateral dilaton – no o2 supply / hypoxia
unesocoric – hernaton of the brain
Motor functon evaluaton
inspect for the muscle size if it is atropy ( loss of muscle tone/
skinny).Hypertropy ( no resistance).

Muscle tone – is the normal state of the muscle tension.

spastc- increase resistance to passive stretching.
flaccid – no control/ muscle tone hypotonia.

Motor strength
5/5 normal movt. against gravity and resistance.
4/5 full range of moton against moderate resistance and gravity.
3/5 full range against gravity only not against resistance.
ASSESSMENT IN INCREASE INTRA CRANIAL PRESSU
RE
RESTLESSNESS – inital signs of increase ICP.
HEADACHE – due to tracton or pressures.
VOMITING – results from the pressure at the medulla oblongata it may be projectle.
DIPLOPIA –pressures at the CN VI ( abducens) which controls lateral rectus muscles of the eye.
DECREASE LOC – due to affecton of ascending retcular actvatng system.
CUSHING REFLEX – due to cerebral hypoxia.
SYSTOLE – increase due to increase force of contractons.
DIASTOLE – remains normal or decrease due to longer tme required for the heart to relax
WIDENING OF THE PULSE PRESSURE
RESPIRATORY RATE – slow due to involvement of the medulla oblongata and pons.
TEMPERATURE – increase due to involvement of hypothalamus.
UNESOCORIA – due to CN 111 compression.There is ipsilateral pupil dilaton.
FIXED DILATED –indicate uncal hernaton.Brain stem compression.
PUPIL EDEMA - result from compression of the optc nerve or “choked disc)
DECORTICATE – involvement of the mid brain-cerebral cortex
DECEREBRATE – brain stem involvement
CEREBELLAR EXAMINATION
Finger to nose test

NURSING MANAGEMENT
1. Impaired gas exchange
Maintaining airway clearance.
Pulmonary hygiene
Oxygen
Tracheostomy care
2. Alteration in tissue perfusion
Mobilizaton
Positonning
Prevent thrombophlebits
Maintaining cerebral blood flow
3. Impaired physical mobility
Maintaining body alignment
ROM exercise
Tracton
4. Impaired skin integrity
Skin care to incontnent patent.
4. Impaired skin integrity
skin care to incontnent patent.
5. Self care deficit
Bathing
Mouth care
Eye care
Nail care
6. Alteration in fluid volume
Intra venous fluids
7. Alteration in nutrition
Meetng with nutritonal needs
Dealing with dysphagia
Tube feeding
TPN
8. Alteration in bowel elimination
8. Alteration in pattern of urinary elimination
Catheter care
Bladder training
SPECIFIC NURSING CA
RE OF THE PEDIATRIC
CRITICALLY – ILL PATIE
NTS
Big difference in little people
1. size
2. weight – dose/kg

FORMULA:
<6 mos age in month x 600+3000
>6 mos age in month x 500+3000
1 yr and above age in years x 2 + 8

3. Body proportons
4. Anatomy
a. Airway face and mandible are small.
b. Trachea – short and soft.
c. Breathing – lungs are immature. Both upper and lower airways are relatvely small and
are consequently obstracted.
5. Physiology
d. Airway and breathing ( infants have a greater metabolic rate and O2 consumpton.
6. Psychology
a. Communicaton – infants and young children either have no longer ability or are stll dev
eloping their speech.
RECOGNITION OF SERIOUSLY ILL CHILD
1. HYPOXIA – cardiac arrest is usually secondary to hypoxia.
2. SHOCK – circulatory failure

3. RECOGNITION OF POTENTIAL RESPIRATORY FAILURE

NORMAL RESPIRATION IN PEDIATRIC
AGE BPM
O – 12 30 – 60
1–3 24 – 40
3 -5 22 - 34
5 -12 18 – 30
18 ABOVE 12 – 16
RESPIRATORY MECHANICS (manifestatons)
a. Tachypnea -1st
b. Slow or irregular
c. Nasal flaring
d. Retractons ( inspiraton)
e. Head bobbing
f. Gruntng – to increase end expiratory airway pressure by premature glottic closure accompanyi
ng late expiratory contracton of the diaphragm.
2. EFFECTIVENESS OF BREATHING
Air entry – effectveness of ventlaton is clinically assessed by evaluaton of c
hest expansion and breath sounds.
Pulse oximeter – monitor O2 saturaton
ABG

II RECOGNITION OF POTENTIAL CIRCULATORY FAILURE

1. Tachycardia – compensatory mech.
2. Bradycardia
3. Hypotension – late and pre terminal signs
4. Pulses
5. Capillary refill
III. RECOGNITION OF POTENTIAL NEUROLOGIC FAILU
RE
Use of glascow coma scale

GENERAL NURSING CARE

1. improve cardiac fxn.
2. Monitor CVP.
3. Observe the intensity of peripheral pulses, color of the skin, capillary refill a
nd temp.
4. Monitor ECG for configuraton of the P wave.
5. Be familiar of the cardiac drugs. (inotropics, vasodilators, beta blockers)
6. Adequate cardiac output.
Good skin turgor
Good capillary refill
Pt. is alert and awake
Adequate u.o.
7.Improve respiratory function
Mechanical ventlaton
- Needed to maintain adequate oxygenaton.
- Should be maintained untl hemodynamic and respiratory functon are stable
Provide pulmonary toilette
- Tracheal suctoning should be performed immediately with in the first hour of
return from theatre and as secretons dictates.
- Ascultate both lungs before and after suctoning
- Do chest physiotherapy
- CPT session should be short and frequent using appropriate tech such as per
cussion, vibraton, hand ventlaton and suctoning.
SIGNS OF NEONATAL SEPSIS
1. Lethargy
2. Seizures
3. Apneic spells
4. Increase or decrease respiraton
5. Persistence jaundice
g. Stridor – an inspiratory high pitched sound.(signs of upper resp. obst
ruction). . Wheezes – indicates lower airway narrowing
THANK YOU!

Maria Cristina S. Alteran RN MN