Management of Patients With Neurologic Dysfunction

Ziad . M.Alostaz RN-BC,MSN,ACNS

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

CONT
Persistent vegetative state: patient is devoid of cognitive function but has sleepwake cycles Akinetic mutism: unresponsiveness to the environment, the patient makes no movement or sound but sometimes opens eyes

Nursing ProcessAssessment 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

Nursing ProcessDiagnosis 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 ProcessPlanning 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 patients 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

CONT
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 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

Maintain body temperature

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

Increased Intracranial Pressure (ICP)

Monro-Kellie hypothesis: because of limited space in the skull, an increase in any one skull componentbrain tissue, blood, or CSFwill cause a change in the volume of the others Compensation to maintain a normal ICP of less than 15 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

CONT.
Brain tissues may shift through the dura and result in herniation Autoregulation: refers to the brains 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

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 ICPEarly

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 ICPLate

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
Cushings triad: bradycardia, hypertension, and bradypnea Projectile vomiting

Manifestations of Increased ICPLate (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

Nursing ProcessAssessment 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

ICP Monitoring

Nursing ProcessDiagnosis 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

Collaborative Problems/Potential Complications

Brain stem herniation

Diabetes insipidus
SIADH Infection

Nursing ProcessPlanning 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

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 15 to 30 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 Treat constipation Avoid any movement that cause increase ICP (valsalva maneuver ) Monitor fluid status carefully; during acute phase, monitor I&O every hour Use strict aseptic technique for management of ICP monitoring system

Questions:

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