Neurological Med Surg

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 61

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, 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 sleep-wake 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 Posturing Decerebrate Posturing
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
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 patients 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 airwayHOB
elevated 30, lateral or semiprone position
Suctioning, oral hygiene, and CPT
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, scrupulous 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 requiredmonitor 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

Monro-Kellie hypothesis: because of limited space in the
skull, an increase in any one of components of the skullbrain
tissue, blood, and CSFwill cause a change in the volume of
the others
Compensation to maintain a normal ICP of 1020 mm Hg is
normally accomplished by shifting or displacing CSF
With disease or injury ICP may increase
Increased ICP decreases cerebral perfusion and causes
ischemia, cell death, and (further) edema
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
CO
2
plays a role; decreased CO
2
results in vasoconstriction,
increased CO
2
results in vasodilatation
Increased Intracranial Pressure
Brain with Intracranial Shifts
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.

ICP and CPP
CCP (cerebral perfusion pressure) is closely linked to ICP
CCP = MAP (mean arterial pressure) ICP
Normal CCP is 70100
A CCP of less than 50 results in permanent neurolgic
damage
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
Headacheconstant, 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
Cushings triad: bradycardia, hypertension, bradypnea
Projectile vomiting
Further deterioration of LOC; stupor to coma
Hemiplegia, decortication, decerebration, or flaccidity
Respiratory pattern alterations including Cheyne-Stokes
breathing and arrest
Loss of brainstem reflexespupil, gag, corneal, and swallowing
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
Location of the foramen of Monro for
calibration of ICP monitoring system
LICOX Catheter System
Diagnoses

Ineffective airway clearance
Ineffective breathing pattern
Ineffective cerebral perfusion
Deficient fluid volume related to fluid restriction
Risk for infection related to ICP monitoring
Complications
Brainstem herniation
Diabetes insipidus
SIADH
Infection

Planning
Major goals may include:
Maintenance of patent airway
Normalization of respirations
Adequate cerebral tissue perfusion
Respirations
Fluid balance
Absence of infection
Interventions
Frequent monitoring of respiratory status and lung
sounds and measures to maintain a patent airway
Position with head in neutral position and elevation of
HOB 060 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
Cranioplasty: repair of cranial defect using a plastic or
metal plate
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
Question
What is the purpose of burr holes in neurosurgical
procedures?
A. Make a bone flap in the skull.
B. Aspirate a brain abscess.
C. Evacuate a hematoma.
D. All of the above.
Answer
D

The purpose of burr holes in neurosurgical procedures is to
make a bone flap in the skull, aspirate a brain abscess, and
evacuate a hematoma.

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 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.
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

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
Complications
Increased ICP
Bleeding and hypovolemic shock
Fluid and electrolyte disturbances
Infection
Seizures
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
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 2436 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 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.
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

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

Headache
AKA cephalgia
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.
Persons undergoing a headache evaluation require a
detailed history and physical assessment with neurologic
exam to rule out various physical and psychological
causes.
Diagnostic testing may be used to evaluate underlying
cause if there are abnormalities on the neurologic exam.
Nursing Management of Headache: Pain
Provide individualized care and treatment
Prophylactic medications may be used for recurrent
migraines
Migraines and cluster headaches requires 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 a preventive
strategies and lifestyle changes for headache prevention
Medication instruction and treatment regimen
Stress reduction techniques
Nonpharmacologic therapies
Follow-up care
Encouragement of healthy lifestyle and health promotion
activities

Neurological Med Surg

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