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 orientationAlertnessMotor responses Respiratory status Eye signsReflexesPosturesGlasgow Coma ScaleSee Table 61-1

Decorticate

Decerebrate

Nursing Process—Diagnosis of the Patient With Altered Level of

Consciousness

Ineffective airway clearanceRisk of injuryDeficient fluid volumeImpaired oral mucosaRisk for impaired skin integrity and

impaired tissue integrity (cornea) Ineffective thermoregulationImpaired urinary elimination and bowel

incontinenceDisturbed sensory perceptionInterrupted 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 increaseIncreased 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 consciousnessAny 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 sideHeadache: 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

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 ScalePupil checksAssess selected cranial nervesTake frequent vital signsAssess 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

Nursing Process—Planning 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

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 hemorrhageCraniectomy: 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 perfusionRisk for imbalanced body temperaturePotential for impaired gas exchangeDisturbed sensory perceptionBody image disturbanceImpaired communication (aphasia)Risk for impaired skin integrityImpaired 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 treatmentProphylactic medications may be used for

recurrent migrainesMigraines and cluster headaches require

abortive medications instituted as soon as possible with onset

Provide medications as prescribedProvide 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