Neurological Med Surg

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Chapter 61

Management of Patients With
Neurologic Dysfunction


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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
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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

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Question
The body temperature of an unconscious patient is never
taken by which route?
A. Axillary
B. Mouth
C. Rectal
D. Tympanic
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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.
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Decorticate Posturing Decerebrate Posturing
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Nursing Process: The Care of the Patient
with Altered Level of Consciousness—
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
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Collaborative Problems/Potential
Complications
• Respiratory distress or failure
• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures
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Nursing Process: The Care of the Patient
with Altered Level of Consciousness—
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
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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 patient’s 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 airway—HOB
elevated 30°, lateral or semiprone position
– Suctioning, oral hygiene, and CPT
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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
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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 required—monitor 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.
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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

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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
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• Monro-Kellie hypothesis: because of limited space in the
skull, an increase in any one of components of the skull—brain
tissue, blood, and CSF—will cause a change in the volume of
the others
• Compensation to maintain a normal ICP of 10–20 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 brain’s 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
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Brain with Intracranial Shifts
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Question
Is the following statement True or False?

The earliest sign of increasing ICP is a change in LOC.
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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.

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ICP and CPP
• CCP (cerebral perfusion pressure) is closely linked to ICP
• CCP = MAP (mean arterial pressure) – ICP
• Normal CCP is 70–100
• A CCP of less than 50 results in permanent neurolgic
damage
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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
• Headache—constant, increasing in intensity or
aggravated by movement or straining
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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
– Cushing’s 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 reflexes—pupil, gag, corneal, and swallowing
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Nursing Process: The Care of the Patient
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
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ICP Monitoring
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Intracranial Pressure Waves
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Location of the foramen of Monro for
calibration of ICP monitoring system
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LICOX Catheter System
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Nursing Process: The Care of the Patient
with Increased Intracranial Pressure—
Diagnoses

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

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Nursing Process: The Care of the Patient
with Increased Intracranial Pressure—
Planning
• Major goals may include:
– Maintenance of patent airway
– Normalization of respirations
– Adequate cerebral tissue perfusion
– Respirations
– Fluid balance
– Absence of infection
– Absence of complications
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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 0–60° 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; every hour I&O during
acute phase
• Use strict aseptic technique for management of ICP
monitoring system
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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
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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.
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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.

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Burr Holes
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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

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Preoperative Care: Nursing Management
• Obtain baseline neurologic assessment
• Assess patient and family understanding of and
preparation for surgery.
• Provide information, reassurance, and support

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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.
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Nursing Process: The Care of the Patient
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

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Nursing Process: The Care of the Patient
Undergoing Intracranial Surgery—
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
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Collaborative Problems/Potential
Complications
• Increased ICP
• Bleeding and hypovolemic shock
• Fluid and electrolyte disturbances
• Infection
• Seizures
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Nursing Process: The Care of the Patient
Undergoing Intracranial Surgery—
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
– Absence of complications
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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 24–36 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

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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.
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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.
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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
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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
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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
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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

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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


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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.
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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
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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