Copyright © 2008 Lippincott Williams & Wilkins. 1 Management of Neurologic Dysfunction.

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Copyright © 2008 Lippincott Williams & Wilkins.

Management of Neurologic Dysfunction

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The Neurologic System

• Central nervous system controls the body’s vital functions

• Relies on structural integrity for support and homeostasis– Structural disruptions (eg, stroke, tumor)

• Relies on the body’s ability to maintain a homeostatic environment– Homeostatic disruptions (eg, toxins, lyte

imbalance)

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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 – Cause may be neurologic, toxicologic or metabolic– Initial changes may be subtle

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Nursing Process—Assessment of the Patient With Altered LOC

• Verbal response and orientation• Alertness• Motor responses • Respiratory status and pattern• Eye signs• Reflexes• Postures• Glasgow Coma Scale

– Eye opening, verbal and motor response

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Glascow Coma Scale• EYE OPENING• None 1 = Even to supra-orbital pressure• To pain 2 = Pain from sternum/limb/supra-orbital pressure• To speech 3 = Non-specific response, not necessarily to command• Spontaneous 4 = Eyes open, not necessarily aware _______• MOTOR RESPONSE• None 1 = To any pain; limbs remain flaccid• Extension 2 = Shoulder adducted and shoulder and forearm internally rotated

(DECEREBRATE)• Flexor response 3 = Withdrawal response or assumption of hemiplegic posture

(DECORTICATE)• Withdrawal 4 = Arm withdraws to pain, shoulder abducts• Localizes pain 5 = Arm attempts to remove supra-orbital/chest pressure• Obeys commands 6 = Follows simple commands _______• VERBAL RESPONSE• None 1 = No verbalization of any type• Incomprehensible 2 = Moans/groans, no speech• Inappropriate 3 = Intelligible, no sustained sentences• Confused 4 = Converses but confused, disoriented• Oriented 5 = Converses and oriented________

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Decorticate Posturing

Decerebrate Posturing

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Nursing Process—Diagnosis 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

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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—Planning the Care of the Patient With Altered

LOC• Goals include: – Maintenance of clear airway (this is priority)– 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

• 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 (PRIORITY)– 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 position

– Provide suctioning, oral hygiene, and CPT – Monitor ability patient’s to maintain airway and manage

secretions

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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

• Implement measures to protect eyes

• Provide frequent, scrupulous oral care

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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, 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• 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

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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

• Reinforce and provide consistent information to family

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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 increase• Increased ICP decreases cerebral perfusion,

causes ischemia, cell death, and (further) edema

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Increased Intracranial Pressure (cont.)

• Brain tissues may shift through the dura and result in herniation

• Decreased cerebral blood flow

– Systemic BP rises to maintain cerebral flow

• Occurs w/ low HR and irregular respiration

– CO2 plays a role; decreased CO2 results in vasoconstriction, and increased CO2 results in vasodilation

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Increased Intracranial Pressure

• Cerebral Edema– Defined as an abnormal accumulation of fluid in

the brain tissue– As the brain swells, body attempts to

compensate for increased ICP• Autoregulation (blood vessels)• Decreased CSF production

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Brain With Intracranial Shifts

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ICP and CPP

• CPP (cerebral perfusion pressure) is closely linked to ICP

• CPP = MAP (mean arterial pressure) – ICP

• Normal CPP is 60 to 100

• A CPP of less than 50 results in permanent neurolgic damage

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Manifestations of Increased ICP—Early

• Changes in level of consciousness (FIRST)

• 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

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Manifestations of Increased ICP—Late

• Respiratory and vasomotor changes

• VS:

– Cushing’s triad: bradycardia, hypertension (with widened pulse pressure), and bradypnea

• Vomiting

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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

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• Diagnostic studies– CT, cerebral angiogram, MRI, direct pressure

measurement (via ventriculostomy)

• Complications– Inadequate cerebral perfusion– Brain stem herniation– Diabetes insipidus– SIADH

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Collaborative Care– Monitoring ICP

• Usually with ventriculostomy for ICP monitoring

– Decreasing cerebral edema• Osmotic diuretics• Corticosteroids

– Controlling fever

– Cerebral oxygenation

– Maintaining cerebral perfusion• Maintaining systemic BP and increasing CO

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– Reducing metabolic cellular demands• Sedation (propofol most common)• Barbiturate coma

– Reducing CSF and IC blood volume• Ventriculostomy - CSF drainage• Hyperventilation as short term measure only for refractory

increased ICP

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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 Scale• Pupil checks• Assess selected cranial nerves• Take frequent vital signs• Assess intracranial pressure

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ICP Monitoring

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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—Diagnosis of the Patient With Increased

Intracranial Pressure• Ineffective tissue perfusion, cerebral• Ineffective airway clearance

• Ineffective breathing pattern

• Deficient fluid volume related to fluid restriction

• Risk for infection related to ICP monitoring

• Impaired physical mobility

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Nursing Process—Planning for Patient With Increased

Intracranial Pressure• Major goals may include:

– Maintenance of patent airway

– Normalization of respirations

– Adequate cerebral tissue perfusion

– Fluid balance

– Absence of infection

– Absence of complications

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Interventions• Frequent monitoring of respiratory status, LOC, lung

sounds and measure to maintain a patent airway

• Position with the head in neutral position and HOB elevation 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 sterile technique for management of ICP monitoring system

• Monitor for signs/symptoms of infection

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Interventions

• Monitor for early signs of increased ICP

– LOC change, pupillary/EOM changes, weakness, HA

• Monitor for late signs of increased ICP

– LOC deteriorates, Cushing’s triad, vomiting, posturing, loss of reflexes

• Monitor ICP if indicated

• Monitor for secondary complications

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Intracranial Surgery

• Craniotomy: opening of the skull– Purposes: remove tumor, relieve elevated ICP,

evacuate a blood clot, and control hemorrhage

• Craniectomy: excision of a portion of the skull

• 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

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Supratentorial Approach for Cranial Surgery

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Infratentorial Approach for Cranial Surgery

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Transsphenoidal Approach for Cranial Surgery

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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 (phenytoin)

• Corticosteroids, fluid restriction, hyperosmotic agents (mannitol), and diuretics may be used to reduce cerebral edema

• Antibiotics may be administered to reduce potential infection

• Benzodiazepine 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, and monitoring ICP and neurologic status

• The patient may be intubated and have arterial and central venous lines, ventriculostomy

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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

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Nursing Process—Diagnosis of the Patient Undergoing

Intracranial Surgery

• Ineffective tissue perfusion

• 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—Planning the Care of the Patient Undergoing

Intracranial Surgery• Major goals may include:

– Improved cerebral 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 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 elevated 30° according to needs related to the surgery and surgeon’s preference

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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

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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

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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

• Monitoring for increased ICP and bleeding

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Seizures• Uncontrolled, paroxysmal electrical

discharge of neurons in the brain that disrupts normal function

• Classification of seizures: see table 59-6– 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• Includes tonic-clonic, absence

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Specific Causes of Seizures• Head trauma

• Drug -related processes

• Infectious processes

• Intracranial events

• Metabolic imbalances

• Medical disorders

• Other

• Table 58-8

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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

– Eg, aura, type of movements, pupils, incontinence, changes in consciousness, cognitive

• Nursing actions during seizure for patient safety and protection

• See handout; table 59-12 for home teaching

• After seizure care, prevent complications

– Risks include hypoxia, vomiting, aspiration

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Epilepsy

• Acondition in which a person has spontaneously recurring seizures– Classified by patterns of clinical features, including

onset, family history and seizure type– Idiopathic or secondary

• Causes– Include idiopathic, birth trauma, head injury,

infectious disease, toxins, circulatory problems, brain tumor, abcess, congenital malformations,

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Epilepsy• Diagosis

– History and physical exam– Electroencephalogram– Video recording of seizures

• Treatment– Pharmacologic (treat, not cure)

• Review epilepsy meds - table 59-9

– Surgical management• For cessation or reduction of seizures (see table 59-

10)

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Guidelines for Seizure Care

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Status Epilepticus• Acute prolonged seizure activity; a series of

generalized seizures that occur without full recovery of consciousness between attacks

• Generally lasts longer than 30 minutes• Heavy metabolic demand may result in interference

with respiration and hypoxia of the brain• Medical management is aimed at stopping the

seizures– Airway– IV lorazepam, diazepam for abrupt cessation– Phenytoin or fosphenytoin for maintenace of seizure-free

state; phenobarbital in extreme cases

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Headache• Also called cephalgia

• 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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Headache

• Migraine– Characterized by periodic and recurrent

attacks of severe HA lasting 4-72 hours– Throbbing pain– Most common in women , 25-55 years– Familial tendency– Subtypes

• May be with or without aura

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Headache• Migraine

– Triggers include menstrual cycles, bright light, stress, sleep deprivation, medications, foods (MSG, tyramine, nitrites, milk products, red wine, chocolate)

– Phases• Prodrome (60%)• Aura (30%)-neurologic symptoms correspond to cerebral

vasoconstriction• Headache-severe, throbbing; may have N/V, photophobia; 4-72

hours• Recovery-exhaustion, muscle aches

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Headache• Migraine Treatment

– Abortive - relief of HA in progress• Includes NSAIDS, opiods, triptans (serotonin receptor

agonists) , ergotamine preparations (table 59-3)– Prevention

• Avoidance of triggers• Beta blockers• Antiepileptics • Calcium channel blockers• Antidepressants• Botox• Relaxation therapy

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Headache• Tension-type headache

– Chronic, mild to moderate in intensity, most common type

– May last days-weeks-months– Muscular origin vs. neurovascular origin– Characterized by steady pressure that usually begins

in the forehead, temples, or neck– Treated symptomatically: heat, massage, analgesics,

muscle relaxants

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Headache

• Cluster headache– Severe form of vascular headache; may be

precipitated by ETOH, vasodilators, nitrites, histamines

– Described as sharp, stabbing, intense– Far more common in men– Treatment

• Abortive may include 100% oxygen x 15 minutes,, triptans, NSAIDS, opioids

• Preventive therapy may include beta blockers, ergotamine, lithium, naproxen

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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

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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

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Nursing Management of Headache—Pain

• Provide individualized care and treatment

• Prophylactic medications and teaching

• Migraines and cluster headaches require abortive medications instituted as soon as possible with onset

• Provide medications as prescribed

• Provide comfort measures

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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

Copyright © 2008 Lippincott Williams & Wilkins. 1 Management of Neurologic Dysfunction.

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Transcript of Copyright © 2008 Lippincott Williams & Wilkins. 1 Management of Neurologic Dysfunction.