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