Management of Patients With Neurologic Dysfunction

7/31/2019 Management of Patients With Neurologic Dysfunction

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Management of Patients With

Neurologic Dysfunction

Ziad . M.Alostaz

RN-BC,MSN,ACNS


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Altered Level of Consciousness (LOC)

Level of responsiveness and consciousness isthe most important indicator of the patient'scondition

LOC is a continuum from normal alertness andfull cognition (consciousness) to coma

Altered LOC is not the disorder but the result

of a pathology Coma:unconsciousness, unresponsiveness,

and inability to arouse


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CONT

Persistent vegetative state: patient is devoid of

cognitive function but has sleepwake cycles

Akinetic mutism: unresponsiveness to the

environment, the patient makes no movement

or sound but sometimes opens eyes


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Nursing ProcessAssessment of the

Patient With Altered LOC

Verbal response and orientation

Alertness

Motor responses

Respiratory status Eye signs

Reflexes

Postures

Glasgow Coma Scale

See Table 61-1


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Nursing ProcessDiagnosis 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 impairedtissue integrity (cornea)

Ineffective thermoregulation

Impaired urinary elimination and bowelincontinence 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 ProcessPlanning 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


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Interventions

A major nursing goal is to compensate for thepatient's loss of protective reflexes and to assumeresponsibility for total patient care; protectionincludes maintaining the patients dignity and

privacy Maintain an airway

Frequent monitoring of respiratory status includingauscultation of lung sounds

Position the patient to promote accumulation ofsecretions and prevent obstruction of upper airway:HOB elevated 30, lateral or semiprone position

Provide suctioning, oral hygiene, and CPT


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Maintaining Tissue Integrity

Assess skin frequently, especially areas with high potentialfor 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 patchescautiously as the cornea may contact patch

Provide frequent, scrupulous oral care


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CONT

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 asrequired: monitor ordered rate of IV fluids carefully

Maintain body temperature Adjust environment and cover patient appropriately

If temperature is elevated, use minimum amount ofbedding, administer acetaminophen, use hypothermiablanket, give a cooling sponge bath, and allow fan to blowover patient to increase cooling

Monitor temperature frequently and use measures toprevent 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, potentialconstipation, 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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Increased Intracranial Pressure (ICP)

Monro-Kellie hypothesis: because of limitedspace in the skull, an increase in any one skullcomponentbrain tissue, blood, or CSFwillcause a change in the volume of the others

Compensation to maintain a normal ICP of lessthan 15 mm Hg is normally accomplished byshifting 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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CONT.

Brain tissues may shift through the dura andresult in herniation

Autoregulation: refers to the brains ability tochange the diameter of blood vessels tomaintain cerebral blood flow

CO2 plays a role; decreased CO2 results invasoconstriction, and increased CO2 results invasodilatation


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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 to 100

A CCP of less than 50 results in permanent

neuralgic damage


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Manifestations of Increased ICPEarly

Changes in level of consciousness

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 ICPLate

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 temperatureincrease

Cushings triad: bradycardia, hypertension, and bradypnea

Projectile vomiting


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Manifestations of Increased ICPLate

(cont.)

Further deterioration of LOC; stupor to coma

Hemiplegia, decortication, decerebration, or

flaccidity

Respiratory pattern alterations includingCheyne-Stokes breathing and arrest

Loss of brain stem reflexes: pupil, gag, corneal,and swallowing


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Nursing ProcessAssessment of the Patient

With Increased

Intracranial Pressure

Conduct frequent and ongoing neurologicassessment

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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Nursing ProcessDiagnosis of the Patient With

Increased Intracranial Pressure

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

Brain stem herniation

Diabetes insipidus

SIADH

Infection


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Nursing ProcessPlanning 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

Absence of complications


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Interventions

Frequent monitoring of respiratory status and lung sounds andmeasure to maintain a patent airway

Position with the head in neutral position and HOB elevation of 15to 30 to promote venous drainage

Avoid hip flexion, Valsalva maneuver, abdominal distention, orother stimuli that may increase ICP

Maintain a calm, quiet atmosphere and protect patient from stress

Treat constipation

Avoid any movement that cause increase ICP (valsalva maneuver )

Monitor fluid status carefully; during acute phase, monitor I&Oevery hour

Use strict aseptic technique for management of ICP monitoringsystem


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Questions:

Thank you

Management of Patients With Neurologic Dysfunction

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