Stacy Chapter 61 PowerPoint Presentation: Management of Patients with Neurologic Dysfunction Flashcards
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
Assessment of the Patient with Altered
Level of Consciousness
Verbal response
Alertness
Motor response (posturing)
Respiratory status
Eye signs
Reflexes
Refer to Table 61-1
Collaborative Problems and Potential
Complications of Patients with Altered Level of Consciousness
Respiratory distress or failure
Pneumonia
Aspiration
Pressure ulcer
Deep vein thrombosis (DVT)
Contractures
Planning and Goals for the Patient with
Altered Level of Consciousness
Goals may include:
o Maintenance of clear airway
o Protection from injury
o Attainment of fluid volume balance
o Maintenance of skin integrity
o Absence of corneal irritation
o Effective thermoregulation
o Accurate perception of environmental stimuli
o Maintenance of intact family or support system
o Absence of complications
Nursing Interventions for the Patient with
Altered Level of Consciousness #1
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
o Frequent monitoring of respiratory status, including
auscultation of lung sounds
o Positioning to promote accumulation of secretions and
prevent obstruction of upper airway—head of bed (HOB)
elevated 30 degrees; lateral or semiprone position
o Suctioning, oral hygiene, and CPT
Nursing Interventions for the Patient with
Altered Level of Consciousness #2
Maintaining tissue integrity
o Assess skin frequently, especially areas with high potential
for breakdown
o Frequent turning; use turning schedule
o Careful positioning in correct body alignment; use of
splints, foam boots, trochanter rolls, and specialty beds as
needed
o Passive ROM
o Clean eyes with cotton balls moistened with saline
o Use artificial tears as prescribed
o Measures to protect eyes; use eye patches cautiously
because the cornea may contact patch
o Frequent, scrupulous oral care
Nursing Interventions for the Patient with
Altered Level of Consciousness #3
Maintaining fluid status
o Assess fluid status by examining tissue turgor and
mucosa, laboratory test data, and I&O
o Administer IVs, tube feedings, and fluids via feeding tube
as required; monitor ordered rate of IV fluids carefully
Maintaining body temperature
o Adjust environment and cover patient appropriately
o 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
o Monitor temperature frequently and use measures to
prevent shivering
Nursing Interventions for the Patient with
Altered Level of Consciousness #4
Promoting bowel and bladder function
o Assess for urinary retention and urinary incontinence
o May require indwelling or intermittent catheterization
o Bladder training program
o Assess for abdominal distention, potential constipation,
and bowel incontinence
o Monitor bowel movements
o Promote elimination with stool softeners, glycerin
suppositories, or enemas as indicated
o Diarrhea may result from infection, medications, or
hyperosmolar fluids
Nursing Interventions for the Patient with
Altered Level of Consciousness #5
Sensory stimulation and communication
o Talk to and touch patient and encourage family to talk to
and touch the patient
o Maintain normal day–night pattern of activity; orient the
patient frequently
o Note: When arousing from coma, a patient may
experience a period of agitation; minimize stimulation at
this time
o Programs for sensory stimulation
o Allow family to ventilate and provide support
o Reinforce and provide consistent information to family
o Referral to support groups and services for family
Increased Intracranial Pressure
Monro–Kellie hypothesis: because of limited space in the skull,
an increase in any one of components of the skull (brain
tissue, blood, 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 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
CO2 plays a role; decreased CO2 results in vasoconstriction,
and increased CO2 results in vasodilatation
Cerebral Response to ICP
Cerebral perfusion pressure (CPP) 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
neurologic damage
Early Manifestations of Increased ICP
Changes in LOC
Any change in condition
o 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
Late Manifestations of Increased ICP
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
o Cushing 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
Assessment of the Patient with Increased
Intracranial Pressure
Obtain history of events leading to illness
Evaluate mental status, LOC
Assessment of selected cranial nerves
Assess cerebellar function, reflexes, motor and
sensory function
Glasgow Coma Scale, pupil checks
Frequent vital signs
Assessment of intracranial pressure
Collaborative Problems and Potential
Complications of the Patient with Increased
Intracranial Pressure
Brainstem herniation
Diabetes insipidus
SIADH
Planning and Goals for the Patient with
Increased Intracranial Pressure
Major goals may include:
o Maintenance of patent airway
o Normalization of respirations
o Adequate cerebral tissue perfusion
o Respirations
o Fluid balance
o Absence of infection
o Absence of complications
Nursing Interventions for the Patient with
Increased Intracranial Pressure
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 to
60 degrees 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
intracranial Surgery
Craniotomy:
opening of the skull
o Purposes:
remove tumor, relieve elevated ICP,
evacuate a blood clot, control hemorrhage
o Refer to Table 61-3
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, aspirate a hematoma or
abscess, or make a bone flap
