Neurology

Management of Patients with Neurological Dysfunction

Chapter 61

Nursing management

• Ineffective airway clearance r/t alt. LOC– HOB – Lateral/semi-prone– Suctioning

• Hyper-oxygenate – Chest physiotherapy– Postural drainage– Auscultate – Intubation– Mech. vent

Nursing management

• Risk of injury r/t LOC– Padded side-rails– Lines & equipment– Restraints– Dignity

• Privacy• Speak to pt

Nursing management

• Deficient fluid volume r/t NPO– Skin turgor– Mucous membranes– I&O– labs

Question?

• Which of the following lab values is most useful in assessing dehydration?– K+– Na+– Hematocrit– BUN– Urine specific gravity

Question?

• What affect does dehydration have on a pt BUN level?– Increase– Decrease

Question?

• What affect does dehydration have on a pt. Hematocrit level?– Increase– Decrease

Nursing management

• Impaired oral mucous membranes r/t mouth breathing etc.– for dryness, inflammation, crusting– Oral care q8h– Lips– Move endotracheal tube each day (rt–lf–rt)

Nursing management

• Alt. in nutrition, less than body requires– NGT/GT– HOB

Question?

• Mrs. Jones has an NGT and has 2 medication that need to be given at 12:00 pm. Can the nurse crush the meds and give them at the same time?– Yes– No

• Each med is given separate and flush with 20-30 ml of water after each dose

Question?• How do you measure for NGT tube placement?A. From the tip of the nose ear lobe xyphoid

process B. From the tip of the nose ear lobe xyphoid

process + 6 inchesC. From the ear lobe tip of the nose xyphoid

processD. From the ear lobe tip of the nose xyphoid

process + 6 inches

Question?

• What is the most effective way to check NGT placement?

A. Inject 20 cc of air and listen for gurgleB. Aspirate stomach contentsC. X-ray

Question?

• Mrs. Nop had an NGT placed 7 days ago and is tolerating feeding well. You are assigned to give her a 250 bolus feeding of Ensure. How should you make sure the NGT is in the stomach and not the lung?

A. Inject 20 cc of air and listen for gurgleB. Aspirate stomach contentsC. X-rayD.None of the above are necessary

Nursing management

• Risk for impaired skin integrity r/t immobility– Reg. turning

• drag

– ROM– Splints

• Foam boats

– Beds

Nursing management

• Impaired tissue integrity of cornea r/t I corneal reflex– Clean

• Cotton-ball & normal saline

– Cold compress• edema post-op

– Eye patch warning!

Nursing management

• Ineffective thermoregulation r/t damage to hypothalamic center– Minimal bedding– Anti-pyretic– Cool sponge bath– Fan– Hypothermic blanket

Nursing management

• Impaired urinary elimination (incontinence or retention)– Scan bladder– Retention Foley– S&S of infection

• Fever• Cloudy urine

Nursing management

• Bowel incontinence– Bowel sounds– Abd girth– Monitor BM

• Frequency• Consistency

Nursing management

• Disturbed sensory perception– Touch– Talk– Orient– Familiar sounds (tape player)

• Favorite TV/radio

– When arousing from coma • stimuli

Nursing management

• Interrupted family processes r/t health crisis– Grief process

What’s your advice?

• While assessing the patency of a central line for an unresponsive, terminally ill patient, I was startled when the patients wife said to me, “this isn’t how it was suppose to be. He’s just a year away from retirement, and we had wonderful plans to travel across the country.” I didn’t know what to say except, “I’m sorry.” I’d like to do better if this situation come up again. What should I have said?

Small Group Questions

1. What is the priority nrs dx for a patient with alt. LOC?

2. Describe cerebral blood flow during suctioning.3. How can a nrs best assess for dehydration?4. Give 5 nrs interventions for a patient at risk for

injury & for impaired joint and skin integrity.

Increased Intracranial Pressure

• Rigid vault• Contains 3 components

– Brain tissue– Blood– CSF

• Normal ICP 10-20 mmHg

I-ICP

• Minor changes in ICP– Straining– Coughing– Sneezing– Posture– BP

I-ICP

• Etiology of I-ICP– Head injury– Stroke– Inflammatory process– Intra-Cranial surgery

I-ICP

• I-ICP Cycle– I-ICP – cerebral perfusion – Ischemia – Further edema – Herniation (shift brain tissue) – Deathmosis

I-ICP

• PaCO2 • Cerebral vasodilatation

• cerebral blood flow

• -ICP

• PaCO2 • Cerebral

vasoconstriction • cerebral blood flow

• -ICP

I-ICP

• Cerebral edema– Abn. of fluid – brain tissue volume – I-ICP

I-ICP

• Compensation– Bodies attempt to ICP– Cushing’s response

• Widening PP• Bradycardia

• Decompensation– Ischemia– Infarction

What is the earliest S&S of I-ICP?

A. HyporeflexiaB. ParesethesiaC. Visual distrubanceD. Altered level of consciousnessE. Motor slowingF. Pupils fixed

I-ICP

• Early S&S– #1 Alt LOC

• restlessness or confusion

– H/A– Pupillary changes– Weakness on one side

I-ICP

• Late S&S– Stupor coma– Pulse & Resp

• • Erratic (Cheyne-stoke, ataxic, Biot’s)

– BP & Temp•

– Projectile vomiting

I-ICP

• Late S&S– Decorticated posturing– Decerebrate posturing– Loss of protective reflexes

Where did it go?

• What goes first?– Orientation to time– Orientation to person– Response to verbal stimuli– Response to painful stimuli– Protective reflexes

I-ICP

• Ominous sign!• Grave sign!

Complications of I-ICP

• Herniation• Diabetes Insipidus• SIADH

I-ICP Dx / Assessment

• CT• MRI

I-ICP Management

• Monitor ICP– Ventricular catheter– Sub-arachnoid screw

3 goals of I-ICP management

• edema• CSF volume• Cerebral blood volume

I-ICP management

• Decrease Edema– Osmotic diuretic

• Mannitol/Osmitrol– I&O– Indwelling catheter– via serum osmolality

I-ICP management

• Decrease edema– Corticosteroids

• Dexamethasone /Decadrone– S/E

» Hyperglycemia» GI bleed

– Give with» Antacids / Tums» Histamine H2 receptor blockers / Tagamet (cimetidine)

I-ICP management

• Decreasing edema– Fluids

• – HOB

• – Body temperature

• Lower– cerebral edema– metabolism

I-ICP management

• Decreasing CSF– Drain CSF

• Via lumbar puncture• Not too much • Ventricles collapse

I-ICP management

• Decrease cerebral blood flow– O2

• Hyperventilate • Vasoconstriction• Hgb levels

– Control fever• Anti-pyretics• Cooling blanket• shivering I-ICP

I-ICP management

• Decrease cerebral blood flow– Decrease metabolic demand

• Induce coma– Phenobarbital

• Paralyzing agents– Monitor cardiac– Vent– Monitor ICP – monitor Arterial pressure– Monitor serum barbituate levels

I-ICP management

• Decrease cerebral blood flow– Decrease metabolic demand

• Prevent Seizures– Phenytoin / Dilantin– Diazepam / valium– Monitor serum levels

• Prevent infections

– Control BP

I-ICP Nursing Management

• Maintain patent airway• Optimizing cerebral tissue perfusion

– Position • HOB • Head neutral position• Avoid extreme hip flexion

– valsalva maneuver I-ICP• Stool softeners• emena• Suctioning

I-ICP Nursing Management

• Optimizing cerebral tissue perfusion– Calm atmosphere– Space nursing tasks– Minimal stimuli

• Monitor ICP

Intracranial surgery

• Craniotomy:– Opening the skull surgically to gain access to

intracranial structures

Intracranial surgery

• Burr hole– Circular opening made in the skull by a drill

Intracranial surgery

• Craniectomy– An excision of a portion of the skull

Intracranial surgery

• Cranioplasty– Repair of a cranial defect by means of a plastic or

metal plate

Intracranial surgery

• Transsphenoidal– Through the nasal sinuses to gain access to the

pituitary gland

Intracranial surgery

• Pre-op– Diagnostic procedures

• CT scan• MRI• Cerebral angiography

– Anticonvulsants• Phenytoin / Dilantin

– Corticosteroids• Dexamethasone / Decadron

Intracranial surgery

• Pre-op– Fluids

• Restricted

– Diuretics• Mannitol• Furosemide / Lasix

– Anxiety• Diazepam / Valium

Intracranial surgery

• Pre-op– Antibiotics– Shave head– Indwelling catheter– Warn pt about post-op environment– Baseline neuro check

Intracranial surgery

• Post-op– Continue Pre-op meds– Reduce cerebral edema

• Mannitol• Dexamethasone

– Relieve pain• Acetaminophen / Tylenol• Codeine• Morphine sulfate

Which of the following would be of concern while assessing the ABG’s of a patient post-op craniotomy?

A. PaO2 105B. HypoxemiaC. HypercapniaD. HypercarbiaE. Hypocapnia

Intracranial surgery

• Post-op– Prevent seizures

• Phenytoin / Dilantin• Diazepam / valium• Monitor serum levels

– Monitor ICP– Edema peaks 24-36 hrs post-op– Temp control

Intracranial surgery

• Post-op– Periorbital edema /

ecchymosis– Enhancing self image

• Verbalize frustration• Cover head with turban• Wig until hair grows

Seizures

• Definition– Abnormal motor, sensory autonomic or psychic

activity resulting from sudden excessive discharge from cerebral neurons

What is Epilepsy?

• disorder • briefly interrupts the normal electrical activity

of the brain• too many neurons fire at one time• "electrical storm" • seizure

Seizures

• Classification– Partial

– Seizure that begins in one part of the brain• Simple

– Repetitive purposeless behavior– Dreamlike state– No loss of consciousness– Duration: < 1 minute– I.e. talking unintelligibly, dizziness, hand shake, picking at

clothes, chewing, smacking lips, spitting, fondling self

Seizures

• Classification– Partial

• Simple• Complex

– Repetitive purposeless behavior– Loss of consciousness– Lasts 2-15 minute– Not aware of behavior

Seizures

• Classification– Generalized

– Seizure that involves electrical discharges in the whole brain

• Absence Seizure– Occurs must often in children– Period of staring– Duration: several seconds

• Tonic-Clonic Seizure

Seizures

• Classification– Generalized

• Tonic-Clonic Seizure– (grand mal seizure)– Tonic – rigidity– Clonic – contraction and relaxation of all muscles jerky,

rhythmic

Seizures

• Possible Etiology– Underlying cause is electrical disturbance emitting of

abnormal, recurring, uncontrolled electric discharge• Idiopathic origin• Head injury• Hypoglycemia• Brain tumor• Infection • Anoxia

Seizures

• Clinical manifestations– Prodromal phase

• Vague emotional changes• Minutes – hours before seizure

Seizures

• Clinical manifestations– Prodromal phase– Aura

• Brief sensory experience• Precedes seizure by a few seconds• Usually the same aura each time

Seizures

• Clinical manifestations– Prodromal phase– Aura– Loss of consciousness

• May or may not occur

– Seizure activity

Seizures

• Seizure activity– Tonic Phase

• Duration: 30-60 sec• Rigidity fall• Pupils fixed & dilated• Hands and jaws clenched• Stop breathing

– Clonic phase

Seizures

• Seizure activity– Clonic phase

• Contraction & relaxation of all muscles, jerky rhythmic fashion• Incontinent• Frothing at the mouth• Dyspnea• Epileptic cry• Tongue chew• Lasts 1-2 minutes subsides

Seizures

• Characteristics – Post-seizure / postictal

• Recover period• Deep sleep• Confused

Seizures

• Medical management– Anticonculsants

• Caramazepine / Tegretol– S/E

» Severe rash» Blood dyscrasias» Hepatitis

• Clonazepam / Klonopin– S/E

» Hepatotoxicity» Behavioral changes

Seizures

– Anticonculsants• Phenytoin / Dilantin

– S/E» Gum hyperplasia» Rash» Nystagmus» Blood dyscrasias» PG cleft palate

Seizures– Anticonculsants

• Valproate / Depakene– S/E

» Hepatotoxicity» Blood dyscrasias» Skin rash

• Diazepam / Valium• Phenobarbital / Luminal

– S/E» Drowsiness» Rash» pain

Seizures

• Nrs Management w/ anticonvulsants– Do not stop abruptly seizures– Monitor levels– Take regularly– Inform of all meds– Alcohol only in moderation

Seizures

• Before Seizure– At risk for injury

• Padded side rails• Suction machine in room• Loose clothing• Know aura

Seizures

• Fear r/t possibility of a seizure– Take meds routinely– ID triggers

• Stress• New environment• Menstruation• Fever• Sleep deprivation• Alcohol

Seizures

• Fear– Avoid photic stim

• Bight flickering lights• TV• Wear dark glasses

– Regular routine– Wear ID band

Seizures

• Ineffective coping– Embarrassed– Feel rejected, avoided, discriminated– Frequently lonely psych problems– Driving restrictions

Seizures

• Knowledge deficit– Take meds daily– records of meds & seizures– Drug levels routine– Avoid activities requiring alertness after meds– Showers or bath?

• Shower!

– Exercise– Sleep

Seizures

During a seizure• Safety

– Ease to floor– Protect the head– Turn to side– Loosen clothing– In bed?

• Remove pillow• Side rails up

– Do not • pry open mouth• Insert anything in mouth• restrain

– Stay with pt

• Support patient– Privacy

Seizures

• Observe & document– Circumstance (before)

– Aura?– 1st – Movement– Area– Pupils– Automatisms– Incontinent

– Duration– Unconsciousness– Weakness– Dysphasia– Post seizure behavior

Seizures

• After a seizure– Document– At risk for

• Hypoxia• Vomiting• Aspiration

• Recovery position

Seizures

• Nursing care– Side lying– Bed low– Padded side rails– stimulation

• Dim lights• Noise

– VS– Check mouth– Clean pt– Allow to “sleep it off”

Status Epilepticus

• Defines– Prolonged seizure

activity– Series of

generalizes seizures w/o full recovery btw attacks

– Medical emergency

Status Epilepticus

• Affects– Metabolic demand– Respiration– Anoxia– Brain damage

Status Epilepticus

• Medical Management– Goal

• Stop seizure activity• Airway

• Rx of choice– Diazepam

• Valium

Status Epilepticus

• Dx– Blood studies

• Electolytes• Glucose• Phenytoin level

What alteration in glucose level can commonly lead to seizures?

A. HyperglycemiaB. Hypoglycemia