Medical-Surgical Nursing The Neurologic Concepts

JIMMELLEE ELLEN P. OLILANG, RN

References:


BRUNNER & SUDDARTH S TEXTBOOK OF MEDICALSURGICAL NURSING

Learning Objectives
on the completion of this chapter, the learner will be able to:


Describe the structure and functions of the central and peripheral nervous systems. Differentiate between pathologic changes that affect motor control and those that affect sensory pathways. Compare the functioning of the sympathetic and parasympathetic nervous systems. Describe the significance of physical assessment to the diagnosis of neurologic dysfunction. Describe changes in neurologic function associated with aging and their impact on neurologic assessment findings. Describe diagnostic tests used for assessment of suspected neurologic disorders and the related nursing implications.

Outline of Our Lecture

Anatomy and Physiology  Application of the Nursing process in the approach of neurologic problems:


ASSESSMENT relevant techniques and lab procedures  DIAGNOSIS  PLANNING  IMPLEMENTATION  EVALUATION


Outline of the lecture

Trauma and related accidents

Traumatic brain injury  Spinal cord injury


Cerebrovascular Accidents

Outline of the lecture



Degenerative disorders- demyelinating

Multiple sclerosis  Guillain-Barre syndrome


Degenerative disordersNON-demyelinating


Alzheimer s disease  Parkinson s disease



Outline of the lecture



Motor dysfunction- CNS



Epilepsy

Motor dysfunction- cranial nerve

Bell s palsy  Trigeminal neuralgia


Motor dysfunction- peripheral



Myasthenia gravis

Outline of the lecture



Infectious Disease
Meningitis Brain abscess Encephalitis


IMPLEMENTATION PHASE

Increased Intracranial pressure  Altered level of consciousness  Seizures  Autonomic dysreflexia / hyperreflexia  Spinal shock  Cognitive impairment  Bowel incontinence


IMPLEMENTATION PHASE

Impaired physical mobility Impaired swallowing Disturbed sensory perception



A. CEREBRAL DISORDERS Epilepsy Seizures Brain Tumors Cerebrovascular Disease Brain Infections Headaches
B. DEGENERATIVE NEUROLOGIC DISORDERS Dementia (Alzheimers) Parkinson s Disease Creutzfeldt-Jakob Disease Huntington s Disease Multiple Sclerosis Guillain Barre Syndrome Myasthenia Gravis Amyotrophic Lateral Sclerosis

C. PERIPHERAL NERVOUS SYSTEM DISORDERS Lower Back Pain Trigeminal Neuralgia Bell s Palsy Vascular Spinal Cord Lesions Disorders of the Peripheral Nerves

D. NEUROLOGIC TRAUMA Spinal Cord Injury Head Injury

Anatomy and Physiology



Gross anatomy


The nervous system is divided into the central and peripheral nervous system


Control all motor, sensory, autonomic, cognitive and behavioral activities.

The Central nervous system consists of the BRAIN and the SPINAL CORD  The peripheral nervous system consists of the SPINAL NERVES and the CRANIAL NERVES



Can be further divided into the: SOMATIC OR VOLUNTARY NERVOUS SYSTEM AND THE AUTONOMIC OR INVOLUNTARY NERVOUS SYSTEM

BRAIN


- it collects, integrates, and interprets all stimuli

- it initiates & monitors voluntary & involuntary motor activity

CEREBRUM (cerbral cortex)  BRAIN STEM  CEREBELLUM

Cerebrum
-Gives us the ability to think & reason -enclosed in 3 membrane layers called meninges is composed of lobes Frontal lobe- personality, memory and motor function  Parietal lobe- sensory function  Temporal lobe- hearing and olfaction and emotion by the limbic system  Occipital lobe- vision

Anatomy and Physiology

The cerebellum is involved in coordination and equilibrium  The diencephalon (a part of the cerebellum) consists of the :


Thalamus- the relay center of all sensory input  Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response


Anatomy and Physiology

The brainstem (beneath the diencephalon)  Relays messages between the cerebrum & diencephalon & spinal cord  Regulates automatic body fxns e.g. HR, RR, swallowing, & coughing  is composed of:  midbrain- for visual and auditory reflexes  Pons- respiratory apneustic center, nucleus of cranial nerves5,6,7,8  Medulla oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12


Peripheral Nervous System

Includes:  Peripheral sensory nerves transmit stimuli from sensory receptors in the skin, muscles, sensory organs, & the viscera to the dorsal horn of the spinal cord  The upper motor neurons of the brain & the lower motor neurons of cell bodies in the ventral horn of the spinal cord carry impulses that affect the movement


Autonomic Nervous System



Contains motor neurons that regulate visceral organs & innervate ( supply nerves to ) smooth & cardiac muscles & the glands

TWO PARTS OF ANS

1. sympathetic nervous system  Controls the fight or flight response



2. parasympathetic nervous systrem  Maintains the baseline of the body functions  Resposible for the rest & digest response


 or nervous system is the body s communication network  it coordinates and organizes the functions of all other body systems
NERVOUS SYSTEM

Central Nervous System

eri heral Nervous System

Brain

S inal Cord

Motor (Efferent) Neurons

Sensory (Afferent ) Neuron Sym athetic Nervous System arasym athetic Nervous System

Somatic Nervous System

Autonomic Nervous System

 the NEURON or NERVE CELL is the nervous system s fundamental unit this highly specialized conductor cell receives and transmits electrochemical nerve impulses  delicate, threadlike nerve fibers called AXONS & DENDRITES extend from the cell body & transmit signals  Axons carry impulses away from the cell body;dendrites carry impulses to the cell body  this intricate network of interlocking receptors & transmitters, along with the brain & spinal cord, forms a living computer that controls & regulates every mental and physical function

Each neuron communicates with each other to a specific target tissue through neurotransmitters

 These neurotransmitters are produced & stored in the synaptic vesicles;they enable conduction of impulses across the synaptic cleft
MAJOR NEUROTRANSMITTERS:

1. Acetycholine

2. Serotonin 3. Dopamine
4.

 The action of neurotransmitters is to potentiate, terminate or modulate a specific action & can either excite or inhibit the target cell s activity.

Norepinephrine 5. Gamma-aminobutyric acid (GABA) 6. Enkephalin,endorphin

Major Neurotransmitters
NEUROTRANSMITTER SOURCE ACTION

ACETYLCHOLINE - (major transmitter of the parasympathetic nervous system) SEROTONIN DOPAMINE

Many areas of the brain; Usually excitatory; autonomic Nervous System parasympathetic effects sometimes inhibitory (simulation of heart by vagal nerve)

Brain stem, hypothalamus, dorsal horn of the spinal cord Substantia Nigra and basal ganglia

Inhibtory, helps control mood and sleep, inhibits pain pathways Usually inhibits, affects behavior (attention, emotions, fine movements)

Major Neurotransmitters
NEUROTRANSMITTER SOURCE ACTION Usually excitatory; parasympathetic effects sometimes inhibitory (simulation of heart by vagal nerve)

ACETYLCHOLINE - (major transmitter of the parasympathetic nervous system) SEROTONIN DOPAMINE ENKEPHALIN, ENDORPHIN

Many areas of the brain; autonomic Nervous System

Brain stem, hypothalamus, dorsal Inhibtory, helps control mood horn of the spinal cord and sleep, inhibits pain pathways Substantia Nigra and basal ganglia Nerve terminals in the spine, brain stem, thalamus and hypothalamus, pituitary gland Usually inhibits, affects behavior (attention, emotions, fine movements) Excitatory; pleasurable sensation, inhibits pain transmission

 consists of the brain & the spinal cord that are protected by the bony skull and vertebrae, cerebrospinal fluid (CSF) and three membranes: the dura mater, the arachnoid membrane and the pia mater The brain is contained in the rigid skull, which protects it from injury;the major bones of the skull are the frontal, temporal, parietal & occipital bones; These bones join at the suture lines  The es f the ertebr l c l s rr r tect the s i l cor or ll consists of cer ical, thoracic, l bar ertebrae,sacr coccyx.

Scalp skin Inner /Outer layers of the Skull Dura mater (2 layers)  is a tough,fibrous, leatherlike tissue Composed of two layers: 1. Endosteal dura:forms the periosteum Of the skull & is continuous with the Lining of the vertebral canal 2. Meningeal dura: a thick membrane covers the brain, dipping between the brain tissue & providing support & protection Arachnoid mater: is a thin, fibrous membrane that hugs the brain & spinal cord Pia mater: is a continuous layer of Connective tissue that covers & Contours the spinal tissue & brain

 The epidural space lies between the skull & the dura mater

 Between the dura mater & the arachnoid membrane is the subdural space  Between the arachnoid membrane & the pia mater is the subarachnoid space  Within the subarachnoid space & the brain s four ventricles is CSF, a liquid composed of water & traces of organic materials (especially CHON) glucose and minerals;this fluid protects the brain & spinal tissue from jolts & blows

ASSESSMENT OF THE NEUROLOGIC SYSTEM



HISTORY


Initial interview provides excellent opportunity to explore the current condition and events while observing appearance, mental status, posture, movement and affect.

A confused client becomes an unreliable source of history

ASSESSMENT OF THE NEUROLOGIC SYSTEM

PHYSICAL EXAMINATION


5 categories:

1.  2.  3.  4.  5.


Cerebral function- LOC, mental status Cranial nerves Motor function Sensory function Reflexes

ASSESSMENT OF THE NEUROLOGIC SYSTEM

Neuro Check  Level of consciousness  Pupillary size and response  Verbal responsiveness  Motor responsiveness  Vital signs

CEREBRAL FUCTION

Assess the degree of wakefulness/alertness  Note the intensity of stimulus to cause a response  Apply a painful stimulus over the nailbeds with a blunt instrument  Ask questions to assess orientation to person, place and time


Cerebral function

Utilize the Glasgow Coma Scale  An easy method of describing mental status and abnormality detection  Tests 3 areas- eye opening, verbal response and motor response  Scores are evaluated- range from 3-15  No ZERO score


Glasgow Coma Scale

Glasgow Coma Score Eye Opening (E) Verbal Response (V) Motor Response (M)

Glasgow Coma Scale

Glasgow Coma Score Eye Opening (E) 4=Spontaneous 3=To voice 2=To pain 1=None (No response)

Glasgow Coma Scale

Glasgow Coma Score  Verbal Response (V) 5=Normal/oriented 4=Disoriented/CONFUSED 3=Words, but incoherent/ inappropriate 2=Incomprehensible/mumbled words 1=None

Glasgow Coma Scale

Glasgow Coma Score  Motor Response (M) 6=Normal- obeys command 5=Localizes pain 4=Withdraws to pain 3=Decorticate posture 2=Decerebrate posture 1=None (flaccid)

GLASGOW COMA SCALE

CONSCIOUS glasgow coma of 12 15  LIGHT STUPOROUS 9 11  DEEP STUPOROUS 7 8  LIGHT COMA 4 6  DEEP COMA 3


PUPILLARY CHANGES
Unilateral dilated (4mm) uncal herniation Fixed non-reactive Brain stem compression Subdural / epidural hematoma Tentorial / herniation Bilateral dilated (4mm) Fixed non-reactive Bilateral mid-sized (2mm) Fixed non-reactive Severe midbrain damage CP arrest Midbrain involvement caused by edema, hemorrhage, infarction, lacerations, contusions

Pipillary Changes
Bilateral Pinpoint (<1mm) Non-reactive Unilateral, small (1.5mm) Non-reactive Lesions of the pons

Disruption of the SNS supply to the head due to spinal card lesion above T1

CRANIAL NERVES
Cranial Nerves I II III

olfactory smell optic

oculomotor

vision
Most eye movt, pupillary constriction, upper eyelid elevation

IV V

trochlear

Down & in down movt

sensations

trigeminal Chewing, corneal reflex, face & scalp

VI

abducent

Lateral eye movement

CRANIAL NERVES
Cranial Nerves VI VII VIII IX

abducent

Lateral eye movement

facial acoustic glossopha ryngeal

Expressions in forehead Hearing & balance

Swallowing, salivating, taste

Swallowing, gag reflex, talking, sensations of the throat, larynx & abdl viscera, activities of thoracic & abdl viscera, e.g. HR, & peristalsis

vagus
accessory
hypoglossal

XI XII

Shoulder movt, head rotation

Tongue movt

Cranial Nerve Function: Cranial Nerve 1Olfactory

Check first for the patency of the nose  Instruct to close the eyes  Occlude one nostrils at a time  Hold familiar substance and asks for the identification  Repeat with the other nostrils  PROBLEM- ANOSMIA- loss of smell


Cranial Nerve Function: Cranial Nerve 2Optic

Check the visual acuity with the use of the Snellen chart  Check for visual field by confrontation test  Check for pupillary reflex- direct and consensual  Fundoscopy to check for papilledema


Snellen chart

Cranial Nerve Function: Cranial Nerve 3, 4 and 6

Assess simultaneously the movement of the extra-ocular muscles Deviations:  Opthalmoplegia- inability to move the eye in a direction



Diplopia- complaint of double vision

Cranial Nerve Function: Cranial Nerve 5 trigeminal

Sensory portion- assess for sensation of the facial skin  Motor portion- assess the muscles of mastication  Assess corneal reflex


Cranial Nerve Function: Cranial Nerve 7 facial

Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water  Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids


Cranial Nerve Function: Cranial Nerve 8- vestibuloauditory

Test patient s hearing acuity  Observe for nystagmus and disturbed balance


Cranial Nerve Function: Cranial Nerve 9glossopharyngeal

Together with Cranial nerve 10 vagus  Assess for gag reflex  Watch the soft palate rising after instructing the client to say AH  The posterior one-third of the tongue is supplied by the glossopharyngeal nerve


Cranial Nerve Function: Cranial Nerve 11accessory



Press down the patient s shoulder while he attempts to shrug against resistance

Cranial Nerve Function: Cranial Nerve 12hypoglossal



Ask patient to protrude the tongue and note for symmetry

NEUROLOGIC ASSESSMENT


CEREBRAL FUNCTION


Includes level of consciousness, intellectual function, speech, speech, memory, patterns of emotional behavior, balance & coordination

DESCRIBING LEVEL OF CONCIOUSNESS

AWAKE alert & completely oriented - responds to verbal & painful stimuli SLEEP becomes alert & oriented when awakened - responds to stimuli CONFUSION has short attention span & misinterpret information - disoriented to time, place, person & has trouble following commands, but still responds to stumuli

DESCRIBING LEVEL OF CONSCIOUSNESS

DELIRIUM disoriented, agitated, & perhaps may have hallucinations, & responds to stimuli  OBTUNDED remains drowsy when awakened, disoriented & confused - stays awake only if he s continously stimulated LIGHT STUPOR does not respond to stimuli, withdraws quickly & forcefully from moderate pain which he can localize DEEP STUPOR responds only to a strong stimulus, when he can t localize - may note decerebrate posture


DESCRIBING LEVEL OF CONSCIOUSNESS

doesn t responds to any stimuli - vital signs may be stable - may note brain stem & spinal cord reflexes - EEG shows activity CEREBRAL DEATH vital signs must be maintained artificially - has reflexes & no EEG activity - doesn t responds to stimuli


COMA

ASSESS Motor function

Assess muscle tone and strength by asking patient to flex or extend the extremities over resistance  Grading of muscle strength


GRADING SCALE FOR MOTOR STRENGTH

5/5 movement against gravity with strong resistance 4/5 movement against gravity with some resistance 3/5 movement against gravity with out resistance 2/5 movement not against gravity 1/5 trace movement 0/5 no movement

Assessing the motor function of the cerebellum

Test for balance- heel to toe  Test for coordination- rapid alternating movements and finger to nose test
 

ROMBERG s is actually a test for the posterior spinothalamic tract

Assessing the motor function of the brainstem

Test for the Oculocephalic reflex- doll s eye  Normal response- eyes appear to move opposite to the movement of the head  Abnormal- eyes move in the same direction

Assessing the motor function of the brainstem

Test for the Oculovestibular reflex  Slowly irrigate the ear with cold water and warm water  Normal response- cOld- OppOsite, wArM- sAMe

Assessing the sensory function

Evaluate symmetric areas of the body  Ask the patient to close the eyes while testing  Use of test tubes with cold and warm water  Use blunt and sharp objects  Use wisp of cotton  Ask to identify objects placed on the hands  Test for sense of position


Assessing the reflexes  Deep tendon/muscle-stretch reflexes

assymetrical indicate paralysis - brisk response indicate localizing value - absent deep coma

Biceps  Triceps  Brachioradialis  Patellar  Assessing the sensory function Achilles



Assessing the reflexes



Superficial /cutaneous reflexes

Abdominal  Cremasteric  Anal


Pathologic/primitive reflex
Babinski- stroke the lateral aspect of the soles doing an inverted J (+)- DORSIFLEXION of the Big toe with fanning out of the little toes  Brudzinski & kernig s sign meningeal irritation in meningitis


Grading of reflexes
Deep tendon reflex  0- absent  + present but diminished  ++ normal  +++ increased  ++++ hyperactive or clonic Superficial reflex  0 absent  +present

DIAGNOSTIC TESTS


EEG (electroencephalogram) represents a record of electrical activity generated in the brain.

It provides physiologic assessment of cerebral activity and determining brain death  Test diagnosing and evaluating Sz disorders, coma, or organic brain syndrome  Withhold medications that may interfere with the resultsanticonvulsants, sedatives and stimulants  Wash hair thoroughly before procedure  It takes 45 to 60 mins


Nursing interventions to patient undergoing EEG

Recommend the patient not to sleep the night before the procedure to increase the chances of recording Sz activities.  Anti Sz agents, tranquilizers, stimulants and depressants shld be withheld 24 to 48 hours before the test


DIAGNOSTIC TESTS
CT scan makes use of a narrow x-ray beam to scan the body part in successive layers  With radiation risk  If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected.


The injection of the water soluble iodinated contrast agent into the subarachnoid space through the lumbar puncture improves the visualization of the spinal and intracranial contents on these images.

Nursing interventions for patient undergoing CT scan

Teach the patient the need to lie quietly throughout the procedure  Sedation could be used if agitation and restlessness interfere with the successful study  For patient is to be using a contrast agent:


Assess the patient for allergy to iodine and shellfish because the agent is iodine based  IV line is needed for the contrast flushing  A period of fasting for 4 hours is needed


Assess for the S/Sx of allergy like flushing, nausea & vomiting

DIAGNOSTIC TESTS

MRI Uses magnetic waves Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure

DIAGNOSTIC TESTS

Cerebral arteriography Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site

DIAGNOSTIC TESTS

Lumbar puncture and examination of CSF Ensure consent, determine ability to lie still Contraindicated in patients with increased ICP Keep flat on bed after procedure Increase fluid intake after procedure CSF pressure with the patient in lateral position is normally 70 200 mmH20.
> 200 mm H20 = abnormal

Lumbar puncture (spinal tap)

It is performed to obtain CSF for examination, to measure and reduce CSF pressure, to determine presence or absence of blood in the CSF, to detect subarachnoid block, & to administer antibiotics intrathecally (into the spinal canal)  Queckenstedt s Test lumbar manometric test compress the jugular veins on each side of the neck during the lumbar puncture


Normal- CSF pressure is increased  Slow rise and fall in pressure- indicates a partial block due to a lesion compressing the spinal arachnoid pathways


Lumbar puncture (spinal tap)



Cerebrospinal Analysis
Normal clear & colorless  Cerebral contusion, laceration, subarachnoid hemorrhage - Pink, blood-tinged, or bloody CSF


Increased Intracranial pressure

Intracranial pressure more than 15 mmHg Brunner= Normal intracranial pressure 10-20 mmHg Causes:  Head injury  Stroke  Inflammatory lesions  Brain tumor  Surgical complications

Increased Intracranial pressure

Pathophysiology  The cranium only contains the brain substance (1400g), the CSF (75mL) and the blood/blood vessels (75 ml)  MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other  Any increase or alteration in these structures will cause increased ICP  Increased ICP from any cause decrease cerebral perfusion, stimulates further swelling and may shift brain tissue through openings in the rigid dura, resulting herniation

Increased Intracranial pressure

Pathophysiology Decompensatory mechanisms:  1. Decreased cerebral perfusion  2. Decreased O2 leading to brain hypoxia  3. Cerebral edema  4. Brain herniation

Decreased cerebral blood flow

Vasomotor reflexes are stimulated initially slow bounding pulses  Increased concentration of carbon dioxide will cause VASODILATION increased flow increased ICP


Cerebral Edema


Abnormal accumulation of fluid in the intracellular space, extracellular space or both.

Herniation


Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem

Cerebral response to increased ICP

1. 2.

Steady perfusion up to 40 mmHg Cushing s response

 

Vasomotor center triggers rise in BP to increase ICP Sympathetic response is increased BP but the heart rate is SLOW Respiration becomes SLOW

Increased intracranial pressure

CLINICAL PICTURE:

Subtle to dramatic changes in LOC; restlessness, confusion, drowsiness, stupor, coma Double or blurred vision, headache, nausea\ and vomiting, photosensitivity Decreased motor function Late findings: Changes in vital signs (widening of pulse pressure, bradycardia, tachypnea)

Increased Intracranial pressure

CLINICAL MANIFESTATIONS Early manifestations:  Changes in the LOC- usually the earliest  Pupillary changes- fixed, slowed response  Headache  vomiting

Increased Intracranial pressure

CLINICAL MANIFESTATIONS late manifestations:  Cushing reflex- systolic hypertension, bradycardia and wide pulse pressure  bradycardia  Hyperthermia  Abnormal posturing

Increased Intracranial pressure

Nursing interventions: Maintain patent airway  1. Elevate the head of the bed 15-30 degrees- to promote venous drainage  Assess VS  2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levels constricts blood vessels reduces edema  Notify physicians of findings  Keep head in neutral alignment  Avoid flexion of the neck or hips

Increased Intracranial Pressure

minimize environmental stimuli  document patient s status, phone call to physician and physician response thereafter


Increased intracranial pressure



FOCUSED ASSESSMENT
Assess neuro status  Assess cranial nerves as condition allows  Asses Oxygen saturation, cardiac rhythm  Assess for signs of decreased oxygenation


STABILIZING & MONITORING

Monitor neuro status & V/S  Keep SBP bet. 100mmHg-160mmHg (check AP for parameters)g  Limit suctioning (<10secs in duration, adm. O2 before hand; limit to 2 passes  Maintain O2 sat at 100%


Increased ICP
Maintain & assess I&O  Monitor ABG & electrolytes  Insert oral / nasal airway if neccesary  Maintain quiet environment; protect from injury  Provide education/reassurance/comfort measures  Document all findings & communicate to physicians  Obtain/perform chest physiotherapy as needed; assess nutritional status; obtain consult as needed


Increased Intracranial pressure

Nursing interventions  3. Administer prescribed medications- usually

Mannitol- to produce negative fluid balance  corticosteroid- to reduce edema  anticonvulsants- to prevent seizures


Increased Intracranial pressure

Nursing interventions  4. Reduce environmental stimuli  5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning

Increased Intracranial pressure

Nursing interventions  6. Keep head on a neutral position. AvOIDextreme flexion, valsalva  7. monitor for secondary complications


Diabetes insipidus- output of >200 mL/hr  SIADH



Altered level of consciousness

It is a function and symptom of multiple pathophysiologic phenomena  Causes: head injury, toxicity and metabolic derangement  Disruption in the neuronal transmission results to improper function


Altered level of consciousness

Assessment  Orientation to time, place and person  Motor function  Decerebrate  Decorticate  Sensory function

Altered level of consciousness

Patient is not oriented  Patient does not follow command  Patient needs persistent stimuli to be awake  Inability to speak  Confused, lethargic, obtunded, stuporous, or comatose


Altered level of consciousness

 1. 2. 3. 4. 5. 6.

Etiologic Factors Head injury Stroke Drug overdose Alcoholic intoxication Diabetic ketoacidosis Hepatic failure

Altered level of consciousness

ASSESSMENT 1. Behavioral changes initially 2. Pupils are slowly reactive 3. Then , patient becomes unresponsive and pupils become fixed dilated Glasgow Coma Scale is utilized


Altered level of consciousness

Nursing Intervention 1. Maintain patent airway  Elevate the head of the bed to 30 degrees  Suctioning 2. Protect the patient  Pad side rails  Prevent injury from equipments, restraints and etc.

Altered level of consciousness

Nursing Intervention 3. Maintain fluid and nutritional balance  Input and output monitoring  IVF therapy  Feeding through NGT 4. Provide mouth care  Cleansing and rinsing of mouth  Petrolatum on the lips

Altered level of consciousness

Nursing Intervention 5. Maintain skin integrity  Regular turning every 2 hours  30 degrees bed elevation  Maintain correct body alignment by using trochanter rolls, foot board 6. Preserve corneal integrity  Use of artificial tears every 2 hours

Altered level of consciousness

Nursing Intervention 7. Achieve thermoregulation  Minimum amount of beddings  Rectal or tympanic temperature  Administer acetaminophen as prescribed 8. Prevent urinary retention  Use of intermittent catheterization

Altered level of consciousness

Nursing Intervention 9. Promote bowel function  High fiber diet  Stool softeners and suppository 10. Provide sensory stimulation  Touch and communication  Frequent reorientation

SEIZURES

Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons  A part or all of the brain may be involved


SEIZURES
 

PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively CLINICAL PICTURE  Repetitive, jerky mov t of all extremities  Extreme muscle rigidity  LOC or disorientation  Tongue or eye deviation  Cyanosis/apnea  Urinary or fecal incontinence  Blinking or repetitive behaviors (playing buttons)

SEIZURE


CLINICAL PICTURE Difficulty in arousing Aura ( warning or recognition that seizures may occur)

SEIZURES
 1. 2. 3. 4. 5.

ETIOLOGIC FACTORS Idiopathic Fever Head injury CNS infection Metabolic and toxic conditions

SEIZURE


6 types of seizures:
Simple partial-sensory symptoms (flashing lights, smells, auditory hallucinations)  Autonomic symptoms (sweating, flushing, pupil dilation)  Psych symptoms ( dream states, anger, fear)  Complex partial seizure  Altered LOC  Amnesia


Absence seizure


A brief change in LOC indicated by blinking or rolling of the eyes, a blank stare, and a slight mouth mov t

SEIZURE


Myoclonic seizure  Brief involutary muscular jerks of the body or extremities Generelized tonic-clonic seizure
     

Typically beginning with a loud cry Change in LOC Body stiffening, alternating between muscle spasm & relaxation Tongue biting, incontinence, labored breathing, apnea, cyanosis, Upon wakening, possible confusion & difficulty talking Drowsiness, fatigue, headache, muscle soreness, weakness General loss of postural tone Temporary loss of consciousness

Atonic seizure
 

SEIZURES
Nursing Interventions During seizure  1. remove harmful objects from the patient s surrounding  2. ease the client to the floor  3. protect the head with pillows  4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure

SEIZURES

Nursing Interventions During seizure  5. loosen constrictive clothing  6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

SEIZURES
Nursing Interventions POST seizure  1. place patient to the side to drain secretions and prevent aspiration  2. help re-orient the patient if confused  3. provide care if patient became incontinent during the seizure attack  4. stress importance of medication regimen

HEADACHE


Cephalgia-pain in the head

90% is caused by muscle contraction & vascular abnormalities  Indicates underlying intracranial, systemic, psychological disorder TYPES OF HEADACHE:


1. 2. 3.

Primary headache- no organic cause Secondary headache- with organic cause Migraine headache/throbbing vascular headache-periodic attacks of headache due to vascular disturbance
  

Affect 10% of Americans Begin in childhood or adolescence & recur throughout adulthood Tend to run in families w/c are common in women than men

4.

Tension headache-the most common type- due to muscle tension

CAUSES OF HEADACHE
Emotional stress or fatigue  Menstruation  Environmental stimuli (crowds, noise, bright lights)  Glaucoma  Inflammation of the eyes or nasal/paranasal sinus mucosa  Disease of the scalp, teeth, external/middle ear  Vasodilators (nitrates, alcohol, histamine)  Systemic disease  HPN  Head trauma/tumor  Intracranial bleeding


headache



Migraine-unilateral pulsating pain w/c become more

generalized overtime lasting up to 2days
Stages of migraine

1. 2.

3. 4.

Prodrome stage symptom indicating the onset Aura phase a sensation that forewarns of an attack - Usually affects the patient s eyesight with brilliant flickering lights or blurring of vision, but may also result from numbness or weakness of limbs Headache Recovery phase

OTHER TYPES OF HEADACHE

HEADACHE


Muscular contraction & tractioninflammatory vascular headache

Dull, persistent ache or severe, unrelenting pain  Tender spots on the head & neck  Feeling of tightness around the head with a characteristic hatband distribution


HEADACHE


INTRACRANIAL BLEEDING
Neuro deficits, such as paresthesia & muscle weakness  Unrelieved by opiods


HEADACHE


TUMOR


Pain that s most severe when the patient is awake

headache
Nursing Interventions  1. Avoid precipitating factors  2. modify lifestyle  3. relieve pain by pharmacologic measures
 

Beta-blockers Serotonin antagonists- triptan"

Autonomic Dysreflexia/hyperreflexia

Seen commonly in spinal cord injury  An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation


Autonomic Dysreflexia/hyperreflexia

SKELETAL SPINE

Autonomic Dysreflexia/hyperreflexia
     

Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion

Autonomic Dysreflexia/hyperreflexia
NURSING INTERVENTIONS  1. Elevate the head of the bed immediately  2. Check for bladder distention and empty bladder with urinary catheter  3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer  4. Administer antihypertensive medications- usually hydralazine

Spinal Shock
Pathophysiology  The sudden depression of reflex activity in the spinal cord below the level of injury  The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions

Spinal Shock
  

Nursing Interventions 1. Assist in chest physical therapy 2. Manage potential complication- DVT

Cognitive Impairment
Nursing Interventions 1. Assist or encourage the patient to use eyeglass, hearing aid or assistive devices 2. Reorient the patient by calling his name frequently 3. Provide background information as to date, time, place, environment

Cognitive Impairment
Nursing Interventions 4. Use large signs as visual cues 5. Post patient's photo on the door 6. Encourage family members to bring personal articles and place them in the same area

Bowel and Bladder incontinence

 

Establish a regular pattern for bowel care Maintain a dietary intake. Avoid foods that can cause excessive gas production

CONGENITAL DISORDERS: Hydrocephalus



 

Excessive CSF accumulation in the brain s ventricular system leading to their enlargement and swelling In infants- head enlarges In children and adults- brain compression

CONGENITAL DISORDERS: Hydrocephalus



Non-communicating hydrocephalus results from CSF outflow obstruction Communicating hydrocephalus results from faulty absorption or increased CSF production

CONGENITAL DISORDERS: Hydrocephalus

    

Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes or setting sun; sclera is above the iris; depressed eyes

CONGENITAL DISORDERS: Hydrocephalus

  

DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography x ray exam of the ventricles of the brain after the introduction of the introduction of the contrast medium, such as air or radiopaque material; has been replaced by ct scan & MRI

CONGENITAL DISORDERS: Hydrocephalus



GOAL OF Treatment: to minimize & prevent brain damage by improving CSF flow

Nursing Intervention  1. monitor neurologic status  2. teach parents to watch for signs of shunt malfunction, and periodic surgery to lengthen the shunt as child grows


hydrocephalus


Shunting-surgical intervention to primary treat hydrocephalus



It includes the direct removal of the obstruction with in the brain so as to allow CSF to bypass the obstructed area, if the obstructed cannot be removed Shunting of CSF to an outside of the brain
 

Right atrium of the heart Abdominal peritoneum

Cautery destruction by burning or removal of the parts of the ventricles that produce CSF may reduce CSF production

Traumatic brain injury

1. CONCUSSION  Involves jarring of head without tissue injury  Temporary loss of neurologic function lasting for a few minutes to hours

Traumatic brain injury

2. CONTUSION  Involves structural damage  The patient becomes unconscious for hours

Traumatic brain injury

3. Diffuse Axonal injury  Involves widespread damage to the neurons  Patient has decerebrate and decorticate posture

Traumatic brain injury

4. Intracranial hemorrhage Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery Symptoms develop rapidly

Traumatic brain injury

4. Intracranial hemorrhage Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels Symptoms usually develop slowly

Traumatic brain injury

4. Intracranial hemorrhage Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities Symptoms develop insidiously, beginning with severe headache and neurologic deficits

Traumatic brain injury

MANIFESTATIONS  1. Altered LOC  2. CSF otorrhea  3. CSF rhinorrhea  4. Racoon eyes and battle sign


HALO SIGN- blood stain surrounded by a yellowish stain

Traumatic brain injury

NURSING MANAGEMENT 1. Monitor for declining LOC- use of Glasgow 2. Maintain patent airway  Elevate bed, suction prn, monitor ABG

Traumatic brain injury

NURSING MANAGEMENT 3. Monitor F and E balance  Daily weights  IVF therapy  Monitor possible development of DI and SIADH

Traumatic brain injury

4. Provide adequate nutrition 5. Prevent injury  Use padded side rails  Minimize environmental stimuli  Assess bladder  Consider the use of intermittent catheter

Traumatic brain injury

6. Maintain skin integrity  Prolonged immobility will likely cause skin breakdown  Turn patient every 2 hours  Provide skin care every 4 hours  Avoid friction and shear forces

Traumatic brain injury

7. Monitor potential complications  Increased ICP  Post-traumatic seizures  Impaired ventilation

Spinal cord injury

    

The most frequent vertebrae Concussion Contusion Compression Transection

C5-C7, T12 and L1

 is trauma to the spinal cord which results In complete (transection) or partial disruption Nerve tracts & neurons  The level of cord involved dictates the consequences of spinal cord injury  most frequently vertebrae involved are: 5th,6th, 7th cervical 12th thoracic 1st lumbar  injuries may involve contusions, laceration, Or compression of the spinal cord  majority of spinal cord injury occur from car accidents, falls or sports injuries  Risk factors: male High risk lifestyle activities Active in sports Age (teen to early 20 s) Alcohol and/or drug abuse

After an injury

Petechial hemorrhages in the Central gray matter of the cord Spinal Shock: decrease reflexes flaccid paralsis ischemia Neurogenic Shock: Sudden disruption of sympathetic nervous system Hypotension Spinal cord loses function Below the level of lesion bradycardia Hypothermia Warm/dry extremities Peripheral vasodilation that lead venous pooling Decrease cardiac output

Edema results to Permanent damage

Spinal cord injury

Clinical manifestations  1. Paraplegia  2. quadriplegia  3. spinal shock

 are classified according to cause, level of injury and degree of disruption produced

Central cord syndrome Characteristics: Motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved. Cause: Injury or edema of the central cord, usually of the cervical area.

Anterior cord syndrome Characteristics: Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact. Cause: The syndrome may be caused by acute disk herniation or hyperflexion injuries associated with fracturedislocation of vertebra. It also may occur as a result of injury to the anterior spinal artery, which supplies the anterior two-thirds of the spinal cord.

Brown-Squard syndrome (lateral cord syndrome) Characteristics: Ipsilateral paralysis or paresis, together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain & temperature. Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, fracture/ dislocation of a unilateral articular process, or possibly an acute ruptured disk.

PHARMACOLOGY

DIAGNOSTIC TESTS/LABORATORY

1. History & physical examination 2. X-rays 3. MRI 4. CT Scan 5. Electromyography

COMPLICATION

1. 2. 3. 4. 5. 6. 7. 8.

Paralysis Autonomic dysreflexia Neurogenic shock (spinal shock) Contractures Muscle atrophy Pressure ulcers Stool impaction Death

1. Glucocorticoids: Decadron 2. Vasopressors: Norepinephrine,dopamine 3. Muscle relaxants: methocarbamol 4. Anti-spasmodics:dantrolene sodium 5. Analgesics:opioid & non opioid NSAIDS 6. Antidepressants 7. Histamine H2 receptor antagonists 8. Anticoagulant 9. Stool softeners 10. vasodilators

NURSING MANAGEMENT

1. Assess/Monitor: a.Vital signs b.Neurological status c. For signs of thrombophlebitis d. For spinal shock e. For autonomic dysreflexia: hypertension,bradycardia,flushed face & neck,severe headache,nasal stuffiness, dilated pupils,Blurred vision, sweating, nausea) f. Oxygen saturation levels g. For bladder distention h. For indications of altered body image/ Self concept

2. Nursing activities: a.Maintain patent airway b. Maintain mechanical ventilation as Prescribed c. Perform passive exercises d. Encourage deep breathing exercises e. Encourage active exercises f. Maintain skin integrity g. Assist with turning as needed h. Maintain adequate fluid intake i.Teach self-catheterization j.Institute bowel retraining as needed k.Teach regarding sexual function/ dysfunction

Spinal cord injury

   

DIAGNOSTIC TEST Spinal x-ray CT scan MRI

Spinal cord injury

   

EMERGENCY MANAGEMENT A-B-C Immobilization Immediate transfer to tertiary facility

Spinal cord injury

NURSING INTERVENTION  1. Promote adequate breathing and airway clearance  2. Improve mobility and proper body alignment  3. Promote adaptation to sensory and perceptual alterations  4. Maintain skin integrity

Spinal cord injury

   

5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage complications
   

Thromboplebhitis Orthostaic hypotension Spinal shock Autonomic dysreflexia

Spinal cord injury



9. Assists with surgical reduction and stabilization of cervical vertebral column

is an umbrella term that refers to any functional abnormality of the CNS that occurs when the normal blood supply to the brain is disrupted Modifiable risk factors include:
A.Hypertension: major risk factor is the key to preventing stroke B.Cardiovascular disease: cerebral emboli may originate in the heart;atrial fibrillation, coronary artery disease, heart failure, left ventricular hypertrophy, MI, RHD C.High cholesterol levels D.Obesity E. Elevated hematocrit:increases the risk of cerebral infarction F. Diabetes mellitus G. Oral contraceptive use H. Smoking I. Drug abuse J. Excessive alcohol consumption

CEREBROVASCULAR ACCIDENTS
  

Can be divided into two major categories 1. Ischemic stroke- caused by thrombus and embolus 2. Hemorrhagic stroke- caused commonly by hypertensive bleeding

It can be divided into two major categories:

1. Ischemic: vascular occlusion and significant hypoperfusion occur;causes: are large artery thrombosis, small penetrating artery thrombosis, cardiogenic embolic, cryptogenic (no known cause)

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke



There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus

Pathophysiology of ischemic stroke

 

Disruption of blood supply Decreased ATP production leads to impaired membrane function Cellular injury and death can occur

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

Motor Loss  Hemiplegia  Hemiparesis

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

Communication loss  Dysarthria= difficulty in speaking  Aphasia= Loss of speech  Apraxia= inability to perform a previously learned action

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

Perceptual disturbances  Hemianopia Sensory loss  paresthesia

RISKS FACTORS
Non-modifiable  Advanced age  Gender  race Modifiable  Hypertension  Cardio disease  Obesity  Smoking  Diabetes mellitus  hypercholesterolemia

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

   

DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 1. Improve Mobility and prevent joint deformities  Correctly position patient to prevent contractures
  

Place pillow under axilla Hand is placed in slight supination- C Change position every 2 hours

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 2. Enhance self-care  Carry out activities on the unaffected side  Prevent unilateral neglect  Keep environment organized  Use large mirror

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 3. Manage sensory-perceptual difficulties  Approach patient on the Unaffected side  Encourage to turn the head to the affected side to compensate for visual loss

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 4. Manage dysphagia  Place food on the UNAFFECTED side  Provide smaller bolus of food  Manage tube feedings if prescribed

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 5. Help patient attain bowel and bladder control  Intermittent catheterization is done in the acute stage  Offer bedpan on a regular schedule  High fiber diet and prescribed fluid intake

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 6. Improve thought processes  Support patient and capitalize on the remaining strengths

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 7. Improve communication  Anticipate the needs of the patient  Offer support  Provide time to complete the sentence  Provide a written copy of scheduled activities  Use of communication board  Give one instruction at a time

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 8. Maintain skin integrity  Use of specialty bed  Regular turning and positioning  Keep skin dry and massage NON-reddened areas  Provide adequate nutrition

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 9. Promote continuing care  Referral to other health care providers

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

NURSING INTERVENTIONS 10. Improve family coping 11. Help patient cope with sexual dysfunction

2. Hemorrhagic: there is extravasation of blood in the brain; causes: are intracerebral hemorrhage, subarachnoid hemorrhage,cerebral aneurysm & arteriovenous malformation

CVA: Hemorrhagic Stroke



Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage

CVA: Hemorrhagic Stroke

    

Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances

 Destruction (infarction) of brain cells caused by a reduction in oxygen supply.

 Symptoms depend on the area of the brain involved and extent of damage; may be masked or delayed because of compensatory collateral circulation through the circle of Willis.

CVA: Hemorrhagic Stroke

   

DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP)

CVA: Hemorrhagic Stroke

   

NURSING INTERVENTIONS 1. Optimize cerebral tissue perfusion 2. relieve Sensory deprivation and anxiety 3. Monitor and manage potential complications

General manifestations

CEREBROVASCULAR ACCIDENTS
The stroke continuum  1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration  2. Reversible Neurologic deficits  3. Stroke in evolution  4. Completed stroke

 Classified using the time course in the following manner:

1. Transient Ischemic Attack (TIA)

 Temporary episode of neurologic dysfunction manifested by a sudden loss of motor, sensory or visual function It may last a few seconds or minutes but no longer 24 hours Complete recovery usually occurs between attacks Serve as a warning of impending stroke which has its greatest incidence in the first month after the first attack 2. Reversible Ischemic Neurologic Deficits (RIND) Signs & symptoms are consistent with but more pronounced than a TIA and last more than 24 hours Symptoms resolve in days with no permanent neurologic deficits 3. Stroke in evolution  Worsening of neurologic signs & symptoms over several minutes or hours;  This is a progressing stroke

4. Complete Stroke  Stabilization of the neurologic signs and symptoms This indicates no further progression of the hypoxic insult to the brain from this particular ischemic attack CLINICAL FINDINGS OF CVD: 1. Subjective: syncope; headache; changes in level of consciousness; transient paresthesias (with TIAs); mood swings. 2. Objective: a.Convulsions b.Hemiplegia on side opposite the lesion (initially flaccid then spastic)

COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES

Left Hemispheric Stroke Paralysis /weakness on R side of the body Right visual field deficit Aphasia (expressive,receptive, Or global) Altered intellectual ability Slow, cautious behavior Right Hemispheric Stroke Paralysis/weakness on L side of the body Left visual field deficit Spatial-perceptual deficits Increased distractibility Impulsive behavior and poor judgment Lack of awareness of deficits

CLINICAL FINDINGS OF CVD: c. Aphasia: brain unable to fulfill its communicative functions because of damage to input, integrative, or output centers. 1.Expressive (motor or Brocas) aphasia: difficulty making thoughts known to others; speaking and writing is most affected.

2. Receptive (sensory or Wernickes) aphasia: difficulty understanding what others is trying to communicate; interpretation of speech and reading is most affected.

3. Global aphasia: affects both expression and reception

CLINICAL FINDINGS OF CVD: d.Dysphagia e.Sensory changes; hemianopia (loss of half of visual field) f. Alterations in reflexes g. Altered bladder and bowel function h. CSF is bloody if cerebral or subarachnoid hemorrhage is present. i. Abnormal EEG, CT scan, MRI j.Cerebral Angiography may reveal vascular abnormalities such as aneurysms, narrowing or occlusions. k.Signs of increased intracranial pressure

THERAPEUTIC INTERVENTIONS FOR CVD: 1.Complete bed rest with sedation as needed. 2.Maintenance of oxygenation by oxygen therapy or mechanical ventilation. 3. Maintenance of nutrition by parenteral route or nasogastric feedings if the client is unable to swallow. 4. Anticoagulant therapy if thrombus or embolus is present; antiplatelet therapy. 5. Antihypertensives and anticonvulsants if indicated. 6. Glucocorticoids may be used to reduce cerebral edema and intacranial pressure.

7.Surgical intervention. a.To relieve pressure and control bleeding if hemorrhage is present. b.Carotid endarterectomy to improve cerebral blood flow when carotid arteries are narrowed by arteriosclerotic patches

NURSING CARE OF CLIENTS WITH CVD: 1. Assessment of: a.Adequacy of airway and respiratory function. b.Neurologic status c.Presence of signs of increased ICP.

2.Assist with lumbar puncture if performed; may be performed if subarachnoid hemorrhage is suspected. 3. Monitor vital signs; avoid using affected extremity for BP because it may produce falsely lowered readings. 4.Maintain patency of the airway by positioning, suctioning, and inserting an artificial airway.

5.Provide for drainage and expansion of lungs with head turned to side; provide oxygen as necessary.

6.Encouraged deep breathing; utilize mechanical ventilation if ordered.

7.Involve all members of the health team when planning care. 8. Assist client and family to set realistic goals; provide encouragement and praise.

9.Accept and explore feelings of fear, anger, and depression; accept mood swings and emotional outburst.

10.Provide frequent oral hygiene; use artificial tears if blink reflex is absent. 11.Institute seizure precautions. 12.Provide elastic or pneumatic stockings for both legs. 13.Prevent pressure ulcers. 14.Prevent muscle atrophy and contractures. a.Provide passive range- of- motion exercises; active range of motion and other exercises may be instituted later. b.Use devices to prevent footdrop, flexion of fingers, external rotation of hips, adduction of shoulders and arms.

15.Provide tube feedings if swallowing and gag reflexes are depressed or absent. 16.Provide food in a form that is easily swallowed (mechanical soft, puree, thickening products); encourage intake of nutrient- dense foods; when client is capable of chewing, introduce dietary fiber to promote normal bowel function.

17. Assist with feeding (e.g. use a padded spoon handle; feed on the unaffected side of mouth; fed in as close to a sitting position as possible)

18.Encourage the client with speech difficulties to communicate. a.Be aware of own reactions to the speech difficulty. b.Evaluate extent of the clients ability to understand and express self. a. Reinforce what has been learned in speech therapy. b. Convey that there is a problem with communication, not with intelligence, try to eliminate anxiety related to communication attempts. c. Avoid pushing to point of frustration. d. Keep distractions at a minimum, since they interfere with the reception and integration of messages. e. Speak slowly, clearly, and in short sentences, and do not raise voice. f. Use alternate means of communication. g. Involve client in a social interactions. Be alert for clues and gestures when speech is garbled.

19.Make a definite transition between tasks to prevent or reduce confusion.

20.Attempt to prevent fecal impaction and/or urinary tract problems. a.Provide adequate fluid intake. b.Provide a diet with enough roughage for sufficient quantity of bowel content and proper consistency for evacuation; avoid straining at stool because it can raise ICP; administer stool softeners as ordered. c.Avoid preoccupation with elimination; avoid encouragement of incontinence. d.Stimulate normal elimination by exercise and activity. e.Help develop regular bowel and bladder patterns. f.Respect the individual; provide for privacy and individually of routine. g.Utilize physical and psychologic techniques to stimulate elimination.

21.Create environment that keeps sensory monotony to a minimum; orient to time and place, increase social contacts, provide visual stimuli, extend environment.

22. Provide for self-esteem; encourage wearing own clothes, doing self-care activities, making decisions. 23.Help with adjustment to altered body image and self-esteem.

THANK YOU!