Dr Achal Gupta

Mob: 9004858393
Consultant Brain & Endoscopic Spine Surgeon,
St Joseph’s Hospital and St Mary’s Hospital
Ex- Medanta Hospital Lucknow & Lilavati Hospital
Mumbai.
Website: neurospine.in
Goals of Nursing Care
• Maintain adequate cerebral perfusion
• Remain normothermic
• Be free from pain, discomfort, and infection
• Attain maximal cognitive, motor and sensory function
Assessment
• Monitor conscious level frequently….. GCS
• Voluntary movement- strength & asymmetry in upper extremities
• Deep Tendon Reflexes
• Pupillary Light Reflex
• Corneal Reflex
• Gag Reflex
• Swallowing Reflex
Smart Nursing Observations
• Ineffective airway clearance
• Risk for raised ICP
• Imbalanced fluid volume
• Impaired skin integrity
• Self care deficit
• Imbalanced nutrition
• Incontinence: bowel/ bladder
• Risk for aspiration
• Poor cough and swallow reflexes
• Risk for contractures
• Altered family process
Nursing care progress
• Oropharyngeal suctioning…aspirate secretions
• Hemiplegic patient: affected side to keep the uppermost
• Chest percussion and postural drainage…. For tenacious secretions
• Denture removal
• Proper neck positioning for patent airway
• Patient positioning every 2-3 hours
• Oral Hygiene 4 hourly with chlorhexidine based solution … lips coated with
water soluble lubricant
• Clean the nasal openings/ eyes with cotton
• Urine output
• Incalculable fluid loss
Ineffective cerebral tissue perfusion
• Vital charting, GCS, SpO2 and ABG
• Head elevation to 300
• Reduce agitation….may require some sedation
• Reduce cerebral edema …. May need mannitol/neurotol, steroids, 3%
saline
Progress Nursing Care
• Schedule the routine care to avoid fatigue…. Suctioning, turning,
bathing/sponging
• Talk softly and limit touch and unnecessary stimulation
• Daily weight and nutrition assessment
• Regular change of iv lines, RT and catheter
• Watch for area around iv line for any swelling
• No iv line at plegic side
• Positiong: use of pillows as required at pressure points:knee/hands
• After positioning, inspect oral cavity for possible tongue fall back
• Bed care/ hair care/ skin and nail care
Progress Nursing Care: Impaired skin integrity
• Clinical photograph daily
• Frequent back care
• Regular positioning
• Air mattress
• Use of gel pads/ avoid pressure over the area…sometimes need innovation
• Adequate nutritional and hydration status
• Close eyes at night…..refresh tear/methyl cellulose drops.. Protective eye
shields/eye taping
• Private parts care
• INVOLVE THE FAMILY IN SELF CARE NEEDS

• Incontinence, perspiration, poor nutrition, obesity and old age…

contributes to bed sore
Minimising Injury/accidents in hospital
• Side rails
• Seizure precaution
• Adequate support while mobilising patient with possible spine injury
• Judicious sedation
• Appropriate restrain
• Catheter fixation with micropore
• Diligent removal of dressings
• Avoid discussion about the prognosis of the patient/ speaking ill
about patient. “BE EMPATHETIC”
Interpretation
• 15/15- Good orientation • Presence of ET/ tracheostomy
• 3/15- Deep coma tube/ hearing defect/ speech
defect
• Best motor response
• <8: Severe Brain Injury
• 9-12: Moderate Brain Injury
• >13: Mild Brain Injury
P1
• A patient fell while rock climbing. When you apply a deep
sternal rub, he extends his arms and legs and shows no
other response.
P2
• The patient is pulseless and apneic.
P3

• A 73-year-old patient looks at spontaneously you when you

speak to her. When you ask her the date, she says "blue."
You note left-sided weakness when she grips your fingers.
P4
• A trauma patient moans, bends his arms towards his chest,
and points his toes when your partner attempt to start an IV,
but doesn’t open eyes
P5
• You are assessing a 20-year-old male suspected of
overdosing. He is staring off into space, writhing, and
babbling. When your partner starts an IV, he cries out
incomprehensibly but does not pull away.
P6
• You are transporting an altered mental status (high suspicion
inebriated) patient. When you attempt to insert a nasal
airway he opens his eyes, slaps your hand away, curses at
you but unsure where he is, and sits up. When you stop, he
lays down on the stretcher.
P7
• The patient extends their elbow when you put pressure on
the nail bed. They can talk in sentences and are
disorientated. They are unable to open their eyes.