Chapter 66 Management of Patients With Neurologic Dysfunction

Chapter 66
Management of Patients With

Neurologic Dysfunction
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Altered Level of Consciousness (LOC)
• 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
Nursing Process: The Care of the Patient
With Altered Level of Consciousness—
Assessment
• Assess verbal response and orientation

• Alertness
• Motor responses
• Respiratory status
• Eye signs
• Reflexes
• Postures
• Glasgow Coma Scale
Decorticate Posturing Decerebrate Posturing

Question
The body temperature of an unconscious patient is never
taken by which route?
A. Axillary
B. Mouth
C. Rectal
D. Tympanic

Answer
B. Mouth
The body temperature of an unconscious patient is never

taken by mouth. Rectal or tympanic (if not
contraindicated) temperature measurement is preferred
to the less accurate axillary temperature.

Diagnoses
• Ineffective airway clearance
• Risk of injury
• Deficient fluid volume
• Impaired oral mucosa
• Risk for impaired skin integrity and impaired tissue integrity
(cornea)
• Ineffective thermoregulation
• Impaired urinary elimination and bowel incontinence
• Disturbed sensory perception
• Interrupted family processes
Collaborative Problems and Potential
Complications
• Respiratory distress or failure
• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures

Planning
• Goals may 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
Interventions
• 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
– Frequent monitoring of respiratory status, including
auscultation of lung sounds
– Positioning to promote accumulation of secretions
and prevent obstruction of upper airway—head of
bed (HOB) elevated 30 degrees; lateral or semiprone
position
– Suctioning, oral hygiene, and CPT
Maintaining Tissue Integrity
• Assess skin frequently, especially areas with high potential for
breakdown
• Frequent turning; use turning schedule
• Careful positioning in correct body alignment
• Passive ROM
• Use of splints, foam boots, trochanter rolls, and specialty beds
as needed
• Clean eyes with cotton balls moistened with saline
• Use artificial tears as prescribed
• Measures to protect eyes; use eye patches cautiously because
the cornea may contact patch
• Frequent, scrupulous oral care
Interventions
• Maintaining fluid status
– Assess fluid status by examining tissue turgor and
mucosa, laboratory test data, and I&O.
– Administer IVs, tube feedings, and fluids via feeding tube
as required; monitor ordered rate of IV fluids carefully
• Maintaining body temperature
– Adjust environment and cover patient appropriately.
– 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.
– Monitor temperature frequently and use measures to
prevent shivering.
Promoting Bowel and Bladder Function
• Assess for urinary retention and urinary incontinence
• May require indwelling or intermittent catheterization
• Bladder training program
• Assess for abdominal distention, potential constipation,
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
Sensory Stimulation and Communication
• Talk to and touch patient and encourage family to talk to
and touch the patient
• Maintain normal day–night pattern of activity
• Orient the patient frequently
• Note: When arousing from coma, a patient may
experience a period of agitation; minimize stimulation at
this time.
• Programs for sensory stimulation
• Allow family to ventilate and provide support
• Reinforce and provide and consistent information to
family
• 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

Brain With Intracranial Shifts

Question
Is the following statement true or false?
The earliest sign of increasing ICP is a change in LOC.

Answer
True
The earliest sign of increasing ICP is a change in LOC.

Slowing of speech and delay in response to verbal
suggestions are other early indicators.

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 neurologic
damage

Manifestations of Increased ICP: Early
• Refer to Chart 66-2
• Changes in LOC
• Any change in condition
– 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
Manifestations of Increased ICP: Late
• 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
– Cushing’s 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
With Increased Intracranial Pressure—
Assessment
• Frequent and ongoing neurologic assessment
• Evaluate neurologic status as completely as possible
• Glasgow Coma Scale
• Pupil checks
• Assessment of selected cranial nerves
• Frequent vital signs
• Assessment of intracranial pressure

ICP Monitoring

Intracranial Pressure Waves

Location of the Foramen of Monro for
Calibration of ICP Monitoring System

LICOX Catheter System

Diagnoses
• Ineffective airway clearance

• Ineffective breathing pattern
• Ineffective cerebral perfusion
• Deficient fluid volume related to fluid restriction
• Risk for infection related to ICP monitoring

Complications
• Brainstem herniation
• Diabetes insipidus
• SIADH
• Infection

Planning
• Major goals may include
– Maintenance of patent airway
– Normalization of respirations
– Adequate cerebral tissue perfusion
– Respirations
– Fluid balance
– Absence of infection
Interventions
• 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
• Refer to Table 66-2
Intracranial Surgery
• Craniotomy: opening of the skull
– Purposes: remove tumor, relieve elevated ICP,
evacuate a blood clot, control hemorrhage
– Refer to Table 66-3
• 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
Burr Holes

Question
What is the purpose of burr holes in neurosurgical
procedures?
A. Make a bone flap in the skull
B. Aspirate a brain abscess
C. Evacuate a hematoma
D. All of the above

Answer
D. All of the above
The purpose of burr holes in neurosurgical procedures is to

make a bone flap in the skull, aspirate a brain abscess,
and evacuate a hematoma.

Preoperative Care: Medical Management
• Preoperative diagnostic procedures may include CT scan,
MRI, angiography, or transcranial Doppler flow studies
• Medications are usually given to reduce risk of seizures
• Corticosteroids, fluid restriction, hyperosmotic agent
(mannitol), and diuretics may be used to reduce cerebral
edema
• Antibiotics may be administered to reduce potential
infection
• Diazepam may be used to alleviate anxiety

Preoperative Care: Nursing Management
• Obtain baseline neurologic assessment
• Assess patient and family understanding of and
preparation for surgery
• Provide information, reassurance, and support

Postoperative Care
• Postoperative care is aimed at detecting and reducing
cerebral edema, relieving pain, preventing seizures,
monitoring ICP, and neurologic status.
• The patient may be intubated and have arterial and
central venous lines.

Undergoing Intracranial Surgery—
Assessment
• Careful, frequent monitoring of respiratory function,
including ABGs
• Monitor VS and LOC frequently; note any potential signs
of increasing ICP
• Assess dressing and for evidence of bleeding or CSF
drainage
• Monitor for potential seizures; if seizures occur, carefully
record and report these
• Monitor for signs and symptoms of complications
• Monitor fluid status and laboratory data
Diagnoses
• Ineffective cerebral tissue perfusion
• Risk for imbalanced body temperature
• Potential for impaired gas exchange
• Disturbed sensory perception
• Body image disturbance
• Impaired communication (aphasia)
• Risk for impaired skin integrity
• Impaired physical mobility
Complications
• Increased ICP
• Bleeding and hypovolemic shock
• Fluid and electrolyte disturbances
• Infection
• Seizures

Planning
• Major goals may include
– Improved tissue perfusion
– Adequate thermoregulation
– Normal ventilation and gas exchange
– Ability to cope with sensory deprivation
– Adaptation to changes in body image

Maintaining Cerebral Perfusion
• Monitor respiratory status; even slight hypoxia or
hypercapnia can affect cerebral perfusion
• Assess VS and neurologic status every 15 minutes to
every hour
• Strategies to reduce cerebral edema; cerebral edema
peaks 24 to 36 hours
• Strategies to control factors that increase ICP
• Avoid extreme head rotation
• HOB may be flat or elevated 30 degrees according to
needs related to the surgery and surgeon preference
Interventions
• Regulating temperature
– Cover patient appropriately.
– Treat high temperature elevations vigorously; apply
ice bags, use hypothermia blanket, administer
prescribed acetaminophen.
• Improving gas exchange
– Turn and reposition every 2 hours.
– Encourage deep breathing and incentive spirometry.
– Suction or encourage coughing cautiously as needed
(suctioning and coughing increase ICP).
– Humidification of oxygen may help loosen secretions.
Interventions (cont’d)
• Sensory deprivation
– Periorbital edema may impair vision, announce
presence to avoid startling the patient; cool
compresses over eyes and elevation of HOB may be
used to reduce edema if not contraindicated.
• Enhancing self-image
– Encourage verbalization
– Encourage social interaction and social support
– Attention to grooming
– Cover head with turban and, later, a wig

Interventions (cont’d)
• Monitor I&O, weight, blood glucose, serum and urine
electrolyte levels, and osmolality and urine specific
gravity.
• Preventing infections
– Assess incision for signs of hematoma or infection.
– Assess for potential CSF leak.
– Instruct patient to avoid coughing, sneezing, or nose
blowing, which may increase the risk of CSF leakage.
– Use strict aseptic technique.
• Patient education for self-care
Question
What sign or symptom is not an indication of CSF leakage?
A. Patient complains of a salty taste in the mouth
B. Patient complains of postnasal drip
C. Clear fluid draining from nose
D. Altered LOC

Answer
D. Altered LOC
Signs and symptoms of CSF leakage that the nurse should

investigate further would include: patient complaints of
salty taste in their mouth, postnasal drip or if the nurse
observes clear fluid draining from nose or incision.
Altered LOC is a sign of increased ICP but not a sign or
symptom of CSF leakage.

Seizures
• Abnormal episodes of motor, sensory, autonomic, or
psychic activity (or a combination of these) resulting
from a sudden, abnormal, uncontrolled electrical
discharge from cerebral neurons
• Classification of seizures
– Partial seizures: begin in one part of the brain
• Simple partial: consciousness remains intact
• Complex partial: impairment of consciousness
– Generalized seizures: involve the whole brain

Specific Causes of Seizures
• Cerebrovascular disease
• Hypoxemia
• Fever (childhood)
• Head injury
• Hypertension
• Central nervous system infections
• Metabolic and toxic conditions
• Brain tumor
• Drug and alcohol withdrawal
• Allergies
Plan of Care for a Patient Experiencing a
Seizure
• Observation and documentation of patient signs and
symptoms before, during, and after seizure
• Nursing actions during seizure for patient safety and
protection
• After seizure care to prevent complications
• Refer to Chart 66-4

Headache
• Also known as cephalgia
• One of the most common physical complaints
• Primary headache has no known organic cause and
includes migraine, tension headache, and cluster
headache
• Secondary headache is a symptom with an organic cause
such as a brain tumor or aneurysm
• Headache may cause significant discomfort for the
person and can interfere with activities and lifestyle

Assessment of Headache
• A detailed description of the headache is obtained.
• Include medication history and use
• The types of headaches manifest differently in different
persons and symptoms in one individual may also may
change over time.
• Although most headaches do not indicate serious
disease, persistent headaches require investigation.
• Persons undergoing a headache evaluation require a
detailed history and physical assessment with neurologic
exam to rule out various physical and psychological
causes.
• Diagnostic testing may be used to evaluate underlying
cause if there are abnormalities on the neurologic exam.
Nursing Management of Headache: Pain
• Provide individualized care and treatment
• Prophylactic medications may be used for recurrent
migraines
• Migraines and cluster headaches requires abortive
medications instituted as soon as possible with onset
• Provide medications as prescribed
• Provide comfort measures
– Quiet, dark room
– Massage
– Local heat for tension
Nursing Management of Headache:
Education
• Help patient identify triggers and develop a preventive
strategies and lifestyle changes for headache prevention
• Medication instruction and treatment regimen
• Stress reduction techniques
• Nonpharmacologic therapies
• Follow-up care
• Encouragement of healthy lifestyle and health promotion
activities

Chapter 66 Management of Patients With Neurologic Dysfunction

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Chapter 66

Management of Patients With

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Assess verbal response and orientation

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The body temperature of an unconscious patient is never

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The earliest sign of increasing ICP is a change in LOC.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The earliest sign of increasing ICP is a change in LOC.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Ineffective airway clearance

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The purpose of burr holes in neurosurgical procedures is to

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Signs and symptoms of CSF leakage that the nurse should

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

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