Care of Clients with Problem in Inflammatory and

Immunologic Response and Perception and

Coordination

Alteration in Neural Regulation

 Etiology

 Degenerative Neurologic Disorders

 Seizure Disorders

 Disorder of consciousness

 Direct damage/trauma
• Concussions
• Contusion
• Laceration

 Increased intracranial pressure

 Intracranial Tumors

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation
 Diagnostic Procedures

 Skull Films

 Spine Films

 Computerized Axial Tomography Scan (CAT

Scan)

 Electroencephalography (EEG)

 Electromyography (EMG)

 Nerve Conduction Velocity (NCV)

 Cerebral Angiography (Arteriogram)

 Lumbar Puncture

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation
 Diagnostic Procedures

 Myelography

 Magnetic Resonance Imaging (MRI)

 Pneumoencephalography

 Ventriculography

 Positive Emission Tomography

 Single photon emission computed

tomography

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation
 Diagnostic Procedures

 Noninvasive carotid flow studies

 Transcranial Doppler

 Evoked Potentials (Auditory and Visual)

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation
 Nursing Diagnoses Taxonomy

 Ineffective airway clearance related to

upper airway obstruction by tongue and
soft tissues and inability to clear
respiratory secretions

 Potential fluid volume deficit related to

inability to ingest fluids, dehydration from
osmotic therapy

 Altered oral mucous membranes related to

mouth breathing, absence of pharyngeal
reflexes and inability to ingest fluids

 Potential impairment of skin integrity

related to immobility or restlessness

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation
 Nursing Diagnoses Taxonomy

 Impaired tissue integrity of cornea related

to diminished or absent of corneal reflex

 Potential hyperthermia related to potential

damage to hypothalmic center

 Altered urinary eliminations (incontinence

or retention ) related to unconscious state

 Altered bowel elimination (incontinence or

retnetion related to unconscious state

 Altered family process related to sudden

crisis of unconsciousness

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Alteration in Neural
Regulation
Regulation
 Pharmacologic Management

 Mannitol -an osmotic diuretic, to reduce

cerebral edema by inducing diuresis

 Lasix (furosemide)-a diuretic to reduced

cerebral edema

 Decadron (dexamethasone) -a
corticosteroid to reduce cerebral edema by
anti inflammatory effect

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Alteration in Neural
Regulation
Regulation
 Surgical Management

 Craniotomy - is the surgical opening of the

skull to gain access to intracranial
structures, remove tumors, relieve
intracranial pressure, evacuate a blood clot
or stop hemorrhage.

 Craniectomy – is the excision of a portion

of the skull

 Cranioplasty –is the repair of a cranial

defect by means of a plastic or metal
plate

 Thymectomy – is the removal of thymus

glands

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Alteration in Neural
Regulation
Regulation
 Surgical Management

 Rhizotomy- surgical severing of a nerve

root.

 Plasmapheresis – is an adjunctive therapy

for clients with refracoty

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Alteration in Neural
Regulation
Regulation
 Complications

 Intracranial bleeding and hematoma

 Cerebral edema

 Infections

 Seizures

 Cranial nerve dysfunction

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Assessment

• Mental status

- Orientation to: people, time and place

- Memory

>> Immediate recall

>> Recent memory
>> Remote memory

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Assessment
• Level of consciousness

- Level 1 : Conscious , Cognitive ,

coherent
- Level 2 : Confused, Drowsy, lethargic
obtunded, somnolent
- Level 3 : Stuporous
- Level 4 : Light coma and Deep
coma

• Glasgow Coma Scale (GCS)

- Eye opening
- Best Verbal Response
- Best Motor l Response

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

• Sensory Function
- stereognosis the ability to perceive
sensory stimuli
- agnosia - inability to perceive sensory
stimuli

• Motor function
- Apraxia - inability to perform fine
motor activities
- Agraphia - is inability to write
- Atraxia is uncoordinated movement,
characterized by wide- base stance
and swaying manner of walking
- General appearance of muscles
- Muscle power , tone and volume
- Movemen
>> Bradikinesia is slow muscle
movement not associated with
weakness
>> Akenisia is absence of muscle
movement

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management
• Motor function

- Coordination
- Station and gait

• Reflex Testing
- superficial reflexes
• Pupilliary reflex PERRLA ( pupils equal,
round, reactive to light,
accommodation)

• Corneal reflex

• Biceps reflex

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

• Triceps reflex

• Patellar reflex

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management
• Abdominal reflex
• Cremasteric reflex
• Anal reflex
• Ankle reflex

• Babinski reflex

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management
- deep tendon reflexes
- Reflexes to assess meningeal irritation
>> Kernigs Sign

>> Brudzinki’s reflex

- Oculovestibular Reflex or Caloric Ice

Water test

- Oculocephalic Reflex or Dolls eye

phenomenon

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

• Cranial Nerve testing

- I Olfactory
- II Optic
- III Oculomotor
- IV Trochlear
- V Trigeminal
- VI Abducens
- VII Facial
- VIII Acoustic
- IX Glossopharyngeal
- X Vagus Nerve
- XI Spinal Accessory
- XII Hypoglossal

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

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Regulation

 Nursing Management

• Language and Speech

• Bladder and Bowel Functioning

• Intracranial Pressure

- Restlessness
- Headache
- Vomiting
- Diplopia
- Decrease in level of consciousness
- Vital signs changes

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

• Pupillary Changes
- Aniscura
- Pinpoint pupils
- Fixed, dilated pupils
- Papilledema

• Lateralizing Signs

• Brain Stem Function Impairment

- Doll’ s Eye sign

- Decortication
- Decerebration

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management
• Brain Stem Function Impairment

- Doll’ s Eye sign

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management
• Brain Stem Function Impairment
- Decortication

Decerebration

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Managing Increased Intracranial Pressure

• Position the patient on semi-fowlers
• Adequate oxygenation
• Safety
• Rest
• Avoid factors that increase ICP
» Nausea and vomiting
» Sneezing/ coughing
» Valsalva maneuver
» Over suctioning
» Restraints
» Rectal examination
» Enema
» Flexion of waist, hip, neck (bending or
stooping)
• Control hypertension
• Restrict fluid intake to 1200 to 15000 mls/
day

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Maintaining Effective Airway

• Place the patient in semi prone position or
lateral position

• Keep airway free of secretions

– Insert oral airways if tongue is paralyzed or
is obstructing .
– Prepare for insertion of cuffed endotracheal
tube
– Employ oxygen therapy as prescribed
– Evaluate pulses (radial, carotid, apical and
pedal)

• Measure blood pressure

• Maintain circulation, support the blood

pressure and treat life threatening cardiac
dysrhythmias.

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Attaining and Maintaining Fluid balance

Electrolyte

• Monitor prescribed intravenous fluids

• Use hyperaliminentation feedings

• Initiate nasogastric feedings

• Measure urinary output and specific gravity

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Maintain Healthy Oral Mucous Membrane

• Remove dentures

• Inspect patient’s mouth for dryness,

inflammation
and presence of crusting

• Clean the mouth with prescribed solution

every 2 hours

• Apply lip emollient

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Maintaining Skin Integrity

• Keep the skin clean, dry and free of
pressure.

• Clip the patients nail to prevent

excoriation

• Turn the patient from side to side on a

regular

• Reposition carefully after turning

• Put all extremities through range of

motion exercises at least 4 times daily,

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Maintaining Corneal Integrity

• Protect the eyes from corneal irritation.

• Make sure the patient’s eye is not rubbing

against the bedding if blinking and corneal
reflexes are absent

• Prepare for temporary tarsorraphy

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Reducing Fever

• Look for possible sites of infections

• Control persistent elevations of

temperature

• Cool room to 18.3 degree Celsius.

• Remove bedding over the patient except

light sheet

• Employ cool water sponging and an electric

fan blowing over the patient to increase
surface cooling

• Consider use of hypothermia blanket if

hyperthermia is of neurogenic in origin.

• Esophageal or other core temperature is

monitored continually

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Promoting urinary elimination

• Palpate over the patient’s bladder at

interval

• Insert an indwelling urethral catheter for

short term management

• Use intermittent bladder catheterization

for retention as soon as possible

• Monitor for fever and cloudy urine, inspect

the urethral orifice for suppurative
discharge

• Initiate a bladder training program as soon

as consciousness is regained

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Promoting Bowel Function

• Observe for constipation

• Stool softener may be prescribed and given with

tube feeding

• Glycerin suppository may be prescribed

• Monitor for diarrhea

• Perform rectal examination if fecal impaction is

suspected

• Use commercial fecal collection bags and

meticulous skin care if patient has fecal
incontinence.

• Auscultate for bowel sounds, measure abdominal

girth with a tape measure to detect abdominal
distention.

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Other Nursing Interventions

• Use every sensory avenue to stimulate the
patient

• Use physical touch and reassuring voice

tone

• Encourage family to talk in a meaningful

way the patient even when he is not
responding.

• Orient patient to people, time, place and

situation

• Have adequate room lighting to prevent

hallucination as patient regain
consciousness

• Be aware of the varying phases of

restlessness
Alteration in Neural Regulation
 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Other Nursing Interventions

• Provide social contacts and environmental

enrichment

• Be aware that the patient after regaining

consciousness

• Give an explanation of what has happened

• Permit the patient to asks questions

Alteration in Neural Regulation

 Care of Clients with Problem in Inflammatory and
Immunologic Response and Perception and
Coordination

Alteration in Neural
Regulation

 Nursing Management

 Evaluation
• Maintain clear airway, cough up secretions

• Attains/maintains adequate fluid volume

status, absence of clinical signs of
dehydration

• Has intact healthy appearing oral mucous

membrane

• Absence of skin breakdown

• Absence of trauma to cornea

• Temperature within acceptable range

• Demonstrates bladder continence

• Maintaining normal bowel function

Alteration in Neural Regulation