Management of Neurologic Dysfunction

1. Management of Neurologic Dysfunction

2. The Neurologic System • Central nervous system controls the body’s vital functions • Relies on structural integrity for support and homeostasis • Structural disruptions (eg, stroke, tumor) • Relies on the body’s ability to maintain a homeostatic environment • Homeostatic disruptions (eg, toxins, lyte imbalance)

3. 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 • Cause may be neurologic, toxicologic or metabolic • Initial changes may be subtle

4. Nursing Process—Assessment of the Patient With Altered LOC • Verbal response and orientation • Alertness • Motor responses • Respiratory status and pattern • Eye signs • Reflexes • Postures • Glasgow Coma Scale • Eye opening, verbal and motor response

5. Glascow Coma Scale • EYE OPENING • None 1 = Even to supra-orbital pressure • To pain 2 = Pain from sternum/limb/supra-orbital pressure • To speech 3 = Non-specific response, not necessarily to command • Spontaneous 4 = Eyes open, not necessarily aware _______ • MOTOR RESPONSE • None 1 = To any pain; limbs remain flaccid • Extension 2 = Shoulder adducted and shoulder and forearm internally rotated (DECEREBRATE) • Flexor response 3 = Withdrawal response or assumption of hemiplegic posture (DECORTICATE) • Withdrawal 4 = Arm withdraws to pain, shoulder abducts • Localizes pain 5 = Arm attempts to remove supra-orbital/chest pressure • Obeys commands 6 = Follows simple commands _______ • VERBAL RESPONSE • None 1 = No verbalization of any type • Incomprehensible 2 = Moans/groans, no speech • Inappropriate 3 = Intelligible, no sustained sentences • Confused 4 = Converses but confused, disoriented • Oriented 5 = Converses and oriented________

6. Decorticate Posturing Decerebrate Posturing

7. Nursing Process—Diagnosis of the Patient With Altered Level of Consciousness • 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

8. Collaborative Problems/Potential Complications • Respiratory distress or failure • Pneumonia • Aspiration • Pressure ulcer • Deep vein thrombosis (DVT) • Contractures

9. Nursing Process—Planning the Care of the Patient With Altered LOC • Goals include: • Maintenance of clear airway (this is priority) • 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

10. Interventions • compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care; protection includes maintaining the patient’s dignity and privacy • Maintain an airway (PRIORITY) • Frequent monitoring of respiratory status including auscultation of lung sounds • Position the patient to promote accumulation of secretions and prevent obstruction of upper airway: HOB elevated 30°, lateral position • Provide suctioning, oral hygiene, and CPT • Monitor ability patient’s to maintain airway and manage secretions

11. Maintaining Tissue Integrity • Assess skin frequently, especially areas with high potential for breakdown • Turn patient frequently; use turning schedule • Carefully position patient in correct body alignment • Perform passive range of motion • Use splints, foam boots, trochanter rolls, and specialty beds as needed • Clean eyes with cotton balls moistened with saline • Implement measures to protect eyes • Provide frequent, scrupulous oral care

12. Interventions • Maintain fluid status • Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O • Administer IVs, tube feedings, and fluids via feeding tube as required: monitor ordered rate of IV fluids carefully • Maintain body temperature • Adjust environment and cover patient appropriately • If temperature is elevated, use minimum amount of bedding, administer acetaminophen, and allow fan to blow over patient to increase cooling • Monitor temperature frequently and use measures to prevent shivering

13. Promoting Bowel and Bladder Function • Assess for urinary retention and urinary incontinence • May require indwelling or intermittent catherization • Initiate 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

14. Sensory Stimulation and Communication • Talk to and touch the patient and encourage the family to talk to and touch the patient • Maintain normal day–night pattern of activity • Orient the patient frequently • A patient aroused from coma may experience a period of agitation; minimize stimulation at this time • Initiate programs for sensory stimulation • Reinforce and provide consistent information to family

15. Increased Intracranial Pressure (ICP) • Monro-Kellie hypothesis: because of limited space in the skull, an increase in any one skull component—brain tissue, blood, or 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, causes ischemia, cell death, and (further) edema

16. Increased Intracranial Pressure (cont.) • Brain tissues may shift through the dura and result in herniation • Decreased cerebral blood flow • Systemic BP rises to maintain cerebral flow • Occurs w/ low HR and irregular respiration • CO2 plays a role; decreased CO2 results in vasoconstriction, and increased CO2 results in vasodilation

17. Increased Intracranial Pressure • Cerebral Edema • Defined as an abnormal accumulation of fluid in the brain tissue • As the brain swells, body attempts to compensate for increased ICP • Autoregulation (blood vessels) • Decreased CSF production

18. Brain With Intracranial Shifts

19. ICP and CPP • CPP (cerebral perfusion pressure) is closely linked to ICP • CPP = MAP (mean arterial pressure) – ICP • Normal CPP is 60 to 100 • A CPP of less than 50 results in permanent neurolgic damage

20. Manifestations of Increased ICP—Early • Changes in level of consciousness (FIRST) • Any change in condition • Restlessness, confusion, increasing drowsiness, increased respiratory effort, and 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

21. Manifestations of Increased ICP—Late • Respiratory and vasomotor changes • VS: • Cushing’s triad: bradycardia, hypertension (with widened pulse pressure), and bradypnea • Vomiting

22. Manifestations of Increased ICP—Late(cont.) • Further deterioration of LOC; stupor to coma • Hemiplegia, decortication, decerebration, or flaccidity • Respiratory pattern alterations including Cheyne-Stokes breathing and arrest • Loss of brain stem reflexes: pupil, gag, corneal, and swallowing

23. Increased Intracranial Pressure • Diagnostic studies • CT, cerebral angiogram, MRI, direct pressure measurement (via ventriculostomy) • Complications • Inadequate cerebral perfusion • Brain stem herniation • Diabetes insipidus • SIADH

24. Increased Intracranial Pressure Collaborative Care • Monitoring ICP • Usually with ventriculostomy for ICP monitoring • Decreasing cerebral edema • Osmotic diuretics • Corticosteroids • Controlling fever • Cerebral oxygenation • Maintaining cerebral perfusion • Maintaining systemic BP and increasing CO

25. Increased Intracranial Pressure • Reducing metabolic cellular demands • Sedation (propofol most common) • Barbiturate coma • Reducing CSF and IC blood volume • Ventriculostomy - CSF drainage • Hyperventilation as short term measure only for refractory increased ICP

26. Nursing Process—Assessment of the Patient With Increased Intracranial Pressure • Conduct frequent and ongoing neurologic assessment • Evaluate neurologic status as completely as possible • Glasgow Coma Scale • Pupil checks • Assess selected cranial nerves • Take frequent vital signs • Assess intracranial pressure

27. ICP Monitoring

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

29. LICOX Catheter System

30. Nursing Process—Diagnosis of the Patient With Increased Intracranial Pressure • Ineffective tissue perfusion, cerebral • Ineffective airway clearance • Ineffective breathing pattern • Deficient fluid volume related to fluid restriction • Risk for infection related to ICP monitoring • Impaired physical mobility

31. Nursing Process—Planning for Patient With Increased Intracranial Pressure • Major goals may include: • Maintenance of patent airway • Normalization of respirations • Adequate cerebral tissue perfusion • Fluid balance • Absence of infection • Absence of complications

32. Interventions • Frequent monitoring of respiratory status, LOC, lung sounds and measure to maintain a patent airway • Position with the head in neutral position and HOB elevation 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; during acute phase, monitor I&O every hour • Use strict sterile technique for management of ICP monitoring system • Monitor for signs/symptoms of infection

33. Interventions • Monitor for early signs of increased ICP • LOC change, pupillary/EOM changes, weakness, HA • Monitor for late signs of increased ICP • LOC deteriorates, Cushing’s triad, vomiting, posturing, loss of reflexes • Monitor ICP if indicated • Monitor for secondary complications

34. Intracranial Surgery • Craniotomy: opening of the skull • Purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, and control hemorrhage • Craniectomy: excision of a portion of the skull • Burr holes: circular openings for exploration or diagnosis, to provide access to ventricles, for shunting procedures, to aspirate a hematoma or abscess, or to make a bone flap

35. Supratentorial Approach for Cranial Surgery

36. Infratentorial Approach for Cranial Surgery

37. Transsphenoidal Approach for Cranial Surgery

38. Burr Holes

39. 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 (phenytoin) • Corticosteroids, fluid restriction, hyperosmotic agents (mannitol), and diuretics may be used to reduce cerebral edema • Antibiotics may be administered to reduce potential infection • Benzodiazepine may be used to alleviate anxiety

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

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

42. Nursing Process—Assessment of the Patient Undergoing Intracranial Surgery • 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 them • Monitor for signs and symptoms of complications • Monitor fluid status and laboratory data

43. Nursing Process—Diagnosis of the Patient Undergoing Intracranial Surgery • Ineffective tissue perfusion • Disturbed sensory perception • Body image disturbance • Impaired communication (aphasia) • Risk for impaired skin integrity • Impaired physical mobility

44. Collaborative Problems/Potential Complications • Increased ICP • Bleeding and hypovolemic shock • Fluid and electrolyte disturbances • Infection • Seizures

45. Nursing Process—Planning the Care of the Patient Undergoing Intracranial Surgery • Major goals may include: • Improved cerebral tissue perfusion • Adequate thermoregulation • Normal ventilation and gas exchange • Ability to cope with sensory deprivation • Adaptation to changes in body image • Absence of complications

46. Maintaining Cerebral Perfusion • Monitor respiratory status; even slight hypoxia or hypercapnia can affect cerebral perfusion • Assess VS and neurologic status every 15 minutes to one hour • Implement strategies to reduce cerebral edema; cerebral edema peaks in 24 to 36 hours • Implement strategies to control factors that increase ICP • Avoid extreme head rotation • Head of bed may be elevated 30° according to needs related to the surgery and surgeon’s preference

47. Interventions • Regulate temperature • Cover patient appropriately • Treat high temperature elevations vigorously; apply ice bags, use hypothermia blanket, and administer prescribed acetaminophen • Improve gas exchange • Turn and reposition the patient every 2 hours • Encourage deep breathing and incentive spirometry • Suction or encourage coughing cautiously as needed (suctioning and coughing increase ICP) • Humidify oxygen to help loosen secretions

48. Interventions (cont.) • Sensory deprivation • Periorbital may impair vision, so announce your presence to avoid startling the patient; cool compresses over eyes and HOB elevation may be used to reduce edema if not contraindicated • Enhance self-image • Encourage verbalization • Encourage social interaction and social support • Pay attention to grooming • Cover head with turban

49. Interventions (cont.) • Monitor I&O, weight, blood glucose, serum, urine electrolyte levels, 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 • Monitoring for increased ICP and bleeding

50. Seizures • Uncontrolled, paroxysmal electrical discharge of neurons in the brain that disrupts normal function • Classification of seizures: see table 59-6 • 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 • Includes tonic-clonic, absence