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Neurology

Neurology. Management of Patients with Neurological Dysfunction Chapter 61. Nursing management. Ineffective airway clearance r/t alt. LOC HOB h Lateral/semi-prone Suctioning Hyper-oxygenate Chest physiotherapy Postural drainage Auscultate Intubation Mech. vent. Nursing management.

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Neurology

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  1. Neurology Management of Patients with Neurological Dysfunction Chapter 61

  2. Nursing management • Ineffective airway clearance r/t alt. LOC • HOB h • Lateral/semi-prone • Suctioning • Hyper-oxygenate • Chest physiotherapy • Postural drainage • Auscultate • Intubation • Mech. vent

  3. Nursing management • Risk of injury r/t i LOC • Padded side-rails • Lines & equipment • Restraints • Dignity • Privacy • Speak to pt

  4. Nursing management • Deficient fluid volume r/t NPO • P Skin turgor • P Mucous membranes • I&O • P labs

  5. Question? • Which of the following lab values is most useful in assessing dehydration? • K+ • Na+ • Hematocrit • BUN • Urine specific gravity

  6. Question? • What affect does dehydration have on a pt BUN level? • Increase • Decrease

  7. Question? • What affect does dehydration have on a pt. Hematocrit level? • Increase • Decrease

  8. Nursing management • Impaired oral mucous membranes r/t mouth breathing etc. • P for dryness, inflammation, crusting • Oral care q8h • Lips • Move endotracheal tube each day (rt–lf–rt)

  9. Nursing management • Alt. in nutrition, less than body requires • NGT/GT • HOB h

  10. Question? • Mrs. Jones has an NGT and has 2 medication that need to be given at 12:00 pm. Can the nurse crush the meds and give them at the same time? • Yes • No • Each med is given separate and flush with 20-30 ml of water after each dose

  11. Question? • How do you measure for NGT tube placement? • From the tip of the nose  ear lobe  xyphoid process • From the tip of the nose  ear lobe  xyphoid process + 6 inches • From the ear lobe  tip of the nose  xyphoid process • From the ear lobe  tip of the nose  xyphoid process + 6 inches

  12. Question? • What is the most effective way to check NGT placement? • Inject 20 cc of air and listen for gurgle • Aspirate stomach contents • X-ray

  13. Question? • Mrs. Nop had an NGT placed 7 days ago and is tolerating feeding well. You are assigned to give her a 250 bolus feeding of Ensure. How should you make sure the NGT is in the stomach and not the lung? • Inject 20 cc of air and listen for gurgle • Aspirate stomach contents • X-ray • None of the above are necessary

  14. Nursing management • Risk for impaired skin integrity r/t immobility • Reg. turning • X drag • ROM • Splints • Foam boats • Beds

  15. Nursing management • Impaired tissue integrity of cornea r/t I corneal reflex • Clean • Cotton-ball & normal saline • Cold compress • i edema post-op • Eye patch warning!

  16. Nursing management • Ineffective thermoregulation r/t damage to hypothalamic center • Minimal bedding • Anti-pyretic • Cool sponge bath • Fan • Hypothermic blanket

  17. Nursing management • Impaired urinary elimination (incontinence or retention) • Scan bladder • Retention  Foley • P S&S of infection • Fever • Cloudy urine

  18. Nursing management • Bowel incontinence • Bowel sounds • Abd girth • Monitor BM • Frequency • Consistency

  19. Nursing management • Disturbed sensory perception • Touch • Talk • Orient • Familiar sounds (tape player) • Favorite TV/radio • When arousing from coma  • i stimuli

  20. Nursing management • Interrupted family processes r/t health crisis • Grief process

  21. What’s your advice? • While assessing the patency of a central line for an unresponsive, terminally ill patient, I was startled when the patients wife said to me, “this isn’t how it was suppose to be. He’s just a year away from retirement, and we had wonderful plans to travel across the country.” I didn’t know what to say except, “I’m sorry.” I’d like to do better if this situation come up again. What should I have said?

  22. Small Group Questions • What is the priority nrs dx for a patient with alt. LOC? • Describe cerebral blood flow during suctioning. • How can a nrs best assess for dehydration? • Give 5 nrs interventions for a patient at risk for injury & for impaired joint and skin integrity.

  23. Increased Intracranial Pressure • Rigid vault • Contains 3 components • Brain tissue • Blood • CSF • Normal ICP 10-20 mmHg

  24. I-ICP • Minor changes in ICP • Straining • Coughing • Sneezing • Posture • BP

  25. I-ICP • Etiology of I-ICP • Head injury • Stroke • Inflammatory process • Intra-Cranial surgery

  26. I-ICP • I-ICP Cycle • I-ICP  • i cerebral perfusion  • Ischemia  • Further edema  • Herniation (shift brain tissue)  • Deathmosis

  27. I-ICP • h PaCO2  • Cerebral vasodilatation  • h cerebral blood flow  • h-ICP • i PaCO2  • Cerebral vasoconstriction  • i cerebral blood flow  • i-ICP

  28. I-ICP • Cerebral edema • Abn. h of fluid  • h brain tissue volume  • I-ICP

  29. I-ICP • Compensation • Bodies attempt to i ICP • Cushing’s response • Widening PP • Bradycardia • Decompensation • Ischemia • Infarction

  30. What is the earliest S&S of I-ICP? • Hyporeflexia • Paresethesia • Visual distrubance • Altered level of consciousness • Motor slowing • Pupils fixed

  31. I-ICP • Early S&S • #1 Alt LOC • h restlessness or confusion • H/A • Pupillary changes • Weakness on one side

  32. I-ICP • Late S&S • Stupor  coma • Pulse & Resp • i • Erratic (Cheyne-stoke, ataxic, Biot’s) • BP & Temp • h • Projectile vomiting

  33. I-ICP • Late S&S • Decorticated posturing • Decerebrate posturing • Loss of protective reflexes

  34. Where did it go? • What goes first? • Orientation to time • Orientation to person • Response to verbal stimuli • Response to painful stimuli • Protective reflexes

  35. I-ICP • Ominous sign! • Grave sign!

  36. Complications of I-ICP • Herniation • Diabetes Insipidus • SIADH

  37. I-ICP Dx / Assessment • CT • MRI

  38. I-ICP Management • Monitor ICP • Ventricular catheter • Sub-arachnoid screw

  39. 3 goals of I-ICP management • i edema • i CSF volume • i Cerebral blood volume

  40. I-ICP management • Decrease Edema • Osmotic diuretic • Mannitol/Osmitrol • I&O • Indwelling catheter • P via serum osmolality

  41. I-ICP management • Decrease edema • Corticosteroids • Dexamethasone /Decadrone • S/E • Hyperglycemia • GI bleed • Give with • Antacids / Tums • Histamine H2 receptor blockers / Tagamet (cimetidine)

  42. I-ICP management • Decreasing edema • Fluids • i • HOB • h • Body temperature • Lower • i cerebral edema • i metabolism

  43. I-ICP management • Decreasing CSF • Drain CSF • Via lumbar puncture • Not too much  • Ventricles collapse

  44. I-ICP management • Decrease cerebral blood flow • O2 • Hyperventilate  • Vasoconstriction • Hgb levels • Control fever • Anti-pyretics • Cooling blanket • X shivering  I-ICP

  45. I-ICP management • Decrease cerebral blood flow • Decrease metabolic demand • Induce coma • Phenobarbital • Paralyzing agents • Monitor cardiac • Vent • Monitor ICP • monitor Arterial pressure • Monitor serum barbituate levels

  46. I-ICP management • Decrease cerebral blood flow • Decrease metabolic demand • Prevent Seizures • Phenytoin / Dilantin • Diazepam / valium • Monitor serum levels • Prevent infections • Control BP

  47. I-ICP Nursing Management • Maintain patent airway • Optimizing cerebral tissue perfusion • Position • HOB h • Head neutral position • Avoid extreme hip flexion • X valsalva maneuver  I-ICP • Stool softeners • X emena • Suctioning

  48. I-ICP Nursing Management • Optimizing cerebral tissue perfusion • Calm atmosphere • Space nursing tasks • Minimal stimuli • Monitor ICP

  49. Intracranial surgery • Craniotomy: • Opening the skull surgically to gain access to intracranial structures

  50. Intracranial surgery • Burr hole • Circular opening made in the skull by a drill

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