Nursing Care: Goals and Airway/Breathing

Importance of Nursing Care - Goals

• Goals include maintaining ABCs
• Protecting from injury and infection is key
• Maintaining skin integrity is vital
• Providing eye care is necessary
• Facilitate elimination
• Regulate body temperature

Airway/Breathing Considerations

• NPO if airway/swallowing is compromised
• Position the patient properly to facilitate oral drainage
• Keep the patient's neck in a neutral position
• Limit suctioning to less than 10 seconds per pass
• Pre-oxygenate with 100% O2 before and after suctioning
• Perform Trach/ET care as needed
• Elevate the head of the bed to 30 degrees unless contraindicated
• Monitor the rate, depth, and pattern of respirations
• Observe for signs and symptoms of respiratory distress
• Auscultate breath sounds

Promoting Adequate Circulation

• Continuously monitor the patient's vital signs
• Assess for and report any dysrhythmias
• Apply elastic or compression stockings as ordered
• Monitor for signs and symptoms of deep vein thrombosis (DVT)
• Keep the head and neck in a neutral position
• Elevate the head of the bed to 30 degrees
• Avoid positions known to increase intracranial pressure (ICP)
• Avoid hip flexion and prone positions
• Refrain from clustering nursing activities
• Allow intracranial pressure (ICP) to decrease before starting another procedure
• Provide "soft" stimuli such as soft music and family voices

Addressing Disability (Neurological) Issues

• Monitor temperature, especially if elevated
• Consider potential infectious sources
• Remove excess clothing and bedding
• Administer antipyretics and other cooling interventions as ordered
• Be aware of sensory/perceptual alterations
• Provide sensory stimuli
• Talk to the patient and encourage family to touch and talk to the patient
• Turn on the TV, radio, or tape recorder when no one is in the room
• If the patient begins to awaken, use orientation instruments such as a clock, calendar, window, family pictures, and favorite objects
• Ensure a combative patient has a quiet and calm environment

Caring for the Skin and Eyes

• Provide frequent skin care to prevent breakdown
• Keep lips and skin lubricated to avoid dryness
• Monitor skin for redness and breakdown
• Keep heels off the bed to prevent pressure sores
• Turn and reposition the patient at least every 2 hours
• Maintain frequent oral hygiene to prevent infection
• Inspect eyes for signs of irritation
• Position the patient to protect eyes, using a shield or protective covering as ordered
• Instill eye drops as ordered

Musculoskeletal and Integumentary Interventions

• Provide range of motion exercises at least four times a day (QID)
• Be careful with range of motion due to the risk of increased intracranial pressure (ICP)
• Position the patient in proper body alignment and reposition every 2 hours to prevent contractures
• Use trochanter rolls, splints, slings, pillows, and foot positioners as appropriate
• Collaborate with physical therapy to optimize the patient's physical function
• Do not pull or tug on joints
• Use a draw sheet to reposition the patient in bed
• Care for the Family

Caring for the Patient's Family

• Recognize and address the crisis state the family is experiencing
• Acknowledge their anxiety, denial, fear, and anticipatory grieving
• Involve them in decision-making and care to empower them
• Find a spokesperson to serve as a liaison; it is helpful to have someone acting as a point of contat
• Provide support groups that they can attend
• Offer religious support if appropriate
• Discuss and deal with the possibility of a poor outcome

Gastrointestinal and Genitourinary Management

• Monitor intake and output to track fluid balance
• If the patient has an indwelling catheter, maintain its patency and monitor for infection
• Use strict aseptic technique when handling catheters
• Remove indwelling catheters as soon as possible to reduce infection risk
• Consider intermittent catheterization to promote bladder function where appropriate
• Provide peri care to maintain hygiene and prevent infection
• Monitor and record the character and frequency of bowel movements to assess bowel function
• Auscultate for bowel sounds to assess gut activity
• Initiate a bowel program to manage constipation or incontinence.

Nutrition and Hydration

• Monitor the patient's weight, intake, and output to track nutritional status
• Initiate early nutrition to support healing
• Request a dietary consult to address nutritional needs
• Collaborate with a dietician
• Count calories to ensure adequate intake, and be aware of requirements
• Address any fluid volume deficit
• Maintain accurate intake and output records to track fluid balance
• Assess skin turgor and mucous membranes and monitor vital signs
• Assess urine specific gravity and serum osmolarity to evaluate hydration status
• Provide hydration as ordered by the physician
• Possible Complications

Potential Complications and Interventions

• Pneumonia: Provide oral care, follow VAP protocol, and ensure hand hygiene
• Aspiration: Position patient in high Fowler's, order appropriate diet, ensure suction is available, assess cough, swallow, and gag reflexes
• Infection: Monitor and care for skin, lines, drains, tubes, and central lines; prevent UTI and VAP; address skin breakdown and sepsis
• Respiratory Failure: requires close monitoring and intervention
• Contractures: Implement range of motion exercises and early mobility.
• Pressure ulcers: Reposition and rotate the patient as ordered to prevent pressure ulcers
• Metabolic: Be aware of hormonal shifts and ADH alterations from increased intracranial pressure (ICP): SIADH (urine output decreases) and DI (excessive urination/thirst)

Caring for Patients with Complex Neurological Disorders

• Apply the ABCD (Airway, Breathing, Circulation, Disability) approach
• Establish a baseline to assess changes
• Perform a focused assessment, including:
• Level of consciousness
• Motor function
• Pupillary function
• Respiratory function
• Vital signs

Stages of Consciousness

• Consciousness is not a disorder but a manifestation of one
• Alert - Pt is awake and responsive
• Confused - Pt has diminished alertness, disorientation, memory disruptions, impaired thinking, and malfunctions in awareness and thinking
• Somnolent - Pt is sleepy
• Lethargic - Pt is very drowsy and falls asleep in between care
• Stuporous - Pt is difficult to arose

Additional Info

• Decorticate (abnormal flexion) indicates a change/damage to the cerebral hemisphere, internal capsule, and thalamus
• Decerebrate indicates damage to the brainstem
• Consciousness, pupils, motor / verbal response, and eye opening response are measured on a continuum for assessment

Assessments and Diagnostics

• Assessments include a head-to-toe assessment, complete neurological exam, and Glasgow Coma Scale (GCS) score
• Diagnostic tests: CT scan, MRI, EEG (electroencephalogram), CBC (complete blood count), CMP (comprehensive metabolic panel), liver function tests, ammonia levels, ABGs (arterial blood gases), and drug screen
• Priority
• ABCs

GCS Scale

• Eye Opening Response
• Spontaneous - 4 points
• To verbal command - 3 points
• To pain only - 2 points
• No Response - 1 point
• Verbal Response
• Oriented – 5 points
• Confused, but able to answer questions - 4 points
• Inappropriate words - 3 points
• Sounds but no words - 2 points
• No Response - 1 point
• Motor Response
• Obeys Commands - 6 points
• Localizes to pain - 5 points
• Withdraws to pain - 4 points
• Flexion (decorticate) - 3 points
• Extension (decerebrate) - 2 points
• No Response - 1 point
• Intubation renders GCS inaccurate, "T" to indicate intubation

Assessing Motor Function

• Equal strength (can lift arm independently) & has control of movement
• Evaluate muscle size and tone
• Inspect size and shape
• Eval opposition
• Tone: tension in relaxed muscle/ resistance during passive stretching: rigid, spastic, hypertonia, hypotonia or flaccid
• Hypertonia: ↑ muscle tone
• Hypotonia: ↓ muscle tone

Estimating Muscle Strength: Grading Scale

• 0/5: no movement or muscle contraction
• 1/5: trace contraction
• 2/5: active movement with gravity eliminated
• 3/5: active movement against gravity
• 4/5: active movement with some resistance
• 5/5: active movement with full resistance

Assessing Pupillary Function

• Evaluates damage and pressure
• A hallmark sign of severe neurologic injury is a change in pupil size and reactivity
• Documented in mm using CN III
• Anisocoria is unequal pupils
• Assess size and shape

Assessing Pupillary and Respiratory Reflexes

• Certain medications, surgeries, can affect pupillary size/shape/reactivity
• Shape
• Use a pupillometer
• Pupils fixed/dilated, brain death
• Evaluate direct and consensual response to light
• Cranial Nerves II and III
• Pupillary Reflexes
• Brisk/Sluggish/Fixed response
• Assess Extra-ocular movements-Size cardinal fields
• CN III, IV, VI can only be performed in stable C-spine
• Oculocephalic Reflex (Doll's Eyes)
• Positive reflex: eyes move opposite of head rotation
• Negative reflex: eyes stay midline with head rotation
• Nystagmus: irregular shaking of eyes

Considerations for Respiratory Function

• Pattern controlled by brain stem (regular)
• Maintain patent airway
• Impaired cough/gag/swallow reflexes

Observing Respiratory Patterns

• Observe for irregular patterns - may indicate neurological injury
• Input from cerebrum and brainstem work together
• Changes indicate level of brainstem injury
• Aspiration can occur
• Keep pt NPO and position for secretions

Nursing Interventions for Breathing

• Medulla oblongata regulates breathing/HR/BP
• Trend ABGs
• Hypoxia and hypercapnia can cause ↑ICP
• CO2 is a vasodilator, hypoxia damages tissue + ↑ inflammation
• Airway is the priority! Check cough, gag & swallow reflexes

Recognizing Late Signs of Increased Intracranial Pressure (ICP)

• Caused by a decrease in cerebral blood flow:
• Increased blood pressure
• Loss of cerebral autoregulation
• Increased systolic blood pressure
• Widening pulse pressure
• Decreased heart rate
• Pressure on lower brainstem causes bradycardia and Cushing response
• Cushing Triad
• Late Indicator of Increased ICP

Managing Increased ICP

• Decreasing cerebral perfusion pressure (CPP) or O2 to the brain causes brain ischemia
• Brain activates sympathetic nervous system to compensate, increasing ↑BP and initially ↑ HR
• ↑BP signals carotid and aortic baroreceptors to activate the parasympathetic nervous system and slowing HR
• Brainstem may dysfunction and cause irregular respirations with ceased breathing, indicating a worsening prognosis
• High pulse pressure increases risk for heart disease, dysrhythmias, and stroke

Brain Facts and Cerebrovascular Function

• Functions
• Controls breathing and cardiac output
• Cerebral blood flow: ~750-800 mL/min (15-20% of cardiac output)
• Autoregulation
• Brain maintains constant BF despite changes in arterial pressure
• Limited parameters
• MAP: 50-150 mmHg
• ICP: <40 mmHg

Cerebral Perfusion Pressure

• CPP = MAP - ICP, normal range = 70-100 mmHg
• Altered states require
• Inadequate: brain tissue ischemia → brain cell death
• High MAP use nitrates
• Low MAP use fluids/ pressors
• EVD drains CSF to relieve pressure

Monitoring Brain Oxygenation

• Jugular Venous Oxygen Saturation (SjO2): fiberoptic cable gives continuous reads
• Normal range = 55-75%
• Partial Pressure of Brain Tissue Oxygen (PbtO2)
• Place probe >10 mmHg monitors consumption CPP <30 mmHg = incompatible with life

Monro-Kellie Hypothesis

• Skull's rigid-filled non-compressible contents - brain, blood, CSF If one ↑. others ↓ to equilibrium otherwise, ↑ ICP Skull cannot expand→ fixed component

Diagnostics

• CT SCAN: donut shaped open both sides, assess for allergies
• MRI/MRA: safety checklist; enclosed space
• Claustrophobia
• PET Measures the blood flow Signs of ICP
• Change in
• Level of Consciousness- earliest sign
• Vision
• HA. vomiting

ICP Management Guidelines

• Positioning, maintain neutral alignment
• Monitor airway
• Limit stimulus

Increased Intracranial Pressure (ICP)

• Potentially life-threatening
• Stuporous to comatose
• Early Sign
• Change in LOC (earliest sign)
• Pupillary changes (CN III effected)
• Vision / extra-ocular movement impairment (CN II, III, IV, VI effected)
• Motor function impairment
• Headache, vomiting
• Late Sign:
• Cushing's Triad (systolic HTN with widened pulse pressure, bradycardia, respiratory change) Charts 61-1 and 62-2 have info on the detection and medical management

Care of the Patient With Increased ICP

• Still needs editing
• Airway: manage airway
• Perfusion: optimize perfusion or flow Monitor for complications:
• Rebleed
• Monitor pt

Common traits to TBI

• Can be fatal
• Serious and it's life threatening.
• Causes by sever trauma

Assessing TBI

• The location and s/s will affect how TBI.
• physical,GCS, Neuro exam.
• Assess LOC

What to do

• Get a great basline of pt
• Follow ACLS because everything is related

Diagnosing TBI quickly

• What's the best tool
• CT Scan

TBI

#1 goals

1. Decrease Intercranial pressure
2. Adequate blood flow, and 02

TBI type

• Primary- brain matter has direct trauma
• Skull fracture, blood vessel tears the bleeding and swelling
• Head inury

TBI Secondary

• Evolves over time hrs/ days
• glucose o2 inadequate can cause
• Biochemical changes inside the brain = can cause hemmorages in the brain and hypoxia

What a nurse can treat for tBI

What's the TBI

1. Mild
2. Severe

Mild TBI treatment

• Change of behavior not as bad has some speech

Severe TBI

• Loss change of all of your abilities perlla

Nursing Care

• Prevent another injury and watch there activitys

Skull Fractures

• Linear
• Depresswd : skull is down warfs
• Compound ; skin open direct path of the brain -Comminuted : bone fragment in skull
• basilar skull fracture; high risk infect high risk head injuries

What s/s to moniter in T6

• Is this a real
• High fever is it Meningitis

Top Priority SCI

• stabilize spine with C/spjne and traction,
• manage infection

SCI Autonomic Dysrefleia

Autonomic Dysrefleia

• what will yo
• SBP sky high and low other side

TIA how does a person get it

• Atributes is there can't get to a place

How dose a person get SCI -

1. Spinal fusion and rods