6. 1- Neurologic Dysfunction. (1).pptx

Management of Patients with Neurologic - Altered Level ofDysfunction Consciousness - Increase Intracranial Pressure (ICP)  Neurologic Dysfunction Objectives:  Review the anatomy & physiology of the nervous system  Identify the diagnostic tests used...

Management of Patients with Neurologic - Altered Level ofDysfunction Consciousness - Increase Intracranial Pressure (ICP)  Neurologic Dysfunction Objectives:  Review the anatomy & physiology of the nervous system  Identify the diagnostic tests used to determine neurologic disorders.  Describe the multiple needs of the patients with altered level of consciousness, increased intracranial pressure, & seizures in terms of their clinical manifestation, complications & medical and nursing management.  Use the nursing process as a framework for care of patient with neurologic disorders. 2  Neurologic Dysfunction  The nervous system consists of two division: 1- The Central Nervous System (CNS): Brain Spinal Cord 2- The Peripheral Nervous System  Cranial Nerve  Spinal Nerve  Autonomic and Somatic Systems  The Function of the Nervous System is to Control all Motor, Sensory, Autonomic, Cognitive & Behavioral Activities. 3  Autonomic Nervous System The autonomic nervous system regulates involuntary body functions. Its function is to regulates activities of internal organs and to maintain and restore internal homeostasis.  Sympathetic Nervous System – “Fight or Flight” responses – Main neurotransmitter is Norepinephrine  Parasympathetic Nervous System – Controls mostly visceral functions Regulated by centers in the spinal cord, brainstem, and hypothalamus. Neurologic Assessment: Health History Pain and Seizures Dizziness (abnormal sensation of imbalance or movement ,feeling of falling) and Vertigo (illusion of movement, usually rotation, spinning sensation) Visual disturbances Weakness Abnormal sensations Decorticate Posture (adduction & flexion of upper extremities, internal rotation of legs, planter & feet flexion). Indicates damage to the brain & corticospinal tract. Decerebrate Posture (extension & internal rotation of the arms, planter flexion of the feet). Indicates a severe injury to the brain at the level of the brainstem.  Neurologic Assessment Decorticate Posturing Decerebrate Posturing Diagnostic Tests Of Neurologic Dysfunction  Computed Tomography Scanning (CT)  Magnetic Resonance Imaging (MRI)  Positron Emission Tomography (PET)  Cerebral Angiography  Myelography (X- ray of spinal subarachnoid space)  Electroencephlography (EEG)  Lumbar Puncture (LP)  Cerebrospinal Fluid Analysis (CSF)  Nerve conduction studies  Neurologic physical examination 7 Diagnostic Test Of Neurologic Dysfunction 8  Altered Level of Consciousness (LOC) LOC is a continuum from normal alertness and full cognition (consciousness) to coma. Altered LOC is not a disorder but the result of a pathology. Coma: unconsciousness, unarousable, unresponsiveness. Unconscious state in which the Patient is unaware of self or the environment & unresponsive to verbal or painful stimuli. This occurs with many primary diseases. The Patient depends on the nurse for maintenance of all basic human needs, nourishment, bathing, elimination, respiration, prevention of complications and assessment and provision of care for problems. The cause may be neurologic (Head injury, Stroke), 9 toxicologic, or metabolic.   Etiology / Cause Head and Neck Trauma Meningitis Encephalitis Drug Overdose Toxic Exposure Diabetic Ketoacidosis Insulin Shock Liver Failure & Renal Failure (Uremia) Cardiac Arrest Cerebrovascular Accident (CVA) 10  Assessment & Diagnostic Findings Unresponsive to voice and pain. Dilated or pinpoint pupils. Fixed pupils (no response to light). Involuntary movements. Flaccidity or rigidity of muscles. Depressed or hyperactive reflexes. Decerebrate or Decorticate posturing. Hyperthermia. Glasgow Coma Score < 8. Odor of Acetone on breath. Behavioral changes (Restlessness & Anxiety). 11 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 Nursing Process: The Care of the Patient With Altered Level of Consciousness—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  Nursing Diagnosis  Altered Tissue Perfusion  Risk of Infection r/t immobility , invasive monitoring devices and lines, and compromised immune system.  Altered Nutrition: less than body requirements r/t hypermetabolism and inability to ingest food and fluids as manifested by inability to feed self , metabolic needs in excess of intake & weight loss. 14  Complications for Altered LOC Respiratory distress or failure  Pneumonia  Aspiration  Pressure ulcers Sepsis Deep Vein Thrombosis (DVT) Contractures  Disturbed gastrointestinal function 15 Nursing Process: The Care of the Patient With Altered Level of Consciousness—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 Clear Airway Frequent monitoring of respiratory status, including auscultation of lung sounds. Ensure patent airway. 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. Administer Oxygen via nasal cannula or non- rebreathing mask.  Maintaining Tissue Integrity Assess skin frequently, especially areas with high potential for breakdown. Frequent turning; use turning schedule every 2 hours. 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.  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  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. Speak to Patient, use proper name, introduce self, explain all care. 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 & provide consistent information to family. Referral to support groups and services for family.  Increased Intracranial Pressure (ICP)  Cranial Cavity Contained:  Brain Tissue (1.400 g)  Blood (75 ml)  CSF (75 ml) The volume & pressure of these 3 components produce ICP. Fluid accumulation or a lesion takes up space in the cranial cavity, producing ICP: the brain is gradually compressed, may lead to cessation of life-sustaining functions: may be sudden or progress slowly.  Normal ICP is below 15 mm Hg mean pressure 22  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 CO 2 results in vasoconstriction, and increased CO2 results in vasodilatation. Brain With Intracranial Shifts  ICP and CPP CPP (Cerebral Perfusion Pressure) is closely linked to ICP. CPP = MAP (Mean Arterial Pressure) – ICP Normal CCP/CPP is 70 to 100. A CCP/CPP of less than 50 results in permanent neurologic damage. Increased Intracranial Pressure (ICP)  ICP Causes:  Head Injury  Tumors  Subarachnoid Hemorrhage  Hematoma  Edema from trauma  Viral Encephalopathy  Increased ICP from any cause: decrease cerebral perfusion, edema, & shifts brain tissue through openings in the rigid dura (Herniation). 26  Manifestations of Increased ICP: Early Changes in LOC Slowing of speech and delay in response to verbal suggestions. Any change in condition (Restlessness, confusion, increasing drowsiness, increased respiratory effort, purposeless movements). Pupillary Changes (Diminished pupils’ response to light (fixed), unequal pupil size, & dilated pupils) 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.  Management of Increased ICP  Depends on cause  Patient requires invasive monitoring of ICP (intraventricular, subarachnoid, epidural, or intraparenchymal) ICP Monitoring 29  Increased ICP Management  Craniotomy  Surgical drainage of hematoma, or CSF drainage (ventricular; continuous or intermittent) or Lumbar (intrathecal). 30  Increased ICP Management  Restricting Fluids  Controlling Fever  Maintaining Systemic BP  Oxygenation  Medications Osmotic Diuretics: Mannitol & Dexamethasone GI ulcer prophylactics such as Tagamet. Anticonvulsants. 31 Nursing Process: The Care of the Patient 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). Nursing Process: The Care of the Patient With Increased Intracranial Pressure—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 of Increased ICP  Brain stem herniation  Diabetes insipidus  Syndrome of inappropriate antidiuretic hormones (SIADH)  Infection 34 Nursing Process: The Care of the Patient With Increased Intracranial Pressure—Planning  Major goals may include Maintenance of patent airway Normalization of respirations Adequate cerebral tissue perfusion Respirations Fluid balance Absence of infection Absence of complications  Interventions Frequent monitoring of respiratory status and lung sounds. Maintain patent airway- O2 (PaO2 at 100 Hg or greater), suction secretions with care (not last longer than 15 seconds). Coughing is discouraged. Prevent aspiration. Intubation and controlled ventilation to PaCo2 of 30 to 35 mmHg. Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage. Never place in Trendelenburg position. Use of a cervical collar promotes venous drainage and prevents jugular vein distortion.  Increased ICP - Nursing Interventions Avoid hip flexion, extreme rotation of the neck and flexion of the neck, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP. V/S and Neuro checks q15 minutes, systolic arterial pressures must be between 100 to 160 mm Hg. 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. 37  Increased ICP - Nursing Interventions Observe pupillary response ( usually unequal and may not react to light). Report changes in LOC immediately. Seizure precautions. Provide care for Coma Patient, especially if on ventilator to hyperventilate. NPO or fluid limited by doctor order. 38