L9.1 (std copy) - Intracranial problems GCS PDF

RND 30704 MUSCULOSKELETAL & NEUROSCIENCE NURSING NURSING NEEDS OF PATIENT WITH: Altered Level of Consciousness Glasgow Coma Scale Pn. Tuminah Sabar Altered Level of Consciousness 2  LEARNING OUTCOMES At the end of the session, the students shou...

RND 30704 MUSCULOSKELETAL & NEUROSCIENCE NURSING NURSING NEEDS OF PATIENT WITH: Altered Level of Consciousness Glasgow Coma Scale Pn. Tuminah Sabar Altered Level of Consciousness 2  LEARNING OUTCOMES At the end of the session, the students should be able to: define altered level of consciousness; describe the pathophysiology of altered level of consciousness; describe the clinical manifestations; state the diagnostic test; describe the interdisciplinary care / medical management; discuss nursing care for patients with altered level of consciousness 3  INTRODUCTION Altered level of consciousness (LOC) is present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness Alteration in level of consciousness occur along a continuum (Alert → confused → lethargic → obtunded → stupors → comatose) Coma is a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli, although nonpurposeful responses to painful stimuli and brainstem reflexes may be present 4  Pathophysiology It is a result of multiple pathophysiologic phenomena. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic or kidney injury, diabetic ketoacidosis) → cellular edema or other mechanisms, such as disruption of chemical transmission → disruption in the cells of the nervous system, neurotransmitters, or brain anatomy 5  Clinical Manifestations Decrease in alertness and consciousness Changes in the pupillary response, eye opening response, verbal response, and motor response. Restlessness or increased anxiety - initial alterations in LOC Pupils - sluggish (response is slower) As the patient becomes comatose, the pupils become fixed (no response to light) 6  Diagnostic Test CT, MRI Electroencephalography (EEG) Cerebral angiography, brain scan Transcranial doppler Lumbar puncture Serum glucose, electrolytes, Urine osmolality ABGs, liver function tests, toxicology 7  Assessment Evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. Perform GCS assessment If the patient is comatose and has localized signs such as abnormal pupillary and motor responses, it is assumed that neurologic disease is present until proven otherwise. If the patient is comatose but pupillary light reflexes are preserved, a toxic or metabolic disorder is suspected 8  Medical Management Determine Level of Involvement Level of consciousness – GCS Presence or absence of localizing neurologic manifestation - posture Pupil size & reactivity to light Deep tendon & superficial reflexes – to assess brain stem involvement Response to noxious stimuli – loud verbal → shaking → painful stimulus Evidence of trauma Blood test – if manifestation suggested metabolic disorder History 9  Medical Management…cont Interdisciplinary Care Identification of underlying cause Preservation of function Prevention of deterioration Immediate Treatment ABCs (Treatment by protocol) Maintain patency airway Airway placement & oral or nasal intubation Tracheostomy Mechanical ventilation Monitor circulatory status (BP, HR) to ensure adequate cerebral perfusion 10  Medical Management …cont Infusion of an isotonic or slightly hypertonic solution, such as normal saline or Ringer’s Lactate – if dehydration Intravenous 50% glucose - if hypoglycemia Nutritional support Tube feeding Enteral feeding with gastrostomy tube Total parenteral nutrition (TPN) 11  Medical Management …cont Medications: Insulin Furosemide (Lasix), mannitol (osmotic diuretic) – in cerebral edema Antibiotics - if suspected or confirmed meningitis Antiseizure – IV lorazepam/diazepam Steroid, barbiturate therapy & neuromuscular blocking agent – decrease ICP Naloxone – for opioid overdose 12  Surgical Management Surgery to decompress the cranial vault – if coma due to structural cause Burr-hole may required in subdural hematoma Craniotomy – to remove tumor, abscess or intracerebral hematoma Shunt – to relieve hydrocephalus 13  Potential Complications Respiratory distress or failure Pneumonia (hypostatic pneumonia) Aspiration Pressure ulcer Deep vein thrombosis (DVT) Contractures 14  Nursing Assessment Glasgow coma scale (GCS) Eyes opening Best verbal response Best motor response Neurologic examination Monitor parameters such as Respiratory function Pupillary reaction Reflexes 15  Nursing Assessment …cont A: Decorticate posturing and flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet B: Decerebrate posturing, involving extension and outward rotation of upper extremities and plantar flexion of the feet 16  Nursing Assessment … cont Onset or slowly progressive Patient & family awareness & understanding of the symptoms Ability to think, think abstractly, calculate & make everyday decision Recent history of infection, falls & other trauma Medication used – prescription, OTC drugs & alcoholism Visual changes 17  Nursing Assessment …cont All other body systems function, such as Circulation Respiration Fluid and electrolyte balance Skin integrity Elimination Laboratory results 18  Nursing Diagnosis Ineffective airway clearance related to lack of airway clearance Risk for suffocation related to loss of gag reflex Deficient fluid volume related to inability to take fluids by mouth Risk for aspiration related to loss of gag reflex Impaired oral mucous membrane related to mouth breathing Risk for disuse syndrome related lack of voluntary movement Risk for impaired skin integrity related to prolonged immobility 19  Nursing Diagnosis … cont Risk for imbalanced nutrition: Less than body requirements Ineffective thermoregulation related to damage to hypothalamic center Impaired urinary elimination related to impairment in neurologic function Bowel incontinence related to impairment in neurologic function Interrupted family process related to health crisis 20  Nursing Objectives Maintain effective breathing pattern Maintain adequate systemic blood pressure to perfuse tha brain Maintain body temperature within normal limits Safety precautions in place Consume adequate balanced nutrients Maintain regular bowel elimination maintain urinary incontinence 21  Nursing Interventions Maintain airway Initial airway management – oral airway ETT insertion with ventilator support to maintain patency of the airway/improve ventilation Elevating the head of the bed to 30 degrees to prevent aspiration Place the patient in a lateral or semiprone position to allows the jaw and tongue to fall forward & promote drainage of secretions Suction to remove secretions from the posterior pharynx and upper trachea - adequate ventilation before and after suctioning to prevent hypoxia 22  Nursing Interventions…cont Promote cerebral perfusion Maintain hydration, prevent hypovolemia Monitor effects of antihypertensive Promote adequate cardiac output & systemic blood pressure Maintain bladder incontinence Remove indwelling catheter as soon as possible Provide regular toileting to prevent urinary incontinence 23  Nursing Interventions…cont Preserving corneal integrity Eye swabbing with sterile normal saline to remove debris and discharge Instilled artificial tears every 2 hours as prescribed Cold compresses as prescribed for periorbital edema that occurs after cranial surgery Used eye patches cautiously because of the potential for corneal abrasion from contact with the patch 24  Nursing Interventions…cont Maintaining body temperature Removing all bedding over the patient (with the possible exception of a light sheet, towel, or small drape) Administering acetaminophen or ibuprofen as prescribed Giving cool sponge baths Using a hypothermia blanket Monitoring temperature frequently to assess the patient’s response to the therapy and to prevent an excessive decrease in temperature and shivering 25  Nursing Intervention…cont Risk of aspiration Monitor ABG result & SPO2 to determine the level of O2 Assess breath sound every 1-2 hours Keep suctioning equipment available Perform suctioning only as needed Suctioning with gentle & not more than 10 seconds – prevent increased ICP Observe for bradycardia & dysrhythmias secondary to hypoxia Hyperoxygenate before, during & after the procedure - reduce risk of cerebral desaturation 2 hourly turning to facilitate drainage of secretion Nutritional support – NG tube/gastrostomy feeding 26  Nursing Interventions…cont Maintain mucosal membrane Inspect patient’s mouth 8 hourly Water soluble lubricant to the lips - prevent drying, cracking & encrustation Oral care – twice a day Clean nasal passage from mucus & crust formation – do not clean for patient with a skull base fracture If on ventilator:  Comprehensive mouth care with antiseptic such as chlorhexidine  Moved the tube to the opposite side of the mouth daily to prevent ulceration of the mouth and lips 27  Nursing Interventions…cont Maintain skin integrity Provide total nursing care Turning every 2 hours – to prevent ischemic necrosis over pressure areas Place on ripple mattress 8 hourly perianal care Risk for disuse syndrome (contracture) Hand & forearm splints – prevent contracture of fingers & wrist Orthotic devices to support the feet Skin care & passive exercise 4 hourly 28  Nursing Interventions…cont Maintain nutrition IV fluid begun on admission Required complete nutritional assessment Enteral feeding Assess fluid electrolyte status Avoid overhydration – risk for cerebral edema Accurate intake & output documentation Prevent injury Raised side rails – rails are padded Implement seizure precautions as needed Provide eye care –prevent corneal damage Prevent injury from invasive lines and equipment, restrains, tight dressing 29 GLASGOW COMA SCALE (GCS) 30  Learning Outcomes At the end of the session, the students should be able to: define Glasgow Coma Scale (GCS) explain the 3 components of GCS calculate and interpret GCS score describe the: I. Pupillary assessment II. Limb movement assessment carry out the GCS assessment and documentation accurately 31  Introduction The Glasgow Coma Scale (GCS) is a common neurologic assessment for the level of consciousness (LOC) The most widely recognized as assessment tool Used to identify the trends in the patient’s overall function & predict outcomes Changes in the GCS score can indicate the deterioration or improvement of the patient’s condition Neurological assessment using the GCS will be performed by registered nurses accurately as required by the patient’s condition and doctor’s order 32  Glasgow Coma Scale Components in GCS  Eyes opening  Best verbal response  Best motor response The GCS will incorporate assessment of:  Pupillary size and response to light stimulation  Strength of upper and lower extremities  Vital signs 33  Glasgow Coma Scale Score Eyes Open Spontaneously 4 To speech 3 To pain 2 None 1 Best Verbal Orientated 5 Response Confused 4 Inappropriate Word 3 Incomprehensible sound 2 None 1 Best Motor Obey commands 6 Response Localize pain 5 Flexion to pain 4 Abnormal Flexion 3 Extension to pain 2 None 1 34  Eye Opening First approach - observe the patient’s eyes opening response without speaking to the patient  Spontaneously - score of 4  To speech - score of 3  Painful stimulation - score of 2  No response – score of 1 Damage to the oculomotor nerve (CNIII) – patients unable to open their eyes 35  Eye opening…cont Appropriate painful stimulus that can be used:  Peripheral stimuli Apply pressure to the side of finger next to the nail Nail bed pressure: press one of the patient’s fingernail bed with a pen firmly (not too hard) for 10 – 30 seconds  Central painful stimulation Squeezing the trapezius Supraorbital pressure Rubbing the sternum 36  Eye opening…cont Central painful stimulation Supraorbital pressure Apply pressure to notch on the supra-orbital margin Contraindication - patient with head injury, frontal craniotomy, or facial surgery Try to AVOID supraorbital pressure as it can cause damage to the eyes  If it is done in your institution, perform accurately & cautiously to prevent injury to patient’s eyes 37  Eye opening…cont Rubbing the sternum Usually done by the doctor Please DO NOT attempt this maneuver if you are unsure of the correct technique or no supervision by the registered qualified clinical staff Squeezing the trapezius Use the thumb & 2 fingers to grasp the trapezius muscle 38  Eye opening…cont Central stimulation tends to make patients close their eyes and grimace DO NOT pinch the patient’s body as this can cause severe bruising DO NOT twist the patient’s nipple, there are NO reference to the validity of using nipple twist as an appropriate painful stimuli 39  Verbal Response The 'best verbal' response assesses both the reception, or comprehension of speech and its expression It is how he/she answers you when asked questions To assess the patient’s orientation to self, environment & time Damage of the speech centre – patient unable to respond to painful or verbal stimuli Ask appropriate questions, such as name, place, time & month or year Avoid asking questions about the date or day of the week 40  Verbal response…cont Five possible responses Orientated - score 5 Confused - score 4 Inappropriate words - score 3 Incomprehensible sounds - score 2 None - score 1 41  Motor Response Tests the area of the brain that identifies sensory inputs and translates this into motor response Obey commands - score 6 Localizes to pain - score 5 Flexion/withdrawal to pain - score 4 Flexion posturing /decorticate - score 3 Extension posturing /decerebrate - score 2 No motor response - score 1 42 Motor response…cont 43  GCS Scoring Total the points from all 3 parts of the GCS & compare the score obtained with the patient’s baseline score and the previous score If a decrease in the score of even 1 point occurs, complete a detailed neurologic assessment, including  Pupillary response  Cranial nerves  Motor assessment  Sensory assessment A decrease of 2 points in the GCS with a score of 9 and below indicates serious injury Notify the staff nurse in charge or doctor promptly 44  Interpretation of GCS The first GCS score - baseline score Subsequent scores provides :  assessment of trends or changes in neurologic status  a significant & reliable indicator of the severity of head injury Score 13-15 = mild although significant head injury Score 9-12 = moderated head injury Score 8 or less - severe brain injury (coma) Score of 3 - patient who is unresponsive to painful stimuli, does not open the eyes, and has complete muscular flaccidity 45  Special Consideration GCS is based on the patient’s ability to respond and to communicate The GCS may invalid if the patient; is intubated with endotracheal tube or tracheostomy tube and cannot speak (recorded as “t” in GCS chart) eyes are swollen closed (recorded as “c” in GCS chart) is not able to understand your language has hearing loss is blind is aphasic is paralyzed or hemiplegic has fracture limb/limbs (indicate with sign “#” in GCS chart) 46 47  Pupillary Assessment Assess and document pupil equality  Pupil size  Reaction to light of each pupil Any changes in pupil reaction, shape or size area - late sign of raised ICP Sluggish or suddenly dilated unequal pupils  oedema or haematoma is worsening  the oculomotor cranial nerve is being compressed through the foramen magnum – require urgent intervention Dilated or unequal pupils that do not react to light - suggest temporal lobe herniation 48  Pupillary assessment…cont Estimate the size of each pupil in millimeters (mm) before and after light stimulation Use a penlight/pen torch to provides more accurate data because of the smaller size of the light and the ability to focus the beam directly at the pupil Method:  Bring the penlight from the lateral aspect of the patient’s head toward the eye  Observe for constriction in the eye  Then test the opposite eye in the same manner 49  Pupillary assessment…cont Pupil reaction to light Normal response - Brisk and equal constriction of the pupils to direct and indirect light Abnormal response – sluggish or unequal response to direct and indirect light Pupil Size 50 51  Pupillary assessment…cont Pupil size description: Pinpoint - opiate overdose and pons haemorrhage Small - normal if in a bright room. May be seen with Horner's syndrome (cervical nerve impairment), pon hemorrhage, ophthalmic drops, metabolic coma etc Midposition - normal but if nonreactive may cause by midbrain damage Large – normal if in dark room. May be seen with some drugs and some orbital injuries Dilated - bilateral, fixed and dilated pupils are seen in the terminal stage of severe anoxia-ischemia or at death Anti-cholinergic drugs can dilate pupils 52 Upper and Lower Limb Movement It is to measure the strength of voluntary movement of the arms and legs Difficult to detect - if patient cannot cooperate with assessment or having paralysis Observe the patient carefully as the patient move If patient is restless, paralysis may become obvious as the paralyzed limb does not move as other body parts move Observe for the following:  Compare the tone of one side of the body with the other  Lifting the arms or legs on both sides, releasing them, and watching them drop on the bed  The position of the limbs at rest 53 Upper and Lower Limb Movement…cont Both upper and lower limbs should be tested and recorded separately if there is a difference Can be done/observe during assessing best motor response Normal power – If client is able to obey commands; Power of the hands - ask patient to squeeze your both hands as tightly as possible & release it  Power of the legs - ask the patient to push against your hands with his feet or ask patient to lift up his leg against your hand Mild weakness - when one side of the limb has normal power but the other side shows mild weakness 54 Upper and Lower Limb Movement…cont Severe weakness – when there is significant difference in the power of the limbs, e.g. one side with normal power, while the other side shows severe weakness Spastic flexion – stiff, slow arm movement, forearm flexed, and hand held against body Extension - straightening of the elbow or knee in response to pain stimuli No response - no response of the affected limb when pain stimuli is applied 55 56 57  Documentation Documentation should contain specific descriptive terms For example, instead of documenting word like “stuporous”; record the evidence of stupor that you have observed, such as “no response to verbal commands, responded only to tracheal suctioning with abnormal flexor posturing” Avoid descriptive words that open to individual interpretation, for example, “lethargic”, “stuporous”, “semi-comatose” etc. Documentation should be done continuously and accurately according to your institution policy and protocol 58