Module 5: Nursing Care of Clients with Altered Perception PDF

201 MODULE 5: Nursing Care of Clients with Altered Perception Lesson 1 - Understanding Neurologic System Lesson 2 - Nursing Care of Clients with Altered Perception Traumatic Brain Injury...

201 MODULE 5: Nursing Care of Clients with Altered Perception Lesson 1 - Understanding Neurologic System Lesson 2 - Nursing Care of Clients with Altered Perception Traumatic Brain Injury Acute Ischemic Stroke Traumatic Spinal Cord Injury (Assessment and Management) SHELDY M. PERALTA, RN, MAN  202 MODULE 5: NURSING CARE OF CLIENTS WITH ALTERED PERCEPTION INTRODUCTION Nurses constitute the largest category of healthcare personnel in nearly every country of the global community. They are the key professionals who need to be included in the process of setting a worldwide agenda for holistic patient care. As you begin the study of critical care nursing, you may be excited, uncertain, and even somewhat anxious. The field of critical care nursing often seems a little unfamiliar or mysterious, making it hard to imagine what the experience will be like or what nurses do in this area. This module presents essential information about how to safely and competently care for critically ill patients with altered perception and their families. It recognizes the learners’ needs to assimilate foundational knowledge before attempting to master more complex critical care nursing concepts. LEARNING OUTCOMES After studying the module, you should be able to: 1. Demonstrate safe, appropriate and holistic care utilizing the nursing process. 2. Identify health needs of clients by demonstrating proper and effective health assessment and management to care for higher acuity patients and provide evidence-based interventions. 3. Observe bioethical principles, core values, and standards of nursing care. 4. Identify own learning needs. MODULE ORGANIZER There are two lessons in the module. Read each lesson carefully then answer the exercises/activities to find out how much you have benefited from it. Work on these exercises carefully and submit your output to your tutor or to the CCHAMS office. Submit your outputs to your tutor at the CCHAMS office. You may also wish to send an electronic copy of your outputs your instructor’s email or to our NUPC 119 Google classroom using your official DMMMSU email. Aside from the main content, there are supplementary materials included in this module to strengthen your learning represented by the following icons: Books or Journals Video Links Website Pages This icon introduces some important ideas to remember. Read carefully and store them in your memory. Module 5: Care of Clients with Altered Perception SMPERALTA  203 ? At the end of the lesson/module you will find this icon. It signifies a module test to determine how well you achieved in the objectives of the module. Read carefully the questions and they must have to be answered to reinforce your learning. If you cannot answer the question satisfactorily, go back to the text. Answers to the test are to be submitted to the faculty concerned. In case you encounter difficulty, discuss this with your tutor during the face-to-face meeting. If not contact your tutor at the CCHAMS office. Good luck and happy reading!!! Module 5: Care of Clients with Altered Perception SMPERALTA  204 Lesson 1 & Understanding Nervous System THE NERVOUS SYSTEM The neurologic (or nervous) system is the organ system that coordinates all body functions. This complex system allows a person to adapt to changes within his body and in the environment. The nervous system is divided into the central nervous system (CNS), the peripheral nervous system, and the autonomic nervous system. Through complex and coordinated interactions, these three parts integrate all physical, intellectual, and emotional activities. Central nervous system The CNS includes the brain and the spinal cord, the two structures that collect and interpret voluntary and involuntary motor and sensory stimuli. Brain The brain consists of the cerebrum (cerebral cortex), the brain stem, and the cerebellum. It collects, integrates, and interprets all stimuli; in addition, it initiates and monitors voluntary and involuntary motor activity. The cerebrum gives us the ability to think and reason. Within the skull, it’s enclosed in three membrane layers called meninges. If blood or fluid accumulates between these layers, pressure builds inside the skull and compromises brain function. The cerebrum has four lobes and two hemispheres. The right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body. Each lobe controls and coordinates specific functions. A part of the cerebrum called the diencephalon contains the thalamus and hypothalamus. The thalamus relays sensory impulses and plays an important part in conscious pain awareness. The hypothalamus regulates many body functions, including temperature control, pituitary hormone production, appetite, thirst, and water balance. The brain stem is beneath the diencephalon and is divided into the midbrain, pons, and medulla. The brain stem contains the nuclei for cranial nerves III through XII. It relays messages between the cerebrum and diencephalon and the spinal cord; it also regulates automatic body functions, such as heart rate, breathing, swallowing, and coughing. The cerebellum is located below the occipital lobes at the back of the brain and consists of two hemispheres. It facilitates smooth, coordinated muscle movement and equilibrium. Spinal cord The spinal cord is the primary pathway for nerve impulses traveling between peripheral areas of the body and the brain. It also contains the sensory-to-motor pathway known as the reflex arc. A reflex arc is the route followed by nerve impulses to and from the CNS in the production of a reflex action. The spinal cord extends from the upper border of the first cervical vertebra to the lower border of the first lumbar vertebra. It’s encased by meninges, the same membrane structure as the brain, and is protected by the bony vertebrae of the spine. The spinal cord is made up of an H-shaped mass of gray matter, divided into the dorsal (posterior) and ventral (anterior) horns. White matter surrounds the horns. Module 5: Care of Clients with Altered Perception SMPERALTA  205 Dorsal white matter contains ascending tracts that transmit impulses up the spinal cord to higher sensory centers. Ventral white matter contains descending motor tracts that transmit motor impulses down from the higher motor centers to the spinal cord. Sensory (afferent) nerve fibers originate in the nerve roots along the spine — cervical, thoracic, lumbar, or sacral — and supply specific areas of the skin. These areas, known as dermatomes, provide a nerve “map” of the body and help when testing sensation to determine the location of a lesion. Peripheral nervous system The peripheral nervous system includes the peripheral and cranial nerves. Peripheral sensory nerves transmit stimuli from sensory receptors in the skin, muscles, sensory organs, and viscera to the dorsal horn of the spinal cord. The upper motor neurons of the brain and the lower motor neurons of cell bodies in the ventral horn of the spinal cord carry impulses that affect movement. The 12 pairs of cranial nerves are the primary motor and sensory paths in the brain, head, and neck. Autonomic nervous system The autonomic nervous system contains motor neurons that regulate visceral organs and innervate (supply nerves to) smooth and cardiac muscles and the glands. This nervous system has two parts: the sympathetic portion, which controls fight-or-flight responses the parasympathetic portion, which maintains baseline body functions (rest and digest). Assessment Conducting an assessment for possible neurologic impairment includes a thorough health history and an investigation of physical signs of impairment. History Begin by asking the patient what brings him to seek care at this time. Gather details about his current health, previous health, family health, and lifestyle. Also, perform a complete systems review. It’s best to include members of the patient’s family in the assessment process, if they’re available, or a close friend. If the patient does have neurologic impairment, he may have trouble remembering or remembering accurately. Family or friends can help corroborate or correct the details. Physical examination A complete neurologic examination is so long and detailed that — as a medical-surgical nurse — you’ll probably never per- form one in its entirety. Instead, you’ll rely on a brief neurologic assessment of key neurologic status indicators, including: LOC pupil size and response verbal responsiveness extremity strength and movement vital signs. When baseline values are established, regular reevaluation of these indicators, called neuro checks, will reveal trends in the patient’s neurologic function and help detect the transient changes that may signal pending problems. If the initial assessment suggests that the patient has an existing neurologic problem, a more detailed assessment is warranted. Always examine the patient’s neurologic system in an Module 5: Care of Clients with Altered Perception SMPERALTA  206 orderly fashion. Begin with the highest levels of neurologic function and proceed to the lowest, covering these five areas: mental status (cerebral function) cranial nerve function sensory function motor function reflexes. Mental Status Mental status assessment begins when you talk to the patient during the health history. Responses to your ques- tions reveal clues about the patient’s orientation and memory. Use such clues as a guide during the physical assessment. Make sure that you ask questions that require more than yes-or- no answers. Otherwise, confusion or disorientation might not be apparent. If you have doubts about a patient’s mental status, per- form a screening examination. (See Quick check of mental status, page 60.) Use the mental status examination to check these three parameters: LOC speech cognitive function. Level of Consciousness Watch for any change in the patient’s LOC. It’s the earliest and most sensitive indicator that his neurologic status has changed. Many terms are used to describe LOC, and definitions differ slightly among practitioners. To avoid confusion, clearly describe the patient’s response to various stimuli using these definitions: Alert—Patient follows commands and responds completely and appropriately to stimuli. Lethargic—Patient is drowsy, has delayed but appropriate responses to verbal stimuli, and may drift off to sleep during the examination. Stuporous—Patient requires vigorous stimulation for a response. Responses vary in appropriateness. Comatose—Patient doesn’t respond appropriately to verbal or painful stimuli and can’t follow commands or communicate verbally. Start by quietly observing the patient’s behavior. If the patient is sleeping, try to rouse him by providing an appropriate stimulus, in this order: auditory tactile painful. Always start with a minimal stimulus, increasing intensity as necessary. The Glasgow Coma Scale offers an objective way to assess the patient’s LOC. Speech Listen to how well the patient expresses thoughts. Does he choose the correct words or seem to have problems finding or articulating words? To assess for dysarthria (difficulty forming words), ask the patient to repeat the phrase, “No ifs, ands, or buts.” Assess speech comprehension by determining the patient’s ability to follow instructions and cooperate with your examination. Keep in mind that language performance tends to fluctuate with the time of day and changes in physical condition. A healthy person may have language difficulty when ill or fatigued. However, increasing speech difficulties may indicate deteriorating neurologic status, which warrants further evaluation. Module 5: Care of Clients with Altered Perception SMPERALTA  207 Cognitive function Assess cognitive function by testing the patient’s: memory orientation attention span calculation ability thought content abstract thinking judgment insight emotional status. Short-term memory is commonly affected first in a patient with neurologic disease. A patient with intact short-term memory can generally remember and repeat five to seven nonconsecutive numbers right away and again 10 minutes later. To quickly test your patient’s orientation, memory, and attention span, use the mental status screening questions. Orientation to time is usually disrupted first; orientation to person, last. Always consider the patient’s environment and physical condition when assessing orientation. For example, a patient admitted to the critical care unit for several days may not be oriented to time because of the constant activity and noise of the monitoring equipment. When testing attention span and calculation skills, keep in mind that lack of mathematical ability and anxiety can affect the patient’s performance. If he has difficulty with numerical computation, ask him to spell the word “world” backwards. While he’s performing these functions, note his ability to pay attention. Disordered thought patterns may indicate delirium or psychosis. Assess thought pattern by evaluating the clarity and cohesiveness of the patient’s ideas. Is his conversation smooth, with logical transitions between ideas? Does he have hallucinations (sensory perceptions that lack appropriate stimuli) or delusions (beliefs not supported by reality)? Test the patient’s judgment by asking him how he would respond to a hypothetical situation. For example, what would he do if he were in a public building and the fire alarm sounded? Evaluate the appropriateness of his answer. Test your patient’s insight by finding out: whether the patient has a realistic view of himself whether he’s aware of his illness and circumstances. Assess insight by asking, for example, “What do you think caused your chest pain?” Expect different patients to have different degrees of insight. For instance, a patient may attribute chest discomfort to indigestion rather than acknowledge that he has had a heart attack. Throughout the interview, assess your patient’s emotional status. Note his mood, emotional lability or stability, and the appropriate- ness of his emotional responses. Also, assess the patient’s mood by asking how he feels about himself and his future. Keep in mind that signs and symptoms of depression in an elderly patient may be atypical. Module 5: Care of Clients with Altered Perception SMPERALTA  208 Cranial nerve function Cranial nerve assessment reveals valuable information about the condition of the CNS, especially the brain stem. Figure 1. 12 Cranial Nerves Because of their location, some cranial nerves are more vulnerable to the effects of increasing intracranial pressure (ICP). Therefore, a neurologic screening assessment of the CNS focuses on these key nerves: optic (II) oculomotor (III) trochlear (IV) abducens (VI). Also evaluate other nerves if the patient’s history or symptoms indicate a potential CNS disorder or when performing a complete nervous system assessment. Assess the olfactory nerve (cranial nerve [CN] I) first. Check the patency of each nostril. Then instruct the patient to close his eyes. Occlude one nostril, and hold a familiar, pungent-smelling substance under the patient’s nose and ask him to identify it. Repeat this with the other nostril. Next, assess the optic (CN II) and oculomotor (CN III) nerves: To assess the optic nerve, check visual acuity, visual fields, and retinal structures. Do this by asking the patient to read a newspaper, starting with large headlines and moving to small print. To assess the oculomotor nerve, check pupil size, pupil shape, and pupillary response to light. When assessing pupil size, look for trends, such as a gradual increase in the size of one pupil or appearance of unequal pupils. Module 5: Care of Clients with Altered Perception SMPERALTA  209 Make sure that the patient’s pupils constrict when exposed to light and that his eyes adapt to seeing objects at various distances. Ask the patient to follow your finger through six cardinal positions of gaze: left superior left lateral left inferior right superior right lateral right inferior. Pause slightly before moving from one position to the next, to assess the patient for nystagmus, or involuntary eye movement, and the ability to hold gaze in that particular position. To assess the sensory portion of the trigeminal nerve (CN V), gently touch the right and left sides of the patient’s forehead with a cotton ball while his eyes are closed. Instruct him to tell you the moment the cotton touches each area. Compare the patient’s responses on both sides. Repeat the technique on the right and left cheek and on the right and left jaw. Next, repeat the entire procedure using a sharp object, such as the tip of a safety pin. Ask the patient to describe and compare both sensations. To assess the motor function of the trigeminal nerve, ask the patient to clench his teeth while you palpate his temporal and masseter muscles. To test the motor portion of the facial nerve (CN VII), ask the patient to: wrinkle his forehead raise and lower his eyebrows smile to show his teeth puff out his cheeks. Also, with the patient’s eyes tightly closed, attempt to open his eyelids. As you conduct each part of this test, look for symmetry. The sensory portion of the facial nerve (CN VII) supplies taste sensation to the anterior two-thirds of the tongue. Test the taste sensation by placing items with various flavors on the patient’s tongue. Use items such as sugar (sweet), salt, lemon juice (sour), and quinine (bitter). Between items, have the patient wash away each substance with a sip of water. To assess the acoustic nerve (CN VIII), first test the patient’s hearing. Ask the patient to cover one ear. Then stand on the opposite side and whisper a few words. Find out whether the patient can repeat what you said. Test the other ear in the same way. To test the vestibular portion of the acoustic nerve, observe the patient for nystagmus and disturbed balance. Note reports of the room spinning or dizziness. Test the glossopharyngeal nerve (CN IX) and vagus nerve (CN X) together because their innervation overlaps in the pharynx: The glossopharyngeal nerve is responsible for swallowing, salivating, and taste perception on the posterior one-third of the tongue. The vagus nerve controls swallowing and is responsible for voice quality. Assess these nerves, first, by listening to the patient’s voice. Then check the gag reflex by touching the tip of a tongue blade against the posterior pharynx and asking the patient to open wide and say “ah.” Watch for the symmetrical upward movement of the soft palate and uvula and for the midline position of the uvula. To assess the spinal accessory nerve (CN XI), which controls the sternocleidomastoid muscles and the upper portion of the trapezius muscles, press down on the patient’s shoulders while he attempts to shrug against this resistance. Note shoulder strength and symmetry while inspecting and palpating the trapezius muscles. Module 5: Care of Clients with Altered Perception SMPERALTA  210 To further test the trapezius muscles, apply resistance from one side while the patient tries to return his head to midline position. Look for neck strength. Repeat on the other side. To assess the hypoglossal nerve (CN XII), follow these steps: Ask the patient to stick out his tongue. Look for any deviation from the midline, atrophy, or fasciculations. Test tongue strength by asking the patient to push his tongue against his cheek as you apply resistance. Observe the tongue for symmetry. Test the patient’s speech by asking him to repeat the sentence, “Round the rugged rock that ragged rascal ran.” Sensory Function Assess the sensory system to evaluate: ability of the sensory receptors to detect stimuli ability of the afferent nerves to carry sensory nerve impulses to the spinal cord ability of the sensory tracts in the spinal cord to carry sensory messages to the brain. Five sensations During your assessment, check five types of sensation, including: pain, light touch, vibration, position, and discrimination. Motor Function Assess motor function to aid evaluation of these structures and functions: the cerebral cortex and its initiation of motor activity by way of the pyramidal pathways the corticospinal tracts and their capacity to carry motor messages down the spinal cord the lower motor neurons and their ability to carry efferent impulses to the muscles the muscles and their capacity to carry out motor commands the cerebellum and basal ganglia and their capacity to coordinate and fine-tune movement. Diagnostic Tests Diagnostic testing to evaluate the nervous system typically includes imaging studies, angiography, and electrophysiologic studies. Other tests, such as lumbar puncture and transcranial Doppler studies, may also be used. Imaging Studies The most common imaging studies used to detect neurologic disorders include computed tomography (CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan, and skull and spinal X-rays. Two newer types of imaging, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are also available as diagnostic tools for cerebrovascular disease. Computed tomography scan CT scanning of intracranial structures combines radiology and computer analysis of tissue density (determined by contrast dye absorption). CT scanning doesn’t show blood vessels as well as an angiogram does; however, it carries less risk of complications and causes less trauma than cerebral angiography. Module 5: Care of Clients with Altered Perception SMPERALTA  211 Spine scanning CT scanning of the spine is used to assess such disorders as herniated disk, spinal cord tumors, and spinal stenosis. Brain scanning CT scanning of the brain is used to detect brain contusion, brain calcifications, cerebral atrophy, hydrocephalus, inflammation, space-occupying lesions (tumors, hematomas, edema, and abscesses), and vascular anomalies (arteriovenous malformation [AVM], infarctions, blood clots, and hemorrhage). Nursing Consideration Confirm that the patient isn’t allergic to iodine or shellfish to avoid an adverse reaction to the contrast medium. If the test calls for a contrast medium, tell the patient that it’s injected into an existing I.V. line or that a new line may be inserted. Pre-procedure testing should include evaluation of renal function (serum creatinine and blood urea nitrogen [BUN] levels) because the contrast medium can cause acute renal failure. Warn the patient that he may feel flushed or notice a metallic taste in his mouth when the contrast medium is injected. Tell him that the CT scanner circles around him for 10 to 30 minutes, depending on the procedure and type of equipment. Explain that he must lie still during the test. Tell him that the contrast medium may discolor his urine for 24 hours. Suggest that he drink more fluids to flush the medium out of his body, unless this is contraindicated or he has oral intake restrictions; otherwise, the practitioner may write an order to increase the I.V. flow rate. Magnetic Resonance Imaging MRI generates detailed pictures of body structures. The test may involve the use of a contrast medium such as gadolinium. Compared with conventional X-rays and CT scans, MRI provides superior contrast of soft tissues, sharply differentiating healthy, benign, and cancerous tissue and clearly revealing blood vessels. In addition, MRI permits imaging in multiple planes, including sagittal and coronal views in regions where bones normally hamper visualization. MRI is especially useful for studying the CNS because it can reveal structural and biochemical abnormalities associated with such conditions as transient ischemic attack (TIA), tumors, multiple sclerosis (MS), cerebral edema, and hydrocephalus. Nursing Consideration Confirm that the patient isn’t allergic to the contrast medium (usually gadolinium). If the test calls for a contrast medium, tell the patient that it’s injected into an existing I.V. line or that a new line may be inserted. Explain that the procedure can take up to 11⁄2 hours; tell the patient that he must remain still for intervals of 5 to 20 minutes. Instruct the patient to remove all metallic items, such as hair clips, bobby pins, jewelry (including body-piercing jewelry), watches, eyeglasses, hearing aids, and dentures. Explain that the test is painless, but that the machinery may seem loud and frightening and the tunnel confining. Tell the patient that he’ll receive earplugs to reduce the noise. Provide sedation, as ordered, to promote relaxation during the test. Module 5: Care of Clients with Altered Perception SMPERALTA  212 After the procedure, increase the I.V. flow rate, as ordered, or encourage the patient to increase his fluid intake to flush the contrast medium from his system. Positron Emission Tomography Scan PET scanning provides colorimetric information about the brain’s metabolic activity. It works by detecting how quickly tissues consume radioactive isotopes. PET scanning is used to reveal cerebral dysfunction associated with tumors, seizures, TIA, head trauma, Alzheimer’s disease, Parkinson’s disease, MS, and some mental illnesses. In addition, a PET scan can be used to evaluate the effect of drug therapy and neurosurgery. Here’s how PET scanning works: A technician administers a radioactive gas or an I.V. injection of glucose or other biochemical substance tagged with isotopes, which act as tracers. The isotopes emit positrons that combine with negatively charged electrons in tissue cells to create gamma rays. The PET scanner registers the emitted gamma rays and a computer translates the information into patterns that reflect cerebral blood flow, blood volume, and neuron and neurotransmitter metabolism. Nursing Considerations Provide reassurance that PET scanning doesn’t expose the pa- tient to dangerous levels of radiation. Explain that insertion of an I.V. catheter may be required. Instruct the patient to lie still during the test. Skull and Spinal X-Rays Skull X-rays are typically taken from two angles: anteroposterior and lateral. The practitioner may order other angles, including Waters view, or occipitomental projection, to examine the frontal and maxillary sinuses, facial bones, and eye orbits. Skull X-rays are used to detect fractures; bony tumors or unusual calcifications; pineal displacement or skull or sella turcica erosion, which indicates a space-occupying lesion; and vascular abnormalities. The practitioner may order anteroposterior and lateral spinal X-rays when: spinal disease is suspected injury to the cervical, thoracic, lumbar, or sacral vertebral segments exists. Depending on the patient’s condition, other X-ray images may be taken from special angles, such as the open-mouth view (to confirm odontoid fracture). Spinal X-rays are used to detect spinal fracture; displacement and subluxation due to partial dislocation; destructive lesions, such as primary and metastatic bone tumors; arthritic changes or spondylolisthesis; structural abnormalities, such as kyphosis, scoliosis, and lordosis; and congenital abnormalities. Nursing Considerations Reassure the patient that X-rays are painless. As ordered, administer an analgesic before the procedure if the patient has existing pain, so he’ll be more comfortable. Module 5: Care of Clients with Altered Perception SMPERALTA  213 Remove the patient’s cervical collar if cervical X-rays reveal no fracture and the practitioner permits it. Angiography Angiographic studies include cerebral angiography and digital subtraction angiography (DSA). Cerebral angiography During cerebral angiography, the doctor injects a radiopaque contrast medium, usually into the brachial artery (through retrograde brachial injection) or femoral artery (through catheterization). This procedure highlights cerebral vessels, making it easier to: detect stenosis or occlusion associated with thrombus or spasm identify aneurysms and AVMs locate vessel displacement associated with tumors, abscesses, cerebral edema, hematoma, or herniation assess collateral circulation Nursing Considerations Explain the procedure to the patient, and answer all questions honestly. Confirm that the patient isn’t allergic to iodine or shellfish because a person with such allergies may have an adverse reaction to the contrast medium. Pre-procedure testing should include evaluation of renal function (serum creatinine and BUN levels) and potential risk of bleeding (prothombin time [PT], partial thromboplastin time [PTT], and platelet count). Notify the practitioner of abnormal results. Instruct the patient to lie still during the procedure. Explain that he’ll probably feel a flushed sensation in his face as the dye is injected. Maintain bed rest, as ordered, and monitor the patient’s vital signs. Monitor the catheter injection site for signs of bleeding. As ordered, keep a sandbag over the injection site. Monitor the patient’s peripheral pulse in the arm or leg used for catheter insertion, and mark the site of the pulse for reference. Unless contraindicated, encourage the patient to drink more flu- ids to flush the dye from the body; alternatively, increase the I.V. flow rate as ordered. Monitor the patient for neurologic changes and such complications as hemiparesis, hemiplegia, aphasia, and impaired LOC. Monitor for adverse reactions to the contrast medium, which may include restlessness, tachypnea and respiratory distress, tachycardia, facial flushing, urticaria, and nausea and vomiting. Digital Subtraction Angiography Like cerebral angiography, DSA highlights cerebral blood vessels. DSA is done this way: Using computerized fluoroscopy, a technician takes an image of the selected area, which is then stored in a computer’s memory. After administering a contrast medium, the technician takes several more images. The computer produces high-resolution images by manipulating the two sets of images. Arterial DSA requires more contrast medium than cerebral angiography but, because the dye is injected I.V., DSA doesn’t increase the patient’s risk of stroke and, therefore, the test can be done on an outpatient basis. Module 5: Care of Clients with Altered Perception SMPERALTA  214 Nursing Considerations Confirm that the patient isn’t allergic to iodine or shellfish be- cause a person with these allergies may have an adverse reaction to the contrast medium. Pre-procedure testing should include evaluation of renal function (serum creatinine and BUN levels) and potential risk of bleeding (PT, PTT, and platelet count). Notify the practitioner of abnormal results. Restrict the patient’s consumption of solid food for 4 hours be- fore the test. Explain that the test requires insertion of an I.V. catheter, if not already present. Instruct the patient to remain still during the test. Explain that he’ll probably feel flushed or have a metallic taste in his mouth as the contrast medium is injected. Tell the patient to alert the doctor immediately if he feels dis- comfort or shortness of breath during the test. After the test is completed, encourage the patient to resume normal activities. Unless contraindicated, encourage the patient to drink more fluids for the rest of the day to flush the contrast medium from the body. Alternatively, increase the I.V. flow rate as ordered. Electrophysiologic Studies Common electrophysiologic studies include EEG and evoked potential studies. Electroencephalography During EEG, the brain’s continuous electrical activity is recorded. The results are used to identify seizure disorders; metabolic encephalopathy; other multifocal brain lesions, such as those caused by demetia or herpes; and brain death. Nursing Considerations Explain that a technician applies paste and attaches electrodes to areas of skin on the patient’s head and neck after these areas have been lightly abraded to ensure good contact. Instruct the patient to remain still during the test. Discuss what the patient may be asked to do during the test, such as hyperventilating for 3 minutes or sleeping, depending on the purpose of the EEG. After the test, use acetone to remove any remaining paste from the patient’s skin. Evoked Potential Studies Evoked potential studies are used to measure the nervous system’s electrical response to a visual, auditory, or sensory stimulus. The results are used to detect subclinical lesions such as tumors of CN VIII and complicating lesions in a patient with MS. Evoked potential studies are also useful in diagnosing blindness and deafness in infants. Nursing Considerations Explain to the patient that he must remain still during the test. Describe how a technician applies paste and electrodes to the head and neck before testing. Describe activities—such as gazing at a checkerboard pattern or a strobe light or listening with headphones to a series of clicks— performed during testing. The patient may have electrodes placed on an arm and leg and be asked to respond to a tapping sensation. Explain that the test equipment may emit noises. Other Tests Other neurologic tests include lumbar puncture and transcranial Doppler studies. Module 5: Care of Clients with Altered Perception SMPERALTA  215 Lumbar Puncture During lumbar puncture, a sterile needle is inserted into the sub- arachnoid space of the spinal canal, usually between the third and fourth lumbar vertebrae. A doctor does the lumbar puncture, with a nurse assisting. It requires sterile technique and careful patient positioning. Lumbar puncture is used to: detect blood in cerebrospinal fluid (CSF) obtain CSF specimens for laboratory analysis inject dyes or gases for contrast in radiologic studies. It’s also used to administer drugs or anesthetics and to relieve increased ICP by removing CSF. Contraindications and cautions Lumbar puncture is contraindicated in patients with lumbar deformity or infection at the puncture site. It’s performed cautiously in patients with increased ICP because the rapid decrease of pressure that follows withdrawal of CSF can cause tonsillar herniation and medullary compression. Nursing Considerations Calmly describe lumbar puncture to the patient, explaining that the procedure may cause some discomfort. Reassure the patient that a local anesthetic is administered be- fore the test. Tell him to report any tingling or sharp pain he feels as the anesthetic is injected. To prevent headache after the test, instruct the patient to lie flat for 4 to 6 hours after the procedure. Monitor the patient for neurologic deficits and complications, such as headache, fever, back spasms, or seizures, according to facility policy. Administer analgesics as needed. Monitor the puncture site for signs of infection. Transcranial Doppler Studies In transcranial Doppler studies, the velocity of blood flow through cerebral arteries is measured. The results provide information about the presence, quality, and changing nature of blood flow to an area of the brain. The types of waveforms and velocities obtained by testing indicate whether disease exists. Test results commonly aren’t definitive, but this is a noninvasive way to obtain diagnostic information. High velocities are typically abnormal, suggesting that blood flow is too turbulent or the vessel is too narrow. They may also indicate stenosis or vasospasm. High velocities may also indicate AVM due to the extra blood flow associated with stenosis or vasospasm. Nursing concerns Tell the patient that the study usually takes less than 1 hour, depending on the number of vessels examined and on any interfering factors. Explain that a small amount of gel is applied to the skin and that a probe is then used to transmit a signal to the artery being studied. Treatments Treatments for patients with neurologic dysfunction may include medication therapy, surgery, and other forms of treatment. Module 5: Care of Clients with Altered Perception SMPERALTA  216 Medication Therapy For many of your patients with neurologic disorders, medication or drug therapy is essential. For example: thrombolytics are used to treat patients with acute ischemic stroke anticonvulsants are used to control seizures corticosteroids are used to reduce inflammation. Types of drugs commonly used to treat patients with neurologic disorders include: analgesics anticonvulsants anticoagulants and antiplatelets barbiturates benzodiazepines calcium channel blockers corticosteroids diuretics thrombolytics. When caring for a patient undergoing medication therapy, stay alert for severe adverse reactions and interactions with other drugs. Some drugs such as barbiturates also carry a high risk of toxicity. Successful therapy hinges on strict adherence to the medication schedule. Compliance is especially critical for drugs that require steady blood levels for therapeutic effectiveness such as anti-convulsant. Surgery Life-threatening neurologic disorders usually call for emergency surgery. Surgery commonly involves craniotomy, a procedure to open the skull and expose the brain. You may be responsible for the patient’s care before and after surgery. Here are some general preoperative and post- operative pointers: The prospect of surgery usually causes fear and anxiety, so give ongoing emotional support to the patient and his family. Make sure that you’re ready to answer their questions. Postoperative care may include teaching about diverse topics, such as ventricular shunt care and tips about cosmetic care after craniotomy. Be ready to give good advice after surgery. Craniotomy During craniotomy, a surgical opening into the skull exposes the brain. This procedure allows various treatments, such as ventricular shunting, excision of a tumor or abscess, hematoma aspiration, and aneurysm clipping (placing one or more surgical clips on the neck of an aneurysm to destroy it). The degree of risk depends on your patient’s condition and the complexity of the surgery. Craniotomy raises the risk of having various complications, such as: infection hemorrhage respiratory compromise increased ICP. Nursing Considerations Encourage the patient and his family to ask questions about the procedure. Provide clear, honest answers to reduce their confusion and anxiety and to enhance effective coping. Explain that the patient’s head will be shaved before surgery. Module 5: Care of Clients with Altered Perception SMPERALTA  217 Discuss the recovery period so the patient understands what to expect. Explain that he’ll awaken with a dressing on his head to protect the incision and may have a surgical drain. Tell him to expect a headache and facial swelling for 2 to 3 days after surgery, and reassure him that he’ll receive pain medication. Monitor the patient’s neurologic status and vital signs, and re- port any acute change immediately. Watch for signs of increased ICP, such as pupil changes, weakness in extremities, headache, and change in LOC. Monitor the incision site for signs of infection or drainage. Provide emotional support to the patient and his family as they cope with remaining neurologic deficits. Cerebral aneurysm repair Surgical intervention is the only sure way to prevent rupture or rebleeding of a cerebral aneurysm. In cerebral aneurysm repair, a craniotomy is performed to expose the aneurysm. Depending on the shape and location of the aneurysm, the surgeon then uses one of several corrective techniques, such as: clamping the affected artery wrapping the aneurysm wall with a biological or synthetic material clipping or ligating the aneurysm. Other techniques for surgery include interventional radiology in conjunction with endovascular balloon therapy. This technique occludes the aneurysm or vessel and uses cerebral angiography to treat arterial vasospasm. In some cases, a type of nonsurgical repair called electro- thrombosis is used. Nursing Considerations Tell the patient and his family that monitoring is done in the critical care unit before and after surgery. Explain that several I.V. lines, intubation, and mechanical ventilation may be needed. Monitor the incision site for signs of infection or drainage. Monitor the patient’s neurologic status and vital signs, and re- port acute changes immediately. Watch for signs of increased ICP, such as pupil changes, weakness in extremities, headache, and a change in LOC. Give emotional support to the patient and his family to help them cope with remaining neurologic deficits. Other Treatments Other treatments include barbiturate coma, CSF drainage, ICP monitoring, and plasmapheresis. Barbiturate coma The practitioner may order barbiturate coma when conventional treatments, such as fluid restriction, diuretic or corticosteroid therapy, or ventricular shunting, don’t correct sustained or acute episodes of increased ICP. During barbiturate coma, the patient receives high I.V. doses of a short-acting barbiturate (such as pentobarbital [Nembutal]) to produce a comatose state. The drug reduces the patient’s metabolic rate and cerebral blood flow. The goal of barbiturate coma is to relieve increased ICP and protect cerebral tissue. It’s a last resort for patients with: Module 5: Care of Clients with Altered Perception SMPERALTA  218 acute ICP elevation (over 40 mm Hg) persistent ICP elevation (over 20 mm Hg) rapidly deteriorating neurologic status that’s unresponsive to other treatments. If barbiturate coma doesn’t reduce ICP, the patient’s prognosis for recovery is poor. Nursing Considerations Focus your attention on the patient’s family. The patient’s condition and apprehension about the treatment is likely to frighten them. Provide clear explanations of the procedure and its effects, and encourage them to ask questions. Convey a sense of optimism but provide no guarantees of the treatment’s success. Prepare the family for expected changes in the patient during therapy, such as decreased respirations, hypotension, and loss of muscle tone and reflexes. Closely monitor the patient’s ICP, electrocardiogram (ECG), bispectral index, and vital signs. Notify the practitioner of in- creased ICP, arrhythmias, or hypotension. Because the patient is in a drug-induced coma, devote special care to prevent pressure ulcers. Cerebrospinal fluid drainage The goal of CSF drainage is to reduce ICP to the desired level and keep it at that level. Fluid is withdrawn from the lateral ventricle through ventriculostomy. To place the ventricular drain, a neurosurgeon inserts a ventricular catheter through a burr hole in the patient’s skull. This is usually done in the operating room. Nursing Considerations Maintain a continuous hourly output of CSF by raising or lowering the drainage system drip chamber. Drain the CSF, as ordered, by putting on gloves and turning the main stopcock on to drainage and allowing the CSF to collect in the drip chamber. To stop drainage, turn off the stopcock to drainage. Record the time and the amount of collected CSF. Check the patient’s dressing frequently for drainage. Check the tubing for patency by watching the CSF drops in the drip chamber. Observe the CSF for color, clarity, amount, blood, and sediment. Maintain the patient on bed rest with the head of the bed at 30 to 45 degrees to promote drainage. Observe for complications, such as excessive CSF drainage, characterized by headache, tachycardia, diaphoresis, and nausea. Overly rapid accumulation of drainage is a neurosurgical emergency. Cessation of drainage may indicate clot formation. Intracranial Pressure Monitoring In ICP monitoring, pressure exerted by the brain, blood, and CSF against the inside of the skull is measured. ICP monitoring enables prompt intervention, which can avert damage caused by cerebral hypoxia and shifts of brain mass. Indications for ICP monitoring include: head trauma with bleeding or edema overproduction or insufficient absorption of CSF cerebral hemorrhage space-occupying lesions. Module 5: Care of Clients with Altered Perception SMPERALTA  219 There are four basic types of ICP monitoring systems. Regardless of which system is used, the insertion procedure is always performed by a neurosurgeon in the operating room, emergency department (ED), or critical care unit. Insertion of an ICP monitoring device requires sterile technique to reduce the risk of CNS infection. The neurosurgeon inserts a ventricular catheter or subarachnoid screw through a twist-drill hole created in the skull. Both devices have built-in transducers that convert ICP to electrical impulses displayed as waveforms, allowing constant monitoring. Nursing Considerations Observe digital ICP readings and waveforms. Assess the patient’s clinical status and monitor routine and neurologic vital signs every hour or as ordered. Calculate cerebral perfusion pressure (CPP) hourly. To calculate CPP, subtract ICP from mean arterial pressure (MAP). Inspect the insertion site at least every 24 hours for redness, swelling, and drainage. Plasmapheresis Symptoms of several neurologic disorders are reduced through plasma exchange, or plasmapheresis. In plasmapheresis, blood from the patient flows into a cell separator, which separates plasma from formed elements. The plasma is then filtered to remove toxins and disease media- tors, such as immune complexes and autoantibodies, from the patient’s blood. The cellular components are then transfused back into the patient using fresh frozen plasma or albumin in place of the plasma removed. Plasmapheresis benefits patients with neurologic disorders such as Guillain-Barré syndrome and, especially, myasthenia gravis. In myasthenia gravis, plasmapheresis is used to remove circulating anti-acetylcholine receptor antibodies. Plasmapheresis is used most commonly for patients with long-standing neuromuscular disease, but it can also be used to treat patients with acute exacerbations. Some acutely ill patients require treatment up to four times per week; others about once every 2 weeks. When it’s successful, treatment may relieve symptoms for months, but results vary. Nursing concerns Discuss the treatment and its purpose with the patient and his family. Explain that the procedure can take up to 5 hours. During that time, blood samples are taken frequently to monitor calcium and potassium levels. Blood pressure and heart rate are checked regularly. Tell the patient to report any paresthesia (numbness, burning, tingling, prickling, or increased sensitivity) during treatment. If possible, give the patient prescribed medications after treatment because they’re removed from the blood during treatment. Monitor the patient’s vital signs according to your facility’s policy. Check puncture sites for signs of bleeding or extravasation. Module 5: Care of Clients with Altered Perception SMPERALTA  220 Lesson 2 & Common Neurologic System Disorders COMMON NEUROLOGIC SYSTEM DISORDERS you encounter in the Critical Care Unit 1. TRAUMATIC BRAIN INJURY Traumatic brain injury usually results from a violent blow or jolt to the head or body. An object that goes through brain tissue, such as a bullet or shattered piece of skull, also can cause traumatic brain injury. Mild traumatic brain injury may affect your brain cells temporarily. More-serious traumatic brain injury can result in bruising, torn tissues, bleeding and other physical damage to the brain. These injuries can result in long-term complications or death. Causes Traumatic brain injury is usually caused by a blow or other traumatic injury to the head or body. The degree of damage can depend on several factors, including the nature of the injury and the force of impact. Common events causing traumatic brain injury include the following: Falls. Falls from bed or a ladder, down stairs, in the bath, and other falls are the most common cause of traumatic brain injury overall, particularly in older adults and young children. Vehicle-related collisions. Collisions involving cars, motorcycles or bicycles — and pedestrians involved in such accidents — are a common cause of traumatic brain injury. Violence. Gunshot wounds, domestic violence, child abuse and other assaults are common causes. Shaken baby syndrome is a traumatic brain injury in infants caused by violent shaking. Sports injuries. Traumatic brain injuries may be caused by injuries from a number of sports, including soccer, boxing, football, baseball, lacrosse, skateboarding, hockey, and other high-impact or extreme sports. These are particularly common in youth. Explosive blasts and other combat injuries. Explosive blasts are a common cause of traumatic brain injury in active-duty military personnel. Although how the damage occurs isn't yet well understood, many researchers believe that the pressure wave passing through the brain significantly disrupts brain function. Traumatic brain injury also results from penetrating wounds, severe blows to the head with shrapnel or debris, and falls or bodily collisions with objects following a blast. Risk factors The people most at risk of traumatic brain injury include: Children, especially newborns to 4-year-olds Young adults, especially those between ages 15 and 24 Adults age 60 and older Males in any age group Symptoms Traumatic brain injury can have wide-ranging physical and psychological effects. Some signs or symptoms may appear immediately after the traumatic event, while others may appear days or weeks later. Mild traumatic brain injury Module 5: Care of Clients with Altered Perception SMPERALTA  221 The signs and symptoms of mild traumatic brain injury may include: Physical symptoms Headache Nausea or vomiting Fatigue or drowsiness Problems with speech Dizziness or loss of balance Sensory symptoms Sensory problems, such as blurred vision, ringing in the ears, a bad taste in the mouth or changes in the ability to smell Sensitivity to light or sound Cognitive, behavioral or mental symptoms Loss of consciousness for a few seconds to a few minutes No loss of consciousness, but a state of being dazed, confused or disoriented Memory or concentration problems Mood changes or mood swings Feeling depressed or anxious Difficulty sleeping Sleeping more than usual Moderate to severe traumatic brain injuries Moderate to severe traumatic brain injuries can include any of the signs and symptoms of mild injury, as well as these symptoms that may appear within the first hours to days after a head injury: Physical symptoms Loss of consciousness from several minutes to hours Persistent headache or headache that worsens Repeated vomiting or nausea Convulsions or seizures Dilation of one or both pupils of the eyes Clear fluids draining from the nose or ears Inability to awaken from sleep Weakness or numbness in fingers and toes Loss of coordination Cognitive or mental symptoms Profound confusion Agitation, combativeness or other unusual behavior Slurred speech Coma and other disorders of consciousness Children's symptoms Infants and young children with brain injuries might not be able to communicate headaches, sensory problems, confusion and similar symptoms. In a child with traumatic brain injury, you may observe: Change in eating or nursing habits Unusual or easy irritability Persistent crying and inability to be consoled Change in ability to pay attention Change in sleep habits Seizures Module 5: Care of Clients with Altered Perception SMPERALTA  222 Sad or depressed mood Drowsiness Loss of interest in favorite toys or activities Complications Several complications can occur immediately or soon after a traumatic brain injury. Severe injuries increase the risk of a greater number of and more-severe complications. Altered consciousness Moderate to severe traumatic brain injury can result in prolonged or permanent changes in a person's state of consciousness, awareness or responsiveness. Different states of consciousness include: Coma. A person in a coma is unconscious, unaware of anything and unable to respond to any stimulus. This results from widespread damage to all parts of the brain. After a few days to a few weeks, a person may emerge from a coma or enter a vegetative state. Vegetative state. Widespread damage to the brain can result in a vegetative state. Although the person is unaware of surroundings, he or she may open his or her eyes, make sounds, respond to reflexes, or move. It's possible that a vegetative state can become permanent, but often individuals progress to a minimally conscious state. Minimally conscious state. A minimally conscious state is a condition of severely altered consciousness but with some signs of self-awareness or awareness of one's environment. It is sometimes a transitional state from a coma or vegetative condition to greater recovery. Brain death. When there is no measurable activity in the brain and the brainstem, this is called brain death. In a person who has been declared brain dead, removal of breathing devices will result in cessation of breathing and eventual heart failure. Brain death is considered irreversible. Physical complications Seizures. Some people with traumatic brain injury will develop seizures. The seizures may occur only in the early stages, or years after the injury. Recurrent seizures are called post-traumatic epilepsy. Fluid buildup in the brain (hydrocephalus). Cerebrospinal fluid may build up in the spaces in the brain (cerebral ventricles) of some people who have had traumatic brain injuries, causing increased pressure and swelling in the brain. Infections. Skull fractures or penetrating wounds can tear the layers of protective tissues (meninges) that surround the brain. This can enable bacteria to enter the brain and cause infections. An infection of the meninges (meningitis) could spread to the rest of the nervous system if not treated. Blood vessel damage. Several small or large blood vessels in the brain may be damaged in a traumatic brain injury. This damage could lead to a stroke, blood clots or other problems. Headaches. Frequent headaches are very common after a traumatic brain injury. They may begin within a week after the injury and could persist for as long as several months. Vertigo. Many people experience vertigo, a condition characterized by dizziness, after a traumatic brain injury. Sometimes, any or several of these symptoms might linger for a few weeks to a few months after a traumatic brain injury. When a combination of these symptoms lasts for an extended period of time, this is generally referred to as persistent post-concussive symptoms. Module 5: Care of Clients with Altered Perception SMPERALTA  223 Traumatic brain injuries at the base of the skull can cause nerve damage to the nerves that emerge directly from the brain (cranial nerves). Cranial nerve damage may result in: Paralysis of facial muscles or losing sensation in the face Loss of or altered sense of smell or taste Loss of vision or double vision Swallowing problems Dizziness Ringing in the ear Hearing loss Intellectual problems Many people who have had a significant brain injury will experience changes in their thinking (cognitive) skills. It may be more difficult to focus and take longer to process your thoughts. Traumatic brain injury can result in problems with many skills, including: Cognitive problems Memory Learning Reasoning Judgment Attention or concentration Executive functioning problems Problem-solving Multitasking Organization Planning Decision-making Beginning or completing tasks Communication problems Language and communications problems are common following traumatic brain injuries. These problems can cause frustration, conflict and misunderstanding for people with a traumatic brain injury, as well as family members, friends and care providers. Communication problems may include: Difficulty understanding speech or writing Difficulty speaking or writing Inability to organize thoughts and ideas Trouble following and participating in conversations Communication problems that affect social skills may include: Trouble with turn taking or topic selection in conversations Problems with changes in tone, pitch or emphasis to express emotions, attitudes or subtle differences in meaning Difficulty understanding nonverbal signals Trouble reading cues from listeners Trouble starting or stopping conversations Inability to use the muscles needed to form words (dysarthria) Module 5: Care of Clients with Altered Perception SMPERALTA  224 Behavioral changes People who've experienced brain injury may experience changes in behaviors. These may include: Difficulty with self-control Lack of awareness of abilities Risky behavior Difficulty in social situations Verbal or physical outbursts Emotional changes Emotional changes may include: Depression Anxiety Mood swings Irritability Lack of empathy for others Anger Insomnia Sensory problems Problems involving senses may include: Persistent ringing in the ears Difficulty recognizing objects Impaired hand-eye coordination Blind spots or double vision A bitter taste, a bad smell or difficulty smelling Skin tingling, pain or itching Trouble with balance or dizziness Degenerative brain diseases The relationship between degenerative brain diseases and brain injuries is still unclear. But some research suggests that repeated or severe traumatic brain injuries might increase the risk of degenerative brain diseases. But this risk can't be predicted for an individual — and researchers are still investigating if, why and how traumatic brain injuries might be related to degenerative brain diseases. A degenerative brain disorder can cause gradual loss of brain functions, including: Alzheimer's disease, which primarily causes the progressive loss of memory and other thinking skills Parkinson's disease, a progressive condition that causes movement problems, such as tremors, rigidity and slow movements Dementia pugilistica — most often associated with repetitive blows to the head in career boxing — which causes symptoms of dementia and movement problems Prevention Follow these tips to reduce the risk of brain injury: Seat belts and airbags. Always wear a seat belt in a motor vehicle. A small child should always sit in the back seat of a car secured in a child safety seat or booster seat that is appropriate for his or her size and weight. Alcohol and drug use. Don't drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive. Module 5: Care of Clients with Altered Perception SMPERALTA  225 Helmets. Wear a helmet while riding a bicycle, skateboard, motorcycle, snowmobile or all-terrain vehicle. Also wear appropriate head protection when playing baseball or contact sports, skiing, skating, snowboarding or riding a horse. Pay attention to your surroundings. Don't drive, walk or cross the street while using your phone, tablet or any smart device. These distractions can lead to accidents or falls. Preventing falls The following tips can help older adults avoid falls around the house: Install handrails in bathrooms Put a nonslip mat in the bathtub or shower Remove area rugs Install handrails on both sides of staircases Improve lighting in the home, especially around stairs Keep stairs and floors clear of clutter Get regular vision checkups Get regular exercise Preventing head injuries in children The following tips can help children avoid head injuries: Install safety gates at the top of a stairway Keep stairs clear of clutter Install window guards to prevent falls Put a nonslip mat in the bathtub or shower Use playgrounds that have shock-absorbing materials on the ground Make sure area rugs are secure Don't let children play on fire escapes or balconies Diagnostic Tests Traumatic brain injuries may be emergencies. In the case of more-severe TBIs, consequences can worsen rapidly without treatment. Doctors or first responders need to assess the situation quickly. Glasgow Coma Scale This 15-point test helps a doctor or other emergency medical personnel assess the initial severity of a brain injury by checking a person's ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues. Abilities are scored from three to 15 in the Glasgow Coma Scale. Higher scores mean less severe injuries Imaging tests Computerized tomography (CT) scan. This test is usually the first performed in an emergency room for a suspected traumatic brain injury. A CT scan uses a series of X- rays to create a detailed view of the brain. A CT scan can quickly visualize fractures and uncover evidence of bleeding in the brain (hemorrhage), blood clots (hematomas), bruised brain tissue (contusions), and brain tissue swelling. Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of the brain. This test may be used after the person's condition stabilizes, or if symptoms don't improve soon after the injury. Intracranial Pressure Monitor Tissue swelling from a traumatic brain injury can increase pressure inside the skull and cause additional damage to the brain. Doctors may insert a probe through the skull to monitor this pressure. Module 5: Care of Clients with Altered Perception SMPERALTA  226 Treatment Treatment is based on the severity of the injury. Mild injury Mild traumatic brain injuries usually require no treatment other than rest and over-the- counter pain relievers to treat a headache. However, a person with a mild traumatic brain injury usually needs to be monitored closely at home for any persistent, worsening or new symptoms. He or she may also have follow-up doctor appointments. The doctor will indicate when a return to work, school or recreational activities is appropriate. Relative rest — which means limiting physical or thinking (cognitive) activities that make things worse — is usually recommended for the first few days or until your doctor advises that it's OK to resume regular activities. It isn't recommended that you rest completely from mental and physical activity. Most people return to normal routines gradually. Immediate emergency care Emergency care for moderate to severe traumatic brain injuries focuses on making sure the person has enough oxygen and an adequate blood supply, maintaining blood pressure, and preventing any further injury to the head or neck. People with severe injuries may also have other injuries that need to be addressed. Additional treatments in the emergency room or intensive care unit of a hospital will focus on minimizing secondary damage due to inflammation, bleeding or reduced oxygen supply to the brain. Medications Medications to limit secondary damage to the brain immediately after an injury may include: Anti-seizure drugs. People who've had a moderate to severe traumatic brain injury are at risk of having seizures during the first week after their injury. An anti-seizure drug may be given during the first week to avoid any additional brain damage that might be caused by a seizure. Continued anti-seizure treatments are used only if seizures occur. Coma-inducing drugs. Doctors sometimes use drugs to put people into temporary comas because a comatose brain needs less oxygen to function. This is especially helpful if blood vessels, compressed by increased pressure in the brain, are unable to supply brain cells with normal amounts of nutrients and oxygen. Diuretics. These drugs reduce the amount of fluid in tissues and increase urine output. Diuretics, given intravenously to people with traumatic brain injury, help reduce pressure inside the brain. Surgery Emergency surgery may be needed to minimize additional damage to brain tissues. Surgery may be used to address the following problems: Removing clotted blood (hematomas). Bleeding outside or within the brain can result in a collection of clotted blood (hematoma) that puts pressure on the brain and damages brain tissue. Repairing skull fractures. Surgery may be needed to repair severe skull fractures or to remove pieces of skull in the brain. Bleeding in the brain. Head injuries that cause bleeding in the brain may need surgery to stop the bleeding. Opening a window in the skull. Surgery may be used to relieve pressure inside the skull by draining accumulated cerebrospinal fluid or creating a window in the skull that provides more room for swollen tissues. Module 5: Care of Clients with Altered Perception SMPERALTA  227 Rehabilitation Most people who have had a significant brain injury will require rehabilitation. They may need to relearn basic skills, such as walking or talking. The goal is to improve their abilities to perform daily activities. Therapy usually begins in the hospital and continues at an inpatient rehabilitation unit, a residential treatment facility or through outpatient services. The type and duration of rehabilitation is different for everyone, depending on the severity of the brain injury and what part of the brain was injured. Rehabilitation specialists may include: Physiatrist, a doctor trained in physical medicine and rehabilitation, who oversees the entire rehabilitation process, manages medical rehabilitation problems and prescribes medication as needed Occupational therapist, who helps the person learn, relearn or improve skills to perform everyday activities Physical therapist, who helps with mobility and relearning movement patterns, balance and walking Speech and language therapist, who helps the person improve communication skills and use assistive communication devices if necessary Neuropsychologist, who assesses cognitive impairment and performance, helps the person manage behaviors or learn coping strategies, and provides psychotherapy as needed for emotional and psychological well-being Social worker or case manager, who facilitates access to service agencies, assists with care decisions and planning, and facilitates communication among various professionals, care providers and family members Rehabilitation nurse, who provides ongoing rehabilitation care and services and who helps with discharge planning from the hospital or rehabilitation facility Traumatic brain injury nurse specialist, who helps coordinate care and educates the family about the injury and recovery process Recreational therapist, who assists with time management and leisure activities Vocational counselor, who assesses the ability to return to work and appropriate vocational opportunities and who provides resources for addressing common challenges in the workplace 2. STROKE Stroke, also known as a cerebrovascular accident or brain attack, is a sudden impairment of cerebral circulation in one or more blood vessels. A stroke interrupts or diminishes oxygen supply and commonly causes serious damage or necrosis in the brain tissues. The sooner circulation returns to normal after a stroke, the better your patient’s chances are for a complete recovery. However, about one-half of the patients who survive a stroke remain permanently disabled and experience a recurrence within weeks, months, or years. It’s the leading cause of admission to long-term care. Stroke is the third most common cause of death in the United States and the most common cause of neurologic disability. It affects more than 700,000 people each year and is fatal in about one-half of these cases. Module 5: Care of Clients with Altered Perception SMPERALTA  228 Causes Stroke typically results from one of three causes: thrombosis of the cerebral arteries supplying the brain or of the intracranial vessels occluding blood flow embolism from a thrombus outside the brain, such as in the heart, aorta, or common carotid artery hemorrhage from an intracranial artery or vein, such as from hypertension, ruptured aneurysm, AVM, trauma, hemorrhagic dis- order, or septic embolism. Risk factor Risk factors that predispose patients to stroke include: hypertension family history of stroke history of TIA (See TIA and elderly patients) cardiac disease, including arrhythmias, coronary artery disease, acute myocardial infarction, dilated cardiomyopathy, and valvular disease diabetes familial hyperlipidemia cigarette smoking increased alcohol intake obesity, sedentary lifestyle use of hormonal contraceptives. Pathophysiology Regardless of the cause, the underlying event leading to stroke is oxygen and nutrient deprivation. Here’s what happens: Normally, if the arteries become blocked, autoregulatory mechanisms maintain cerebral circulation until collateral circulation develops to deliver blood to the affected area. If the compensatory mechanisms become overworked or cerebral blood flow remains impaired for more than a few minutes, oxygen deprivation leads to infarction of brain tissue. The brain cells cease to function because they can’t engage in anaerobic metabolism or store glucose or glycogen for later use. Ischemic stroke Here’s what happens when a thrombotic or embolic stroke causes ischemia: Some of the neurons served by the occluded vessel die from lack of oxygen and nutrients. The result is cerebral infarction, in which tissue injury triggers an inflammatory response that in turn increases ICP. Injury to the surrounding cells disrupts metabolism and leads to changes in ionic transport, localized acidosis, and free radical formation. Calcium, sodium, and water accumulate in the injured cells, and excitatory neurotransmitters are released. Consequent continued cellular injury and swelling set up a vicious cycle of further damage. Hemorrhagic stroke Here’s what happens when a hemorrhage causes a stroke: Impaired cerebral perfusion causes infarction, and the blood acts as a space-occupying mass, exerting pressure on the brain tissues. The brain’s regulatory mechanisms attempt to maintain equilibrium by increasing blood pressure to maintain CPP. The increased ICP forces CSF out, thus restoring equilibrium. Module 5: Care of Clients with Altered Perception SMPERALTA  229 If the hemorrhage is small, the patient may have minimal neurologic deficits. If the bleeding is heavy, ICP increases rapidly and perfusion stops. Even if the pressure returns to normal, many brain cells die. Initially, the ruptured cerebral blood vessels may constrict to limit the blood loss. This vasospasm further compromises blood flow, leading to more ischemia and cellular damage. If a clot forms in the vessel, decreased blood flow also promotes ischemia. If the blood enters the subarachnoid space, meningeal irritation occurs. Blood cells that pass through the vessel wall into the surrounding tissue may break down and block the arachnoid villi, causing hydrocephalus. Signs and Symptoms Clinical features of stroke vary, depending on the artery affected (and, consequently, the portion of the brain it supplies), the severity of the damage, and the extent of collateral circulation that develops to help the brain compensate for decreased blood supply. A stroke in the left hemisphere produces symptoms on the right side of the body; in the right hemisphere, symptoms on the left side. Common signs and symptoms of stroke include sudden onset of: hemiparesis on the affected side (may be more severe in the face and arm than in the leg) unilateral sensory defect (such as numbness, or tingling) generally on the same side as the hemiparesis slurred or indistinct speech or the inability to understand speech blurred or indistinct vision, double vision, or vision loss in one eye (usually described as a curtain coming down or gray-out of vision) mental status changes or loss of consciousness (particularly if associated with one of the above symptoms) very severe headache (with hemorrhagic stroke). Diagnostic Tests Here are some test findings that can help diagnose a stroke: CT scan discloses structural abnormalities, edema, and lesions, such as non-hemorrhagic infarction and aneurysms. Results are used to differentiate a stroke from other disorders, such as a tumor or hematoma. Patients with TIA generally have a normal CT scan. CT scan shows evidence of hemorrhagic stroke immediately and of ischemic (thrombotic or embolic) stroke within 72 hours after onset of symptoms. CT scan should be obtained within 25 minutes after the patient arrives in the ED, and results should be available within 45 minutes of arrival to determine whether hemorrhage is present. If hemorrhagic stroke is present, thrombolytic therapy is contraindicated. MRI is used to identify areas of ischemia and infarction and cerebral swelling. Cerebral angiography shows details of disruption or displacement of the cerebral circulation by occlusion or hemorrhage. DSA is used to evaluate patency of the cerebral vessels and shows evidence of occlusion of the cerebral vessels, a lesion, or vascular abnormalities. Carotid duplex scan is a high-frequency ultrasound that shows blood flow through the carotid arteries and reveals stenosis due to atherosclerotic plaque and blood clots. Transcranial Doppler studies are used to evaluate the velocity of blood flow through major intracranial vessels, which can indicate vessel diameter. Brain scan shows ischemic areas but may not be conclusive for up to 2 weeks after stroke. Single photon emission CT scanning and PET scan show areas of altered metabolism surrounding lesions that aren’t revealed by other diagnostic tests. Module 5: Care of Clients with Altered Perception SMPERALTA  230 Lumbar puncture reveals bloody CSF when stroke is hemorrhagic. No laboratory tests confirm the diagnosis of stroke, but some tests aid diagnosis and some are used to establish a baseline for thrombolytic treatment. A blood glucose test shows whether the patient’s symptoms are related to hypoglycemia. Hemoglobin level and hematocrit may be elevated in severe occlusion. Baselines obtained before thrombolytic therapy begins include CBC, platelet count, PTT, PT, fibrinogen level, and chemistry panel. Treatment The goal is to begin treatment within 3 hours of symptom onset. Drugs of choice Thrombolytics (also called fibrinolytics) are the drugs of choice in treating a stroke patient. The patient must first meet certain criteria to be considered for this type of treatment. Drug therapy for the management of stroke includes: thrombolytics for emergency treatment of ischemic stroke aspirin or clopidogrel (Plavix) as an antiplatelet agent to prevent recurrent stroke benzodiazepines to treat patients with seizure activity anticonvulsants to treat seizures or to prevent them after the patient’s condition has stabilized stool softeners to avoid straining, which increases ICP antihypertensives and antiarrhythmics to treat patients with risk factors for recurrent stroke analgesics to relieve the headaches that may follow a hemorrhagic stroke. Medical management Medical management of stroke commonly includes physical rehabilitation, dietary and drug regimens to reduce risk factors, surgery, and care measures to help the patient adapt to deficits, such as motor impairment and paralysis. Surgery Depending on the cause and extent of the stroke, the patient may undergo: a craniotomy to remove a hematoma a carotid endarterectomy to remove atherosclerotic plaques from the inner arterial wall an extracranial bypass to circumvent an artery that’s blocked by occlusion or stenosis. Your facility may have a stroke protocol and stroke team com- posed of specially trained nurses who respond to potential stroke patients. When a patient shows signs and symptoms of a stroke, first assess the patient using a stroke assessment tool such as the Cincinnati Stroke Scale. Module 5: Care of Clients with Altered Perception SMPERALTA  231 Figure 2. Cincinnati Pre-Hospital Stroke Scale After your initial assessment, call the stroke team nurse, who will evaluate the patient, complete a neurologic assessment, report findings to the practitioner, and facilitate rapid and appropriate care of the patient, including emergency interventions, diagnostic tests, and transfer to the critical care unit. Nursing Considerations Secure and maintain the patient’s airway and anticipate the need for ET intubation and mechanical ventilation. Monitor oxygen saturation levels via pulse oximetry and ABG levels as ordered. Administer supplemental oxygen as ordered to maintain oxygen saturation greater than 90%. Place the patient on a cardiac monitor, and monitor for cardiac arrhythmias. Assess the patient’s neurologic status frequently, at least every 15 to 30 minutes, initially, then hourly as indicated. Observe for signs of increased ICP. If cerebral edema is suspected, maintain ICP sufficient for adequate cerebral perfusion but low enough to avoid brain herniation. Elevate the head of the bed 25 to 30 degrees. Assess hemodynamic status frequently. Give fluids as ordered and monitor I.V. infusions to avoid overhydration, which may in- crease ICP. For a patient receiving thrombolytic therapy, assess the patient for signs and symptoms of bleeding every 15 to 30 minutes and institute bleeding precautions. Monitor results of coagulation studies. Monitor the patient for seizures and administer anticonvulsants as ordered. Institute safety precautions to prevent injury. If the patient had a TIA, administer antiplatelet agents. Module 5: Care of Clients with Altered Perception SMPERALTA  232 Turn the patient often and position him using careful body alignment. Apply antiembolism stockings or intermittent sequential compression devices. Take steps to prevent skin breakdown. Begin exercises as soon as possible. Perform passive ROM exercises for both the affected and unaffected sides. Teach and encourage the patient to use his unaffected side to exercise his affected side. Manage GI problems. Be alert for signs of straining at stool as it increases ICP. If the patient is receiving steroids, monitor for signs of GI irritation. Modify the patient’s diet, as appropriate, such as by increasing fiber. Provide meticulous eye and mouth care. Maintain communication with the patient. If he’s aphasic, set up a simple method of communicating. Provide psychological support. 3. SPINAL CORD INJURY Spinal injuries include fractures, contusions, and compressions of the vertebral column. They usually result from trauma to the head or neck. Fractures of the 5th, 6th, or 7th cervical; 12th thoracic; and 1st lumbar vertebrae are most common. The real danger with spinal injury is spinal cord damage due to cutting, pulling, twisting, and compression. Spinal cord injury can occur at any level, and the damage it causes may be partial or involve the entire cord. Complications of spinal cord injury include neurogenic shock and spinal shock. Causes The most serious spinal cord trauma typically results from motor vehicle accidents, falls, sports injuries, diving into shallow water, and gunshot or stab wounds. Less serious injuries commonly occur from lifting heavy objects and minor falls. Spinal dysfunction may also result from hyperparathyroidism and neoplastic lesions. Pathophysiology Spinal cord trauma results from acceleration, deceleration, or other deforming forces. Types of trauma include: hyperextension due to acceleration–deceleration forces hyperflexion from sudden and excessive force vertebral compression from downward force from the top of the cranium, along the vertical axis, and through the vertebra rotational twisting, which adds shearing forces. After a Trauma Here’s what happens during spinal cord trauma: An injury causes microscopic hemorrhages in the gray matter and pia-arachnoid. The hemorrhages gradually increase in size until all of the gray matter is filled with blood, which causes necrosis. From the gray matter, the blood enters the white matter, where it impedes circulation within the spinal cord. Resulting edema causes compression and decreases the blood supply. The spinal cord loses perfusion and becomes ischemic. The edema and hemorrhage are usually greatest in the two segments above and below the injury. Module 5: Care of Clients with Altered Perception SMPERALTA  233 The edema temporarily adds to the patient’s dysfunction by increasing pressure and compressing the nerves. For example, edema near the 3rd to 5th cervical vertebrae may interfere with respiration. After acute injury Here’s what happens following acute trauma: In the white matter, circulation usually returns to normal within 24 hours after injury. In the gray matter, an inflammatory reaction prevents restoration of circulation. Phagocytes appear at the site within 35 to 48 hours after injury. Macrophages engulf degenerating axons, and collagen replaces the normal tissue. Scarring and meningeal thickening leave the nerves in the area blocked or tangled. Signs and Symptoms In your assessment, look for: history of trauma, a neoplastic lesion, an infection that could produce a spinal abscess, or an endocrine disorder muscle spasm and back or neck pain that worsens with movement; in cervical fractures, pain that causes point tenderness; in dorsal and lumbar fractures, pain that may radiate to other areas, such as the legs mild paresthesia to quadriplegia and shock, if the injury damages the spinal cord; in milder injury, symptoms that may be delayed several days or weeks. Specific signs and symptoms depend on the type and degree of injury. Diagnostic Tests Diagnoses of acute spinal cord injuries are based on the results of these tests: Spinal X-rays reveal fracture. Myelography shows the location of fracture and site of com- pression. CT scan and MRI show the location of fracture and the site of compression and reveal spinal cord edema and a possible spinal cord mass. Neurologic evaluation is used to locate the level of injury and detect cord damage. Treatments The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage. Other treatment is supportive. Cervical injuries require immobilization, using sandbags on both sides of the patient’s head, a hard cervical collar, or skeletal traction with skull tongs or a halo device. When a patient shows clinical evidence of a spinal cord injury, high doses of I.V. methylprednisolone (Solu-Medrol) may be started to reduce inflammation. However, the evidence on its effectiveness is limited, and its use is debated. Nursing Considerations Here’s what you should do for patients with spinal cord injuries: Immediately stabilize the patient’s spine. As with all spinal injuries, suspect cord damage until proven otherwise. Perform a neurologic assessment to establish a baseline and continually reassess neurologic status for changes. Assess respiratory status closely at least every hour, initially. Obtain baseline tidal volume, vital capacity, negative inspiratory forces, and minute volume. Auscultate breath sounds and check secretions as necessary. Module 5: Care of Clients with Altered Perception SMPERALTA  234 Monitor oxygen saturation levels as ordered. Administer supple- mental oxygen as indicated. Assess cardiac status frequently, at least every hour initially. Begin cardiac monitoring. Monitor blood pressure and hemodynamic status frequently. If a pulmonary artery catheter is in place, inform the practitioner if there’s a decrease in right atrial pressure, pulmonary artery pressure, pulmonary wedge pressure, and systemic vascular resistance that indicates neurogenic shock. If your patient becomes hypotensive, prepare to administer vasopressors. Prepare the patient for surgical stabilization, if necessary. Assess GI status closely for signs of ulceration or bleeding. Anticipate nasogastric (NG) tube insertion and low intermittent suctioning. Assess the abdomen for distention, auscultate bowel sounds, and report any decrease or absence. Be alert for paralytic ileus, which usually occurs 72 hours after injury. Monitor intake and output for fluid imbalance. Insert an indwelling urinary catheter as ordered. Begin measures to prevent skin breakdown due to immobilization, including repositioning, padding, and care of equipment such as halo or traction devices. Monitor laboratory and diagnostic test results, including BUN and creatinine levels, complete blood count (CBC), and urine culture (if indicated). Monitor the patient for deep vein thrombosis and pulmonary embolism. Apply antiembolism stockings or intermittent sequential compression devices as ordered. Provide emotional support to the patient and his family. Begin rehabilitation as soon as possible. An obese patient with spinal cord injury may have additional needs. END OF MODULE 5 Module 5: Care of Clients with Altered Perception SMPERALTA  235 4 MODULE SUMMARY In this module, you were able to have some review about the neurologic system. Common neurologic system disorders seen in the critical area, its assessment and management were also discussed. Additional treatment modalities were also discussed for further understanding about the nursing care of clients with altered perception. Congratulations! You may now proceed to module 6 after taking the graded quiz. ? SUMMATIVE TEST 1. Graded quiz, covering the three lessons, will be administered thru correspondence. FEEDBACK After using this module I perceived that this module is __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________ I would recommend that ______________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ _____________________________________ Module 5: Care of Clients with Altered Perception SMPERALTA  236 Module 5: Care of Clients with Altered Perception SMPERALTA