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7/31/2019 Management of Patients With Neurologic Dysfunction
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Management of Patients With
Neurologic Dysfunction
Ziad . M.Alostaz
RN-BC,MSN,ACNS
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Altered Level of Consciousness (LOC)
Level of responsiveness and consciousness isthe most important indicator of the patient'scondition
LOC is a continuum from normal alertness andfull cognition (consciousness) to coma
Altered LOC is not the disorder but the result
of a pathology Coma:unconsciousness, unresponsiveness,
and inability to arouse
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CONT
Persistent vegetative state: patient is devoid of
cognitive function but has sleepwake cycles
Akinetic mutism: unresponsiveness to the
environment, the patient makes no movement
or sound but sometimes opens eyes
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Nursing ProcessAssessment of the
Patient With Altered LOC
Verbal response and orientation
Alertness
Motor responses
Respiratory status Eye signs
Reflexes
Postures
Glasgow Coma Scale
See Table 61-1
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Nursing ProcessDiagnosis of the Patient
With Altered Level of Consciousness
Ineffective airway clearance Risk of injury Deficient fluid volume Impaired oral mucosa
Risk for impaired skin integrity and impairedtissue integrity (cornea)
Ineffective thermoregulation
Impaired urinary elimination and bowelincontinence Disturbed sensory perception Interrupted family processes
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Collaborative Problems/Potential
Complications
Respiratory distress or failure
Pneumonia
Aspiration
Pressure ulcer
Deep vein thrombosis (DVT)
Contractures
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Nursing ProcessPlanning the Care of
the Patient With Altered LOC Goals include:
Maintenance of clear airway
Protection from injury
Attainment of fluid volume balance Maintenance of skin integrity
Absence of corneal irritation
Effective thermoregulation
Accurate perception of environmental stimuli Maintenance of intact family or support system
Absence of complications
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Interventions
A major nursing goal is to compensate for thepatient's loss of protective reflexes and to assumeresponsibility for total patient care; protectionincludes maintaining the patients dignity and
privacy Maintain an airway
Frequent monitoring of respiratory status includingauscultation of lung sounds
Position the patient to promote accumulation ofsecretions and prevent obstruction of upper airway:HOB elevated 30, lateral or semiprone position
Provide suctioning, oral hygiene, and CPT
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Maintaining Tissue Integrity
Assess skin frequently, especially areas with high potentialfor breakdown
Turn patient frequently; use turning schedule
Carefully position patient in correct body alignment
Perform passive range of motion Use splints, foam boots, trochanter rolls, and specialty beds
as needed
Clean eyes with cotton balls moistened with saline
Use artificial tears as prescribed
Implement measures to protect eyes; use eye patchescautiously as the cornea may contact patch
Provide frequent, scrupulous oral care
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CONT
Maintain fluid status Assess fluid status by examining tissue turgor and mucosa,
lab data, and I&O
Administer IVs, tube feedings, and fluids via feeding tube asrequired: monitor ordered rate of IV fluids carefully
Maintain body temperature Adjust environment and cover patient appropriately
If temperature is elevated, use minimum amount ofbedding, administer acetaminophen, use hypothermiablanket, give a cooling sponge bath, and allow fan to blowover patient to increase cooling
Monitor temperature frequently and use measures toprevent shivering
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Promoting Bowel and Bladder
Function Assess for urinary retention and urinary
incontinence May require indwelling or intermittent
catherization Initiate bladder-training program
Assess for abdominal distention, potentialconstipation, and bowel incontinence
Monitor bowel movements
Promote elimination with stool softeners,glycerin suppositories, or enemas as indicated
Diarrhea may result from infection, medications,or hyperosmolar fluids
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Increased Intracranial Pressure (ICP)
Monro-Kellie hypothesis: because of limitedspace in the skull, an increase in any one skullcomponentbrain tissue, blood, or CSFwillcause a change in the volume of the others
Compensation to maintain a normal ICP of lessthan 15 mm Hg is normally accomplished byshifting or displacing CSF
With disease or injury, ICP may increase Increased ICP decreases cerebral perfusion,
causes ischemia, cell death, and (further) edema
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CONT.
Brain tissues may shift through the dura andresult in herniation
Autoregulation: refers to the brains ability tochange the diameter of blood vessels tomaintain cerebral blood flow
CO2 plays a role; decreased CO2 results invasoconstriction, and increased CO2 results invasodilatation
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ICP and CPP
CCP (cerebral perfusion pressure) is closely
linked to ICP
CCP = MAP (mean arterial pressure) ICP
Normal CCP is 70 to 100
A CCP of less than 50 results in permanent
neuralgic damage
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Manifestations of Increased ICPEarly
Changes in level of consciousness
Any change in condition
Restlessness, confusion, increasing drowsiness, increased
respiratory effort, and purposeless movements
Pupillary changes and impaired ocular movements
Weakness in one extremity or one side
Headache: constant, increasing in intensity, or aggravated by
movement or straining
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Manifestations of Increased ICPLate
Respiratory and vasomotor changes
VS: increase in systolic blood pressure, widening of pulse
pressure, and slowing of the heart rate; pulse may fluctuate
rapidly from tachycardia to bradycardia and temperatureincrease
Cushings triad: bradycardia, hypertension, and bradypnea
Projectile vomiting
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Manifestations of Increased ICPLate
(cont.)
Further deterioration of LOC; stupor to coma
Hemiplegia, decortication, decerebration, or
flaccidity
Respiratory pattern alterations includingCheyne-Stokes breathing and arrest
Loss of brain stem reflexes: pupil, gag, corneal,and swallowing
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Nursing ProcessAssessment of the Patient
With Increased
Intracranial Pressure
Conduct frequent and ongoing neurologicassessment
Evaluate neurologic status as completely as
possible Glasgow Coma Scale
Pupil checks
Assess selected cranial nerves Take frequent vital signs
Assess intracranial pressure
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ICP Monitoring
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Nursing ProcessDiagnosis of the Patient With
Increased Intracranial Pressure
Ineffective airway clearance
Ineffective breathing pattern
Ineffective cerebral perfusion
Deficient fluid volume related to fluid
restriction
Risk for infection related to ICP monitoring
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Collaborative Problems/Potential Complications
Brain stem herniation
Diabetes insipidus
SIADH
Infection
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Nursing ProcessPlanning the Care of the Patient With
Increased
Intracranial Pressure
Major goals may include:
Maintenance of patent airway
Normalization of respirations
Adequate cerebral tissue perfusion
Respirations
Fluid balance
Absence of infection
Absence of complications
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Interventions
Frequent monitoring of respiratory status and lung sounds andmeasure to maintain a patent airway
Position with the head in neutral position and HOB elevation of 15to 30 to promote venous drainage
Avoid hip flexion, Valsalva maneuver, abdominal distention, orother stimuli that may increase ICP
Maintain a calm, quiet atmosphere and protect patient from stress
Treat constipation
Avoid any movement that cause increase ICP (valsalva maneuver )
Monitor fluid status carefully; during acute phase, monitor I&Oevery hour
Use strict aseptic technique for management of ICP monitoringsystem
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Questions:
Thank you