Managing clients with Neurologic Dysfunction

Ma. Tosca Cybil A. Torres, RN, MAN

Outline

• Altered LOC• Increase ICP• Seizure disorders• Headache

Altered Level of Consciousness

client is not oriented, does not follow

commands, or needs persistent stimuli to

achieve a state of alertness.

Coma- a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli.

Akinetic mutism- state of unresponsiveness to the environment in which the patient makes no voluntary movement

Persistent vegetative state- a condition in which the unresponsive client resumes sleep-wake cycles after coma but is devoid of cognitive or affective mental function.

Locked-in syndrome- tetraplegia with inability to speak, but vertical eye movement s and lid elevation remain intact and are used to indicate responsiveness.

The level of responsiveness and consciousness is the MOST important

indicator of the patient’s condition.

Causes of Altered LOC

Neurologic Toxicologic Metabolic

Assessment

Includes: Mental status Cranial nerve function Cerebellar function Reflex, motor, and sensory

function Glasgow Coma Scale

Alertness Motor response

Complications

Respiratory failure Pneumonia Pressure ulcersAspiration DVTContractures

Medical Mgt

The first PRIORITY of tx for a client with altered LOC is to

obtain and maintain a

PATENT AIRWAY

Possible nursing diagnoses

Ineffective airway clearance

Risk for injury Deficient fluid

volume Risk for

impaired skin integrity

Impaired tissue integrity of cornea

Ineffective thermoregulation

Bowel incontinence

Impaired urinary elimination

Disturbed sensory perception

Interrupted family processes

The nurse assume responsibility for the client until the basic

reflexes return and the patient becomes

conscious and oriented. Therefore, the major nursing goal is to

compensate for the absence of these

protective reflexes.

If the client begins to emerge from

unconsciousness, every measure that

is available and appropriate in calming and

quieting the client should be used.

Nursing Interventions

Maintaining the airway

Protecting the client

Managing fluid balance and managing nutritional needs

Providing mouth care

Maintaining skin and joint integrity

Preserving corneal integrity

Maintaining body temperature

Prevent urinary retention

Promoting bowel function

Providing sensory stimulation

Managing the family’s needs

Monitoring and managing potential complications

Increased Intracranial Pressure

Intracranial pressure greater than 20 mmHg

Etiology: Head injury Stroke Inflammatory lesions Brain tumor Intracranial surgery

Complications

• Brain stem herniation• DI• SIADH

SIGNS AND SYMPTOMSEarly Signs•decreased level of consciousness

•Restlessness•Confusion •difficulty with memory and thinking

•pupillary dysfunction

• Impaired extraocular movements

•changes in vision

•deterioration of motor function

•Headache•decreasing Glascow Coma Score

Later Signs

•continued decrease in level of consciousness •dilated pupils, no reaction to light •Altered respiratory functions •hemiplegia that progresses • projectile vomiting •hyperthermia •papilledema •Loss of brain stem reflexes•Vital signs will present the "Cushing triad". hypertention, bradycardia, widening pulse pressure

INTERVENTIONS FOR THE PATIENT WITH INCREASED ICP

Goals of Therapya.Decrease cerebral blood flow

b.Decreasing cerebral edema

c.Lowering volume of CSF

Medical management

• Monitoring intracranial pressure and cerebral oxygenation

• Decreasing cerebral edema • Maintaining cerebral perfusion • Reducing cerebral fluid and

intracranial blood volume • Controlling • Maintaining oxygenation • Reducing metabolic demands

Nursing diagnoses

• Ineffective airway clearance • Ineffective breathing pattern• Ineffective cerebral tissue

perfusion • Deficient fluid volume • Risk for infection

Nursing Interventions

• Maintaining a patent airway • Achieving an adequate breathing

pattern • Optimizing cerebral tissue

perfusion • Maintaining negative fluid

balance • Preventing infection • Monitoring and managing

potential complications

Nursing Management includes:

 • Maintain the patients head midline to

facilitate blood flow.

• Maintain the head of the bed at 30 - 45 degrees to facilitate venous drainage.

• Avoid activities that can increase ICP such as suctioning or gagging.

• Treat hyperthermia

• Decrease environmental stimuli

• Dim all lights

• Speak softly

• Touch gently and only when needed

• Maintain fluid balance via accurate I & O.

• Monitor electrolytes as these patients are prone to hypernatremia, hypoglycemia, and hypokalemia with diuretic usage.

• Monitor hyperventilation to maintain CO2 levels at 25 - 35mm Hg to prevent vasodilation

Medical Management includes:

1.Anticonvulsant therapy for seizures.

2.Use of diuretics such as Mannitol

3.50% Dextrose solution if hypoglycemia is present and persistent.

4. Surgical decompression-         considered life saving

measure-         opening of the skull can lead

to severe herniation

Specific Treatment

a.Surgical removal of intracranial masses.

b. Placement of extraventricular drain (temporary).

c. Placement of VP shunt (usually permanent).

Seizure Disorders

Seizures- episodes of abnormal motor, sensory,

autonomic, or psychic activity that results from

sudden excessive discharge from cerebral

neurons

Epilepsy

a group of syndromes characterized by

unprovoked, uncontrolled, recurring

seizures due to excessive firing of

hyperexcitable neurons of the brain

International Classification of Seizures

Partial Seizures Complex Partial Seizures

Generalized Seizures

•With motor symptoms •With special sensory or somatosensory symptoms •With autonomic symptoms •Compound forms

•With impairment of consciousness only •With cognitive symptoms •With affective symptoms •With psychosensory symptoms •With psychomotor symptoms •Compound forms

•Tonic clonic seizures•Tonic seizures•Clonic seizures •Absence seizure (Petit mal) •Atonic seizures•Myoclonic seizures (bilaterally massive epileptic) •Unclassified seizure

GENERALIZED SEIZURES

TONIC CLONIC Begins with tonic, loss of consciousness, then clonic

TONIC Stiffening or rigidity of muscles, loss of consciousness

CLONIC Rhythmic jerking of muscle contraction and relaxation

ABSENCE Brief loss of conscious awareness and staring into space; appears to be daydreaming

MYOCLONIC Brief stiffening or jerking of extremity, either single or in groups

ATONIC Loss of muscle tone

PARTIAL SEIZURES

SIMPLE PARTIAL Begins with an aura; may have unilateral unusual sensation or movement of extremity, autonomic, or psychic changes; no loss of consciousness

COMPLEX PARTIAL Loss of consciousness; automatism

JACKSONIAN Begin in one part of the body and may progress to a generalized tonic-clonic seizure

Causes

• CVA• Hypoxemia • Fever• Head injury • HTN• CNS infection • Metabolic and

toxic conditions

• Brain tumor • Drug and alcohol

withdrawal • Allergies

Nursing management

DURING A SEIZURE, the

major responsibility of the nurse is to

observe and record the

sequence of signs.

Documentation would include:

• Circumstances before the seizure • The occurrence of an aura • The first thing the patient does in the seizure • The type of movements in the part of the

body involved• The areas of the body involved • The size of both pupils and whether the eyes

are open • Whether the eyes or head turned to one side • The presence or absence of automatisms • Incontinence of urine or stool • Duration of each phase of the seizure

Documentation would include:

• Unconsciousness• Any obvious paralysis or

weakness of arms or legs after the seizure

• Inability to speak • Movements at the end of the

seizure • Whether or not the patient

sleeps afterward • Cognitive status

Nursing care during a seizure

• Provide privacy and protect the patient from curious onlookers • Ease the patient to the floor, if possible • Loosen constrictive clothing • Push aside any furniture that may injure the patient during the

seizure • If the patient in in bed, remove the pillows and raise all side

rails • In an aura precedes the seizure, insert an oral airway• DO NOT ATTEMPT TO PRY OPEN JAWS THAT ARE

CLENCHED IN A SPASM OR TO INSERT ANYTHING.• No attempt should be made to restrain the patient during the

seizure • If possible, place the patient on one side with head flexed

forward.

After a Seizure

The nurse’s role is to document the events

leading to and occurring during and after the

seizure and to prevent complications

Nursing care after the seizure

• Keep the patient on one side------Make sure the airway is patent

• The patient, on awakening, should be reoriented to the environment

• If the patient becomes agitated after a seizure, use a calm persuasion and gentle restraints.

Nursing diagnoses

Risk for injury Fear Ineffective individual coping

Deficient knowledge

Nursing interventions

• Preventing injury • Reducing fear of seizures• Improving coping mechanisms• Providing patient and family

education • Monitoring and managing potential

complications • Promoting home and community

based care

Status Epilepticus

A series of generalized

seizures that occur without full recovery of

consciousness between attacks

Medical management

The goals of treatment are to stop the seizures as quickly as possible, to

ensure adequate cerebral oxygenation, and to

maintain the patient in a seizure-free state

Headache

• Cephalgia • Most common of all human

physical complaints

Types of headache

1. Primary headache- no organic cause ca be identified a. Migraine- a symptom complex

characterized by periodic and recurrent attacks of severe headache lasting from 4-72H

b. Tension-type- tend to be chronic and less severe

c. Cluster- severe form of vascular headache

Assessment

The diagnostic evaluation includes a detailed

history, a PA of the head and neck, and a

complete neurologic examination

Migraine

Migraine with an aura:

Phases: Prodrome Aura phaseHeadache phaseRecovery phase