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Published on May 18, 2008

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Nursing Management of the Adult Client with Neurologic Alterations NURS 228 Janie Best, MSN, RN, APRN, BC

Objectives Relate principles of anatomy and physiology to the nursing care of individuals with common health problems of the nervous system. Analyze the common health problems that accompany alterations in cerebral circulation in the adult patient Altered Level of consciousness (LOC) Increased intracranial pressure

Relate principles of anatomy and physiology to the nursing care of individuals with common health problems of the nervous system.

Analyze the common health problems that accompany alterations in cerebral circulation in the adult patient

Altered Level of consciousness (LOC)

Increased intracranial pressure

The Nervous System Central Nervous System (CNS) Brain Spinal Cord Peripheral Nervous System (PNS) Cranial nerves Spinal nerves Autonomic nervous system Sympathetic Parasympathetic

Central Nervous System (CNS)

Brain

Spinal Cord

Peripheral Nervous System (PNS)

Cranial nerves

Spinal nerves

Autonomic nervous system

Sympathetic

Parasympathetic

Anatomy Brain Cerebrum Hemispheres Lobes: Frontal, Parietal, Temporal, Occiptial Thalamus, Hypothalamus, Basal ganglia Cerebellum Brain Stem

Brain

Cerebrum

Hemispheres

Lobes: Frontal, Parietal, Temporal, Occiptial

Thalamus, Hypothalamus, Basal ganglia

Cerebellum

Brain Stem

 

Anatomy Protective Structures Dura mater Arachnoid Pia mater CSF Clear, colorless Produced by choroid plexus (ventricles/arachnoid layer) 500 mL daily; Most absorbed by body

Protective Structures

Dura mater

Arachnoid

Pia mater

CSF

Clear, colorless

Produced by choroid plexus (ventricles/arachnoid layer)

500 mL daily; Most absorbed by body

Brain Requirements Blood Flow 750 ml / minute 20% of total oxygen uptake Glucose 80% of body’s glucose use Blood Flow Regulation CO 2 Oxygen

Blood Flow

750 ml / minute

20% of total oxygen uptake

Glucose

80% of body’s glucose use

Blood Flow Regulation

CO 2

Oxygen

Diagnostic Studies Skull and Spine Radiography CT (Computerized Tomography) MRI (Magnetic Resonance Imaging) PET (Positron Emission Tomography) EEG (Electroencephalogram) EMG (Electromyography)

Skull and Spine Radiography

CT (Computerized Tomography)

MRI (Magnetic Resonance Imaging)

PET (Positron Emission Tomography)

EEG (Electroencephalogram)

EMG (Electromyography)

Diagnostic Studies – Cerebral Angiography Pre-procedure care Assess for allergy to iodine and shellfish NPO 4-6 hrs Baseline neuro assessment Education Immobile during / following procedure Expect brief feeling of warmth / burning in behind eyes, or in jaw, teeth, tongue, lips May have metallic taste Post Procedure Care Bedrest x 8 hrs Increase Fluids Monitor Neuro assessment / VS Peripheral pulses Observe for s/s altered cerebral blood flow Hematoma at femoral injection site Keep bed FLAT if femoral artery is used

Pre-procedure care

Assess for allergy to iodine and shellfish

NPO 4-6 hrs

Baseline neuro assessment

Education

Immobile during / following procedure

Expect brief feeling of warmth / burning in behind eyes, or in jaw, teeth, tongue, lips

May have metallic taste

Post Procedure Care

Bedrest x 8 hrs

Increase Fluids

Monitor

Neuro assessment / VS

Peripheral pulses

Observe

for s/s altered cerebral blood flow

Hematoma at femoral injection site

Keep bed FLAT if femoral artery is used

Diagnostic Studies – Myelography / Lumbar Puncture Post Procedure Care HOB > 30 0 – 45 0 for 3 – 8 hrs Drink plenty of fluids Monitor VS and Urinary output Pre Procedure Care NPO Sedative may be given Lateral recumbent position with knees drawn up to abdomen and chin onto chest Patient Ed. - Position of x-ray table may be changed during procedure LP is contraindicated if suspected IICP

Post Procedure Care

HOB > 30 0 – 45 0 for 3 – 8 hrs

Drink plenty of fluids

Monitor VS and Urinary output

Pre Procedure Care

NPO

Sedative may be given

Lateral recumbent position with knees drawn up to abdomen and chin onto chest

Patient Ed. - Position of x-ray table may be changed during procedure

Neurological Assessment Hx present illness A – associated symptoms P – what provokes / pallliates symptoms Q – Quality of pain R – region and radiation S – severity of pain on scale of 1-10 T – timing (start / stop, intermittent, constant)

Hx present illness

A – associated symptoms

P – what provokes / pallliates symptoms

Q – Quality of pain

R – region and radiation

S – severity of pain on scale of 1-10

T – timing

(start / stop, intermittent, constant)

Neurological Assessment Physical Exam Mental status Cranial Nerves Motor system Cerebellar - balance / coordination Sensory system Reflexes

Physical Exam

Mental status

Cranial Nerves

Motor system

Cerebellar - balance / coordination

Sensory system

Reflexes

 

Abnormal Findings Babinski Reflex CNS disease of pyramidal tract Clonus Hyperactive reflexes Corneal reflex Loss - dysfunction of Cranial nerve 5 Gag reflex Loss - Dysfunction of cranial nerves IX and X Text: 1839-1840

Babinski Reflex

CNS disease of pyramidal tract

Clonus

Hyperactive reflexes

Corneal reflex

Loss - dysfunction of Cranial nerve 5

Gag reflex

Loss - Dysfunction of cranial nerves IX and X

Abnormal Findings Battle’s sign Raccoon’s eye Rhinorrhea Otorrhea

Battle’s sign

Raccoon’s eye

Rhinorrhea

Otorrhea

Doll’s Eyes - Oculocephalic Reflex http:// connection.lww.com/Products/morton/documents/images/Ch33/jpg/Ch33-006B.jpg

Doll’s Eyes - Oculocephalic Reflex

 

No motor tone or function, limp Cerebellar function Flacid posturing Extension & external rotation of arms & wrists, extension, plantar flexion, internal rotation of feet Cerebellar function Decerebrate posturing Internal rotation of arms &wrists, extension, internal rotation & plantar flexion of the feet Cerebellar function Decorticate posturing Eyes fail to follow normal movements Brainstem Doll’s eyes

Altered LOC - Etiology Vowel A lcohol E pilepsy I nsulin O piates U rates (renal failure) TIPPS T rauma I nfection P sych P oisons S hock

Vowel

A lcohol

E pilepsy

I nsulin

O piates

U rates (renal failure)

TIPPS

T rauma

I nfection

P sych

P oisons

S hock

Altered LOC Arousal Alertness, response to stimuli Content Awareness of time, place, person

Arousal

Alertness, response to stimuli

Content

Awareness of time, place, person

Altered LOC Level of Consciousness Continuum Terminology Alert Confusion Somnolent Lethargic Obtunded / Stupor Comatose

Level of Consciousness

Continuum

Terminology

Alert

Confusion

Somnolent

Lethargic

Obtunded / Stupor

Comatose

Glasgow Coma Scale Best Eye-opening response 1 = no response 4 = spontaneously Best Verbal response 1= no response 5 = oriented Best Motor response 1 = no response 6 = obeys commands Score < 7 is consistent with significant alteration in LOC (coma)

Best Eye-opening response

1 = no response

4 = spontaneously

Best Verbal response

1= no response

5 = oriented

Best Motor response

1 = no response

6 = obeys commands

Assessment of Respirations Cheyne-Stokes Rhythmical pattern: waxing/ waning in depth, followed by periods of apnea Neurogenic hyperventilation Regular, rapid (> 24 / min), deep sustained respirations Apneustic Irregular respirations with pauses at the end of inspiration & expiration Ataxic Totally irregular in rhythm & depth Cluster Clusters of irregular breaths with irregularly spaced apnea

Cheyne-Stokes

Rhythmical pattern: waxing/ waning in depth, followed by periods of apnea

Neurogenic hyperventilation

Regular, rapid (> 24 / min), deep sustained respirations

Apneustic

Irregular respirations with pauses at the end of inspiration & expiration

Ataxic

Totally irregular in rhythm & depth

Cluster

Clusters of irregular breaths with irregularly spaced apnea

Assessment of other Vital Signs Spinal shock Metabolic coma Drug overdose Brainstem lesions Decrease Temperature CNS infection Subarachnoid hemorrhage, hypothalamic lesions, hemmorhage of hypothalamus or brainstem Increase Temperature Implications ↑ /  Vital Sign

Assessment of other Vital Signs Cerebral trauma – Cushing’s triad HTN Blood Pressure Poor cerebral oxygenation Late stages of IICP Increase Decrease Pulse Implications ↑ or  Vital Sign

Brain Death Persistent vegetative state Brain death Rule out spinal cord injury Other causes of neurologic impairment No neuromuscular paralyzing agent effects Criteria documented in chart includes Flat EEG Absence of spontaneous respirations Pupils fixed and dilated

Persistent vegetative state

Brain death

Rule out

spinal cord injury

Other causes of neurologic impairment

No neuromuscular paralyzing agent effects

Criteria documented in chart includes

Flat EEG

Absence of spontaneous respirations

Pupils fixed and dilated

Altered LOC Nursing Interventions Airway maintenance Fluid balance and Nutrition Mouth care Skin and joint integrity Preventing injury Temperature regulation Bladder and bowel function

Nursing Interventions

Airway maintenance

Fluid balance and Nutrition

Mouth care

Skin and joint integrity

Preventing injury

Temperature regulation

Bladder and bowel function

Altered LOC Nursing Interventions Sensory stimulation Family needs Preventing complications Pneumonia Aspiration Respiratory failure DVT/PE Outcomes Assume the unconscious patient CAN hear!

Nursing Interventions

Sensory stimulation

Family needs

Preventing complications

Pneumonia

Aspiration

Respiratory failure

DVT/PE

Outcomes

Intracranial Pressure (ICP) Pressure exerted by the combined volume of Brain tissue CSF Blood Normal ICP: 10 – 20 mmHg Normal CSF pressure 5-13 mmHg

Pressure exerted by the combined volume of

Brain tissue

CSF

Blood

Normal ICP:

10 – 20 mmHg

Normal CSF pressure

5-13 mmHg

Intracranial Pressure (ICP) Closed Box Brain tissue (80%) Blood (10%) CSF (10%) Brain Injury Skull may contain swollen brain tissue, blood or CSF Skull May become too full ↑ pressure on brain tissue

Closed Box

Brain tissue (80%)

Blood (10%)

CSF (10%)

Brain Injury

Skull may contain swollen brain tissue, blood or CSF

Skull

May become too full

↑ pressure on brain tissue

Intracranial Pressure (ICP) Compensation: Monro-Kellie Hypothesis Change in volume of one of the contents must have a change in volume of one or both of the other components in order to remain stable

Compensation:

Monro-Kellie Hypothesis

Change in volume of one of the contents must have a change in volume of one or both of the other components in order to remain stable

Intracranial Pressure (ICP) Brain volume – limited expansion; controlled by Blood – brain barrier Cerebral blood volume – controlled by cerebral blood flow CSF - ↑ CSF absorption- or-  CSF production Shunting of venous blood out of the skull

Brain volume – limited expansion; controlled by Blood – brain barrier

Cerebral blood volume – controlled by cerebral blood flow

CSF -

↑ CSF absorption- or-

 CSF production

Shunting of venous blood out of the skull

Blood-Brain Barrier Permeable to water, oxygen, CO 2 , other gases, glucose and lipid soluble compounds Movement across barrier depends on: Particle size Lipid solubility Chemical dissociation Protein-binding capacity

Permeable to water, oxygen, CO 2 , other gases, glucose and lipid soluble compounds

Movement across barrier depends on:

Particle size

Lipid solubility

Chemical dissociation

Protein-binding capacity

Cerebral Blood Flow / Volume Increased Flow / volume: Effects Systemic hypotension ↑ metabolic rate Acidosis Hypercapnia, ischemia Cerebral vasodilation Decreased Blood flow / volume: Effects Hypertension ↓ metabolic rate Alkalosis Hypocapnia Cerebral edema Low cardiac output Cerebral vasoconstriction

Increased Flow / volume:

Effects

Systemic hypotension

↑ metabolic rate

Acidosis

Hypercapnia, ischemia

Cerebral vasodilation

Decreased Blood flow / volume:

Effects

Hypertension

↓ metabolic rate

Alkalosis

Hypocapnia

Cerebral edema

Low cardiac output

Cerebral vasoconstriction

↑ Brain Volume Cause: Space – occupying lesions Cerebral edema Effect : Herniation http://www.uth.tmc.edu/radiology/test/er_primer/skull_brain/skull.html

Cause:

Space – occupying lesions

Cerebral edema

Effect :

Herniation

Cerebrospinal Fluid Functions Support / cushioning Maintain stable chemical balance of CNS Excrete toxic wastes CO 2 , lactate, hydrogen ions Causes of ↑CSF : ↑ production Obstructed circulation ↓ absorption Effect : ↑ cerebral blood volume Hydrocephalus

Functions

Support / cushioning

Maintain stable chemical balance of CNS

Excrete toxic wastes

CO 2 , lactate, hydrogen ions

Causes of ↑CSF :

↑ production

Obstructed circulation

↓ absorption

Intracranial Pressure (ICP) Compensation depends on Location of lesion Rate of expansion Compliance or volume-buffering capacity of body

Compensation depends on

Location of lesion

Rate of expansion

Compliance or volume-buffering capacity of body

Cycle of malignant progressive brain swelling ↑ ICP  Cerebral brain flow Tissue hypoxia ↑ pCO 2  pH Cerebral vasodilation & edema from From: Hudak, C.: Critical care nursing: p. 640

IICP CPP (Cerebral Perfusion Pressure) CPP = MAP – ICP Normal CPP – 70 to 100 mmHg IICP – CPP > 100 mmHg or < 50 mmHg < 50 mmHg – irreversible damage Cushing’s Response (Cushing’s reflex) ↑ SBP w/ widening pulse pressure ↓ pulse

CPP (Cerebral Perfusion Pressure)

CPP = MAP – ICP

Normal CPP – 70 to 100 mmHg

IICP – CPP > 100 mmHg or < 50 mmHg

< 50 mmHg – irreversible damage

Cushing’s Response (Cushing’s reflex)

↑ SBP w/ widening pulse pressure

↓ pulse

IICP Cushing’s Triad ↑ systolic blood pressure  diastolic blood pressure Bradycardia Activation ICP ≥ Mean arterial pressure Ominous sign

Cushing’s Triad

↑ systolic blood pressure

 diastolic blood pressure

Bradycardia

Activation

ICP ≥ Mean arterial pressure

Ominous sign

 

IICP Early Indicators ∆ LOC ( earliest indicator ) Slowing of speech Delays in response to verbal suggestions Pupillary changes, Impaired EOMs Ipsilateral weakness Headache (constant, increasing intensity, aggravated by movement)

Early Indicators

∆ LOC ( earliest indicator )

Slowing of speech

Delays in response to verbal suggestions

Pupillary changes, Impaired EOMs

Ipsilateral weakness

Headache

(constant, increasing intensity, aggravated by movement)

IICP Later Indicators Continued deterioration of LOC Pulse, Respiratory rate decreased/erratic BP, Temp increase Altered respiratory patterns Cheyne-Stokes respirations Ataxic breathing Projective vomiting Hemiplegia, Posturing Loss of pupillary, corneal, gag, swallowing reflexes

Later Indicators

Continued deterioration of LOC

Pulse, Respiratory rate decreased/erratic

BP, Temp increase

Altered respiratory patterns

Cheyne-Stokes respirations

Ataxic breathing

Projective vomiting

Hemiplegia, Posturing

Loss of pupillary, corneal, gag, swallowing reflexes

 

IICP - Complications Cerebral Herniation DI (Diabetes Insipidus) - ↓ secretion ADH Clinical manifestations SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) - ↑ secretion ADH Clinical manifestations

Cerebral Herniation

DI (Diabetes Insipidus) - ↓ secretion ADH

Clinical manifestations

SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) - ↑ secretion ADH

Clinical manifestations

IICP – Complications DI DI (Diabetes Insipidus) - ↓ secretion ADH Clinical manifestations Polydipsia, polyuria, dehydration Urine output increases dramatically (up to 20 L / 24hr) Urine specific gravity falls to 1.001 – 1.005 Urine osmolality ↓ to 50 – 100 mOsm/kg.

DI (Diabetes Insipidus) - ↓ secretion ADH

Clinical manifestations

Polydipsia, polyuria, dehydration

Urine output increases dramatically (up to 20 L / 24hr)

Urine specific gravity falls to 1.001 – 1.005

Urine osmolality ↓ to 50 – 100 mOsm/kg.

IICP – Complications - DI Treatment Fluid and electrolyte management Vasopressin Thiazide diuretics Complications Cardiovascular collapse Tissue hypoxia Seizures Encephalopathy

Treatment

Fluid and electrolyte management

Vasopressin

Thiazide diuretics

Complications

Cardiovascular collapse

Tissue hypoxia

Seizures

Encephalopathy

IICP – Complications - SIADH SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) – Pathophysiology: ↑ secretion ADH or  production of ADH Results in ↑ in total body water Secretion continues with  osmolality of plasma Causes Pituitary tumor Head injury CNS infection Bronchogenic (oat cell), or pancreatic carcinoma

SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) –

Pathophysiology:

↑ secretion ADH or  production of ADH

Results in ↑ in total body water

Secretion continues with  osmolality of plasma

Causes

Pituitary tumor

Head injury

CNS infection

Bronchogenic (oat cell), or pancreatic carcinoma

IICP – Complications - SIADH Clinical manifestations Water retention -> water intoxication Hyponatremia Signs / symptoms Personality changes Headache Decreased mentation Lethargy N, V, diarrhea Decreased tendon reflexes Seizures, coma

Clinical manifestations

Water retention -> water intoxication

Hyponatremia

Signs / symptoms

Personality changes

Headache

Decreased mentation

Lethargy

N, V, diarrhea

Decreased tendon reflexes

Seizures, coma

IICP – Complications - SIADH Treatment Treat underlying disease Alleviate excessive water retention Nursing care – depressed LOC Complications Seizures Coma Death

Treatment

Treat underlying disease

Alleviate excessive water retention

Nursing care – depressed LOC

Complications

Seizures

Coma

Death

IICP – Medical Management Goals Decreasing Cerebral Edema Lowering CSF Volume Decreasing Cerebral Blood Volume

Goals

Decreasing Cerebral Edema

Lowering CSF Volume

Decreasing Cerebral Blood Volume

IICP – Medical Management Neuro Exam Ventriculostomy ICP monitoring ↑ risk infection, bleeding, destruction of neurons Contraindications Coagulopathies, small or collapsed ventricles, severe generalized cerebral edema CSF Drainage Clear CSF

Neuro Exam

Ventriculostomy

ICP monitoring

↑ risk infection, bleeding, destruction of neurons

Contraindications

Coagulopathies, small or collapsed ventricles, severe generalized cerebral edema

CSF Drainage

Clear CSF

AVOID Lumbar Puncture in IICP Risk of: Herniation of brainstem Infection Headache IICP – Medical Management

AVOID Lumbar Puncture in IICP

Risk of:

Herniation of brainstem

Infection

Headache

IICP – Medical Management Medications Osmotic diuretics (cerebral edema reduction) Corticosteroids (cerebral edema reduction) Inotropics (maintain CPP) Antipyretics (fever control) Barbiturates (reduces metabolic demands)

Medications

Osmotic diuretics (cerebral edema reduction)

Corticosteroids (cerebral edema reduction)

Inotropics (maintain CPP)

Antipyretics (fever control)

Barbiturates (reduces metabolic demands)

Osmotic Diuretics Mannitol Increases cerebral tissue perfusion and reduces ICP Draws fluid from cerebral interstitial spaces into the vascular space Test dose Serum osmolality must be monitored Complication – acute renal failure Contraindication – active intracranial bleeding Monitor: neurologic and renal status IV site for signs of Extravasation

Mannitol

Increases cerebral tissue perfusion and reduces ICP

Draws fluid from cerebral interstitial spaces into the vascular space

Test dose

Serum osmolality must be monitored

Complication – acute renal failure

Contraindication – active intracranial bleeding

Monitor:

neurologic and renal status

IV site for signs of Extravasation

 

IICP – Nursing Diagnoses Ineffective cerebral tissue perfusion Ineffective airway clearance Ineffective breathing pattern Protection from injury

Ineffective cerebral tissue perfusion

Ineffective airway clearance

Ineffective breathing pattern

Protection from injury

IICP Planning and Goals Maintain patent airway Adequate breathing pattern Optimal cerebral tissue perfusion Maintain negative fluid balance Absence of complications Calm, safe environment (minimal noise, dim lights)

Planning and Goals

Maintain patent airway

Adequate breathing pattern

Optimal cerebral tissue perfusion

Maintain negative fluid balance

Absence of complications

Calm, safe environment (minimal noise, dim lights)

IICP – Expected Outcomes Maintain patent airway Attain optimal breathing pattern Demonstrate optimal cerebral tissue perfusion Attain desired fluid balance Has no signs or symptoms of infection Absence of complications

Maintain patent airway

Attain optimal breathing pattern

Demonstrate optimal cerebral tissue perfusion

Attain desired fluid balance

Has no signs or symptoms of infection

Absence of complications

Critical Thinking Case Study Chapter 6: Case Study 15, pp. 395-398.

Chapter 6: Case Study 15, pp. 395-398.

References Deglin, J.H., Vallerand, A.H. (2005). Davis’s Drug Guide for Nurses, 10 th Ed. Philadelphia. F.A. Davis. Pp. 739-741. Hogan, M., Madayag, T. (2004). Medical-Surgical Nursing: Reviews and rationales. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 167 – 210. Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Nervous System. In: Critical Care Nursing: A holistic approach, 7 th ed. Lippincott. Philadelphia. Pp. 613-637. Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Endocrine System. In: Critical Care Nursing: A holistic approach, 7 th ed. Lippincott. Philadelphia. Pp. 834-836.

Deglin, J.H., Vallerand, A.H. (2005). Davis’s Drug Guide for Nurses, 10 th Ed. Philadelphia. F.A. Davis. Pp. 739-741.

Hogan, M., Madayag, T. (2004). Medical-Surgical Nursing: Reviews and rationales. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 167 – 210.

Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Nervous System. In: Critical Care Nursing: A holistic approach, 7 th ed. Lippincott. Philadelphia. Pp. 613-637.

Hudak, C., Gallo, B, Morton, P. (1998). Patient Management: Endocrine System. In: Critical Care Nursing: A holistic approach, 7 th ed. Lippincott. Philadelphia. Pp. 834-836.

References LeMone, P., Burke, K. (2008). Medical Surgical Nursing: Critical thinking in client care. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 1503 – 1554. Smeltzer, S., Bare, B. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott, Williams, & Wilkins. Philadelphia. Pp. 1821 -1886. Wagner, K.D., Johnson, K., Kidd, P.S. (2006). Neurologic. In: High Acuity Nursing. Upper Saddle River, N.J. pp. 402-425.

LeMone, P., Burke, K. (2008). Medical Surgical Nursing: Critical thinking in client care. Pearson Education, Inc. Upper Saddle River, NJ. Pp. 1503 – 1554.

Smeltzer, S., Bare, B. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott, Williams, & Wilkins. Philadelphia. Pp. 1821 -1886.

Wagner, K.D., Johnson, K., Kidd, P.S. (2006). Neurologic. In: High Acuity Nursing. Upper Saddle River, N.J. pp. 402-425.

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