1388 UNIT XII / Responses to Altered Neurologic Function

Monty Cook is a 22-year-old musician who

plays in a local rock band. He is unmarried and
lives with his parents. He is known by everyone in the community
as a quiet, low-key, easygoing person and an excellent guitar
player. During a performance 2 days ago, he had difficulty playing
his guitar, complaining of bright stage lights blazing in his eyes.
When he tried to keep his head down to prevent the lights from
hurting his eyes, he noticed his neck was very stiff. After the per-
formance, one of the newest members of the band remarked that
it certainly was not their best performance. Monty responded an-
grily that maybe the new members of the group needed more
practice. Then he stomped out and went home to bed.
He wakes at 4:00 A.M. with a severe headache, sweating, and
chills; his temperature is 102F, and he cannot bend his neck with-
out severe pain. His mother recognizes that he is agitated and irri-
table, which is uncharacteristic. Frightened, she rushes him to the
hospital emergency room. A lumbar puncture performed in the
emergency room reveals turbid, cloudy fluid, a markedly increased
white blood cell count, and protein with a decreased glucose con-
tent. Bacterial meningitis is the medical diagnosis. Mr. Cook is ad-
mitted to the hospital for treatment and care.
ASSESSMENT
When the nurse, Aisha Aldi, enters Mr. Cooks isolation room, she
sees him thrashing about in the bed, talking incoherently, and be-
coming more agitated. On assessment, Ms. Aldi notes dry mucous
membranes, cracked lips, and small petechiae over the upper
torso and abdomen. Mr. Cooks temperature is 104F. Kernigs sign
is positive. Intravenous broad-spectrum antibiotics are prescribed
and initiated. After the first 2 hours on duty, Ms. Aldi notes a de-
crease in Mr. Cooks level of consciousness.
DIAGNOSES
Hyperthermia, related to infection and abnormal temperature
regulation by hypothalamus
Disturbed thought processes, related to intracranial infection
Ineffective protection, related to progression of illness
EXPECTED OUTCOMES
Have a decrease in body temperature.
Become less restless and agitated.
Remain free of injury.
PLANNING AND IMPLEMENTATION
Monitor vital signs every 2 hours.
Provide sponge baths if temperature continues to rise.
Provide a quiet, nonstimulating environment with the shades
drawn.
Provide oral care every 4 hours.
Measure and compare intake and output every 2 hours.
Perform neurologic assessments every 2 to 4 hours.
Monitor for and report seizure activity and decreasing level of
consciousness.
Keep bed in low position with side rails elevated.
Administer prescribed intravenous antibiotics.
EVALUATION
After 4 days of antibiotic therapy, Mr. Cooks temperature has re-
turned to near normal. Ms. Aldi notes that he has begun opening
his eyes and visually tracking her as she moves about the room.
Mr. Cook responds to a request to squeeze Ms. Aldis fingers
and after several hours asks her what had happened. On day 5,
Mr. Cook states that he feels better and his headache is gone. He
asks for sips of juice and begins urinating regularly. Seven days
after admission, Mr. Cook is discharged and is able to go home
with his mother. He has some weakness in his legs, but otherwise
has no evidence of neurologic deficits.
Critical Thinking in the Nursing Process
1. What strategies should the nurse use to decrease the envi-
ronmental stimuli for Mr. Cook, and what is the rationale for
doing these?
2. If you were caring for Mr. Cook in the initial phase of the illness
and he became combative, what would you do?
3. Develop a plan of care for Mr. Cook for the nursing diagnosis,
Acute pain. Consider the effect of narcotics on respiratory
function in designing the plan.
See Evaluating Your Response in Appendix C.
Nursing Care Plan
A Client with Bacterial Meningitis
THE CLIENT WITH A BRAIN TUMOR
Brain tumors are growths within the cranium, including tu-
mors in brain tissue, meninges, pituitary gland, or blood ves-
sels. Brain tumors may be benign or malignant, primary or
metastatic, and intracerebral or extracerebral. Regardless of
type or location, brain tumors are potentially lethal as they
grow within a closed cranial vault and displace or impinge on
CNS structures.
INCIDENCE AND PREVALENCE
An estimated 17,000 new cases of malignant brain tumors are
diagnosed in the United States each year (American Cancer
Society, 2001). In addition, more than 100,000 people die
each year from metastatic brain tumors (Porth, 2002). Al-
though brain tumors can occur in any age group, the highest
incidence is among young children and among adults ages 50
to 70. In the adult population, the most common tumor is
glioblastoma multiforme, followed by meningioma and cy-
toma. Glioblastomas represent more than 50% of all primary
intracranial lesions.
The cause of many brain tumors is unknown. Although a
number of chemical and viral agents can cause brain tumors in
laboratory animals, there is no evidence that these agents cause
tumors in humans. Other factors associated with brain tumors
include heredity, cranial irradiation, and exposure to some
chemicals (Porth, 2002).