Medical Surgical Nursing 2

LECTURE/WEEK2/PPT-BASED&VIDEO-BASED
GUIDELINES FOR NURSING INTERVENTION FOR NEURO CHECKS
PERSONS WITH DECREASED LEVEL OF Level of Consciousness (LOC)
CONSCIOUSNESS OR COMA Alertness Fully awake, responds to
internal and external stimuli.
• Maintain patent airway. Lethargic Arose from sleep, but
• Monitor vital signs and neurological stimulation seizes the client
status. sleeps again.
• Maintain integrity of the skin. Stuporous State in which response is
• Maintain joint mobility/promote evoked only by strong
activity. continuous noxious stimuli.
• Maintain sensory function/maintain Comatose Absence of voluntary
stimulation. response to stimuli including
• Promote safety. the painful stimuli.
• Maintain fluids and nutritional status. One should indicate
• Maintain bowel and bladder whether the client is in
functioning. moderately in deep coma
• Maintain good hygiene. (there is presence of reflex
• Support family/ maintain response to stimuli) or deep
psychosocial functioning. coma (absence of reflexes).
Nursing Interventions:
MAINTAIN PATENT AIRWAY 1 To define the stimuli to which the client
Keep the oral airway in place in the responds. (e.g., is the patient responding
oral cavity, suctioning and positioning are to verbal or painful stimuli?)
the measures to maintain patent airway. 2 Check ability to follow simple
Nasopharyngeal and oral commands.
secretions must be aspirated as frequent, 3 Client’s responses to any stimuli should
as necessary. be recorded as descriptive as possible.
Turn the client from right lateral to (Very clear and specific to the type of
left lateral in a semi-prone position to stimuli where the client respond).
facilitate drainage of secretions from the oral 4 Check whether or not the client is
cavity and prevent the tongue from falling oriented to time, place, or person.
back that would obstruct the airway. Pupillary Reactions
The supine should never be used Size The average diameter of the
‘cause it favors aspiration of secretions. pupil is 3 to 4 mm.
The dentures should be removed. Shape Should be round
The nostrils should be kept clean. Equality Equal in size. If there is difference
Highest priority nursing care. of the in size, this is called
pupils “anisocoria”.
MONITOR VITAL SIGNS AND NEUROLOGICAL Pupillary Normally, the pupil constrict
STATUS reactions briskly when exposed to light.
Observe quality and rhythms – pulse and to light Assessment should be in a
respirations (rate and rhythms should be darker room in order to observe
observed so that, proper therapy can be properly the pupillary reactions.
implemented before any complication can Nursing Interventions:
happen). 1 Observe the size, shape, equality of the
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pupils and the pupillary reaction to light.
Motor Strength
Check for the motor function first, for
example:
➔ To test for the peripheral response to
pain by applying pressure on the nail
bed.
Motor strength is the presence or absence
of voluntary movement strength.
Nursing Interventions:
1 Ask the patient to squeeze our fingers or
move their leg and note the patient’s
ability to follow the request.
Sensory Function
Assessing the patient’s ability of the ff:
Touch Also called as the “tactile
sensation”. Assess by lightly
touching the designated
area with a whisk of cotton.
Normal response: Perceives
the sensation and can
accurately point out the
area where it touched.
Pain Assess by lightly pricking
parts of the body with a
sharp and dull ends of an
object such as a safety pin.
Normal response: Same as
the touch and can correctly
point where it touched can
tell if the prick is dull or
sharp.
Temperature Touching the skin with
alternating fashion with hot
and cold water that has
been placed in the test tube.
Ask the patient to identify
whether the test tube placed
is hot or cold.
Position Evaluate by moving the
client’s extremities in
various directions while the
patients’ eyes are closed. If
thought perception is
normal, the client can
verbalize the direction in
which the extremity is
moved.
MAINTAIN INTEGRITY OF THE SKIN
Pressure Ulcer Formation or “decubitus
sores (common skin problem if a patient is
unconscious or in coma)
FACTORS IN PRESSURE ULCER FORMATION
Pressure Primary factor. There are
areas of the body that are
considered as bony
prominence areas where
most of the pressure sores
are formed, which are the ffg:
1) Iliac crest
2) Great femoral
trochanter
3) Heels
4) Ischial tuberosities
5) Scapula
6) Sacrum
Intensity Second factor. Low pressure
for long periods of time
produces more damage than
high pressure for short period.
Shearing Happens when the patient is
Force moved upward by just pulling
the patient, then tendency
this action would irritate the
skin of the patient.
Remember, lift the patient’s
body, not pull.
Excessive This is a good venue or
moisture habitat for formation of fungal
infections.
STAGES OF ULCER FORMATION
Ischemia Characterized by blanching of
the skin (whitish, graying
color of the skin)
Nursing Intervention/s:
1 Frequently change the position of the
patient in order to prevent ulcer
formation. Change position frequently
every two hours.
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LECTURE/WEEK2/PPT-BASED&VIDEO-BASED
Hyperemia Redness and increased
temperature at the pressure
area. Reason: Hemorrhage
has already occurred in the
bony prominence area.
Nursing Intervention/s:
1 Gently massage the bony prominence
area in a circular motion to prevent
further damage of the skin.
Ulcerations Has four (4) stages ;
Stage 1: Non blanching
erythema (skin is warm and
tender to touch.
Stage 2: Skin breakdown
(limited to the dermis there is
excoriation, blistering,
drainage more sharply
defined erythema, variable
skin temperature, local
swelling, and edema).
Stage 3: Ulcer formation
(formation into the
subcutaneous tissues - crater
formation can be seen, slag,
scar and/or drainage)
Stage 4: Extend beyond the
deep fascia into the muscle or
bone. Decayed area which
may be larger than visible.
There is osteomyelitis and
sepsis may be present.
Granulation tissue or
epithelialization may be
present at wound margins.
Nursing Intervention/s:
1 Regularly turn the patient as scheduled
to sides every two hours.
2 If the patient can’t afford to purchase a
sheep skin (absorbs moisture from the
body), alternatives can be used such as
foam rubbers, gel pads, egg crate
mattress, wool (promotes warmth and
dryness) and floatation beds to prevent
skin breakdown over bony prominence
areas.
3 Avoid point pressure on a particular site
so that weight is distributed evenly over
a wide area.
4 Bed must be free from wrinkles and
debris because this can irritate the skin
of the patient.
5 Skin should always be kept clean and
dried by washing with soap and water as
often as necessary.
6 Change linens when wet.
7 Maintain and provide adequate nutrition
by assistance with meals to ensure that
a proper diet is eaten.
8 Powder may be used to help in the
moisture absorption
MAINTAIN JOINT MOBILITY/PRMOTE ACTIVITY
Positioning is crucial in prevent deformities
of the extremities. We see to it that upper
extremity deformities will include the
following:
1) Abduction deformities
2) Internal rotation of the arm
3) Flexion Contractures of the elbow
4) Mishaps (???)
Lower extremity deformities which include.
1) Abduction and external rotation of
the hip
2) Flexion Contractures of the hip
3) Knee and foot drop (???) will not
happen to the patient.
Basic positions: Supine or lateral/side lying
or prone position.
Mechanical Aids
Bed boards Can be placed under
the mattress to
provide better
skeletal support
Footboards, Prevent deformity of
blankets, tennis the feet.
shoes For the tennis shoes,
one of the
complication to
prevent is the foot
drop, patient must
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use or advised to measures can be prescribed to protect
use the tennis shoes. the affected eye of the patient)
Trochanter rolls, Prevent outward 2. Ophthalmic solutions (prescribed for
blankets, mattress rotation of the irrigation or insulation, usually being
pad, pillow, and affected hip. administered 3 to 4 times a day. This is
sandbags applied to prevent excessive dryness of
Hand rolls Prevent flexion the eye.)
contractures of the 3. Cover the eyes with the butterfly gauze.
fingers and for 4. Communicate with clients. (Always
flaccid hands. communicate with client as if the client
Hard cone Used for spastic can hear you)
hands. 5. Cautioned family about patients
Nursing Intervention/s: hearing ability. (The hearing sense is
Facilitate maintenance of the body in a near usually the last sense to disappear).
functional position as possible. 6. Speak to client. (Providing information
Exercise: (To prevent the formation of any of all aspects of the care).
deformities, assist and instruct the patient to 7. Keep explanation simple. (Until the
carry out exercises.) patient is responsive and the nurse must
Range of To provide full movement for all assure, he/she understand more
Motion joints of the body, prevent joint detailed explanations).
exercises and muscular contractures,
(ROM) thereby facilitate maintenance MAINTAIN FLUIDS AND NUTRITIONAL STATUS
of joint mobility, keep maintain 1. IVF – max. 3000mL/day
muscle tone and improve 2. Nasogastric Tube (for feeding, we
venous and lymphatic should determine the amount to be
circulation. given for feeding)
Types of Range of Motion Exercises 3. Test gag reflex (touching the
Passive ROM Performed for the client at a posterior pharynx with a cotton swab
time the client cannot do and observe if the client is
them. Can be done by the swallowing. If gag reflex had
Nurse or physical therapist. returned, we can start by giving
Active ROM Performed by the client fluids first, then solid foods are
without of any individuals or gradually added and remember the
mechanical needs. Maintain client should be spoon fed).
the strength of the muscles 4. Oral Hygiene after feeding. (Oral
Active Performed by the client, or hygiene should be practiced at least
assistance Self-assisted or have every two hours to prevent drying of
exercise assistance from other them mucous membranes and
person or mechanical needs. prevent parotitis).
5. Remove Dentures. (This can be
MAINTAIN SENSORY FUNCTION/MAINTAIN accidentally aspirated by the
patient)
STIMULATION
6. Input and Output (and weight of the
1. Observe characteristics of the eyes.
patient in order to fully determine the
(Especially on the affected site and
degree of fluid balance).
report for any changes, so that
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MAINTAIN BOWEL AND BLADDER FUNCTIONING
1. Indwelling catheter (can be
prescribed and usually remains until
the client gains consciousness).
2. Asepsis (maintenance and principles
of asepsis should be applied to
prevent infection, nosocomial
infections or other
complications/problems to arise).
3. Input and Output
4. Diet: Bulk with fluid intake (prevent
constipation and impaction)
SUPPORT FAMILY/MAINTAIN PSYCHOSOCIAL
FUNCTIONING
1. Assess state of client. (Explain
simple terms, what happened, the
reason for therapeutic measures,
and the basis for behavior shown)
2. Orient client. (The patient should be
oriented with the environment and
provide emotional support)
3. Promote sense of security.
4. Avoid situation that may evoke
unwanted situations. (such as
restation as much as possible)
5. Spend time with family. (The nurse
should spend time with the family to
assess their reaction to the client’s
behavior and helping them
understand the basis for it).
6. Instruct family on the importance of
accepting client.
Care of Neurosurgical Clients
POST-OPERATIVE CARE
Positioning:
a. Supratentorial – place the patient in
a semi – fowler’s position, since lowering
head can cause venous congestion and
bleeding. Position flat in back and no
Trendelenburg position (increase ICP).
b. Commonalities (can be applied for
both supratentorial and infratentorial
procedures) – keep off operative sites, turn
to sides every 2 hours, mouth dependent
position to drain secretions.
c. Infratentorial – Position flat on either
side, keep off back because of impaired
swallowing and gag reflexes, head gradually
elevated on the 3rd day post-op.
Vital Signs:
a. Commonalities = Monitor vital signs
& neurological status, observe for shock and
increase in ICP.
b. Infratentorial = observe for
respiratory difficulty.
Foods and Fluids:
a. Supratentorial = limit to 1500ml for
the first 24 hours. (To control edema, food
diets as tolerated after return of swallowing
and gag reflexes)
b. Commonalities = Input and Output
c. Infratentorial = No oral fluids or solid
for the first 24 hours. Begin oral fluids and
diet on 2nd post-operative day after
ascertaining presence of swallowing and gag
reflexes.
Other Nursing Responsibilities in the care of
a Neuro-surgical client:
1) Check the dressing for drainage and
excessive bleeding or to enforce
dressing, as necessary.
2) Restrain patient as necessary to
prevent disturbance of dressing.
3) Suction is necessary to clear airway
being careful not to stimulate cough
reflex since this facilitate increasing
ICP.
4) Encourage deep breathing.
coughing should be discouraged.
5) Apply ice bath to head as necessary
for headache.
6) Monitor bowel and bladder
elimination.
7) Catheterize if necessary.
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8) Avoid enemas (since this may
increase ICP)
9) Give prescribed analgesics,
anticonvulsants, stimulants, or
steroids.
10) Follow eye care regimen if corneal
reflex is absent.
11) Facilitate advanced activities as
indicated.