NCM 116: NURSING CARE OF PATIENTS WITH  Pupillary and oculomotor responses

NEUROLOGIC DYSFUNCTION • Oval

• Eccentric
1. ALTERED LEVEL OF CONSCIOUSNESS
• Fixed and dilated
 Is a patient who is not oriented, does not • Spontaneous eye movement/ocular reflex
follow commands, or needs persistent manifestations
stimuli to achieve a state of alertness. • Doll eyes movements
 CONSCIOUSNESS: Awareness + appropriate • Fixation
responses
 LOC affected by changes in:

 Arousal Functions

- RAS: Thalamus and Brainstem

 Cognitive Function

- All mental activities controlled by

cerebral hemispheres

Pathophysiology

 Arousal and cognition

 Causes of R A S damage
 Stroke
 Demyelinating diseases
 Compression of the brainstem with edema,
ischemia
 Causes
• Bilateral hemispheric lesions
• Motor responses
• Metabolic disorders
• Responses to stimuli
• Localized masses
• Appropriate response
 Altered L O C results from
• Flaccidity
• Changes in blood, oxygen, or glucose flow
• Reflexive responses
to brain
• Decorticate posturing
• Changes in cell membranes
• Decerebrate posturing
 Manifestations as function deteriorates
• Patient difficult to rouse
 The usual duration of coma is 2 to 4 weeks.
• Agitation, confusion
 Akinetic mutism is a state of unresponsiveness
• Loss of orientation to time, place, person
to the environment in which the patient makes
• Patient unresponsive
no voluntary movement.
 Patterns of respirations
 Persistent vegetative state is a condition in
• Cheyne-Stokes respirations
which the unresponsive patient resumes sleep –
• Neurogenic hyperventilation
wake cycles after coma but is devoid of
• Apneustic respirations
cognitive or affective mental function.
• Ataxic/apneic respirations
• Death of cerebral hemispheres
• Continued brainstem/cerebellum
function
 •Characteristics of PVS • Serum osmolality
• Sleep-wake cycles • Arterial blood gases
• Basic functions, but without • Liver function tests
interaction • Toxicology screening
• Diagnosis
Medications
• Condition must persist for at
least 1 month • Saline
 Locked-in syndrome results from a lesion • Glucose, insulin
affecting the pons and results in paralysis and • Naloxone
the inability to speak, but vertical eye • Wernicke encephalopathy
movements and lid elevation remain intact and • Thiamine
are used to indicate responsiveness. • Management of fluid/electrolyte imbalance
• Blocked efferent pathways • Furosemide
• Intact cognitive abilities • Osmotic diuretic
• Unable to communicate through speech • Meningitis
or movement • Antibiotics
Brain Death
• First priority of treatment for the patient with
• Cessation of all brain functions, including altered LOC is to obtain and maintain a patent
brainstem airway.
• Diagnostic criteria  Intubation or tracheostomy may be
• Unresponsive coma performed
• Absent motor/reflex movements  Mechanical Ventilator may be used to
• No spontaneous respirations maintain adequate oxygenation and
• Diagnostic criteria ventilation
• Pupils fixed and dilated  IV access may be placed for fluid
• Absent ocular responses maintenance and medications.
• Flat EEG  Nutritional support, via a feeding tube or a
• No cerebral blood flow gastrostomy tube, is initiated as soon as
possible.
Prognosis
Nursing Diagnoses
• Varies according to
• Underlying cause Based on the assessment data, the major nursing
• Pathologic process diagnoses may include the following:
• Age
• Ineffective airway clearance related to altered
• General medical condition
• Recovery of consciousness within 2 weeks a LOC
• Risk of injury related to decreased LOC
favorable outcome
• Prognosis poor for patients who lack pupillary • Deficient fluid volume related to inability to
take fluids by mouth
reaction 6 hours after onset
• Impaired oral mucous membrane related to
Medical Management mouth breathing, absence of pharyngeal reflex,
and altered fluid intake
Diagnosis • Risk for impaired skin integrity related to
• Blood glucose prolonged immobility
• Serum electrolytes
 • Impaired tissue integrity of cornea related to • Nutrition
diminished or absent corneal reflex • Enteral feedings with gastrostomy tube
• Ineffective thermoregulation related to damage preferred
to hypothalamic center • TPN may be used
• Impaired urinary elimination (incontinence or
retention) related to impairment in neurologic 2. INCREASED INTRACRANIAL PRESSURE
sensing and control
• Bowel incontinence related to impairment in
neurologic sensing and control and also related
to changes in nutritional delivery methods
• Disturbed sensory perception related to
neurologic impairment
• Interrupted family processes related to health
crisis

Based on the assessment data, potential complications • The rigid cranial vault contains brain
may include: tissue (1400 g), blood (75 mL), and CSF
(75 mL). The volume and pressure of
• Respiratory distress or failure these three components are usually in a
• Pneumonia state of equilibrium and produce the
• Aspiration ICP.
• Pressure ulcer • ICP is usually measured in the lateral
• Deep vein thrombosis (DVT) ventricles, with the normal pressure
• Contractures being 0 to 10 mm Hg, and 15 mm Hg
being the upper limit of normal
Nursing Interventions
(Hickey, 2009).
• Maintaining the Airway
NURSING ALERT
• Protecting the Patient
• Maintaining Fluid Balance and Managing Nutritional • The earliest sign of increasing ICP is
Needs a change in LOC. Slowing of speech
• Providing Mouth Care and delay in response to verbal
• Maintaining Skin and Joint Integrity suggestions are other early
• Preserving Corneal Integrity indicators.
• Maintaining Body Temperature  Hydrocephalus
• Preventing Urinary Retention • Abnormal production, circulation,
• Promoting Bowel Function or reabsorption of CSF
• Providing Sensory Stimulation • Noncommunicating
• Meeting the Family’s Needs  CSF drainage from
• Monitoring and Managing Potential Complications ventricular system
obstructed
Interprofessional Care
• Communicating
• Surgery  CSF not effectively
• Intracerebral tumor, hemorrhage, absorbed through
hematoma arachnoid villi
• Other treatments  Decreased Cerebral Blood Flow - resulting
• Support of airway and respirations in ischemia and cell death.
  Cerebral Edema - abnormal accumulation  Widening pulse pressure
of water or fluid in the intracellular space,  Bradycardia
extracellular space, or both, associated with  Cushing triad
an increase in the volume of brain tissue.
• Compensatory mechanisms include
autoregulation as well as
decreased production and flow of
CSF.
• Autoregulation refers to the brain’s
ability to change the diameter of its
blood vessels to maintain a
constant cerebral blood flow during Pathophysiology
alterations in systemic blood
pressure. Click link: https://youtu.be/Rwui57uipVI
 Cerebral Response to Increased Intracranial  Brain with intracranial shifts from supratentorial
Pressure – Cushing’s Reflex and Cushing’s Triad lesions.
• Autoregulate becomes ineffective
 1, Herniation of the cingulate gyrus
and decompensation (ischemia and under the falx cerebri.
infarction) begins.
 2, Central transtentorial herniation.
 3, Uncal herniation of the temporal lobe
into the tentorial notch.
 4, Infratentorial herniation of the
cerebral tonsils.

Manifestations

• Level of consciousness
• Behavior, personality changes
• Memory and judgment impaired Adapted from Porth, C. M. & Matfin, G. (2009).
• Progressive decrease in LOC Pathophysiology: Concepts of altered health
• Motor responses states (8th ed.). Philadelphia: Lippincott
• Weakness on contralateral side Williams & Wilkins.
• Vision and pupils
• Blurred vision, decreased visual
acuity, and diplopia common
• Vital signs
• Cushing response
 Rising systolic blood
pressure
 • Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)
Assessment

Click link: https://youtu.be/Z8t3pgjrSxc  Forms of brain herniation due to Increased ICP.

• A, Cingulate herniation occurs when the
cingulate gyrus is compressed under the
falx
cerebri.
• B, Central herniation occurs when a
centrally
located lesion compresses central and
midbrain structures.
• C, Lateral herniation occurs when a lesion at
the side of the brain compresses the uncus
or hippocampal gyrus.
• D, Infratentorial herniation occurs when the
cerebellar tonsils are forced downward,
Interventions compressing the medulla and top of the
Click link: https://youtu.be/W8rvORyBVkk spinal cord.

Interprofessional Care
Complications
• Underlying cause
 Brain Stem Herniation • Diagnosis
• Displacement of brain tissue from normal • CT scan or MRI
position • Serum osmolality
• Supratentorial • ABGs
 Cingulate • Medications
 Central or transtentorial • Chemical restraints
• Osmotic diuretics
 Uncal or lateral
• Loop diuretics
transtentorial
• Surgery
• Infratentorial
• Infarcted, necrotic tissue removed
• Diabetes Insipidus
• Drainage catheter, shunt
• ICP monitoring
 • Glasgow Coma Scale score of 8 or
less
• Epidural probe
• Subarachnoid bolt or screw
• Intraventricular catheter
• Transcranial blood flow
• Mechanical ventilation
• Prevent hypoxemia, hypercapnia
• Arterial oxygen at about 100 mmHg
• Arterial carbon dioxide at about 35
mmHg
Nursing Diagnoses
Based on the assessment data, the major nursing
diagnoses for patients with increased ICP include the
following:
 Ineffective airway clearance related to
diminished protective reflexes (cough, gag)
 Ineffective breathing patterns related to
neurologic dysfunction (brain stem
compression, structural displacement)
 Ineffective cerebral tissue perfusion related to
the effects of increased ICP
 Deficient fluid volume related to fluid restriction
 Risk for infection related to ICP monitoring
system (fiberoptic or intraventricular catheter)
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
 DETECTING EARLY INDICATIONS OF
INCREASING INTRACRANIAL PRESSURE.
 DETECTING LATER INDICATIONS OF
INCREASING INTRACRANIAL PRESSURE
 MONITORING INTRACRANIAL PRESSURE
 MONITORING FOR SECONDARY
COMPLICATIONS
 Patient and Family Education
 MAINTAIN QUIET ENVIRONMENT WITH
MINIMAL STIMULI
 AVOID UPSETTING PATIENT: MAY
INCREASE ICP
3. INTRACRANIAL SURGERY
 A craniotomy involves opening the skull
surgically to gain access to intracranial
structures. This procedure is performed to
remove a tumor, relieve elevated ICP,
evacuate a blood clot, or control
hemorrhage.
 The surgeon cuts the skull to create a
bony flap, which can be repositioned
after surgery and held in place by
periosteal or wire sutures.
  Two approaches through the skull are administered to reduce cerebral edema if
used: supratentorial and infratentorial the patient has a brain tumor.
craniotomy • Hyperosmotic agent (mannitol) and a
 A third approach is the diuretic agent such as furosemide (Lasix)
transsphenoidal. • Antibiotics
• Administration of diazepam (Valium) or
lorazepam (Ativan) may be prescribed

Nursing Management

• Thorough preoperative assessment as it

Preoperative Management
• Diagnostic evaluation (CT scan, MRI,
Transcranial Doppler)
• Administration of antiseizure medication
such as phenytoin (Dilantin) or a phenytoin
metabolite (Cerebyx) to reduce the risk of
postoperative seizures [paroxysmal
transient disturbances of the brain resulting
from a discharge of abnormal electrical
activity (Karch, 2008)].
• Administration of corticosteroids such as
dexamethasone (Decadron) may be
serves as a baseline parameter
• LOC and responsiveness to stimuli
• Identifying any neurologic deficits, such
as paralysis, visual dysfunction,
alterations in personality or speech
• Bladder and bowel disorders
• Distal and proximal motor strength in
both upper and lower extremities is
recorded on a 5-point scale.
• Ensure adequate preparation for surgery
• Use of trochanter rolls for motor deficits
• Writing materials or picture and word cards
for aphasic patients
• Preparation of the patient and family by
providing information about what to expect
during and after surgery
• Hair is removed with the use of clippers and
the surgical site prepared immediately
before surgery
• Indwelling urinary catheter is inserted in the
operating room
• Central and arterial line placed for fluid
administration and monitoring of pressures
after surgery
• Altered cognitive state may make the
patient unaware of the impending surgery,
encouragement and attention to the
patient’s needs are necessary.
Postoperative Management
• Reducing Cerebral Edema
• Relieving Pain and Preventing Seizures
• Monitoring Intracranial Pressure
Postoperative Management for Transsphenoidal
Approach
 • Management focuses on preventing  MONITORING FOR INCREASED
infection and promoting healing INTRACRANIAL PRESSURE AND
• Nasal packing inserted during surgery is BLEEDING
checked frequently for blood or CSF  MANAGING FLUID AND ELECTROLYTE
drainage, is removed in 3 to 4 days. DISTURBANCES
• Oral care is provided every 4 hours or more  PREVENTING INFECTION
frequently as mouth dryness and thirst is a  MONITORING FOR SEIZURE ACTIVITY
major discomfort caused by mouth  MONITORING FOR SEIZURE ACTIVITY
breathing.
• Teeth are not brushed until the incision 4. SEIZURE DISORDERS
above the teeth has healed
• The use a room humidifier is necessary to
keep the mucous membranes moist and to
soothe irritation
• Head of the bed is elevated for at least 2
weeks after surgery.

Nursing Diagnoses

Based on the assessment data, the patient’s major

nursing diagnoses after intracranial surgery may include
the following:

• Ineffective cerebral tissue perfusion related

to cerebral edema
• Risk for imbalanced body temperature
 These are episodes of abnormal motor,
related to damage to the hypothalamus,
sensory, autonomic, or psychic activity (or a
dehydration, and infection
combination of these) that result from
• Potential for impaired gas exchange related
sudden excessive discharge from cerebral
to hypoventilation, aspiration, and
neurons (Hickey, 2009)
immobility
• Disrupts skeletal motor function, sensation,
• Disturbed sensory perception related to
autonomic function of viscera, behavior,
periorbital edema, head dressing,
consciousness
endotracheal tube, and effects of ICP
• Strong genetic component
• Body image disturbance related to change
• Cause UNKNOWN in 70% of cases
in appearance or physical disabilities
• The specific causes of seizures are varied
Nursing Interventions and can be categorized as idiopathic
(genetic, developmental defects) and
• Maintaining Cerebral Tissue Perfusion acquired.
• Regulating Temperature
• Improving Gas Exchange Causes of acquired seizures include:
• Managing Sensory Deprivation
 Cerebrovascular disease
• Enhancing Self-Image
 Hypoxemia of any cause, including vascular
• Monitoring and Managing Potential
insufficiency
Complications
 Fever (childhood)
 Head injury
 Hypertension
  Central nervous system infections
 Metabolic and toxic conditions (eg, renal failure,
hyponatremia, hypocalcemia, hypoglycemia,
pesticide exposure)
 Brain tumor
 Drug and alcohol withdrawal
 Allergies
Nursing Management
 During a Seizure
 Major responsibility of the nurse is to observe
and record the sequence of signs
 The circumstances before the seizure
 The occurrence of an aura
 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
(lip smacking or repeated swallowing)
 Cognitive status (confused or not
confused) after the seizure
 Unconsciousness, if present, and its
duration
 Any obvious paralysis or weakness of
arms or legs after the seizure
 Inability to speak after the seizure
 Movements at the end of the seizure
Seizure Disorder and Nursing Care During a Seizure
Click link: https://youtu.be/1Wrhr6bwS8Y
https://youtu.be/lr2G34fl4Fg
Epilepsy
Click link: https://youtu.be/uwB8AZ2vK1g
Nursing Diagnoses
Based on the assessment data, the patient’s major
nursing diagnoses may include the following:
• Risk for injury related to seizure activity
• Fear related to the possibility of seizures
• Ineffective individual coping related to
stresses imposed by epilepsy
• Deficient knowledge related to epilepsy and
its control
Interprofessional Care
 Diagnosis
• M R I or C T scan
• Electroencephalogram (E E G)
 • Lumbar puncture • Blurred vision
• Blood studies • Anorexia, hunger, diarrhea, abdominal
 Medications cramping
• Antiepileptic drugs (AEDs) • Facial pallor
• Raise seizure threshold or limit • Sweating
spread of abnormal brain activity • Stiffness or tenderness of neck
• Lowest possible dose
Cluster Headache
 Surgery
• Resective surgery • Extremely severe, unilateral, burning pain
• Responsive Neurostimulator System behind or around the eyes
 Vagal nerve stimulation therapy • Daily "clusters" for several weeks or
• Battery implanted in chest wall months, followed by remission
• Typically begins 2-3 hours after falling
5. HEADACHE asleep and awakens person

Manifestations of Cluster Headache

• Intense unilateral pain around or behind

one eye
• Rhinorrhea, lacrimation, flushing, sweating,
facial edema, miosis or ptosis

Interprofessional Care

 Headache, or cephalgia, is one of the most • Diagnosis

common of all human physical complaints. • Thorough history, physical
 Pain within cranial vault assessment
 Headache is a symptom rather than a disease • Neurodiagnostic testing
entity; it may indicate organic disease • Brain scan, MRI, skull and cervical
(neurologic or other disease), a stress response, spine x-ray, EEG, lumbar puncture
vasodilation (migraine), skeletal muscle tension for CSF
(tension headache), or a combination of factors. • Serum metabolic screens,
 One of the most frequent manifestations of a hypersensitivity testing
health problem
Medications
Migraine Headache
• Prophylactic medications
• Recurring primary headache • Medications to alleviate headache
• Triggering event • Migraine
• Neurologic dysfunction  Beta-blockers
• With or without an aura  Tricylcic antidepressants
• Vessels narrow, reducing blood flow  Ergot alkaloids
• Vasodilation, swelling, pain  SSRIs
 Calcium channel
Manifestations of Migraine Headache
antagonists
• Throbbing pain, intensifies with movement  Narcotic analgesics or
• Chills, nausea and vomiting, fatigue antiemetics
• Sensitivity to light, sound, or odor
Nursing Management

• Relieving Pain
• Teaching Patients Self-Care
• Stress Reduction

Headache

Click link: https://youtu.be/8pMj2tgvRrY

SUMMARY

In this lesson module you learned the:

• First priority of treatment for the patient

with altered LOC is to obtain and maintain
a patent airway.
• Maintaining Negative Fluid Balance
necessary for patients with increase ICP.
• Thorough preoperative assessment is
important as it serves as a baseline
parameter for patient undergoing
intracranial surgery
• Major responsibility of the nurse during
seizure is to observe and record the
sequence of signs as well as to provide
PATIENT SAFETY.
• Headache is a symptom rather than a
disease entity; a primary headache is one
for which no organic cause can be
identified.