Chapter 66 - Management of Patients With Neurologic Dysfunction

Chapter
Chapter 66
66
Management
Management of
of Patients
Patients With
With
Neurologic
Neurologic Dysfunction
Dysfunction
Altered Level of Consciousness (LOC)
• Level of responsiveness and consciousness is the most

important indicator of the patient's condition
• LOC is a continuum from normal alertness and full cognition
(consciousness) to coma
• Altered LOC is not the disorder but the result of a pathology
• Coma: unconsciousness, unarousable unresponsiveness
• Akinetic mutism: unresponsiveness to the environment,
makes no movement or sound but sometimes opens eyes
• Persistent vegetative state: devoid of cognitive function but
has sleep–wake cycles
• Locked-in syndrome: inability to move or respond except
for eye movements due to a lesion affecting the pons
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Nursing Process: The Care of the Patient
With Altered Level of Consciousness—
Assessment
• Verbal response
• Alertness
• Motor Response (posturing)
• Respiratory status
• Eye signs
• Reflexes
• Refer to Table 66-1

Decorticate Posturing Decerebrate Posturing

Question
The body temperature of an unconscious patient is never

taken by which route?
A.Axillary
B.Mouth
C.Rectal
D.Tympanic

Answer
B. Mouth
The body temperature of an unconscious patient is never

taken by mouth. Rectal or tympanic (if not
contraindicated) temperature measurement is preferred
to the less accurate axillary temperature

Diagnoses
• Ineffective airway clearance

• Risk of injury
• Deficient fluid volume
• Impaired oral mucosa
• Risk for impaired skin integrity and impaired tissue integrity
(cornea)
• Ineffective thermoregulation
• Impaired urinary elimination and bowel incontinence
• Disturbed sensory perception
• Interrupted family processes

Collaborative Problems and Potential
Complications
• Respiratory distress or failure

• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures

Planning
• Goals may include

– Maintenance of clear airway
– Protection from injury
– Attainment of fluid volume balance
– Maintenance of skin integrity
– Absence of corneal irritation
– Effective thermoregulation
– Accurate perception of environmental stimuli
– Maintenance of intact family or support system
– Absence of complications

Interventions
• A major nursing goal is to compensate for the patient's

loss of protective reflexes and to assume responsibility for
total patient care. Protection also includes maintaining the
patient’s dignity and privacy
• Maintaining an airway
– Frequent monitoring of respiratory status, including
auscultation of lung sounds
– Positioning to promote accumulation of secretions and
prevent obstruction of upper airway—head of bed
(HOB) elevated 30 degrees; lateral or semiprone
position
– Suctioning, oral hygiene, and CPT

Maintaining Tissue Integrity
• Assess skin frequently, especially areas with high potential for

breakdown
• Frequent turning; use turning schedule
• Careful positioning in correct body alignment
• Passive ROM
• Use of splints, foam boots, trochanter rolls, and specialty beds
as needed
• Clean eyes with cotton balls moistened with saline
• Use artificial tears as prescribed
• Measures to protect eyes; use eye patches cautiously because
the cornea may contact patch
• Frequent, scrupulous oral care
Interventions
• Maintaining fluid status

– Assess fluid status by examining tissue turgor and
mucosa, laboratory test data, and I&O
– Administer IVs, tube feedings, and fluids via feeding tube
as required; monitor ordered rate of IV fluids carefully
• Maintaining body temperature
– Adjust environment and cover patient appropriately
– If temperature is elevated, use minimum amount of
bedding, administer acetaminophen, use hypothermia
blanket, give a cooling sponge bath, and allow fan to blow
over patient to increase cooling
– Monitor temperature frequently and use measures to
prevent shivering
Promoting Bowel and Bladder Function
• Assess for urinary retention and urinary incontinence

• May require indwelling or intermittent catheterization
• Bladder training program
• Assess for abdominal distention, potential constipation,
and bowel incontinence
• Monitor bowel movements
• Promote elimination with stool softeners, glycerin
suppositories, or enemas as indicated
• Diarrhea may result from infection, medications, or
hyperosmolar fluids

Sensory Stimulation and Communication
• Talk to and touch patient and encourage family to talk to

and touch the patient
• Maintain normal day–night pattern of activity
• Orient the patient frequently
• Note: When arousing from coma, a patient may
experience a period of agitation; minimize stimulation at
this time
• Programs for sensory stimulation
• Allow family to ventilate and provide support
• Reinforce and provide consistent information to family
• Referral to support groups and services for family

Increased Intracranial Pressure
• Monro–Kellie hypothesis: because of limited space in the skull, an

increase in any one of components of the skull (brain tissue,
blood, CSF) will cause a change in the volume of the others
• Compensation to maintain a normal ICP of 10 to 20 mm Hg is
normally accomplished by shifting or displacing CSF
• With disease or injury, ICP may increase
• Increased ICP decreases cerebral perfusion and causes ischemia,
cell death, and (further) edema
• Brain tissues may shift through the dura and result in herniation
• Autoregulation: refers to the brain’s ability to change the diameter
of blood vessels to maintain cerebral blood flow
• CO2 plays a role; decreased CO2 results in vasoconstriction, and
increased CO2 results in vasodilatation

Brain With Intracranial Shifts

Question
Is the following statement true or false?
The earliest sign of increasing ICP is a change in LOC

Answer
True
The earliest sign of increasing ICP is a change in LOC.

Slowing of speech and delay in response to verbal
suggestions are other early indicators

ICP and CPP
• CCP (cerebral perfusion pressure) is closely linked to ICP

• CCP = MAP (mean arterial pressure) – ICP
• Normal CCP is 70 to 100
• A CCP of less than 50 results in permanent neurologic
damage

Manifestations of Increased ICP: Early
• Refer to Chart 66-2

• Changes in LOC
• Any change in condition
– Restlessness, confusion, increasing drowsiness,
increased respiratory effort, purposeless movements
• Pupillary changes and impaired ocular movements
• Weakness in one extremity or one side
• Headache: constant, increasing in intensity, or
aggravated by movement or straining

Manifestations of Increased ICP: Late
• Respiratory and vasomotor changes

• VS: Increase in systolic blood pressure, widening of pulse
pressure, and slowing of the heart rate; pulse may fluctuate
rapidly from tachycardia to bradycardia; temperature increase
– Cushing triad: bradycardia, hypertension, bradypnea
• Projectile vomiting
• Further deterioration of LOC; stupor to coma
• Hemiplegia, decortication, decerebration, or flaccidity
• Respiratory pattern alterations including Cheyne–Stokes
breathing and arrest
• Loss of brainstem reflexes: pupil, gag, corneal, and
swallowing

With Increased Intracranial Pressure—
Assessment
• Obtain history of events leading to illness

• Evaluate mental status, LOC
• Assessment of selected cranial nerves
• Assess cerebellar function, reflexes, motor and sensory
function
• Glasgow Coma Scale, pupil checks
• Frequent vital signs
• Assessment of intracranial pressure

ICP Monitoring

Intracranial Pressure Waves

Location of the Foramen of Monro for
Calibration of ICP Monitoring System

LICOX Catheter System

Diagnoses
• Ineffective airway clearance

• Ineffective breathing pattern
• Ineffective cerebral perfusion
• Deficient fluid volume related to fluid restriction
• Risk for infection related to ICP monitoring

Complications
• Brainstem herniation
• Diabetes insipidus
• SIADH

Planning
• Major goals may include

– Maintenance of patent airway
– Normalization of respirations
– Adequate cerebral tissue perfusion
– Respirations
– Fluid balance
– Absence of infection

Interventions
• Frequent monitoring of respiratory status and lung sounds

and measures to maintain a patent airway
• Position with head in neutral position and elevation of HOB
0 to 60 degrees to promote venous drainage
• Avoid hip flexion, Valsalva maneuver, abdominal distention,
or other stimuli that may increase ICP
• Maintain a calm, quiet atmosphere and protect patient from
stress
• Monitor fluid status carefully; every hour I&O during acute
phase
• Use strict aseptic technique for management of ICP
monitoring system

Intracranial Surgery
• Craniotomy: opening of the skull

– Purposes: remove tumor, relieve elevated ICP,
evacuate a blood clot, control hemorrhage
– Refer to Table 66-3
• Craniectomy: excision of portion of skill
• Cranioplasty: repair of cranial defect using a plastic or
metal plate
• Burr holes: circular openings for exploration or diagnosis to
provide access to ventricles or for shunting procedures,
aspirate a hematoma or abscess, or make a bone flap

Burr Holes

Question
What is the purpose of burr holes in neurosurgical

procedures?
A.Make a bone flap in the skull
B.Aspirate a brain abscess
C.Evacuate a hematoma
D.All of the above

Answer
D. All of the above
The purpose of burr holes in neurosurgical procedures is to

make a bone flap in the skull, aspirate a brain abscess,
and evacuate a hematoma

Preoperative Care: Medical Management
• Preoperative diagnostic procedures may include CT scan,

MRI, angiography, or transcranial Doppler flow studies
• Medications are usually given to reduce risk of seizures
• Corticosteroids, fluid restriction, hyperosmotic agent
(mannitol), and diuretics may be used to reduce cerebral
edema
• Antibiotics may be given to reduce potential infection
• Diazepam may be used to alleviate anxiety

Preoperative Care: Nursing Management
• Obtain baseline neurologic assessment

• Assess patient and family understanding of and
preparation for surgery
• Provide information, reassurance, and support

Postoperative Care
• Postoperative care is aimed

– Detecting and reducing cerebral edema
– Relieving pain
– Preventing seizures
– Monitoring ICP and neurologic status
• The patient may be intubated and have arterial and

central venous lines

Undergoing Intracranial Surgery—
Assessment
• Careful, frequent monitoring of respiratory function,

including ABGs
• Monitor VS and LOC frequently; note any potential signs
of increasing ICP
• Assess dressing and for evidence of bleeding or CSF
drainage
• Monitor for potential seizures; if seizures occur, carefully
record and report these
• Monitor for signs and symptoms of complications
• Monitor fluid status and laboratory data

Undergoing Intracranial Surgery—Diagnoses
• Ineffective cerebral tissue perfusion

• Risk for imbalanced body temperature
• Potential for impaired gas exchange
• Disturbed sensory perception
• Body image disturbance
• Impaired communication (aphasia)
• Risk for impaired skin integrity
• Impaired physical mobility

Complications
• Increased ICP
• Bleeding and hypovolemic shock
• Fluid and electrolyte disturbances
• Infection
• CSF leak
• Seizures

Undergoing Intracranial Surgery—Planning
• Major goals may include

– Improved tissue perfusion
– Adequate thermoregulation
– Normal ventilation and gas exchange
– Ability to cope with sensory deprivation
– Adaptation to changes in body image

Maintaining Cerebral Perfusion
• Monitor respiratory status; even slight hypoxia or

hypercapnia can affect cerebral perfusion
• Assess VS and neurologic status every 15 minutes to
every hour
• Strategies to reduce cerebral edema; cerebral edema
peaks 24 to 36 hours
• Strategies to control factors that increase ICP
• Avoid extreme head rotation
• HOB may be flat or elevated 30 degrees according to
needs related to the surgery and surgeon preference

Interventions
• Regulating temperature
– Cover patient appropriately
– Treat high temperature elevations vigorously; apply
ice bags, use hypothermia blanket, administer
prescribed acetaminophen
• Improving gas exchange
– Turn and reposition every 2 hours
– Encourage deep breathing and incentive spirometry
– Suction or encourage coughing cautiously as needed
(suctioning and coughing increases ICP)
– Humidification of oxygen may help loosen secretions
Interventions (cont.)
• Sensory deprivation
– Periorbital edema may impair vision, announce
presence to avoid startling the patient; cool
compresses over eyes and elevation of HOB may be
used to reduce edema if not contraindicated
• Enhancing self-image
– Encourage verbalization
– Encourage social interaction and social support
– Attention to grooming
– Cover head with turban and, later, a wig

Interventions (cont.)
• Monitor I&O, weight, blood glucose, serum and urine

electrolyte levels, and osmolality and urine specific
gravity
• Preventing infections
– Assess incision for signs of hematoma or infection
– Assess for potential CSF leak
– Instruct patient to avoid coughing, sneezing, or nose
blowing, which may increase the risk of CSF leakage
– Use strict aseptic technique
• Patient education for self-care

Question
What sign or symptom is not an indication of CSF leakage?

A.Patient complains of a salty taste in the mouth
B.Patient complains of postnasal drip
C.Clear fluid draining from nose
D.Altered LOC

Answer
D. Altered LOC
Signs and symptoms of CSF leakage that the nurse should

investigate further would include: patient complaints of
salty taste in their mouth, postnasal drip or if the nurse
observes clear fluid draining from nose or incision.
Altered LOC is a sign of increased ICP but not a sign or
symptom of CSF leakage

Seizures
• Abnormal episodes of motor, sensory, autonomic, or

psychic activity (or a combination of these) resulting from
a sudden, abnormal, uncontrolled electrical discharge
from cerebral neurons
• Classification of seizures
– Focal: originates in one hemisphere
– Generalized: occur and engage bilaterally
– Unknown: epilepsy spasms
– “Provoked” related to acute, reversible condition

Specific Causes of Seizures
• Cerebrovascular disease
• Hypoxemia
• Fever (childhood)
• Head injury
• Hypertension
• Central nervous system infections
• Metabolic and toxic conditions
• Brain tumor
• Drug and alcohol withdrawal
• Allergies

Plan of Care for a Patient Experiencing a
Seizure
• Observation and documentation of patient signs and

symptoms before, during, and after seizure
• Nursing actions during seizure for patient safety and
protection
• After seizure care to prevent complications
• Refer to Chart 66-4

Headache
• Also known as cephalgia

• One of the most common physical complaints
• Primary headache has no known organic cause and
includes migraine, tension headache, and cluster
headache
• Secondary headache is a symptom with an organic cause
such as a brain tumor or aneurysm
• Headache may cause significant discomfort for the person
and can interfere with activities and lifestyle

Assessment of Headache
• A detailed description of the headache is obtained

• Include medication history and use
• The types of headaches manifest differently in different
persons and symptoms in one individual may also may
change over time
• Although most headaches do not indicate serious disease,
persistent headaches require investigation
• Persons undergoing a headache evaluation require a
detailed history and physical assessment with neurologic
exam to rule out various physical and psychological
causes
• Diagnostic testing may be used to evaluate underlying
cause if there are abnormalities on the neurologic exam

Nursing Management of Headache: Pain
• Provide individualized care and treatment

• Prophylactic medications may be used for recurrent
migraines
• Migraines and cluster headaches requires abortive
medications instituted as soon as possible with onset
• Provide medications as prescribed
• Provide comfort measures
– Quiet, dark room
– Massage
– Local heat for tension

Nursing Management of Headache:
Education
• Help patient identify triggers and develop a preventive

strategies and lifestyle changes for headache prevention
• Medication instruction and treatment regimen
• Stress reduction techniques
• Nonpharmacologic therapies
• Follow-up care
• Encouragement of healthy lifestyle and health promotion
activities

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Chapter

• Level of responsiveness and consciousness is the most

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

The body temperature of an unconscious patient is never

Copyright © 2018 Wolters Kluwer · All Rights Reserved

The body temperature of an unconscious patient is never

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Ineffective airway clearance

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Respiratory distress or failure

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Goals may include

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• A major nursing goal is to compensate for the patient's

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Assess skin frequently, especially areas with high potential for

• Maintaining fluid status

• Assess for urinary retention and urinary incontinence

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Talk to and touch patient and encourage family to talk to

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Monro–Kellie hypothesis: because of limited space in the skull, an

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Is the following statement true or false?

The earliest sign of increasing ICP is a change in LOC

Copyright © 2018 Wolters Kluwer · All Rights Reserved

The earliest sign of increasing ICP is a change in LOC.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• CCP (cerebral perfusion pressure) is closely linked to ICP

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Refer to Chart 66-2

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Respiratory and vasomotor changes

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Obtain history of events leading to illness

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Ineffective airway clearance

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Major goals may include

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Frequent monitoring of respiratory status and lung sounds

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Craniotomy: opening of the skull

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

What is the purpose of burr holes in neurosurgical

Copyright © 2018 Wolters Kluwer · All Rights Reserved

D. All of the above

The purpose of burr holes in neurosurgical procedures is to

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Preoperative diagnostic procedures may include CT scan,

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Obtain baseline neurologic assessment

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Postoperative care is aimed

• The patient may be intubated and have arterial and