NCM 118

CARE OF CLIENTS WITH

LIFE THREATENING
CONDITIONS, ACUTELY
ILL/MULTI-ORGAN
PROBLEMS, HIGH ACUITY,
AND EMERGENCY
SITUATION
This course deals with the concepts, principles, theories, and
techniques of nursing care of sick adult clients with life-
threatening conditions, acutely ill/multi-organ problems, high
acuity, and emergency situation, toward health promotion, disease
prevention, restoration, and maintenance, and rehabilitation. The
learners are expected to provide safe, appropriate, and holistic
nursing care to groups of clients with health problems and special
needs utilizing the nursing process.
 Course Learning Outcomes:
At the end of the course, the students are expected to:
 
1. Apply knowledge of physical, social, natural and health sciences
and humanities in the practice of nursing.
2. Provide safe, appropriate, and holistic care to individuals, families,
population groups and communities utilizing nursing process.
3. Apply guidelines and principles of evidence-based practice in the
delivery of care.
4. Practice nursing in accordance with existing laws, legal, ethical
and moral principles.
5. Practice beginning management and leadership skills in the
delivery of client care using a systems approach.
6. Adopt the nursing core values in the practice of the profession.
7. Work effectively in collaboration with inter, intra- and multi-
disciplinary and multi-cultural teams.
 CNS
Management of
Client’s with
I STROKE
II Increased
Intracranial
Pressure.
Activity 1…
 B

A
 THE
BRAIN
 Presentation:
I. Anatomy and Physiology
II. Assessment
III. Laboratory studies and
diagnostic tests
IV. Medications
V. Some Disease Conditions
VI. Nursing Interventions
Review:

Central
Nervous
System…
body’s internal
communication
network
It coordinates all body
functions
 Central Nervous System
 brain and spinal cord
 collect
and interpret voluntary and
involuntary motor and sensory stimuli
 Covered by membrane layers

Meninges
protect the CNS from injury or infection
Overview…
Brain Structures and Functions:
Cerebrum
thoughts and actions. gives us the ability to think and reason out.
 Frontal Lobe- associated with reasoning, planning, parts of
speech, movement, emotions, and problem solving
 Parietal Lobe-
movement, orientation, recognition, perception of stimuli
 Occipital Lobe- visual processing
 Temporal Lobe- perception and recognition of auditory stimuli,
memory, and speech
 movement, orientation, recognition, reasoning, planning, parts of speech,
perception of stimuli movement, emotions, and problem solving

perception and
recognition of auditory
visual processing stimuli, memory, and
speech
Cerebellum- “little brain”
- regulation and coordination of movement,
posture, and balance.
 Brain Stem
responsible for basic vital life functions -
breathing, heartbeat, and blood pressure.

- Midbrain- functions for

vision, hearing, eye
movement, and body
movement.
- Pons- responsible for
maintaining vital body
functions, such as
breathing and heart rate
- Medulla- contains the
cardiac, respiratory, vomiting
and vasomotor centers and
deals with autonomic,
involuntary functions, such as
breathing, heart rate and blood
The Cranial Nerves
Cranial Nerve: Major Functions:
      
I. Olfactory Smell
II. Optic Vision
III. Oculomotor Eyelid and Eyeball movement
IV. Trochlear innervates superior oblique;
turns eye downward and
laterally
V. Trigeminal Chewing; face & mouth touch
& pain
VI. Abducens turns eye laterally
VII. Facial controls most facial expressions
secretion of tears & saliva
taste
VIII. hearing; equillibrium sensation
Vestibulocochlear
(auditory)
IX. Glossopharyngeal Taste; senses carotid blood pressure
X. Vagus senses aortic blood pressure; slows
heart rate; stimulates digestive
organs; taste
XI. Accessory controls trapezius &
sternocleidomastoid; controls
swallowing movements
XII. Hypoglossal controls tongue movements
CN DYSFUNCTION INTERVENTIONS
I Decreased sense of smell Is often accompanied by impaired taste and weight loss

II Decreased visual acuity and Frequent reorientation to environment. Position objects around client in
deference to visual impairment
visual fields

III Double vision (diplopia) Intermittent eye patching

IV,VI Lubricate eyes to protect against corneal abrasions

V Decreased facial sensation Caution in shaving and mouth care. Choose easy to chew foods with high
caloric content. Protect corneas from abrasion by using lubricant
Inability to chew
Decreased corneal reflexes

VII Facial weakness and decreased taste(ant. Oral hygiene. Account for decreased food intake. Cosmetic approach to hiding
tongue) facial weakness.

VIII Hearing loss, imbalance, vertigo, tinnitus SAFETY! Move slowly to prevent nausea and emesis. Assist ambulation

IX Dysarthria, Dysphagia, cardiac and respiratory Maintain airway. Prevent aspiration. Swallow therapy
instability
X

XI Inability to turn shoulders or turn head from Mobility aids. Physical therapy
side to side

XII Dysarthria, dysphagia Maintain airway. Prevent aspiration. Swallow therapy

Neurologic Disorders

STROKE / CVA
INCREASED INTRACRANIAL
PRESSURE
 Stroke/CerebroVascular
Accident
 CVA / Stroke….
 Sudden interruption of blood supply
to the brain.
 Most common site:
middle cerebral artery, and
carotid artery..
Causes: Pathophysiology

 Thrombosis Clot / spasm / rupture

 Embolism
 Vessel Rupture or ↓ perfusion (act of pumping)

spasm
Ischemia
(deficient supply of blood to a body part)

Infarction (stroke)
(an area of necrosis in the tissue/organ)
 Assessment findings
Usual Signs:
 Loss of consciousness

CVA:  Paresthesia (sensation of

pricking ,tingling ,creeping of the
 Hemiplegia skin w/o any cause)
 Sensory impairment  Garbled speech (distorted)
 Aphasia  ↑ ICP
 Homonymous
 severe headache
hemianopsia(blindness in ½ of the visual field)
 nuchal pain
 photophobia
 Bladder impairment  blurred vision
 Respiratory impairment  restlessness
 Mental deficits..  ↑ Temp..
 CVA/Stroke
interruption or severely reduced blood supply to
a part of the brain, thus depriving brain tissue
of oxygen and food
 Risk factors: hypertension, individual who
smokes, high cholesterol
 Other Signs and Symptoms:
 1. sudden dizziness, loss of balance and
coordination
2. confusion, slurring of speech, aphasia
3. blurred, blackened of double vision
4. headache accompanied by vomiting,
dizziness or altered consciousness..
 Types of Stroke:
Ischemic stroke
Hemorrhagic Stroke
Transient Ischemic Attack
(TIA)
1. Ischemic stroke
- almost 90% of strokes
- occurs when arteries are
narrowed or blocked causing
severely reduced blood flow
↓
Brain cells deprived of oxygen
and nutrients
↓
Cells begin to die within
minutes
(irreversible neuron damage
occurs within 2-4 minutes)
1.1 Thrombotic Stroke - occurs when a blood clot forms in one
of the arteries that supply blood to the brain

- a clot usually forms in areas damaged by atherosclerosis

(fatty deposits & hardening of the inner layer of an artery)

- can occur within one of the two carotid arteries of the neck
1.2 Embolic Stroke - occurs when a blood clot or other debris
forms form in a blood vessel away from the brain (commonly in
the heart and is swept through the blood stream to lodge in
narrow brain arteries)
2. Hemorrhagic Stroke - occurs when a blood vessel in the
brain leaks or ruptures
- causes: uncontrolled hypertension, aneurysms, rupture of AV
malformations
2.1 Intracerebral Hemorrhage - a blood vessel in the brain
bursts or spills into the surrounding brain tissue, damaging cells
- HPN – most common cause over time can cause
small arteries to become brittle and susceptible to cracking and
rupture
2.2 Subarachoid Hemorrhage - bleeding starts in
an artery on or near the surface of the brain and
spills into the space between the brain and the
surface of the brain and the skull.

- commonly caused by rupture of an aneurysm which

can develop with age or be present from birth.
Vasospasm

Decreased blood flow to parts of the brain...

 3. Transient Ischemic Attack (TIA)
– ministroke.
- brief episode of symptoms similar to those in stroke.

causes:
temporary decrease
in blood supply to part
of brain due to a clot.
- last less than five
minutes, does not
leave lasting effects
since blockage is
temporary
 Personal or family history of stroke,
heart attack or TIA

Diabetes RISK
Being age 55 or older
RISK
FACTORS
FACTORS

Physical inactivity Being overweight

Cigarette smoking or exposure to

second hand smoke
 HPN – risk begins
High cholesterol Heavy or binge
at BP readings
-total cholesterol drinking-effect of
above 115/75
above 200 mg/dL alcohol on liver
mmHg

RISK
RISK
FACTORS
FACTORS

Use of elicit drugs such as

CVD including heart Use of birth control pills or
hormone therapies that
failure, a heart defect,
include estrogen-inhibit cell
heart infection or proliferation in
abnormal heart rhythm
cardiovascular system
cocaine and
methamphetamines- CNS
stimulants that bind to
specific receptors at pre-
synaptic sites preventing
reuptake of
neurotransmitters
Incidence: increases with age (more women than men)
Complications:
Complications Treatment
Paralysis Physical therapy
Difficulty swallowing or Therapy with speech and
talking language pathologist

Memory loss or trouble Rehabilitation therapies

understanding
Pain May improve as time
passes
Tests and Diagnosis:
 Physical examination
 Blood tests

- clotting time, FBS, CBC, others

 CT scan, MRI, arteriography,
echocardiography..
Treatment and Drugs:
1. Ischemic Stroke –
1.1 clot bursting drugs
: aspirin-antiplatelet effect
: heparin/warfarin- prevents
clots from forming.
: injection of Tissue
Plasminogen Activator
(TPA)-
dissolves blood clots..
1.2 emergency procedures
: TPA delivered directly to
brain
: mechanical clot removal
thru catheter maneuver
1.3 Other procedures:
: carotid endarterectomy
: angioplasty and stents
2. Hemorrhagic stroke –
2.1 emergency measures
: anti-hypertensive drugs
: prevent seizures or reduce
vasospasm
: stop bleeding – bed rest while
body absorbs blood
: surgery for large clots...
2.2 surgical blood vessel
repair
2.2.1 aneurysm clipping
2.2.2 coiling (aneurysm
embolization)
2.2.3 surgery
Prevention:
1. Control HPN
2. Lower amount of cholesterol and
saturated fat in diet
3. don’t smoke
4. Control diabetes
5. Maintain a healthy weight
6. Eat a diet rich in fruits and vegetables
7. Exercise regularly
8. Drink alcohol in moderation
9. don’t use elicit drugs..
 Preventive Medications:

anti-platelet drugs anti-coagulants

aspirin, clopidogrel or
aspirin, clopidogrel or heparin and warfarin
ticlopidine heparin and warfarin
ticlopidine
 Nursing Interventions
 Promote communication
Use alternative methods
(gestures, pictures, alphabet
board, magic slate)
Give simple commands
Avoid distraction (TV, noise)
 Assist with ADL (eating, toileting
etc.)
 Allow time for activities (eating
etc.)
 Teach about assistive devices (walker,
cane, wheelchair)
 Assist with ROM
 Administer meds as prescribed
 Monitor Respiration and LOC of patient
taking pain medication (narcotic
analgesics depresses respi and LOC)
 Prepare for surgery..
 Endarterectomy
(removal of an inner layer of an artery
when thickened)
 Craniotomy …..
Increased Intracranial
Pressure
rise in the pressure inside
the skull

due to brain injury

Causes:
1.Rise in cerebrospinal fluid
2. Presence of mass
3. bleeding / fluid around
brain.
4. swelling within the brain
matter..
Conditions causing ↑ICP:
1. Aneurysm - > hemorrhage
2. Brain tumor
3. Encephalitis
4. Hydrocephalus
5. Hypertensive brain hemorrhage
6. Intraventricular hemorrhage
7. Meningitis
8. Severe head injury
9. Subdural hematoma
10. Status epilepticus
11. stroke.
Pathophysiology
Trauma

Edema

↑ ICP

Blood vessel compression

↓ perfusion

↓ O2

Brain cell death

Recommended procedures:
> ICP monitoring device

> Burr Hole

Symptoms:
A. Infants -( bulging of fontanel )
– behavior
B. Older children and adults
changes, decreased consciousness,
headache, lethargy, neurological
problems, seizures, vomiting

Exams and Tests:

MRI, CT scan, Intracranial pressure
measurement
Treatment:
 Breathing support
 Draining of CSF to lower pressure in brain
 Medications to decrease swelling
 Operation..
Possible complications:
 Permanent neurological problems, Reversible
neurological problems,
Seizures,
Stroke,
D eath..
 Interventions
 Assess patient frequently (v/s,
LOC, respiration etc.)
 maintain airway patency
 Maintain normal temperature
(↑ temp causes ↑ ICP)
 Suction as needed: hyperventilate
with 100% O2 before and after
suctioning
 Positioning: Elevate bed 30 to 40
degrees in neutral position
 Prevent a rise in ICP
Provide a Quiet environment
Prevent
Coughing
Vomiting – give antiemetics
as ordered
Straining at stool – give
laxatives as ordered
Give meds as ordered
Osmotic diuretics
(mannitol)
Corticosteroids (decadron)
Stool softeners (colace)
Anticonvulsants (dilantin)
 Glasgow Coma Scale

neurological scale
aim:
give a reliable objective
way of recording the
conscious state of a
person.
A technique
 objectifying a client’s level of
responses,
 client’s best response in each
area is given a numerical
value,
 the three values is totaled for
a score ranging from 3 - 15.
 EYE OPENING ABILITY:
opens eyes spontaneously--------------- (4)
to speech
(opens eyes when told to) -------- (3)
to pain
(opens eyes only on
painful stimulus)------------------- (2)
none (doesn’t open eyes in response
to stimulus -------------------------- (1)
 VERBAL RESPONSE:
Oriented
(Tells correct date)-------------(5)
Confused conversation
(Tells incorrect year)----------( 4)
Inappropriate words
(replies randomly with incorrect
words)-----------------------------(3)
Incomprehensible sounds
(moans or screams)----------- (2)
None
(no response)---------------------(1)
 MOTOR RESPONSE,UPPER LIMB:
Obeys commands
(shows fingers when ask)--------- (6)
Localizes to pain
(reaches toward pain stimulus
& tries to remove it----------------- (5)
Withdraws to pain
(moves away from painful
stimulus) ---------------------------- (4)
Abnormal flexion
(decorticate)------------------------- (3)
Abnormal
(Extension/decerebrate)-------- - (2)
None
(Flaccid)------------------------------ (1)
A 50 year old male client with CVA, can open
his eyes in response to auditory stimuli; can
respond with incomprehensible sounds; and
can move his hands in and up, toward the
cortex. The nurse performing neurological
assessment determines the client’s Glasgow
coma scale as:

a. 11
b. 8
c. 14
d. 5
Answer: A

4 + 2 + 5 = 11
Interpretation:
Awake and oriented (15):
Mild (13-14):

Moderate Disability (8-12):

Loss of consciousness greater than 30 minutes
Physical or cognitive impairments which may or may
not resolve
Benefit from Rehabilitation

Severe Disability (3-7):

Coma: unconscious state, no meaningful response, no
voluntary activities.
Vegetative State (Less Than 3):
Deep coma, Sleep wake cycles
Awake, but no interaction with environment
No localized response to pain

Persistent Vegetative State:

Vegetative state lasting longer than one month

Brain Death:
No brain function ...