Neurologic Dysfunction

Altered level of Consciousness (LOC): Causes, presentation

• Level of responsiveness and consciousness is the most important indicator of the patient’s condition → based on patients baseline

• 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

  • Causes: neuro (head injury, stroke), toxic (drugs, ETOH), or metabolic (hepatic/kidney injury, DKA)

  • 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

What are the components that are assessed with Altered Level of Consciousness?

• Eye opening/response

• Verbal response

• Motor response (posturing)

• Alertness

• Respiratory status

• Symmetry

• Reflexes

• Becomes restless, anxious initially if decreased state of consciousness

What are the two abnormal posture response to stimuli?

Planning and Goals for the patient with Altered Level of Consciousness

• 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

  • Accute perception of environmental stimuli

  • Maintenance of intact family or support system

  • Absence of complications

What are the cerebral response to intercranial pressure (ICP)?

• Cerebral perfusion pressure (CPP) is closely linked to ICP

• CPP = MAP – ICP

• Normal CCP is 70 to 100

• A CCP of less than < 50 results in permanent neurologic damage

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 is decreased → vasoconstriction

  • CO2 is increased → vasodilatation

What are the early manifestations of increased ICP?

• 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

What are the late manifestations of increased ICP?

• Respiratory and vasomotor changes

• VS: Increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate; pulse may fluctuate apidly from tachycardia to bradycardia; temperature increase

  • Cushing triad: bradypnea, bradycardia, hypertension

• 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

What is assessment of patient with increased intracranial pressure?

• 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

What are the nursing interventions for the patient with increased ICP?

• 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 30 to 45 degrees to promote venous drainage unless contraindicated

• 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

Types of intracranial surgery

• CraniOtomy: Opening of the skull

  • Purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, control hemorrhage

  • Refer to Table 61-3

• 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

What is the preoperative care: medical management with intracranial surgery?

• Preoperative diagnostic tests: 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

  • Mannitol is used to decrease ICP(diuretic)

• Antibiotics may be given to reduce potential infection

• Diazepam may be used to alleviate anxiety

What is the postoperative care for intracranial surgery?

• Postoperative care is aimed at

  • 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

What is the assessment of the pqtient undergoing intracranial surgery?

• 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

  • Time seizure to know how long it lasted and possible damage

  • If seizures occur, carefully record and report

• Monitor for signs and symptoms of complications

• Monitor fluid status and laboratory data

What are the nursing interventions done for patients undergoing intracranial surgery?

• 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

• 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

• 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

• 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

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

  • Can be d/t light sounds or stress

• Classification of seizures

  • Focal: originates in one hemisphere

  • Generalized: occur and engage bilaterally

  • Unknown: epilepsy spasms

  • “Provoked” related to acute, reversible condition

What are the 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

What is the 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 61-4

Headache

• Also known as cephalalgia

• 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 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

What is the nursing management of headache:pain and education?

• Provide individualized care and treatment

• Prophylactic medications may be used for recurrent migraines

• Migraines and cluster headaches require abortive medications instituted as soon as possible with onset

• Hydration, low stimulating environment, cold compress

• Provide medications as prescribed

• Provide comfort measures

  • Quiet, dark room

  • Massage

  • Local heat for tension