Managing clients with neurologic dysfunction
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Transcript of Managing clients with neurologic dysfunction
Managing clients with Neurologic Dysfunction
Ma. Tosca Cybil A. Torres, RN, MAN
Outline
• Altered LOC• Increase ICP• Seizure disorders• Headache
Altered Level of Consciousness
client is not oriented, does not follow
commands, or needs persistent stimuli to
achieve a state of alertness.
Coma- a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli.
Akinetic mutism- state of unresponsiveness to the environment in which the patient makes no voluntary movement
Persistent vegetative state- a condition in which the unresponsive client resumes sleep-wake cycles after coma but is devoid of cognitive or affective mental function.
Locked-in syndrome- tetraplegia with inability to speak, but vertical eye movement s and lid elevation remain intact and are used to indicate responsiveness.
The level of responsiveness and consciousness is the MOST important
indicator of the patient’s condition.
Causes of Altered LOC
Neurologic Toxicologic Metabolic
Assessment
Includes: Mental status Cranial nerve function Cerebellar function Reflex, motor, and sensory
function Glasgow Coma Scale
Alertness Motor response
Complications
Respiratory failure Pneumonia Pressure ulcersAspiration DVTContractures
Medical Mgt
The first PRIORITY of tx for a client with altered LOC is to
obtain and maintain a
PATENT AIRWAY
Possible nursing diagnoses
Ineffective airway clearance
Risk for injury Deficient fluid
volume Risk for
impaired skin integrity
Impaired tissue integrity of cornea
Ineffective thermoregulation
Bowel incontinence
Impaired urinary elimination
Disturbed sensory perception
Interrupted family processes
The nurse assume responsibility for the client until the basic
reflexes return and the patient becomes
conscious and oriented. Therefore, the major nursing goal is to
compensate for the absence of these
protective reflexes.
If the client begins to emerge from
unconsciousness, every measure that
is available and appropriate in calming and
quieting the client should be used.
Nursing Interventions
Maintaining the airway
Protecting the client
Managing fluid balance and managing nutritional needs
Providing mouth care
Maintaining skin and joint integrity
Preserving corneal integrity
Maintaining body temperature
Prevent urinary retention
Promoting bowel function
Providing sensory stimulation
Managing the family’s needs
Monitoring and managing potential complications
Increased Intracranial Pressure
Intracranial pressure greater than 20 mmHg
Etiology: Head injury Stroke Inflammatory lesions Brain tumor Intracranial surgery
Complications
• Brain stem herniation• DI• SIADH
SIGNS AND SYMPTOMSEarly Signs•decreased level of consciousness
•Restlessness•Confusion •difficulty with memory and thinking
•pupillary dysfunction
• Impaired extraocular movements
•changes in vision
•deterioration of motor function
•Headache•decreasing Glascow Coma Score
Later Signs
•continued decrease in level of consciousness •dilated pupils, no reaction to light •Altered respiratory functions •hemiplegia that progresses • projectile vomiting •hyperthermia •papilledema •Loss of brain stem reflexes•Vital signs will present the "Cushing triad". hypertention, bradycardia, widening pulse pressure
INTERVENTIONS FOR THE PATIENT WITH INCREASED ICP
Goals of Therapya.Decrease cerebral blood flow
b.Decreasing cerebral edema
c.Lowering volume of CSF
Medical management
• Monitoring intracranial pressure and cerebral oxygenation
• Decreasing cerebral edema • Maintaining cerebral perfusion • Reducing cerebral fluid and
intracranial blood volume • Controlling • Maintaining oxygenation • Reducing metabolic demands
Nursing diagnoses
• Ineffective airway clearance • Ineffective breathing pattern• Ineffective cerebral tissue
perfusion • Deficient fluid volume • Risk for infection
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
Nursing Management includes:
• Maintain the patients head midline to
facilitate blood flow.
• Maintain the head of the bed at 30 - 45 degrees to facilitate venous drainage.
• Avoid activities that can increase ICP such as suctioning or gagging.
• Treat hyperthermia
• Decrease environmental stimuli
• Dim all lights
• Speak softly
• Touch gently and only when needed
• Maintain fluid balance via accurate I & O.
• Monitor electrolytes as these patients are prone to hypernatremia, hypoglycemia, and hypokalemia with diuretic usage.
• Monitor hyperventilation to maintain CO2 levels at 25 - 35mm Hg to prevent vasodilation
Medical Management includes:
1.Anticonvulsant therapy for seizures.
2.Use of diuretics such as Mannitol
3.50% Dextrose solution if hypoglycemia is present and persistent.
4. Surgical decompression- considered life saving
measure- opening of the skull can lead
to severe herniation
Specific Treatment
a.Surgical removal of intracranial masses.
b. Placement of extraventricular drain (temporary).
c. Placement of VP shunt (usually permanent).
Seizure Disorders
Seizures- episodes of abnormal motor, sensory,
autonomic, or psychic activity that results from
sudden excessive discharge from cerebral
neurons
Epilepsy
a group of syndromes characterized by
unprovoked, uncontrolled, recurring
seizures due to excessive firing of
hyperexcitable neurons of the brain
International Classification of Seizures
Partial Seizures Complex Partial Seizures
Generalized Seizures
•With motor symptoms •With special sensory or somatosensory symptoms •With autonomic symptoms •Compound forms
•With impairment of consciousness only •With cognitive symptoms •With affective symptoms •With psychosensory symptoms •With psychomotor symptoms •Compound forms
•Tonic clonic seizures•Tonic seizures•Clonic seizures •Absence seizure (Petit mal) •Atonic seizures•Myoclonic seizures (bilaterally massive epileptic) •Unclassified seizure
GENERALIZED SEIZURES
TONIC CLONIC Begins with tonic, loss of consciousness, then clonic
TONIC Stiffening or rigidity of muscles, loss of consciousness
CLONIC Rhythmic jerking of muscle contraction and relaxation
ABSENCE Brief loss of conscious awareness and staring into space; appears to be daydreaming
MYOCLONIC Brief stiffening or jerking of extremity, either single or in groups
ATONIC Loss of muscle tone
PARTIAL SEIZURES
SIMPLE PARTIAL Begins with an aura; may have unilateral unusual sensation or movement of extremity, autonomic, or psychic changes; no loss of consciousness
COMPLEX PARTIAL Loss of consciousness; automatism
JACKSONIAN Begin in one part of the body and may progress to a generalized tonic-clonic seizure
Causes
• CVA• Hypoxemia • Fever• Head injury • HTN• CNS infection • Metabolic and
toxic conditions
• Brain tumor • Drug and alcohol
withdrawal • Allergies
Nursing management
DURING A SEIZURE, the
major responsibility of the nurse is to
observe and record the
sequence of signs.
Documentation would include:
• Circumstances before the seizure • The occurrence of an aura • The first thing the patient does in the seizure • 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 • Incontinence of urine or stool • Duration of each phase of the seizure
Documentation would include:
• Unconsciousness• Any obvious paralysis or
weakness of arms or legs after the seizure
• Inability to speak • Movements at the end of the
seizure • Whether or not the patient
sleeps afterward • Cognitive status
Nursing care during a seizure
• Provide privacy and protect the patient from curious onlookers • Ease the patient to the floor, if possible • Loosen constrictive clothing • Push aside any furniture that may injure the patient during the
seizure • If the patient in in bed, remove the pillows and raise all side
rails • In an aura precedes the seizure, insert an oral airway• DO NOT ATTEMPT TO PRY OPEN JAWS THAT ARE
CLENCHED IN A SPASM OR TO INSERT ANYTHING.• No attempt should be made to restrain the patient during the
seizure • If possible, place the patient on one side with head flexed
forward.
After a Seizure
The nurse’s role is to document the events
leading to and occurring during and after the
seizure and to prevent complications
Nursing care after the seizure
• Keep the patient on one side------Make sure the airway is patent
• The patient, on awakening, should be reoriented to the environment
• If the patient becomes agitated after a seizure, use a calm persuasion and gentle restraints.
Nursing diagnoses
Risk for injury Fear Ineffective individual coping
Deficient knowledge
Nursing interventions
• Preventing injury • Reducing fear of seizures• Improving coping mechanisms• Providing patient and family
education • Monitoring and managing potential
complications • Promoting home and community
based care
Status Epilepticus
A series of generalized
seizures that occur without full recovery of
consciousness between attacks
Medical management
The goals of treatment are to stop the seizures as quickly as possible, to
ensure adequate cerebral oxygenation, and to
maintain the patient in a seizure-free state
Headache
• Cephalgia • Most common of all human
physical complaints
Types of headache
1. Primary headache- no organic cause ca be identified a. Migraine- a symptom complex
characterized by periodic and recurrent attacks of severe headache lasting from 4-72H
b. Tension-type- tend to be chronic and less severe
c. Cluster- severe form of vascular headache
Assessment
The diagnostic evaluation includes a detailed
history, a PA of the head and neck, and a
complete neurologic examination
Migraine
Migraine with an aura:
Phases: Prodrome Aura phaseHeadache phaseRecovery phase