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Managing clients with neurologic dysfunction

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    • 1. Managing clients with Neurologic Dysfunction
      Ma. Tosca Cybil A. Torres, RN, MAN
    • 2. Outline
      • Altered LOC
      • 3. Increase ICP
      • 4. Seizure disorders
      • 5. Headache
    • Altered Level of Consciousness
      client is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.
    • 6. Coma- a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli.
      Akineticmutism- 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.
    • 7. The level of responsiveness and consciousness is the MOST important indicator of the patient’s condition.
    • 8. Causes of Altered LOC
    • Assessment
      • Includes:
      • 11. Mental status
      • 12. Cranial nerve function
      • 13. Cerebellar function
      • 14. Reflex, motor, and sensory function
      • 15. Glasgow Coma Scale
      • 16. Alertness
      • 17. Motor response
    • Complications
    • Medical Mgt
      The first PRIORITY of tx for a client with altered LOC is to obtain and maintain a PATENT AIRWAY
    • 23. Possible nursing diagnoses
      • Ineffective airway clearance
      • 24. Risk for injury
      • 25. Deficient fluid volume
      • 26. Risk for impaired skin integrity
      • 27. Impaired tissue integrity of cornea
      • 28. Ineffective thermoregulation
      • 29. Bowel incontinence
      • 30. Impaired urinary elimination
      • 31. Disturbed sensory perception
      • 32. 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.
    • 33. If the client begins to emerge from unconsciousness, every measure that is available and appropriate in calming and quieting the client should be used.
    • 34. Nursing Interventions
      • Maintaining the airway
      • 35. Protecting the client
      • 36. Managing fluid balance and managing nutritional needs
      • 37. Providing mouth care
      • 38. Maintaining skin and joint integrity
      • 39. Preserving corneal integrity
      • 40. Maintaining body temperature
      • 41. Prevent urinary retention
      • 42. Promoting bowel function
      • 43. Providing sensory stimulation
      • 44. Managing the family’s needs
      • 45. Monitoring and managing potential complications
    • Increased Intracranial Pressure
      • Intracranial pressure greater than 20 mmHg
      • 46. Etiology:
      • 47. Head injury
      • 48. Stroke
      • 49. Inflammatory lesions
      • 50. Brain tumor
      • 51. Intracranial surgery
    • Complications
    • SIGNS AND SYMPTOMS
      Early Signs
      • decreased level of consciousness
      • 54. Restlessness
      • 55. Confusion
      • 56. difficulty with memory and thinking
      • 57. pupillary dysfunction
      • 58. Impaired extraocular movements
      • 59. changes in vision
      • 60. deterioration of motor function
      • 61. Headache
      • 62. decreasing Glascow Coma Score
    • Later Signs
      • continued decrease in level of consciousness
      • 63. dilated pupils, no reaction to light
      • 64. Altered respiratory functions
      • 65. hemiplegia that progresses
      • 66. projectile vomiting
      • 67. hyperthermia
      • 68. papilledema
      • 69. Loss of brain stem reflexes
      • 70. Vital signs will present the "Cushing triad".
      hypertention, bradycardia, widening pulse pressure
    • 71. INTERVENTIONS FOR THE PATIENT WITH INCREASED ICP
      Goals of Therapy
      Decrease cerebral blood flow
      Decreasing cerebral edema
      Lowering volume of CSF
    • 72. Medical management
      • Monitoring intracranial pressure and cerebral oxygenation
      • 73. Decreasing cerebral edema
      • 74. Maintaining cerebral perfusion
      • 75. Reducing cerebral fluid and intracranial blood volume
      • 76. Controlling
      • 77. Maintaining oxygenation
      • 78. Reducing metabolic demands
    • Nursing diagnoses
      • Ineffective airway clearance
      • 79. Ineffective breathing pattern
      • 80. Ineffective cerebral tissue perfusion
      • 81. Deficient fluid volume
      • 82. Risk for infection
    • Nursing Interventions
      • Maintaining a patent airway
      • 83. Achieving an adequate breathing pattern
      • 84. Optimizing cerebral tissue perfusion
      • 85. Maintaining negative fluid balance
      • 86. Preventing infection
      • 87. Monitoring and managing potential complications
    • Nursing Management includes:
       
      • Maintain the patients head midline to facilitate blood flow.
      • 88. Maintain the head of the bed at 30 - 45 degrees to facilitate venous drainage.
      • 89. Avoid activities that can increase ICP such as suctioning or gagging.
      • 90. Treat hyperthermia
      • 91. Decrease environmental stimuli
      • Dim all lights
      • 92. Speak softly
      • 93. Touch gently and only when needed
      • 94. Maintain fluid balance via accurate I & O.
      • 95. Monitor electrolytes as these patients are prone to hypernatremia, hypoglycemia, and hypokalemia with diuretic usage.
      • 96. Monitor hyperventilation to maintain CO2 levels at 25 - 35mm Hg to prevent vasodilation
    • Medical Management includes:
      Anticonvulsant therapy for seizures.
      Use of diuretics such as Mannitol
      50% Dextrose solution if hypoglycemia is present and persistent.
      Surgical decompression
      -         considered life saving measure
      -         opening of the skull can lead to severe herniation
    • 97. Specific Treatment
      Surgical removal of intracranial masses.
      b. Placement of extraventricular drain (temporary).
      c. Placement of VP shunt (usually permanent).
    • 98. Seizure Disorders
      Seizures- episodes of abnormal motor, sensory, autonomic, or psychic activity that results from sudden excessive discharge from cerebral neurons
    • 99. Epilepsy
      a group of syndromes characterized by unprovoked, uncontrolled, recurring seizures due to excessive firing of hyperexcitable neurons of the brain
    • 100. International Classification of Seizures
    • 101.
    • 102. Causes
    • Nursing management
      DURING A SEIZURE, the major responsibility of the nurse is to observe and record the sequence of signs.
    • 112. Documentation would include:
      • Circumstances before the seizure
      • 113. The occurrence of an aura
      • 114. The first thing the patient does in the seizure
      • 115. The type of movements in the part of the body involved
      • 116. The areas of the body involved
      • 117. The size of both pupils and whether the eyes are open
      • 118. Whether the eyes or head turned to one side
      • 119. The presence or absence of automatisms
      • 120. Incontinence of urine or stool
      • 121. Duration of each phase of the seizure
    • Documentation would include:
      • Unconsciousness
      • 122. Any obvious paralysis or weakness of arms or legs after the seizure
      • 123. Inability to speak
      • 124. Movements at the end of the seizure
      • 125. Whether or not the patient sleeps afterward
      • 126. Cognitive status
    • Nursing care during a seizure
      • Provide privacy and protect the patient from curious onlookers
      • 127. Ease the patient to the floor, if possible
      • 128. Loosen constrictive clothing
      • 129. Push aside any furniture that may injure the patient during the seizure
      • 130. If the patient in in bed, remove the pillows and raise all side rails
      • 131. In an aura precedes the seizure, insert an oral airway
      • 132. DO NOT ATTEMPT TO PRY OPEN JAWS THAT ARE CLENCHED IN A SPASM OR TO INSERT ANYTHING.
      • 133. No attempt should be made to restrain the patient during the seizure
      • 134. 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
    • 135. Nursing care after the seizure
      • Keep the patient on one side------Make sure the airway is patent
      • 136. The patient, on awakening, should be reoriented to the environment
      • 137. If the patient becomes agitated after a seizure, use a calm persuasion and gentle restraints.
    • Nursing diagnoses
    • Nursing interventions
      • Preventing injury
      • 141. Reducing fear of seizures
      • 142. Improving coping mechanisms
      • 143. Providing patient and family education
      • 144. Monitoring and managing potential complications
      • 145. Promoting home and community based care
    • Status Epilepticus
      A series of generalized seizures that occur without full recovery of consciousness between attacks
    • 146. 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
    • 147. Headache
      • Cephalgia
      • 148. Most common of all human physical complaints
    • Types of headache
      Primary headache- no organic cause ca be identified
      Migraine- a symptom complex characterized by periodic and recurrent attacks of severe headache lasting from 4-72H
      Tension-type- tend to be chronic and less severe
      Cluster- severe form of vascular headache
    • 149. Assessment
      The diagnostic evaluation includes a detailed history, a PA of the head and neck, and a complete neurologic examination
    • 150. Migraine
      Migraine with an aura:
      Phases:
      Prodrome
      Aura phase
      Headache phase
      Recovery phase

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