Managing clients with Neurologic Dysfunction <br />Ma. Tosca Cybil A. Torres, RN, MAN <br />
Outline <br /><ul><li>Altered LOC
Increase ICP
Seizure disorders
Headache  </li></li></ul><li>Altered Level of Consciousness <br />client is not oriented, does not follow commands, or nee...
Coma- a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external ...
The level of responsiveness and consciousness is the MOST important indicator of the patient’s condition.<br />
Causes of Altered LOC<br /><ul><li>Neurologic
Toxicologic
Metabolic </li></li></ul><li>Assessment<br /><ul><li>Includes:
Mental status
Cranial nerve function
Cerebellar function
Reflex, motor, and sensory function
Glasgow Coma Scale
Alertness
Motor response </li></li></ul><li>Complications<br /><ul><li>Respiratory failure
Pneumonia
Pressure ulcers
Aspiration
DVT
Contractures</li></li></ul><li>Medical Mgt<br />The first PRIORITY of tx for a client with altered LOC is to obtain and ma...
Possible nursing diagnoses <br /><ul><li>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</li></li></ul><li>The nurse assume responsibility for the client until the basic reflexes ret...
If the client begins to emerge from unconsciousness, every measure that is available and appropriate in calming and quieti...
Nursing Interventions <br /><ul><li>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
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  • Managing clients with neurologic dysfunction

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