Nursing Management of the Adult Client with Neurologic Alterations

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Nursing Management of the Adult Client with
Neurologic Alterations

• NURS 228
• Janie Best, MSN, RN, APRN, BC

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Objectives

• Relate principles of anatomy and physiology to
  the nursing care of individuals with common
  health problems of the nervous system.
• Analyze the common health problems that accompany
  alterations in cerebral circulation in the adult
  patient
• Altered Level of consciousness (LOC)
• Increased intracranial pressure

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The Nervous System

• Central Nervous System (CNS)
• Brain
• Spinal Cord
• Peripheral Nervous System (PNS)
• Cranial nerves
• Spinal nerves
• Autonomic nervous system
• Sympathetic
• Parasympathetic

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Anatomy

• Brain
• Cerebrum
• Hemispheres
• Lobes Frontal, Parietal, Temporal, Occiptial
• Thalamus, Hypothalamus, Basal ganglia
• Cerebellum
• Brain Stem

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Anatomy

• Protective Structures
• Dura mater
• Arachnoid
• Pia mater
• CSF
• Clear, colorless
• Produced by choroid plexus (ventricles/arachnoid
  layer)
• 500 mL daily Most absorbed by body

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Brain Requirements

• Blood Flow
• 750 ml / minute
• 20 of total oxygen uptake
• Glucose
• 80 of bodys glucose use
• Blood Flow Regulation
• CO2
• Oxygen

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Diagnostic Studies

• Skull and Spine Radiography
• CT (Computerized Tomography)
• MRI (Magnetic Resonance Imaging)
• PET (Positron Emission Tomography)
• EEG (Electroencephalogram)
• EMG (Electromyography)

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Diagnostic Studies Cerebral Angiography

• Pre-procedure care
• Assess for allergy to iodine and shellfish
• NPO 4-6 hrs
• Baseline neuro assessment
• Education
• Immobile during / following procedure
• Expect brief feeling of warmth / burning in
  behind eyes, or in jaw, teeth, tongue, lips
• May have metallic taste

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Diagnostic Studies Cerebral Angiography

• Post Procedure Care
• Bedrest x 4 - 8 hrs
• Increase Fluids
• Monitor
• Neuro assessment / VS
• Peripheral pulses
• Observe
• for s/s altered cerebral blood flow
• Hematoma at injection site
• Keep bed FLAT if femoral artery is used

Pain BELOW injection site may indicate embolism
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Diagnostic Studies Myelography / Lumbar
Puncture

• Pre Procedure Care
• NPO
• Sedative may be given
• Lateral recumbent position with knees drawn up to
  abdomen and chin onto chest
• Patient Ed. - Position of x-ray table may be
  changed during procedure

www.upmc.com
LP is contraindicated if suspected IICP
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Diagnostic Studies Myelography / Lumbar
Puncture

• Post Procedure Care
• HOB gt 300 450 for 3 hrs
• Drink plenty of fluids
• Monitor VS and Urinary output
• Observe for post procedure headache

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Diagnostic Studies Myelography / Lumbar
Puncture

• Complications
• Headache
• Herniation of intracranial contents
• Spinal epidural abscess
• Spinal epidural hematoma

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Neurological Assessment

• Hx present illness
• A associated symptoms
• P what provokes / palliates symptoms
• Q Quality of pain
• R region and radiation
• S severity of pain on scale of 1-10
• T timing
• (start / stop, intermittent, constant)

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Neurological Assessment

• Physical Exam
• Mental status
• Cranial Nerves
• Motor system
• Cerebellar - balance / coordination
• Sensory system
• Reflexes

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Abnormal Findings

• Babinski Reflex
• CNS disease of pyramidal tract
• Clonus
• Hyperactive reflexes
• Corneal reflex
• Loss - dysfunction of Cranial nerve 5
• Gag reflex
• Loss - Dysfunction of cranial nerves IX and X

Text 1839-1840
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Abnormal Findings
Battles sign

• Raccoons eye

• Rhinorrhea
• Otorrhea

www.aic.cuhk.edu.hk
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• Dolls Eyes - Oculocephalic Reflex

http//connection.lww.com/Products/morton/document
s/images/Ch33/jpg/Ch33-006B.jpg
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Altered LOC - Etiology

• Vowel
• Alcohol
• Epilepsy
• Insulin
• Opiates
• Urates (renal failure)

• TIPPS
• Trauma
• Infection
• Psych
• Poisons
• Shock

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Altered LOC

• Arousal
• Alertness, response to stimuli
• Content
• Awareness of time, place, person

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Altered LOC

• Level of Consciousness
• Continuum
• Terminology
• Alert
• Confusion
• Somnolent
• Lethargic
• Obtunded / Stupor
• Comatose

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Glasgow Coma Scale

• Best Eye-opening response
• 1 no response
• 4 spontaneously
• Best Verbal response
• 1 no response
• 5 oriented

• Best Motor response
• 1 no response
• 6 obeys commands

Score 7 is consistent with significant
alteration in LOC (coma)
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Assessment of Respirations

• Cheyne-Stokes
• Rhythmical pattern waxing/ waning in depth,
  followed by periods of apnea
• Neurogenic hyperventilation
• Regular, rapid (gt 24 / min), deep sustained
  respirations
• Apneustic
• Irregular respirations with pauses at the end of
  inspiration expiration
• Ataxic
• Totally irregular in rhythm depth
• Cluster
• Clusters of irregular breaths with irregularly
  spaced apnea

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Assessment of other Vital Signs
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Assessment of other Vital Signs
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Nursing Diagnoses

• Potential for
• Ineffective airway clearance
• Risk for Aspiration
• Risk for Impaired Skin Integrity
• Impaired Physical Mobility
• Risk for Imbalanced Nutrition Less than body
  requirements

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Brain Death

• Persistent vegetative state
• Brain death
• Rule out
• spinal cord injury
• Other causes of neurologic impairment
• No neuromuscular paralyzing agent effects
• Criteria documented in chart includes
• Flat EEG
• Absence of spontaneous respirations
• Pupils fixed and dilated

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Altered LOC

• Nursing Interventions
• Airway maintenance
• Fluid balance and Nutrition
• Mouth care
• Skin and joint integrity
• Preventing injury
• Temperature regulation
• Bladder and bowel function

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Altered LOC

• Nursing Interventions
• Sensory stimulation
• Family needs
• Preventing complications
• Pneumonia
• Aspiration
• Respiratory failure
• DVT/PE
• Outcomes

Assume the unconscious patient CAN hear!
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Blood-Brain Barrier

• Permeable to water, oxygen, CO2, other gases,
  glucose and lipid soluble compounds
• Movement across barrier depends on
• Particle size
• Lipid solubility
• Chemical dissociation
• Protein-binding capacity

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Intracranial Pressure (ICP)

• Pressure exerted by the combined volume of
• Brain tissue
• CSF
• Blood
• Normal ICP
• 10 20 mmHg
• Normal CSF pressure
• 5-13 mmHg

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Intracranial Pressure (ICP)

• Closed Box
• Brain tissue (80)
• Blood (10)
• CSF (10)
• Brain Injury
• Skull may contain swollen brain tissue, blood or
  CSF
• Skull
• May become too full
• ? pressure on brain tissue

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Intracranial Pressure (ICP)

• Brain volume limited expansion controlled by
  Blood brain barrier
• Cerebral blood volume controlled by cerebral
  blood flow
• CSF -
• ? CSF absorption- or-
• ? CSF production
• Shunting of venous blood out of
  the skull

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Cerebral Blood Flow / Volume

• Increased Flow / volume
• Effects
• Systemic hypotension
• ? metabolic rate
• Acidosis
• Hypercapnia, ischemia
• Cerebral vasodilation

• Decreased Blood flow / volume
• Effects
• Hypertension
• ? metabolic rate
• Alkalosis
• Hypocapnia
• Cerebral edema
• Low cardiac output
• Cerebral vasoconstriction

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? Brain Volume

• Cause
• Space occupying lesions
• Cerebral edema
• Effect
• Herniation

http//www.uth.tmc.edu/radiology/test/er_primer/sk
ull_brain/skull.html
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Cerebrospinal Fluid

• Functions
• Support / cushioning
• Maintain stable chemical balance of CNS
• Excrete toxic wastes
• CO2, lactate, hydrogen ions
• Causes of ?CSF
• ?production
• Obstructed circulation
• ?absorption

Effect ? cerebral blood volume Hydrocephalus
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Intracranial Pressure (ICP)

• Compensation depends on
• Location of lesion
• Rate of expansion
• Compliance or volume-buffering capacity of body

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Intracranial Pressure (ICP)

• Compensation
• Monro-Kellie Hypothesis
• Change in volume of one of the contents must have
  a change in volume of one or both of the other
  components in order to remain stable

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Cycle of malignant progressive brain swelling
? ICP
Cerebral vasodilation edema
? Cerebral brain flow
? pCO2 ? pH
Tissue hypoxia
From Hudak, C. Critical care nursing p. 640
from
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IICP

• Cushings Response
• ? SBP w/ widening pulse pressure
• ? pulse

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IICP

• Cushings Triad
• ? systolic blood pressure
• ? diastolic blood pressure
• Bradycardia
• Ominous sign

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IICP

• Early Indicators
• Change in LOC (earliest indicator)
• Slowing of speech
• Delays in response to verbal suggestions
• Pupillary changes, Impaired EOMs
• Ipsilateral weakness
• Headache
• (constant, increasing intensity, aggravated by
  movement)

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IICP

• Later Indicators
• Continued deterioration of LOC
• Pulse, Respiratory rate decreased/erratic
• BP, Temp increase
• Altered respiratory patterns
• Cheyne-Stokes respirations
• Ataxic breathing
• Projective vomiting
• Hemiplegia, Posturing
• Loss of pupillary, corneal, gag, swallowing
  reflexes

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IICP - Complications

• Cerebral Herniation
• DI (Diabetes Insipidus) - ? secretion ADH
• Clinical manifestations
• SIADH (Syndrome of Inappropriate release of
  Antidiuretic Hormone) - ? secretion ADH
• Clinical manifestations

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IICP Complications DI

• DI (Diabetes Insipidus) - ? secretion ADH
• Clinical manifestations
• Polydipsia, polyuria, dehydration
• Urine output increases dramatically (up to 20 L /
  24hr)
• Urine specific gravity falls to 1.001 1.005
• Urine osmolality ? to 50 100 mOsm/kg.

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IICP Complications - DI

• Treatment
• Fluid and electrolyte management
• Vasopressin
• Thiazide diuretics
• Complications
• Cardiovascular collapse
• Tissue hypoxia
• Seizures
• Encephalopathy

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IICP Complications - SIADH

• SIADH (Syndrome of Inappropriate release of
  Antidiuretic Hormone)
• Pathophysiology
• ? secretion ADH or ? production of ADH
• Results in ? in total body water
• Secretion continues with ? osmolality of plasma
• Causes
• Pituitary tumor
• Head injury
• CNS infection
• Bronchogenic (oat cell), or pancreatic carcinoma

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IICP Complications - SIADH

• Clinical manifestations
• Water retention ? water intoxication
• Hyponatremia

• Signs / symptoms
• Personality changes
• Headache
• Decreased mentation
• Lethargy
• N, V, diarrhea
• Decreased tendon reflexes
• Seizures, coma

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IICP Complications - SIADH

• Treatment
• Treat underlying disease
• Alleviate excessive water retention
• Nursing care depressed LOC

• Complications
• Seizures
• Coma
• Death

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IICP Medical Management

• Goals
• Decreasing Cerebral Edema
• Lowering CSF Volume
• Decreasing Cerebral Blood Volume

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IICP Medical Management

• Neuro Exam
• Ventriculostomy
• ICP monitoring
• ? risk infection, bleeding, destruction of
  neurons
• Contraindications
• Coagulopathies, small or collapsed ventricles,
  severe generalized cerebral edema
• CSF Drainage
• Clear CSF

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IICP Medical Management

• AVOID Lumbar Puncture in IICP
• Risk of
• Herniation of brainstem
• Infection
• Headache

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IICP Medical Management

• Medications
• Osmotic diuretics (cerebral edema reduction)
• Corticosteroids (cerebral edema reduction)
• Inotropics (maintain CPP)
• Antipyretics (fever control)
• Barbiturates (reduces metabolic demands)

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Osmotic Diuretics

• Mannitol
• Increases cerebral tissue perfusion and reduces
  ICP
• Draws fluid from cerebral interstitial spaces
  into the vascular space
• Test dose
• Serum osmolality monitored to assess hydration
• Complication acute renal failure
• Contraindication active intracranial bleeding
• Monitor
• Neurologic and renal status
• IV site for signs of extravasation

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Medical Management IICP

• Fluid restriction
• Dehydration / hemoconcentration? fluid crosses
  osmotic gradient ? decreased cerebral edema
• AVOID overhydration
• Reduce metabolic demands
• Barbituates
• paralyzing agents (propofol)
• ? coma ? decreased metabolic requirements

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IICP Nursing Diagnoses

• Ineffective cerebral tissue perfusion
• Ineffective airway clearance
• Ineffective breathing pattern
• Deficient fluid volume r/t fluid restriction
• Risk for infection
• Protection from injury

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IICP

• Nursing Interventions
• Maintain patent airway
• Adequate breathing pattern
• Optimal cerebral tissue perfusion
• Maintain negative fluid balance
• Absence of complications
• Calm, safe environment (minimal noise, dim lights)

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IICP Expected Outcomes

• Maintain patent airway
• Attain optimal breathing pattern
• Demonstrate optimal cerebral tissue perfusion
• Attain desired fluid balance
• Has no signs or symptoms of infection
• Absence of complications

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Critical Thinking Case Study

• Chapter 6 Case Study 15, pp. 395-398.

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NCLEX Questions

• Which of the following pathophysiologic events
  results in irregular respiratory patterns as LOC
  decreases?
• Brainstem responses to changes in PaCO2
• Loss of the oculocephalic reflex
• Pressure on the meninges
• Reflexive motor responses

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NCLEX Questions

• Which of the following pathophysiologic events
  results in irregular respiratory patterns as LOC
  decreases?
• Brainstem responses to changes in PaCO2
• Loss of the oculocephalic reflex
• Pressure on the meninges
• Reflexive motor responses

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NCLEX Questions

• Which of the following drugs may be used first to
  reduce ICP?
• Analgesics
• Barbituates
• Loop diuretics
• Neuromuscular blocking agents

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NCLEX Questions

• The Glasgow Coma Scale assesses
• Arousal
• Cognition
• Problem-solving abilities
• Speech patterns

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References

• Deglin, J.H., Vallerand, A.H. (2005). Daviss
  Drug Guide for Nurses, 10th Ed. Philadelphia.
  F.A. Davis. Pp. 739-741.
• Hogan, M., Madayag, T. (2004). Medical-Surgical
  Nursing Reviews and rationales. Pearson
  Education, Inc. Upper Saddle River, NJ. Pp. 167
  210.
• Hudak, C., Gallo, B, Morton, P. (1998). Patient
  Management Nervous System. In Critical Care
  Nursing A holistic approach, 7th ed.
  Lippincott. Philadelphia. Pp. 613-637.
• Hudak, C., Gallo, B, Morton, P. (1998). Patient
  Management Endocrine System. In Critical Care
  Nursing A holistic approach, 7th ed.
  Lippincott. Philadelphia. Pp. 834-836.

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References

• LeMone, P., Burke, K. (2008). Medical Surgical
  Nursing Critical thinking in client care.
  Pearson Education, Inc. Upper Saddle River, NJ.
  Pp. 1503 1554.
• Smeltzer, S., Bare, B. (2004). Brunner
  Suddarths Textbook of Medical-Surgical Nursing.
  Lippincott, Williams, Wilkins. Philadelphia.
  Pp. 1821 -1886.
• Wagner, K.D., Johnson, K., Kidd, P.S. (2006).
  Neurologic. In High Acuity Nursing. Upper
  Saddle River, N.J. pp. 402-425.