Chapter 61
Management of Patients with
Neurologic Dysfunction
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Altered Level of Consciousness (LOC)
 Level of responsiveness and consciousness is the most
important indicator of the patient’s condition
 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
 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
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Assessment of the Patient with Altered
Level of Consciousness
Verbal response
Alertness
Motor response (posturing)
Respiratory status
Eye signs
Reflexes
Refer to Table 61-1
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Abnormal Posture Response to Stimuli
Decorticate Posturing
Decerebrate Posturing
Adapted from Posner, J. B., Saper, C. B., Schiff, N. D., et al. (2007). Plum and
Posner’s diagnosis of stupor and coma (4th ed.). Oxford, UK: Oxford University
Press.
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Question #1
The body temperature of an unconscious patient is
never taken by which route?
A. Axillary
B. Mouth
C. Rectal
D. Tympanic
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Answer to Question #1
B. Mouth
Rationale: The body temperature of an unconscious
patient is never taken by mouth. Rectal or tympanic
(if not contraindicated) temperature measurement is
preferred to the less accurate axillary temperature.
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Collaborative Problems and Potential
Complications of Patients with Altered Level
of Consciousness
Respiratory distress or failure
Pneumonia
Aspiration
Pressure ulcer
Deep vein thrombosis (DVT)
Contractures
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Planning and Goals for the Patient with
Altered Level of Consciousness
 Goals may include:
o Maintenance of clear airway
o Protection from injury
o Attainment of fluid volume balance
o Maintenance of skin integrity
o Absence of corneal irritation
o Effective thermoregulation
o Accurate perception of environmental stimuli
o Maintenance of intact family or support system
o Absence of complications
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Nursing Interventions for the Patient with
Altered Level of Consciousness #1
 A major nursing goal is to compensate for the patient’s loss of
protective reflexes and to assume responsibility for total
patient care. Protection also includes maintaining the patient’s
dignity and privacy
 Maintaining an airway
o Frequent monitoring of respiratory status, including
auscultation of lung sounds
o Positioning to promote accumulation of secretions and
prevent obstruction of upper airway—head of bed (HOB)
elevated 30 degrees; lateral or semiprone position
o Suctioning, oral hygiene, and CPT
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Nursing Interventions for the Patient with
Altered Level of Consciousness #2
 Maintaining tissue integrity
o Assess skin frequently, especially areas with high potential
for breakdown
o Frequent turning; use turning schedule
o Careful positioning in correct body alignment; use of
splints, foam boots, trochanter rolls, and specialty beds as
needed
o Passive ROM
o Clean eyes with cotton balls moistened with saline
o Use artificial tears as prescribed
o Measures to protect eyes; use eye patches cautiously
because the cornea may contact patch
o Frequent, scrupulous oral care
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Nursing Interventions for the Patient with
Altered Level of Consciousness #3
 Maintaining fluid status
o Assess fluid status by examining tissue turgor and
mucosa, laboratory test data, and I&O
o Administer IVs, tube feedings, and fluids via feeding tube
as required; monitor ordered rate of IV fluids carefully
 Maintaining body temperature
o Adjust environment and cover patient appropriately
o If temperature is elevated, use minimum amount of
bedding, administer acetaminophen, use hypothermia
blanket, give a cooling sponge bath, and allow fan to blow
over patient to increase cooling
o Monitor temperature frequently and use measures to
prevent shivering
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Nursing Interventions for the Patient with
Altered Level of Consciousness #4
 Promoting bowel and bladder function
o Assess for urinary retention and urinary incontinence
o May require indwelling or intermittent catheterization
o Bladder training program
o Assess for abdominal distention, potential constipation,
and bowel incontinence
o Monitor bowel movements
o Promote elimination with stool softeners, glycerin
suppositories, or enemas as indicated
o Diarrhea may result from infection, medications, or
hyperosmolar fluids
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Nursing Interventions for the Patient with
Altered Level of Consciousness #5
 Sensory stimulation and communication
o Talk to and touch patient and encourage family to talk to
and touch the patient
o Maintain normal day–night pattern of activity; orient the
patient frequently
o Note: When arousing from coma, a patient may
experience a period of agitation; minimize stimulation at
this time
o Programs for sensory stimulation
o Allow family to ventilate and provide support
o Reinforce and provide consistent information to family
o Referral to support groups and services for family
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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 plays a role; decreased CO2 results in vasoconstriction,
and increased CO2 results in vasodilatation
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Question #2
Is the following statement true or false?
The earliest sign of increasing ICP is a change in LOC.
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Answer to Question #2
True
Rationale: The earliest sign of increasing ICP is a
change in LOC. Slowing of speech and delay in
response to verbal suggestions are other early
indicators.
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Cerebral Response to ICP
Cerebral perfusion pressure (CPP) is closely linked
to ICP
CCP = MAP (mean arterial pressure) – ICP
Normal CCP is 70 to 100
A CCP of less than 50 results in permanent
neurologic damage
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Early Manifestations of Increased ICP
Changes in LOC
Any change in condition
o 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
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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
rapidly from tachycardia to bradycardia; temperature increase
o Cushing triad: bradycardia, hypertension, bradypnea
 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
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Assessment of the 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
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ICP Monitoring
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Intracranial Pressure Waves
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Location of the Foramen of Monro for
Calibration of ICP Monitoring System
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Collaborative Problems and Potential
Complications of the Patient with Increased
Intracranial Pressure
Brainstem herniation
Diabetes insipidus
SIADH
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Planning and Goals for the Patient with
Increased Intracranial Pressure
Major goals may include:
o Maintenance of patent airway
o Normalization of respirations
o Adequate cerebral tissue perfusion
o Respirations
o Fluid balance
o Absence of infection
o Absence of complications
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Nursing Interventions for the Patient with
Increased Intracranial Pressure
 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 0 to
60 degrees to promote venous drainage
 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
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Intracranial Surgery
Craniotomy: opening of the skull
o Purposes: remove tumor, relieve elevated ICP,
evacuate a blood clot, control hemorrhage
o 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
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Burr Holes
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Question #3
What is the purpose of burr holes in neurosurgical
procedures?
A. Make a bone flap in the skull
B. Aspirate a brain abscess
C. Evacuate a hematoma
D. All of the above
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Answer to Question #3
D. All of the above
Rationale: The purpose of burr holes in neurosurgical
procedures is to make a bone flap in the skull,
aspirate a brain abscess, and evacuate a hematoma.
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Preoperative Care: Medical Management
Preoperative diagnostic procedures may include 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
Antibiotics may be given to reduce potential
infection
Diazepam may be used to alleviate anxiety
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Preoperative Care: Nursing Management
Obtain baseline neurologic assessment
Assess patient and family understanding of and
preparation for surgery
Provide information, reassurance, and support
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Postoperative Care
Postoperative care is aimed at
o Detecting and reducing cerebral edema
o Relieving pain
o Preventing seizures
o Monitoring ICP and neurologic status
The patient may be intubated and have arterial and
central venous lines
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Assessment of the Patient 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; if seizures occur,
carefully record and report these
Monitor for signs and symptoms of complications
Monitor fluid status and laboratory data
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Collaborative Problems and Potential
Complications of the Patient Undergoing
Intracranial Surgery
Increased ICP
Bleeding and hypovolemic shock
Fluid and electrolyte disturbances
Infection
CSF leak
Seizures
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Planning and Goals for the Patient
Undergoing Intracranial Surgery
Major goals may include:
o Improved tissue perfusion
o Adequate thermoregulation
o Normal ventilation and gas exchange
o Ability to cope with sensory deprivation
o Adaptation to changes in body image
o Absence of complications
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Nursing Interventions for the Patient
Undergoing Intracranial Surgery #1
 Maintaining cerebral perfusion
o Monitor respiratory status; even slight hypoxia or
hypercapnia can affect cerebral perfusion
o Assess VS and neurologic status every 15 minutes to
every hour
o Strategies to reduce cerebral edema; cerebral edema
peaks 24 to 36 hours
o Strategies to control factors that increase ICP
o Avoid extreme head rotation
o HOB may be flat or elevated 30 degrees according to
needs related to the surgery and surgeon preference
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Nursing Interventions for the Patient
Undergoing Intracranial Surgery #2
 Regulating temperature
o Cover patient appropriately
o Treat high temperature elevations vigorously; apply ice
bags, use hypothermia blanket, administer prescribed
acetaminophen
 Improving gas exchange
o Turn and reposition every 2 hours
o Encourage deep breathing and incentive spirometry
o Suction or encourage coughing cautiously as needed
(suctioning and coughing increases ICP)
o Humidification of oxygen may help loosen secretions
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Nursing Interventions for the Patient
Undergoing Intracranial Surgery #3
Sensory deprivation
o 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
o Encourage verbalization
o Encourage social interaction and social support
o Attention to grooming
o Cover head with turban and, later, a wig
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Nursing Interventions for the Patient
Undergoing Intracranial Surgery #4
 Monitor I&O, weight, blood glucose, serum and urine
electrolyte levels, and osmolality and urine specific gravity
 Preventing infections
o Assess incision for signs of hematoma or infection
o Assess for potential CSF leak
o Instruct patient to avoid coughing, sneezing, or nose
blowing, which may increase the risk of CSF leakage
o Use strict aseptic technique
 Patient education for self-care
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Question #4
What sign or symptom is not an indication of CSF
leakage?
A. Patient complains of a salty taste in the mouth
B. Patient complains of postnasal drip
C. Clear fluid draining from nose
D. Altered LOC
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Answer to Question #4
D. Altered LOC
Rationale: Signs and symptoms of CSF leakage that
the nurse should investigate further would include
patient complaints of salty taste in their mouth,
postnasal drip or if the nurse observes clear fluid
draining from nose or incision. Altered LOC is a sign of
increased ICP but not a sign or symptom of CSF
leakage.
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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
Classification of seizures
o Focal: originates in one hemisphere
o Generalized: occur and engage bilaterally
o Unknown: epilepsy spasms
o “Provoked” related to acute, reversible condition
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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
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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
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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
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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
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Nursing Management of Headache: Pain
 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
 Provide medications as prescribed
 Provide comfort measures
o Quiet, dark room
o Massage
o Local heat for tension
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Nursing Management of Headache:
Education
Help patient identify triggers and develop a
preventive strategies and lifestyle changes for
headache prevention
Medication instruction and treatment regimen
Stress reduction techniques
Nonpharmacologic therapies
Follow-up care
Encouragement of healthy lifestyle and health
promotion activities
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