Neurology
Management of Patients with
Neurological Dysfunction
Chapter 61
Nursing management
• Ineffective airway clearance r/t alt. LOC
– HOB h
– Lateral/semi-prone
– Suctioning
• Hyper-oxygenate
–
–
–
–
–
Chest physiotherapy
Postural drainage
Auscultate
Intubation
Mech. vent
Nursing management
• Risk of injury r/t i LOC
– Padded side-rails
– Lines & equipment
– Restraints
– Dignity
• Privacy
• Speak to pt
Nursing management
• Deficient fluid volume
r/t NPO
–
–
–
–
P Skin turgor
P Mucous membranes
I&O
P labs
Question?
• Which of the following lab values is most
useful in assessing dehydration?
– K+
– Na+
– Hematocrit
– BUN
– Urine specific gravity
Question?
• What affect does dehydration have on a pt
BUN level?
– Increase
– Decrease
Question?
• What affect does dehydration have on a pt.
Hematocrit level?
– Increase
– Decrease
Nursing management
• Impaired oral mucous membranes r/t mouth
breathing etc.
– P for dryness, inflammation, crusting
– Oral care q8h
– Lips
– Move endotracheal tube each day (rt–lf–rt)
Nursing management
• Alt. in nutrition, less than body requires
– NGT/GT
– HOB h
Question?
• Mrs. Jones has an NGT and has 2 medication
that need to be given at 12:00 pm. Can the
nurse crush the meds and give them at the
same time?
– Yes
– No
• Each med is given separate and flush with 2030 ml of water after each dose
Question?
• How do you measure for NGT tube placement?
A. From the tip of the nose  ear lobe  xyphoid
process
B. From the tip of the nose  ear lobe  xyphoid
process + 6 inches
C. From the ear lobe  tip of the nose  xyphoid
process
D. From the ear lobe  tip of the nose  xyphoid
process + 6 inches
Question?
•
What is the most effective way to check NGT
placement?
A. Inject 20 cc of air and listen for gurgle
B. Aspirate stomach contents
C. X-ray
Question?
• Mrs. Nop had an NGT placed 7 days ago and is
tolerating feeding well. You are assigned to give her
a 250 bolus feeding of Ensure. How should you make
sure the NGT is in the stomach and not the lung?
A. Inject 20 cc of air and listen for gurgle
B. Aspirate stomach contents
C. X-ray
D.None of the above are necessary
Nursing management
• Risk for impaired skin
integrity r/t immobility
– Reg. turning
• X drag
– ROM
– Splints
• Foam boats
– Beds
Nursing management
• Impaired tissue integrity of cornea r/t I
corneal reflex
– Clean
• Cotton-ball & normal saline
– Cold compress
• i edema post-op
– Eye patch warning!
Nursing management
• Ineffective thermoregulation r/t damage to
hypothalamic center
– Minimal bedding
– Anti-pyretic
– Cool sponge bath
– Fan
– Hypothermic blanket
Nursing management
• Impaired urinary elimination (incontinence or
retention)
– Scan bladder
– Retention  Foley
– P S&S of infection
• Fever
• Cloudy urine
Nursing management
• Bowel incontinence
– Bowel sounds
– Abd girth
– Monitor BM
• Frequency
• Consistency
Nursing management
• Disturbed sensory perception
– Touch
– Talk
– Orient
– Familiar sounds (tape player)
• Favorite TV/radio
– When arousing from coma 
• i stimuli
Nursing management
• Interrupted family processes r/t health crisis
– Grief process
What’s your advice?
• While assessing the patency of a central line for an
unresponsive, terminally ill patient, I was startled
when the patients wife said to me, “this isn’t how it
was suppose to be. He’s just a year away from
retirement, and we had wonderful plans to travel
across the country.” I didn’t know what to say
except, “I’m sorry.” I’d like to do better if this
situation come up again. What should I have said?
Small Group Questions
1. What is the priority nrs dx for a patient with alt.
LOC?
2. Describe cerebral blood flow during suctioning.
3. How can a nrs best assess for dehydration?
4. Give 5 nrs interventions for a patient at risk for
injury & for impaired joint and skin integrity.
Increased Intracranial Pressure
• Rigid vault
• Contains 3 components
– Brain tissue
– Blood
– CSF
• Normal ICP 10-20 mmHg
I-ICP
• Minor changes in ICP
– Straining
– Coughing
– Sneezing
– Posture
– BP
I-ICP
• Etiology of I-ICP
– Head injury
– Stroke
– Inflammatory process
– Intra-Cranial surgery
I-ICP
• I-ICP Cycle
– I-ICP 
– i cerebral perfusion 
– Ischemia 
– Further edema 
– Herniation (shift brain tissue) 
– Deathmosis
I-ICP
• h PaCO2 
• Cerebral vasodilatation

• h cerebral blood flow

• h-ICP
• i PaCO2 
• Cerebral
vasoconstriction 
• i cerebral blood flow

• i-ICP
I-ICP
• Cerebral edema
– Abn. h of fluid 
– h brain tissue volume 
– I-ICP
I-ICP
• Compensation
– Bodies attempt to i ICP
– Cushing’s response
• Widening PP
• Bradycardia
• Decompensation
– Ischemia
– Infarction
What is the earliest S&S of
I-ICP?
A.
B.
C.
D.
E.
F.
Hyporeflexia
Paresethesia
Visual distrubance
Altered level of consciousness
Motor slowing
Pupils fixed
I-ICP
• Early S&S
– #1 Alt LOC
• h restlessness or confusion
– H/A
– Pupillary changes
– Weakness on one side
I-ICP
• Late S&S
– Stupor  coma
– Pulse & Resp
•i
• Erratic (Cheyne-stoke, ataxic, Biot’s)
– BP & Temp
•h
– Projectile vomiting
I-ICP
• Late S&S
– Decorticated posturing
– Decerebrate posturing
– Loss of protective reflexes
Where did it go?
• What goes first?
– Orientation to time
– Orientation to person
– Response to verbal stimuli
– Response to painful stimuli
– Protective reflexes
I-ICP
• Ominous sign!
• Grave sign!
Complications of I-ICP
• Herniation
• Diabetes Insipidus
• SIADH
I-ICP Dx / Assessment
• CT
• MRI
I-ICP Management
• Monitor ICP
– Ventricular catheter
– Sub-arachnoid screw
3 goals of I-ICP management
• i edema
• i CSF volume
• i Cerebral blood volume
I-ICP management
• Decrease Edema
– Osmotic diuretic
• Mannitol/Osmitrol
– I&O
– Indwelling catheter
– P via serum osmolality
I-ICP management
• Decrease edema
– Corticosteroids
• Dexamethasone /Decadrone
– S/E
» Hyperglycemia
» GI bleed
– Give with
» Antacids / Tums
» Histamine H2 receptor blockers / Tagamet (cimetidine)
I-ICP management
• Decreasing edema
– Fluids
• i
– HOB
• h
– Body temperature
• Lower
– i cerebral edema
– i metabolism
I-ICP management
• Decreasing CSF
– Drain CSF
• Via lumbar puncture
• Not too much 
• Ventricles collapse
I-ICP management
• Decrease cerebral blood flow
– O2
• Hyperventilate 
• Vasoconstriction
• Hgb levels
– Control fever
• Anti-pyretics
• Cooling blanket
• X shivering  I-ICP
I-ICP management
• Decrease cerebral blood flow
– Decrease metabolic demand
• Induce coma
– Phenobarbital
• Paralyzing agents
–
–
–
–
–
Monitor cardiac
Vent
Monitor ICP
monitor Arterial pressure
Monitor serum barbituate levels
I-ICP management
• Decrease cerebral blood flow
– Decrease metabolic demand
• Prevent Seizures
– Phenytoin / Dilantin
– Diazepam / valium
– Monitor serum levels
• Prevent infections
– Control BP
I-ICP Nursing Management
• Maintain patent airway
• Optimizing cerebral tissue perfusion
– Position
• HOB h
• Head neutral position
• Avoid extreme hip flexion
– X valsalva maneuver  I-ICP
• Stool softeners
• X emena
• Suctioning
I-ICP Nursing Management
• Optimizing cerebral tissue perfusion
– Calm atmosphere
– Space nursing tasks
– Minimal stimuli
• Monitor ICP
Intracranial surgery
• Craniotomy:
– Opening the skull surgically to gain access to
intracranial structures
Intracranial surgery
• Burr hole
– Circular opening made in the skull by a drill
Intracranial surgery
• Craniectomy
– An excision of a portion of the skull
Intracranial surgery
• Cranioplasty
– Repair of a cranial defect by means of a plastic or
metal plate
Intracranial surgery
• Transsphenoidal
– Through the nasal sinuses to gain access to the
pituitary gland
Intracranial surgery
• Pre-op
– Diagnostic procedures
• CT scan
• MRI
• Cerebral angiography
– Anticonvulsants
• Phenytoin / Dilantin
– Corticosteroids
• Dexamethasone / Decadron
Intracranial surgery
• Pre-op
– Fluids
• Restricted
– Diuretics
• Mannitol
• Furosemide / Lasix
– i Anxiety
• Diazepam / Valium
Intracranial surgery
• Pre-op
– Antibiotics
– Shave head
– Indwelling catheter
– Warn pt about post-op environment
– Baseline neuro check
Intracranial surgery
• Post-op
– Continue Pre-op meds
– Reduce cerebral edema
• Mannitol
• Dexamethasone
– Relieve pain
• Acetaminophen / Tylenol
• Codeine
• Morphine sulfate
Which of the following would be of concern while
assessing the ABG’s of a patient post-op craniotomy?
A.
B.
C.
D.
E.
PaO2 105
Hypoxemia
Hypercapnia
Hypercarbia
Hypocapnia
Intracranial surgery
• Post-op
– Prevent seizures
• Phenytoin / Dilantin
• Diazepam / valium
• Monitor serum levels
– Monitor ICP
– Edema peaks 24-36 hrs post-op
– Temp control
Intracranial surgery
• Post-op
– Periorbital edema /
ecchymosis
– Enhancing self image
• Verbalize frustration
• Cover head with turban
• Wig until hair grows
Seizures
• Definition
– Abnormal motor, sensory autonomic or psychic
activity resulting from sudden excessive discharge
from cerebral neurons
What is Epilepsy?
• disorder
• briefly interrupts the normal electrical activity
of the brain
• too many neurons fire at one time
• "electrical storm" 
• seizure
Seizures
• Classification
– Partial
– Seizure that begins in one part of the brain
• Simple
–
–
–
–
–
Repetitive purposeless behavior
Dreamlike state
No loss of consciousness
Duration: < 1 minute
I.e. talking unintelligibly, dizziness, hand shake, picking at
clothes, chewing, smacking lips, spitting, fondling self
Seizures
• Classification
– Partial
• Simple
• Complex
–
–
–
–
Repetitive purposeless behavior
Loss of consciousness
Lasts 2-15 minute
Not aware of behavior
Seizures
• Classification
– Generalized
– Seizure that involves electrical discharges in the whole brain
• Absence Seizure
– Occurs must often in children
– Period of staring
– Duration: several seconds
• Tonic-Clonic Seizure
Seizures
• Classification
– Generalized
• Tonic-Clonic Seizure
– (grand mal seizure)
– Tonic – rigidity
– Clonic – contraction and relaxation of all muscles  jerky,
rhythmic
Seizures
• Possible Etiology
– Underlying cause is electrical disturbance  emitting of
abnormal, recurring, uncontrolled electric discharge
•
•
•
•
•
•
Idiopathic origin
Head injury
Hypoglycemia
Brain tumor
Infection
Anoxia
Seizures
• Clinical manifestations
– Prodromal phase
• Vague emotional changes
• Minutes – hours before seizure
Seizures
• Clinical manifestations
– Prodromal phase
– Aura
• Brief sensory experience
• Precedes seizure by a few seconds
• Usually the same aura each time
Seizures
• Clinical manifestations
– Prodromal phase
– Aura
– Loss of consciousness
• May or may not occur
– Seizure activity
Seizures
• Seizure activity
– Tonic Phase
•
•
•
•
•
Duration: 30-60 sec
Rigidity  fall
Pupils fixed & dilated
Hands and jaws clenched
Stop breathing
– Clonic phase
Seizures
• Seizure activity
– Clonic phase
•
•
•
•
•
•
•
Contraction & relaxation of all muscles, jerky rhythmic fashion
Incontinent
Frothing at the mouth
Dyspnea
Epileptic cry
Tongue chew
Lasts 1-2 minutes  subsides
Seizures
• Characteristics
– Post-seizure / postictal
• Recover period
• Deep sleep
• Confused
Seizures
• Medical management
– Anticonculsants
• Caramazepine / Tegretol
– S/E
» Severe rash
» Blood dyscrasias
» Hepatitis
• Clonazepam / Klonopin
– S/E
» Hepatotoxicity
» Behavioral changes
Seizures
– Anticonculsants
• Phenytoin / Dilantin
– S/E
»
»
»
»
»
Gum hyperplasia
Rash
Nystagmus
Blood dyscrasias
PG  cleft palate
Seizures
– Anticonculsants
• Valproate / Depakene
– S/E
» Hepatotoxicity
» Blood dyscrasias
» Skin rash
• Diazepam / Valium
• Phenobarbital / Luminal
– S/E
» Drowsiness
» Rash
» h pain
Seizures
• Nrs Management w/ anticonvulsants
– Do not stop abruptly  seizures
– Monitor levels
– Take regularly
– Inform of all meds
– Alcohol only in moderation
Seizures
• Before Seizure
– At risk for injury
•
•
•
•
Padded side rails
Suction machine in room
Loose clothing
Know aura
Seizures
• Fear r/t possibility of a seizure
– Take meds routinely
– ID triggers
•
•
•
•
•
•
Stress
New environment
Menstruation
Fever
Sleep deprivation
Alcohol
Seizures
• Fear
– Avoid photic stim
• Bight flickering lights
• TV
• Wear dark glasses
– Regular routine
– Wear ID band
Seizures
• Ineffective coping
– Embarrassed
– Feel rejected, avoided, discriminated
– Frequently lonely  psych problems
– Driving restrictions
Seizures
• Knowledge deficit
–
–
–
–
–
Take meds daily
records of meds & seizures
Drug levels routine
Avoid activities requiring alertness after meds
Showers or bath?
• Shower!
– Exercise
– Sleep
Seizures
During a seizure
• Safety
–
–
–
–
–
Ease to floor
Protect the head
Turn to side
Loosen clothing
In bed?
• Remove pillow
• Side rails up
– Do not
• pry open mouth
• Insert anything in mouth
• restrain
– Stay with pt
• Support patient
– Privacy
Seizures
• Observe & document
–
–
–
–
Circumstance (before)
Aura?
1st
Movement
– Area
– Pupils
– Automatisms
– Incontinent
–
–
–
–
–
Duration
Unconsciousness
Weakness
Dysphasia
Post seizure behavior
Seizures
• After a seizure
– •Document
Recovery position
– At risk for
• Hypoxia
• Vomiting
• Aspiration
Seizures
• Nursing care
–
–
–
–
Side lying
Bed low
Padded side rails
i stimulation
• Dim lights
• Noise i
–
–
–
–
VS
Check mouth
Clean pt
Allow to “sleep it off”
Status Epilepticus
• Defines
– Prolonged seizure
activity
– Series of
generalizes seizures
w/o full recovery
btw attacks
–
Medical emergency
Status Epilepticus
• Affects
– Metabolic demand
– Respiration
– Anoxia
– Brain damage
Status Epilepticus
• Medical
Management
– Goal
• Stop seizure activity
• Airway
• Rx of choice
– Diazepam
• Valium
Status Epilepticus
• Dx
– Blood studies
• Electolytes
• Glucose
• Phenytoin level
What alteration in glucose level can
commonly lead to seizures?
A. Hyperglycemia
B. Hypoglycemia