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Tuesday, May 20, 2008

Nursing Management of the Adult Client with Neurologic Alterations

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Nursing Management of the Adult Client with Neurologic Alterations Slide Transcript
Slide 1: Nursing Management of the Adult Client with Neurologic Alterations NURS 228 Janie Best, MSN, RN, APRN, BC

Slide 2: 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

Slide 3: The Nervous System Central Nervous System (CNS) Brain Spinal Cord Peripheral Nervous System (PNS) Cranial nerves Spinal nerves Autonomic nervous system Sympathetic Parasympathetic

Slide 4: Anatomy Brain Cerebrum Hemispheres Lobes: Frontal, Parietal, Temporal, Occiptial Thalamus, Hypothalamus, Basal ganglia Cerebellum Brain Stem

Slide 6: 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

Slide 7: Brain Requirements Blood Flow 750 ml / minute 20% of total oxygen uptake Glucose 80% of body’s glucose use Blood Flow Regulation CO2 Oxygen

Slide 8: Diagnostic Studies Skull and Spine Radiography CT (Computerized Tomography) MRI (Magnetic Resonance Imaging) PET (Positron Emission Tomography) EEG (Electroencephalogram) EMG (Electromyography)

Slide 9: Diagnostic Studies – Cerebral Angiography Post Procedure Care Pre-procedure care Bedrest x 8 hrs Assess for allergy to iodine and shellfish Increase Fluids NPO 4-6 hrs Monitor Baseline neuro assessment Neuro assessment / VS Education Peripheral pulses Immobile during / Observe following procedure for s/s altered cerebral Expect brief feeling of blood flow warmth / burning in Hematoma at femoral behind eyes, or in jaw, injection site teeth, tongue, lips Keep bed FLAT if femoral May have metallic taste artery is used

Slide 10: Diagnostic Studies – Myelography / Lumbar Puncture Pre Procedure Care Post Procedure Care NPO HOB > 300 – 450 for 3 Sedative may be given – 8 hrs Lateral recumbent position with knees Drink plenty of fluids drawn up to abdomen Monitor VS and and chin onto chest Urinary output Patient Ed. - Position of x-ray table may be changed during procedure LP is contraindicated if suspected IICP

Slide 11: Neurological Assessment Hx present illness A – associated symptoms P – what provokes / pallliates symptoms Q – Quality of pain R – region and radiation S – severity of pain on scale of 1-10 T – timing (start / stop, intermittent, constant)

Slide 12: Neurological Assessment Physical Exam Mental status Cranial Nerves Motor system Cerebellar - balance / coordination Sensory system Reflexes

Slide 14: 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

Slide 15: Abnormal Findings Battle’s sign Raccoon’s eye Rhinorrhea Otorrhea

Slide 16: Doll’s Eyes - Oculocephalic Reflex http:// connection.lww.com/Products/morton/documents/images/Ch33/jpg/Ch33-006B.jpg

Slide 18: Doll’s eyes Brainstem Eyes fail to follow normal movements Decorticate Cerebellar Internal rotation of arms &wrists, posturing function extension, internal rotation & plantar flexion of the feet Decerebrate Cerebellar Extension & external rotation of arms & posturing function wrists, extension, plantar flexion, internal rotation of feet Flacid posturing Cerebellar No motor tone or function function, limp

Slide 19: Altered LOC - Etiology Vowel TIPPS Alcohol Trauma Epilepsy Infection Insulin Psych Opiates Poisons Urates (renal failure) Shock

Slide 20: Altered LOC Arousal Alertness, response to stimuli Content Awareness of time, place, person

Slide 21: Altered LOC Level of Consciousness Continuum Terminology Alert Confusion Somnolent Lethargic Obtunded / Stupor Comatose

Slide 22: Glasgow Coma Scale Best Eye-opening Best Motor response response 1 = no response 1 = no response 6 = obeys commands 4 = spontaneously Best Verbal response 1= no response 5 = oriented Score < 7 is consistent with significant alteration in LOC (coma)

Slide 23: Assessment of Respirations Cheyne-Stokes Rhythmical pattern: waxing/ waning in depth, followed by periods of apnea Neurogenic hyperventilation Regular, rapid (> 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

Slide 24: Assessment of other Vital Signs Vital Sign ↑/ Implications Temperature Increase CNS infection Subarachnoid hemorrhage, hypothalamic lesions, hemmorhage of hypothalamus or brainstem Temperature Decrease Spinal shock Metabolic coma Drug overdose Brainstem lesions

Slide 25: Assessment of other Vital Signs Vital Sign ↑ or  Implications Pulse Increase Poor cerebral oxygenation Decrease Late stages of IICP Blood Pressure HTN Cerebral trauma – Cushing’s triad

Slide 26: 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

Slide 27: Altered LOC Nursing Interventions Airway maintenance Fluid balance and Nutrition Mouth care Skin and joint integrity Preventing injury Temperature regulation Bladder and bowel function

Slide 28: Altered LOC Nursing Interventions Sensory stimulation Family needs Preventing complications Pneumonia Aspiration Respiratory failure DVT/PE Assume the unconscious patient CAN hear! Outcomes

Slide 29: 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

Slide 30: 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

Slide 31: 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

Slide 32: 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

Slide 33: 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

Slide 34: Cerebral Blood Flow / Volume Increased Flow / Decreased Blood flow / volume: volume: Effects Effects Systemic hypotension Hypertension ↑ metabolic rate ↓ metabolic rate Acidosis Alkalosis Hypercapnia, Hypocapnia ischemia Cerebral edema Cerebral vasodilation Low cardiac output Cerebral vasoconstriction

Slide 35: ↑ Brain Volume Cause: Space – occupying lesions Cerebral edema Effect: Herniation http://www.uth.tmc.edu/radiology/test/ er_primer/skull_brain/skull.html

Slide 36: Cerebrospinal Fluid Functions Support / cushioning Maintain stable chemical balance of CNS Excrete toxic wastes CO2, lactate, hydrogen ions Effect: Causes of ↑CSF: ↑ cerebral blood volume ↑production Hydrocephalus Obstructed circulation ↓absorption

Slide 37: Intracranial Pressure (ICP) Compensation depends on Location of lesion Rate of expansion Compliance or volume- buffering capacity of body

Slide 38: 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

Slide 39: IICP CPP (Cerebral Perfusion Pressure) CPP = MAP – ICP Normal CPP – 70 to 100 mmHg IICP – CPP > 100 mmHg or < 50 mmHg < 50 mmHg – irreversible damage Cushing’s Response (Cushing’s reflex) ↑ SBP w/ widening pulse pressure ↓ pulse

Slide 40: IICP Cushing’s Triad ↑ systolic blood pressure  diastolic blood pressure Bradycardia Activation ICP ≥ Mean arterial pressure Ominous sign

Slide 42: IICP Early Indicators ∆ 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)

Slide 43: 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

Slide 45: IICP - Complications Cerebral Herniation DI (Diabetes Insipidus) - ↓ secretion ADH Clinical manifestations SIADH (Syndrome of Inappropriate release of Antidiuretic Hormone) - ↑ secretion ADH Clinical manifestations

Slide 46: 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.

Slide 47: IICP – Complications - DI Treatment Fluid and electrolyte management Vasopressin Thiazide diuretics Complications Cardiovascular collapse Tissue hypoxia Seizures Encephalopathy

Slide 48: 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

Slide 49: IICP – Complications - SIADH Clinical manifestations Signs / symptoms Water retention → Personality changes water intoxication Headache Hyponatremia Decreased mentation Lethargy N, V, diarrhea Decreased tendon reflexes Seizures, coma

Slide 50: IICP – Complications - SIADH Treatment Complications Treat underlying Seizures disease Coma Alleviate excessive Death water retention Nursing care – depressed LOC

Slide 51: IICP – Medical Management Goals Decreasing Cerebral Edema Lowering CSF Volume Decreasing Cerebral Blood Volume

Slide 52: 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

Slide 53: IICP – Medical Management AVOID Lumbar Puncture in IICP Risk of: Herniation of brainstem Infection Headache

Slide 54: IICP – Medical Management Medications Osmotic diuretics (cerebral edema reduction) Corticosteroids (cerebral edema reduction) Inotropics (maintain CPP) Antipyretics (fever control) Barbiturates (reduces metabolic demands)

Slide 55: Osmotic Diuretics Mannitol Increases cerebral tissue perfusion and reduces ICP Draws fluid from cerebral interstitial spaces into the vascular space Test dose Serum osmolality must be monitored Complication – acute renal failure Contraindication – active intracranial bleeding Monitor: neurologic and renal status IV site for signs of Extravasation

Slide 57: IICP – Nursing Diagnoses Ineffective cerebral tissue perfusion Ineffective airway clearance Ineffective breathing pattern Protection from injury

Slide 58: IICP Planning and Goals Maintain patent airway Adequate breathing pattern Optimal cerebral tissue perfusion Maintain negative fluid balance Absence of complications Calm, safe environment (minimal noise, dim lights)

Slide 59: 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

Slide 60: Critical Thinking Case Study Chapter 6: Case Study 15, pp. 395-398.

Slide 61: References Deglin, J.H., Vallerand, A.H. (2005). Davis’s 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.

Slide 62: 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 & Suddarth’s 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.





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