WEEK 6

Alteration in Neural Regulation

Care of Clients with Problem in Inflammatory and Immunologic Response and Perception and

Coordination

Etiology

Degenerative Neurologic Disorders

Seizure Disorders

Disorder of consciousness

Direct damage/trauma• Concussions• Contusion • Laceration

Increased intracranial pressure

Intracranial Tumors




Coordination


Diagnostic Procedures

Skull Films

Spine Films

Computerized Axial Tomography Scan (CAT Scan)

Electroencephalography (EEG)

Electromyography (EMG)

Nerve Conduction Velocity (NCV)

Cerebral Angiography (Arteriogram)

Lumbar Puncture



Coordination



Myelography

Magnetic Resonance Imaging (MRI)

Pneumoencephalography

Ventriculography

Positive Emission Tomography

Single photon emission computed tomography



Coordination



Noninvasive carotid flow studies

Transcranial Doppler

Evoked Potentials (Auditory and Visual)



Coordination


Nursing Diagnoses Taxonomy

Ineffective airway clearance related to upper airway obstruction by tongue and soft tissues and inability to clear respiratory secretions

Potential fluid volume deficit related to inability to ingest fluids, dehydration from osmotic therapy

Altered oral mucous membranes related to mouth breathing, absence of pharyngeal reflexes and inability to ingest fluids

Potential impairment of skin integrity related to immobility or restlessness



Coordination


Nursing Diagnoses Taxonomy

Impaired tissue integrity of cornea related to diminished or absent of corneal reflex

Potential hyperthermia related to potential damage to hypothalmic center

Altered urinary eliminations (incontinence or retention ) related to unconscious state

Altered bowel elimination (incontinence or retnetion related to unconscious state

Altered family process related to sudden crisis of unconsciousness



Coordination


Pharmacologic Management

Mannitol -an osmotic diuretic, to reduce cerebral edema by inducing diuresis

Lasix (furosemide)-a diuretic to reduced cerebral edema

Decadron (dexamethasone) -a corticosteroid to reduce cerebral edema by anti inflammatory effect




Coordination


Surgical Management

Craniotomy - is the surgical opening of the skull to gain access to intracranial structures, remove tumors, relieve

intracranial pressure, evacuate a blood clot or stop hemorrhage.

Craniectomy – is the excision of a portion of the skull

Cranioplasty –is the repair of a cranial defect by means of a plastic or metal plate

Thymectomy – is the removal of thymus glands




Coordination


Surgical Management

Rhizotomy- surgical severing of a nerve root.

Plasmapheresis – is an adjunctive therapy for clients with refracoty




Coordination


Complications

Intracranial bleeding and hematoma

Cerebral edema

Infections

Seizures

Cranial nerve dysfunction




Coordination


Nursing Management

Assessment

• Mental status

- Orientation to: people, time and place

- Memory

>> Immediate recall >> Recent memory >> Remote memory



Coordination


Nursing Management

Assessment• Level of consciousness - Level 1 : Conscious , Cognitive , coherent - Level 2 : Confused, Drowsy,

lethargic obtunded, somnolent - Level 3 : Stuporous - Level 4 : Light coma and Deep coma

• Glasgow Coma Scale (GCS)

- Eye opening - Best Verbal Response - Best Motor l Response



Coordination


Nursing Management

• Sensory Function - stereognosis the ability to perceive sensory stimuli - agnosia - inability to perceive sensory stimuli

• Motor function - Apraxia - inability to perform fine motor activities - Agraphia - is inability to write - Atraxia is uncoordinated movement, characterized by wide- base stance and swaying manner of walking - General appearance of muscles - Muscle power , tone and volume - Movemen

>> Bradikinesia is slow muscle

movement not associated with weakness >> Akenisia is absence of muscle movement



Coordination


Nursing Management• Motor function

- Coordination

- Station and gait

• Reflex Testing - superficial reflexes

• Pupilliary reflex PERRLA ( pupils equal, round, reactive to light, accommodation)

• Corneal reflex

• Biceps reflex



Coordination


Nursing Management

• Triceps reflex

• Patellar reflex



Coordination


Nursing Management• Abdominal reflex • Cremasteric reflex • Anal reflex • Ankle reflex

• Babinski reflex



Coordination


Nursing Management - deep tendon reflexes

- Reflexes to assess meningeal irritation >> Kernigs Sign

>> Brudzinki’s reflex

- Oculovestibular Reflex or Caloric Ice Water test

- Oculocephalic Reflex or Dolls eye phenomenon



Coordination


Nursing Management

• Cranial Nerve testing - I Olfactory - II Optic - III Oculomotor - IV Trochlear - V Trigeminal - VI Abducens - VII Facial - VIII Acoustic - IX Glossopharyngeal - X Vagus Nerve - XI Spinal Accessory - XII Hypoglossal



Coordination


Nursing Management

• Language and Speech

• Bladder and Bowel Functioning

• Intracranial Pressure

- Restlessness - Headache - Vomiting - Diplopia - Decrease in level of

consciousness - Vital signs changes



Coordination


Nursing Management

• Pupillary Changes - Aniscura - Pinpoint pupils - Fixed, dilated pupils - Papilledema

• Lateralizing Signs

• Brain Stem Function Impairment

- Doll’ s Eye sign - Decortication - Decerebration



Coordination


Nursing Management• Brain Stem Function Impairment

- Doll’ s Eye sign



Coordination


Nursing Management• Brain Stem Function Impairment - Decortication

Decerebration



Coordination


Nursing Management

Managing Increased Intracranial Pressure• Position the patient on semi-fowlers• Adequate oxygenation• Safety• Rest• Avoid factors that increase ICP

» Nausea and vomiting» Sneezing/ coughing» Valsalva maneuver » Over suctioning» Restraints» Rectal examination» Enema» Flexion of waist, hip, neck

(bending or stooping)

• Control hypertension• Restrict fluid intake to 1200 to 15000

mls/ day



Coordination


Nursing Management

Maintaining Effective Airway • Place the patient in semi prone

position or lateral position

• Keep airway free of secretions – Insert oral airways if tongue is

paralyzed or is obstructing .– Prepare for insertion of cuffed

endotracheal tube – Employ oxygen therapy as prescribed – Evaluate pulses (radial, carotid, apical

and pedal)

• Measure blood pressure

• Maintain circulation, support the blood pressure and treat life threatening cardiac dysrhythmias.



Coordination


Nursing Management

Attaining and Maintaining Fluid balance Electrolyte

• Monitor prescribed intravenous fluids

• Use hyperaliminentation feedings

• Initiate nasogastric feedings

• Measure urinary output and specific gravity



Coordination


Nursing Management

Maintain Healthy Oral Mucous Membrane

• Remove dentures

• Inspect patient’s mouth for dryness, inflammation

and presence of crusting

• Clean the mouth with prescribed solution every 2 hours

• Apply lip emollient



Coordination


Nursing Management

Maintaining Skin Integrity• Keep the skin clean, dry and free of

pressure.

• Clip the patients nail to prevent excoriation

• Turn the patient from side to side on a regular

• Reposition carefully after turning

• Put all extremities through range of motion exercises at least 4 times daily,



Coordination


Nursing Management

Maintaining Corneal Integrity

• Protect the eyes from corneal irritation.

• Make sure the patient’s eye is not rubbing

against the bedding if blinking and corneal reflexes are absent

• Prepare for temporary tarsorraphy



Coordination


Nursing Management

Reducing Fever

• Look for possible sites of infections

• Control persistent elevations of temperature

• Cool room to 18.3 degree Celsius.

• Remove bedding over the patient except light sheet

• Employ cool water sponging and an electric fan blowing over the patient to increase surface cooling

• Consider use of hypothermia blanket if hyperthermia is of neurogenic in origin.

• Esophageal or other core temperature is monitored continually



Coordination


Nursing Management

Promoting urinary elimination

• Palpate over the patient’s bladder at interval

• Insert an indwelling urethral catheter for short term management

• Use intermittent bladder catheterization for retention as soon as possible

• Monitor for fever and cloudy urine, inspect the urethral orifice for suppurative discharge

• Initiate a bladder training program as soon as consciousness is regained



Coordination


Nursing Management

Promoting Bowel Function

• Observe for constipation

• Stool softener may be prescribed and given with tube feeding

• Glycerin suppository may be prescribed

• Monitor for diarrhea

• Perform rectal examination if fecal impaction is suspected

• Use commercial fecal collection bags and meticulous skin care if patient has fecal incontinence.

• Auscultate for bowel sounds, measure abdominal girth with a tape measure to detect abdominal distention.



Coordination


Nursing Management

Other Nursing Interventions • Use every sensory avenue to stimulate

the patient

• Use physical touch and reassuring voice tone

• Encourage family to talk in a meaningful way the patient even when he is not responding.

• Orient patient to people, time, place and situation

• Have adequate room lighting to prevent hallucination as patient regain consciousness

• Be aware of the varying phases of restlessness



Coordination


Nursing Management

Other Nursing Interventions

• Provide social contacts and environmental enrichment

• Be aware that the patient after regaining consciousness

• Give an explanation of what has happened

• Permit the patient to asks questions



Coordination


Nursing Management

Evaluation• Maintain clear airway, cough up

secretions

• Attains/maintains adequate fluid volume status, absence of clinical signs of dehydration

• Has intact healthy appearing oral mucous membrane

• Absence of skin breakdown

• Absence of trauma to cornea

• Temperature within acceptable range

• Demonstrates bladder continence

• Maintaining normal bowel function

WEEK 6

Documents

neural alteration

response alteration

coordination alteration

visual alteration

restlessness alteration

refracoty alteration

immunologic response

intracranial structures