neuro dysfunctions

7/30/2019 Neuro Dysfunctions

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Neurologic Dysfunctions

Altered Level of Consciousness



Altered Level of Consciousness

• Patient who is not oriented, does not followcommands, or needs persistent stimuli to a

state of alertness.

• Level of responsiveness and consciousness

important indicator of the patient's condition• Altered LOC is not a disorder but the result

pathology



Altered Level of Consciousness (LO

• LOC is a continuum from normal alertness and full cognition (conscio

• Coma:

• unconsciousness, unarousable, unresponsiveness

• Akinetic mutism:

• unresponsiveness to the environment, makes no movement or sou

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 le

pons



Pathology

• Underlying cause

• disruption in the cells of the nervous syst

neurotransmitters, or brain anatomy

• Disruptions result from cellular edema or

mechanisms, such as disruption of chem

transmission at receptor sites by antibodi



Pathophysiology

• Due to multiplepathophysiologic

causes

• Head injury

• Toxicological: OD,ETOH intoxication

• Metabolic: Hepatic,

renal or DKA



Clinical Manifestations

• Subtle behavioral changes [INITIALLY]

• Restlessness or increased anxiousness

• Pupillary changes

• Sluggish

• Fixed and Nonresponsive if in comatose state

• Coma

• Glascow coma scale <7: does not open eyes

spontaneously, nonverbal responses, no move

extremities



Assessment and Diagnosis

• Complete H&P: emphasis on neurological s

• Evaluate mental status, cranial nerves, cere

function [balance and coordination], reflexe

motor and sensory function

• LOC

• Indicator of neuro function

• Assess based on Glasgow Coma Scare

• Eye opening, verbal response, motor response



Glasgow Coma Scale



Assessment/Diagnostics

• Common diagnostic procedures used to idecause of unconsciousness include

• Computed tomography (CT) scanning,

• Magnetic resonance imaging (MRI), and

• Electroencephalography (EEG).

• Less common procedures include

• Positron emission tomography (PET) and

• Single photonemission computed tomography



Assessment/Diagnostics• Blood glucose,

• Electrolytes [BMP]• Serum ammonia, and liver function tests [LF

• Blood urea nitrogen (BUN)/Creatinine levels

osmolality; calcium level

• Coagulations studies: partial thromboplastinprothrombin times.

• Other studies may be used to evaluate seru

alcohol and drug concentrations, and arteria

gases.



Medical Management

• Obtain & maintain patent airway: 1ST PRIOR

• Possible intubation and vented

• Monitor cardiovascular system to ensure pe

adequate

• Neuro care• Nutrititional care if indicated

• IV access

• Pharmacologic management as indicated



Nursing Process: The Care of the Patient with Altered

Level of Consciousness — Assessment

• Assess verbal response and orientation

• Alertness

• Motor responses

• Respiratory status

• Eye signs• Reflexes

• Postures

• Glasgow Coma Scale



Nurisng Diagnoses

• Ineffective airway clearance• Risk of injury

• Deficient fluid volume

• Impaired oral mucosa

• Risk for impaired skin integrity and impaired tissu

integrity (cornea)• Ineffective thermoregulation

• Impaired urinary elimination and bowelincontinence

• Disturbed sensory perception

• Interrupted family processes



Potential Complications

• Respiratory distress or failure

• Pneumonia

• Aspiration

• Pressure ulcer

• Deep vein thrombosis (DVT)

• Contractures



Planning and Goals

• Goals may include:• Maintenance of clear airway• Protection from injury• Attainment of fluid volume balance• Maintenance of skin integrity• Absence of corneal irritation

• Effective thermoregulation• Accurate perception of environmental stimuli• Maintenance of intact family or support system• Absence of complications



Nursing Interventions

• A major nursing goal is to compensate for the patient's losreflexes and to assume responsibility for total patient care

also includes maintaining the patient’s dignity and privacy

• Maintaining an airway

• Frequent monitoring of respiratory status including aus

lung sounds• Positioning to promote accumulation of secretions and

obstruction of upper airway—HOB elevated 30°, latera

position

• Suctioning, oral hygiene, and CPT



Skin Integrity

• Assess skin frequently, especially areas with high potentia

breakdown• Frequent turning; use turning schedule

• Careful positioning in correct body alignment

• Passive ROM

• Use of splints, foam boots, trochanter rolls, and specialty

needed• Clean eyes with cotton balls moistened with saline

• Use artificial tears as prescribed

• Measures to protect eyes; use eye patches cautiously as

may contact patch

• Frequent, scrupulous oral care



Nursing Interventions

• Maintaining fluid status• Assess fluid status by examining tissue turgor and muc

and I&O.

• Administer IVs, tube feedings, and fluids via feeding tu

required—monitor ordered rate of IV fluids carefully.

• Maintaining body temperature• Adjust environment and cover patient appropriately.

• If temperature is elevated, use minimum amount of bed

administer acetaminophen, use hypothermia blanket, g

sponge bath, and allow fan to blow over patient to incre

• Monitor temperature frequently and use measures to p

shivering.



Nursing Interventions: Bowel & Bla

• Assess for urinary retention and urinary inc• May require indwelling or intermittent cathe

• Bladder-training program

• Assess for abdominal distention, potentialconstipation, and bowel incontinence

• Monitor bowel movements

• Promote elimination with stool softeners, glysuppositories, or enemas as indicated

• Diarrhea may result from infection, medicathyperosmolar fluids



Nursing Interventions: Sensory &

Communication

• Talk to and touch patient and encourage family totouch the patient

• Maintain normal day night pattern of activity

• Orient the patient frequently

• Note: When arousing from coma, a patient may eperiod of agitation; minimize stimulation at this tim

• Programs for sensory stimulation

• Allow family to ventilate and provide support

• Reinforce and provide and consistent information

• Referral to support groups and services for family



Nursing Alert

• If the patient begins to emerge from unconsness, every measure that is available and a

for calming and quieting the patient should

Any form of restraint is likely to be countere

resistance, leading to self-injury or to a danincrease in ICP. Therefore, physical restrain

be avoided if possible; a written prescription

obtained if their use is essential for the patie

being.



Nursing Alert

• The body temperature of an unconscious pnever taken by mouth.

• Rectal or tympanic (if not con-traindicated)

temperature measurement is preferred toth

accurate axillary temperature.



Abnormal Posturing

• Response to noxious stimuli: Flaccidity with

of motor response

• Decorticate posture (flexion and internal r

forearms and hands)

• Seen with cerebral hemisphere pathology and

depression of brain function

• Decerebrate posture (extension and exter

rotation)

• deeper and more severe dysfunction than does

posturing; implies brain pathology; poor progn

neuro dysfunctions

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