Chapter 66 Management Of Patients With Neuro Dysfunction Flashcards
(39 cards)
What are priority nursing interventions for altered loc?
▪️Maintaining the Airway ▪️Protecting the Patient ▪️Maintaining Fluid Balance and Managing Nutritional Needs ▪️Providing Mouth Care ▪️Maintaining Skin and Joint Integrity ▪️Preserving Corneal Integrity ▪️Maintaining Body Temperature ▪️Preventing Urinary Retention ▪️Promoting Bowel Function ▪️Restoring Health Maintenance ▪️Meeting the Family’s Needs ▪️Monitoring and Managing Potential Complications
What are nursing diagnoses for altered loc?
- Ineffective airway clearance related to altered LOC
- Risk of injury related to decreased LOC
- Deficient fluid volume related to inability to take fluids by mouth
- Risk for imbalanced nutrition: less than body requirements related to inability to ingest nutrients to meet metabolic needs
- Impaired oral mucous membrane related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake
- Risk for impaired skin integrity related to prolonged immobility
- Impaired tissue integrity of cornea related to diminished or absent corneal reflex
- Ineffective thermoregulation related to damage to hypothalamic center
- Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control
- Bowel incontinence related to impairment in neurologic sensing and control and also related to changes in nutritional delivery methods
- Ineffective health maintenance related to neurologic impairment
- Interrupted family processes related to health crisis
What is the Monroe-Kellie hypothesis?
Monro-Kellie hypothesis: theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents—brain tissue, blood, or cerebrospinal fluid—causes a change in the volume of the others; also referred to as Monro-Kellie doctrine
What does IICP?
Increased ICP from any cause decreases cerebral perfusion, stimulates further swelling (edema), and may shift brain tissue, resulting in herniation—a dire and frequently fatal event.
What are some sequelae of IICP?
▪️Decreased Cerebral Blood Flow-Increased ICP may reduce cerebral blood flow, resulting in ischemia and cell death.
▪️Cerebral Edema
What is the cerebral response to IICP?
As ICP rises, compensatory mechanisms in the brain work to maintain blood flow and prevent tissue damage. The brain can maintain a steady perfusion pressure if the arterial systolic blood pressure is 50 to 150 mm Hg and the ICP is less than 40 mm Hg.
What is Cushing’s response?
Cushing’s response: the brain’s attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure.
What is Cushing’s Triad?
Cushing’s triad: three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation.
What is decortication?
decortication: an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities
What is decerebration?
decerebration: an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities.
What are complications of IICP?
Complications of increased ICP include brain stem herniation, diabetes insipidus, and syndrome of inappropriate antidiuretic hormone (SIADH).
What are the medical priorities of IICP management?
Immediate management to relieve increased ICP requires decreasing cerebral edema, lowering the volume of CSF, or decreasing cerebral blood volume while maintaining cerebral perfusion.
What are methods used to monitor IICP?
▪️ventriculostomy: a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid.
▪️subarachnoid screw or bolt: device placed into the subarachnoid space to measure intracranial pressure
▪️epidural monitor: a sensor placed between the skull and the dura to monitor intracranial pressure
▪️fiberoptic monitor: a system that uses light refraction to determine intracranial pressure
How is cerebral edema decreased?
Osmotic diuretics such as mannitol may be administered to dehydrate the brain tissue and reduce cerebral edema.
How is fever controlled with IICP?
Strategies to reduce body temperature include administration of antipyretic medications, as prescribed, and the use of a hypothermia blanket.
How is oxygenation maintained while metabolic demands decreased?
Arterial blood gases and pulse oximetry are monitored to ensure that systemic oxygenation remains optimal. Metabolic demands may be reduced through the administration of high doses of barbiturates if the patient is unresponsive to conventional treatment. The mechanism by which barbiturates decrease ICP and protect the brain is uncertain, but the resultant comatose state is thought to reduce the metabolic requirements of the brain, thus providing cerebral protection.
What are nursing interventions with IICP?
▪️Maintaining a Patent Airway
▪️Achieving an Adequate Breathing Pattern
▪️Optimizing Cerebral Tissue Perfusion
▪️Maintaining Negative Fluid Balance
▪️Preventing Infection
▪️Monitoring and Managing Potential Complications
What is a craniotomy?
craniotomy: a surgical procedure that involves entry into the cranial vault.
What are three approaches to craniotomy?
(1) above the tentorium (supratentorial craniotomy) into the supratentorial compartment, or (2) below the tentorium into the infratentorial (posterior fossa) compartment. A third approach, the transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland.
What are preop considerations with craniotomy?
▪️Answer family questions
▪️Explain that hair may be clipped or shaved
▪️Discuss recovery and possible drain
▪️Discuss headache and facial swelling expected for 2-3 days postop and that pain will be managed
▪️Perform a thorough baseline neuro assessment and document it
▪️Inform patient they will go to ICU postop
What is postop care after Supratentorial and Infratentorial craniotomy?
▪️Gradually increase activity level, as ordered
▪️Monitor incision site for infection or drainage
▪️Monitor neuro status and vs
▪️Provide pt and family emotional support
▪️Reducing Cerebral Edema
▪️Relieving Pain and Preventing Seizures
▪️Monitoring Intracranial Pressure
What is the postop care for Transphenoidal craniotomy?
▪️Vital signs are measured to monitor hemodynamic, cardiac, and ventilatory status.
▪️The head of the bed is raised
▪️ The patient is cautioned against blowing the nose or engaging in any activity that raises ICP, such as bending over or straining during urination or defecation.
▪️Intake and output are measured as a guide to fluid and electrolyte replacement and to assess for diabetes insipidus.
▪️ Daily weight is monitored. Fluids are usually given after nausea ceases, and the patient then progresses to a regular diet.
▪️The nasal packing inserted during surgery is checked frequently for blood or CSF drainage.
▪️Oral care is provided at least q4h
What are the different kinds of seizures?
▪️Simple Partial Seizure
Sensory symptoms- flashing lights, smells, auditory hallucinations
Autonomic symptoms- sweating, flushing, pupil dilation
Psychic symptoms- dream states, anger, fear
▪️Complex Partial Seizure
Altered loc
Amnesia
▪️Absence Seizure
A brief change in loc
▪️Myoclonic Seizure
Brief involuntary muscle jerks of body or extremities
▪️Generalized tonic-clonic Seizure
Starts with cry
Change in loc
Alternating spasms and relaxation
Tongue biting, incontinence, labored breathing, apnea, cyanosis
Upon awakening, possible confusion and difficulty talking
Drowsiness, fatigue, headache, muscle soreness, weakness
What is status epilepticus?
A continuous seizure that must be interrupted using emergency measures.
