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Nursing Care of Patients with

Neurological Dysfunction

Elaine Harris, RN, MS, CCRN

Care of Adults with High AcuityNeeds

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Goals of Nursing Assessment

Gather data a!out functioning of the ner"ous

system in an un!iased, orderly manner and

clearly record it

#ollow data o"er time, loo$ing for

correlations and trends

Analy%e the data to de"elo& a list of

&otential or actual diagnoses Determine effects of dysfunction on daily

li"ing and a!ility to &erform self'care

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Mental Status Assessment

(ests to e"aluate le"el of consciousness

and arousal, orientation to en"ironment

and thought content

)*C is the most critical &arameter and

e"aluates function of the cere!ral

hemis&here

Res&onsi"eness is categori%ed according

to the &atient+s arousal to eternal stimuli

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)e"els of Arousal

Awa$e'''the &atient may

slee& more than usual or

!e confused when first

awa$ening

)ethargic'''drowsy !utfollows sim&le commands

when stimulated

*!tunded'''arousa!le with

stimuli- Res&onds "er!allywith .ust one or two words-

#ollows sim&le commands

!ut otherwise drowsy

Stu&orous'''"ery hard to

arouse/ inconsistently may

follow commands or s&ea$ a

single word with much

stimulation Semi'Comatose'''mo"ements

are &ur&oseful when

stimulated/ does not follow

commands or s&ea$

coherently Comatose'''may res&ond with

reflei"e &osturing !ut limited

s&ontaneous mo"ement

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*rientation to En"ironment

0hat is your name1 0here are you now1

0hat is the month, year, date, time1

An increase in wrong answers indicatesincreasing confusion and &ossi!le

deterioration

2ncrease in correct res&onses may

indicate im&ro"ement

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Assessment of Cogniti"e A!ility

Maimum score 3 45- 65 or lower 3 neuro im&airment

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Assessment of Motor #unction

(ests of strength and coordination

0hat elicits motor res&onse1 0ords1 Pain1

E"aluate the a!ility to follow commands

As$ &atient to mo"e etremity against gra"ity

7Noious stimuli8 3 eliciting &ain !y &inching

tra&e%ius muscle, &ressure on su&raor!ital

ridge, sternal ru!, or com&ressing nail!eds

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Motor Assessment, continued

7)ocali%ation8 means the &atient tries to

remo"e the stimulus in an organi%ed way

70ithdrawal8 means the &atient sim&ly

&ulls away from the noious stimuli

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Decere!rate Rigidity

Etension, adduction and hy&er&ronation

of the u&&er etremities- Etension of

lower etremities with &lantar fleion of the

feet- May clinch teeth-

Denotes mid!rain or &ons in.ury

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Decorticate Rigidity

#leion of the arms, wrists, fingers

Adduction of u&&er etremities and

etension of legs- Cere!ral hemis&here

in.ury

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Assessment of Strength, Coordination

7Pronator Drift8

As$ &atient to lift legs one at a time

straight off !ed against your resistance

0ea$ness indicates damage to motor

neuron &athways

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Motor Strength, Coordination, cont

Hemi&aresis 9wea$ness:

Hemi&legia 9&aralysis:

Remem!er the cere!ellum is res&onsi!lefor smooth synchroni%ation, !alance, and

ordering of mo"ement-

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Assessment of ;ital Signs

(em&, HR,

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Assessment of Res&irations

Shallow, ra&id res&irations can indicate a

&ro!lem with maintenance of the airway or

need for suctioning

Snoring or stridor can indicate &artiallyo!structed airways

Cheyne'Sto$es Res&irations'''crescendo'

decrescendo alternating with &eriods of a&nea Hy&o"entilation must !e a"oided for

res&iratory acidosis occurs-

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*ther Assessment Areas

Pu&il changes 9si%e and sha&e:

Cranial ner"e function

Sensation 9&erce&tion of !eing touched:

Pro&rioce&tion 970hich way am 2 mo"ing your

finger1:

Stereognosis 9a!ility to recogni%e o!.ects !y

touch: Gra&hestesia 9a!ility to recogni%e num!ers or

letters traced lightly on the s$in:

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Signs of 2ncreased 2ntracranial Pressure

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2ncreased 2CP, continued

Manifested !y deterioration in all as&ects of

neurological functioning

)*C decreases as 2CP increases- May !egin

with restlessness, confusion, com!ati"enessand decom&ensate =uic$ly

Pu&il reactions !egin to diminish 9&u&il

i&silateral to the in.ury will dilate first: Motor function declines, may &osture

Changes in ;S come late

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Cushing+s (riad

A cluster of changes that indicate "ery

high 2CP and im&ending herniation>

2ncreased systolic

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Nursing Care During Diagnostic Studies

Com&uter (omogra&hy 9C(:

Measures density of tissues, !lood and !one

Cere!ral edema a&&ears less dense and therefore

is lighter in color than normal Always used =uic$ly in trauma setting, sei%ures,

headaches, )*C, diagnosis of sus&ected stro$es

0ill show s$ull fractures, tissue swelling,

hematomas, tumors

Patient education> lie still, may ha"e

claustro&ho!ia

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Diagnostics, con+t

Magnetic Resonance 2maging 9MR2:

More detailed images that loo$ li$e anatomy

Does N*( show !ony anomalies as well as

C(

Can interfere with &acema$ers, and &atients

with surgical cli&s and &rostetic im&lants

made of ferrous materials can+t !e scanned ;entilators, monitors may !e &ro!lematic

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Diagnostics, con+t

Cere!ral Angiogra&hy

Gold standard for e"aluating "ascular &ro!lems

Can re"eal large and small aneurysms and A;

malformations

Radiogra&hic catheter is &assed through

femoral artery to each of the arterial "essels

!ringing !lood to the !rain and s&inal cord Radio&a=ue contrast is in.ected and ra&id

images are ta$en

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Diagnostics, con+t

Cere!ral !lood flow studies

Radioisoto&e is in.ected 2; and the !rain is

scanned to determine which areas show

accumulation

Can determine cere!ral "asos&asms and

!rain death 9no !lood flow:

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Head 2n.uries

2n.ury to scal&, s$ull, or !rain

Most serious is 7closed head in.ury8 with

traumatic !rain in.ury 9(

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Head 2n.ury, continued

M;C and falls are the most common causes

#irearms, assaults, s&orts'related in.uries,

recreational in.uries, and war'related in.uries

High &otential for &oor outcomes

GCS on arri"al at the hos&ital is a strong

&redictor of sur"i"al, with GCS !elow ?

indicating only a 45'@5 chance of sur"i"al

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S$ull #ractures

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S$ull #racture, con+t

Rhinorrhea 9CS# lea$ing from nose: or *torrhea

9CS# lea$ing from ear: confirm torn dura

Ris$ of meningitis is great

(est fluid to see if it is CS#> glucose test stri&will !e &ositi"e if it is CS#-

2f there is !loody drainage, do 7halo test8> let

drainage dri& on a BB-

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S$ull #ractures, con+t

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Concussion

A diffuse in.ury to the head- May or may

not lose consciousness

*ften a !rief disru&tion of )*C and

amnesia regarding the e"ent- Headache,

lethargy can &ersist u& to 6 months

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Cere!ral Contusion

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E&idural Hematoma

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Su!dural Hematoma

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Su!dural, con+t

(he i&silateral &u&il dilates and !ecomes

fied if 2CP is significantly ele"ated

Chronic, su!'acute hematomas can occur

6'FB days after in.ury and are common in

older adults 9!rain atro&hy 3 more s&ace:

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Su!dural Hematoma, con+t

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Emergency Nursing Care for Head

2n.uries

Assure &atent airway

Assume cer"ical

s&ine in.ury A)0AS

2mmediate C( *ygen "ia non'

re!reather or

intu!ation

2; access with 6 large

!ore catheters

Em&loy all measures

to reduce 2CP

9ele"ate head of !ed

45 degrees: Control eternal

!leeding with

&ressure dressing !ut

N* firm &ressure untilde&ressed s$ull

fracture ruled out

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Emergency, con+t

N* NG (

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Nursing Diagnoses for Head 2n.uries

Ris$ for ineffecti"e cere!ral tissue

&erfusion R( interru&tion of cere!ral !lood

flow

Hy&erthermia R( increased meta!olism,

infection, loss of cere!ral integrati"e

function due to hy&othalamic in.ury

Acute &ain

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Nursing Goals for Head 2n.uries

Maintain ade=uate cere!ral oygenation

Remain normothermic

Achie"e &ain control

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Health Promotion to Pre"ent Head

2n.uries

Seat !elts 9!ac$seat, too:

Child safety seats

Helmits for motorcycles and !i$es

Protecti"e headwear for lum!er.ac$s,construction wor$ers, miners, horse!ac$ riders,

snow!oarders

(al$ to grou&s of teenagers

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2ncreased 2ntracranial Pressure

Normal 2CP is K'FK mmHg

2ncreased 2CP is life'threatening and results

from an increase in any of the three

com&onents within the s$ull 9!rain, !lood, CS#: 2ncreased 2CP will decrease cere!ral &erfusion

&ressure and can cause !rain ischemia or

infarction

Edema distorts !rain tissue, further increasing

2CP

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2ncreased 2CP, con+t

Goal> (o maintain cere!ral !lood flow

Sustained increases in 2CP result in !rain

stem com&ression and herniation of the

!rain from the s$ull into the s&inal canal-

(his is fatal

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Clinical Manifestations of 2ncreased 2CP

Change in )*C

Change in "ital signs 9Cushing+s (riad:

Cranial Ner"e 222 com&ression 9i&silateral

&u&il change:

Decreased motor function 9contralateral to

in.ury:

Headache

;omiting

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Monitoring 2CP

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Monitoring 2CP

Gold standard is "entriculostomy- Catheter is &laced into

the lateral "entricle and attached to an eternal

transducer

Measures &ressure inside "entricle and facilitates

remo"al of CS# if the 2CP gets too high 9normally 65'45ml of CS# is &roduced e"ery hour:

(ransducer is le"eled at the (RAGS of the ear- Must

re'%ero transduced any time &atient+s &osition is changed

(hree'way sto&'coc$ o&ens to allow CS# to drain once&ressure reaches a certain le"el

2CP should N*( eceed FK mmHg

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Cere!ral Perfusion Pressure Calculation

(his can only !e done if the &atient has an

2CP monitor

CPP = MAP ICP

Normal CPP is L5'F55- )ess than K5 is

associated with ischemia and tissue death

)ess than 45 is incom&ati!le with life Reminder> MAP 3 9systolic

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Monitoring

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Nursing Management of the Patient

with 2ncreased 2ntracranial Pressure

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2CP Management

Maintain ade=uate cere!ral

&erfusion 9$ee&

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2CP management, con+t

uic$ly treat &ain and

aniety

Oee& room dar$ and =uiet

9noise increases rate of

meta!olism and raises2CP:

Monitor com!inations of

sedati"es, &aralytics,

analgesics PR*P*#*) 9Di&ri"an:

often used due to short

half'life

N*RCR*N 9&aralytic:

allows com&lete res&iratory

control

2I*, electrolytes

(urn slowly, gently

A"oid hi& fleion 9increases

intraa!dominal &ressure

which increases 2CP:

Protect from self'in.ury Pad side rails

(al$, touch e"en if in 7coma8

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Stro$e

*ccurs when there is

ischemia to &art of the

!rain *R hemorrhage

into the !rain Results in death of

!rain cells

A!out 6K of &eo&le

with stro$es areyounger than LK

4rdleading cause of

death !ehind heart

disease and cancer

2schemic stro$es9&artial or com&lete

occlusion of an artery:

account for nearly

?5 of stro$es Pla=ue !uild'u& in

cere!ral !lood "essels

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Hemorrhagic Stro$e

92ntracere!ral Hemorrhage:

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Hemorrhagic Stro$e, cont

Commonly occurs

during acti"itysudden

onset of sym&toms with

ra&id &rogression o"er

minutes

70orst headache 2+"e

e"er had8, then NI;,

decreasing )*C,

wea$ness, de"iation of

eyes, dilated &u&ils,

&osturing

Su!arachnoid

Hemorrhage'''

intracranial !leedinginto the cere!ros&inal

fluid'filled s&ace

!etween the

arachnoid and &iamater mem!ranes

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Su!arachnoid Hemorrhage, con+t

sually caused !y ru&ture of an aneurysm

B5 die immediately with no warning

Can ha&&en at any age

Cocaine causes shar& increases in

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Diagnosis of Cere!ral

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N i C f P ti t ith C ! l

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Nursing Care for Patients with Cere!ral

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Surgical Re&air of Aneurysms

Can surgically cli& the wea$ened area of

the artery

Coiling is most commonly done'''insert a

metal coil into lumen of aneurysm "iainter"entional neuroradiology- Coils

&re"ent !lood &ulsation within the

aneurysm and e"entually a throm!us formswithin the aneurysm and it !ecomes sealed

off

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7Cli&&ing8 and 7Coiling8 Aneurysms

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S&inal Cord 2n.ury 9SC2:

oung adult men FL'45 are at greatest ris$

Causes> M;C 3 B6/ falls 3 6@/

"iolence 3 FK/ s&orts in.uries 3 @

S&inal cord is wra&&ed in tough layers of

dura and is rarely torn or transected !y

direct trauma 9unless GS0 or sta!:-

Most often cord com&ression is made !y

!one dis&lacement

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Mechanisms of 2n.ury

#leion or hy&eretension

#leion'rotation

Etension'rotation

Com&ression

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Post'2n.ury Edema

Edema occurs !y 6B hours after the initial

in.ury

Harmful !ecause of lac$ of s&ace for

tissue e&ansion, so more cordcom&ression occurs

Edema occurs a!o"e and !elow the in.ury

Etent of in.ury and &rognosis for reco"erycannot !e determined for at least @6 hours

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Neurogenic Shoc$

)oss of "asomotor tone caused !y the in.ury

Hy&otension and !radycardia occur

)oss of sym&athetic ner"ous system

inner"ation causes &eri&heral "asodilation,"enous &ooling and decreased cardiac out&ut

Most often occurs with cer"ical or high

thoracic in.ury 9('L or higher: 0arm, dry s$in

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)e"el of 2n.ury

Cer"ical, thoracic, or lum!ar

Cer"ical and lum!ar in.uries are most common

!ecause these le"els of the s&ine ha"e the

greatest flei!ility and mo"ement Cer"ical s&ine in.ury will cause &aralysis of all B

etremities 9tetra&legia:

2f low in the cer"ical s&ine, the arms are rarely

com&letely &araly%ed (horacic or lum!ar in.uries cause &ara&legia 9loss

of sensation and &aralysis of the legs:

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Degree of 2n.ury

Copletecord in"ol"ement results in total loss of

sensory and motor function !elow the le"el of in.ury

Incopletein"ol"ement results in a mied loss of

"oluntary motor acti"ity and sensation 9some tracts

are intact:

!rown"#e$uard #yndroe> damage to of the

cord- )oss of motor function and "asomotor

&aralysis on the i&silateral side- (he contralateralside has loss of &ain and tem& sensation- Most

common with &enetrating trauma

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Nursing CareRes&iratory

Degree of in"ol"ement corres&onds to le"el

of in.ury

C'B or a!o"e causes total loss of res&iratory

muscle function, so mechanical "entilation isreuired

)ower cer"ical and thoracic in.uries &araly%e

a!dominal muscles and intercostal muscles9&oor cough, atelectasis and &neumonia:

Airway always first &riority of care

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Cardio"ascular Care

Any in.ury a!o"e ('L influences

sym&athetic ner"ous system regulation

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rinary Care

Neurogenic !ladder and urinary retention are

common

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G2 System Care

2n.uries ('K or higher cause hy&omotility

Paralytic ileus and gastric distention are common

NG is &laced early to relie"e distention

Reglan may hel& encourage gastric em&tying

Pre"ent stress ulcers 9H6 !loc$ers, &roton &um& inhi!itors

Neurogenic !owel if in.ury is to ('F6 or a!o"e> !owel is

arefleic and anal s&hincter tone is a!sent

high fi!er diet, ade=uate fluids, Dulcola

su&&ository followed 45 minutes later with digital rectalstimulation to cause !owel elimination

Stool softeners e"ery day

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S$in Care

Pre"ent s$in !rea$down with fre=uent

&osition change 9)*GR*)):

0eight gain or weight loss can contri!ute

to !rea$down

;isual and tactile eam of s$in e"ery F6

hours

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(hermoregulation

Poi%ilotheris'''a!ility to maintain

normal !ody tem&erature

2nterru&tion of the sym&athetic ner"ous

system &re"ents &eri&heral tem& sensationsfrom reaching hy&othalamus

2na!ility to shi"er or sweat !elow the le"el of

in.ury Maintain heatJcool with warming or cooling

!lan$ets, a&&ro&riate clothing

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Dee& ;enous (hrom!osis Pre"ention

;ery common in first 4 months to get a D;(

Peo&le will not ha"e &ain or tenderness in

the legs

Pulmonary em!olus is the leading cause ofdeath after initial in.ury

D;( &re"ention with )o"eno, se=uential

com&ression de"ices, &osition changes,R*M

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Seuality

Onowledge of the le"el and com&leteness

of the in.ury is needed to understand male

&atients+ &otential for orgasm, erection,

and fertility 0omen with SC2 remain fertile and can

ha"e successful &regnancies

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High Dose Steroids After 2n.ury1

(his is still &rotocol, !ut has !een

=uestioned lately

0as thought to decrease edema in the

cord and im&ro"e function

Stay tuned to the E

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Autonomic Dysrefleia

Patients with in.uries ('L or higher may

de"elo& Autonomic Dysrefleia

A massi"e uncom&ensated C; reaction

mediated !y the sym&athetic ner"oussystem

*ccurs in res&onse to ;2SCERA)

S(2M)A(2*N

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Autonomic Dysrefleia, con+t

Rece&tors !elow the le"el of in.ury are stimulated

(hey res&ond with refle arterial "asoconstriction

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Sym&toms of Autonomic Dysrefleia

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Nursing Care for Autonomic Dysrefleia

Always measure

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G i f d D i

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Grief and De&ression

G i f d D i

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Grief and De&ression

Peo&le with s&inal cord in.uries may feel o"erwhelmingloss

)oss of control o"er e"eryday life acti"ities and must

de&end on others for daily care

May !elie"e they are useless and !urdens to their families Grief is a difficult, life'long &rocess

Goal is for 7ad.ustment8 to occur-the a!ility to go on with

li"ing with certain limitations

#amilies need grief care as well to a"oid guilt andmis&laced sym&athy

Su&&ort grou&s are "ery im&ortant

< i D th

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