Management of Patients With Neurologic Dysfunction

Chapter 61
Management of Patients With

Neurologic Dysfunction
Copyright © 2008 Lippincott Williams & Wilkins.

Level of Consciousness (LOC)
• Consciousness is a state of being that has 2
important aspects.
1. Wakefulness
2. Awareness
1. Self
2. Environment
3. Time

Altered Level of Consciousness (LOC)
• Level of responsiveness and consciousness is the
most important indicator of the patient's condition
• LOC is a continuum from normal alertness and full
cognition (consciousness) to coma
• Altered LOC is not the disorder but the result of a
pathology; patient is not oriented, does not follow
commands, or needs persistent stimuli to achieve
a state of alertness
• Coma: unconsciousness, unresponsiveness, and
inability to arouse

Altered Level of Consciousness (LOC)
(cont.)
• Akinetic mutism: unresponsiveness to the
environment, the patient makes no voluntary
movement or sound but sometimes opens eyes
• Persistent vegetative state: patient is devoid of
cognitive or affective mental function but has sleep–
wake cycles
• Locked-in syndrome: patient is unable to move
(paralysis) or respond except for eye movements
due to a lesion affecting the pons; cognition is intact

Levels of Consciousness
• Alert – oriented to 3 spheres
• Lethargic – oriented but sleepy
• Obtunded – drowsy; respond to verbal stimuli
• Stuporous – drowsy; responded to noxious
stimuli
• Coma
• (semi-coma) – intact reflexes

Causes of Decreased LOC
• NEUROLOGIC
– Disruption in the cells of the nervous system,
neurotransmitters, or brain anatomy
– Disruptions result from cellular edema,
disruptions of chemical transmission at receptor
sites by antibodies
– eg, head injury, stroke
• TOXICOLOGIC
– eg, drug overdose, alcohol intoxication
• METABOLIC
– eg, hepatic or renal failure, diabetic ketoacidosis
Clinical manifestations
• Early
– Subtle behavioral changes, such as
restlessness or increased anxiety
– Sluggish pupillary response to light
• Late
– COMA: Pupils become fixed (no response to
light)
– Does NOT open eyes, respond verbally, or
move the extremities in response to a
request to do so

Nursing Process—Assessment of the
Patient With Altered LOC
• Verbal response and • Mental status
orientation
• Cranial nerve
• Alertness function
• Motor responses • Cerebellar function
(balance &
• Respiratory status coordination)
• Eye signs
• Reflexes
• Postures
• Glasgow Coma Scale
Glasgow Coma Scale
Eye opening response 4 Spontaneous
3 To voice
2 To pain
1 None
Best verbal response 5 Oriented
4 Confused
3 Inappropriate words
2 Incomprehensible sounds
1 None
Best motor response 6 Obeys command
5 Localizes pain
4 Withdraws
3 Flexion (decorticate)
2 Extension (decerebrate)
1 None
Decorticate Posturing Decerebrate Posturing

Level of Consciousness (LOC) is the single most
important indicator of neurologic function!

A 40 y/o male was brought into the ER after being
thrown from the motorcycle he was driving when he
veered off the road trying to avoid running over a kitten.
The patient was not wearing any helmet. According to
bystanders he was thrown approximately 2 meters away
from his bike, landing head first into the ground.
Upon arrival in the ER he was observed to be
opening his eyes when his name was being called. A
quick interview revealed that he knew where he was, and
what happened to him. He was also observed to be able
to move his extremities when told to. What is the GCS
score of this patient?

Eye opening 4 Spontaneous
response
3 To voice
2 To pain
1 None
Best verbal 5 Oriented E–3
response
4 Confused V–5
M–6
1 None
Best motor 6 Obeys command
GCS Score
response
- 14
5 Localizes pain
4 Withdraws
1 None

The patient was admitted and was brought to the
CT Scan room. The test showed a subdural hematoma.
He was scheduled for OR. On the way to the OR he
suddenly had one episode of projectile vomiting then he
became unresponsive to verbal calling. However his eyes
opened when sternal rub was done. He also assumed a
decorticate position. What is the present GCS score of
the patient?

response
3 To voice
2 To pain
1 None
Best verbal 5 Oriented E–2
response
4 Confused V–1
M–3
1 None
Best motor 6 Obeys command
GCS Score
response
-6
5 Localizes pain
4 Withdraws
1 None

An emergency craniectomy was done to remove
the hematoma. After the surgery the patient still had no
spontaneous verbal output, no eye opening and and now
assumed a decerebrate posture? What would be his
GCS score?

response
3 To voice
2 To pain
1 None E–1
Best verbal 5 Oriented
response V–1
4 Confused
3 Inappropriate words M–2
1 None GCS Score
Best motor
response
6 Obeys command -4
5 Localizes pain
4 Withdraws
1 None

Nursing Process—Diagnosis of the Patient
With Altered Level of Consciousness
• Ineffective airway clearance r/t altered LOC
• Risk of injury r/t decreased LOC
• Deficient fluid volume r/t inability to take fluids by mouth
• Impaired oral mucosa r/t mouth breathing, absence of gag reflex,
and altered fluid intake
• Risk for impaired skin integrity r/t prolonged immobility
• Impaired tissue integrity (cornea) r/t diminished or absent
corneal reflex
• Ineffective thermoregulation r/t damage to hypothalamic center
• Impaired urinary elimination and bowel incontinence r/t
impairment in neurologic sensing and control
• Disturbed sensory perception r/t neurologic impairment
• Interrupted family processes r/t health crisis
Nursing Process—Planning the Care of the
Patient With Altered LOC
• Goals 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

Interventions
• A major nursing goal is to compensate

for the patient's loss of protective
reflexes and to assume responsibility
for total patient care; protection
includes maintaining the patient’s
dignity and privacy

Interventions
Maintain an airway
– Frequent monitoring of respiratory status
including auscultation of lung sounds q 8o
– Position the patient to promote accumulation of
secretions and prevent obstruction of upper
airway: HOB elevated 30°, lateral or semiprone
position
– Provide suctioning and oral hygiene
– Mechanical ventilation care (ET, tracheostomy),
oral care, ABG monitoring

Interventions
Protecting the Patient

• Padded side rails
• Prevent injury from invasive lines and equipment,
restraints (when indicated), environmental irritants, damp
bedding or dressings, tubes and drains
• Ensure patient’s dignity
– Provide privacy during nursing care
– Speak to patient during nursing care
– Do not speak negatively (light coma patient can hear)
– ADVOCACY

Interventions
Maintaining Tissue Integrity

• Assess skin frequently, especially areas with high
potential for breakdown
• Turn patient frequently; use turning schedule
• Carefully position patient in correct body alignment
• Perform passive range of motion
• Use splints, foam boots, trochanter rolls, and specialty
beds as needed
• Clean eyes with cotton balls moistened with saline
• Use artificial tears as prescribed
• Implement measures to protect eyes; use eye patches
cautiously as the cornea may contact patch
• Provide frequent, scrupulous oral care
Interventions
• Maintain fluid status
– Assess fluid status by examining tissue turgor and
mucosa, lab data, and I&O
– Administer as required: monitorIVs, tube feedings,
and fluids via feeding tube ordered rate of IV fluids
carefully
• Maintain body temperature
– Adjust environment and cover patient appropriately
– If temperature is elevated, use minimum amount of
bedding, administer acetaminophen, use hypothermia
blanket, give a cooling sponge bath, and allow fan to
blow over patient to increase cooling
– Monitor temperature frequently and use measures to
prevent shivering

Interventions
Promoting Bowel and Bladder Function

• Assess for urinary retention and urinary incontinence
• May require indwelling or intermittent catherization
• Initiate bladder-training program
• Assess for abdominal distention, potential constipation,
and bowel incontinence
• Monitor bowel movements
• Promote elimination with stool softeners, glycerin
suppositories, or enemas as indicated
• Diarrhea may result from infection, medications, or
hyperosmolar fluids
Interventions
Sensory Stimulation and Communication

• Talk to and touch the patient and encourage the family
to talk to and touch the patient
• Maintain normal day–night pattern of activity
• Orient the patient frequently
• A patient aroused from coma may experience a period
of agitation; minimize stimulation at this time
• Initiate programs for sensory stimulation
• Allow family to ventilate and provide support
• Reinforce and provide consistent information to family
• Provide referral to support groups and services for the
family
Collaborative Problems/Potential
Complications
• Respiratory distress or failure
• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures
Increased Intracranial Pressure (ICP)
• Monro-Kellie hypothesis: because of limited space
in the skull, an increase in any one skull
component—brain tissue, blood, or CSF—will cause
a change in the volume of the others
• Compensation to maintain a normal ICP of 10 to
20 mm Hg is normally accomplished by shifting or
displacing CSF (increasing absorption, decreasing
production)
• With disease or injury, ICP may increase
• Increased ICP decreases cerebral perfusion, causes
ischemia, cell death, and (further) edema
Increased Intracranial Pressure (cont.)
• Brain tissues may shift through the dura and result

in herniation
• Autoregulation: refers to the brain’s ability to

change the diameter of blood vessels to maintain
cerebral blood flow
• CO2 plays a role; decreased CO2 results in

vasoconstriction, and increased CO2 results in
vasodilatation

Brain With Intracranial Shifts
Herniation – shifting of
brain tissue from an area
of high pressure to an
area of lower pressure

ICP and CPP
• CCP (cerebral perfusion pressure) is closely linked

to ICP
• CCP = MAP (mean arterial pressure) – ICP
• Normal CCP is 70 to 100
• A CCP of less than 50 results in permanent

neuralgic damage

Manifestations of Increased ICP—Early
• Changes in level of consciousness
• Any change in condition
– Restlessness, confusion, increasing drowsiness,
increased respiratory effort, and purposeless
movements
• Pupillary changes and impaired ocular movements
• Weakness in one extremity or one side
• Headache: constant, increasing in intensity, or
aggravated by movement or straining
Manifestations of Increased ICP—Late
• Respiratory and vasomotor changes
• VS: Cushing’s reflex: increase in systolic blood

pressure, widening of pulse pressure, and slowing of
the heart rate; pulse may fluctuate rapidly from
tachycardia to bradycardia and temperature increase
– Cushing’s triad: bradycardia, hypertension, and

bradypnea (grave sign)
– Herniation of the brain stem and occlusion of

cerebral blood flow can occur
• Projectile vomiting
Manifestations of Increased ICP—Late
(cont.)
• Further deterioration of LOC; stupor to coma
• Hemiplegia, decortication, decerebration, or

flaccidity
• Respiratory pattern alterations including Cheyne-

Stokes breathing and arrest
• Loss of brain stem reflexes: pupil, gag, corneal,

and swallowing
Patient With Increased
Intracranial Pressure
• Conduct frequent and ongoing neurologic assessment
(LOC)
• Evaluate neurologic status as completely as possible
• Glasgow Coma Scale
• Pupil checks
• Assess selected cranial nerves
• Take frequent vital signs
• Assess intracranial pressure
Cheyne Stokes
Respiration
Biot’s
Respiration
Several short breaths followed by
long, irregular periods of apnea.

Anisocoria

ICP Monitoring

Intracranial Pressure Waves

Location of the Foramen of Monro for
Calibration of ICP Monitoring System

LICOX Catheter System

With Increased Intracranial Pressure
• Ineffective airway clearance
• Ineffective breathing pattern
• Ineffective cerebral perfusion
• Deficient fluid volume related to fluid restriction
• Risk for infection related to ICP monitoring

Complications
• Brain stem herniation
• Diabetes insipidus
• SIADH
• Infection

Patient With Increased
Intracranial Pressure
• Major goals may include:
– Maintenance of patent airway
– Normalization of respirations
– Adequate cerebral tissue perfusion
– Respirations
– Fluid balance
– Absence of infection
Interventions
• Frequent monitoring of respiratory status and lung sounds and
measure to maintain a patent airway
• Assists in administering 100% oxygen or controlled
hyperventilation
• Position with the head in neutral position and HOB elevation of 0°
to 60° to promote venous drainage
• Avoid hip flexion, Valsalva maneuver, abdominal distention, or
other stimuli that may increase ICP
• Maintain a calm, quiet atmosphere and protect patient from stress
• Monitor fluid status carefully; during acute phase, monitor I&O
every hour
• Use strict aseptic technique for management of ICP monitoring
system

Intracranial Surgery
• Craniotomy: opening of the skull

– Purposes: remove tumor, relieve elevated ICP,
evacuate a blood clot, and control hemorrhage
• Craniectomy: excision of a portion of the skull
• Cranioplasty: repair of a cranial defect using a plastic
or metal plate
• Burr holes: circular openings for exploration or
diagnosis, to provide access to ventricles, for shunting
procedures, to aspirate a hematoma or abscess, or to
make a bone flap
Supratentorial Approach for
Cranial Surgery

Infratentorial Approach for
Cranial Surgery

Transphenoidal Approach for
Cranial Surgery

Burr Holes

Ventriculo-Peritoneal Shunt

Preoperative Care—Medical Management
• Preoperative diagnostic procedures may include CT
scan, MRI, angiography, or transcranial Doppler flow
studies
• Medications are usually given to reduce risk of
seizures
• Corticosteroids, fluid restriction, hyperosmotic
agents (mannitol), and diuretics may be used to
reduce cerebral edema
• Antibiotics may be administered to reduce potential
infection
• Diazepam may be used to alleviate anxiety
Preoperative Care—Nursing Management
• Obtain baseline neurologic assessment
• Assess patient and family understanding of and

preparation for surgery
• Provide information, reassurance, and support

Postoperative Care
• Postoperative care is aimed at detecting and

reducing cerebral edema, relieving pain,
preventing seizures, and monitoring ICP and
neurologic status
• The patient may be intubated and have arterial

and central venous lines

Patient Undergoing Intracranial Surgery
• Careful, frequent monitoring of respiratory function,
including ABGs
• Monitor VS and LOC frequently; note any potential signs
of increasing ICP
• Assess dressing and for evidence of bleeding or CSF
drainage
• Monitor for potential seizures; if seizures occur, carefully
record and report them
• Monitor for signs and symptoms of complications
• Monitor fluid status and laboratory data
Undergoing Intracranial Surgery
• Ineffective cerebral tissue perfusion
• Risk for imbalanced body
temperature
• Potential for impaired gas exchange
• Disturbed sensory perception
• Body image disturbance
• Impaired communication (aphasia)
• Risk for impaired skin integrity
• Impaired Copyright
physical mobility
© 2008 Lippincott Williams & Wilkins.
Complications
• Increased ICP
• Bleeding and hypovolemic shock
• Fluid and electrolyte disturbances
• Infection
• Seizures

Patient Undergoing Intracranial Surgery
• Major goals may include:
– Improved tissue perfusion
– Adequate thermoregulation
– Normal ventilation and gas exchange
– Ability to cope with sensory deprivation
– Adaptation to changes in body image
Maintaining Cerebral Perfusion
• Monitor respiratory status; even slight hypoxia or
hypercapnia can affect cerebral perfusion
• Assess VS and neurologic status every 15 minutes to
one hour
• Implement strategies to reduce cerebral edema;
cerebral edema peaks in 24 to 36 hours
• Implement strategies to control factors that increase
ICP
• Avoid extreme head rotation
• Head of bed may be flat or elevated 30° according to
needs related to the surgery and surgeon’s preference
Interventions
• Regulate temperature
– Cover patient appropriately
– Treat high temperature elevations vigorously; apply
ice bags, use hypothermia blanket, and administer
prescribed acetaminophen
• Improve gas exchange
– Turn and reposition the patient every 2 hours
– Encourage deep breathing and incentive spirometry
– Suction or encourage coughing cautiously as needed
(suctioning and coughing increase ICP)
– Humidify oxygen to help loosen secretions
Interventions (cont.)
• Sensory deprivation
– Periorbital edema may impair vision, so
announce your presence to avoid startling the
patient; cool compresses over eyes and HOB
elevation may be used to reduce edema if not
contraindicated
• Enhance self-image
– Encourage verbalization
– Encourage social interaction and social support
– Pay attention to grooming
– Cover head with turban and later with a wig
Interventions (cont.)
• Monitor I&O, weight, blood glucose, serum, urine

electrolyte levels, osmolality, and urine specific gravity
• Preventing infections
– Assess incision for signs of hematoma or infection
– Assess for potential CSF leak
– Instruct patient to avoid coughing, sneezing, or nose
blowing, which may increase the risk of CSF leakage
– Use strict aseptic technique
• Patient teaching for self-care

Seizures
• Abnormal episodes of motor, sensory, autonomic,
or psychic activity (or a combination of these)
resulting from a sudden, abnormal, uncontrolled
electrical discharge from cerebral neurons
• Classification of seizures:
– Partial seizures: begin in one part of the brain
 Simple partial: consciousness remains intact
 Complex partial: impairment of consciousness
– Generalized seizures: involve the whole brain
Specific Causes of Seizures

Tonic Clonic Seizures

Generalized Tonic Clonic Seizures

Stages in a Grand Mal Seizure
1. Prodromal period - from hours to days
2. Aura – warning before the seizure
Reflects the portion of the brain which might be
affected
3. Tonic Stage – all muscles of the body contract and
the person falls to the ground
4. Clonic stage – contraction and relaxation of
muscles
5. Post-ictal period – coma
Absence Seizures

Absence Seizures

Atonic/akinetic Seizures

Complex partial seizures

Simple partial Seizures

Pharmacological management:
• Valproic Acid - Generalized Tonic-Clonic, Atypical
Absence, Myoclonic and Atonic Seizures
• Ethosuximide – Absence Seizures
• Diazepam, Lorazepam – Initial drugs used to
terminate seizure attack

Plan of Care for a Patient
Experiencing a Seizure
• Observation and documentation of patient signs
and symptoms before, during, and after seizure
• Nursing actions during seizure for patient safety

and protection
• After seizure care: prevent complications

Guidelines for Seizure Care

Headache
• Also called cephalgia, it is one of the most
common physical complaints
• Primary headache has no known organic cause
and includes migraine, tension headache, and
cluster headache
• Secondary headache is a symptom with an
organic cause such as a brain tumor or aneurysm
• Headache may cause significant discomfort for
the person and can interfere with activities and
lifestyle
Headache
Migraine headache
Symptoms of a migraine attack may include heightened sensitivity to light and
sound, nausea, auras (loss of vision in one eye or tunnel vision), difficulty of
speech and intense pain predominating on one side of the head.

Headache
1. Aura- bright spots or flashing lights, 5-60

minutes
2. Headache Stage- vasodilation, a decline in
serotonin level and the onset of throbbing
headache
3. Post-headache Phase- headache area is
sensitive to touch and deep aching is present.

Headache
• Prodromal phase
- client has specific symptoms (food cravings or mood
changes)
• Aura phase (if present)
- generally involves visual changes, flashing lights, or
diplopia (double vision)
• Headache phase
- last few hours to few days
• Termination phase
- intensity of headache decreases
• Postprodrome phase
- client is often fatigued, may be irritable, and has muscle
pain
Assessment of Headache
• A detailed description of the headache is obtained
• Include medication history and use
• The types of headaches manifest differently in

different persons, and symptoms in one individual
may also may change over time
• Although most headaches do not indicate serious

disease, persistent headaches require
investigation

Assessment of Headache (cont.)
• Persons undergoing a headache evaluation require

a detailed history and physical assessment with
neurological exam to rule out various physical and
psychological causes
• Diagnostic testing may be used to evaluate the

underlying cause if the neurologic exam is
abnormal

Diagnosis
• Based on History, Physical and Neurologic

assessment
• MRI
• CT scan

Goal: Pain Management
• Aim: alleviate pain during aura phase (if present) or
soon after headache started
• Acetaminophen and NSAIDs: naproxen
• Antiemetics: prochlorpherazine (Compazine) ;
metoclopramide (Reglan, Clopra)
• Ergotamine derivatives
– Ergotamine tartrate (Cafergot)
– Dihydroergotamine (DHE)

Nursing Management of Headache—Pain
• Provide individualized care and treatment
• Prophylactic medications may be used for recurrent
migraines
• Migraines and cluster headaches require abortive
medications instituted as soon as possible with onset
• Provide medications as prescribed
• Provide comfort measures
– Quiet, dark room
– Massage
– Local heat for tension
Nursing Management of Headache—
Teaching
• Help patient identify triggers and develop
preventive strategies and lifestyle changes
for headache prevention
• Provide medication instruction and treatment
regimen
• Implement stress reduction techniques
• Implement nonpharmacologic therapies
• Provide follow-up care
• Encourage healthy lifestyle and health
promotion activities

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Chapter 61

Management of Patients With

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

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• A major nursing goal is to compensate

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Protecting the Patient

Copyright © 2008 Lippincott Williams & Wilkins.

Maintaining Tissue Integrity

Copyright © 2008 Lippincott Williams & Wilkins.

Promoting Bowel and Bladder Function

Sensory Stimulation and Communication

• Deep vein thrombosis (DVT)

• Brain tissues may shift through the dura and result

• Autoregulation: refers to the brain’s ability to

• CO2 plays a role; decreased CO2 results in

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• CCP (cerebral perfusion pressure) is closely linked

• CCP = MAP (mean arterial pressure) – ICP

• Normal CCP is 70 to 100

• A CCP of less than 50 results in permanent

Copyright © 2008 Lippincott Williams & Wilkins.

• Respiratory and vasomotor changes

• VS: Cushing’s reflex: increase in systolic blood

– Cushing’s triad: bradycardia, hypertension, and

– Herniation of the brain stem and occlusion of

• Further deterioration of LOC; stupor to coma

• Hemiplegia, decortication, decerebration, or

• Respiratory pattern alterations including Cheyne-

• Loss of brain stem reflexes: pupil, gag, corneal,

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• Ineffective airway clearance

• Ineffective breathing pattern

• Ineffective cerebral perfusion

• Deficient fluid volume related to fluid restriction

• Risk for infection related to ICP monitoring

Copyright © 2008 Lippincott Williams & Wilkins.

• Brain stem herniation

Copyright © 2008 Lippincott Williams & Wilkins.