Patients With Neurologic Dysfunction Health And Social Care Essay

3472 words (14 pages) Essay

1st Jan 1970 Health And Social Care Reference this

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Keshin Himura is a 42-year-old patient diagnosed with pituitary prolactinoma, a benign tumor that arises from the pituitary gland, resulting in a decrease in libido and impotence and increased milk production of the breast. The patient also has complaints of headache and drowsiness and the presence of visual field changes and papilledema preoperatively.

What postoperative care should the nurse provide the patient?

The nurse should provide the following postoperative care to the patient:

Evaluate gag reflex and ability to swallow

Offer semisoft diet

Perform neurologic checks

Monitor vital signs

Maintain neurologic flow chart

Reorient patient when necessary to person, time and place

If with seizures, carefully monitor and and protect from injury

Check motor function at intervals

Assess for sensory disturbances

Evaluate speech

The patient’s family asks the nurse how will they know that the problems the patient had before surgery have stopped; what is the nurse’s best response?

Through observation, conducting series of test that will be provided by the physician (e.g. MRI, CT scans) to check if the tumors are already diminished, because presence of tumor will still inhibit the signs and symptoms of the disorder. The primary objective of the surgical intervention is to remove or destroy the entire tumor without increasing the neurologic deficit and to relieve symptoms by decompression. And if there is no evidence of tumor, the normal levels of hormone would return in usual, the patient will no longer experience the symptoms of the disease.

What management strategies should the nurse anticipate will be ordered to care for diabetes insipidus if it occurs?

The objective of the therapy is:

To replace ADH

To ensure adequate fluid replacement

To correct the underlying intracranial problem (pituitary prolactinoma)

A fluid deprivation test is ordered by the physician to confirm for the diagnosis of diabetes insipidus by:

withholding fluids by 8 to 12 hours

Patient is weighed frequently during the test

Plasma and urine osmolality studies are performed at the beginning and end of the test.

The inability to increase the specific gravity and osmolality of the urine is an indication of Diabetes insipidus

Pharmacologic Therapy

Administer Desmopressin (DDAVP) intranasally, BID as ordered

Nursing Management

Establish baseline data ( weight, BP, I/O patter), Monitor BP and weight frequently throughout therapy and report sudden changes to physician

Monitor I/O and specific gravity and serum osmolality as ordered

If patient has Coronary artery disease, use this drug with caution as this drug causes vasoconstriction

Avoid concentrated fluids as this increase urine volume

What discharge instructions should the nurse provide the patient and family?

Most patients will spend at least one night in the intensive care unit (ICU) and then typically 2 or 3 additional nights on a regular (non-ICU) ward after surgery

The patient will likely have some incisional pain and mild to moderate headache for which he will be given pain medication.

A CT scan or MRI will be ordered before discharge

Ask patient to return 2-3weeks after surgery

Inform patient to return 2-3months after 1st check-up

Inform family to watch out for signs of DI (intense thirst, frequent urination). Refer immediately

Management of Patients with Neurologic Dysfunction  

Case Study 2

Hiehachi Nishima, a 22-year-old patient who weighs 150 pounds, presents to the emergency department (ED) after being thrown from his horse and passing out for a few minutes; he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. The respirations are very shallow, and the lips and nail bed became blue. The patient lost control of bladder and bowel. The patient bit his tongue and blood is coming from the mouth. The radiology department calls and is ready for the patient.

List in the correct order the actions that should be taken by the nurse.

Before and during a seizure, the patient is assessed and the following items are documented:

The circumstances before the seizure

The occurrence of aura

The first thing the patient does in the seizure – where movements or stiffness begins, conjugate gaze position, position of head

The type of movements in the part of the body involved

The areas of the body involved

The size of the pupils and whether the eyes are open

Whether the eyes or the head are turned to one side

The presence or absence of automatisms

Incontinence of urine or stool

Unconsciousness and its duration

Any obvious paralysis or weakness of arms or legs after the seizure

Inability to speak after the seizure

Movements at the end of the seizure

Whether or not the patient sleeps or not afterwards

Cognitive status after the seizure

In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient not only physically but also psychologically. Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient.

After the patient has a seizure, the nurse’s role is to document the events leading to and occurring during and after the seizure to prevent complications.

Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure and the specific nursing care for each stage.

The patient had a tonic-clonic (gran mal) seizure. There are three phases namely the aura, the tonic and the clonic phase.

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In the aura phase is the forewarning of an epileptic attack. It characterized by episodes of Déjà vu or Jamais vu. The client may also have auditory, olfactory, or even visual hallucinations, abnormal tastes, and tingling sensations. Physical symptoms include dizziness, headache, lightheadedness, nausea, numbness. Though in this case, the client did not show signs of the aura phase.

*Nsg Mgt:

Provide privacy and protect the patient from curious onlookers

Patients who have an aura may have time to seek a safe, private place

Ease the patient to the floor, if possible

Loosen constrictive clothing

Push aside any furniture that may injure the patient during a seizure

If an aura precedes the seizure, insert an oral airway to reduce the possibility of the patient’s biting the tongue

The next is the tonic phase. It is usually the shortest part of the seizure, lasting not more than only a few seconds. In this case, it is when the patient had an epileptic cry, became unconscious and stiffened his entire body.

*Nsg Mgt:

Protect the head with a pad to prevent injury from striking a hard surface

If the patient is in bed, remove pillows and raise side rails

The last is the clonic phase. It is when the client had violent muscle contractions, very shallow respirations, the lips and nail beds became blue, lost control of bladder and bowel and bit his tongue.

*Nsg Mgt:

Do not attempt to pry open jaws that are clenched in a spasm or to insert anything. Broken teeth and injury to the lips and tongue may result from such an action.

No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can cause injury

If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use if necessary to clear secretions.

The ED physician orders the following: Valium (diazepam) 10 mg every 10 to 15 minutes prn for seizures (maximum dose of 30 mg). Once seizures stop, administer Dilantin (phenytoin) 10 mg/kg IVPB. ECG monitoring continuously, VS, GCS, neuro checks every 30 minutes. Explain what meds the nurse should provide, in what order, and how they should be administered.

The nurse should provide Valium injection (diazepam) 10 mg IM PRN every 10 to 15 mins. (max 30mg) for his seizure to relief the muscle spasm. For the long term relief, administer Dilantin (phenytoin) 10 mg/kg IVPB loading dose STAT, once the seizures stop. Dilantin (phenytoin) is an anti-seizure medication (anticonvulsant), especially to prevent tonic-clonic (grand mal) seizures and complex partial seizures (psychomotor seizures).We use piggyback to administer different IV drugs at different times. Dilantin can cause irritability to the veins and can cause serious tissue and/or nerve damage if it infiltrates. So we should administer it with normal saline. Draw up the drugs in a syringe and attach it to the piggyback port on the IV tubing cassette, which is run concurrently with the primary IV fluid (normal saline). Run it slowly and keep an eye on the ECG monitor. This ECG monitoring should be done continuously to help identify irregular heartbeats. For the vital signs, Glasgow coma scale and neuro V/S, it should be check every 30 minutes to provide reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment.

Group Assignments

Have each member address nursing management related to caring for an unconscious patient.

Preventing Urinary Retention

Palpate bladder at intervals to determine whether urinary retention is present

If patient is not voiding, an indwelling catheter is inserted and connected to a closed drainage system as ordered

Observe for fever and cloudy urine for infection

Observe the area around the urethral orifice for any drainage

As soon as consciousness is regained, a bladder-training program initiated

Promote Bowel Function

Assess abdomen for distention by listening for bowel sounds (irregular gurgling sounds should be heard every 5-20sec)

Measuring the girth of the abdomen with a tape measure.

Monitor for the number and consistency of bowel movements

Perform rectal examination for signs of fecal impaction as ordered.

Stool softeners may be prescribed and can be administered with tube feedings

Glycerin suppository may be indicated to facilitate bowel emptying

May require enema every other day to empty lower colon

Maintain Skin and Joint Integrity

Monitor pressure areas for possible ulcerations

Establish a regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin

This provides kinesthetic, proprioceptive and vestibular stimulation

Avoid dragging and pulling the patient up in the bed, because this creates a shearing force and friction on the skin surface

Maintain correct body position

Passive exercise of the extremities is important to prevent contractures

Splints or foam boots may be used to prevent foot drop and pressure of bedding on the toes

Trochanter rolls may be used to support the hip joints and keep the legs in proper alignment

Providing Mouth Care

Inspect mouth for dryness, inflammation, and crusting

Cleanse and rinse mouth carefully to remove secretions and crusts and to keep the mucous membranes moist

Administer petrolatum on the lips to prevent drying, cracking and encrustations.

If patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth and lips

Perform routine tooth brushing every 8hrs to decrease ventilator-associated pneumonia

Maintaining the Airway

Elevate the head of bed to 30 degrees to prevent aspiration.

Place the client in lateral position to allow the jaw and tongue to fall forward to promote drainage of secretions.

Suction for secretions as needed

Maintain oral hygiene

Chest physiotherapy and postural drainage to promote pulmonary hygiene

Auscultate the patient’s chest every 8 hours to assess for any deviated breath sounds.

If the patient has a mechanical ventilator, maintain the patency of the endotracheal tube or tracheostomy, provide oral care, monitor arterial blood gas measurements and maintaining ventilator settings.

Protecting the Patient

Raise side rails up as always to prevent injury

Ensure the patient’s dignity during altered LOC, speaking to the client during nursing care activities.

Maintaining Fluid Balance and Managing Nutritional Needs

Assess skin turgor and mucous membrane for dryness

Monitor for intake and output and determine the needs for catheterization

Preserving Corneal Integrity

Patient’s eyes may be cleansed with cotton balls moistened with sterile normal saline to remove any discharge.

For artificial tears (prescription by the physician), may introduce every 2 hours.

Maintaining Body Temperature

The environment can be adjusted (depending on the patient’s condition) to promote normal body temperature.

If body temperature is elevated, a minimum amount of bedding is used.

For geriatric patients and doesn’t have any elevated temperature, a warmer environment is needed.

Providing Sensory Stimulation

Communicate with patient, and encourage the family members to do it so.

Orient the patient to time, date, and place once for every 8 hours.

Have each group member develop a nursing diagnosis related to a patient with an altered level of consciousness. Identify potential problems and complications related to the nursing diagnosis.

Nursing Diagnosis

Potential Problems and Complications

1. Ineffective airway clearance related to altered level of consciousness

Aspiration

2. Risk for impaired skin integrity related to prolonged immobility

Bed sore

Pressure ulceration

3. Impaired Urinary elimination: retention related to impairment in neurologic sensing and control

Bladder distention

Infection

Formation of stones

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

Periorbital edema

Ulcerations

Corneal abrasions

5. Deficient fluid volume related to inability to take fluids by mouth

Dehydration

Cerebral edema

6. Interrupted family processes related to changes in the cognitive and physical status of their loved one

Crisis

Severe anxiety, denial, anger, remorse, grief, and reconciliation

7. Risk for injury related to decreased LOC

Falls

8. Ineffective thermoregulation related to damage to hypothalamic center

Hyperthermia

9. Impaired oral mucous membrane related to mouth breathing , absence of pharyngeal reflex and altered fluid intake

Dryness

Inflammation

Crusting

10. Bowel incontinence related to impairment neurologic sensing and control

Abdominal distention

Diarrhea

Frequent loose stools

As a group, identify potential complications that may arise in the postoperative phase of cranial surgery.

Increased ICP

Monro-Kellie hypothesis states that, because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others.because brain tissue has limited space to expand, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral volume resulting to an increase ICP.

Bleeding and hypovolemic shock

An accumulation of blood under the bone flap (extradural, subdural, or intracerebral hematoma) may pose a threat to life. A clot must be suspected in any patient who does not awaken as expected or whose conditions deteriorates.

Fluid and electrolyte disturbances

IV solutions and blood component therapy for patients with intracranial conditions must be administered slowly. If they are administered too rapidly, they can increase ICP. The quantity of fluids administered may be restricted to minimize the possibility of cerebral edema.

Infection

The risk of infection is great when ICP is monitored with an intraventricular catheter and increases with the duration of the monitoring.

Seizures

Underlying cause is an electrical disturbance in the nerve cells in one section of the brain. An abnormal motor, sensory, autonomic, or physical activity that result from sudden excessive discharge from cerebral neurons.

Have each group member identify a type of seizure. Describe clinical manifestations, diagnosis, and treatment of each.

Generalized Seizures:

This are seizures that mainly involves electrical charges in the whole brain, its clinical manifestations includes loss of consciousness for a short or long period of time.

Types of Seizure

Clinical Manifestation

“Grand Mal” or Generalized tonic-clonic

Unconsciousness

Convulsions

Muscle rigidity

Absence

Short loss of unconsciousness

Myoclonic

Irregular jerky movements

Clonic

Repetitive jerky movements

Tonic

Muscle stiffness and rigidity

Atonic

Loss of muscle tone

Diagnosis:

Physical examination particularly neurologic examination

EEG

For temporary and reversible causes of seizures:

Blood chemistry

Blood sugar

Complete Blood Count

Cerebrospinal fluid analysis

Kidney function test

Liver function tests

Test to determine the cause and location:

EEG (electroencephalograph) to measure the electrical activity in the brain

Head CT or MRI scan

Lumbar puncture-spinal tap

Treatment:

When a seizure occurs, protect the person from injury, make the environment safe for you and the patient.

Protect the patient’s head

Loosen tight clothing

Place the patient into a side-lying position if vomiting occurs

Stay with patient until she or he is fully recovered

Monitor the patient’s vital signs

Medications such as anticonvulsants may be given as ordered to reduce the number of future seizures.

The DON’T’s During Seizures:

Don’t restrain the patient

Don’t place anything between the patient’s teeth during a seizure

Don’t move the patient unless he or she is in danger or near something hazardous

Don’t try to stop the patient from convulsing.

Partial Seizures:

This are seizures that mainly involves electrical charges in one part of the brain, its clinical manifestations includes abnormal muscle movements, automatisms, abnormal sensations, hallucinations, nausea, sweating, dilated pupils, rapid heart rate and pulse rate, changes in vision.

Types of Seizure

Clinical Manifestation

Simple

(consciousness is intact)

Jerky movements

Muscle rigidity, spasm

Unusual sensation

Memory and emotional disturbance

Complex

(consciousness is impaired)

Automatisms: lip smacking, chewing, walking and repetitive involuntary and coordinated movements

Diagnosis:

CT scan

MRI

EEG

EEG-video recordings

Treatment:

Vagus Nerve Stimulation in which a small battery is implanted in the chest wall which will program to deliver short bursts of energy to the brain.

Corpus Callosotomy is a type of surgical intervention that will cut the connections between the two sides of the brain that will prevent drop attacks..

Multiple sub-pial transection which is a surgical technique that will cut a certain connection between nerve cells.

Keshin Himura is a 42-year-old patient diagnosed with pituitary prolactinoma, a benign tumor that arises from the pituitary gland, resulting in a decrease in libido and impotence and increased milk production of the breast. The patient also has complaints of headache and drowsiness and the presence of visual field changes and papilledema preoperatively.

What postoperative care should the nurse provide the patient?

The nurse should provide the following postoperative care to the patient:

Evaluate gag reflex and ability to swallow

Offer semisoft diet

Perform neurologic checks

Monitor vital signs

Maintain neurologic flow chart

Reorient patient when necessary to person, time and place

If with seizures, carefully monitor and and protect from injury

Check motor function at intervals

Assess for sensory disturbances

Evaluate speech

The patient’s family asks the nurse how will they know that the problems the patient had before surgery have stopped; what is the nurse’s best response?

Through observation, conducting series of test that will be provided by the physician (e.g. MRI, CT scans) to check if the tumors are already diminished, because presence of tumor will still inhibit the signs and symptoms of the disorder. The primary objective of the surgical intervention is to remove or destroy the entire tumor without increasing the neurologic deficit and to relieve symptoms by decompression. And if there is no evidence of tumor, the normal levels of hormone would return in usual, the patient will no longer experience the symptoms of the disease.

What management strategies should the nurse anticipate will be ordered to care for diabetes insipidus if it occurs?

The objective of the therapy is:

To replace ADH

To ensure adequate fluid replacement

To correct the underlying intracranial problem (pituitary prolactinoma)

A fluid deprivation test is ordered by the physician to confirm for the diagnosis of diabetes insipidus by:

withholding fluids by 8 to 12 hours

Patient is weighed frequently during the test

Plasma and urine osmolality studies are performed at the beginning and end of the test.

The inability to increase the specific gravity and osmolality of the urine is an indication of Diabetes insipidus

Pharmacologic Therapy

Administer Desmopressin (DDAVP) intranasally, BID as ordered

Nursing Management

Establish baseline data ( weight, BP, I/O patter), Monitor BP and weight frequently throughout therapy and report sudden changes to physician

Monitor I/O and specific gravity and serum osmolality as ordered

If patient has Coronary artery disease, use this drug with caution as this drug causes vasoconstriction

Avoid concentrated fluids as this increase urine volume

What discharge instructions should the nurse provide the patient and family?

Most patients will spend at least one night in the intensive care unit (ICU) and then typically 2 or 3 additional nights on a regular (non-ICU) ward after surgery

The patient will likely have some incisional pain and mild to moderate headache for which he will be given pain medication.

A CT scan or MRI will be ordered before discharge

Ask patient to return 2-3weeks after surgery

Inform patient to return 2-3months after 1st check-up

Inform family to watch out for signs of DI (intense thirst, frequent urination). Refer immediately

Management of Patients with Neurologic Dysfunction  

Case Study 2

Hiehachi Nishima, a 22-year-old patient who weighs 150 pounds, presents to the emergency department (ED) after being thrown from his horse and passing out for a few minutes; he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. The respirations are very shallow, and the lips and nail bed became blue. The patient lost control of bladder and bowel. The patient bit his tongue and blood is coming from the mouth. The radiology department calls and is ready for the patient.

List in the correct order the actions that should be taken by the nurse.

Before and during a seizure, the patient is assessed and the following items are documented:

The circumstances before the seizure

The occurrence of aura

The first thing the patient does in the seizure – where movements or stiffness begins, conjugate gaze position, position of head

The type of movements in the part of the body involved

The areas of the body involved

The size of the pupils and whether the eyes are open

Whether the eyes or the head are turned to one side

The presence or absence of automatisms

Incontinence of urine or stool

Unconsciousness and its duration

Any obvious paralysis or weakness of arms or legs after the seizure

Inability to speak after the seizure

Movements at the end of the seizure

Whether or not the patient sleeps or not afterwards

Cognitive status after the seizure

In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient not only physically but also psychologically. Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient.

After the patient has a seizure, the nurse’s role is to document the events leading to and occurring during and after the seizure to prevent complications.

Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure and the specific nursing care for each stage.

The patient had a tonic-clonic (gran mal) seizure. There are three phases namely the aura, the tonic and the clonic phase.

In the aura phase is the forewarning of an epileptic attack. It characterized by episodes of Déjà vu or Jamais vu. The client may also have auditory, olfactory, or even visual hallucinations, abnormal tastes, and tingling sensations. Physical symptoms include dizziness, headache, lightheadedness, nausea, numbness. Though in this case, the client did not show signs of the aura phase.

*Nsg Mgt:

Provide privacy and protect the patient from curious onlookers

Patients who have an aura may have time to seek a safe, private place

Ease the patient to the floor, if possible

Loosen constrictive clothing

Push aside any furniture that may injure the patient during a seizure

If an aura precedes the seizure, insert an oral airway to reduce the possibility of the patient’s biting the tongue

The next is the tonic phase. It is usually the shortest part of the seizure, lasting not more than only a few seconds. In this case, it is when the patient had an epileptic cry, became unconscious and stiffened his entire body.

*Nsg Mgt:

Protect the head with a pad to prevent injury from striking a hard surface

If the patient is in bed, remove pillows and raise side rails

The last is the clonic phase. It is when the client had violent muscle contractions, very shallow respirations, the lips and nail beds became blue, lost control of bladder and bowel and bit his tongue.

*Nsg Mgt:

Do not attempt to pry open jaws that are clenched in a spasm or to insert anything. Broken teeth and injury to the lips and tongue may result from such an action.

No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can cause injury

If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use if necessary to clear secretions.

The ED physician orders the following: Valium (diazepam) 10 mg every 10 to 15 minutes prn for seizures (maximum dose of 30 mg). Once seizures stop, administer Dilantin (phenytoin) 10 mg/kg IVPB. ECG monitoring continuously, VS, GCS, neuro checks every 30 minutes. Explain what meds the nurse should provide, in what order, and how they should be administered.

The nurse should provide Valium injection (diazepam) 10 mg IM PRN every 10 to 15 mins. (max 30mg) for his seizure to relief the muscle spasm. For the long term relief, administer Dilantin (phenytoin) 10 mg/kg IVPB loading dose STAT, once the seizures stop. Dilantin (phenytoin) is an anti-seizure medication (anticonvulsant), especially to prevent tonic-clonic (grand mal) seizures and complex partial seizures (psychomotor seizures).We use piggyback to administer different IV drugs at different times. Dilantin can cause irritability to the veins and can cause serious tissue and/or nerve damage if it infiltrates. So we should administer it with normal saline. Draw up the drugs in a syringe and attach it to the piggyback port on the IV tubing cassette, which is run concurrently with the primary IV fluid (normal saline). Run it slowly and keep an eye on the ECG monitor. This ECG monitoring should be done continuously to help identify irregular heartbeats. For the vital signs, Glasgow coma scale and neuro V/S, it should be check every 30 minutes to provide reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment.

Group Assignments

Have each member address nursing management related to caring for an unconscious patient.

Preventing Urinary Retention

Palpate bladder at intervals to determine whether urinary retention is present

If patient is not voiding, an indwelling catheter is inserted and connected to a closed drainage system as ordered

Observe for fever and cloudy urine for infection

Observe the area around the urethral orifice for any drainage

As soon as consciousness is regained, a bladder-training program initiated

Promote Bowel Function

Assess abdomen for distention by listening for bowel sounds (irregular gurgling sounds should be heard every 5-20sec)

Measuring the girth of the abdomen with a tape measure.

Monitor for the number and consistency of bowel movements

Perform rectal examination for signs of fecal impaction as ordered.

Stool softeners may be prescribed and can be administered with tube feedings

Glycerin suppository may be indicated to facilitate bowel emptying

May require enema every other day to empty lower colon

Maintain Skin and Joint Integrity

Monitor pressure areas for possible ulcerations

Establish a regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin

This provides kinesthetic, proprioceptive and vestibular stimulation

Avoid dragging and pulling the patient up in the bed, because this creates a shearing force and friction on the skin surface

Maintain correct body position

Passive exercise of the extremities is important to prevent contractures

Splints or foam boots may be used to prevent foot drop and pressure of bedding on the toes

Trochanter rolls may be used to support the hip joints and keep the legs in proper alignment

Providing Mouth Care

Inspect mouth for dryness, inflammation, and crusting

Cleanse and rinse mouth carefully to remove secretions and crusts and to keep the mucous membranes moist

Administer petrolatum on the lips to prevent drying, cracking and encrustations.

If patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth and lips

Perform routine tooth brushing every 8hrs to decrease ventilator-associated pneumonia

Maintaining the Airway

Elevate the head of bed to 30 degrees to prevent aspiration.

Place the client in lateral position to allow the jaw and tongue to fall forward to promote drainage of secretions.

Suction for secretions as needed

Maintain oral hygiene

Chest physiotherapy and postural drainage to promote pulmonary hygiene

Auscultate the patient’s chest every 8 hours to assess for any deviated breath sounds.

If the patient has a mechanical ventilator, maintain the patency of the endotracheal tube or tracheostomy, provide oral care, monitor arterial blood gas measurements and maintaining ventilator settings.

Protecting the Patient

Raise side rails up as always to prevent injury

Ensure the patient’s dignity during altered LOC, speaking to the client during nursing care activities.

Maintaining Fluid Balance and Managing Nutritional Needs

Assess skin turgor and mucous membrane for dryness

Monitor for intake and output and determine the needs for catheterization

Preserving Corneal Integrity

Patient’s eyes may be cleansed with cotton balls moistened with sterile normal saline to remove any discharge.

For artificial tears (prescription by the physician), may introduce every 2 hours.

Maintaining Body Temperature

The environment can be adjusted (depending on the patient’s condition) to promote normal body temperature.

If body temperature is elevated, a minimum amount of bedding is used.

For geriatric patients and doesn’t have any elevated temperature, a warmer environment is needed.

Providing Sensory Stimulation

Communicate with patient, and encourage the family members to do it so.

Orient the patient to time, date, and place once for every 8 hours.

Have each group member develop a nursing diagnosis related to a patient with an altered level of consciousness. Identify potential problems and complications related to the nursing diagnosis.

Nursing Diagnosis

Potential Problems and Complications

1. Ineffective airway clearance related to altered level of consciousness

Aspiration

2. Risk for impaired skin integrity related to prolonged immobility

Bed sore

Pressure ulceration

3. Impaired Urinary elimination: retention related to impairment in neurologic sensing and control

Bladder distention

Infection

Formation of stones

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

Periorbital edema

Ulcerations

Corneal abrasions

5. Deficient fluid volume related to inability to take fluids by mouth

Dehydration

Cerebral edema

6. Interrupted family processes related to changes in the cognitive and physical status of their loved one

Crisis

Severe anxiety, denial, anger, remorse, grief, and reconciliation

7. Risk for injury related to decreased LOC

Falls

8. Ineffective thermoregulation related to damage to hypothalamic center

Hyperthermia

9. Impaired oral mucous membrane related to mouth breathing , absence of pharyngeal reflex and altered fluid intake

Dryness

Inflammation

Crusting

10. Bowel incontinence related to impairment neurologic sensing and control

Abdominal distention

Diarrhea

Frequent loose stools

As a group, identify potential complications that may arise in the postoperative phase of cranial surgery.

Increased ICP

Monro-Kellie hypothesis states that, because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others.because brain tissue has limited space to expand, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral volume resulting to an increase ICP.

Bleeding and hypovolemic shock

An accumulation of blood under the bone flap (extradural, subdural, or intracerebral hematoma) may pose a threat to life. A clot must be suspected in any patient who does not awaken as expected or whose conditions deteriorates.

Fluid and electrolyte disturbances

IV solutions and blood component therapy for patients with intracranial conditions must be administered slowly. If they are administered too rapidly, they can increase ICP. The quantity of fluids administered may be restricted to minimize the possibility of cerebral edema.

Infection

The risk of infection is great when ICP is monitored with an intraventricular catheter and increases with the duration of the monitoring.

Seizures

Underlying cause is an electrical disturbance in the nerve cells in one section of the brain. An abnormal motor, sensory, autonomic, or physical activity that result from sudden excessive discharge from cerebral neurons.

Have each group member identify a type of seizure. Describe clinical manifestations, diagnosis, and treatment of each.

Generalized Seizures:

This are seizures that mainly involves electrical charges in the whole brain, its clinical manifestations includes loss of consciousness for a short or long period of time.

Types of Seizure

Clinical Manifestation

“Grand Mal” or Generalized tonic-clonic

Unconsciousness

Convulsions

Muscle rigidity

Absence

Short loss of unconsciousness

Myoclonic

Irregular jerky movements

Clonic

Repetitive jerky movements

Tonic

Muscle stiffness and rigidity

Atonic

Loss of muscle tone

Diagnosis:

Physical examination particularly neurologic examination

EEG

For temporary and reversible causes of seizures:

Blood chemistry

Blood sugar

Complete Blood Count

Cerebrospinal fluid analysis

Kidney function test

Liver function tests

Test to determine the cause and location:

EEG (electroencephalograph) to measure the electrical activity in the brain

Head CT or MRI scan

Lumbar puncture-spinal tap

Treatment:

When a seizure occurs, protect the person from injury, make the environment safe for you and the patient.

Protect the patient’s head

Loosen tight clothing

Place the patient into a side-lying position if vomiting occurs

Stay with patient until she or he is fully recovered

Monitor the patient’s vital signs

Medications such as anticonvulsants may be given as ordered to reduce the number of future seizures.

The DON’T’s During Seizures:

Don’t restrain the patient

Don’t place anything between the patient’s teeth during a seizure

Don’t move the patient unless he or she is in danger or near something hazardous

Don’t try to stop the patient from convulsing.

Partial Seizures:

This are seizures that mainly involves electrical charges in one part of the brain, its clinical manifestations includes abnormal muscle movements, automatisms, abnormal sensations, hallucinations, nausea, sweating, dilated pupils, rapid heart rate and pulse rate, changes in vision.

Types of Seizure

Clinical Manifestation

Simple

(consciousness is intact)

Jerky movements

Muscle rigidity, spasm

Unusual sensation

Memory and emotional disturbance

Complex

(consciousness is impaired)

Automatisms: lip smacking, chewing, walking and repetitive involuntary and coordinated movements

Diagnosis:

CT scan

MRI

EEG

EEG-video recordings

Treatment:

Vagus Nerve Stimulation in which a small battery is implanted in the chest wall which will program to deliver short bursts of energy to the brain.

Corpus Callosotomy is a type of surgical intervention that will cut the connections between the two sides of the brain that will prevent drop attacks..

Multiple sub-pial transection which is a surgical technique that will cut a certain connection between nerve cells.

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