34 General care of patients with neurologic disorders
Nursing diagnosis:
Decreased intracranial adaptive capacity
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for and report any of the following indicators of IICP or impending/occurring herniation: | Intracranial pressure (ICP) is the pressure exerted by brain tissue, cerebrospinal fluid (CSF), and cerebral blood volume within the rigid, unyielding skull. An increase in any one of these components without a corresponding decrease in another will increase ICP. Normal ICP is 0-10 mm Hg; IICP is greater than 15 mm Hg. Cerebral perfusion pressure (CPP) is the difference between mean arterial pressure and ICP. As ICP rises, CPP may decrease. Normal CPP is 70-100 mm Hg. If CPP falls below 40-60 mm Hg, ischemia occurs. When CPP falls to 0, cerebral blood flow ceases. Cerebral edema and IICP usually peak 2-3 days after injury and then decrease over 1-2 wk. |
| Early indicators of IICP: Declining Glasgow Coma Scale score; alterations in level of consciousness (LOC) ranging from irritability, restlessness, and confusion to lethargy; possible onset of or worsening of headache; beginning pupillary dysfunction, such as sluggishness; visual disturbances, such as diplopia or blurred vision; onset of or increase in sensorimotor changes or deficits, such as weakness; onset of or worsening of nausea. | The single most important assessment indicator of early IICP is a change in LOC. |
| Late indicators of IICP: Continuing decline in Glasgow Coma Scale score; continued deterioration in LOC leading to stupor and coma; projectile vomiting; hemiplegia; posturing; widening pulse pressure, decreased HR, and increased SBP; Cheyne-Stokes breathing or other respiratory irregularity; pupillary changes, such as oval-shaped, inequality, dilation, and nonreactivity to light; papilledema; and impaired brain stem reflexes (corneal, gag, swallowing). | Late assessment indicators of IICP signal impending or actual herniation and are generally related to brain stem compression and disruption of cranial nerves and vital centers. |
| Brain herniation: Deep coma, fixed and dilated pupils (first unilateral and then bilateral), posturing progressing to bilateral flaccidity, lost brain stem reflexes, and continuing deterioration in vital signs (VS) and respirations. | Brain herniation occurs when IICP causes displacement of brain tissue from one cranial compartment to another. |
| If changes occur, prepare for possible transfer of patient to intensive care unit (ICU). | Insertion of ICP sensors for continuous ICP monitoring, continuous bedside cerebral blood flow (CBF) monitoring (e.g., continuous transcranial Doppler), CSF ventricular drainage, vasopressor usage (e.g., dopamine), intubation, mechanical ventilation, propofol sedation, neuromuscular blocking, or barbiturate coma therapy may be necessary. Continuous cardiac monitoring for dysrhythmias also will be done. Intensive insulin therapy may be needed to maintain optimal serum glucose values. Testing (e.g., computed tomography [CT]) may be done, but lumbar puncture (LP) is contraindicated or used with caution in the presence of IICP. |
| Institute preventive measures for patients at risk for IICP. These include ensuring a patent airway, delivering O2 as prescribed, and may include intubation and mechanical ventilation as necessary. Assess arterial blood gas (ABG) or pulse oximetry values. | Preventing hypoxia necessitates maintaining oxygen saturation at greater than 92%. Therefore, it is important to preoxygenate before suctioning and limit suctioning to 10 sec. Prevention of CO2 retention (and the resulting respiratory acidosis) is essential for preventing vasodilation of cerebral arteries, which can lead to cerebral edema. |
| Be aware that CBF measurements, continuous jugular venous oxygen saturation (SjO2), and brain tissue oxygenation (PbtO2) should be considered to assess for effectiveness (i.e., decreased IICP without decreased cerebral oxygen delivery) if hyperventilation is used as a treatment. | Mechanical hyperventilation, by lowering cerebral Paco2, results in an alkalosis, which causes cerebral vasoconstriction resulting in decreased CBF and ICP. The vasoconstriction also may cause decreased cerebral oxygen delivery, which could increase injury by increasing cerebral ischemia. Hyperventilation (e.g., with Ambu bag or if ventilated to keep Paco2 to 30-35 mm Hg) is now generally used only in cases of acute deterioration as a “quick fix” until other interventions can be instituted (e.g., mannitol) or in cases in which IICP is refractory and responds to nothing else. |
| Maintain head and neck alignment to avoid hyperextension, flexion, or rotation, ensuring that tracheostomy, endotracheal tube ties, or O2 tubing does not compress the jugular vein, and avoiding Trendelenburg position for any reason. | These measures promote venous blood return to the heart to reduce cerebral congestion. |
| Ensure that pillows under patient’s head are flat. | This measure maintains head in a neutral rather than flexed position, thereby preventing backup of jugular venous outflow. |
| Keep head of bed (HOB) at whatever level optimizes CPP. | CPP needs to be at least 70 mm Hg or as prescribed to prevent ischemia. Without monitoring equipment, having the HOB at 30 degrees is considered safe and effective in promoting venous drainage and lowering ICP as long as patient is not hypovolemic, which could threaten CPP. |
| Take precautions against increased intraabdominal and intrathoracic pressure in the following ways: | |
| This action reduces intrathoracic pressure. | |
| This prevents increases in intraabdominal and intrathoracic pressures that could raise ICP. | |
| These measures prevent straining at stool, which would increase intraabdominal and intracranial pressures. | |
| Movements involving pushing would increase intraabdominal and intrathoracic pressures. | |
| This action prevents increases in intraabdominal and intrathoracic pressures. | |
| As above. | |
| These positions increase intraabdominal pressure. | |
| Straining against restraints increases ICP. | |
| Valsalva’s maneuver increases intraabdominal and intrathoracic pressures. | |
| Administer intravenous (IV) fluids with an infusion control device to prevent fluid overload. Keep accurate intake and output (I&O) records. (Patient usually has an indwelling urinary catheter.) | Isotonic or hypertonic IV fluids are given to maintain normovolemia and balanced electrolyte status. Fluid restrictions are avoided because resulting increased blood viscosity and decreased volume may lead to hypotension, thereby decreasing CPP. |
| When administering additional IV fluids (e.g., IV drugs) avoid using D5W. | D5W’s hypotonicity can increase cerebral edema and hyperglycemia, which have been associated with inferior neurologic outcomes. |
| Help maintain patient’s body temperature within normal limits by giving prescribed antipyretics, regulating temperature of the environment, limiting use of blankets, keeping patient’s trunk warm to prevent shivering, and administering tepid sponge baths or using hypothermia blanket or convection cooling units to reduce fever. | Hypothalamic dysfunction from swelling or injury may cause hyperthermia. In turn, fever increases metabolic requirements (10% for each 1° C) and aggravates hypoxia. |
| When using a hypothermia blanket, wrap the patient’s extremities in blankets or towels, and if prescribed, administer chlorpromazine. | Both measures prevent shivering, which would increase ICP. Mild (e.g., 35° C) hypothermia treatment also may be attempted to minimize metabolic needs of the brain if ICP is increased. |
| Administer prescribed osmotic (e.g., mannitol) and loop diuretics (e.g., furosemide). | These agents reduce cerebral edema and blood volume, thereby lowering ICP. |
| Administer BP medications as prescribed. | These medications keep BP within prescribed limits that will promote optimal CBF without increasing cerebral edema. Hypotension is particularly detrimental inasmuch as it directly affects CBF. Hypertension may be allowed or treated first with drugs such as labetalol. Vasoactive drugs such as nitroprusside may worsen cerebral edema via vasodilation. |
| Administer prescribed analgesics promptly and as necessary. | Pain can increase ICP. Barbiturates and opioids usually are contraindicated because of the potential for masking the signs of IICP and causing respiratory depression. However, intubated, restless patients are usually sedated. A continuous propofol or midazolam drip has been demonstrated to decrease IICP. Lidocaine is sometimes used to block coughing before suctioning an endotracheal tube. |
| Administer antiepilepsy drugs (AEDs) as prescribed. | AEDs prevent or control seizures, which would increase cerebral metabolism, hypoxia, and CO2 retention, which in turn would increase cerebral edema and ICP. |
| Monitor bladder drainage tubes for obstruction or kinks. | A distended bladder can increase ICP. |
| Provide a quiet and soothing environment. Control noise and other environmental stimuli. Speak softly, use a gentle touch, and avoid jarring the bed. Try to limit painful procedures; avoid tension on tubes (e.g., urinary catheter); and consider limiting pain-stimulation testing. Avoid unnecessary touch (e.g., leave BP cuff in place for frequent VS; use automatic recycling BP monitoring devices); and talk softly, explaining procedures before touching to avoid startling patient. Try to avoid situations in which the patient may become emotionally upset. Do not say anything in the presence of the patient that you would not say if he or she were awake. Limit visitors as necessary. | A quiet and soothing environment optimally will help keep BP and other pressures within therapeutic limits. Family discussions should take place outside the room. |
| Encourage significant other to speak quietly to patient. If possible, arrange for patient to listen to soft favorite music with earphones. | Hearing a familiar voice or listening to soft music may promote relaxation and decrease ICP. |
| Individualize care to ensure rest periods and optimal spacing of activities; avoid turning, suctioning, and taking VS all at one time. Plan activities and treatments accordingly so that patient can sleep undisturbed as often as possible. | Multiple procedures and nursing care activities can increase ICP. For example, rousing patients from sleep has been shown to increase ICP. |
| Administer mild sedatives (e.g., diphenhydramine) or antianxiety agents (haloperidol, lorazepam, midazolam) as prescribed to restless/agitated patient. Attempt to identify and relieve cause (e.g., overstimulation, pain) before medicating. | These measures decrease restlessness or decrease/control agitation that may increase ICP. |
| Administer skeletal muscle relaxants (e.g., propofol, atracurium, pancuronium) as prescribed. (This therapy requires intubation and ventilation.) | These agents decrease the skeletal muscle tension that is seen with abnormal flexion and extension posturing, which can increase ICP. Bispectral index technology (BIS) may be used to guide administration of these drugs for sedation and neuromuscular blockade. BIS translates information from the electroencephalogram (EEG) into a single number that represents each patient’s LOC. This number ranges from 100 (indicating an awake patient) to zero (indicating the absence of brain activity). |
Nursing diagnosis:
Risk for aspiration
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| For patients with new or increasing neurologic deficit, perform a dysphagia screening to assess for impaired swallowing. For more details, see next nursing diagnosis. | Dysphagia screening will identify patients at risk for aspiration. These patients should be kept nothing by mouth (NPO) until a swallowing evaluation can be performed. |
| Assess lung sounds before and after patient eats, effectiveness of patient’s cough, and quality, amount, and color of sputum. | New onset of crackles or wheezing can signal aspiration. Patients with a weak cough are at risk for aspiration. An increase in quantity or color change of sputum may indicate an infection from aspiration. |
| Keep HOB elevated after meals or assist patient into a right side-lying position. | This position facilitates flow of ingested food and fluids by gravity from the greater stomach curve to the pylorus, thereby minimizing potential for regurgitation and aspiration. |
| If indicated, consult health care provider about use of an upper gastrointestinal (GI) stimulant (e.g., metoclopramide). | Metoclopramide stimulates upper GI tract motility and gastric emptying, which also decreases potential for regurgitation. |
| Provide oral hygiene after meals. | Oral hygiene removes food particles that could be aspirated. |
| Assess the mouth frequently, and suction prn. | These actions assess for particles or secretions that could be aspirated and removes them. |
| If patient has nausea or vomiting or has secretions, turn on one side. | This position facilitates drainage and prevents their aspiration. |
| Anticipate need for artificial airway if secretions cannot be cleared. Teach significant other the Heimlich maneuver. | These measures help ensure a patent airway. |
| For general interventions, see this nursing diagnosis in “Older Adult Care,” p. 90. |
Nursing diagnosis:
Impaired swallowing
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for factors that affect ability to swallow safely, including LOC, gag and cough reflexes, and strength and symmetry of tongue, lip, and facial muscles. | This assessment determines if swallowing deficits are present that necessitate aspiration precautions. |
| Assess for coughing, regurgitation of food and fluid through the nares, drooling, food oozing from the lips, food trapped in buccal spaces, and development of a weak, “wet,” or hoarse voice during or after eating. | These are signs of impaired swallowing. |
Check swallow reflex by first asking patient to swallow own saliva. Place a finger gently on top of larynx. If the larynx elevates with the attempt, next ask patient to swallow 3-5 mL of plain water. Document your findings. | Inability to swallow own saliva or small amount of water and presence of a stationary larynx during attempt to swallow signal loss of the swallowing reflex. |
| Obtain a referral to a speech therapist for patients with a swallowing dysfunction. | The act of swallowing is complex, and interventions vary according to the phase of swallowing that is dysfunctional. Video fluoroscopy may be used to evaluate swallowing, and some patients with swallowing dysfunction are referred to speech therapists for evaluation. |
| Encourage patient to practice any prescribed exercises. | Exercises such as tongue and jaw ROM; sound phonation such as “gah-gah-gah” to promote elevation of the soft palate; puckering lips; and sticking the tongue out to touch the nose, chin, cheeks may be prescribed to facilitate swallowing ability. |
| Recognize that a nasogastric (NG) tube may hinder patient’s ability to relearn to swallow. | NG tubes may desensitize and impair reflexive response to food bolus stimulus. |
| Alert health care provider to your findings. | Parenteral nutrition may be necessary for patients who cannot chew or swallow effectively or safely. |
| Keep suction equipment and a manual resuscitation bag with face mask at patient’s bedside. Suction secretions in patient’s mouth as necessary. | This equipment enables immediate intervention in the event aspiration occurs. |
| Ensure that patient is alert and responsive to verbal stimuli before attempting to swallow. Provide a rest period before meals or swallowing attempts. | Patients who are drowsy, inattentive, or fatigued have difficulty cooperating and are at risk of aspirating. |
| Initiate swallowing attempts with plain water (see earlier). Progressively add easy-to-swallow food and liquids as patient’s ability to swallow improves. Determine which foods and liquids are easiest for patient to swallow. | Generally, semisolid foods of medium consistency, such as puddings, hot cereals, and casseroles, tend to be easiest to swallow. Thicker liquids, such as nectars, tend to be better tolerated than thin liquids. |
| If indicated/prescribed, add commercially available powders (e.g., Thicket) to liquids. | Thickening foods increases their viscosity and makes them more easily swallowed. Gravy or sauce added to dry foods often facilitates swallowing as well. |
| Avoid giving peanut butter, chocolate, or milk. | Foods such as these may stick in the patient’s throat or produce mucus. |
| Avoid nuts, hard candies, or popcorn. | These foods may be aspirated. |
| Reduce stimuli in the room (e.g., turn off television, lower radio volume, minimize conversation, and limit disruptions from phone calls). Caution patient not to talk while eating. | These measures help patient focus on swallowing. |
| If patient must remain in bed, use high Fowler’s position if possible. Support shoulders and neck with pillows. | Most patients swallow best when in an upright position. Sitting in a straight-back chair with feet on the floor is ideal. |
| Ensure that patient’s head is erect and flexed forward slightly, with chin at the midline and pointing toward chest (i.e., the “chin tuck”). | This head position minimizes the risk that food will go into the airway by forcing the trachea to close and the esophagus to open. In addition, stroking the anterior neck lightly may help some patients swallow. |
| Maintain patient in an upright position for at least 30-60 min after eating. | This position helps prevent regurgitation and aspiration by facilitating flow of foods and fluids by gravity from the stomach to the pylorus. |
| Teach patient to break down the act of chewing and swallowing into the following steps. | Taking patient through these steps promotes concentration and focus, which will help ensure optimal swallowing. |
| Start with small amounts of food or liquid. Feed slowly. | For optimum safety, each bite should not exceed 5 mL (1 tsp). |
| Ensure that each previous bite has been swallowed. Check mouth for pockets of food. After every few bites of solid food, provide a liquid to help clear the mouth. | Food may become pocketed in the affected side of the mouth, which could result in aspiration. |
| Avoid using a syringe. | The force of the fluid in the syringe, if sprayed, may cause aspiration. |
| Avoid use of drinking straws. | The act of sucking may add to the complexity of swallowing and allow too much liquid to enter the mouth, thereby increasing the risk of aspiration. |
| Tear a piece out of a Styrofoam cup to make a space for the nose so that patient can drink with neck flexed. | Having the neck in a flexed position minimizes risk that food will go into the airway by forcing the trachea to close and the esophagus to open. |
| Teach patient who has food that pockets in the buccal spaces to periodically sweep mouth with tongue or finger or to clean these areas with a napkin. Explain that applying external pressure to cheek with a finger will help remove trapped food. | These actions help prevent aspiration of food particles, stomatitis, and tooth decay. |
| Teach patient who has a weak or paralyzed side to place food on side of the face patient can control. | Tilting head toward stronger side will allow gravity to help keep food or liquid on side of the mouth patient can manipulate. However, some patients may find that rotating head to the weak side will close the damaged side of the pharynx and facilitate more effective swallowing. |
| Serve only warm or cool foods to individuals with loss of oral sensation. | Patients with loss of oral sensation may be unable to identify foods or fluids of tepid temperature with tongue or oral mucosa. Verbal cues and use of a mirror may help ensure that these patients keep their mouths clear after swallowing. |
| To facilitate movement of food in some patients, encourage repeated swallowing attempts. Evaluate patient’s swallowing ability at different times of the day. Reschedule mealtimes to times when patient has improved swallowing, or, as appropriate, discuss with health care provider the possibility of changing dose schedule of patient’s antiparkinsonian medication. | Patients with a rigid tongue (e.g., with parkinsonism) have difficulty getting the tongue to move a bolus of food into the pharynx for swallowing. |
| If decreased salivation is contributing to patient’s swallowing difficulties, perform one of the following before feeding: swab patient’s mouth with a lemon-glycerin sponge; have patient suck on a tart-flavored hard candy, dill pickle, or lemon slice; teach patient to move tongue in a circular motion against inside of cheek; or use artificial saliva. | These actions stimulate salivation, which optimally will contribute to effective swallowing. |
| Moisten food with melted butter, broth or other soup, or gravy. Dip dry foods such as toast into coffee or other liquid. | These actions moisten and soften food when salivation is decreased. |
| Rinse patient’s mouth as needed. | This intervention removes particles and lubricates the mouth. |
| Investigate medications patient is taking for potential side effect of decreased salivation. | Drugs such as anti-parkinsonian medications or those with extrapyramidal side effects may result in decreased salivation. |
| Consult with health care provider regarding use of tablets, capsules, and liquids for patients with swallowing difficulties. Check with pharmacist to confirm that crushing a tablet or opening a capsule does not adversely affect its absorption or duration (i.e., slow-release medications should not be crushed). | Tablets or capsules may be swallowed more easily when added to foods such as puddings or ice cream. Crushed tablets or opened capsules also mix easily into these types of foods. Liquid forms of medications also may be available through the pharmacy. |
| For patients taking anti-Parkinson’s medications, assess relationship of peak medication effect with swallowing. | Coordinating meals with peak medication effect may facilitate swallowing. |
| Teach significant other the Heimlich or abdominal thrust maneuver. | This information helps ensure that he or she can intervene in the event of patient’s choking. |
Nursing diagnosis:
Risk for falls
related to weakness, impaired balance, or unsteady gait occurring with sensorimotor deficit
Desired Outcomes: Patient is free of trauma caused by gait unsteadiness. Before hospital discharge, patient demonstrates proficiency with assistive devices if appropriate.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess gait and monitor for weakness, difficulty with balance, tremors, spasticity, or paralysis. | These are indicators of motor deficits that could lead to falls. |
| Document baseline assessments. | Documentation helps ensure that changes in status can be detected and interventions made promptly to help prevent falls. |
| Incorporate a fall risk assessment tool into patient’s plan of care. Include appropriate interventions, specific-to-patient lifting/transferring/mobilization aids and techniques, and appropriate amount of assistance. Update as appropriate with changes in patient status. | Assessment and documentation of patient’s fall risk via an armband, identifying wall placard, and/or care plan provides added insurance in helping prevent injury to patient resulting from falls. |
| Assist patient as needed when unsteady gait, weakness, or paralysis is noted. Instruct patient to ask or call for assistance with ambulation. Frequently check on patients who may forget to call for assistance. Stand on patient’s weak side to assist with balance and support. Use transfer belt for safety. Instruct patient to use stronger side for gripping railing when stair climbing or using a cane. | These measures minimize risk of falls by providing assistance and surveillance. |
| Orient patient to new surroundings. Keep necessary items (including water, snacks, phone, call light) within easy reach. | These measures minimize risk of falls as a result of strange environment, unfamiliarity with such items as call light, and need to walk to get them. |
| Assess patient’s ability to use these items. | Patients who are very weak or partially paralyzed may require a tap bell or specially adapted call light. |
| Maintain an uncluttered environment with unobstructed walkways. Ensure adequate lighting at night (e.g., provide a night light) to help prevent falls in the dark. In addition, keep side rails up and bed in its lowest position with bed brakes on. | These measures promote safety by ensuring better sensory acuity. |
| Encourage patient to use any needed hearing aids and corrective lenses when ambulating. | These measures minimize risk of tripping, falls in the dark, or injury from inability to see or hear. |
| For unsteady, weak, or partially paralyzed patient, encourage use of low-heel, nonskid, supportive shoes for walking. Teach use of a wide-based gait. | These measures minimize risk of falls in patients with special needs. |
| Instruct patient to note foot placement when ambulating or transferring. | This action ensures that the foot is flat and in a position of support before patient ambulates and transfers. |
| Teach, reinforce, and encourage use of assistive device, such as a cane, walker, or crutches. | These devices provide added stability. |
| Teach exercises that strengthen arm and shoulder muscles for using walkers and crutches. Teach safe use of transfer or sliding boards. Teach patients in wheelchairs how and when to lock and unlock wheels. | These actions promote added stability and safety. |
| Demonstrate how to secure and support weak or paralyzed arms. | These actions help prevent subluxation and injury from falling into wheelchair spokes or wheels. |
| Suggest that patients with poor sitting balance may need a seat or chest belt, H-straps for leg positioning, and a wheelchair with an anti-tip device. | Such devices likely will prevent patients with poor sitting balance from falling or tipping the wheelchair. |
| Teach patient to maintain sitting position before assuming standing position for ambulating. | Maintaining this position for a few minutes gives patient time to get feet flat and under self for balance and minimizes any dizziness that may occur because of rapid position changes. |
| Monitor spasticity, antispasmodic medications, and their effect on physical function. | Uncontrolled or severe spasms may cause falls, whereas mild to moderate spasms can be useful in activities of daily living (ADLs) and transfers if patient learns to control and trigger them. |
| Review with patient and significant other potential safety needs at home. | Such measures include safety appliances (wall, bath, toilet grab rails; elevated toilet seat; nonslip surface in bathtub or shower). Loose rugs should be removed to prevent slipping and falling. Temperatures on hot water heaters should be turned down to prevent scalding in the event of a fall in the shower or tub. Furniture in the home may need to be moved to provide clear, safe pathways that avoid sharp corners on furniture, glass cabinets, or large windows patient could fall against. Strategically placed additional lighting also may be needed. Edges of steps in the home may require taping with brightly colored strips to provide sufficient contrast so that edges can be recognized and more safely negotiated. Beds should be modified to prevent rolling. Activity should be balanced with rest periods because fatigue tends to increase unsteadiness and potential for falls. Ramps may need to be used instead of stairs. |
| Seek referral for physical therapist (PT) as appropriate. | Patient may have special needs that cannot be met by nursing staff. |
Only gold members can continue reading. Log In or Register to continue
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
