1 / 91

Neurology

Neurology. Management of Patients with Neurological Dysfunction Chapter 61. Nursing management. Ineffective airway clearance r/t alt. LOC HOB h Lateral/semi-prone Suctioning Hyper-oxygenate Chest physiotherapy Postural drainage Auscultate Intubation Mech. vent. Nursing management.

shauna
Télécharger la présentation

Neurology

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Neurology Management of Patients with Neurological Dysfunction Chapter 61

  2. Nursing management • Ineffective airway clearance r/t alt. LOC • HOB h • Lateral/semi-prone • Suctioning • Hyper-oxygenate • Chest physiotherapy • Postural drainage • Auscultate • Intubation • Mech. vent

  3. Nursing management • Risk of injury r/t i LOC • Padded side-rails • Lines & equipment • Restraints • Dignity • Privacy • Speak to pt

  4. Nursing management • Deficient fluid volume r/t NPO • P Skin turgor • P Mucous membranes • I&O • P labs

  5. Question? • Which of the following lab values is most useful in assessing dehydration? • K+ • Na+ • Hematocrit • BUN • Urine specific gravity

  6. Question? • What affect does dehydration have on a pt BUN level? • Increase • Decrease

  7. Question? • What affect does dehydration have on a pt. Hematocrit level? • Increase • Decrease

  8. Nursing management • Impaired oral mucous membranes r/t mouth breathing etc. • P for dryness, inflammation, crusting • Oral care q8h • Lips • Move endotracheal tube each day (rt–lf–rt)

  9. Nursing management • Alt. in nutrition, less than body requires • NGT/GT • HOB h

  10. Question? • Mrs. Jones has an NGT and has 2 medication that need to be given at 12:00 pm. Can the nurse crush the meds and give them at the same time? • Yes • No • Each med is given separate and flush with 20-30 ml of water after each dose

  11. Question? • How do you measure for NGT tube placement? • From the tip of the nose  ear lobe  xyphoid process • From the tip of the nose  ear lobe  xyphoid process + 6 inches • From the ear lobe  tip of the nose  xyphoid process • From the ear lobe  tip of the nose  xyphoid process + 6 inches

  12. Question? • What is the most effective way to check NGT placement? • Inject 20 cc of air and listen for gurgle • Aspirate stomach contents • X-ray

  13. Question? • Mrs. Nop had an NGT placed 7 days ago and is tolerating feeding well. You are assigned to give her a 250 bolus feeding of Ensure. How should you make sure the NGT is in the stomach and not the lung? • Inject 20 cc of air and listen for gurgle • Aspirate stomach contents • X-ray • None of the above are necessary

  14. Nursing management • Risk for impaired skin integrity r/t immobility • Reg. turning • X drag • ROM • Splints • Foam boats • Beds

  15. Nursing management • Impaired tissue integrity of cornea r/t I corneal reflex • Clean • Cotton-ball & normal saline • Cold compress • i edema post-op • Eye patch warning!

  16. Nursing management • Ineffective thermoregulation r/t damage to hypothalamic center • Minimal bedding • Anti-pyretic • Cool sponge bath • Fan • Hypothermic blanket

  17. Nursing management • Impaired urinary elimination (incontinence or retention) • Scan bladder • Retention  Foley • P S&S of infection • Fever • Cloudy urine

  18. Nursing management • Bowel incontinence • Bowel sounds • Abd girth • Monitor BM • Frequency • Consistency

  19. Nursing management • Disturbed sensory perception • Touch • Talk • Orient • Familiar sounds (tape player) • Favorite TV/radio • When arousing from coma  • i stimuli

  20. Nursing management • Interrupted family processes r/t health crisis • Grief process

  21. What’s your advice? • While assessing the patency of a central line for an unresponsive, terminally ill patient, I was startled when the patients wife said to me, “this isn’t how it was suppose to be. He’s just a year away from retirement, and we had wonderful plans to travel across the country.” I didn’t know what to say except, “I’m sorry.” I’d like to do better if this situation come up again. What should I have said?

  22. Small Group Questions • What is the priority nrs dx for a patient with alt. LOC? • Describe cerebral blood flow during suctioning. • How can a nrs best assess for dehydration? • Give 5 nrs interventions for a patient at risk for injury & for impaired joint and skin integrity.

  23. Increased Intracranial Pressure • Rigid vault • Contains 3 components • Brain tissue • Blood • CSF • Normal ICP 10-20 mmHg

  24. I-ICP • Minor changes in ICP • Straining • Coughing • Sneezing • Posture • BP

  25. I-ICP • Etiology of I-ICP • Head injury • Stroke • Inflammatory process • Intra-Cranial surgery

  26. I-ICP • I-ICP Cycle • I-ICP  • i cerebral perfusion  • Ischemia  • Further edema  • Herniation (shift brain tissue)  • Deathmosis

  27. I-ICP • h PaCO2  • Cerebral vasodilatation  • h cerebral blood flow  • h-ICP • i PaCO2  • Cerebral vasoconstriction  • i cerebral blood flow  • i-ICP

  28. I-ICP • Cerebral edema • Abn. h of fluid  • h brain tissue volume  • I-ICP

  29. I-ICP • Compensation • Bodies attempt to i ICP • Cushing’s response • Widening PP • Bradycardia • Decompensation • Ischemia • Infarction

  30. What is the earliest S&S of I-ICP? • Hyporeflexia • Paresethesia • Visual distrubance • Altered level of consciousness • Motor slowing • Pupils fixed

  31. I-ICP • Early S&S • #1 Alt LOC • h restlessness or confusion • H/A • Pupillary changes • Weakness on one side

  32. I-ICP • Late S&S • Stupor  coma • Pulse & Resp • i • Erratic (Cheyne-stoke, ataxic, Biot’s) • BP & Temp • h • Projectile vomiting

  33. I-ICP • Late S&S • Decorticated posturing • Decerebrate posturing • Loss of protective reflexes

  34. Where did it go? • What goes first? • Orientation to time • Orientation to person • Response to verbal stimuli • Response to painful stimuli • Protective reflexes

  35. I-ICP • Ominous sign! • Grave sign!

  36. Complications of I-ICP • Herniation • Diabetes Insipidus • SIADH

  37. I-ICP Dx / Assessment • CT • MRI

  38. I-ICP Management • Monitor ICP • Ventricular catheter • Sub-arachnoid screw

  39. 3 goals of I-ICP management • i edema • i CSF volume • i Cerebral blood volume

  40. I-ICP management • Decrease Edema • Osmotic diuretic • Mannitol/Osmitrol • I&O • Indwelling catheter • P via serum osmolality

  41. I-ICP management • Decrease edema • Corticosteroids • Dexamethasone /Decadrone • S/E • Hyperglycemia • GI bleed • Give with • Antacids / Tums • Histamine H2 receptor blockers / Tagamet (cimetidine)

  42. I-ICP management • Decreasing edema • Fluids • i • HOB • h • Body temperature • Lower • i cerebral edema • i metabolism

  43. I-ICP management • Decreasing CSF • Drain CSF • Via lumbar puncture • Not too much  • Ventricles collapse

  44. I-ICP management • Decrease cerebral blood flow • O2 • Hyperventilate  • Vasoconstriction • Hgb levels • Control fever • Anti-pyretics • Cooling blanket • X shivering  I-ICP

  45. I-ICP management • Decrease cerebral blood flow • Decrease metabolic demand • Induce coma • Phenobarbital • Paralyzing agents • Monitor cardiac • Vent • Monitor ICP • monitor Arterial pressure • Monitor serum barbituate levels

  46. I-ICP management • Decrease cerebral blood flow • Decrease metabolic demand • Prevent Seizures • Phenytoin / Dilantin • Diazepam / valium • Monitor serum levels • Prevent infections • Control BP

  47. I-ICP Nursing Management • Maintain patent airway • Optimizing cerebral tissue perfusion • Position • HOB h • Head neutral position • Avoid extreme hip flexion • X valsalva maneuver  I-ICP • Stool softeners • X emena • Suctioning

  48. I-ICP Nursing Management • Optimizing cerebral tissue perfusion • Calm atmosphere • Space nursing tasks • Minimal stimuli • Monitor ICP

  49. Intracranial surgery • Craniotomy: • Opening the skull surgically to gain access to intracranial structures

  50. Intracranial surgery • Burr hole • Circular opening made in the skull by a drill

More Related