NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Neurologic Dysfunction

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: The Unconscious Client

Focus topic: Medical–Surgical Nursing

 

Definition: Unconsciousness is a state of depressed cerebral functioning with altered sensory and motor function.

Medical–Surgical Nursing: Assessment

A. Possible causes: vascular disorders, intracranial mass, head trauma, cerebral toxins, metabolic disorders, acute infection.

  • Intracranial.
    a. Supratentorium mass/lesion compressing or displacing brain stem.
    b. Infratentorium destructive lesions.
  • Extracranial.
    a. Metabolic encephalopathy (most common).
    b. Psychiatric conditions.

B. Glasgow Coma Scale below provides objective, consistent way to monitor client’s neurological condition.

  • Comatose state based on three areas associated with level of consciousness.
  • Scoring system.
    a. Based on a scale of 1 to 15 points.
    b. Any score below 8 indicates coma is present; the lowest score, 3, indicates severe impairment or that the client may be deceased.
  • Eye opening is the most important indicator.

C. Respiratory function and airway patency.
D. Adequate circulation.
E. Fluid and electrolyte balance.

Medical–Surgical Nursing

Medical–Surgical Nursing: Implementation

A. Maintain open airway and adequate ventilation.

  • Check for airway obstruction.
    a. May result in retention of carbon dioxide (with cerebral vasodilation, edema, and increased intracranial pressure).
    b. Hypoxia (with potential irreversible brain damage).
  • Monitor respiratory signs and symptoms continuously.
    a. Color, chest expansion, deformities.
    b. Rate, depth, and rhythm of respirations.
    c. Air movement at nose/mouth or through endotracheal tube.
    d. Breath sounds, adventitious sounds.
    e. Accumulation of secretions or blood in mouth.
    f. Signs of respiratory distress: hypoxemia, hypercapnia, or atelectasis.
  • Provide airway.
    a. Head tilt; modified jaw thrust if cervical injury suspected.
    b. Cuffed endotracheal or tracheostomy tube (maintain airway, avenue for suctioning and/or mechanical ventilation).
    c. Assisted ventilation if necessary.
  • Position client to facilitate breathing.
    a. Side-lying or semiprone (to prevent tongue from occluding airway and secretions from pooling in pharynx).
    b. Frequent change of position.
  • Provide pulmonary toilet.
    a. Deep breathing and coughing if not contraindicated.
    b. Suctioning of secretions as necessary.
  • Have emergency equipment available.

B. Maintain adequate circulation.

  • Blood pressure.
    a. Hypertension—result of increased intracranial pressure.
    b. Hypotension—result of immobility.
  • Pulse.
    a. Check quality and presence of all pulses.
    b. Check rate and rhythm of apical and/or radial pulse.
    c. Hypoxia may cause arrhythmias
    d. Usually premature ventricular contractions.

C. Monitor neurological status.

  • Level of consciousness.
  • Pupillary signs.
  • Motor function.
  • Sensory function.

D. Maintain nutrition, fluid and electrolyte balance.

  • Keep client NPO while unconscious (check for gag and swallowing reflexes).
  • Give intravenous fluids, hyperalimentation as required—check for dehydration.
  • Use caution with IV rates in presence of increased intracranial pressure.
  • Record intake, output, and daily weight.
  • Maintain oral and nasal hygiene.
  • Resume oral intake carefully as consciousness returns.
    a. Check gag reflex.

b. Use ice chips or water as first liquid.
c. Keep suction equipment ready.

E. Promote elimination.

  • Urinary: retention catheter.
    a. Maintain daily hygiene of meatus.
    b. Ensure patency to prevent bladder distention, urinary stasis, infection, and urinary calculi.
    c. Evaluate amount, color, consistency of output; check specific gravity.
  • Bowel: suppositories and enemas.
    a. Establish routine elimination patterns.
    b. Observe for complications.
    c. Check for paralytic ileus.
    (1) Abdominal distention.
    (2) Constipation and/or impaction.
    (3) Diarrhea.

F. Maintain integrity of the skin.

  • High risk of pressure ulcers due to:
    a. Loss of vasomotor tone.
    b. Impaired peripheral circulation.
    c. Paralysis, immobility, and loss of muscle tone.
    d. Hypoproteinemia.
  • Loss of sensation of pressure, pain, or temperature—decreased awareness of developing pressure ulcers or burns.
  • Monitor for edema: dependent areas.
  • Skin care.
    a. Clean and dry skin; avoid powder because it may cake.
    b. Massage with lotion around and toward bony prominences once a day if area is not red.
    c. Alternate air fluidized therapy bed with egg crate mattress.
    d. Keep linen from wrinkling; avoid mechanical friction against linen.
    e. Turn client every 2 hours; position with pillows to protect pressure on bony prominences.

G. Maintain personal hygiene.

  • Eye: Loss of corneal reflex may contribute to corneal irritation, keratitis, blindness.
    a. Assess corneal reflex and signs of irritation.
    b. Instill artificial tears or close eyelids and cover with moistened pads to protect cornea.
  • Nose: Trauma or infection in nose or nasopharynx may cause meningitis.
    a. Observe for drainage of CSF.
    b. Clean and lubricate nares; do not clean inside nostrils.
    c. Change nasogastric (NG) tube per policy and prn.
  • Mouth: Mouth breathing contributes to drying and crusting excoriation of mucous membranes, which may contribute to aspiration and respiratory tract infections.
    a. Examine the mouth daily with a good light.
    b. Clean teeth, gums, mucous membranes, tongue, and uvula to prevent crusting and infection; lubricate lips.
    c. Inspect for retained food in the mouth of clients who have facial paralysis; follow with mouth care.
  • Ear: Drainage of CSF from the ear indicates damage to the base of the brain and a danger of meningitis.
    a. Inspect ear for drainage of CSF; if clear drainage tests positive for glucose (using a Labstix), drainage is CSF. Notify physician immediately.
    b. Loosely cover ear with sterile, dry dressing.

H. Maintain optimal positioning and movement.

  • Prevent further trauma.
    a. Maintain body alignment, support head and limbs when turning, logroll.
    b. Do not flex or twist spine or hyperextend neck if spinal cord injury is suspected.
  • Provide adequate positioning.
    a. Disuse of muscle leads to contractures, osteoporosis, and compromised venous return.
    b. Maintain and support joints and limbs in most functional anatomic position.
    c. Avoid improper use of knee gatch or pillows under knee.
    d. Use a foot-board or high-top sneakers to prevent foot-drop. If sneakers are used, be sure to remove daily and inspect feet.
  • Avoid complete immobility.
    a. Perform range of motion (against resistance if possible), weight bearing, and/or tilt table.
    b. Change position every 2 hours.

I. Provide psychosocial support for client and family.

  • Assume that an unconscious client can hear; frequently reassure and explain procedures to client.
  • Encourage family interaction.

J. Institute safety precautions.

  • Use side rails at all times.
  • Remove dentures and dental bridges.
  • Remove contact lenses.
  • Avoid restraints.
  • Do not leave client who is unstable unattended for more than 15–30 minutes.
  • Keep tongue blade at bedside.

Medical–Surgical Nursing: Increased Intracranial Pressure

Focus topic: Medical–Surgical Nursing

Definition: An increase in intracranial bulk due to blood, CSF, or brain tissue leading to an increase in pressure. Can be caused by trauma, hemorrhage, tumors, abscess, contusion, hydrocephalus, edema, inflammation, or metabolic insult to the body. This is a potentially life-threatening situation because it diminishes cerebral perfusion pressure (CPP), increases the risks of brain ischemia and infarction, and is linked to a poor prognosis.

Medical–Surgical Nursing: Assessment

A. Level of consciousness (LOC): most sensitive indication of increasing intracranial pressure (ICP)—changes from restlessness to confusion to declining level of consciousness and coma.

  • Orientation to person, place, purpose, time.
  • Response to verbal/tactile stimuli or simple commands.
  • Response to painful stimuli: purposeful/ nonpurposeful, decorticate, decerebrate, no response.

B. Respiration: rate, depth, and rhythm are more sensitive indications of intracranial pressure than blood pressure and pulse—abnormal breathing patterns associated with ICP.

  • Cheyne–Stokes—rhythmically waxes and wanes, alternating with periods of apnea.
  • Neurogenic hyperventilation.
    a. Sustained regular, rapid, and deep.
    b. Low midbrain, middle pons.
  • Apneustic—irregular breathing with pauses at end of inspiration and expiration.
  • Ataxic (Biot’s)—totally irregular, random rhythm and depth.
  • Apnea may occur.

C. Headache—tension, displacement of brain.
D. Vomiting—irritation of vagal nuclei in floor of fourth ventricle; may be projectile.
E. Pupillary changes.

  • Unilateral dilation of pupil; slow reaction to light (light reflex is most important sign differentiating structural from metabolic coma).
  • Unilateral, fixed, dilated pupil is ominous sign requiring immediate action—may indicate transtentorial herniation of the brain.

F. Motor function—weakness, hemiplegia, positive Babinski, seizure activity.

  • Assessment of posturing in response to noxious stimuli.
    a. Decorticate—nonfunctioning cortex, internal capsule (upper-extremity flexion, and may stiffen and extend legs).
    b. Decerebrate—brain stem lesion (total stiff extension of one or both arms and legs).

G. Pulse and blood pressure.

  • Monitor for trends; changes are often unreliable and occur late with increasing intracranial pressure.
  • Rise in blood pressure, widening pulse pressure; reflex slowing of pulse.
    a. Cushing’s triad—when systolic pressure rises and pulse slows but is more forceful. Tells you ICP is rising but body is coping, irregular respirations. Cushing’s triad is a medical emergency as it is the sign of brain stem compression and impending death.
    b. When systolic pressure drops (below 50 mm Hg) and pulse becomes irregular, thready, and rapid, body is no longer coping—danger.

H. Hyperthermia—possible complication—can signal infection, hemorrhage, or traction on the hypothalamus or brain stem.

Medical–Surgical Nursing

Medical–Surgical Nursing: Implementation

A. Acute phase: surgical management.

1. ICP monitoring.

a. Used to guide clinical plan of care and treatment for clients at risk for or who have increased ICP. Should be used if Glasgow Coma Scale (GCS) score is < 8 or if client has abnormal CT or MRI.
(1) Methods:
(a) Ventriculostomy: A specialized catheter is placed in the lateral ventricle coupled with an external transducer.
i. To insert an intraventricular catheter, a burr hole is drilled through the skull. This directly measures the pressure in the ventricle and allows for administration of drugs, sampling, and removal of CSF. The intraventricular catheter is thought to be the most accurate method.
ii. The ICP can be monitored this way. The ICP also can be lowered by draining CSF out through the catheter.
iii. The catheter may be hard to get into place when the intracranial pressure is high.
(b) Fiber optic catheter: Uses a sensor transducer located within the tip of the catheter. The catheter is placed within the ventricle or brain tissue. It allows for direct measurement of brain pressure. If an epidural sensor is used, it is inserted between the skull and dural tissue. The epidural sensor is placed through a burr hole drilled in the skull. This procedure is less invasive than other methods, but it cannot remove excess CSF.
(c) Subarachnoid bolt or screw: A hollow screw is inserted through a hole drilled in the skull. It is placed between the arachnoid membrane and the cerebral cortex. This method is used if the client needs to be monitored right away. This allows the sensor to record from inside the subdural space.
b. Complications: Infection is a major and serious complication of ICP monitoring. May give prophylactic antibiotics. Risks for infection increased with:
(1) ICP monitoring > 5 days.
(2) Use of ventriculostomy.
(3) Concurrent systemic infection.
(4) Presence of CSF leak.

B. Acute phase: medical management.

  • Elevate head of bed: 30 or 40 degrees as ordered—this allows gravity to drain cerebral veins.
    a. Avoid Trendelenburg position.
    b. Avoid tilting client’s head, which would impede venous flow through jugular veins.
  • Limit fluid intake; restricted to 1200 mL/day.
  • Maintain normal body temperature—administer Tylenol (acetaminophen) as ordered and temperature-regulating blanket. Prevent shivering, which can raise ICP. Thorazine (chlorpromazine) will control shivering.
  • Administer medications: steroids, osmotic diuretics.
    a. Steroids (Decadron [dexamethasone]) decrease cerebral edema by their antiinflammatory effect and decrease capillary permeability in inflammatory processes, thus decreasing leakage of fluid into tissue.
    b. Histamine blocker (Zantac [ranitidine]) is given concomitantly with steroids to counter excess gastric acid secretion.
    c. Mannitol decreases cerebral edema; provides diuretic action by carrying out large volume of water through nephrons. Sometimes combined with Lasix (furosemide) to increase excretion of water and sodium from kidneys.
    d. Hypertonic IV solution administered because it is impermeable to blood–brain barrier; reduces edema by rapid movement of water out of ventricles into bloodstream.
    e. Sedation may be ordered to counter effects of noxious stimuli of ICP and make client comfortable.
  • Maintain patent airway and administer mechanical ventilation. Maintain PaCO2 at 25–30 mm Hg to cause vasoconstriction of cerebral blood vessels, decrease blood flow, and decrease ICP.
  • revent further complications.
    a. Monitor neurological dysfunction versus cardiovascular shock.
    b. Prevent hypoxia: Avoid morphine—it masks signs of increased ICP.
  • Decrease environmental stimuli: Dim lights, speak softly, limit visitors, avoid routine procedures if client is resting, etc.

C. Chronic phase: surgical management.

  • Ventriculoperitoneal shunt systems (most common). Designed to shunt cerebrospinal fluid from the lateral ventricles into the peritoneum.
  • Preoperative care.
    a. Follow care of client with increased intracranial pressure.
    b. Prepare client for craniotomy if necessary.
  • Postoperative care.
    a. Monitor closely for signs and symptoms of increasing intracranial pressure due to shunt failure.
    b. Check for infection (a common and serious complication). If present, removal of the shunt system is indicated in addition to appropriate chemotherapy.
    c. Position client supine and turn from back to unoperative side.

Medical–Surgical Nursing: Cerebral Edema

Focus topic: Medical–Surgical Nursing

Definition: Swelling of the brain that disrupts the stable relationship of the three components housed in the skull: brain, cerebrospinal fluid, and blood.

Medical–Surgical Nursing: Characteristics

A. Cerebral edema causes the intracranial pressure (ICP) to rise.
B. Characterized by accumulation of fluid in the extracellular space, intracellular space, or both.
C. Regardless of the cause, cerebral edema results in an increase in tissue volume, with the potential to cause ICP.
D. Three types.

  • Vasogenic edema results from increased extracellular fluid—most common type.
  • Cytotoxic edema—the result of local disruption of the functional and/or morphologic integrity of cell membrane. Develops from destructive lesions or trauma to the brain resulting in cerebral hypoxia or anoxia, sodium depletion, syndrome of inappropriate antidiuretic hormone (SIADH) secretion.
  • Interstitial edema, associated with movement of cerebrospinal fluid.

Medical–Surgical Nursing: Assessment

A. Earliest indicator is change in level of consciousness (LOC).

  • Lethargic.
  • Talkative or quiet.
  • Restlessness.
  • Irritability.
  • Nausea and vomiting.
  • Disorientation: first to time, then to place and person.

B. Altered respiratory pattern.
C. Pupillary changes.

  • Unequal pupils.
  • Sluggish response to light.
  • Fixed and dilated pupils.
  • Pupillary dysfunction is first noted on the ipsilateral side.
  • Oculomotor dysfunction—inability to move eyes upward, ptosis of the eyelid.

D. Decorticate or decerebrate posturing.
E. Monitor for late signs of increased ICP.

  • Cushing’s triad: increased systolic blood pressure, widened pulse pressure, and slowed heart rate.
  • Irregular respirations.
  • Rise in temperature.

Implementation
See Nursing Management for Increased Intracranial Pressure.

Medical–Surgical Nursing: Hyperthermia

Focus topic: Medical–Surgical Nursing

Definition: Temperature of 41°C (106°F); associated with increased cerebral metabolism, increasing risk of hypoxia, dysfunction of thermoregulatory center—trauma, tumor, cerebral edema, CVA, intracranial surgery; prolonged exposure to high environmental temperatures— heatstroke; infection.

Assessment
A. Shivering.
B. Respiratory function—ventilation and patent airway.
C. Cardiac function—pulse and rhythm; arrhythmias.
D. Urinary function—color, specific gravity, and amount.
E. Nausea and vomiting.
F. Increased temperature—when very high, seizures.
G. Peripheral pulses for systemic blood flow.
H. Skin and mucous membranes for signs of dehydration.

Implementation
A. Maintain patent airway if temperature is very high.

B. Provide safety measures for possible seizure activity.
C. Monitor fluid balance by observing skin condition, urine output, lung sounds, peripheral pulses.
D. Provide methods for inducing hypothermia.

  • External—cool bath, fans, ice bags, hypothermic blanket (most common).
  • Drugs.
    a. Thorazine (chlorpromazine)—reduces peripheral vasoconstriction, muscle tone, shivering; depresses thermoregulation in hypothalamus.
    b. Demerol (meperidine)—relaxes smooth muscle, reduces shivering.
    c. Phenergan (promethazine)—dilates coronary arteries, reduces laryngeal and bronchial irritation.
  • Extracorporeal—usually reserved for surgery.
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E. Monitor effects of hypothermia.

  • Prevent shivering.
    a. Shivering increases CSF pressure and oxygen consumption.
    b. Treatment: chlorpromazine or meperidine.
  • Prevent trauma to skin and tissue.
    a. Frostbite—crystallization of tissues with white or blue discoloration, hardening of tissue, burning, numbness.
    b. Fat necrosis—solidification of subcutaneous fat, creating hard tissue masses.
    c. Initially give complete bath and oil the skin; during procedure, massage skin frequently with lotion or oil to maintain integrity of the skin.
  • Monitor and prevent respiratory complications.
    a. Hypothermia may mask infection, cause respiratory arrest.
    b. Institute measures to maintain open airway and adequate ventilation.
  • Monitor and prevent cardiac complications.
    a. Hypothermia can cause arrhythmias and cardiac arrest.
    b. Monitor cardiac status and have emergency equipment available.
  • Monitor renal function.
    a. Insert Foley catheter.
    b. Monitor urinary output, blood urea nitrogen (BUN); may monitor specific gravity.
  • Prevent vomiting and possible aspiration; client may have loss of gag reflex and reduced peristalsis.
  • Monitor changes in neurological function during hypothermia.
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