I.
Altered Level of Consciousness
Assessment
1. Start with Verbal Response by determining patient’s orientation to time, person, and place.
Planning:
1. Altered LOC = complications related to immobility
2. Must normalize breathing, protect from injury, help return reflexes, attain fluid volume balance,
normal skin integrity etc.
Intervention
• Priority must always be to maintain a patent airway + intubate or tracheostomy.
1. CN X and XII Problem = No Swallowing Reflex >> Accumulation of Secretion >> Airway Problem
• Elevate head to 30 degrees to prevent aspiration
• Suctioning (ventilated first to prevent hypoxia)
• Chest physiotherapy and postural drainage
• Auscultate Q8H
2. Mouth Care: Move tube daily to opposite side to prevent ulceration.
II. Increased Intracranial Pressure
Intracranial Pressure or ICP
- NV: 5-15mmHg; measured in the lateral ventricle with a ventriculostomy or intraventricular catheter
monitoring device (must use aseptic technique to prevent infection)
o Report if CSF drainage is cloudy or with blood
- Affected by the Monro-Kelle Hypothesis;
o ICP is affected by three components: (1) Brain, (2) CSF, (3) Blood. If one increases, the
other two decrease.
Increased ICP
- A true emergency; commonly associated with head injury.
o Other Causes
1. Hemorrhage or Cerebral Edema
2. Expanding Intracranial Lesion (Hematoma or Tumor)
3. Stroke (Ischemic or Hemorrhagic)
- Caused decrease in cerebral perfusion (must not be below 70) > stimulates further cerebral edema
o May shift brain tissue to spinal cord; high to low (brain herniation) – a dire fatal event.
▪ That’s why Lumbar Puncture is contraindicated with increased ICP
o Leads to decreased Cerebral Blood Flow (CBF) >> Ischemia >> Infarction >> death
- Carbon Dioxide Role:
o Too much carbon dioxide (in cases of acidosis) will cause cerebral vasodilation, in which the
carbon dioxide will permeate the brain, increasing CBF, further increasing the ICP.
▪ Intervention: Hyperventilation >> Vasoconstriction > Limit Blood Flow and CO2
- Autoregulation
o Compensatory mechanism of brain to change the diameter of blood vessels to maintain
CBF.
Early Manifestation:
1. Altered LOC (3-RCDD)
a. Restlessness c. Drowsiness
b. Confusion d. Disorientation
2. Pupillary changes and impaired extraocular movement rt pressure in CN II, III, IV, & VI.
3. Weakness in one extremity or one side of body rt compressed pyramidal tracts.
4. Headache (constant) rt pressure and stretching of venous and arterial vessels in base of brain.
Late Manifestation:
1. Cushing’s Response – High BP, Low RR, Low HR, Wide Pulse Pressure
2. Cheyne-Stokes Breathing (hyperventilation) rt increased pressure in frontal lobes.
3. Stuporous
4. Hemiplegia
5. Projectile Vomiting and nausea rt vagus nerve
6. Abnormal Motor Responses
a. Decortication – extreme flexion
b. Decerebration – extreme extension
Diagnostics:
1. MRI and CT Scan – most common diagnostic tests
2. Transcranial Doppler – provides CBF information
3. NO LUMBAR PUNCTURE
Complication (3-BDS)
1. Brain Stem Herniation
2. Puts pressure on Pituitary Gland which causes:
a. Diabetes Inspidius
b. SIADH
Medical Management:
1. Decreased Cerebral Edema – assess fluid status
o Mannitol (Loop Diuretics) – increases urine output
o Head elevation to 30 degrees and neutral head alignment.
o Hypertonic Saline (3%)
o Fluid restriction
o Lower body temperature – to reduce O2 and metabolic requirements of the brain.
▪ Hypothermia Blanket and prescribed Antipyretic.
▪ Shivering rt increased oxygen consumption, decreased brain oxygenation.
2. Lower CSF volume
o Prevent Hypercapnia
▪ Hyperventilation: but must maintain PaCO2 to 30-35 mmHg through ventilation.
3. Decrease cerebral blood volume while maintaining cerebral perfusion
o Positioning:
i. Midline/Neutral Head position – promote venous drainage
ii. Elevate head to 30 degrees
iii. Don’t flex neck too much > compresses JV > increases ICP
iv. Don’t flex hip > increase intra-abdominal pressure > increase ICP
o Avoid Valsalva maneuver (produced by straining, defecating, moving in bed)
i. Give stool softeners > decrease ICP
ii. Exhale when moving to avoid Valsalva.
iii. Logroll when moving (small pillow between legs)
4. Maintain Oxygenation and Reduce Metabolic Demands
o High Doses of Barbiturates if unresponsive to treatment
o Sedation
o Suction – should not last longer than 15 or 10 seconds
▪ Must hyperventilate first using 100% oxygen.
Nursing Diagnosis:
1. Impaired Breathing rt brain stem compression from increased ICP
2. Risk for ineffective tissue perfusion rt effects of increased ICP
3. Hypovolemia associated with fluid restriction (intervention rt cerebral edema)
4. Risk for infection rt ICP monitoring system (must be aseptic)
CPP: 60-100 mmHg
- MAP – ICP
- MAP = SBP + (2 x DBP) // 3
ICP: 5-15 mmHg
III. Headache
Triptans
- First-line treatment for moderate to severe migraine pain.
- Contraindicated with ischemic heart disease
IV. Seizures
Triggers:
1. Stress 6. Fever – especially in childhood; fever
2. Alcoholic Beverage reduces blood supply to the brain. give
3. Electrical shocks phenobarbital
4. Caffeine 7. Hyperventilation
5. Constipation 8. Hypoglycemia
Before Seizure
1. Must always prepare (2-EI)
a. EKG
b. IV (For meds and fluid)
During Seizure – priority is “SAFETY”
1. First things that patient does in seizure 5. Loosen constrictive clothing and remove
a. Movement or stiffness begins eyeglasses
(tonic) 6. Aura – insert oral airway.
b. Conjugate gaze position 7. Remove anything around the environment
c. Position of the head 8. Don’t attempt to open jaw or insert
2. Provide privacy anything
3. If in bed, remove pillows and raise side 9. Don’t restrain
rails 10. Place patient on one side with head flexed
4. Protect head and ease patient to floor if forward, allowing the tongue to fall forward
possible and facilitating the drainage of saliva and
mucus
After Seizure Management
1. Prevent complications – place patient in side-lying or sims position to facilitate drainage.
a. Aspiration – sims and suction; must maintain patent airway
b. Hypoxia
c. Vomiting
2. Seizure-precautions
a. Bed in low position
b. Patient in sims position
c. Side rails up
d. Padded floor for additional safety measure
3. Once awakened
a. Reorient patient to surrounding
b. Patient will be in post-ictal phase: confusion, agitated
Diagnostics: EEG
To prevent epilepsy: most common cause, Head Injury (must be prevented)
Nursing Diagnosis:
1. Risk for injury rt to seizure activity
2. Fear associated with possibility of seizures
3. Difficulty coping associated with stress rt to epilepsy
4. Lack of knowledge aw epilepsy and anticonvulsant meds
Complications
1. Status Epilepticus
o Acute prolonged seizure activity; Seizure lasting 5 minutes or longer; emergency
o EEG to determine nature
o Management:
▪ Patent airway + endotracheal tube
▪ IV diazepam, lorazepam, fosphenytoin
▪ For maintenance of seizure free state: Phenytoin and Phenobarbital
2. Anticonvulsant meds toxicity – never discontinue nor overdose; have levels check regularly.
a. Phenytoin
▪ Considerations: Give proper oral care rt side effect which is damage to gums.
▪ Toxic Effects: Ataxia, Confusion
Epilepsy
- Causes
o Febrile State
o Metabolic State
o Toxins
Partial Seizures
- Transient; one part of the brain
- SIMPLE MOTOR, FOCAL MOTOR – one area, JACKSONIAN – spreads to adjacent parts
- Manifestations:
o Stiffening or jerking of a limb of one side of the face.
o Head turning
o Butterflies in stomach
- Partial Sensory Seizure:
o Numbness and tingling on any area (parietal)
o Bright lights, flashing lights (occipital)
o Difficulty speaking or total speech arrest (posterior temporal)
- Complex/Psychomotor Partial Seizure
o Anterior temporal lobe begins with aura
o Behavioral, emotional, affective, and cognitive functions
o Altered LOC
Form of Generalized Seizure:
1) Grand Mal Seizure or Tonic Clonic Seizure
▪ Tonic Phase
o Stiffening -> Epileptic Cry
o Jaw is Clenched, arms and legs are extended, opisthotonic position
o Urinary incontinence
o Breathing cessation -> cyanosis
o Pupils fixed and dilated
▪ Clonic Phase
o Muscle Rigidity - Alternating contraction
o Hyperventilation
o Eyes roll back
o Client froths in the mouth
V. Head Injuries
Frontal lobe – most commonly injured
Coup – damage; primary impact
Contracoup “Counter Blow”– damage at the back of the brain
Open Head Injury – susceptible to infection and bleeding
Closed Head Injury – confusion, concussion, laceration
Comminuted Fracture – skull is crushed into fragmented pieces
Depressed Fracture – inward depression of bone fragments
Signs and Symptoms:
a. Racoon’s Eyes – bilateral periorbital ecchymosis
b. Battle’s Sign – ecchymosis over the mastoid bone
c. Blood Behind Eardrums – hemotympanum
d. Cranial Nerve injures – CN 2 (optic), 5 (abducens), 7 (facial)
e. Injury to the internal carotid artery
Nursing Diagnosis
1. Risk for infection rt open head injury
2. Pain r/t Traumatic Skull Injury
3. Risk for Ineffective Breathing
4. Risk for Altered Cerebral Tissue Perfusion
5. Risk for Ineffective Thermoregulation
6. Altered Thought Process
