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Department of Medical Nursing, Faculty of Nursing, Chiang Mai University
Teaching Material for 561314: Adult Nursing II
For International Program Nursing Students
Semester I Academic Year 2007
Principle of Holistic of Nursing Care for Adult with Common Problem in the Patients with Neurological System and Family
Dr. Pratoom Soiwong
Assist. Prof. Dr. Nitaya Pinyokham
Objectives: At the end of this session the students would be able to
1. Identify the causes and pathophysiology of common problems in neurological system
2. Pinpoint the nursing assessment of patients with common problems in neurological system
3. Identify nursing diagnosis of patients with common problems in neurological system
4. Specify nursing activities and reasons of each common problem in patients with neurological system
CONTENT
1. Cognitive system
Cognition and memory, the ability to concentrate and attend, elaboration of thought are controlled by prefrontal area. The "Gatekeeper"; (judgment, inhibition), personality and emotional traits.
A cognitive system response for the control and integration of the body’s many activities, including memory, using and understanding language, and intellectual function. Common problems in the cognitive system include alteration of consciousness, seizure, alteration cognitive function and thought process, impaired verbal communication. The details will be described as follows:
1.1 Unconsciousness
Consciousness involves two aspects: arousal and content. The arousal component of consciousness refers to a state of wakefulness dependent of the activity of the reticular activating system (RAS), a network of nerve fibers and cell bodies that is located in the reticular formation in the central part of brainstem and has neural connections to many parts of the nervous system. An intact RAS can maintain a state of wakefulness, even in the absence of a function cortex. The content component of consciousness refers to the ability to reason, think, and feel and to react to stimuli with purpose and awareness. These activities are mediated by the cerebral hemispheres, commonly called the higher centers. Intellect and emotional function are also controlled by these centers. Interruption of impulses from the RAS or alteration of the functioning of the cerebral hemispheres can cause unconsciousness. Any condition that markedly alters the function of the hemispheres or that depresses or destroys the upper brainstem events can result in unconsciousness.
Unconsciousness can be brief, lasting for a few seconds, to an hour or so, or sustained, lasting for a few hours or longer. To produce unconsciousness, a disorder must (1) disrupt the ascending reticular activating system, which extends the length of the brainstem and up into the thalamus; (2) significantly disrupt the function of both cerebral hemispheres; or (3) metabolically depress overall brain function, such as drug overdose. Three kinds of disorder produce sustained unconsciousness.
1.1.1 Structural causes of unconsciousness include brain tumors, head trauma, and cerebral hemorrhage including epidural and subdural hematomas. These types of lesions destroy the reticular activating system or place pressure on brain tissues.
1.1.2. Metabolic cause. Metabolic disorder and diffuse lesions that impair the cerebrum and arousal functions by reducing the supply of oxygen or allowing waste products to accumulate. There are many metabolic cause of coma. The term metabolic is used to describe problems that do not originate in the brain but begin in another system and eventually cause a disorder in the nervous system. Hypoxia is a common cause of metabolic brain disorder Blood loss, height above sea level, or carbon monoxide poisoning may deprive the brain of oxygen. Ischemia, inadequate tissue levels of oxygen, may occur with cardiac disorders in which cardiac output is decreased, such as cardiac arrest or even fainting. Disorder of the liver, lungs, and kidney may produce coma because of the accumulation of metabolic wasted product. Finally, there are many agents that affect the metabolism of neurons, They included toxins; hypoglycemia; fever; infections, such as encephalitis; and fluid electrolyte, or acid-base imbalance.
1.1.3 Psychogenic causes, in which case the patients looks comatose but his or her self-awareness is usually intact, as is in catanotnia and hysteria.
Pathophysiology
Only physiologic causes of coma are described here.
Masses within the brain alter the function of the brain in many ways. Masses or lesions, whether they are growing tumors, edema, or bleeding, place pressure on the brain. Because the brain is enclosed in the cranium, there is no space with in the skull for the expending brain. Pressure slows blood and cerebrospinal fluid flow in than out to the brain and reduces cerebral function. The level of consciousness and ability to move purposefully are affected. When pressure reaches the diencephalons or brainstem, vital function such as heart rhythm and respiration are affected The patients’ outcome depends on the location of the mass, the size and rate of enlargement, and the amount of edema and necrosis in brain tissues. A blow to the head can cause brain lacerations or contusions because the brain is hit and strikes the bony cranium. In addition, the brain can suffer diffuse injury as tissues are torn and sheared.
Metabolic disorders producing coma do so through various mechanisms, Infections for the brain, such as encephalitis, cause inflammations of the meninges and brain tissues. Hyperglycemia and hypoglycemia starve the cells of needed glucose for metabolism. Overdoses of sedative drugs suppress the control nervous system (CNS), special the center for breathing. Failure of the liver, kidney, and lungs allows
metabolic waste to accumulate; this wasted poisons the neurons.
Clinical manifestations
1. Changing in level of consciousness. From the normal alert state, consciousness deteriorates in stage, with each stage having its own definition.
Fully consciousness. A patient who is awake, alert, and fully oriented to self, other, place, and time is considered to be fully consciousness.
Confusion is the loss of the ability to think rapidly and clearly; an impairment in judgment and decision-making.
Lethargy or drowsiness is restriction in activity related to a decreased level of alertness. The patient is easily aroused by speech or touch by returns to lying quietly or sleep when not stimulated.
Stupor is a condition of deep sleep or unresponsiveness from which a patient may be aroused only with forceful or shouting stimulation. Patients response by withdrawing from or capture at the source of pain.
Semicoma is condition of unresponsiveness from which a patient may be aroused only with painful stimulation, such as placing a pencil or pen across the fingernail bed and applying firm pressure produces a constant noxious stimulus and a minimal amount to tissue trauma, sternal rub, or compression, supraorbital pressure, pinching various parts of the extremity or trunk.
Coma is condition of no motor or verbal response to the environment or any stimuli, even deep pain or suctioning or other noxious (irritating, hurtful) stimuli.
2. Breathing pattern. Disorder causing coma and decreased levels of consciousness commonly caused respiratory abnormal. Rapidly expanding lesions in the cerebrum, brainstem, or cerebellum may lead to compression of the pons and medulla, which leads to respiratory failure.
3. Eye movement and pupillary changes. Eye movements in the comatose patient are uncoordinated, and pupillary response is abnormal.
4. Motor response. The patient may exhibit some abnormal motor movement and postures. When the intracranial pressure is increased at the cortical level, abnormal flexion (decorticate) posturing is seen as flexion of the arms, wrists, and finger with the arm adducted at the shoulder. The legs are fully extended and internally rotated. As the pressure increase to the level of the upper pons, abnormal extension (decereration) posturing occurs. In this posture, the legs are extended abnormally, similar to decorticate posturing. The arm are extended stiff and adducted and the hands are hyperpronated. Decerebrate posturing is a serious sign than decorticate.
5. Change in vital sign. Some changes related directly to cause of the unconsciousness. Some conditions causing coma produce autonomic nervous system instability because impairment of the hypothalamus. These disorders may cause a wide variations in blood pressure, pulse, and body temperature.
Nursing management
Nursing diagnoses for patient with unconsciousness
· Altered tissue perfusion related to cerebral tissue swelling (as manifested
by mental state, intracranial pressure > 20 mmHg, decreased cerebral blood flow or oximetry).
· Ineffective airway clearance related to unconsciousness and inability to
mobilized secretions (as manifested by ineffective cough, inability to clear secretion, crackles on auscultation, thick secretions).
· Risk for aspiration related to lack of effective airway clearance and loss
of gag reflex.
· Risk for impaired skin integrity related to nutrition deficit, immobility,
self-care deficit.
· Altered nutrition: less than body requirements related to inability to eat
or swallow.
· Risk for injury related to unconsciousness and inability to immobilize.
· Risk for fluid volume deficit
· Risk for contractures related to disuse.
· High risk fro impaired skin integrity related to fecal incontinence.
· Risk of infection related to immobility, invasive monitoring devices and
lines, and compromised immune system.
· Altered family processes related to uncertain future or coming death of
a family member.
Nursing Interventions
Initial
· Ensure patent airway.
· Administration oxygen via nasal canular or non-rebreather mask.
· Establish IV access with one large-bore catheter and normal saline.
· Administration IV naloxone if narcotic overdose suspected.
· Administration Thiamine to malnourished or known alcoholic patient
to prevent Wernicken’s encephalopathy.
· Administration one vial 50 % dextrose if blood glucose < 60 mg/dl
· Elevate head of bed or position on side to prevent aspiration (unless
trauma involved).
Ongoing monitoring
· Monitoring vital signs, level of consciousness, oxygen saturation,
cardiac rhythm, Glasgow Coma Score, pupil size and reactivity, respiratory status.
· Anticipate need for intubation if gag is absent.
· Anticipate gastric lavage if drug overdose in suspected.
1.2 Seizure disorder and epilepsy
A seizure is an involuntary behavior that occurs abnormally and is generally associated with epilepsy, but can come from other sources. Epileptic seizures are categorized by the location in the brain from which they originate and the two main categories of epileptic seizures are "partial" and "generalized." Partial seizures begin in a discreet area of the brain. A simple partial seizure causes no change in consciousness. The patient may have weakness, numbness and unusual smells or tastes. Sometimes, there is twitching of the muscles or limbs, head turning from side to side, paralysis, sight changes or vertigo.
Complex partial seizures occur in the temporal lobe and consciousness is altered. The patient usually has a change in their ability to interact with their environment and may exhibit automatic behaviors such as walking in a circle, sitting and standing, or smacking their lips. Often, odd thoughts occur to the patient, such as a feeling of déjà vu or uncontrollable laughing or odd smells.
Generalized seizures take place in larger areas of the brain and there are many sub-types. Grand mal seizures include specific movements of the arms and legs or face and may occur with a loss of consciousness. Sometimes there is yelling or crying before the person faints. They may also experience an aura, which is an unusual feeling that often warns the patient that seizure is coming on. The patient abruptly falls and begins to jerk and may become incontinent or drool or bite their tongue. This type of seizure usually lasts between 5 and 20 minutes and the patient may awake in a confused state or may sleep for a while. Sometimes, the patient has prolonged weakness after the event.
Petit mal seizures include a brief loss of consciousness but there is not associated motor dysfunction and there is no aura prior to the seizure. Sometimes it just seems that the person is briefly stopping what they were doing, staring for a few seconds, and then continuing with their activity. The patient does not even have any memory of the event (http://www.wisegeek.com/how-is-epilepsy-treated.htm).
Pathophysiology: Seizures are paroxysmal manifestations of the electrical properties of the cerebral cortex. A seizure results when a sudden imbalance occurs between the excitatory and inhibitory forces within the network of cortical neurons in favor of a sudden-onset net excitation. If the affected cortical network is in the visual cortex, the clinical manifestations are visual phenomena. Other affected areas of primary cortex give rise to sensory, gustatory, or motor manifestations. The pathophysiology of partial-onset seizures differs from the mechanisms underlying generalized-onset seizures. Overall, cellular excitability is increased, but the mechanisms of synchronization appear to substantially differ and are therefore discussed separately.
Complications
· Status epilepticus is a state in which seizures recur in rapid succession
and the patient does not regain consciousness or normal function between seizures. It is the most serious complication of epilepsy and a neurologic emergency. Status epilepticus can involve any type of seizures. During repeated seizures, the brain use more energy than can be supplied. Neuron become exhausted and cease to function. Permanent brain damage may result.
· Tonic-clonic status epilepticus is the most dangerous because it can
cause ventilatory and systemic acidosis, all of which can be fatal. Another complication of epilepsy is severe injury and even death from trauma suffered during seizure. Patient who lose consciousness during a seizure are at greatest risk. Death can result from head injury incurred in a fall, from sinking in the bathtub, or from severe burns.
Nursing management
Nursing diagnosis
Nursing diagnoses for the patient with seizure may include, but are not limited to, these are presented as follow:
1. Ineffective breathing related to neuromuscular impairment secondary to prolonged tonic phase of seizure or during postictal (as manifested by abnormal respiratory rate, rhythm, or depth).
2. Ineffective airway clearance related to tracheobronchial obstruction (as manifested by ineffective cough, inability to remove secretions, absence or abnormal breath sound).
3. Risk for injury related to seizure activity and subsequent impaired physical mobility secondary to postictal weakness or paralysis.
4. Ineffective individual coping related to perceived loss of control and denial of diagnosis as manifested by verbalizations about not having epilepsy, lack of truth-telling regarding seizure frequency, noncompliant behavior.