2. Introduction The central nervous system contains a vast network of neurons controlling the body’s vital functions. Yet this system is vulnerable, and its optimal function depends on several key factors. First, the neurologic system relies on its own structural integrity for support and homeostasis. Examples of structural disruption include head injury, brain tumor, intracranial hemorrhage, infection, and stroke. As brain tissue expands in the inflexible cranium, ICP rises and cerebral perfusion is impaired. Further expansion places pressure on vital centers, which can cause permanent neurologic deficits or lead to brain death.

3. Cont… Second, the neurologic system also relies on the body’s ability to maintain a homeostatic environment. It requires the body to deliver the essential elements of oxygen and glucose and to filter out substrates toxic to the neurons. Sepsis, hypovolemia, myocardial infarction, respiratory arrest, hypoglycemia, electrolyte imbalance, drug and/or alcohol overdose, are all examples of circumstances in which the neurologic system is depressed due to a toxic metabolic effect or due to the body’s mechanical inability to provide essential substrates. Some conditions can be treated and neurologic impairments can be reversed; others result in permanent deficits.

4. Cont… Ongoing assessment of the patient’s neurologic function and health needs, identification of problems, mutual goal setting, development and implementation of care plans (including teaching, counseling, and coordinating activities), and evaluation of the outcomes of care are nursing actions integral to the recovery of the patient. The nurse also collaborates with other members of the health care team to provide essential care, offer a variety of solutions to problems, help patients and families gain control of their lives, and explore the educational and supportive resources available in the community. The goals are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family.

5. Altered Level of Consciousness An altered level of consciousness (LOC) is apparent in the patient who is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. Coma is a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years).

6. Clinical manifestations As the patient’s state of alertness and consciousness decreases, there will be changes in the pupillary response, eye opening response, verbal response, and motor response. Initial changes may be reflected by subtle behavioral changes such as restlessness or increased anxiety. The pupils, normally round and quickly reactive to light, become sluggish (response is slower); as the patient becomes comatose, the pupils become fixed (no response to light). The patient in a coma does not open the eyes, respond verbally, or move the extremities in response to a request to do so.

7. Assessment and Diagnostic Findings A complete assessment is performed, with particular attention to the neurologic system. The neurologic examination should be as complete as the LOC allows. It includes an evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The patient’s responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function; a score of 15 indicates that the patient is fully responsive

8. Assessment and Diagnostic Findings Procedures used to identify the cause of unconsciousness include scanning, imaging, tomography (e.g, computed tomography, magnetic resonance imaging, positron emission tomography), and electroencephalography. Laboratory tests include analysis of blood glucose, electrolytes, serum ammonia, and blood urea nitrogen levels, as well as serum osmolality, calcium level, and partial thromboplastin and prothrombin times. Other studies may be used to evaluate serum ketones and alcohol, drug levels, and arterial blood gas levels.

9. Complications Potential complications for the patient with altered LOC include respiratory failure, pneumonia, pressure ulcers, and aspiration. Respiratory failure may develop shortly after the patient becomes unconscious. If the patient cannot maintain effective respirations, supportive care is initiated to provide adequate ventilation. Pneumonia is common in patients receiving mechanical ventilation or in those who cannot maintain and clear the airway. The patient with altered LOC is subject to all the complications associated with immobility, such as pressure ulcers and disturbed gastrointestinal functioning. Pressure ulcers may become infected and act as a source of sepsis. Aspiration of gastric contents or feedings may occur, precipitating the development of pneumonia or airway occlusion.

10. Medical Management The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated, or a tracheostomy may be performed. Until the patient’s ability to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation. The circulatory status (blood pressure, heart rate) is monitored to ensure adequate perfusion to the body and brain. An intravenous catheter is inserted to provide access for fluids and intravenous medications.

11. Medical Management Neurologic care focuses on the specific neurologic pathology, if any. Nutritional support, using either a feeding tube or a gastrostomy tube, is initiated as soon as possible. In addition to measures to determine and treat the underlying causes of altered LOC, other medical interventions are aimed at pharmacologic management of complications and strategies to prevent complications.

12. Nursing process / Assessment Determining the patient’s orientation to time, person, and place assesses verbal response. Alertness is measured by the patient’s ability to open the eyes spontaneously or to a stimulus. The nurse should assess for per orbital edema or trauma, which may prevent the patient from opening the eyes

13. Motor response includes spontaneous, purposeful movement (eg, the awake patient can move all four extremities with equal strength), movement only in response to noxious stimuli (eg, pressure/pain), or abnormal posturing. If the patient is not responding to commands, the motor response is tested by applying a painful stimulus (firm but gentle pressure) to the nail bed or by squeezing a muscle. If the patient attempts to push away or withdraw, the response is recorded as purposeful or appropriate (“patient withdraws to painful stimuli”).This response is considered purposeful if the patient can cross from one side of the body to the other in response to noxious stimuli. An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate The most severe neurologic impairment results in flaccidity.

15. In addition to LOC, the nurse monitors parameters such as respiratory status, eye signs, and reflexes on an ongoing basis. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a systematic and ongoing manner.

16. Nursing process / Diagnosis Ineffective airway clearance related to altered level of consciousness Risk of injury related to decreased level of consciousness Deficient fluid volume related to inability to take in fluids by mouth Impaired oral mucous membranes related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake Risk for impaired skin integrity related to immobility Impaired tissue integrity of cornea related to diminished or absent corneal reflex

17. Ineffective thermoregulation related to damage to hypothalamic center Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control Bowel incontinence related to impairment in neurologic sensing and control and also related to transitions in nutritional delivery methods Disturbed sensory perception related to neurologic impairment Interrupted family processes related to health crisis COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Deep vein thrombosis

18. Nursing process / Planning & Goals The goals of care for the patient with altered LOC include maintenance of a clear airway, protection from injury, attainment of fluid volume balance, achievement of intact oral mucous membranes, maintenance of normal skin integrity, absence of corneal irritation, attainment of effective thermoregulation, and effective urinary elimination. Additional goals include bowel continence, accurate perception of environmental stimuli, maintenance of intact family or support system, and absence of complications. The major nursing goal is to compensate for the absence of protective reflexes.

19. Nursing process / Nursing Interventions Maintaining the airway. Protecting the patient. Maintaining fluid balance and managing nutritional needs. Providing mouth care. Maintaining skin and joint integrity. Preserving corneal integrity. Achieving thermoregulation. Preventing urinary retention. Promoting bowel function. Providing sensory stimulation. Meeting families’ needs. Monitoring and managing potential complications.

20. Nursing process / Evaluation 1. Maintains clear airway and demonstrates appropriate breath sounds. 2. Experiences no injuries 3. Attains/maintains adequate fluid status a. Has no clinical signs or symptoms of dehydration b. Demonstrates normal range of serum electrolytes c. Has no clinical signs or symptoms of over hydration 4. Attains/maintains healthy oral mucous membranes 5. Maintains normal skin integrity 6. Has no corneal irritation

21. Nursing process / Evaluation 7. Attains or maintains thermoregulation 8. Has no urinary retention 9. Has no diarrhea or fecal impaction 10. Receives appropriate sensory stimulation 11. Family members cope with crisis a. Verbalize fears and concerns b. Participate in patient’s care and provide sensory stimulation by talking and touching 12. Is free of complications a. Has arterial blood gas values within normal range b. Displays no signs or symptoms of pneumonia c. Exhibits intact skin over pressure areas d. Does not develop deep vein thrombosis

24. Increased Intracranial Pressure The rigid cranial vault contains brain tissue (1,400 g), blood (75 mL), and CSF (75 mL). The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP. ICP is usually measured in the lateral ventricles; normal ICP is 10 to 20 mm Hg. Because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others.

25. Increased Intracranial Pressure Because brain tissue has limited space to change, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption of CSF, or decreasing cerebral blood volume. Under normal circumstances, ICP will begin to rise. minor changes in blood volume and CSF volume occur constantly due to alterations in intrathoracic pressure (coughing, sneezing, straining), posture, blood pressure, and systemic oxygen and carbon dioxide levels.

26. Clinical Manifestations When ICP increases to the point at which the brain’s ability to adjust has reached its limits, neural function is impaired; this may be manifested by clinical changes first in LOC and later by abnormal respiratory and vasomotor responses. Any sudden change in the patient’s condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. These signs may result from compression of the brain due to swelling from hemorrhage or edema, an expanding intracranial lesion (hematoma or tumor),or a combination of both.

27. Cont… As ICP increases, the patient becomes reacting only to loud auditory or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required. As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decortications, deceleration, or flaccidity. When the coma is profound, with the pupils dilated and fixed and respirations impaired, death is usually predictable.

28. Assessment and Diagnostic Findings The diagnostic studies used to determine the underlying cause of increased ICP. The patient may undergo cerebral angiography, (CT) scanning, (MRI), or (PET). Transcranial Doppler studies provide information about cerebral blood flow. Lumbar puncture is avoided in patients with increased ICP because the sudden release of pressure can cause the brain to herniate.

29. Complications Complications of increased ICP include brain stem herniation, diabetes insipidus, and syndrome of inappropriate antidiuretic hormone (SIADH). Brain stem herniation results from an excessive increase in ICP, when the pressure builds in the cranial vault and the brain tissue presses down on the brain stem. This increasing pressure on the brain stem results in the cessation of blood flow to the brain, causing irreversible brain anoxia and brain death.

30. Cont… Diabetes insipidus is the result of decreased secretion of antidiuretic hormone. The patient has excessive urine output, and hyperosmolarity results. Therapy consists of administration of fluid volume, electrolyte replacement, and vasopressin therapy. SIADH is the result of increased secretion of antidiuretic hormone. The patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Treatment of SIADH includes fluid restriction, which is usually sufficient to correct the hyponatremia; severe cases call for administration of a 3% hypertonic saline solution.

31. Management Increased ICP is a true emergency and must be treated promptly. Invasive monitoring of ICP is an important component of management, but immediate management to relieve increased ICP involves decreasing cerebral edema, lowering the volume of CSF, or decreasing cerebral blood volume while maintaining cerebral perfusion. These goals are accomplished by administering osmotic diuretics and corticosteroids, restricting fluids, draining CSF, controlling fever, maintaining systemic blood pressure and oxygenation.

32. Management 1. Monitoring ICP The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment.

33. Management 2. Decreasing Cerebral Edema Osmotic diuretics (mannitol) may be given to dehydrate the brain tissue and reduce cerebral edema. They act by drawing water across intact membranes, thereby reducing the volume of brain and extracellular fluid. An indwelling urinary catheter is usually inserted to monitor urinary output and to manage the resulting diuresis. When a patient is receiving osmotic diuretics, serum osmolality should be determined to assess hydration status.

34. Cont… Corticosteroids (eg, Dexamethasone) help reduce the edema surrounding brain tumors when a brain tumor is the cause of increased ICP. Another method for decreasing cerebral edema is fluid restriction. Limiting overall fluid intake leads to dehydration and hemoconcentration, drawing fluid across the osmotic gradient and decreasing cerebral edema. Conversely, over hydration of the patient with increased ICP is avoided, as this will increase cerebral edema. 3. Maintaining oxygenation Arterial blood gases must be monitored to ensure that systemic oxygenation remains optimal.

35. Management 4. Maintaining cerebral perfusion 5. Reducing CSF and intracranial blood volume CSF drainage is frequently performed because the removal of CSF with a ventriculostomy drain may dramatically reduce ICP and restore cerebral perfusion pressure. Caution should be used in draining CSF because excessive drainage may result in collapse of the ventricles. 6. Controlling fever Preventing a temperature elevation is critical because fever increases cerebral metabolism and the rate at which cerebral edema forms.

36. Management 7. Reducing metabolic demands Cellular metabolic demands may be reduced through the administration of high doses of barbiturates. The mechanism by which barbiturates decrease ICP and protect the brain is uncertain. Another method is the administration of pharmacologic paralyzing agents. The patient who receives these agents cannot move, decreasing the metabolic demands and resulting in a decrease in cerebral oxygen demand. Because the patient cannot respond or report pain, sedation and analgesia must be provided because the paralyzing agents do not provide either. Patients receiving high doses of barbiturates or paralyzing agents require continuous cardiac monitoring, endotracheal intubation, MV, ICP monitoring, and arterial pressure monitoring.

37. Nursing process / Assessment Initial assessment includes obtaining a history of events leading to the present illness and other subjective data. The neurologic examination should be as complete as the patient’s condition allows. It includes an evaluation of mental status, LOC, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. Because the patient is critically ill, ongoing assessment will be more focused, including pupil checks, assessment of selected cranial nerves, frequent measurements of vital signs and intracranial pressure, and use of the Glasgow Coma Scale.

38. Nursing process / Diagnosis Ineffective airway clearance related to diminished protective reflexes (cough, gag) Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement) Ineffective cerebral tissue perfusion related to the effects of increased ICP Deficient fluid volume related to fluid restriction Risk for infection related to ICP monitoring system (intraventricular catheter) COLLABORATIVE PROBLEMS / POTENTIAL COMPLICATIONS Brain stem herniation Diabetes insipidus SIADH

39. Nursing process / Planning and Goals The goals for the patient include maintenance of a patent airway, normalization of respiration, adequate cerebral tissue perfusion through reduction in ICP, restoration of fluid balance, absence of infection, and absence of complications.

40. Nursing process / Interventions Maintaining a patent airway. Achieving an adequate breathing pattern. Optimizing cerebral tissue perfusion. Maintaining negative fluid balance. Preventing infection. Monitoring and managing potential complications. Monitoring ICP. Monitoring for Secondary Complications.

41. Detecting Early Indications of Increasing ICP Disorientation, restlessness, increased respiratory effort, purposeless movements, and mental confusion. Pupillary changes. Weakness in one extremity or on one side of the body. Headache that is constant, increasing in intensity, and aggravated by movement.

42. Detecting Later Signs of Increased ICP LOC continues to deteriorate until the patient is comatose. The pulse rate and respiratory rate decrease and the blood pressure and temperature rise. The pulse pressure widens. Altered respiratory patterns. Projectile vomiting. Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes

43. Nursing process / Evaluation Maintains patent airway Attains optimal breathing pattern a. Breathes in a regular pattern b. Attains or maintains arterial blood gas values within acceptable range Demonstrates optimal cerebral tissue perfusion a. Increasingly oriented to time, place, and person b. Follows verbal commands; answers questions correctly Attains desired fluid balance a. Maintains fluid restriction b. Demonstrates serum and urine osmolality values within acceptable range

44. Cont… Has no signs or symptoms of infection a. Has no fever b. Shows no signs of infection at arterial, intravenous, and urinary catheter sites c. Has no purulent drainage from invasive intracranial monitoring device Absence of complications a. Has ICP values that remain within normal limits b. Demonstrates urine output and serum electrolyte levels within acceptable limits

45. THANKS Any Questions