Angelite Nurses

ASSESSMENT

Health History


Nervous System

1. Presenting problem: symptoms may include behavior changes, memory loss, mood changes, nervousness or anxiety, headache, seizures, syncope, vertigo, loss of consciousness; problems with speech, vision, or smell; motor problems (paralysis, tremor); sensory problems (pain, paresthesias)
2. Life-style: drug and alcohol intake, exposure to toxins, recent travel, employment, stressors
3. Use of medications: prescribed and over-the-counter (OTC)
4. Past medical history
1. Perinatal exposure to toxic agents, x-rays; difficult labor and delivery
2. Childhood and adult: history of systemic diseases; seizures; loss of consciousness; head trauma
5. Family history: may uncover diseases with hereditary or congenital background.

Eye

1. Presenting problem: symptoms may include blurred vision, decreased vision, or blind spots; pain, redness, excessive tearing; double vision (diplopia); drainage
2. Use of eyeglasses, contact lenses; date of last eye exam.
3. Life-style: occupation (exposure to fumes, smoke, or eye irritant); use of safety glasses
4. Use of medications: cortisone preparations may contribute to formation of glaucoma and cataracts
5. Past medical history: systemic diseases; previous childhood or adult eye disorders, eye trauma
6. Family history: many eye disorders may be inherited.

Ear

1. Presenting problem: symptoms may include hearing loss, tinnitus (ringing in ear), dizziness or vertigo, pain, drainage
2. Life-style: occupation (exposure to excessive noise levels), swimming habits
3. Use of medications: ototoxic drugs; aspirin (tinnitus)
4. Past medical history
1. Perinatal: rubella in first trimester of pregnancy
2. Childhood and adult: otitis media, perforated eardrum, measles, mumps, allergies, tonsillectomy, and adenoidectomy
5. Family history: hearing loss in family members.

Physical Examination


Nervous System

1. Neurologic examination
1. Mental status exam (cerebral function); see also Psychiatric-Mental Health Nursing in Unit 7
1. General appearance and behavior
2. Level of consciousness; see Neuro Check, below.
3. Intellectual function: memory (recent and remote), attention span, cognitive skills
4. Emotional status
5. Thought content
6. Language/speech
1. expressive aphasia: inability to speak
2. receptive aphasia: inability to understand spoken words
3. dysarthria: difficult speech due to impairment of muscles involved with production of speech
2. Cranial nerves (see Table 4.15)
3. Cerebellar function: posture, gait, balance, coordination
4. Motor function: muscle size, tone, strength; abnormal or involuntary movements
5. Sensory function: light touch, superficial pain, temperature, vibration, and position sense
6. Reflexes
1. Deep tendon: grade from 0 (no response) to 4 (hyperactive); 2 is normal
2. Superficial
3. Pathologic: Babinski's reflex (dorsiflexion of great toe with fanning of other toes) indicates damage to corticospinal tracts (see Figure 4.2)
2. Neuro check
1. Level of consciousness (LOC)
1. Orientation to time, place, and person
2. Speech: clear, garbled, rambling
3. Ability to follow commands
4. If client does not respond to verbal stimuli, apply a painful stimulus (e.g., pressure on nailbeds, squeeze trapezius muscle); note response to pain
1. appropriate: withdrawal, moaning
2. inappropriate: nonpurposeful
5. Abnormal posturing (may occur spontaneously or in response to stimulus)
1. decorticate posturing: extension of legs, internal rotation and adduction of arms with flexion of elbows, wrists, and fingers (damage to corticospinal tracts; cerebral hemispheres)
2. decerebrate posturing: back arched, rigid extension of all four extremities with hyperpronation of arms and plantar flexion of feet (damage to upper brainstem, midbrain, or pons)
2. Glasgow coma scale (seeFigure 4.3)
1. Objective evaluation of LOC, motor/verbal response; a standardized system for assessing the degree of neurologic impairment in critically ill clients.
2. Cannot replace a complete neurologic check, but can be used as an aid in evaluation and to eliminate ambiguous terms such as stupor and lethargy.
3. A score of 15 indicates client is awake and oriented; the lowest score, 3, is deep coma; a score of 7 or below is considered coma.
3. Pupillary reaction and eye movements
1. Observe size, shape, and equality of pupils (note size in millimeters)
2. Reaction to light: pupillary constriction
3. Corneal reflex: blink reflex in response to light stroking of cornea
4. Oculocephalic reflex (doll's eyes): present in unconscious client with intact brainstem
4. Motor function
1. Movement of extremities (paralysis)
2. Muscle strength
5. Vital signs: respiratory patterns (may help localize possible lesion)
1. Cheyne-Stokes respiration: regular, rhythmic alternating between hyperventilation and apnea; may be caused by structural cerebral dysfunction or by metabolic problems, such as diabetic coma.
2. Central neurogenic hyperventilation: sustained, rapid, regular respirations (rate of 25/minute) with normal blood oxygen levels; usually due to brain stem dysfunction.
3. Apneustic breathing: prolonged inspiratory phase, followed by a 2- to 3-second pause; usually indicates dysfunction of respiratory center in pons.
4. Cluster breathing: clusters of irregular breathing, irregularly followed by periods of apnea; usually caused by a lesion in upper medulla and lower pons.
5. Ataxic breathing: breathing pattern completely irregular; indicates damage to respiratory centers of the medulla.

FIGURE 4.2 Pathologic Reflex (Babinski)

FIGURE 4.3 Glasgow Coma Scale (From "What the comatose patient can tell you" by A. Stolarik, RN, 48(4), 32)

Eye

1. Visual acuity: Snellen chart
2. Visual fields (peripheral vision)
1. Confrontation method
2. Perimetry: more precise method
3. External structures
1. Position and alignment of eyes
2. Eyebrows, eyelids, lacrimal apparatus, conjunctiva, sclera, cornea, iris, pupils (size, shape, equality, and reaction to light)
4. Extraocular movements; note paralysis, nystagmus (rapid, abnormal movement of the eyeball)
5. Corneal reflex

Ear

1. Inspection and palpation of auricle, preauricular area, and mastoid area
2. Hearing acuity
1. Whispered voice or ticking watch tests: gross estimation
2. Audiometry: more precise method
3. Tuning fork tests distinguish between sensorineural and conductive deafness.
1. Conductive hearing loss: secondary to problem in external or middle ear; transmission of sound waves to inner ear impaired
2. Sensorineural (perceptive) hearing loss: disease of inner ear or cranial nerve VIII (acoustic branch)
3. Weber's test: handle of vibrating tuning fork placed on midline of client's skull, sound should be heard equally in midline or in both ears; in conductive hearing loss, sound is louder in poorer ear; in sensorineural hearing loss, sound is louder in better ear.
4. Rinne's test: tuning fork placed on mastoid process (bone conduction) until sound no longer heard, then placed in front of the ear (air conduction); sound should be heard longer (almost twice as long) with air conduction than with bone conduction; bone conduction greater than air conduction indicates conductive hearing deficit.

Laboratory/Diagnostic Tests


Nervous System

1. Lumbar puncture (LP)
1. A hollow spinal needle introduced into subarachnoid space of spinal canal between L₄/L₅ for diagnostic or therapeutic reasons
2. Purposes
1. Measures CSF pressure (normal opening pressure 60-150 mm H₂O)
2. Obtain specimens for lab analysis (protein [normally not present], sugar [normally present], cytology, C&S)
3. Check color of CSF (normally clear) and check for blood
4. Inject air, dye, or drugs into the spinal canal
3. Nursing care: pretest
1. Have client empty bladder.
2. Position client in lateral recumbent position with head and neck flexed onto the chest and knees pulled up.
3. Explain the need to remain still during the procedure.
4. Nursing care: posttest
1. Ensure labeling of CSF specimens in proper sequence.
2. Keep client flat for 12-24 hours as ordered.
3. Force fluids.
4. Check puncture site for bleeding, leakage of CSF.
5. Assess sensation and movement in lower extremities.
6. Monitor vital signs.
7. Administer analgesics for headache as ordered.
2. X-rays of skull and spine
1. Used to detect atrophy, erosion, or fractures of bones; calcifications
2. Pretest nursing care: remove hairpins, glasses, hearing aids.
3. Computerized tomography (CT scan)
1. Skull/spinal cord are scanned in successive layers by a narrow beam of x-rays; computer uses information obtained to construct a picture of the internal structure of the brain; contrast medium may or may not be used.
2. Used to detect intracranial and spinal cord lesions and monitor effects of surgery or other therapy.
3. Nursing care
1. Explain appearance of scanner.
2. Instruct client to lie still during procedure.
3. Check for allergy to iodine if contrast material is used.
4. Remove hairpins, etc.
4. Magnetic resonance imaging (MRI)
1. Also known as nuclear magnetic resonance (NMR)
2. Computer-drawn, detailed pictures of structures of the body through use of large magnet, radio waves
3. Used to detect intracranial and spinal abnormalities associated with disorders such as cerebrovascular disease, tumors, abscesses, cerebral edema, hydrocephalus, multiple sclerosis
4. Nursing care
1. Instruct client to remove jewelry, hairpins, glasses, wigs (with metal clips), and other metallic objects.
2. Be aware that this test cannot be performed on anyone with orthopedic hardware, intrauterine devices, pacemaker, internal surgical clips, or other fixed metallic objects in the body.
3. Inform client of need to remain still while completely enclosed in scanner throughout the procedure, which lasts 45-60 minutes.
4. Teach relaxation techniques to assist client to remain still and to help prevent claustrophobia.
5. Warn client of normal audible humming and thumping noises from the scanner during test.
6. Have client void before test.
7. Sedate client if ordered.
5. Brain scan
1. Injection of radioactive isotope, followed by scanning of head; isotopes will accumulate in abnormal lesions and be recorded by the scanner.
2. Used to detect intracranial masses, vascular lesions, infarcts, hemorrhage
3. Nursing care: check for allergy to iodine.
6. Myelography (see Laboratory/Diagnostic Tests)
7. Cerebral angiography
1. Injection of radiopaque substance into the cerebral circulation via carotid, vertebral, femoral, or brachial artery followed by x-rays
2. Used to visualize cerebral vessels and detect tumors, aneurysms, occlusions, hematomas, or abscesses
3. Nursing care: pretest
1. Explain that client may have warm, flushed feeling and salty taste in mouth during procedure.
2. Check for allergy to iodine.
3. Keep NPO after midnight or offer clear liquid breakfast only.
4. Take baseline vital signs and neuro check.
5. Administer sedation if ordered.
4. Nursing care: posttest
1. Maintain pressure dressing over site if femoral or brachial artery used; apply ice as ordered.
2. Maintain bed rest until next morning as ordered.
3. Monitor vital signs and neuro checks frequently; report any changes immediately.
4. Check site frequently for bleeding or hematoma; if carotid artery used, assess for swelling of neck, difficulty swallowing or breathing.
5. Check pulse, color, and temperature of extremity distal to site used.
6. Keep extremity extended and avoid flexion.
8. Echoencephalography: use of ultrasound to detect midline shift of intracranial contents due to brain tumors, hematomas.
9. Electroencephalography (EEG)
1. Graphic recording of electrical activity of the brain by several small electrodes placed on the scalp
2. Used to detect focus or foci of seizure activity and to quantitatively evaluate level of brain function (determine brain death)
3. Pretest nursing care: withhold sedatives, tranquilizers, stimulants for 2-3 days.
4. Posttest nursing care: remove electrode paste with acetone and shampoo hair.

Eye

1. Ophthalmoscopic exam
2. Refraction: detects refractive errors and provides information for prescription of eyeglasses and contact lenses
3. Perimetry: assesses peripheral vision, visual fields
4. Tonometry: measures intraocular pressure (normal: 12-20 mm Hg)

Ear

1. Otoscopic exam
2. Audiometry: screening test for hearing loss and diagnostic test to determine degree and type of hearing loss
3. Vestibular function
1. Caloric test
2. Electronystagmography (ENG)

PLANNING AND IMPLEMENTATION

Goals

1. Nutritional state will be optimal.
2. Normal body temperature will be maintained.
3. Complications will be recognized early and treated promptly.
4. Adequate bowel and bladder elimination will be maintained.
5. Cerebral perfusion will be improved.
6. Adequate respiratory function will be maintained.
7. Client will remain free from any injury resulting from neurosensory deficits.
8. Client's skin integrity will be maintained.
9. Client's ability to communicate will be improved.
10. Sexual health will return to optimal level.
11. Mobility will be restored to optimal level.
12. Maximum independence in self-care activities will be attained.
13. Sensory perception will be improved.
14. Optimal cognitive functioning will be attained.

Interventions


Care of the Unconscious Client

1. Maintain a clear, patent airway.
1. Place client in a side-lying or three-quarters prone position to prevent tongue from obstructing airway.
2. If tongue is obstructing, insert oral airway.
3. Prepare for insertion of a cuffed endotracheal or tracheostomy tube as the client's condition requires.
4. Suction as needed.
5. Check respiratory rate, depth, and quality every 1-2 hours and as needed.
6. Auscultate breath sounds for crackles (rales), rhonchi, or absent breath sounds every 4 hours and before and after suctioning.
2. Take vital signs and perform neuro checks at specified intervals as ordered; report any significant changes immediately.
3. Maintain fluid and electrolyte balance and ensure adequate nutrition.
1. Administer IV fluids, nasogastric tube feedings as ordered.
2. Maintain accurate I&O.
3. Assess client's hydration status: skin turgor, check for dry mucous membranes.
4. Provide mouth care to keep mucous membranes clean, moist, and intact.
4. Provide for client's safety.
1. Keep side rails up at all times.
2. Avoid restraints if at all possible.
3. Observe client carefully for seizures and intervene to avoid precipitating factors: fever, hypoxia, electrolyte imbalance.
4. Protect client if seizure occurs.
5. Speak softly and use client's name during nursing care.
6. Touch client as gently as possible.
7. Protect client's eyes from corneal irritation.
1. Check for corneal reflex.
2. Instill artificial tears as ordered; patch eye.
5. Prevent complications of immobility.
1. Keep skin clean, dry, and pressure free.
2. Turn and reposition client every 2 hours.
3. Perform passive range-of-motion (ROM) exercises every 4 hours.
4. Use nursing measures to prevent deformities: footboard/high-topped sneakers to prevent foot drop, splint to prevent wrist drop.
6. Maintain adequate bladder and bowel elimination.
1. Urinary: indwelling catheter (may use external device in male)
2. Bowel: stool softeners and suppositories as ordered

Care of the Client with Increased Intracranial Pressure (ICP)

1. General information
1. An increase in intracranial bulk due to an increase in any of the major intracranial components: brain tissue, CSF, or blood
2. Increased ICP may be caused by tumors, abscesses, hemorrhage, edema, hydrocephalus, inflammation.
3. Untreated increased ICP can lead to displacement of brain tissue (herniation).
4. Presents life-threatening situation because of pressure on vital structures in the brain stem, nerve tracts, and cranial nerves.
2. Assessment findings
1. Earliest sign: decrease in LOC; progresses from restlessness to confusion and disorientation to lethargy and coma
2. Changes in vital signs (may be a late sign)
1. Systolic blood pressure rises while diastolic pressure remains the same (widening pulse presence)
2. Pulse slows
3. Abnormal respiratory patterns (e.g., Cheyne-Stokes respirations)
4. Elevated temperature
3. Pupillary changes
1. Ipsilateral (same side) dilation of pupil with sluggish reaction to light from compression of cranial nerve III
2. Pupil eventually becomes fixed and dilated.
4. Motor abnormalities
1. Contralateral (opposite side) hemiparesis from compression of corticospinal tracts
2. Decorticate or decerebrate rigidity
5. Headache, projectile vomiting, papilledema (edema of the optic disc)
3. Nursing care
1. Maintain patent airway and adequate ventilation.
1. Prevention of hypoxia and hypercarbia (increased CO₂) important: hypoxia may cause brain swelling and hypercarbia causes cerebral vasodilation, which increases ICP.
2. Before and after suctioning, hyperventilate the client with a resuscitator bag connected to 100% oxygen. Limit suctioning to 15 seconds.
3. Assist with mechanical hyperventilation as indicated: produces hypocarbia (decreased CO₂) causing cerebral vasoconstriction and decreased ICP.
2. Monitor vital sign and neuro checks frequently to detect rises in ICP.
3. Maintain fluid balance: fluid restriction to 1200-1500 ml/day may be ordered.
4. Position client with head of bed elevated to 30°-45° and neck in neutral position unless contraindicated (improves venous drainage from brain).
5. Prevent further increases in ICP.
1. Maintain quiet, comfortable environment.
2. Avoid use of restraints.
3. Prevent straining at stool; administer stool softeners and mild laxatives as ordered.
4. Prevent vomiting; administer antiemetics as ordered.
5. Prevent excessive coughing.
6. Avoid clustering nursing care activities together.
6. Prevent complications of immobility.
7. Administer medications as ordered.
1. Hyperosmotic agents (mannitol [Osmitrol]) to reduce cerebral edema; monitor urine output every hour (should increase).
2. Corticosteroids (dexamethasone [Decadron]); anti-inflammatory effect reduces cerebral edema
3. Diuretics (furosemide [Lasix]) to reduce cerebral edema.
4. Anticonvulsants (phenytoin [Dilantin]) to prevent seizures.
5. Analgesics for headache as needed
1. small doses of codeine
2. stronger opiates are contraindicated since they potentiate respiratory depression, alter LOC, and cause pupillary changes.
8. Assist with ICP monitoring when indicated.
1. ICP monitoring records the pressure exerted within the cranial cavity by the brain, cerebral blood, and CSF.
2. Types of monitoring devices
1. Intraventricular catheter: inserted in lateral ventricle to give direct measurement of ICP; also allows for drainage of CSF if needed
2. Subarachnoid screw (bolt): inserted through skull and dura mater into subarachnoid space
3. Epidural sensor: least invasive method; placed in space between skull and dura mater for indirect measurement of ICP
3. Monitor ICP pressure readings frequently and prevent complications.
1. Normal ICP reading is 0-10 mm Hg; a sustained increase above 15 mm Hg is considered abnormal.
2. Use strict aseptic technique when handling any part of the monitoring system.
3. Check insertion site for signs of infection; monitor temperature.
4. Assess system for CSF leakage, loose connections, air bubbles in lines, and occluded tubing.
9. Provide intensive nursing care for client treated with barbiturate therapy or administration of paralyzing agents.
1. Intravenous administration of barbiturates may be ordered to induce coma artificially in the client who has not responded to conventional treatment
2. Pancuronium (Pavulon) may be administered to paralyze client.
3. Reduces cellular metabolic demands that may protect the brain from further injury
4. Constant monitoring of the client's ICP, arterial blood pressures, pulmonary pressures, arterial blood gases, serum barbiturate levels, and ECG is necessary
5. Provide appropriate nursing care for the client on a ventilator (see Mechanical Ventialation).
10. Observe for hyperthermia secondary to hypothalamus damage.

Care of the Client with Hyperthermia

1. General information
1. Abnormal elevation of body temperation to 41°C (106°F) or above
2. Caused by dysfunction of hypothalamus (temperature regulating center) from edema, head injury, hemorrhage, CVA, brain tumor, or intracranial surgery
3. Hyperthermia increases cerebral metabolism; predisposes to seizures; may cause neurologic damage if prolonged.
2. Nursing care
1. Remove blankets and excess clothing if temperature rises above 38.4°C (101°F).
2. Maintain room temperature at 21.1°C (70°F).
3. Administer antipyretic drugs (acetaminophen [Tylenol]) orally or rectally every 4 hours as ordered.
4. Increase fluid intake to 3000 ml/day unless contraindicated (in increased ICP).
5. Monitor vital signs, especially temperature, every 2-4 hours (more often if hypothermia is used).
6. Monitor urine output and assess for signs of dehydration.
7. Observe for seizure activity and protect client if seizures occur.
8. Change linen frequently if client is diaphoretic (sweating profusely).
9. Apply methods for inducing hypothermia as ordered: cool or tepid sponge baths, fans, hypothermia blanket. (See also Cold Application in Unit 3.)
10. Provide special care for the client with a hypothermia blanket. (See also Cold Application in Unit 3.)
1. Reduce temperature gradually to prevent shivering and serious dysrhythmias; chlorpromazine (Thorazine) may be given for shivering.
2. Provide frequent skin care to prevent breakdown.
1. check every hour for signs of tissue damage or frostbite.
2. apply lotion to skin to prevent drying.
3. turn every 2 hours.
3. Monitor temperature with rectal probe.

Care of the Client with Diminished Eyesight

1. Always speak and identify yourself upon entering the room to prevent startling the client.
2. Orient the client to his surroundings.
1. Walk the client around the room and have him touch the objects in the room, e.g., table, chair.
2. Keep personal belongings and objects in the room in the same place in order to increase client's independence and sense of security.
3. Explain noises or other activities going on in the room.
3. Provide safety measures.
1. Keep call bell nearby.
2. Keep at least one side rail up.
3. If client smokes, supervise smoking.
4. Keep the room orderly and free of clutter.
4. Assist the client in walking by having him take your arm; walk a half step in front of the client.
5. Offer explanations to the client and tell him what to expect next.
6. Provide mental stimulation and prevent sensory deprivation by providing frequent contacts with the staff, visitors, use of radio, TV, etc.

Communicating with the Client with Impaired Hearing

1. Attract the client's attention by raising an arm or hand.
2. Face the client directly when speaking.
3. Do not obscure the client's view of your mouth in any way.
4. Initially state the topic or subject of your conversation to give the client clues as to what you are going to say.
5. Speak slowly and distinctly, but do not overaccentuate words.
6. Speak in a normal tone of voice; do not shout.
7. If you are not certain that the client has understood you, check to be sure that he has.

Irrigation of the Ear

1. Introduction of fluid into external auditory canal for cleansing purposes; may be used to apply antiseptic solutions.
2. Nursing care
1. Explain procedure to the client.
2. Prepare supplies needed: irrigating solution (about 500 ml normal saline at body temperature), irrigating syringe, basin, towel, cotton-tipped applicators, cotton balls.
3. Assist client to a sitting or lying position with head tilted toward the affected ear.
4. Straighten ear canal by pulling auricle upward and backward (down and backward on a child under 3 years).
5. Insert tip of syringe into auditory meatus and direct the solution gently upward toward the top of the canal.
6. Collect returning fluid in basin.
7. Dry the outer ear with cotton balls.
8. Instruct client to lie on affected side to encourage drainage of solution.
9. Record the procedure and results.