Patients With Neurologic Dysfunction Health And Social Care Essay

Patients With Neurologic Dysfunction Health And Social Care Essay Keshin Himura is a 42-year-old patient diagnosed with pituitary prolactinoma, a benign tumor that arises from the pituitary gland, resulting in a decrease in libido and impotence and increased milk production of the breast. The patient also has complaints of headache and drowsiness and the presence of visual field changes and papilledema preoperatively. What postoperative care should the nurse provide the patient? The nurse should provide the following postoperative care to the patient: Evaluate gag reflex and ability to swallow Offer semisoft diet Perform neurologic checks Monitor vital signs Maintain neurologic flow chart Reorient patient when necessary to person, time and place If with seizures, carefully monitor and and protect from injury Check motor function at intervals Assess for sensory disturbances Evaluate speech The patients family asks the nurse how will they know that the problems the patient had before surgery have stopped; what is the nurses best response? Through observation, conducting series of test that will be provided by the physician (e.g. MRI, CT scans) to check if the tumors are already diminished, because presence of tumor will still inhibit the signs and symptoms of the disorder. The primary objective of the surgical intervention is to remove or destroy the entire tumor without increasing the neurologic deficit and to relieve symptoms by decompression. And if there is no evidence of tumor, the normal levels of hormone would return in usual, the patient will no longer experience the symptoms of the disease. What management strategies should the nurse anticipate will be ordered to care for diabetes insipidus if it occurs? The objective of the therapy is: To replace ADH To ensure adequate fluid replacement To correct the underlying intracranial problem (pituitary prolactinoma) A fluid deprivation test is ordered by the physician to confirm for the diagnosis of diabetes insipidus by: withholding fluids by 8 to 12 hours Patient is weighed frequently during the test Plasma and urine osmolality studies are performed at the beginning and end of the test. The inability to increase the specific gravity and osmolality of the urine is an indication of Diabetes insipidus Pharmacologic Therapy Administer Desmopressin (DDAVP) intranasally, BID as ordered Nursing Management Establish baseline data ( weight, BP, I/O patter), Monitor BP and weight frequently throughout therapy and report sudden changes to physician Monitor I/O and specific gravity and serum osmolality as ordered If patient has Coronary artery disease, use this drug with caution as this drug causes vasoconstriction Avoid concentrated fluids as this increase urine volume What discharge instructions should the nurse provide the patient and family? Most patients will spend at least one night in the intensive care unit (ICU) and then typically 2 or 3 additional nights on a regular (non-ICU) ward after surgery The patient will likely have some incisional pain and mild to moderate headache for which he will be given pain medication. A CT scan or MRI will be ordered before discharge Ask patient to return 2-3weeks after surgery Inform patient to return 2-3months after 1st check-up Inform family to watch out for signs of DI (intense thirst, frequent urination). Refer immediately Management of Patients with Neurologic Dysfunction  Ã‚   Case Study 2 Hiehachi Nishima, a 22-year-old patient who weighs 150 pounds, presents to the emergency department (ED) after being thrown from his horse and passing out for a few minutes; he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. The respirations are very shallow, and the lips and nail bed became blue. The patient lost control of bladder and bowel. The patient bit his tongue and blood is coming from the mouth. The radiology department calls and is ready f or the patient. List in the correct order the actions that should be taken by the nurse. Before and during a seizure, the patient is assessed and the following items are documented: The circumstances before the seizure The occurrence of aura The first thing the patient does in the seizure where movements or stiffness begins, conjugate gaze position, position of head The type of movements in the part of the body involved The areas of the body involved The size of the pupils and whether the eyes are open Whether the eyes or the head are turned to one side The presence or absence of automatisms Incontinence of urine or stool Unconsciousness and its duration Any obvious paralysis or weakness of arms or legs after the seizure Inability to speak after the seizure Movements at the end of the seizure Whether or not the patient sleeps or not afterwards Cognitive status after the seizure In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient not only physically but also psychologically. Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient. After the patient has a seizure, the nurses role is to document the events leading to and occurring during and after the seizure to prevent complications. Explain what type of seizure the patient is having, and describe the three phases of the patients seizure and the specific nursing care for each stage. The patient had a tonic-clonic (gran mal) seizure. There are three phases namely the aura, the tonic and the clonic phase. In the aura phase is the forewarning of an epileptic attack. It characterized by episodes of Dà ©jà   vu or Jamais vu. The client may also have auditory, olfactory, or even visual hallucinations, abnormal tastes, and tingling sensations. Physical symptoms include dizziness, headache, lightheadedness, nausea, numbness. Though in this case, the client did not show signs of the aura phase. *Nsg Mgt: Provide privacy and protect the patient from curious onlookers Patients who have an aura may have time to seek a safe, private place Ease the patient to the floor, if possible Loosen constrictive clothing Push aside any furniture that may injure the patient during a seizure If an aura precedes the seizure, insert an oral airway to reduce the possibility of the patients biting the tongue The next is the tonic phase. It is usually the shortest part of the seizure, lasting not more than only a few seconds. In this case, it is when the patient had an epileptic cry, became unconscious and stiffened his entire body. *Nsg Mgt: Protect the head with a pad to prevent injury from striking a hard surface If the patient is in bed, remove pillows and raise side rails The last is the clonic phase. It is when the client had violent muscle contractions, very shallow respirations, the lips and nail beds became blue, lost control of bladder and bowel and bit his tongue. *Nsg Mgt: Do not attempt to pry open jaws that are clenched in a spasm or to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can cause injury If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use if necessary to clear secretions. The ED physician orders the following: Valium (diazepam) 10 mg every 10 to 15 minutes prn for seizures (maximum dose of 30 mg). Once seizures stop, administer Dilantin (phenytoin) 10 mg/kg IVPB. ECG monitoring continuously, VS, GCS, neuro checks every 30 minutes. Explain what meds the nurse should provide, in what order, and how they should be administered. The nurse should provide Valium injection (diazepam) 10 mg IM PRN every 10 to 15 mins. (max 30mg) for his seizure to relief the muscle spasm. For the long term relief, administer Dilantin (phenytoin) 10 mg/kg IVPB loading dose STAT, once the seizures stop. Dilantin (phenytoin) is an anti-seizure medication (anticonvulsant), especially to prevent tonic-clonic (grand mal) seizures and complex partial seizures (psychomotor seizures).We use piggyback to administer different IV drugs at different times. Dilantin can cause irritability to the veins and can cause serious tissue and/or nerve damage if it infiltrates. So we should administer it with normal saline. Draw up the drugs in a syringe and attach it to the piggyback port on the IV tubing cassette, which is run concurrently with the primary IV fluid (normal saline). Run it slowly and keep an eye on the ECG monitor. This ECG monitoring should be done continuously to help identify irregular heartbeats. For the vital signs, Glasgow coma scale and neuro V/S, it should be check every 30 minutes to provide reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. Group Assignments Have each member address nursing management related to caring for an unconscious patient. Preventing Urinary Retention Palpate bladder at intervals to determine whether urinary retention is present If patient is not voiding, an indwelling catheter is inserted and connected to a closed drainage system as ordered Observe for fever and cloudy urine for infection Observe the area around the urethral orifice for any drainage As soon as consciousness is regained, a bladder-training program initiated Promote Bowel Function Assess abdomen for distention by listening for bowel sounds (irregular gurgling sounds should be heard every 5-20sec) Measuring the girth of the abdomen with a tape measure. Monitor for the number and consistency of bowel movements Perform rectal examination for signs of fecal impaction as ordered. Stool softeners may be prescribed and can be administered with tube feedings Glycerin suppository may be indicated to facilitate bowel emptying May require enema every other day to empty lower colon Maintain Skin and Joint Integrity Monitor pressure areas for possible ulcerations Establish a regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin This provides kinesthetic, proprioceptive and vestibular stimulation Avoid dragging and pulling the patient up in the bed, because this creates a shearing force and friction on the skin surface Maintain correct body position Passive exercise of the extremities is important to prevent contractures Splints or foam boots may be used to prevent foot drop and pressure of bedding on the toes Trochanter rolls may be used to support the hip joints and keep the legs in proper alignment Providing Mouth Care Inspect mouth for dryness, inflammation, and crusting Cleanse and rinse mouth carefully to remove secretions and crusts and to keep the mucous membranes moist Administer petrolatum on the lips to prevent drying, cracking and encrustations. If patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth and lips Perform routine tooth brushing every 8hrs to decrease ventilator-associated pneumonia Maintaining the Airway Elevate the head of bed to 30 degrees to prevent aspiration. Place the client in lateral position to allow the jaw and tongue to fall forward to promote drainage of secretions. Suction for secretions as needed Maintain oral hygiene Chest physiotherapy and postural drainage to promote pulmonary hygiene Auscultate the patients chest every 8 hours to assess for any deviated breath sounds. If the patient has a mechanical ventilator, maintain the patency of the endotracheal tube or tracheostomy, provide oral care, monitor arterial blood gas measurements and maintaining ventilator settings. Protecting the Patient Raise side rails up as always to prevent injury Ensure the patients dignity during altered LOC, speaking to the client during nursing care activities. Maintaining Fluid Balance and Managing Nutritional Needs Assess skin turgor and mucous membrane for dryness Monitor for intake and output and determine the needs for catheterization Preserving Corneal Integrity Patients eyes may be cleansed with cotton balls moistened with sterile normal saline to remove any discharge. For artificial tears (prescription by the physician), may introduce every 2 hours. Maintaining Body Temperature The environment can be adjusted (depending on the patients condition) to promote normal body temperature. If body temperature is elevated, a minimum amount of bedding is used. For geriatric patients and doesnt have any elevated temperature, a warmer environment is needed. Providing Sensory Stimulation Communicate with patient, and encourage the family members to do it so. Orient the patient to time, date, and place once for every 8 hours. Have each group member develop a nursing diagnosis related to a patient with an altered level of consciousness. Identify potential problems and complications related to the nursing diagnosis. Nursing Diagnosis Potential Problems and Complications 1. Ineffective airway clearance related to altered level of consciousness Aspiration 2. Risk for impaired skin integrity related to prolonged immobility Bed sore Pressure ulceration 3. Impaired Urinary elimination: retention related to impairment in neurologic sensing and control Bladder distention Infection Formation of stones 4. Impaired tissue integrity of cornea related to diminished or absent corneal reflex Periorbital edema Ulcerations Corneal abrasions 5. Deficient fluid volume related to inability to take fluids by mouth Dehydration Cerebral edema 6. Interrupted family processes related to changes in the cognitive and physical status of their loved one Crisis Severe anxiety, denial, anger, remorse, grief, and reconciliation 7. Risk for injury related to decreased LOC Falls 8. Ineffective thermoregulation related to damage to hypothalamic center Hyperthermia 9. Impaired oral mucous membrane related to mouth breathing , absence of pharyngeal reflex and altered fluid intake Dryness Inflammation Crusting 10. Bowel incontinence related to impairment neurologic sensing and control Abdominal distention Diarrhea Frequent loose stools As a group, identify potential complications that may arise in the postoperative phase of cranial surgery. Increased ICP Monro-Kellie hypothesis states that, 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.because brain tissue has limited space to expand, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral volume resulting to an increase ICP. Bleeding and hypovolemic shock An accumulation of blood under the bone flap (extradural, subdural, or intracerebral hematoma) may pose a threat to life. A clot must be suspected in any patient who does not awaken as expected or whose conditions deteriorates. Fluid and electrolyte disturbances IV solutions and blood component therapy for patients with intracranial conditions must be administered slowly. If they are administered too rapidly, they can increase ICP. The quantity of fluids administered may be restricted to minimize the possibility of cerebral edema. Infection The risk of infection is great when ICP is monitored with an intraventricular catheter and increases with the duration of the monitoring. Seizures Underlying cause is an electrical disturbance in the nerve cells in one section of the brain. An abnormal motor, sensory, autonomic, or physical activity that result from sudden excessive discharge from cerebral neurons. Have each group member identify a type of seizure. Describe clinical manifestations, diagnosis, and treatment of each. Generalized Seizures: This are seizures that mainly involves electrical charges in the whole brain, its clinical manifestations includes loss of consciousness for a short or long period of time. Types of Seizure Clinical Manifestation Grand Mal or Generalized tonic-clonic Unconsciousness Convulsions Muscle rigidity Absence Short loss of unconsciousness Myoclonic Irregular jerky movements Clonic Repetitive jerky movements Tonic Muscle stiffness and rigidity Atonic Loss of muscle tone Diagnosis: Physical examination particularly neurologic examination EEG For temporary and reversible causes of seizures: Blood chemistry Blood sugar Complete Blood Count Cerebrospinal fluid analysis Kidney function test Liver function tests Test to determine the cause and location: EEG (electroencephalograph) to measure the electrical activity in the brain Head CT or MRI scan Lumbar puncture-spinal tap Treatment: When a seizure occurs, protect the person from injury, make the environment safe for you and the patient. Protect the patients head Loosen tight clothing Place the patient into a side-lying position if vomiting occurs Stay with patient until she or he is fully recovered Monitor the patients vital signs Medications such as anticonvulsants may be given as ordered to reduce the number of future seizures. The DONTs During Seizures: Dont restrain the patient Dont place anything between the patients teeth during a seizure Dont move the patient unless he or she is in danger or near something hazardous Dont try to stop the patient from convulsing. Partial Seizures: This are seizures that mainly involves electrical charges in one part of the brain, its clinical manifestations includes abnormal muscle movements, automatisms, abnormal sensations, hallucinations, nausea, sweating, dilated pupils, rapid heart rate and pulse rate, changes in vision. Types of Seizure Clinical Manifestation Simple (consciousness is intact) Jerky movements Muscle rigidity, spasm Unusual sensation Memory and emotional disturbance Complex (consciousness is impaired) Automatisms: lip smacking, chewing, walking and repetitive involuntary and coordinated movements Diagnosis: CT scan MRI EEG EEG-video recordings Treatment: Vagus Nerve Stimulation in which a small battery is implanted in the chest wall which will program to deliver short bursts of energy to the brain. Corpus Callosotomy is a type of surgical intervention that will cut the connections between the two sides of the brain that will prevent drop attacks.. Multiple sub-pial transection which is a surgical technique that will cut a certain connection between nerve cells.