NSG210 Hinkle Ch. 61: Management of Patients with Neurologic Dysfunction

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 61, pp. 1992-2030 (textbooks/HINKLE_MS_CH61.pdf, also in textbooks/exam04/). Week 11 reading (alterations in cognition and sensing, November 4); Exam 4 content (the course calendars end Exam 3 content with the October 28 OB lecture). Numbering note: the syllabus lists “Ch. 62” (16th edition); this is Ch. 61 in the 15th edition (see nsg210-textbook-chapter-crosswalk). Neuro exam basics are in nsg210-hinkle-ch60-neurologic-assessment.

Learning Outcomes

1. Describe causes, clinical manifestations, and medical management of various neurologic dysfunctions.
2. Use the nursing process for the patient with altered level of consciousness (LOC).
3. Identify early and late manifestations of increased intracranial pressure (ICP) and plan care.
4. Compare indications for intracranial vs transsphenoidal surgery and plan perioperative care.
5. Explain types and causes of seizures and plan care for the patient having seizures.
6. Recognize causes, manifestations, and management of headaches.

Key Terms

• Akinetic mutism: unresponsive to environment; no movement or sound, may open eyes
• Altered LOC: not oriented, does not follow commands, or needs persistent stimuli to stay alert
• Brain death: irreversible loss of all function of the entire brain, including the brain stem
• Coma: prolonged unconsciousness
• Craniectomy: removal of part of the skull. Craniotomy: surgical entry into the cranial vault
• Cushing response (reflex): brain raises arterial pressure to overcome rising ICP
• Decerebration: extreme extension of upper and lower extremities (more severe)
• Decortication: flexion of upper extremities, extension of lower extremities
• Delirium: acute confused state starting with disorientation; can progress to altered LOC, irreversible brain damage, death if not treated early
• Dementia: syndrome of general decline in higher brain function with eventual loss of basic ADLs
• Epilepsy: at least two unprovoked seizures occurring more than 24 hours apart
• Herniation: shift of brain tissue from high pressure to lower pressure area
• Locked-in syndrome: pontine lesion; total paralysis but cognition intact
• Minimally conscious state: shows awareness but cannot communicate
• Persistent vegetative state: wakeful but devoid of conscious content (sleep-wake cycles, no awareness)

I. Altered Level of Consciousness

A. Overview

• LOC is the most sensitive indicator of neurologic function; change in LOC is often the earliest sign of deterioration.
• Continuum: alert, confused/disoriented, lethargic, obtunded, stuporous, comatose.
• Causes: neurologic (head injury, stroke, seizure, tumor, infection), toxic (drug overdose, alcohol), metabolic (hepatic or renal failure, DKA, hypoglycemia).

B. Assessment

• Glasgow Coma Scale (GCS): eye opening (1-4), best verbal (1-5), best motor (1-6); total 3-15. Lower scores mean deeper impairment; a low score generally indicates need for airway protection.
• Posturing: decorticate (flexion) vs decerebrate (extension); flaccidity is worse still.
• GCS less than 8: patient is comatose (text, ICP section).
• Table 61-1, assessment of the unconscious patient:
  • Respiratory patterns: Cheyne-Stokes (deep bilateral hemispheres, basal ganglia, upper brain stem); hyperventilation (metabolic problem or brain stem damage); ataxic, irregular respiration = ominous sign of medullary damage
  • Pupils: equal and reactive suggests toxic or metabolic coma; progressive dilation indicates increasing ICP; fixed dilated pupils indicate midbrain injury
  • Corneal reflex tests CN V and VII; absent in deep coma
  • Swallowing reflex absent in coma (CN X, XII)
  • Stiff neck: subarachnoid hemorrhage, meningitis
• Brain death evaluation considered when coma is profound and irreversible with no confounding factors, brain stem reflexes absent, respirations impaired or absent.
• Labs: glucose, electrolytes, BUN, serum osmolality, calcium, PT/PTT, ammonia, toxicology.

C. Nursing Interventions (unconscious patient)

• Priority: airway and breathing pattern. Tongue and epiglottis relax and occlude airway; aspiration risk. Lateral or semiprone position; suction; HOB 30 degrees; prepare for intubation if comatose (GCS less than 8).
• Protect from injury: padded side rails, avoid restraints (straining raises ICP), speak to patient, assume patient can hear.
• Fluid balance and nutrition: enteral feeding; monitor I&O, weight.
• Oral care (reduces ventilator-associated pneumonia); eye care: absent blink reflex leads to corneal injury; lubricating drops, eye patches if needed.
• Thermoregulation: hypothalamic damage can cause high fever; cooling blankets, antipyretics; avoid shivering.
• Skin and joint integrity: turn every 2 hours, splints, ROM, prevent foot drop.
• Bladder and bowel: avoid long-term indwelling catheter; bowel program.
• Sensory stimulation, family communication and support.

II. Increased Intracranial Pressure

A. Pathophysiology

• Monro-Kellie hypothesis: skull is rigid; brain, blood, CSF volume fixed. An increase in one must be offset by a decrease in another (compensation: CSF displaced to spinal canal, reduced CSF production, venous blood volume reduced).
• Normal ICP: 0 to 10 mm Hg; 15 mm Hg is the upper limit of normal.
• Cerebral perfusion pressure (CPP) = MAP minus ICP. Normal 70-100 mm Hg; goal kept 70-80 (greater than 70). CPP below 50 mm Hg causes irreversible neurologic damage.
• Autoregulation fails at high ICP; cerebral blood flow decreases, hypoxia and hypercapnia cause vasodilation, more edema, higher ICP (vicious cycle).
• Cushing response: rising systolic BP, widening pulse pressure, reflex bradycardia. A late sign needing immediate intervention.
• Cushing triad: bradycardia, hypertension, bradypnea. Grave sign; herniation imminent.
• Herniation: uncal (temporal lobe through tentorium; unilateral dilated pupil from CN III compression), central, and through foramen magnum (brain stem compression, death).

B. Clinical Manifestations

• Early: change in LOC (restlessness, confusion, increasing drowsiness, disorientation), slight pupil changes, weakness of one extremity or one side, headache that worsens with movement or straining.
• Late: LOC falls to stupor and coma; Cushing triad; projectile vomiting; hemiplegia, decorticate or decerebrate posturing, flaccidity; fixed dilated pupils; loss of brain stem reflexes; abnormal respirations; hyperthermia.

C. Diagnostics and ICP Monitoring

• CT, MRI, PET, transcranial Doppler. Lumbar puncture is avoided with increased ICP (risk of herniation).
• Monitoring devices: intraventricular catheter (ventriculostomy; can also drain CSF), subarachnoid bolt, epidural or parenchymal fiber-optic sensors. Brain tissue oxygen monitoring (Licox) and jugular venous saturation (SjvO2).
• Transducer level: foramen of Monro, approximately 2.5 cm above the ear (tragus); re-level with position changes.
• Waveforms (Fig. 61-4): A waves (plateau) last 5 to 20 minutes, amplitude 40 to 100 mm Hg, indicate cerebral ischemia (clinically significant, may precede overt signs). B waves last 30 seconds to 2 minutes, up to 50 mm Hg, seen with intracranial hypertension and decreased compliance; may precede A waves. C waves are small rhythmic oscillations (4 to 8 per minute) related to arterial pressure and respirations.
• Complications of monitoring: infection (ventriculitis, meningitis), CSF leak, over-drainage leading to ventricular collapse and herniation, occlusion, hemorrhage.

D. Medical Management

• Decrease cerebral edema: osmotic diuretics (mannitol) or hypertonic saline 3%; indwelling catheter for diuresis; monitor serum osmolality and electrolytes. Dexamethasone for edema around tumors.
• Fluid restriction may be used; avoid overhydration.
• Induced hypothermia: not consistently beneficial; requires careful management of rewarming.
• Maintain CPP greater than 70 mm Hg: fluids, inotropes (dobutamine, norepinephrine).
• Decompressive hemicraniectomy for refractory intracranial hypertension; bone flap replaced later.
• CSF drainage via ventriculostomy; avoid excessive drainage.
• Ventilation: PaCO2 kept greater than 30 mm Hg; hyperventilation below 30 can cause vasoconstriction and ischemia (controversial, short-term only). Avoid hypoxia; maintain PaO2.
• Reduce metabolic demand: sedation (pentobarbital, thiopental, propofol, dexmedetomidine); paralytics lose neuro exam, so monitor ICP, BP, HR, RR, ventilator response.
• Fever control: antipyretics, cooling blankets (fever increases metabolic demand and ICP).
• Seizure prophylaxis as ordered.

E. Nursing Management (Chart 61-1 related)

• Frequent neuro checks: LOC, pupils, motor, vital signs; report any deterioration.
• Positioning: HOB 30 to 45 degrees, head and neck neutral (no flexion or rotation, which impedes venous outflow); avoid hip flexion, Valsalva, isometric exercise.
• Suction no longer than 15 seconds; hyperoxygenate first; limit passes.
• Space nursing activities; avoid clustering activities that raise ICP; ICP should not exceed 25 mm Hg and should return to baseline within 5 minutes after care.
• Stool softeners; avoid straining, coughing, and enemas.
• Calm environment; minimize noxious stimuli; avoid restraints.
• Maintain normothermia.

F. Complications

• Brain stem herniation, diabetes insipidus, SIADH.
• Diabetes insipidus (low ADH): urine output greater than 200 mL/h for 2 consecutive hours, low urine specific gravity, high serum osmolality, hypernatremia. Treatment: fluid replacement and synthetic vasopressin (desmopressin); monitor potassium. Pituitary surgery can cause transient DI lasting several days.
• SIADH (excess ADH): water retention, dilutional hyponatremia, serum hypo-osmolality, concentrated urine. Treatment: fluid restriction (less than 800 mL/day), 3% saline for severe cases; correct sodium slowly (about 1.3 mEq/L/h maximum) to prevent osmotic demyelination. Usually self-limited.

III. Intracranial Surgery

A. Types

• Craniotomy (bone flap); craniectomy (bone removed); cranioplasty (repair with plastic or metal); burr holes (evacuate blood, place shunts or monitors).
• Supratentorial (above the tentorium; cerebrum): HOB 30 degrees.
• Infratentorial (posterior fossa; brain stem, cerebellum): usually flat or per surgeon; avoid neck flexion; at risk for impaired swallowing, apnea, brain stem compression.
• Transsphenoidal: through the upper lip and nasal cavity to the sella turcica (pituitary tumors).

B. Preoperative

• Neuro baseline; anticonvulsant (phenytoin, levetiracetam, or fosphenytoin) to reduce seizures; corticosteroids (dexamethasone) for edema; fluid and electrolyte status; teaching and support.

C. Postoperative

• Neuro and VS frequently; monitor for increased ICP from cerebral edema (peaks 24 to 36 h), bleeding, hematoma.
• Dressings: check for blood and CSF drainage.
• Temperature: hyperthermia (hypothalamic involvement) or hypothermia after long procedures.
• Fluids individualized; oral fluids after 24 h once gag and swallow return.
• Corticosteroids cause hyperglycemia: glucose every 4 to 6 hours, sliding scale insulin; H2 blockers or PPIs for stress ulcers.
• Watch for DI and SIADH (see above).
• Prevent infection (wound, lines, CSF leak, meningitis); monitor CSF leak.
• Pain: acetaminophen, opioids at low doses with careful neuro assessment.
• Seizures may occur postoperatively; anticonvulsants continued.

D. Transsphenoidal Surgery Care

• Teach: no vigorous coughing, nose blowing, straw use, or sneezing (CSF leak).
• Visual acuity and fields checked frequently (optic chiasm proximity); decreasing acuity suggests expanding hematoma.
• HOB elevated; avoid bending over, straining.
• I&O, specific gravity, serum sodium and osmolality, daily weight (DI risk).
• Nasal packing checked for blood or CSF; CSF leak suspected with clear drainage, positive for glucose, or “salty taste” or postnasal drip. Packing removed in 3 to 4 days.
• Oral care every 4 hours; no tooth brushing until incision above teeth heals; warm saline rinses; cool mist vaporizer; petrolatum to lips.
• Home: humidifier; HOB 30 degrees for at least 2 weeks; no nose blowing or sneezing for at least 1 month.

IV. Other Neurologic Dysfunctions

A. Delirium vs Dementia (Table 61-4)

• Delirium: acute, rapid onset; fluctuating course; lasts 1 day to 1 month; up to 80 percent among hospitalized people; reversible if cause treated (medication toxicity, acute illness, fluid and electrolyte disorders). Often the harbinger of acute medical illness.
• Dementia: Alzheimer disease (75 percent of dementias, slow, chronic, irreversible, 2-20 years) and vascular (multi-infarct, 10-20 percent, abrupt or stepwise after stroke or TIA).
• Screening: Confusion Assessment Method (CAM).
• Delirium interventions: identify and treat underlying cause, reorient, glasses and hearing aids, family presence, sleep hygiene, early mobility, manage pain; avoid restraints and deliriogenic medications; baseline mental status for comparison.

B. Pseudobulbar Affect

• Sudden uncontrollable laughing or crying out of proportion to mood; seen with stroke, TBI, ALS, MS, Parkinson, dementia.
• Treatment: dextromethorphan/quinidine.

V. Seizure Disorders

A. Classification (ILAE 2017, Chart 61-4)

• Focal onset (aware or impaired awareness; motor or nonmotor).
• Generalized onset: tonic-clonic, absence, myoclonic, atonic, tonic, clonic.
• Unknown onset (unclassified when data incomplete).
• Causes: cerebrovascular disease, hypoxemia, fever (childhood), head injury, hypertension, CNS infection, metabolic and toxic conditions (renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticides), brain tumor, drug and alcohol withdrawal, allergies.

B. Nursing Care During a Seizure (Chart 61-5)

• Provide privacy; ease to floor; protect head with a pad.
• Loosen clothing; remove glasses; push away furniture.
• In bed: remove pillows, raise padded side rails.
• Do NOT pry open jaws or insert anything in the mouth. Do NOT restrain.
• Side-lying with head flexed forward if possible; suction secretions.
• Observe and document: onset, what the patient was doing, aura, body parts involved and progression, eye deviation, pupils, duration, incontinence, LOC, postictal state.

C. After a Seizure

• Side-lying, suction as needed (hypoxia, vomiting, aspiration risk).
• Seizure precautions: functioning suction, bed low, 2 to 3 padded side rails up.
• Reorient; patient may be drowsy and amnestic for the event.

D. Epilepsy

• About 3 percent lifetime incidence; most common in children and older adults. Primary (idiopathic) or secondary.
• SUDEP (sudden unexpected death in epilepsy): risk with uncontrolled tonic-clonic seizures.
• Women: seizure frequency often rises during menses; anticonvulsants decrease contraceptive effectiveness; congenital anomaly risk 2 to 3 times higher, so preconception counseling and anticonvulsant levels monitored through pregnancy.
• Long-term anticonvulsants: assess for low bone mass and osteoporosis.
• Older adults: high incidence of new-onset epilepsy (cerebrovascular disease leading cause); drug interactions, altered metabolism; monitor for toxicity and osteoporosis.
• Diagnostics: history, EEG, video-EEG, CT, MRI, labs.

E. Medical and Surgical Management

• Pharmacologic: 70 to 80 percent controlled with medication; monotherapy preferred; serum levels; periodic physical, dental, and lab exams (hematopoietic, GU, hepatic effects).
• Surgery for tumors, abscesses, vascular anomalies, or focal intractable epilepsy (resection of epileptogenic focus).
• Vagal nerve stimulator (VNS): implanted under clavicle for refractory focal seizures; patient swipes magnet at aura; complications include infection, arrhythmia, hoarseness, cough, laryngeal spasm.
• Responsive neurostimulation (RNS); MRI-guided laser interstitial thermal therapy (LiTT).
• Ketogenic or modified Atkins diet (high fat, low carbohydrate) for refractory seizures, most effective in children.

F. Nursing Process: Epilepsy

• Diagnoses: risk for injury, fear, difficulty coping, lack of knowledge. Complications: status epilepticus, medication toxicity.
• Avoid triggers: photic stimulation (dark glasses or covering one eye may help), stress, sleep deprivation, alcohol, excessive stimulants, excessive exercise.
• Patients with interrupted medication regimens are at risk for status epilepticus.
• Phenytoin: oral hygiene after each meal, gum massage, daily flossing, regular dental care for gingival hyperplasia.

G. Health Promotion (Chart 61-6)

• Take anticonvulsants daily; never stop even if seizure-free.
• Keep medication and seizure log; notify provider if unable to take medication due to illness.
• Draw serum levels before the morning dose.
• Avoid driving and machinery until medication effects evaluated.
• Report toxicity: drowsiness, lethargy, dizziness, ataxia, hyperactivity, confusion, visual disturbances.
• Avoid OTC medications unless approved; wear medical alert identification.
• Avoid triggers: alcohol, electrical shocks, stress, caffeine, constipation, fever, hyperventilation, hypoglycemia.
• Showers rather than tub baths; never swim alone; exercise in temperature-controlled environment; regular sleep.

VI. Status Epilepticus

• Definition: seizure lasting 5 minutes or longer, or serial seizures without full recovery of consciousness between them; also continuous clinical or electrical seizures lasting at least 30 minutes. Medical emergency.
• Effects: heavy metabolic demand, impaired respirations, cerebral hypoxia and edema, possible irreversible brain damage.
• Precipitating factors: stopping anticonvulsants (most common), fever, infection, illness.
• Management: airway and oxygen (intubate if unresponsive); IV diazepam, lorazepam, or fosphenytoin given slowly to stop seizures; then phenytoin or phenobarbital to maintain; IV dextrose if hypoglycemic; labs (electrolytes, glucose, anticonvulsant levels); EEG; general anesthesia with short-acting barbiturate if refractory.
• Nursing: monitor respiratory and cardiac function (delayed respiratory depression and hypotension from medications); side-lying, suction available; protect IV line; document seizure activity; protect from injury (long-term anticonvulsant users at fracture risk from bone disease); protect self.

VII. Headache

A. Classification (IHS, Chart 61-7)

• Primary (no organic cause): migraine, tension-type, trigeminal autonomic cephalalgias (cluster).
• Secondary: symptom of another cause (tumor, aneurysm, lumbar puncture, subarachnoid hemorrhage, stroke, severe hypertension, meningitis, head injury).

B. Migraine

• Recurrent severe headache lasting hours to days; strong familial tendency; onset at puberty; more common in women.
• Pathophysiology: hyperexcitable brain with cortical spreading depression; inflammatory neuropeptides and serotonin stimulate meningeal nociceptors.
• Triggers: menstrual hormonal changes, bright lights, stress, depression, sleep deprivation, fatigue, odors; tyramine foods (aged cheese, red wine, beer), MSG, chocolate; oral contraceptives.
• Phases:
  • Premonitory (over 80 percent; hours to days before): depression, irritability, feeling cold, food cravings, anorexia, urinary or bowel changes. Treatment here may abort the migraine.
  • Aura (about 30 percent): focal neuro symptoms, visual (light flashes, bright spots, hemianopia), numbness and tingling, mild confusion, slight weakness, dizziness.
  • Headache: severe, incapacitating, photophobia, phonophobia, allodynia, nausea and vomiting.
  • Postdrome: tiredness, weakness, cognitive difficulty, mood changes; neck muscle ache; may sleep for long periods.

C. Other Headache Types

• Tension-type: steady pressure in forehead, temples, or back of neck; bandlike, “weight on top of my head”; most common type; chronic, less severe.
• Cluster: unilateral, excruciating pain in the eye and orbit radiating to face and temple; 1 to 8 per day; 15 minutes to 3 hours; eye tearing and nasal congestion; more common in men. Triggers: alcohol, nitrites, vasodilators, histamines.
• Cranial (temporal) arteritis: older adults, peak over age 70; immune vasculitis; severe headache over temporal artery, tender nodular swollen artery, fatigue, malaise, weight loss, fever; visual loss risk from ischemia. Diagnosed by artery biopsy.

D. Assessment

• Detailed history: location, quality, frequency, duration, triggers, time of day, associated symptoms, what relieves it, family history, medications, occupational exposures (Right-to-Know Law, safety data sheets).
• Medication-overuse headache: daily OTC or prescribed analgesics 8 to 10 days per month.
• Medications that provoke headache: antihypertensives, diuretics, anti-inflammatories, MAO inhibitors.
• Labs: CBC, ESR (arteritis), electrolytes, glucose, creatinine, thyroid. CT, MRI, angiography if neuro exam abnormal.

E. Medical Management

• Migraine: abortive (infrequent attacks) vs preventive (frequent, predictable attacks).
• Triptans (serotonin receptor agonists; sumatriptan and others): first-line for moderate to severe migraine; best taken early; oral onset 20 to 60 minutes, may repeat in 2 to 4 hours; nasal spray useful with vomiting. Contraindicated in ischemic heart disease. Side effects: increased BP, drowsiness, muscle pain, sweating, anxiety. Interaction with St. John’s wort.
• Ergotamine: causes prolonged cranial vasoconstriction; take early; side effects: muscle aches, paresthesias, nausea and vomiting. Never take with a triptan (prolonged vasoactive reaction).
• Other: NSAIDs, antispasmodics, neuroleptics.
• Prophylaxis: beta-blockers, antiepileptics, antidepressants, ACE inhibitors, ARBs; CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab).
• Cluster acute attack: 100 percent oxygen by face mask for 15 minutes, subcutaneous sumatriptan, or intranasal zolmitriptan.
• Cranial arteritis: early corticosteroids to prevent vision loss; do not stop abruptly (relapse); analgesics.

F. Nursing Management

• Goal is pain relief; try nonpharmacologic measures but do not delay medications.
• Migraine attack: quiet, dark environment; HOB 30 degrees; cold compresses; antiemetics.
• Tension headache: local heat, massage, analgesics, antidepressants, muscle relaxants; reassure it is not a tumor; stress reduction, biofeedback.
• Teaching (Chart 61-8): avoid tyramine foods, long gaps between meals, alcohol, fatigue and irregular sleep; hormone fluctuations; headache diary; stress management; correct medication use.

High-Yield Numbers

Priority Nursing Actions and Red Flags

• Change in LOC is the earliest sign of increased ICP: report immediately.
• Cushing triad (bradycardia, hypertension, bradypnea) and widening pulse pressure: late, grave sign of herniation.
• Unilateral fixed dilated pupil: uncal herniation (CN III compression).
• Airway first in the unconscious patient; GCS less than 8, prepare for intubation.
• Avoid neck flexion, hip flexion, Valsalva, clustered care, prolonged suctioning with increased ICP.
• Clear nasal or wound drainage after neurosurgery: suspect CSF leak; check for glucose; report.
• Sudden high urine output with low specific gravity after pituitary or brain surgery: DI.
• During a seizure: nothing in the mouth, no restraints, protect head, side-lying after.
• Seizure longer than 5 minutes or back-to-back without recovery: status epilepticus, emergency.
• Abrupt anticonvulsant withdrawal is the main cause of status epilepticus.
• Temporal arteritis: start steroids early to prevent blindness.
• Triptans contraindicated with ischemic heart disease and never combined with ergotamine.

Medications

Related

• nsg210-hinkle-ch60-neurologic-assessment
• nsg210-hinkle-ch63-neurologic-trauma
• nsg210-hinkle-ch64-neuro-infections-autoimmune
• nsg210-hinkle-ch65-degenerative-neuro
• nsg210-hinkle-ch45-endocrine-disorders (DI, SIADH)
• INDEX