ACUTE NEUROLOGICAL PROBLEMS

INITIAL MANAGEMENT

-GCS and ABCDE: Assessing and keeping the patient alive:

Ensuring adequate ventilation and maintaining the circulation are the immediate priorities in any patient.

• Glasgow Coma Scale

As  a general rule the scores reflect the severity of the neurological status:

-13 to 15: mild

-9 to 12: moderate

-3 to 8: severe

Coma is defined as a GCS of less than 9.

• ABCDE: click here for definition.

• Critical nursing observations: blood sugar, pupillary responses, temperature, pulse, blood pressure, respiratory rate, oxygen saturations, GCS, top to toe examination and a reliable history.

Broadly there are two types of coma: medical coma, which is due to conditions such as liver failure, respiratory failure and diabetic ketoacidosis, in which the management is primarily aimed at the underlying disease; and neurological coma due to conditions such as stroke, subarachnoid haemorrhage and meningitis.

Causes of coma

• Cerebral hemisphere malfunction:

-drug and alcohol intoxication

-hypoxic brain damage

-stroke

-metabolic disorders

-infection

-post-tonic-clonic convulsion

• Brain stem damage:

-direct damage (brain stem stroke)

-indirect damage (cerebral mass or oedema)

STROKE AND STROKE-LIKE EMERGENCIES

Stroke is a syndrome of rapidly developing clinical signs of focal or global disturbance of function, with symptoms lasting 24 hours or longer with no apparent cause other than of vascular origin.

Causes:

• Cerebral infarction (cerebral embolus or thrombosis):

-Anterior circulation infarcts: which result in a variable combination of one-sided weakness (hemiparesis), one-sided sensory loss (hemianaesthesia), visual disturbance (gaze paralysis) and partial loss of the visual field. In addition, there is a variable disturbance of higher functions such as language, neglect of the affected side and incontinence.

*TACI (total anterior circulation infarct), PACI (partial anterior circulation infarct) and LACI (Lacunar anterior circulation infart).

-Posterior circulation infarcts (POCI): also termed a brain stem CVA. Symptoms affect both sides of the body and also, affect coordination in talking, swallowing, looking and balancing. These patients have combination of dysarthria (slurred speech), dysphagia (difficulty swallowing), double vision and dizziness. 

• Transient ischaemic attacks (TIA): these are minor strokes caused by the passage of small emboli that negotiate the cerebral circulation without producing any permanent damage.

• Intracerebral haemorrhage                          

• Subarachnoid haemorrhage

• Subdural haemorrhage

• Extradural haemorrhage

Nursing the patient with a stroke: the first 24h.

-Avoiding aspiration pneumonia and assessing the swallow. Assess security of the airway and maintain oxygen saturation.

-Monitor pulse, temperature and blood pressure.

-Medical history.

-Managing urinary incontinence which suggests disordered higher cortical function and is common in anterior circulation strokes. Catheterisation causes infection and reduction of the bladder capacity so it chould be avoided.

-Communication: vision, hearing, speech and language must be evaluated and documented at an early stage so it will be possible to spot and monitor any changes.

Interventions in the first 24h

-Diagnosis: FAST (Facial drop, Arm weakness and Slurred speech Test)

The Rosier Scale shown above is used to differentiate stroke from "look-alikes" including hypoglycaemia, syncope and epilepsy.

-Imaging: head CT scan.

-Acute drug intervention.

-Monitor blood pressure, temperature and blood sugar.

-Cerebral oedema may develop after a severe stroke and produce a deterioration in the consciousness levelwithin the first day or so.

-Reversing warfarin.

-Avoiding pressure sores: click here for more information.

-Resuscitation status.

-Avoiding venous thromboembolism. stroke victims are at risk of VTE, DVT and pulmonary embolus. 

MENINGOCOCCAL MENINGITIS

Meningococcal bacteria normally live quite naturally in the oropharynx of about 10% of the healthy population. In meningococcal disease , for some unexplained reasonthe bacteria become virulent and invade the bloodstream . The result is meningicoccal septicaemia and, if the nervous system is also invaded, meningococcal meningitis.

Clinical features of meningococcal infection:

-fever

-haemorrhagic rash

-altered level of consciousness

Septicaemia: influenza, vomiting, muscle pain and drowsiness.

Meningitis: photophobia, headache, neck stiffness and coma.

Clinical deterioration can be extremely rapid, the causes of death in meningitis are septicaemic shock and increased Intracranial Pressure (ICP).

Nursing tasks

-Assessment of ABCDE and vital signs every half an hour. Including fluid balance.

-ECG monitoring.

-Give oxygen and secure IV access.

-Administer immediate IV antibiotics (ceftriaxone or cefotaxime).

-Measurement of GCS.

-Note any rash.

-Discuss isolation for 24 hours with Control of Infection.

Other important nursing tasks are: 

-detain any relatives for further history and advice on contacts,

-ensure there are no drug allergies and ensure immediate specimens are taken for bacteriology (blood cultures, urgent PCR, clotted sample for meningococcal serology and oral or nasal posterior pharyngeal wall swab. Also, preparations should be made for a lumbar puncture if needed to confirm diagnosis. 

The signs of worsening meningitis:

-rapidly progressing rash

-poor peripheral circulation: capillary refill > 4 seconds, systolic blood pressure < 90mmHg and falling urinary output

-respiratory rate < 8 or > 30 breaths/min

-pulse < 40 or > 140 beats/min

-falling (less than 12) or fluctuating (by more than 2) GCS

-development of a focal limb weakness

-fitting

-falling pulse and climbing blood pressure.

SUDDEN LOSS OF CONSCIOUSNESS: FAINTS AND FITS

Sudden loss of consciousness followed by a recovery is usually due to a faint (syncope) or a fit (tonic-clonic convulsion). The history will differentiate fits and faints in most cases, as well as knowing the triggers, onset, the attack and the recovery details.

SYNCOPE

Syncope is due to a sudden reduction in the blood supply to the brain, in most cases, if the patient stays horizontal there is a full and rapid recovery. If the patient is upright, the blood supply does not return rapidly and the syncope may progress to an anoxic convulsion (convulsive syncope).

The reduction in cerebral blood supply has two possible causes:

-sudden change in heart rate (heart block, ventricular tachycardia)

-sudden change in blood pressure (reflex syncope, acute gastrointestinal haemorrhage, acute pulmonary embolus, drug side effect).

Types of syncopes
-Cardiac syncope
-Reflex syncope
-Situational syncope

EPILEPTIC SEIZURES
Click here for a detailed explanation.

Nusing tasks:

• Patients who have regained consciousness:

-primary assessment ABCDE

-measure blood sugar and sitting/standing blood pressure

-12-lead ECG and cardiac monitor/telemetry for arrhythmias

-look for injuries, painful areas, bruising and swelling especially in wrists, ankles, hips and shoulders

-look for signs of upper gastrointestinal blood loss (coffee-ground vomit or melaena)

-look for signs of DVT

-obtain drug history and detain relatives or witnesses for more information.

• Patients who are fitting:

-primary assessment ABCDE (especially airway and good venous access)

-ensure the patient cannot injure himself and place him in the recovery position

-give high concentration oxygen with a non re-breathing mask at 15L/min

-carry out blood sugar measurement and bloods for drug levels, biochemistry, clotting, etc.

-take a full history, especially concerning drugs and alcohol.

• Patients with status epilepticus: status epilepticus is defined as fits that continue for 30 min or more without intervening periods of recovery and is a medical emergency. The management is the same as for a single fit but there is a risk of drug-induced respiratory depression. Close monitoring is needed and if the patient´s conculsions cannot be stopped within an hour, the patient needs ITU care.

ACUTE PARALYSIS OF THE LOWER LIMBS

Possible causes:

-spinal cord disorders: acute diseases of the spinal cord are compressive (urgent surgery), inflammatory (specific drug therapy) or vascular. Urgent MRI will differentiate between the three groups.

-Guillain-Barré syndrome: is an ascending paralysis that starts in the feet and moves progressively up the body, to an extent that the respiratory muscles are often involved. The disease can progress rapidly over a matter of hours and put the patient´s breathing at risk.

Respiratory monitoring is the key for the management of the syndrome.

Source:

-A nurse´s survival guide to acute medical emergencies, R. Harrison and L. Daly, Elsevier 2011

IMMEDIATE ASSESSMENT OF THE CRITICALLY ILL (NEWS)

• ABCDE: IMMEDIATE ASSESSMENT AND INTERVENTION.

1. AIRWAY: check there is no problem with the airway, the airway can be maintained with a jaw thrust or chin lift. Placing the patient in the recovery position may be necessary (if no sign or suspicion of spinal injury). Use a Guedel oral airway if tolerated. Administer high-flow oxygen immediately. Look, listen and feel for expired air.

2. BREATHING: 

-Count the respiratory rate: less than 10 (imminent respiratory arrest), more than 20 (ill) and more than 30 (critically ill).

-Listen for noise and assess the effort.

-Perform oximetry.

-Continue high-flow oxygen.

-Keep the saturations greater than 90%.

3. CIRCULATION:

-Assess pulse rate and strength.

-Assess capillary refill.

-Measure the blood pressure.

4. DISABILITY:

-GCS

-Assess pupil size, equality and reaction.

-Measure blood sugar.

5. EXPOSURE:

-Look for a rash and signs of trauma.

-Check for hypothermia.

-Look in the mouth (tongue biting).

• EARLY WARNING: TRACK AND TRIGGER SYSTEMS.

1.  MEDICAL EMERGENCY TEAM CALLING CRITERIA.

2. EARLY WARNING SCORE (EWS AND NEWS) SYSTEMS.

Link to NEWS chart: National Early Warning Score (NEWS)

The NEWS system is a standarised track-and-trigger system that makes recommendations on the urgency of the clinical response required, the clinical competency of the clinical responders and the most appropiate environment for ongoing clinical care.

When a patient is acutely unwell and presents to hospital, or deteriorates and becomes acutely unwell whilst in hospital, time is of the essence and a fast and efficient clinical response is required to optomise clinical outcomes. Current evidence suggests that the triad of:

-early detection,

-timeliness of response and

-competency of the clinical response

is critical to defining clinical outcomes.

NEWS should not be used in patients under 16 years old or during pregnancy.

The National Early Warning Score system has 6 parameters:

1. Respiration rate:

-Causes of high respiration rate: acute illness and distress, generalised pain, sepsis remote from lungs, CNS disturbance and metabolic disturbances such as metabolic acidosis.

-Causes of low respiration rate: CNS depression and narcosis.

2. Oxygen saturations: assessment of pulmonary and cardiac function, it also takes into account if the patient is on any supplemental oxygen.

3. Temperature: pyrexia and hypothermia are extremes of temperature, sensitive markers of acute illness severity and physiological disturbance.

4. Systolic blood pressure: 

-Hypotension: may indicate circulatory compromise due to sepsis or volume depletion, cardiac failure or cardiac rhythm disturbance, CNS depression, hypoadrenalism and/or effect of blood pressure lowering medications. 

-Hypertension: an elevated blood pressure is an important risk factor for cardiovascular disease but it is the low systolic pressure that is most significant in the context of assessing acute illness severity.

5. Pulse rate:

-Tachycardia: may be indicative of circulatory compromise due to sepsis or volume depletion, cardiac failure, pyrexia or pain and general distress. It may be also due to cardiac arrhythmia, metabolic disturbance or drug intoxication.

-Bradycardia: may be on indicator of hypothermia, CNS depression, hypothyroidism or heart block.

6. Level of consciousness:

-A: the patient is awake.

-V: the patient responds to verbal stimulation.

-P: the patient responds to painful stimulation.

-U: the patient is completely unresponsive.

Urine output monitoring is essential for some patients as dictated by their clinical condition (e.g: sepsis) and this must be included on the fluid balance chart.

There are two mechanisms based on the NEWS which can trigger a clinical response:

-a score of 3 in any one parameter, or

-a total NEWS of 5 or more.

NEWS score: 0

NEWS score: 1-4

NEWS score: a score of 3 in any one parameter, or a total NEWS of 5 or more.

NEWS score: 7 or more.

NEWS is an aid to clinical assessment and not a substitute for competent clinical judgement. Clinical concern about a patient´s condition should always override the NEWS score.


Source:
-A nurse´s survival guide to acute medical emergencies, R. Harrison and L. Daly, Elsevier 2011.
-http://tfinews.ocbmedia.com/

IMBALANCED NUTRITION (CARE PLAN) AND MUST (Malnutrition Universal Screening Tool)

IMBALANCED NUTRITION (LESS THAN BODY REQUIREMENTS)

Intake of nutrients insufficient to meet metabolic needs.

Common related factors: inability to ingest or/and digest foods, inability to absorb, metabolize foods or to procure adequate amounts of food, knowledge deficit, unwillingness to eat and increased metabolic needs caused by disease process or therapy.

Common expected outcome: patient or caregiver verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss. Patient weights within 10% of ideal body weight.

IMBALANCED NUTRITION (MORE THAN BODY REQUIREMENTS)

Intake of nutrients that exceeds metabolic needs.

Common related factors: excessive intake in relation to metabolic need, lack of knowledge of nutritional needs, food intake and/or appropriate food preparation, poor dietary habits, use of food as coping mechanism, metabolic disorders, sedentary activity level.

Common expected outcomes: patient verbalizes accurate information about benefits of weight loss and necessary measures to achieve beginning weight reduction. Patient demonstrates appropriate selection of meals or menu planning toward the goal of weight reduction.

MUST (Malnutrition Universal Screening Tool)

‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition 

(undernutrition), or obese. It also includes management guidelines which can be used to develop 

a care plan.

Step 1 

Measure height and weight to get a BMI score using chart provided.

Step 2 

Note percentage unplanned weight loss and score using tables provided.

Step 3 

Establish acute disease effect and score.

Step 4 

Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition.

Step 5 

Use management guidelines and/or local policy to develop care plan.

Sources:

http://www.bapen.org.uk/pdfs/must/must_full.pdf

Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.

CONSTIPATION (CARE PLAN) AND RISK SCALE

CONSTIPATION (NANDA - 1 diagnosis)

Definition: decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

Common Related Factors
-Inadequate fluid intake
-Low-fiber diet
-Inactivity, immobility
-Medication use
-Lack of privacy
-Fear of pain with defecation
-Habitual denial and ignoring of urge to defecate
-Laxative abuse
-Stress/depression
-Tumor or other obstruction mass
-Neurogenic disorders

Defining characteristics
-Infrequent passage of stool
-Passage of hard , dry stool
-Straining at stools
-Passage of liquid fecal seepage
-Frequent but nonproductive desire to defecate
-Anorexia
-Abdominal distention
-Nausea and vomiting
-Dull headache
-Verbalized pain or fear of pain with defecation


Common Expected Outcome
Patient passes soft, formed stool at a frequency perceived as normal by the patient.
Patient or caregiver verbalizes measures that will prevent recurrence of constipation.

Source: Nursing Care Plans Diagnoses, Interventions and Outcomes. Meg Gulanick, 8th Edition.

ETON/NORGINE CONSTIPATION RISK SCALE

LAXATIVES

1. Bulk-forming laxatives:

-Ispaghula husk (Fibrelief, Fybogel, Isogel, Ispagel orange, Regulan).

-Methylcellulose (Celevac).

-Sterculia (Normacol).

2. Stimulant laxatives:

-Bisacodyl

-Dantron (Co-danthramer, Co-danthrusate).

-Docusate sodium (Dioctyl, Docusol, Norgalax Micro-enema).

-Glycerol (Glycerol suppositories).

-Senna (Manevac, Senokot).

-Sodium picosulfate (Dulcolax).

3. Faecal softeners:

-Arachis oil

-Liquid paraffin

4. Osmotic laxatives:

-Lactulose.

-Macrogols (Laxido, Movicol).

-Magnesium salts (Magnesium hydroxide Mixture, Magnesium hydroxide with liquid paraffin, Magnesium sulphate).

-Phosphates (rectal): Carbalax, Fleet Ready-to-use enema, Phosphates Enema. 

-Sodium citrate (rectal): Micolette Micro-enema, Micralax Micro-enema, Relaxit Micro-enema.

5. Bowel cleansing solutions: Citrafleet, Citramag, Fleet Phospho-soda, Klean-Prep, Moviprep, Picolax).

6. Peripheral opioid-receptor antagonists (licensed for the treatment of opioid-induced constipation in patients receiving palliative care):

-Methylnaltrexone Bromide (Relistor sc injection).

Source: BNF 57 March 2009.