Chapter 61: Managing Neurologic Dysfunction

Specific unconscious states covered include akinetic mutism, persistent vegetative state, and the life-ending brain death, and initial medical priority is securing a patent airway, while long-term nursing care focuses on supporting respiratory function, preventing injury, regulating body temperature, ensuring adequate hydration and nutrition, and managing bladder and bowel function. A key focus is increased intracranial pressure (ICP), normally between 0 and 10 millimeters of mercury, which is governed by the Monro-Kellie hypothesis, stating that because the cranial vault is rigid, a change in the volume of brain tissue, blood, or cerebrospinal fluid (CSF) necessitates a compensatory shift in the others to maintain equilibrium. Elevated ICP decreases cerebral perfusion pressure (CPP), which is the difference between mean arterial pressure and ICP, and if CPP drops too low, irreversible neurologic damage occurs; imminent danger is signaled by the Cushing's response and the Cushing's triad. Management of elevated ICP involves administering osmotic diuretics like mannitol to reduce cerebral edema, draining CSF through devices such as a ventriculostomy, and avoiding head and neck positions or maneuvers that impair venous return or increase intra-thoracic pressure. Surgical procedures like craniotomy, which opens the skull to address lesions or hemorrhage, and the transsphenoidal approach, typically used for pituitary gland access, require detailed pre- and post-operative nursing care focused on preventing complications such as infection, hemorrhage, and fluid imbalances like diabetes insipidus or the syndrome of inappropriate antidiuretic hormone (SIADH). The text also addresses delirium, an acute confused state requiring prompt identification using tools like the Confusion Assessment Method (CAM) and treatment of the underlying cause, differentiating it from dementia, which is characterized by chronic, progressive intellectual decline. Furthermore, the chapter details seizure disorders resulting from abnormal electrical discharges in cerebral neurons, classifying them as focal, generalized, or unknown onset, with epilepsy being two or more unprovoked seizures; nursing responsibilities during a seizure prioritize protecting the patient from injury and documenting the event, while treatment often involves anticonvulsant medication, with severe cases sometimes requiring devices like the vagal nerve stimulator (VNS) or responsive neurostimulation systems (RNS), and status epilepticus is highlighted as a medical emergency requiring immediate intervention to halt continuous seizures and ensure oxygenation. Finally, the chapter examines headaches, including primary types like migraines—often triggered by hormonal changes or certain foods and treated with vasoconstrictive triptans—tension headaches, and cluster headaches, stressing the importance of comprehensive patient history and trigger avoidance for preventive management.