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CRITICAL CARE

CHALLENGES
3.BRAIN STEM
4.CEREBELLUM

4 LOBES

1. Frontal – judgement
2. Temporal – comprehension; stock memory
3. Parietal – distance, temperature and pain
4. Occipital – vision (dizziness and blurring of vision)

SPINAL CORD

Basic part
1. sensory – things that receives the messages.
2.motor – will deliver messages.(pain)
3. connector – that’s link the two.

2
ASSESSMENT
• Why is it important?
a. To establish baseline neurological assessment to note
deviations and trends which part of the brain that tells
/control your awareness. “reticullar activating system”.
b. Detect changes in the neurologic status of the patient.
c. Minimize loss of function from neurologic deficits.
d. Determine effects of neurologic dysfunction on ADL.
e. Compare data from previous assessment to the present.

3
PARAMETERS TO BE USE OF NEUROLOGICAL
ASSESSMENT
• History taking
• Vital signs
• LOC
a. Alert – oriented to person, time & place.
b. lethargic- patient sleep most of a time but responded upon calling upon his/her name.
c. Abtended – sleep most of a time but responded by apply painful stimuli or by shouting after
applying to pain and back to sleep.
d. Drowsy/ stupor – to painful stimuli
e. semi-coma – flex or extend by applying pain
f. Coma – no response to all even in painfull stimuli.

• Pupillary assessment
size 2-3mm
Equality
Reaction

Note ! If narcotics is given the pupil size is constricted.


AtSO4 –Dilates the pupils
paracetamol – constricted
pons is damaged pin point
bilateral dilation – no o2 supply / hypoxia
unesocoric – hernation of the brain
• Motor function evaluation
inspect for the muscle size if it is atropy ( loss of muscle tone/
skinny).Hypertropy ( no resistance).

• Muscle tone – is the normal state of the muscle tension.


spastic- increase resistance to passive stretching.
flaccid – no control/ muscle tone hypotonia.

• Motor strength
5/5 normal movt. against gravity and resistance.
4/5 full range of motion against moderate resistance and gravity.
3/5 full range against gravity only not against resistance.
ASSESSMENT IN INCREASE INTRA CRANIAL PRESSURE
• RESTLESSNESS – initial signs of increase ICP.
• HEADACHE – due to traction or pressures.
• VOMITING – results from the pressure at the medulla oblongata it may be projectile.
• DIPLOPIA –pressures at the CN VI ( abducens) which controls lateral rectus muscles of the eye.
• DECREASE LOC – due to affection of ascending reticular activating system.
• CUSHING REFLEX – due to cerebral hypoxia.
• SYSTOLE – increase due to increase force of contractions.
• DIASTOLE – remains normal or decrease due to longer time required for the heart to relax
• WIDENING OF THE PULSE PRESSURE
• RESPIRATORY RATE – slow due to involvement of the medulla oblongata and pons.
• TEMPERATURE – increase due to involvement of hypothalamus.
• UNESOCORIA – due to CN 111 compression.There is ipsilateral pupil dilation.
• FIXED DILATED –indicate uncal hernation.Brain stem compression.
• PUPIL EDEMA - result from compression of the optic nerve or “choked disc)
• DECORTICATE – involvement of the mid brain-cerebral cortex
• DECEREBRATE – brain stem involvement
CEREBELLAR EXAMINATION
• Finger to nose test

NURSING MANAGEMENT
1. Impaired gas exchange
• Maintaining airway clearance.
• Pulmonary hygiene
• Oxygen
• Tracheostomy care

2. Alteration in tissue perfusion


• Mobilization
• Positionning
• Prevent thrombophlebitis
• Maintaining cerebral blood flow

3. Impaired physical mobility


• Maintaining body alignment
• ROM exercise
• Traction

4. Impaired skin integrity


• Skin care to incontinent patient.
4. Impaired skin integrity
skin care to incontinent patient.
5. Self care deficit
• Bathing
• Mouth care
• Eye care
• Nail care
6. Alteration in fluid volume
• Intra venous fluids
7. Alteration in nutrition
• Meeting with nutritional needs
• Dealing with dysphagia
• Tube feeding
• TPN
8. Alteration in bowel elimination
8. Alteration in pattern of urinary elimination
• Catheter care
• Bladder training
SPECIFIC NURSING CARE OF
THE PEDIATRIC
CRITICALLY – ILL
PATIENTS
Big difference in little people
1. size
2. weight – dose/kg
FORMULA:
<6 mos age in month x 600+3000
>6 mos age in month x 500+3000
1 yr and above age in years x 2 + 8

3. Body proportions
4. Anatomy
a. Airway face and mandible are small.
b. Trachea – short and soft.
c. Breathing – lungs are immature. Both upper and lower airways are relatively small and
are consequently obstracted.
5. Physiology
a. Airway and breathing ( infants have a greater metabolic rate and O2 consumption.
6. Psychology
a. Communication – infants and young children either have no longer ability or are still
developing their speech.
RECOGNITION OF SERIOUSLY ILL CHILD
1. HYPOXIA – cardiac arrest is usually secondary to hypoxia.
2. SHOCK – circulatory failure

1. RECOGNITION OF POTENTIAL RESPIRATORY FAILURE


NORMAL RESPIRATION IN PEDIATRIC
AGE BPM
O – 12 30 – 60
1–3 24 – 40
3 -5 22 - 34
5 -12 18 – 30
18 ABOVE 12 – 16

RESPIRATORY MECHANICS (manifestations)


a. Tachypnea -1st
b. Slow or irregular
c. Nasal flaring
d. Retractions ( inspiration)
e. Head bobbing
f. Grunting – to increase end expiratory airway pressure by premature glottic closure
accompanying late expiratory contraction of the diaphragm.
2. EFFECTIVENESS OF BREATHING
• Air entry – effectiveness of ventilation is clinically assessed by evaluation
of chest expansion and breath sounds.
• Pulse oximeter – monitor O2 saturation
• ABG

II RECOGNITION OF POTENTIAL CIRCULATORY FAILURE


1. Tachycardia – compensatory mech.
2. Bradycardia
3. Hypotension – late and pre terminal signs
4. Pulses
5. Capillary refill
III. RECOGNITION OF POTENTIAL NEUROLOGIC FAILURE
• Use of glascow coma scale

GENERAL NURSING CARE


1. improve cardiac fxn.
2. Monitor CVP.
3. Observe the intensity of peripheral pulses, color of the skin, capillary refill
and temp.
4. Monitor ECG for configuration of the P wave.
5. Be familiar of the cardiac drugs. (inotropics, vasodilators, beta blockers)
6. Adequate cardiac output.
• Good skin turgor
• Good capillary refill
• Pt. is alert and awake
• Adequate u.o.
7.Improve respiratory function
• Mechanical ventilation
- Needed to maintain adequate oxygenation.
- Should be maintained until hemodynamic and respiratory function are stable

• Provide pulmonary toilette


- Tracheal suctioning should be performed immediately with in the first hour
of return from theatre and as secretions dictates.
- Ascultate both lungs before and after suctioning
- Do chest physiotherapy
- CPT session should be short and frequent using appropriate tech such as
percussion, vibration, hand ventilation and suctioning.

SIGNS OF NEONATAL SEPSIS


1. Lethargy
2. Seizures
3. Apneic spells
4. Increase or decrease respiration
5. Persistence jaundice
g. Stridor – an inspiratory high pitched sound.(signs of upper resp.
obstruction). . Wheezes – indicates lower airway narrowing
THANK YOU!

Maria Cristina S. Alteran RN MN

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