Nursing with Dr. Hobbick
In each episode, we'll dive deep into the core subjects that you encounter in your nursing classes. From fundamental concepts to advanced topics, we'll break down complex ideas into understandable and relatable discussions. As a nursing professor, my goal is to bridge the gap between classroom theory and real-world practice, ensuring you're well-prepared for the challenges and opportunities that lie ahead.
Join me as we explore essential nursing theories, patient care strategies, healthcare ethics, clinical reasoning, evidence-based practice, and much more. I'll draw upon my extensive experience in both nursing education and practical nursing to provide you with a comprehensive perspective that goes beyond the textbook.
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Nursing with Dr. Hobbick
Neurologic Care
Ever wondered how the Glasgow Coma Scale impacts patient prognosis? Or why outdated methods in feedings could be detrimental for patient care? With Dr. Hobbock as our guide, we untangle these subjects and more in a comprehensive look at the neurologic system in nursing. Together, we debunk ambiguous terms in measuring altered states of consciousness, advocating for the specificity of the Glasgow Coma Scale. We also underscore the importance of regular vitals and go in-depth into the risks of aspiration for patients and methods to prevent it.
As we shift gears, we put the spotlight on the pivotal role of correct processes for feedings and the need to check the placement of an enteral tube. Dr. Hobbock illustrates why old-school methods are no longer reliable and the pressing need for accurate techniques. We further explore the potential complications of immobility and preventive measures. Wrapping up, we dive into monitoring vital signs, recognizing increased intracranial pressure, and the role of constant communication in patient care. Join us on this journey, filled with essential insights and actionable tips, a must-listen for all nursing enthusiasts and healthcare professionals.
Hey and welcome to Nursing with Dr Hobbock. Today's going to be a longer episode because we're going to dive into the neurologic system. The first thing that we're going to talk about is the Glasgow Coma Scale. You should be familiar with this scale. You should have a good idea of it, if not, have it memorized. It's going to measure eye opening either spontaneously to verbal commands to pain or no response. It measures motor responses to a verbal command, to painful stimuli. Do they localize with pain, flex or withdrawal? Do flex or posturing or decorticate Extensive posturing, which is discerabit, or no response, and then a verbal response. Does the patient respond to you oriented and converse? Are they disoriented but conversing? Are they using inappropriate words, incomprehensible sounds or no response? Something to keep in mind is the maximum total for the Glasgow Coma Scale is 15. The minimum is 3. 7 or less indicates coma. 7 or less indicates a coma. The lower the score, the less conscious the patient is. The higher the score, the better. People who have scores greater than 8 usually have a better prognosis for recovery.
Speaker 1:Let's talk about altered states of consciousness. While we're talking about this Glasgow Coma Scale, you're going to use the Glasgow Coma Scale to measure altered states of consciousness. It's much more specific than ambiguous terms like somnolent, obtunded. We kind of want to avoid stuporous lethargic. Those are ambiguous, they're not very, very specific. This Glasgow Coma Scale is much more specific, so make sure that you're familiar with it when you're doing an assessment for someone with an altered level of consciousness.
Speaker 1:You also want to do, of course, regular vital signs Heart rate, blood pressure, sp2. Sometimes it's an oxygen problem, sometimes it's a perfusion problem. There could be a lot of things going on. So we want to make sure we get as many assessment pieces as we can. So get your tools out Pupil size, limb movement. Of course, our vital signs. You want to check skin integrity, corneal integrity. We want to check for bladder fullness. This is a big one to keep in mind for altered level of consciousness or patients with spinal cord injury. We want to check that bladder for fullness. We're going to put an indwelling catheter in if we have to or do straight casts, whatever is ordered. We want to make sure we're listening to lung sounds and cardiac sounds, cardiac status and of course you're going to want to find out is this normal for this patient? Talk to family or a secondary source to find out. These patients are at high risk for aspiration. So we typically are going to feed them enterally or parenterally, so we might see a feeding tube, and we need to remember the correct process for feedings.
Speaker 1:Number one checking placement of an enteral tube via oscultation. You know those old school nurses told you to put your stethoscope on the patient's belly and push some air in. That doesn't work. There's plenty of research to support that. That is not affected. It doesn't tell you if the tube is in the right place. Don't use it. You want to use observation and PH strips, so if your facility doesn't have those, advocate for them. The gold standard is X-ray, so make sure there's an X-ray on file that shows you the tube is in the right place. We don't get an X-ray every time we check the patient though.
Speaker 1:So when we get ready to go do any kind of insertion of anything into an enteral tube medications, feedings you want to check placement and you're going to do that by aspirating gastric contents, checking the PH of those contents, and then you want to make sure that you are checking residual if you're doing enteral feedings. Residual is the residue, the leftovers, the amount that's left after the patient has been a certain period of time. Usually there's an order that tells you how often to check residuals. My experience it's like every four hours or I would check them whenever I'm going to access the tube. What you're going to do is aspirate everything out of the tube that you can. If you have to use a graduated cylinder to hold those contents, if there's a hundred or more, or whatever your facility policy is, that indicates that we may not have good gastric emptying. So checking placement is with PH, checking gastric emptying is with that gastric residual. Now it's really important for you to put that gastric residual back. Number one is partially digested. Number two it's got acid in it. If you take all that acid away from your patient, what's going to happen? Alkylosis. So put all that back in there and follow your facility policy on notifying the provider.
Speaker 1:We want to make sure that we understand that if the patient is comatose, a lot of the times they're going to experience paralytic ileus, meaning that the intestines are not moving. So we're not going to do any kind of insertion, any feeding or anything if there's no bowel sound. So you're always going to check bowel sounds before you access a tube. If the patient has paralytic ileus, we're probably using a NG tube for gastric decompression. So it's going to be to usually low intermittent suction when our patient has an altered level of consciousness.
Speaker 1:You have to make sure that you are working to prevent all of those side effects or complications of immobility. You're doing range of motion every four hours. You're turning the patient at minimum every two. Remember the two hours is a minimum mark. If you can turn them every hour that's way better. I like to coordinate with my aids or my unlicensed assistive personnel that they go in every two hours. I go in every two hours and we stagger it so that we can get that patient moved around every hour. I guarantee this patient is at risk just because of their condition and so two hours may be too long.
Speaker 1:We want to try to get them turned as much as we can. If you anticipate that there's going to be intubation or if there's a problem with the airway, insert an oral airway or of course you're going to call a rapid response and that'll all get taken care of. We're going to monitor PO2 and PCO2. We want to make sure that we are keeping these patients NPO. If your patient has a sudden change in level of consciousness, npo is the way to go. We don't want to put anything in their mouth and then aspirate. So make sure that you're keeping them NPO and we're going to do mouth care every four hours on patients who are NPO because we want to keep that area clean. Of course we want to make sure that we're recording intake and output and then, to avoid those complications, turn on our patients range of motion, maybe advocate for sequential compression devices or elastic compression stockings because we want to prevent those DVTs.
Speaker 1:Urinary Calculi is a complication of immobility. So in making sure that they're getting enough fluid intake, either gastric, po or IV, making sure we're checking that urine specific gravity to see if it's high, making sure we're keeping an eye on intake and output over a 24-hour period and if possible, apply splints like for foot drop to prevent that, to prevent wrist drop. You'll coordinate with your provider for those things. Keeping an eye on our vital signs is going to be important because we're also monitoring potentially for increased intracranial pressure. Any change in heart rate that goes down below 60 or above 100 could indicate that we want to make sure that we're keeping an eye on blood pressure. The blood pressure is going up or we have a widening pulse pressure. Remember that that can indicate increased ICP. Any temperature abnormalities could indicate the patients getting worse. You can monitor their temperature.
Speaker 1:We want to make sure that we are continuing to use the Glasgow Coma Scale to measure the level of consciousness and we're keeping an eye on those pupils, preventing injury. Of course, we're always keeping the bed in low position, side rails up at all times. Make sure that you are patting those rails, that the patient is a safety risk or a seizure risk, and we want to be really careful about monitoring for over sedation because that can impact our vital signs and our assessment, disguise worsening conditions. Make sure that you're keeping an eye on that. Whenever you're touching a patient with an altered state of consciousness it doesn't matter how deep they are You're talking to them, you're telling them what you're doing, constantly talking to the patient. Even if you think they're totally in a coma, you're still going to talk to them and let them know what you're doing, let them know that you're going to touch them, let them know you're doing a bath. Whatever it is you're doing, we still want to make sure that we're doing hygiene. Grooming, bathing, oral hygiene is going to be super important Wash their hair, provide nail care If they need it. We want to make sure that we are checking their eyes for coronal injury. If the eyes are not able to, if the patient's blink reflex is gone, you want to make sure the eyes stay closed and we're going to keep those irrigated, maybe with sterile solution that's prescribed, or instilling an ointment in their eyes, whatever is ordered by the provider. So keep those things in mind for your altered level of consciousness.
Speaker 1:Next, let's talk about traumatic brain injury or head injuries. We have a head injury, which is any traumatic damage to the head. You can have an open traumatic brain injury. Of course this is where we've got a fracture in the skull, or penetration by an object, or closed Closed is more serious because we can have swelling or bleeding inside the brain, inside the skull, and that doesn't give the skull, doesn't give it all, and that can increase intracranial pressure, which can then cause a decrease in actual blood flow to the brain because those capillaries and stuff arteries get compressed.
Speaker 1:The biggest concern that you're going to have, the worst complication, is going to be increased intracranial pressure, which we've already addressed just a little bit ago. Things that you're going to keep an eye on are going to be their symptoms, so unconsciousness, disturbances in consciousness. They may have vertigo, confusion, delirium. They may be disoriented. This should sound very familiar because we're going to use the Glasgow Coma Scale here to measure the patient's worsening or improvement. Hopefully.
Speaker 1:Change in level of responsiveness is the most important symptom of increasing intracranial pressure. Again, that's that change in level of responsiveness. So if you have any kind of change in a patient who's had a head injury, you're going to want to report that stat. Even subtle changes like restlessness, irritability or confusion that's worsening or new, that can indicate that increased ICP. Again, we're watching pulse for elevation or decrease, watching blood pressure if it's going up or if there's a widening pulse, pressure, temperature rise. We want to make sure we control that if we can. We may see headache, vomiting, pupillary changes. We want to keep an eye on those.
Speaker 1:Seizures. Ataxia, abnormal posturing this is where that decerebrate or decorticate comes in. Any leaking of cerebral spinal fluid, either through the nose or the ear remember that we can tell that by the halo sign or it's got glucose in it. Normal mucus does not. Hematomas may be something that we see and if a patient has a CSF leak that can actually keep them from demonstrating those normal signs of increased ICP, they may not occur. Want to keep an eye out for those things.
Speaker 1:Ct MRI scan is going to show either an epidural or subdural hematoma. If it requires surgery, we may get an EEG to measure for seizure activity and what you're going to do as the nurse. You're going to monitor oxygen, p02, pco2. We're looking for hypoxia or hypercapnia. We want to make sure that we're positioning the client semi-prone or lateral recumbent to help prevent aspiration, especially if they're vomiting. We'll make sure you're preventing those complications of immobility. I'm not going to go over those again. We heard those just a little bit ago. We're going to do neurologic vital signs frequently and if we have any signs of deterioration we're going to notify the provider right away.
Speaker 1:We want to avoid anything that's going to increase endocrinial pressure. So, changing bed position, extreme hip flexion, suctioning, endotracheal suctioning, compression of the jugular veins you want to make sure you keep the head straight in that natural position, not turn to one side or the other. A coughing, vomiting, straining, no val salvas those can all increase endocrinial pressure. If the patient has a temperature increase, you want to make sure that you address it right away. Whatever is ordered usually it's acetaminophen or Tylenol we want to get that into the patient a cooling blanket if needed, because an increase in temperature is going to increase cerebral blood flow, which is going to cause an increase in ICP, especially if it's already happening. So we want to make sure that we're not doing that. Now there is such a thing as an intercranial monitoring system. This is a catheter that's inserted into the lateral ventricle and there's a sensor there placed on the dura, or a screw into the subarachnoid space that's attached to a pressure transducer. We want to make sure that we notify the provider stat of anything over 20 millimeters. Mercury no-transcript.
Speaker 1:We might be giving some medications hyper-osmotic agents and diuretics to dehydrate the brain excuse me, dehydrate the brain or to prevent cerebral edema. Manitol is one of the big ones, urea is another one. Steroids we might be giving dexamethasone or methylprednisolone. Sodium succinate Barbiturates are actually gonna reduce brain metabolism and systemic BP, and those are things that we're gonna keep an eye on, of course, in taking out putty. It's gonna be really important, especially if they're on osmotic diuretics. We may have a passive hyperventilation on a ventilator that's gonna lead to respiratory alkalosis which is gonna cause cerebral basoconstriction. And then we're gonna continue our seizure precautions. They may order phenitoin just as a prophylactic for seizures, and then we wanna make sure that we're talking to the patient about post-traumatic syndrome headaches, vertigo, emotional instability, inability to concentrate, impaired memory. They could have post-traumatic epilepsy or even post-traumatic neurosis or psychosis. So that is traumatic brain injury and we'll move on to spinal cord injury next. Thanks for hanging out with me today on Nursing with Dr Hobbock. I hope you enjoy. I'll see you next time with spinal cord injuries.
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