This document outlines various nursing diagnoses and interventions for patients with several different neurological conditions and injuries. It covers patients with altered levels of consciousness, increased intracranial pressure, brain injuries, spinal cord injuries, strokes, seizures, Parkinson's disease, multiple sclerosis, Guillain-Barré syndrome, brain tumors, and those undergoing cervical disc surgery. For each condition, it lists common nursing diagnoses related to issues like impaired mobility, respiratory function, cognition, and self-care as well as interventions to address these concerns.
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Nursing management of CNS.pptx
1.
2. THE PATIENT WITH AN ALTERED LEVEL
OF CONSCIOUSNESS
Ineffective airway clearance related to altered level of consciousness
Risk of injury related to decreased level of consciousness
Deficient fluid volume related to inability to take in fluids by mouth
Impaired oral mucous membranes related to mouth breathing, absence
of pharyngeal reflex, and altered fluid intake
Risk for impaired skin integrity related to immobility
Impaired tissue integrity of cornea related to diminished or absent
corneal reflex
Ineffective thermoregulation related to damage to hypothalamic center
3. Impaired urinary elimination (incontinence or retention) related to
impairment in neurologic sensing and control
Bowel incontinence related to impairment in neurologic sensing and
control and also related to transitions in nutritional delivery methods
Disturbed sensory perception related to neurologic impairment
Interrupted family processes related to health crisis
4. Nursing Interventions
Maintaining the airway
Protecting the patient
Maintaining fluid balance and managing nutritional needs
Providing mouth care
Maintaining skin and joint integrity
Preserving corneal integrity
Achieving thermoregulation
Preventing urinary retention
6. NURSING PROCESS:
THE PATIENT WITH INCREASED ICP
Ineffective airway clearance related to diminished protective reflexes (cough,
gag)
Ineffective breathing patterns related to neurologic dysfunction (brain stem
compression, structural displacement)
Ineffective cerebral tissue perfusion related to the effects of increased ICP
Deficient fluid volume related to fluid restriction
Risk for infection related to ICP monitoring system (fiberoptic or
intraventricular catheter)
Other relevant nursing diagnoses are included in the section on caring for
patients with altered LOC.
8. NURSING PROCESS:
THE PATIENT UNDERGOING
INTRACRANIAL SURGERY
Ineffective cerebral tissue perfusion related to cerebral edema
Potential for ineffective thermoregulation related to damage to the
hypothalamus, dehydration, and infection
Potential for impaired gas exchange related to hypoventilation,
aspiration, and immobility
Disturbed sensory perception related to periorbital edema, head
dressing, endotracheal tube, and effects of ICP
Body image disturbance related to change in appearance or physical
disabilities
10. NURSING PROCESS:
THE PATIENT WITH EPILEPSY
Risk for injury related to seizure activity
Fear related to the possibility of seizures
Ineffective individual coping related to stresses imposed by epilepsy
Deficient knowledge related to epilepsy and its control
11. Nursing Interventions
Preventing injury
Reducing fear of seizures
Improving coping mechanisms
Providing patient and family education
12. NURSING PROCESS:
THE PATIENT RECOVERING
FROM AN ISCHEMIC STROKE
Impaired physical mobility related to hemiparesis, loss of balance and
coordination, spasticity, and brain injury
Acute pain (painful shoulder) related to hemiplegia and disuse
Self-care deficits (hygiene, toileting, grooming, and feeding) related to
stroke sequelae
Disturbed sensory perception related to altered sensory reception,
transmission, and/or integration
Impaired swallowing
Incontinence related to flaccid bladder, detrusor instability, confusion,
or difficulty in communicating
13. Disturbed thought processes related to brain damage, confusion, or
inability to follow instructions
Impaired verbal communication related to brain damage
Risk for impaired skin integrity related to hemiparesis/ hemiplegia, or
decreased mobility
Interrupted family processes related to catastrophic illness and
caregiving burdens
Sexual dysfunction related to neurologic deficits or fear of failure
14. Nursing Interventions
Improving mobility and preventing joint deformities
Preventing shoulder adduction
Positioning the hand and fingers
Changing positions
Establishing an exercise program
Preparing for ambulation
Managing sensory-perceptual difficulties
Managing dysphagia
15. Managing Tube Feedings
Attaining bowel and bladder control
Improving communication
Improving thought processes
Maintaining skin integrity
Improving family coping
Helping the patient cope with sexual dysfunction
16. NURSING PROCESS:
THE PATIENT WITH A
HEMORRHAGIC STROKE
Ineffective cerebral tissue perfusion related to bleeding
Disturbed sensory perception related to medically imposed restrictions
(aneurysm precautions)
Anxiety related to illness and/or medically imposed restrictions
(aneurysm precautions)
18. NURSING PROCESS:
THE PATIENT WITH A BRAIN INJURY
• Ineffective airway clearance and impaired gas exchange related to brain injury
• Ineffective cerebral tissue perfusion related to increased ICP and decreased
CPP
• Deficient fluid volume related to decreased LOC and hormonal dysfunction
• Imbalanced nutrition, less than body requirements, related to metabolic
changes, fluid restriction, and inadequate intake
• Risk for injury (self-directed and directed at others) related to seizures,
disorientation, restlessness, or brain damage
• Risk for imbalanced (increased) body temperature related to damaged
temperature-regulating mechanism
19. • Potential for impaired skin integrity related to bed rest, hemiparesis,
hemiplegia, and immobility
• Disturbed thought processes (deficits in intellectual function,
communication, memory, information processing) related to brain injury
• Potential for disturbed sleep pattern related to brain injury and frequent
neurologic checks
• Potential for compromised family coping related to unresponsiveness of
patient, unpredictability of outcome, prolonged recovery period, and the
patient’s residual physical and emotional deficit
• Deficient knowledge about recovery and the rehabilitation process
20. Nursing interventions
Maintaining the airway
Monitoring fluid and electrolyte balance
Promoting adequate nutrition
Preventing injury
Maintaining body temperature
Maintaining skin integrity
Improving cognitive functioning
Preventing sleep pattern disturbance
Supporting family coping
21. NURSING PROCESS:
THE PATIENT WITH ACUTE
SPINAL CORD INJURY
• Ineffective breathing patterns related to weakness or paralysis of abdominal
and intercostal muscles and inability to clear secretions
• Ineffective airway clearance related to weakness of intercostal muscles
• Impaired physical mobility related to motor and sensory impairment
• Disturbed sensory perception related to motor and sensory impairment
• Risk for impaired skin integrity related to immobility and sensory loss
• Urinary retention related to inability to void spontaneously
• Constipation related to presence of atonic bowel as a result of autonomic
disruption
• Acute pain and discomfort related to treatment and prolonged immobility
22. Nursing Interventions
Promoting adequate breathing and airway clearance
Improving mobility
Promoting adaptation to sensory and perceptual alterations
Maintaining skin integrity
Maintaining urinary elimination
Improving bowel function
Providing comfort measures
23. NURSING PROCESS:
THE PATIENT WITH QUADRIPLEGIA
OR PARAPLEGIA
Impaired physical mobility related to loss of motor function
Risk for disuse syndrome
Risk for impaired skin integrity related to permanent sensory loss and
immobility
Urinary retention related to level of injury
Constipation related to effects of spinal cord disruption
Sexual dysfunction related to neurologic dysfunction
Ineffective coping related to impact of dysfunction on daily living
Deficient knowledge about requirements for long-term management
25. NURSING PROCESS:
THE PATIENT WITH MULTIPLE SCLEROSIS
Impaired physical mobility related to weakness, muscle paresis,
spasticity
Risk for injury related to sensory and visual impairment
Impaired urinary and bowel elimination (urgency, frequency,
incontinence, constipation) related to nervous system dysfunction
Impaired speech and swallowing related to cranial nerve involvement
Disturbed thought processes (loss of memory, dementia, euphoria)
related to cerebral dysfunction
26. Ineffective individual coping related to uncertainty of course of MS
Impaired home maintenance management related to physical,
psychological, and social limits imposed by MS
Potential for sexual dysfunction related to spinal cord involvement or
psychological reactions to condition
27. Nursing Interventions
Promoting physical mobility
Exercises, minimizing spasticity and contractures, activity and rest,
minimizing effects of immobility, preventing injury, enhancing
bladder and bowel control, managing speech and swallowing
difficulties
Improving sensory and cognitive function, vision, cognition and
emotional responses, strengthening coping mechanisms, improving
self-care abilities, promoting sexual functioning
28. NURSING PROCESS:
THE PATIENT WITH
GUILLAIN-BARRÉ SYNDROME
Ineffective breathing pattern and impaired gas exchange related to
rapidly progressive weakness and impending respiratory failure
Impaired physical mobility related to paralysis
Imbalanced nutrition, less than body requirements, related to inability
to swallow
Impaired verbal communication related to cranial nerve dysfunction
Fear and anxiety related to loss of control and paralysis
29. Nursing Interventions
Maintaining respiratory function
Enhancing physical mobility
Providing adequate nutrition
Improving communication
Decreasing fear and anxiety
Monitoring and managing potential complications
30. NURSING PROCESS:
THE PATIENT WITH CEREBRAL
METASTASES OR INCURABLE
BRAIN TUMOR
loss or impairment of motor and sensory function and decreased
cognitive abilities
Imbalanced nutrition, less than body requirements, related to cachexia
due to treatment and tumor effects, decreased nutritional intake, and
malabsorption
Anxiety related to fear of dying, uncertainty, change in appearance,
altered lifestyle
Interrupted family processes related to anticipatory grief and the
burdens imposed by the care of the person with a terminal illness
32. NURSING PROCESS:
THE PATIENT WITH PARKINSON’S DISEASE
Impaired physical mobility related to muscle rigidity and motor weakness
Self-care deficits (feeding, dressing, hygiene, and toileting) related to tremor
and motor disturbance
Constipation related to medication and reduced activity
Imbalanced nutrition, less than body requirements, related to tremor,
slowness in eating, difficulty in chewing and swallowing
Impaired verbal communication related to decreased speech volume,
slowness of speech, inability to move facial muscles
Ineffective coping related to depression and dysfunction due to disease
progression
33. Nursing Interventions
Improving mobility
Enhancing self-care activities
Improving bowel elimination
Improving nutrition
Enhancing swallowing
Encouraging the use of assistive devices
Improving communication
Supporting coping abilities
34. NURSING PROCESS:
THE PATIENT UNDERGOING
A CERVICAL DISCECTOMY
Acute pain related to the surgical procedure
Impaired physical mobility related to the postoperative surgical
regimen
Deficient knowledge about the postoperative course and home care
management
Nursing Interventions
Relieving pain, improving mobility, monitoring and managing
potential complications
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