Page 241 - Critical Care Nursing Demystified

226 CRITICAL CARE NURSING DeMYSTIFIED

An abnormal response is evident with dysconjugate eye movements or no move-
ments whatsoever, which can progress to decorticate or decerebrate posturing in
the comatose patient and the suggestion of an absence of brainstem function.

Respiratory Patterns

Since the medulla and the pons are the centers of the brainstem that control
respirations, patterns of breathing must be assessed as they can be severely
affected by brain injury.

NURSING ALERT
It is not unusual to observe hypoventilation in an individual with an altered level of
consciousness. Therefore, the effectiveness of oxygen and carbon dioxide levels and gas
exchange must be evaluated and maintained accordingly. Hypoxemia and hypercarbia
can lead to further neurologic impairment and an increase in ICP or intracranial pressure.

Further physical examination includes assessing the patient’s cough, gag, and
swallowing reflexes, which may be absent or diminished as a result of brain
trauma, anesthesia, or stroke. Airway protection in the vulnerable patient must
be guaranteed and the dangers of aspiration prevented. With a tongue depres- Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
sor, touch the far posterior surface of the pharynx. If the patient gags, his or her
reflex is intact. The nurse must also assess the position of the patient’s tongue
and uvula. If they are deviated to the side within the patient’s mouth, this can
be an indication of paralysis of the hypoglossal and glossopharyngeal cranial
nerves, wherein an absence of the cough, gag, and swallowing reflexes will be
most likely. The nurse should observe a true cough and swallowing effort in the
patient, which should be present if the gag reflex is intact.

NURSING ALERT
Always check the patient for a gag reflex, especially after anesthetic agents, stroke, or

cerebral trauma. Checking the gag or the 6th cranial nerve helps decrease the likeli-
hood of aspiration, especially before feeding a patient.

Additional Assessments

These should include the signs of CSF leakage from the nose and ears: otorrhea
and rhinorrhea. Battle’s sign and raccoon eyes—severe ecchymosis behind the
ears and around the eyes. Inspect for further signs of physical trauma such as
swelling, bruising, bleeding, lacerations, bodily areas out of alignment or para-
lyzed, and any indications of pain and discomfort on behalf of the patient.