NurseReview.Org Neurology Part 1

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Information about NurseReview.Org Neurology Part 1

Published on November 6, 2007

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Medical-Surgical Nursing A Review of Neurologic Concepts Nurse Licensure Examination Review

Key to Success! Confidence Test taking strategies Ample test preparation and study habits Review of frequent board examination topics Focus on your goals Above all- PRAYERS

Confidence

Test taking strategies

Ample test preparation and study habits

Review of frequent board examination topics

Focus on your goals

Above all- PRAYERS

Outline of Our Review Brief review of Anatomy and Physiology Application of the Nursing process in the approach of neurologic problems: ASSESSMENT – relevant techniques and lab procedures DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Brief review of Anatomy and Physiology

Application of the Nursing process in the approach of neurologic problems:

ASSESSMENT – relevant techniques and lab procedures

DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION

Outline of the review Trauma and related accidents Traumatic brain injury Spinal cord injury Cerebrovascular Accidents

Trauma and related accidents

Traumatic brain injury

Spinal cord injury

Cerebrovascular Accidents

Outline of the review Degenerative disorders- demyelinating Multiple sclerosis Guillain-Barre’ syndrome Degenerative disorders- NON- demyelinating Alzheimer’s disease Parkinson’s disease

Degenerative disorders- demyelinating

Multiple sclerosis

Guillain-Barre’ syndrome

Degenerative disorders-

NON- demyelinating

Alzheimer’s disease

Parkinson’s disease

Outline of the review Motor dysfunction- CNS Epilepsy Motor dysfunction- cranial nerve Bell’s palsy Trigeminal neuralgia Motor dysfunction- peripheral Myasthenia gravis

Motor dysfunction- CNS

Epilepsy

Motor dysfunction- cranial nerve

Bell’s palsy

Trigeminal neuralgia

Motor dysfunction- peripheral

Myasthenia gravis

Outline of the review Infectious Disease Meningitis Brain abscess Encephalitis Neoplastic disease

Infectious Disease

Meningitis

Brain abscess

Encephalitis

Neoplastic disease

IMPLEMENTATION PHASE Increased Intracranial pressure Altered level of consciousness Seizures Autonomic dysreflexia/hyperreflexia Spinal shock Cognitive impairment Bowel incontinence

Increased Intracranial pressure

Altered level of consciousness

Seizures

Autonomic dysreflexia/hyperreflexia

Spinal shock

Cognitive impairment

Bowel incontinence

IMPLEMENTATION PHASE Impaired physical mobility Impaired swallowing Disturbed sensory perception

Impaired physical mobility

Impaired swallowing

Disturbed sensory perception

Anatomy and Physiology Gross anatomy The nervous system is divided into the central and peripheral nervous system The Central nervous system consists of the BRAIN and the Spinal Cord The peripheral nervous system consists of the Spinal nerves and the cranial nerves

Gross anatomy

The nervous system is divided into the central and peripheral nervous system

The Central nervous system consists of the BRAIN and the Spinal Cord

The peripheral nervous system consists of the Spinal nerves and the cranial nerves

Anatomy and Physiology The brain is composed of lobes- Frontal lobe- personality, memory and motor function Parietal lobe- sensory function Temporal lobe- hearing and olfaction and emotion by the limbic system Occipital lobe- vision

The brain is composed of lobes-

Frontal lobe- personality, memory and motor function

Parietal lobe- sensory function

Temporal lobe- hearing and olfaction and emotion by the limbic system

Occipital lobe- vision

Anatomy and Physiology The cerebellum is involved in coordination and equilibrium The diencephalon consists of the : Thalamus- the relay center of all sensory input Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response

The cerebellum is involved in coordination and equilibrium

The diencephalon consists of the :

Thalamus- the relay center of all sensory input

Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response

Anatomy and Physiology The brainstem is composed of the: MIDBRAIN- for visual and auditory reflexes Pons- respiratory apneustic center, nucleus of cranial nerves- 5,6,7,8 Medulla oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12

The brainstem is composed of the:

MIDBRAIN- for visual and auditory reflexes

Pons- respiratory apneustic center, nucleus of cranial nerves- 5,6,7,8

Medulla oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12

ASSESSMENT OF THE NEUROLOGIC SYSTEM HISTORY A confused client becomes an unreliable source of history

HISTORY

A confused client becomes an unreliable source of history

ASSESSMENT OF THE NEUROLOGIC SYSTEM PHYSICAL EXAMINATION 5 categories: 1. Cerebral function- LOC, mental status 2. Cranial nerves 3. Motor function 4. Sensory function 5. Reflexes

PHYSICAL EXAMINATION

5 categories:

1. Cerebral function- LOC, mental status

2. Cranial nerves

3. Motor function

4. Sensory function

5. Reflexes

ASSESSMENT OF THE NEUROLOGIC SYSTEM Neuro Check Level of consciousness Pupillary size and response Verbal responsiveness Motor responsiveness Vital signs

Neuro Check

Level of consciousness

Pupillary size and response

Verbal responsiveness

Motor responsiveness

Vital signs

CEREBRAL FUCTION Assess the degree of wakefulness/alertness Note the intensity of stimulus to cause a response Apply a painful stimulus over the nailbeds with a blunt instrument Ask questions to assess orientation to person, place and time

Assess the degree of wakefulness/alertness

Note the intensity of stimulus to cause a response

Apply a painful stimulus over the nailbeds with a blunt instrument

Ask questions to assess orientation to person, place and time

Cerebral function Utilize the Glasgow Coma Scale An easy method of describing mental status and abnormality detection Tests 3 areas- eye opening, verbal response and motor response Scores are evaluated- range from 3-15 No ZERO score

Utilize the Glasgow Coma Scale

An easy method of describing mental status and abnormality detection

Tests 3 areas- eye opening, verbal response and motor response

Scores are evaluated- range from 3-15

No ZERO score

Glasgow Coma Scale Glasgow Coma Score Eye Opening (E) Verbal Response (V) Motor Response (M)

Glasgow Coma Score

Eye Opening (E)

Verbal Response (V)

Motor Response (M)

Glasgow Coma Scale Glasgow Coma Score Eye Opening (E) 4=Spontaneous 3=To voice 2=To pain 1=None (No response)

Glasgow Coma Score

Eye Opening (E)

4=Spontaneous 3=To voice 2=To pain 1=None (No response)

Glasgow Coma Scale Glasgow Coma Score Verbal Response (V) 5=Normal/oriented 4=Disoriented/ CONFUSED 3=Words, but incoherent/ inappropriate 2=Incomprehensible/mumbled words 1=None

Glasgow Coma Score

Verbal Response (V)

5=Normal/oriented 4=Disoriented/ CONFUSED 3=Words, but incoherent/ inappropriate 2=Incomprehensible/mumbled words 1=None

Glasgow Coma Scale Glasgow Coma Score Motor Response (M) 6=Normal- obeys command 5=Localizes pain 4=Withdraws to pain (Flexion) 3=Decorticate posture 2=Decerebrate posture 1=None (flaccid)

Glasgow Coma Score

Motor Response (M)

6=Normal- obeys command 5=Localizes pain 4=Withdraws to pain (Flexion) 3=Decorticate posture 2=Decerebrate posture

1=None (flaccid)

Cranial Nerve Function: Cranial Nerve 1- Olfactory Check first for the patency of the nose Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for the identification Repeat with the other nostrils PROBLEM- ANOSMIA- “loss of smell”

Check first for the patency of the nose

Instruct to close the eyes

Occlude one nostrils at a time

Hold familiar substance and asks for the identification

Repeat with the other nostrils

PROBLEM- ANOSMIA- “loss of smell”

Cranial Nerve Function: Cranial Nerve 2- Optic Check the visual acuity with the use of the Snellen chart Check for visual field by confrontation test Check for pupillary reflex- direct and consensual Fundoscopy to check for papilledema

Check the visual acuity with the use of the Snellen chart

Check for visual field by confrontation test

Check for pupillary reflex- direct and consensual

Fundoscopy to check for papilledema

Snellen chart

Cranial Nerve Function: Cranial Nerve 3, 4 and 6 Assess simultaneously the movement of the extra-ocular muscles Deviations: Opthalmoplegia- inability to move the eye in a direction Diplopia- complaint of double vision

Assess simultaneously the movement of the extra-ocular muscles

Deviations:

Opthalmoplegia- inability to move the eye in a direction

Diplopia- complaint of double vision

 

Cranial Nerve Function: Cranial Nerve 5 -trigeminal Sensory portion- assess for sensation of the facial skin Motor portion- assess the muscles of mastication Assess corneal reflex

Sensory portion- assess for sensation of the facial skin

Motor portion- assess the muscles of mastication

Assess corneal reflex

Cranial Nerve Function: Cranial Nerve 7 -facial Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids

Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water

Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory Test patient’s hearing acuity Observe for nystagmus and disturbed balance

Test patient’s hearing acuity

Observe for nystagmus and disturbed balance

Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal Together with Cranial nerve 10 –vagus Assess for gag reflex Watch the soft palate rising after instructing the client to say “AH” The posterior one-third of the tongue is supplied by the glossopharyngeal nerve

Together with Cranial nerve 10 –vagus

Assess for gag reflex

Watch the soft palate rising after instructing the client to say “AH”

The posterior one-third of the tongue is supplied by the glossopharyngeal nerve

Cranial Nerve Function: Cranial Nerve 11- accessory Press down the patient’s shoulder while he attempts to shrug against resistance

Press down the patient’s shoulder while he attempts to shrug against resistance

Cranial Nerve Function: Cranial Nerve 12- hypoglossal Ask patient to protrude the tongue and note for symmetry

Ask patient to protrude the tongue and note for symmetry

ASSESS Motor function Assess muscle tone and strength by asking patient to flex or extend the extremities while the examiner places resistance Grading of muscle strength

Assess muscle tone and strength by asking patient to flex or extend the extremities while the examiner places resistance

Grading of muscle strength

Assessing the motor function of the cerebellum Test for balance- heel to toe Test for coordination- rapid alternating movements and finger to nose test ROMBERG’s is actually a test for the posterior spinothalamic tract

Test for balance- heel to toe

Test for coordination- rapid alternating movements and finger to nose test

ROMBERG’s is actually a test for the posterior spinothalamic tract

 

Assessing the motor function of the brainstem Test for the Oculocephalic reflex- doll’s eye Normal response- eyes appear to move opposite to the movement of the head Abnormal- eyes move in the same direction

Test for the Oculocephalic reflex- doll’s eye

Normal response- eyes appear to move opposite to the movement of the head

Abnormal- eyes move in the same direction

Assessing the motor function of the brainstem Test for the Oculovestibular reflex Slowly irrigate the ear with cold water and warm water Normal response- cOld- OppOsite, wArM- sAMe

Test for the Oculovestibular reflex

Slowly irrigate the ear with cold water and warm water

Normal response- cOld- OppOsite, wArM- sAMe

Assessing the sensory function Evaluate symmetric areas of the body Ask the patient to close the eyes while testing Use of test tubes with cold and warm water Use blunt and sharp objects Use wisp of cotton Ask to identify objects placed on the hands Test for sense of position

Evaluate symmetric areas of the body

Ask the patient to close the eyes while testing

Use of test tubes with cold and warm water

Use blunt and sharp objects

Use wisp of cotton

Ask to identify objects placed on the hands

Test for sense of position

Assessing the reflexes Deep tendon reflexes Biceps Triceps Brachioradialis Patellar Assessing the sensory function Achilles

Deep tendon reflexes

Biceps

Triceps

Brachioradialis

Patellar

Assessing the sensory function Achilles

Assessing the reflexes Superficial reflexes Abdominal Cremasteric Anal Pathologic reflex Babinski- stroke the lateral aspect of the soles doing an inverted “J” (+)- DORSIFLEXION of the Big toe with fanning out of the little toes

Superficial reflexes

Abdominal

Cremasteric

Anal

Pathologic reflex

Babinski- stroke the lateral aspect of the soles doing an inverted “J”

(+)- DORSIFLEXION of the Big toe with fanning out of the little toes

Grading of reflexes Deep tendon reflex 0- absent + present but diminished ++ normal +++ increased ++++ hyperactive or clonic Superficial reflex 0 absent +present

Deep tendon reflex

0- absent

+ present but diminished

++ normal

+++ increased

++++ hyperactive or clonic

Superficial reflex

0 absent

+present

DIAGNOSTIC TESTS EEG Withhold medications that may interfere with the results- anticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure

EEG

Withhold medications that may interfere with the results- anticonvulsants, sedatives and stimulants

Wash hair thoroughly before procedure

DIAGNOSTIC TESTS CT scan With radiation risk If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected

CT scan

With radiation risk

If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected

DIAGNOSTIC TESTS MRI Uses magnetic waves Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure

MRI

Uses magnetic waves

Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure

DIAGNOSTIC TESTS Cerebral arteriography Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site

Cerebral arteriography

Note allergies to dyes, iodine and seafood

Ensure consent

Keep patient at rest after procedure

Maintain pressure dressing or sandbag over punctured site

DIAGNOSTIC TESTS Lumbar puncture Ensure consent, determine ability to lie still Contraindicated in patients with increased ICP Keep flat on bed after procedure Increase fluid intake after procedure

Lumbar puncture

Ensure consent, determine ability to lie still

Contraindicated in patients with increased ICP

Keep flat on bed after procedure

Increase fluid intake after procedure

Increased Intracranial pressure Intracranial pressure more than 15 mmHg Brunner= Normal intracranial pressure 10-20 mmHg Causes: Head injury Stroke Inflammatory lesions Brain tumor Surgical complications

Intracranial pressure more than 15 mmHg

Brunner= Normal intracranial pressure 10-20 mmHg

Causes:

Head injury

Stroke

Inflammatory lesions

Brain tumor

Surgical complications

Increased Intracranial pressure Pathophysiology The cranium only contains the brain substance, the CSF and the blood/blood vessels MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other Any increase or alteration in these structures will cause increased ICP

Pathophysiology

The cranium only contains the brain substance, the CSF and the blood/blood vessels

MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other

Any increase or alteration in these structures will cause increased ICP

Increased Intracranial pressure Pathophysiology Compensatory mechanisms: 1. Increased CSF absorption 2. Blood shunting 3. Decreased CSF production

Pathophysiology

Compensatory mechanisms:

1. Increased CSF absorption

2. Blood shunting

3. Decreased CSF production

Increased Intracranial pressure Pathophysiology Decompensatory mechanisms: 1. Decreased cerebral perfusion 2. Decreased PO2 leading to brain hypoxia 3. Cerebral edema 4. Brain herniation

Pathophysiology

Decompensatory mechanisms:

1. Decreased cerebral perfusion

2. Decreased PO2 leading to brain hypoxia

3. Cerebral edema

4. Brain herniation

Decreased cerebral blood flow Vasomotor reflexes are stimulated initially  slow bounding pulses Increased concentration of carbon dioxide will cause VASODILATION  increased flow  increased ICP

Vasomotor reflexes are stimulated initially  slow bounding pulses

Increased concentration of carbon dioxide will cause VASODILATION  increased flow  increased ICP

Cerebral Edema Abnormal accumulation of fluid in the intracellular space, extracellular space or both.

Abnormal accumulation of fluid in the intracellular space, extracellular space or both.

Herniation Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem

Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem

Cerebral response to increased ICP Steady perfusion up to 40 mmHg Cushing’s response Vasomotor center triggers rise in BP to increase ICP Sympathetic response is increased BP but the heart rate is SLOW Respiration becomes SLOW

Steady perfusion up to 40 mmHg

Cushing’s response

Vasomotor center triggers rise in BP to increase ICP

Sympathetic response is increased BP but the heart rate is SLOW

Respiration becomes SLOW

Increased Intracranial pressure CLINICAL MANIFESTATIONS Early manifestations : Changes in the LOC- usually the earliest Pupillary changes- fixed, slowed response Headache vomiting

CLINICAL MANIFESTATIONS

Early manifestations :

Changes in the LOC- usually the earliest

Pupillary changes- fixed, slowed response

Headache

vomiting

Increased Intracranial pressure CLINICAL MANIFESTATIONS late manifestations : Cushing reflex- systolic hypertension , bradycardia and wide pulse pressure bradypnea Hyperthermia Abnormal posturing

CLINICAL MANIFESTATIONS

late manifestations :

Cushing reflex- systolic hypertension , bradycardia and wide pulse pressure

bradypnea

Hyperthermia

Abnormal posturing

Increased Intracranial pressure Nursing interventions: Maintain patent airway 1. Elevate the head of the bed 15-30 degrees- to promote venous drainage 2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levels  constricts blood vessels  reduces edema

Nursing interventions:

Maintain patent airway

1. Elevate the head of the bed 15-30 degrees- to promote venous drainage

2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levels  constricts blood vessels  reduces edema

Increased Intracranial pressure Nursing interventions 3. Administer prescribed medications- usually Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsants-p to prevent seizures

Nursing interventions

3. Administer prescribed medications- usually

Mannitol- to produce negative fluid balance

corticosteroid- to reduce edema

anticonvulsants-p to prevent seizures

Increased Intracranial pressure Nursing interventions 4. Reduce environmental stimuli 5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning

Nursing interventions

4. Reduce environmental stimuli

5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning

Increased Intracranial pressure Nursing interventions 6. Keep head on a neutral position. ACOID- extreme flexion, valsalva 7. monitor for secondary complications Diabetes insipidus- output of >200 mL/hr SIADH

Nursing interventions

6. Keep head on a neutral position. ACOID- extreme flexion, valsalva

7. monitor for secondary complications

Diabetes insipidus- output of >200 mL/hr

SIADH

Altered level of consciousness It is a function and symptom of multiple pathophysiologic phenomena Causes: head injury, toxicity and metabolic derangement Disruption in the neuronal transmission results to improper function

It is a function and symptom of multiple pathophysiologic phenomena

Causes: head injury, toxicity and metabolic derangement

Disruption in the neuronal transmission results to improper function

Altered level of consciousness Assessment Orientation to time, place and person Motor function Decerebrate Decorticate Sensory function

Assessment

Orientation to time, place and person

Motor function

Decerebrate

Decorticate

Sensory function

Altered level of consciousness Patient is not oriented Patient does not follow command Patient needs persistent stimuli to be awake COMA= clinical state of unconsciousness where patient is NOT aware of self and environment

Patient is not oriented

Patient does not follow command

Patient needs persistent stimuli to be awake

COMA= clinical state of unconsciousness where patient is NOT aware of self and environment

Altered level of consciousness Etiologic Factors Head injury Stroke Drug overdose Alcoholic intoxication Diabetic ketoacidosis Hepatic failure

Etiologic Factors

Head injury

Stroke

Drug overdose

Alcoholic intoxication

Diabetic ketoacidosis

Hepatic failure

Altered level of consciousness ASSESSMENT Behavioral changes initially Pupils are slowly reactive Then , patient becomes unresponsive and pupils become fixed dilated Glasgow Coma Scale is utilized

ASSESSMENT

Behavioral changes initially

Pupils are slowly reactive

Then , patient becomes unresponsive and pupils become fixed dilated

Glasgow Coma Scale is utilized

Altered level of consciousness Nursing Intervention 1. Maintain patent airway Elevate the head of the bed to 30 degrees Suctioning 2. Protect the patient Pad side rails Prevent injury from equipments, restraints and etc.

Nursing Intervention

1. Maintain patent airway

Elevate the head of the bed to 30 degrees

Suctioning

2. Protect the patient

Pad side rails

Prevent injury from equipments, restraints and etc.

Altered level of consciousness Nursing Intervention 3. Maintain fluid and nutritional balance Input an output monitoring IVF therapy Feeding through NGT 4. Provide mouth care Cleansing and rinsing of mouth Petrolatum on the lips

Nursing Intervention

3. Maintain fluid and nutritional balance

Input an output monitoring

IVF therapy

Feeding through NGT

4. Provide mouth care

Cleansing and rinsing of mouth

Petrolatum on the lips

Altered level of consciousness Nursing Intervention 5. Maintain skin integrity Regular turning every 2 hours 30 degrees bed elevation Maintain correct body alignment by using trochanter rolls, foot board 6. Preserve corneal integrity Use of artificial tears every 2 hours

Nursing Intervention

5. Maintain skin integrity

Regular turning every 2 hours

30 degrees bed elevation

Maintain correct body alignment by using trochanter rolls, foot board

6. Preserve corneal integrity

Use of artificial tears every 2 hours

Altered level of consciousness Nursing Intervention 7. Achieve thermoregulation Minimum amount of beddings Rectal or tympanic temperature Administer acetaminophen as prescribed 8. Prevent urinary retention Use of intermittent catheterization

Nursing Intervention

7. Achieve thermoregulation

Minimum amount of beddings

Rectal or tympanic temperature

Administer acetaminophen as prescribed

8. Prevent urinary retention

Use of intermittent catheterization

Altered level of consciousness Nursing Intervention 9. Promote bowel function High fiber diet Stool softeners and suppository 10. Provide sensory stimulation Touch and communication Frequent reorientation

Nursing Intervention

9. Promote bowel function

High fiber diet

Stool softeners and suppository

10. Provide sensory stimulation

Touch and communication

Frequent reorientation

SEIZURES Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons A part or all of the brain may be involved

Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons

A part or all of the brain may be involved

SEIZURES PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section  EMITS ELECTRICAL IMPULSES excessively

PATHOPHYSIOLOGY

An electrical disturbance in the nerve cells in one brain section  EMITS ELECTRICAL IMPULSES excessively

SEIZURES ETIOLOGIC FACTORS Idiopathic Fever Head injury CNS infection Metabolic and toxic conditions

ETIOLOGIC FACTORS

Idiopathic

Fever

Head injury

CNS infection

Metabolic and toxic conditions

SEIZURES Nursing Interventions During seizure 1. remove harmful objects from the patient’s surrounding 2. ease the client to the floor 3. protect the head with pillows 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure

Nursing Interventions

During seizure

1. remove harmful objects from the patient’s surrounding

2. ease the client to the floor

3. protect the head with pillows

4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure

SEIZURES Nursing Interventions During seizure 5. loosen constrictive clothing 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

Nursing Interventions

During seizure

5. loosen constrictive clothing

6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

SEIZURES Nursing Interventions POST seizure 1. place patient to the side to drain secretions and prevent aspiration 2. help re-orient the patient if confused 3. provide care if patient became incontinent during the seizure attack 4. stress importance of medication regimen

Nursing Interventions

POST seizure

1. place patient to the side to drain secretions and prevent aspiration

2. help re-orient the patient if confused

3. provide care if patient became incontinent during the seizure attack

4. stress importance of medication regimen

headache Cephalgia Primary headache- no organic cause Secondary headache- with organic cause Migraine headache- periodic attacks of headache due to vascular disturbance Tension headache-the most common type- due to muscle tension

Cephalgia

Primary headache- no organic cause

Secondary headache- with organic cause

Migraine headache- periodic attacks of headache due to vascular disturbance

Tension headache-the most common type- due to muscle tension

headache Migraine Prodrome stage Aura phase Headache Recovery phase

Migraine

Prodrome stage

Aura phase

Headache

Recovery phase

headache Nursing Interventions 1. Avoid precipitating factors 2. modify lifestyle 3. relieve pain by pharmacologic measures Beta-blockers Serotonin antagonists- “triptan"

Nursing Interventions

1. Avoid precipitating factors

2. modify lifestyle

3. relieve pain by pharmacologic measures

Beta-blockers

Serotonin antagonists- “triptan"

Autonomic Dysreflexia/hyperreflexia Seen commonly in spinal cord injury above T6 An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation

Seen commonly in spinal cord injury above T6

An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation

Autonomic Dysreflexia/hyperreflexia Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion

Clinical MANIFESTATIONS

1. Hypertension

2. Bradycardia

3. severe pounding headache

4. diaphoresis

5. nausea and nasal congestion

Autonomic Dysreflexia/hyperreflexia NURSING INTERVENTIONS 1. Elevate the head of the bed immediately 2. Check for bladder distention and empty bladder with urinary catheter 3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer 4. Administer antihypertensive medications- usually hydralazine

NURSING INTERVENTIONS

1. Elevate the head of the bed immediately

2. Check for bladder distention and empty bladder with urinary catheter

3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer

4. Administer antihypertensive medications- usually hydralazine

Spinal Shock Pathophysiology The sudden depression of reflex activity in the spinal cord below the level of injury The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions

Pathophysiology

The sudden depression of reflex activity in the spinal cord below the level of injury

The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions

Spinal Shock Nursing Interventions 1. Assist in chest physical therapy 2. Manage potential complication- DVT

Nursing Interventions

1. Assist in chest physical therapy

2. Manage potential complication- DVT

Cognitive Impairment Nursing Interventions Assist or encourage the patient to use eyeglass, hearing aid or assistive devices Reorient the patient by calling his name frequently Provide background information as to date, time, place, environment

Nursing Interventions

Assist or encourage the patient to use eyeglass, hearing aid or assistive devices

Reorient the patient by calling his name frequently

Provide background information as to date, time, place, environment

Cognitive Impairment Nursing Interventions 4. Use large signs as visual cues 5. Post patient's photo on the door 6. Encourage family members to bring personal articles and place them in the same area

Nursing Interventions

4. Use large signs as visual cues

5. Post patient's photo on the door

6. Encourage family members to bring personal articles and place them in the same area

Bowel and Bladder incontinence Establish a regular pattern for bowel care Maintain a dietary intake. Avoid foods that can cause excessive gas production

Establish a regular pattern for bowel care

Maintain a dietary intake. Avoid foods that can cause excessive gas production

CONGENITAL DISORDERS: Hydrocephalus Excessive CSF accumulation in the brain’s ventricular system In infants, head enlarges In children and adults- brain compression

Excessive CSF accumulation in the brain’s ventricular system

In infants, head enlarges

In children and adults- brain compression

CONGENITAL DISORDERS: Hydrocephalus Non-communicating hydrocephalus results from CSF outflow obstruction Communicating hydrocephalus results from faulty absorption or increased CSF production

Non-communicating hydrocephalus results from CSF outflow obstruction

Communicating hydrocephalus results from faulty absorption or increased CSF production

CONGENITAL DISORDERS: Hydrocephalus Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes

Assessment

1. irritability

2. change in LOC

3. infants- enlargement of the head, thin scalp skin

4. sunset eyes

CONGENITAL DISORDERS: Hydrocephalus DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography

DIAGNOSTIC TESTS

1. Skull x-ray

2. ventriculography

CONGENITAL DISORDERS: Hydrocephalus Nursing Intervention 1. monitor neurologic status 2. teach parents to watch for signs of shunt malfunction, and periodic surgery to lengthen the shunt as child grows

Nursing Intervention

1. monitor neurologic status

2. teach parents to watch for signs of shunt malfunction, and periodic surgery to lengthen the shunt as child grows

CONGENITAL DISORDER- Spinal cord defects 1. Spina bifida occulta- incomplete closure of one or more vertebrae without protrusion of the spinal cord or meninges 2. Spina bifida with meningocele- a sac contains meninges and CSF 3. Spina bifida with meningomyelocele- a sac contains spinal cord substance, meninges and CSF

1. Spina bifida occulta- incomplete closure of one or more vertebrae without protrusion of the spinal cord or meninges

2. Spina bifida with meningocele- a sac contains meninges and CSF

3. Spina bifida with meningomyelocele- a sac contains spinal cord substance, meninges and CSF

CONGENITAL DISORDER: Spinal cord defects Causes 1. environmental factors 2. radiation 3. folic acid deficiency in a pregnant woman 4. possibly genetic

Causes

1. environmental factors

2. radiation

3. folic acid deficiency in a pregnant woman

4. possibly genetic

CONGENITAL DISORDER: Spinal cord defects ASSESSMENT 1. a dimple or tuft of hair in the vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography

ASSESSMENT

1. a dimple or tuft of hair in the vertebral area

2. external sac

DIAGNOSIS

1. Spinal x-ray

2. myelography

CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 1. cover the defect with sterile dressing moistened with sterile saline 2. position the patient on prone or side to protect the fragile sac 3. place a diaper under the infant and change it often

NURSING INTERVENTION

1. cover the defect with sterile dressing moistened with sterile saline

2. position the patient on prone or side to protect the fragile sac

3. place a diaper under the infant and change it often

CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 4. avoid the use of lotion 5. avoid frequent handling 6. Measure the child’s head circumference daily 7. check anal reflex 8. support family members 9. prepare the parents for the possible outcome of eh defect

NURSING INTERVENTION

4. avoid the use of lotion

5. avoid frequent handling

6. Measure the child’s head circumference daily

7. check anal reflex

8. support family members

9. prepare the parents for the possible outcome of eh defect

CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 10. Post-operative care Position on abdomen Check post-operative dressings Place infant’s hips in abduction and feet in neutral position Monitor intake and output Check for urine retention Asess infant frequently as he recovers from the surgery

NURSING INTERVENTION

10. Post-operative care

Position on abdomen

Check post-operative dressings

Place infant’s hips in abduction and feet in neutral position

Monitor intake and output

Check for urine retention

Asess infant frequently as he recovers from the surgery

Traumatic brain injury 1. CONCUSSION Involves jarring of head without tissue injury Temporary loss of neurologic function lasting fore a few minutes to hours

1. CONCUSSION

Involves jarring of head without tissue injury

Temporary loss of neurologic function lasting fore a few minutes to hours

 

Traumatic brain injury 2. CONTUSION Involves structural damage The patient becomes unconscious for hours

2. CONTUSION

Involves structural damage

The patient becomes unconscious for hours

 

Traumatic brain injury 3. Diffuse Axonal injury Involves widespread damage to the neurons Patient has decerebrate and decorticate posture

3. Diffuse Axonal injury

Involves widespread damage to the neurons

Patient has decerebrate and decorticate posture

Traumatic brain injury 4. Intracranial hemorrhage Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery Symptoms develop rapidly

4. Intracranial hemorrhage

Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery

Symptoms develop rapidly

 

Traumatic brain injury 4. Intracranial hemorrhage Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels Symptoms usually develop slowly

4. Intracranial hemorrhage

Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels

Symptoms usually develop slowly

 

Traumatic brain injury 4. Intracranial hemorrhage Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities Symptoms develop insidiously, beginning with severe headache and neurologic deficits

4. Intracranial hemorrhage

Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities

Symptoms develop insidiously, beginning with severe headache and neurologic deficits

 

Traumatic brain injury MANIFESTATIONS 1. Altered LOC 2. CSF otorrhea 3. CSF rhinorrhea 4. Racoon eyes and battle sign HALO SIGN- blood stain surrounded by a yellowish stain

MANIFESTATIONS

1. Altered LOC

2. CSF otorrhea

3. CSF rhinorrhea

4. Racoon eyes and battle sign

HALO SIGN- blood stain surrounded by a yellowish stain

Traumatic brain injury NURSING MANAGEMENT 1. Monitor for declining LOC- use of Glasgow 2. Maintain patent airway Elevate bed, suction prn, monitor ABG

NURSING MANAGEMENT

1. Monitor for declining LOC- use of Glasgow

2. Maintain patent airway

Elevate bed, suction prn, monitor ABG

Traumatic brain injury NURSING MANAGEMENT 3. Monitor F and E balance Daily weights IVF therapy Monitor possible development of DI and SIADH

NURSING MANAGEMENT

3. Monitor F and E balance

Daily weights

IVF therapy

Monitor possible development of DI and SIADH

Traumatic brain injury 4. Provide adequate nutrition 5. Prevent injury Use padded side rails Minimize environmental stimuli Assess bladder Consider the use of intermittent catheter

4. Provide adequate nutrition

5. Prevent injury

Use padded side rails

Minimize environmental stimuli

Assess bladder

Consider the use of intermittent catheter

Traumatic brain injury 6. Maintain skin integrity Prolonged immobility will likely cause skin breakdown Turn patient every 2 hours Provide skin care every 4 hours Avoid friction and shear forces

6. Maintain skin integrity

Prolonged immobility will likely cause skin breakdown

Turn patient every 2 hours

Provide skin care every 4 hours

Avoid friction and shear forces

Traumatic brain injury 7. Monitor potential complications Increased ICP Post-traumatic seizures Impaired ventilation

7. Monitor potential complications

Increased ICP

Post-traumatic seizures

Impaired ventilation

Spinal cord injury The most frequent vertebrae – C5-C7, T12 and L1 Concussion Contusion Compression Transection

The most frequent vertebrae – C5-C7, T12 and L1

Concussion

Contusion

Compression

Transection

 

 

Spinal cord injury Clinical manifestations 1. Paraplegia 2. quadriplegia 3. spinal shock

Clinical manifestations

1. Paraplegia

2. quadriplegia

3. spinal shock

 

Spinal cord injury DIAGNOSTIC TEST Spinal x-ray CT scan MRI

DIAGNOSTIC TEST

Spinal x-ray

CT scan

MRI

Spinal cord injury EMERGENCY MANAGEMENT A-B-C Immobilization Immediate transfer to tertiary facility

EMERGENCY MANAGEMENT

A-B-C

Immobilization

Immediate transfer to tertiary facility

Spinal cord injury NURSING INTERVENTION 1. Promote adequate breathing and airway clearance 2. Improve mobility and proper body alignment 3. Promote adaptation to sensory and perceptual alterations 4. Maintain skin integrity

NURSING INTERVENTION

1. Promote adequate breathing and airway clearance

2. Improve mobility and proper body alignment

3. Promote adaptation to sensory and perceptual alterations

4. Maintain skin integrity

Spinal cord injury 5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage complications Thromboplebhitis Orthostaic hypotension Spinal shock Autonomic dysreflexia

5. Maintain urinary elimination

6. Improve bowel function

7. Provide Comfort measures

8. Monitor and manage complications

Thromboplebhitis

Orthostaic hypotension

Spinal shock

Autonomic dysreflexia

Spinal cord injury 9. Assists with surgical reduction and stabilization of cervical vertebral column

9. Assists with surgical reduction and stabilization of cervical vertebral column

CEREBROVASCULAR ACCIDENTS An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply

An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply

CEREBROVASCULAR ACCIDENTS Can be divided into two major categories 1. Ischemic stroke- caused by thrombus and embolus 2. Hemorrhagic stroke- caused commonly by hypertensive bleeding

Can be divided into two major categories

1. Ischemic stroke- caused by thrombus and embolus

2. Hemorrhagic stroke- caused commonly by hypertensive bleeding

 

 

CEREBROVASCULAR ACCIDENTS The stroke continuum 1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration 2. Reversible Neurologic deficits 3. Stroke in evolution 4. Completed stroke

The stroke continuum

1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration

2. Reversible Neurologic deficits

3. Stroke in evolution

4. Completed stroke

General manifestations

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus

There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus

RISKS FACTORS Non-modifiable Advanced age Gender race Modifiable Hypertension Cardio disease Obesity Smoking Diabetes mellitus hypercholesterolemia

Non-modifiable

Advanced age

Gender

race

Modifiable

Hypertension

Cardio disease

Obesity

Smoking

Diabetes mellitus

hypercholesterolemia

Pathophysiology of ischemic stroke Disruption of blood supply Anaerobic metabolism ensues Decreased ATP production leads to impaired membrane function Cellular injury and death can occur

Disruption of blood supply

Anaerobic metabolism ensues

Decreased ATP production leads to impaired membrane function

Cellular injury and death can occur

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography

DIAGNOSTIC test

1. CT scan

2. MRI

3. Angiography

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke CLINICAL MANIFESTATIONS 1. Numbness or weakness 2. confusion or change of LOC 3. motor and speech difficulties 4. Visual disturbance 5. Severe headache

CLINICAL MANIFESTATIONS

1. Numbness or weakness

2. confusion or change of LOC

3. motor and speech difficulties

4. Visual disturbance

5. Severe headache

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke Motor Loss Hemiplegia Hemiparesis

Motor Loss

Hemiplegia

Hemiparesis

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke Communication loss Dysarthria= difficulty in speaking Aphasia= Loss of speech Apraxia= inability to perform a previously learned action

Communication loss

Dysarthria= difficulty in speaking

Aphasia= Loss of speech

Apraxia= inability to perform a previously learned action

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke Perceptual disturbances Hemianopsia Sensory loss paresthesia

Perceptual disturbances

Hemianopsia

Sensory loss

paresthesia

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS Improve Mobility and prevent joint deformities Correctly position patient to prevent contractures Place pillow under axilla Hand is placed in slight supination- “C” Change position every 2 hours

NURSING INTERVENTIONS

Improve Mobility and prevent joint deformities

Correctly position patient to prevent contractures

Place pillow under axilla

Hand is placed in slight supination- “C”

Change position every 2 hours

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 2. Enhance self-care Carry out activities on the unaffected side Prevent unilateral neglect Keep environment organized Use large mirror

NURSING INTERVENTIONS

2. Enhance self-care

Carry out activities on the unaffected side

Prevent unilateral neglect

Keep environment organized

Use large mirror

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 3. Manage sensory-perceptual difficulties Approach patient on the Unaffected side Encourage to turn the head to the affected side to compensate for visual loss

NURSING INTERVENTIONS

3. Manage sensory-perceptual difficulties

Approach patient on the Unaffected side

Encourage to turn the head to the affected side to compensate for visual loss

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 4. Manage dysphagia Place food on the UNAFFECTED side Provide smaller bolus of food Manage tube feedings if prescribed

NURSING INTERVENTIONS

4. Manage dysphagia

Place food on the UNAFFECTED side

Provide smaller bolus of food

Manage tube feedings if prescribed

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 5. Help patient attain bowel and bladder control Intermittent catheterization is done in the acute stage Offer bedpan on a regular schedule High fiber diet and prescribed fluid intake

NURSING INTERVENTIONS

5. Help patient attain bowel and bladder control

Intermittent catheterization is done in the acute stage

Offer bedpan on a regular schedule

High fiber diet and prescribed fluid intake

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 6. Improve thought processes Support patient and capitalize on the remaining strengths

NURSING INTERVENTIONS

6. Improve thought processes

Support patient and capitalize on the remaining strengths

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 7. Improve communication Anticipate the needs of the patient Offer support Provide time to complete the sentence Provide a written copy of scheduled activities Use of communication board Give one instruction at a time

NURSING INTERVENTIONS

7. Improve communication

Anticipate the needs of the patient

Offer support

Provide time to complete the sentence

Provide a written copy of scheduled activities

Use of communication board

Give one instruction at a time

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 8. Maintain skin integrity Use of specialty bed Regular turning and positioning Keep skin dry and massage NON-reddened areas Provide adequate nutrition

NURSING INTERVENTIONS

8. Maintain skin integrity

Use of specialty bed

Regular turning and positioning

Keep skin dry and massage NON-reddened areas

Provide adequate nutrition

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 9. Promote continuing care Referral to other health care providers

NURSING INTERVENTIONS

9. Promote continuing care

Referral to other health care providers

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 10. Improve family coping 11. Help patient cope with sexual dysfunction

NURSING INTERVENTIONS

10. Improve family coping

11. Help patient cope with sexual dysfunction

CVA: Hemorrhagic Stroke Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage

Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP

Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage

CVA: Hemorrhagic Stroke Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances

Sudden and severe headache

Same neurologic deficits as ischemic stroke

Loss of consciousness

Meningeal irritation

Visual disturbances

CVA: Hemorrhagic Stroke DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP)

DIAGNOSTIC TESTS

1. CT scan

2. MRI

3. Lumbar puncture (only if with no increased ICP)

CVA: Hemorrhagic Stroke NURSING INTERVENTIONS 1. Optimize cerebral tissue perfusion 2. relieve Sensory deprivation and anxiety 3. Monitor and manage potential complications

NURSING INTERVENTIONS

1. Optimize cerebral tissue perfusion

2. relieve Sensory deprivation and anxiety

3. Monitor and manage potential complications

 

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