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NEUROLOGIC DEFICITS
Nur-224
Identify the various types/causes of seizures.
Identify clinical manifestations for clients experiencing neurologic deficits.
Apply the principles of nursing management to care for the patient in the acute stage of ischemic stroke.
Use the nursing process as a framework to develop a plan of care for the client with neurological deficits.
OBJECTIVES
3rd leading cause of death in the US 800,000 people experience a stroke each year An emergency condition in which neurologic deficits
result from a sudden decrease in blood flow to a localized area of the brain.
Major loss of blood supply to the brain severe disability or death
Types of stroke Ischemic (80–85%) Hemorrhagic (15–20%)
CEREBROVASCULAR ACCIDENT
Risk Factors Hypertension Sickle cell anemia Atrial fibrillation Diabetes mellitus Smoking Hyperlipidemia Obesity Sedentary lifestyle TIA or “little stroke”
CEREBRAL VASCULAR ACCIDENT
Characterized by a gradual/rapid onset of neurologic deficits compromised cerebral blood flow
Stroke leads to a loss/impairment of sensorimotor functions on the opposite side the side of the brain that is damaged contralateral deficit.
Stroke in the (R) hemisphere of the brain is manifested by deficits in the (L) side of the body (and vice versa)
CVA
CEREBROVASCULAR ACCIDENT
Disruption of the blood supply to the brain due to an obstruction a thrombus or embolism, or from stenosis of a vessel resulting from a buildup of plaque
Types Large vessel stroke Small vessel stroke Cardiogenic embolism
ISCHEMIC STROKE
ISCHEMIC STROKE
Symptoms depend upon the location and size of the affected area
Numbness or weakness of face, arm, or leg, especially on one side
Confusion or change in mental status Trouble speaking or understanding speech Difficulty in walking, dizziness, or loss of
balance or coordination Sudden, severe headache Perceptual disturbances
ISCHEMIC STROKEClinical Manifestations
(L)/( R) HEMISPHERIC STROKE
L sided stroke R sided stroke
Paralysis/weakness on (R ) side of the body
(R ) visual field deficit Aphasia Altered intellectual
ability
Paralysis/weakness on the (L) side of the body
(L) visual field deficit Impulsive behavior
and poor judgment Lack of awareness of
deficits
Sensoriperceptual deficits
Cognitive and behavioral changes
Communication disorders
Motor deficits
Elimination disorders
COMPLICATIONS
Deficits may include Hemianopia Apraxia Neglect syndrome
SENSIORIPERCEPTUAL DEFICITS
Cognitive changes
Behavioral changes Emotional lability Loss of self-control
Intellectual changes
COGNITIVE /BEHAVIORAL CHANGES
Usually a result of the stroke affecting the dominant hemisphere
Aphasia Expressive Receptive Global
COMMUNICATION DISORDERS
Depending on the area of the brain involved strokes may cause:
Hemiplegia Hemiparesis Flaccidity Spasticity
MOTOR DEFICITS
Bladder elimination Bowel elimination
ELIMINATION DISORDERS
Mini-stroke Brief period of localized cerebral ischemia
that causes neurologic deficit lasting less than 24 hours
Sudden loss of motor, sensory, or visual function
Serves as a warning for impending stroke
Transient Ischemic Attack (TIA)
Acute phase diagnosis the type/cause of the stroke support cerebral circulation control/prevent further deficits
Focus minimize brain injury maximize patient recovery
Ischemic Stroke -Assessment
Complete history/careful physical assessment
CT scan DWI test PLAC tests
Ischemic Stroke – Diagnostic Findings
Prevention Antiplatelet- Aspirin, clopidogrel(Plavix),
ticlopidine(Ticlid)
Acute Stroke fibrinolytic therapy-tissue plasminogen
activator anticoagulant therapy
Antihypertensive medications
MEDICATIONS
Used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow to the brain.
Recombinant t-PA Rapid diagnosis of a stroke and initiation of
therapy (within 3 hours) decrease the size of the stroke and may improve functional abilities after 3 months
Bleeding most common side effect
Thrombolytic Therapy
Surgery (Carotid Endarectomy) Performed to prevent the occurrence of a
stroke Restore blood flow when a stroke has
occurred Repair vascular damage
RehabilitationPhysical therapyOccupational therapySpeech therapy
TREATMENTS
Position on the inoperative side –
Assess respirations/oxygen saturation - hemorrhage -respiratory distress - cranial nerve impairment -hypotension/hypertension
Carotid Endarterectomy Postoperative Care
Stroke prevention – esp known risk factors
Public awareness of signs of TIA/Stroke Sudden – - weakness/numbness - confusion, trouble speaking - trouble walking, dizziness, loss of balance - trouble with vision - severe headache without a cause
HEALTH PROMOTION
Risk for Ineffective Tissue Perfusion- Cerebral Impaired Verbal Communication Impaired Swallowing Impaired Physical Mobility Self-care deficits r/t (bathing, grooming,
hygiene)
Nursing Diagnosis/Interventions
Maintain correct position good body alignment avoid deformities
Change position every 2 hours – if sensation is impaired on one side – the amount of time spent on the affected should be limited.
Prevent pressure ulcers. Affected extremities – ROM exercises Prepare for ambulation ASAP/active
rehabilitation program
Nursing Interventions -Mobility
May swallowing problems (dysphagia). Swallowing difficulties place the patient at
the risk for aspiration, pneumonia, dehydration, and malnutrition.
Start patient on thick liquid/pureed foods easy to swallow
Patient unable to consume oral intake enteral feedings
Long-termed feedings gastrostomy tube
Nursing Interventions- Nutrition
Aphasia –receptive/expressive Face the patient and establish eye contact Develop strategies to make the atmosphere
conducive to communication Speak in a normal manner and tone, speak
slowly Use gestures, pictures, objects, writing, Use same words and gestures be
consistent
Nursing Interventions-Communication
At risk for skin and tissue breakdown Specialty bed Regular turning schedule Minimize shear/friction forces
Nursing Intervention – Skin Integrity
Recovery/rehabilitation may be prolonged and requires patience.
Community based support groups Depression – common /serious problem Caregivers need to be reminder to attend
their own health concerns/well-being respite care.
ISCHEMIC STROKE
Intracranial hemorrhage Cerebral blood vessel ruptures.
May be due to: Intracerebral hemorrhage Intracranial aneurysm AV malformation Subarachnoid hemorrhage
Hemorrhagic Stroke
HEMORRHAGIC STROKE
HEMORRHAGIC STROKE
Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting
Hemorrhagic Stroke –Clinical Manifestations
Maintain optimum tissue perfusion -aneurysm precautions Manage potential complications - vasospasms - hyponatremia - seizures Promote home and community-based care
HEMORRHAGIC STROKE Nursing Interventions
A single event of abnormal, sudden, electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function.
Epilepsy (seizure disorder) – - chronic disorder of abnormal, recurring excessive electrical discharges - recurring seizures accompanied by some type of behavioral change
SEIZURE DISORDERS
affect more than 3 million people strong genetic component
Precipitating factors birth defects head injury/trauma metabolic disorders/renal failure hyponatremia, IICP
The cause is unknown in 70% of all cases
SEIZURE DISORDERS
All people with epilepsy have seizures, but not all people who have a seizure have epilepsy.
Only after a person has two seizures dx. of epilepsy is made
Classification of seizures Partial seizures: begin in one part of the
brain Generalized seizures: involve both
hemispheres of the brain
Seizures
Messages from the body are carried by the neurons (nerve cells) by electrical discharges.
Impulses occur when a nerve cell has a task to perform.
Sometimes there is an excessive imbalance and the cell continues to fire after the task is completed.
Unwanted discharges cause the body to respond erratically.
SEIZURE DISORDERS/Pathophysiology
Consciousness is always impaired Absence seizures (petit mal) -sudden brief cessation of all motor activity accompanied by a blank stare and unresponsiveness. Tonic-clonic seizures (grand mal) - common type of seizures in adults - warning aura may precede generalized seizure activity
Generalized Seizures
Tonic Phase Begins with a sudden loss of consciousness,
sharp muscle contractions Patient may fall to the floor Urinary incontinence is common Breathing ceases and cyanosis develops Pupils are fixed and dilated Tonic phase may lasts – 15 seconds – 1
minute
TONIC-CLONIC SEIZURE
Clonic Phase Alternating contraction/relaxation of the
muscles in all extremities Eyes roll back and the patient froths at the
mouth Phase varies in duration and subsides
gradually Entire seizure generally lasts no more than
60-90 seconds
TONIC-CLONIC SEIZURE
Tonic – Clonic Seizures
Following clonic phase (postictal phase) Person remains unconscious /unresponsive to
stimuli Person is relaxed and breathes quietly Regains consciousness gradually May be confused/disoriented Headache muscle ache and fatigue may follow Amnesia of the seizure may follow
Because of lack of warning with tonic-clonic seizures, head injury, fractures, burns may occur secondary to seizure activity
TONIC-CLONIC SEIZURES
Can develop during seizure activity Seizure becomes continuous– with only short
periods of calm between intense and persistent seizures
Cumulative effect muscular contractions that interfere with respirations
Hypoxia, acidosis, hypoglycemia, hyperthermia and exhaustion may occur if the convulsive activity is not stoped.
medical emergency Goal – stop the seizure (ASAP) Establish and maintain airway is priority
Status Epilepticus
Diagnostic Assessment Confirm the diagnosis, determine any
treatable causes and precipitating factors
Diagnostic Testing MRI/CT Scan EEG Lab data – CBC, biochemistry
SEIZURE DISORDERS/Assessment
Pharmacologic therapy ( AEDs) controls rather than cures seizures
Medication blood levels should be monitored
Antiseizure drugs should not be discontinued abruptly because it can precipitate seizures
Protect the patient from harm, reduce/ prevent seizures activity without impairing cognitive function or producing undesirable side effects
SEIZURE DISORDERS/Medical Management
Phenytoin (Dilantin) Caramazepine ( Tegretol) Gabapentin (Neurotonin) Topiramate (Topamax) Valproate (Depakote,Depakene) Clonazepam (Klonopin) see page 1885
SEIZURE DISORDERS/Medications
Note CNS side effects: blurred vision, slurred speech, confusion
Patients on prolonged therapy may need a diet rich in Vitamin D
Maintain good oral hygiene – phenytoin Obtain liver functions Carry identification indicating type of
seizure -- being treated for
Antiepileptic Drugs
Nursing Diagnosis
Risk for Ineffective Airway Clearance Anxiety Risk for injury r/t seizure activity Readiness for Enhanced Knowledge
Nursing Process
Describe the mechanisms of injury, clinical manifestations, diagnostic testing, and treatment options for patients with brain and spinal cord injuries.
Use the nursing process as a framework for care of clients with brain and spinal cord injury
OBJECTIVES
Involves damage to the neural elements of the spinal cord.
Both sensory and motor function are often involved.
Major causes contusion, compression, laceration, hemorrhage and damage to the blood vessels in the spinal cord.
SPINAL CORD INJURY – (SCI)
A major health problem 200,000 persons in the U.S. live with
disability from SCI Injuries due to: MVAs, falls, acts of violence,
and sports injuries Males account for 82% of SCIs Young people ages 16–30 account for more
than half of all new SCIs African–Americans are at higher risk Risk factors include alcohol and drug use
SPINAL CORD INJURY/SCI
Spinal cord provides a two–way pathway for the conduction of impulses and information to and from the brain and the body
Ascending (sensory) pathways carry information pain, temperature, touch, Descending (motor) pathways carry information about movement
Involve damage to the vertebrae and supporting ligaments as well as the spinal cord.
SPINAL CORD INJURIES
Are the result of excessive force to the spinal column.
Most common causes -> acceleration and deceleration
Acceleration: external force is applied in a rear end collision
Deceleration: occurs in a head on collision
SPINAL CORD INJURIES
Vertebrae frequently Involved 1st, 2nd, and 4th to the 6th cervical vertebra. The 11 thoracic to 2nd lumbar vertebra.
SPINAL CORD INJURY/ SCI
Is determined by the amount of cord involvement
Paraplegia Quadriplegia
CLASSIFICATION of SCI
The patient requires emergency assessment and care and medications.
Initial care immobilization and extrication/stabilization of injuries. And possible surgery.
SCI affects every body system and function.
When injury is C1 to C4 respiratory paralysis is common and ventilator assistance is required
EMERGENCY MANAGEMENT
Neurological examinationDiagnostic x-rays ( cervical spine) CT /MRI ABG’s Trauma Screen
Fluids Medications – corticosteroids, vasopressors,
antispasmodics, NSAIDs, PPI, anticoagulants
Diagnostic Findings
Temporary loss of reflex function (areflexia) below the level of injury at the cervical and upper thoracic spinal cord.
As a result –SNS is interrupted and the PSNS is unopposed.
Muscles become completely paralyzed and flaccid/reflexes are absent
Loss of urinary bladder tone, intestinal peristalsis, perspiration
Recovery from spinal shock is gradual – usually 4-6 weeks.
Complications - Spinal Shock
Exaggerated sympathetic response affects persons with SCI at or above the T6 level.
Caused by visceral distention from distended bladder/impacted rectum
Pounding headache, hypertension, profuse sweating, bradycardia, piloerection (goosebumps)
HOB – high fowler’s, loosen tight clothing Asses bladder distention -catherization Fecal impaction – disimpact immediately
Complications –Autonomic Dysreflexia
Surgery – done to stabilize and support the spine
Stabilization/Immobilization – a type of traction or external fixation device to stabilize the vertebral column and prevent further damage to the cord.
TREATMENTS
SKELETAL FRACTURE REDUCTION/TRACTION
Impaired Gas Exchange Impaired Physical Mobility Impaired Urinary Elimination and
Constipation Sexual Dysfunction
Nursing Diagnosis
Long-term care rehabilitation is needed Learn strategies necessary to cope with
their alterations that the injury imposed on ADL’s
Care for the patient involves members of all health care disciplines
Psychologic support Goal of rehabilitation independence
HOME/COMMUNITY BASED CARE
Herniated intervertebral disk ( ruptured disc, slipped disk) is a rupture of the cartilage surrounding the intervertebral disk with protusion of the nucleus pulposus.
Most common cause of low back pain . May affect 2/3 of people at some point in
their lifetime. Most back problems are related to disk
disease
DEGENERATIVE DISK DISEASE
More common in men than women
Most patient are between the ages of 30-50
Majority of herniated disks occur in the lumbar region (L4 or L5 to S1), when disk herniate in the cervical region, they occur most often in the C6-C7 region
Herniation may be abrupt or gradual
HERNIATED INTERVERTEBRAL DISK
Intervertebral disk is a cartilaginous plate that forms a cushion between the vertebral bodies
Herniation of the intervertebral disk, causes the nucleus of the disk to protrude into the fibrous ring around the disk.
Immediate symptoms are short-lived, and those resulting from injury to the disk do not appear for months or years.
Continuous pressure may cause degenerative changes in the involved area
DEGENERATIVE DISK DISEASE
Pathophysiology
DISK DISEASE
Lumbar Disk recurrent episodes of lower back pain pain radiates across the buttocks and down
the posterior leg (sciatica)
Cervical Disk (C5-C6, C6-C7)Most herniations are the result of degeneration pain and stiffness neck, shoulders, arms pain dull, intermittent pain parethesia of upper extremities
DEGENERATIVE DISK DISEASEClinical Manifestations
Diagnostic findings MRI CT scan EMG Neurologic examination
DEGENERATIVE DISK DISEASEAssessment/Diagnostic Findings
Herniations of the cervical and lumbar disks are most common and are treated conservatively unless the patient is experiencing severe neurologic deficits.
Conservative Treatment Bedrest (no longer recommended) Patient is advised to continue with normal activities while
taking medication for pain, inflammation, and muscle spasms.
NSAID – ibuprofen (Motrin, Advil), naproxen (Naprosyn) Muscle relaxants – cycobenzaprine (Flexeril),
methocarbamol (Robaxin) Hot moist compresses
DEGENERATIVE DISK DISEASEMedical Management
Surgery is sometimes necessary Significant neurological deficit Continuing pain or sciatica Loss of sensory /motor function
Laminectomy-done to relieve the pressure on the nerves
Spinal fusion- insertion of a wedge-shaped piece of bone or bone chips between the vertebrae to stabilize them.
DEGENERATIVE DISK DISEASE
Craniotomy: opening of the skull Purposes: remove tumor, relieve elevated
ICP, evacuate a blood clot, control hemorrhage
Craniectomy: excision of portion of skill Cranioplasty: repair of cranial defect using a
plastic or metal plate Burr holes: circular openings for exploration
or diagnosis, to provide access to ventricles or for shunting procedures, to aspirate a hematoma or abscess, or to make a bone flap
Craniotomy
BURR HOLES
Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies
Medications are usually given to reduce risk of seizures
Corticosteroids, fluid restriction, hyperosmotic agent (mannitol), and diuretics may be used to reduce cerebral edema
Antibiotics may be administered to reduce potential infection
Diazepam may be used to alleviate anxiety
Preoperative Management-medical
Obtain baseline neurologic assessment Assess patient and family understanding of
and preparation for surgery. Provide information, reassurance, and
support
Preoperative -nursing
Intracranial Surgery
Postoperative care is aimed at detecting and reducing cerebral edema
relieving pain preventing seizures, monitor ICP The patient may be intubated and have
arterial and central venous lines.
Post operative
frequent monitoring of respiratory function including ABGs
monitor VS and LOC; noting any potential signs of increasing ICP
assess dressing and check for evidence of bleeding or CSF drainage
monitor for seizures; if seizures occur, carefully record and report these
monitor fluid status and laboratory data
Care of Patient -Assessment
Risk for imbalanced body temperature r/t damage to hypothalamus
Disturbed sensory perception r/t periorbital edema, head dressing
Body image disturbance r/t change in appearance or physical disabilities
Impaired communication (aphasia) r/t injury to brain tissue
Nursing Diagnosis
Strategies to control factors that increase ICP
Avoid extreme head rotation Head of bed may be flat or elevated 30° Suction or encourage coughing cautiously
as needed (suctioning and coughing increase ICP).
Humidification of oxygen may help loosen secretions.
Cerebral perfusion
Sensory deprivation Periorbital edema may impair vision, announce
presence to avoid startling the patient; cool compresses over eyes and elevation of HOB may be used to reduce edema if not contraindicated.
Enhancing self-image Encourage verbalization. Encourage social interaction and social support. Attention to grooming. Cover head with turban and, later, a wig.
Craniotomy- Nursing Interventions
What to expect after surgery medication is taken appropriately rehab – depending on post-op level of function physical therapy – residual weakness/mobility occupational therapy – self care concerns speech therapy – aphasic If prognosis is poor – discuss end of life
preferences
Home/Community based care