Neurovascular Disorders

CVA, TIA, Cerebrovascular defects, Head Injuries, Brain Tumors, Increased

Intracranial Pressure, Epilepsy and Seizures

Objectives

• Discuss various neurological disturbances in motor function and sensory/perceptual function

• Discuss the etiology/pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, and nursing interventions for a stroke patient

Objectives

• List 5 signs of increased intracranial pressure and why they occur

• List nursing interventions that decrease intracranial pressure

• List 4 classifications of seizures, their characteristics, clinical signs, aura, and postictal period

Objectives

• Discuss the etiology/pathophysiology, clinical manifestations, assessment, diagnostic tests, medical management, and nursing interventions for intracranial tumors, craniocerebral trauma, and spinal cord trauma

Objectives

• Discuss patient teaching and home care planning for a patient with a neurological disorder

Cerebrovascular Accidents

Stroke

• An abrupt impairment of brain function resulting in a set of neurologic signs and symptoms that are caused by impaired blood flow to the brain and last more than 24 hours

Risk Factors for Stroke

• Nonmodifiable factors – Risk factors that cannot be changed• Age, race, gender, and heredity

• Modifiable factors – Those that can be eliminated or controlled

• Contributing causes: atherosclerosis, HTN, DM, obesity, smoking, high cholesterol, stress, cocaine use, sedentary lifestyle, oral contraceptives.

Vascular Problems

• Stroke (cerebrovascular accident=CVA)• Also known as “brain attack”– Etiology/pathophysiology• Abnormal condition of the blood vessels of the brain,

characterized by hemorrhage into the brain, or• Formation of an embolus or thrombus that occludes an

artery ischemia to brain tissue affected by the occlusion

Figure 14-16

Three types of stroke.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)

Vascular Problems

• Stroke cont.– Causes neurological deficits of sensation,

movement, thought, memory, or speech.– Strokes may leave people with serious, long-term

disability such as:• Hemiparesis• Inability to walk• Complete or partial dependence in ADLs• Aphasia or dysphagia

Vascular Problems

– Clinical manifestations/assessment• Can affect body functions, personality, spatial-

perceptual alterations, sensation and communication

• The functions affected are directly related to the artery involved and the area of brain that it supplies.

• Permanent damage can result due to anoxia of the brain

Strokes

• Classified as : ischemic or hemorrhagic

• Ischemic strokes are further classified as:– Thrombotic or embolic

Stroke: Pathophysiology

• Hemorrhagic stroke – Blood vessel in brain ruptures; bleeding into the

brain occurs • Ischemic stroke – Obstruction of blood vessel by atherosclerotic

plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain

Figure 28-4

Stroke

• Thrombotic StrokeThrombosis is the most common cause of strokeHTN and DM accelerate the atherosclerotic

process– Seen most often in the 60-90 year old age group– If vessel becomes occluded ischemia

infarction occurs– Usually occur in the larger vessels

Stroke

• Thrombotic stroke cont.– Symptoms: tend to occur during sleep or shortly

after rising– Neurological s/sx worsen for 72 hrs as edema

increases in the infarcted area of the brain

Stroke• Embolic Stroke– The emboli most commonly originates from a

thrombus in the endocardial (inside) layer of the heart• Caused by rheumatic heart disease, mitral

stenosis, AF, MI, atrial-septal defects– Emboli travels upward to the cerebral circulation

and lodges where a vessel narrows.– Most frequently occur in the midcerebral artery

Stroke

• Hemorrhagic Stroke– Bleeding into the brain or subarachnoid space

destroys or replaces brain tissue– Often caused by aneurysms which are a localized

dilation of the wall of a blood vessel

Stroke

• Hemorrhagic Stroke cont.– Aneurysm: usually caused by atherosclerosis, HTN,

trauma, or infection, or congenital weakness in a blood vessel wall

– It ruptures as a result of a small hole hemorrhage spreads rapidly.

– Hemorrhage begins to absorb within 3 weeks– Recurrent rupture is a risk for 7-10 days after the

initial hemorrhage

Transient Ischemic Attack

• Temporary neurologic deficit caused by impairment of cerebral blood flow

• Usually lasts less than 24 hrs.; most resolve within 3 hrs.

• Blood vessels occluded by spasms, fragments of plaque, or blood clots

• Important warning signs for the individual experiencing a full stroke

Transient Ischemic Attack• Signs and symptoms – Dizziness, momentary confusion, loss of speech,

loss of balance, tinnitus, visual disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling or numbness on one side of the body; ataxia

– Between attacks, neurological status is normal

Transient Ischemic Attack

• Medical diagnosis – Health history, physical examination findings, and

results of brain imaging studies– CT without contrast media is the most important

diagnostic study– Laboratory studies, electrocardiography (ECG),

duplex ultrasonography, and cerebral angiography may also be used

Transient Ischemic Attack

• Medical treatment– Depends on the location of the narrowed vessel

and the degree of narrowing– Acetylsalicylic acid (aspirin), ticlopidine

hydrochloride (Ticlid), extended-release dipyridamole (Aggrenox), or clopidogrel bisulfate (Plavix) decrease platelet clumping

– Warfarin (Coumadin) and heparin - anticoagulants

Transient Ischemic Attack

– Surgical Treatment may include: • Carotid endarterectomy and transluminal angioplasty– Carotid endarterectomy: removal of atheromatous

lesion to enable increased blood flow

– Transluminal angioplasty – the insertion of a balloon to open a stenosed artery to allow increased blood flow

Figure 28-3

Strokes

• Assessment: – Subjective Data: description of onset of

symptoms; presence of headache; sensory deficits: numbness, tingling, inability to think clearly, visual problems

– Objective Data: presence of hemiparesis or hemiplegia; LOC, s/sx ICP, respiratory status, aphasia or dysphagia

Stroke

• Diagnostic Tests– CT: can indicate size, location of the lesion and

differentiate between ischemic and hemorrhagic stroke

– MRI – can determine extent of brain injury– PET scan – useful in assessing the extent of tissue

damage by showing the

Stroke

• Medical management• If the patient has had a hemorrhagic stroke as a

result of an aneurysm – surgery may be needed

– Tie off or clip the aneursym; remove the clot

– Treat [within 96 hrs. of bleeding] with calcium channel blockers x21 days

Aneurysm Clipping

Stroke• Medical Management– Ischemic Stroke• Thrombolytics– T-PA (clot buster!) [Tissue Plasminogen Activator]

Digests fibrin and fibrinogen lysing the clot; must be administered within 3 hrs of onset of symptoms– Pts. Screened carefully for coagulation disorders,

recent GI bleed, r/o hemorrhagic stroke –May not be candidate for thrombolytic treatment– Patient choice factor

Stroke

• Medical Management cont.– Ischemic Stroke cont.• Heparin and Coumadin – to prevent formation of more

clots. Used after the first 24 hrs. if treated with t-PA

– Drugs to reduce intracranial pressure:• Decadron (steroid)• Bowel meds (to reduce straining)

Stroke

• Medical Management cont.– First 24-48hrs: • Airway maintenance and supportive treatment• Antihypertensives

– Fluids restricted first few days– IV or Feeding tube may be utilized

Strokes

• Medical Management cont.Other:– P.O. food/fluids: pureed, soft, regular– Neurological checks– Bedrest – depends on the type of stroke, deficits,

and the judgment of the MD– Physical, occupational, and/or speech therapy

Stroke: Signs and Symptoms

• Different signs and symptoms, depending on the type, location, and extent of brain injury

• Hemorrhagic stroke – Occurs suddenly; may include severe headache

described as “the worst headache of my life” – Other symptoms: stiff neck, loss of

consciousness, vomiting, and seizures

Stroke: Signs and Symptoms

• Embolic stroke – Appear without warning – One or more of the following signs and

symptoms: one-sided weakness, numbness, visual problems, confusion and memory lapses, headache, dysphagia, and language problems

Stroke: Signs and Symptoms

• Aphasia – A defect in the use of language; speech, reading, writing,

or word comprehension • Dysarthria – The inability to speak clearly

• Dysphagia– Swallowing difficulty

• Dyspraxia – The partial inability to initiate coordinated voluntary

motor acts • Hemiplegia– Defined as paralysis of one side of the body

Stroke: Signs and Symptoms

• Sensory impairment – Unable to feel touch, pain, or temperature in affected body

parts• Unilateral neglect

– Do not recognize one side of the body as belonging to them

• Homonymous hemianopsia – Perceptual problem: involves loss of one side of field of

vision • Elimination disturbances

– Neurogenic bladder – Flaccid bladder – Bowel incontinence

Figure 28-5

Figure 28-8

Prognosis• Prognosis for TIA or stroke increasingly hopeful

• Critical variables for recovery: patient’s condition before the stroke, time between stroke and diagnosis, treatment and support in acute phase (usually the first 48 hours), severity of patient’s symptoms, and access to rehabilitative therapy

• Long-term recovery may depend on the care received immediately after the stroke

• Most recovery takes place in the first 3-6 months, but progress often continues long after that

Stroke

• Nursing InterventionGoals during the initial phase are aimed at preventing

neurological deficits– Neurological Assessments at regular intervals– Nutrition: route and texture depend on swallow

ability– Self-care deficit and assistance needed. Start

teaching process

Stroke

• Nursing Interventions cont.– Elimination: insert/remove urinary catheter;

monitor s/sx of UTI; bladder and bowel training– Mobility – ROM/exercise/activity: issue: unilateral neglect– Emotional lability/ depression

Stroke

• Nursing Interventions cont.– Communication: many stroke patients have

speech problems• ST will evaluate and treat• Approach in an unhurried way• Communication board may be helpful• Inability to articulate doesn’t mean cognitive

impairment

Stroke

• Patient Teaching– Techniques to compensate for the deficit(s)– “Rehabilitation” starts with admission to the acute

facility– Medication instruction– “Stroke Club” referral for support– Safety– Communication – Caregiver stress relief

Nursing Care in the Rehabilitation Phase

• Interventions– Self-Care Deficit – Risk for Injury – Ineffective Coping – Impaired Verbal Communication – Imbalanced Nutrition – Impaired Physical Mobility – Constipation– Total and Functional Urinary Incontinence

Figure 28-6

Figure 28-7

Figure 28-9

Discharge

• Patients may be discharged to home or go to specialized rehabilitation centers for continued therapy

• Outpatient therapy is an option for some patients

• When able, patients are transitioned back into the home setting

• Essential to include family, friends, and significant others in this process

Discharge

• During and after the rehabilitation phase, patients and families need to be made aware of resources to help them deal with continuing disabilities

• In rehabilitation, the patient is respectfully challenged to return to the highest level of function possible

Craniocerebral Trauma

Head Injury

Craniocerebral Trauma

• Injuries to the brain can result from direct or indirect trauma

• Indirect trauma is caused by tension strains and shearing forces transmitted to the head by stretching the neck

• Direct Trauma occurs when the head is directly injured acceleration-deceleration injury with rotation of the skull and its contents bruising or contusion of the occipital and frontal lobes and the brainstem and cerebellum

Craniocerebral Trauma

• Clinical Manifestations– “open” or “closed” injury– Open head injuries result from skull fractures or

penetrating wounds• Amount of injury is determined by the velocity, mass,

shape, and direction of impact• Skull fracture may also occur

Fractures at the base of the skull are more serious because of their location near the medulla

Craniocerebral Trauma

– Skull cont.– Injuries and fractures may occur with or without

brain injury. • Closed fracture: dura mater intact• Open fracture: dura mater torn

– Closed Head Injury: • Includes concussions, contusions, lacerations• Hemorrhaging may occur in the: scalp, epidural,

subdural, intracerebral, and intraventricular places

Craniocerebral Trauma

• Clinical Manifestations cont.– Closed Head Injuries cont.• Scalp injuries–Lacerations, contusions, abrasions, and

hematomas• Concussion –Trauma with no visible injury to the skull or

brain–Temporary loss of consciousness

Craniocerbral Trauma

– Closed Head Injury cont.• Contusion–Bruising and bleeding in the brain tissue

• Hematoma –Subdural or epidural hematoma

• Intracerebral or Subarachnoid hemorrhage –From lesions within the tissue of the brain

itself

Coup Contra Coup

Hematomas• Epidural– Arterial bleed that forms rapidly between dura

and skull– EMERGENCY!– Note: if lethargy or unconsciousness develop after

the patient regains consciousness, an epidural hematoma may be suspected and needs immediate treatment!

• Subdural– Forms as venous blood collects below the dura– Forms more slowly than epidural bleed

Hematomas

• Subdural cont.– The clot will cause pressure on the brain surface

and will displace brain tissueNote: if a patient who has been conscious for

several days after head injury loses consciousness or develops neurological signs and symptoms, a subdural hematoma should be suspected

Craniocerebral Trauma

• Assessment– Subjective Data: pt. understanding of the injury and

resulting trauma; able to define how the trauma happened; c/o nausea, vomiting, loss of consciousness, abnormal sensations, bleeding from any orifice

– Objective Data: respiratory status, LOC, Pupil size and responsiveness check freq., VS, presence of bleeding; vomiting, abnormal speech. Presence of “battle’s sign” – small hemorrhagic spot behind the ear (poss. fracture of lower skull).

Craniocerebral Trauma

• Diagnostic Tests:– CT, MRI, PET scan to assess soft tissue injuries

• Medical Management– Immediate care is life-saving measures and

maintenance of normal body functions until recovery is ensured

Maintain patent airway, adequate oxygenation• If suctioning needed, do not use nasal passages

due to possibility of skull fx.

Craniocerebral Trauma

• Medical Management cont.– Medications to reduce cerebral edema and

increased intracranial pressure– Analgesics that do not depress respirations– Anticonvulsants prn seizure prevention– Measures to provide cooling if elevated temp– Surgery

Craniocerebral Trauma• Surgical treatment– Directed at evacuating hematomas and débriding

damaged tissue– Bone flap removed to relieve pressure– Catheter may be inserted into the ventricles to remove

CSF and monitor intracranial pressure– Burr holes used to treat epidural and subdural

hematomas

Surgery

Increased Intracranial Pressure(ICP)

Can occur suddenly, progress rapidly, and often requires surgical

interventionCan be fatal if not stopped and

reversed

Increased Intracranial Pressure

– Etiology/pathophysiology• An increase in any content of the cranium

– Blood, CSF, tissue, infection, edema• Cranial vault is rigid and non-expandable• Build up of pressure can occur slowly or rapidly

involving one or both sides of the brain• Rising of pressure decreased cerebral blood flow

inadequate perfusion of the brain • Changes in PCO2, PO2, and pH vasodilation and

cerebral edema further increased pressure brainstem herniation

Increased Intracranial Pressure

– Clinical manifestations/assessmentChange in level of consciousness (EARLY SIGN!)• Diplopia• Headache• Abnormal vital signs (irregular resp., increase BP,

decrease HR, elevated temp.)• Pupillary signs• Vomiting• Changes in motor function (weakness, hemiplegia,

positive Babinski’s reflex, decorticate or decerebrate posturing, and seizures)

Increased Intracranial Pressure

• Assessment: early detection meaures to reverse condition– Subjective Data: pt. understanding of their

condition, c/o visual changes, nausea, pain, personality change, change in ability to think• Double vision (diplopia) occurs early in the process of

ICP• Headache – usually increases with coughing, straining

at stool, or stooping.

Increased Intracranial Pressure

• Objective Data:Chart what is seen; not what is inferredChange in LOC– Pupils check – pupils will usually change on the

same side as the lesion• First and most subtle clue: sluggish pupillary response*Dilated pupils that respond slowly to light are a sign of

impending brainstem herniation• A pupil that is fixed and dilated is called “blown”

Cushing’s Triad

• Late sign of increased ICP (brain herniation)– Increased systolic BP– Widened pulse pressure– Bradycardia

• Other: – +/- irregular respirations– Elevated temperature

Increased Intracranial Pressure

• Characteristic posturing when upper brainstem is herniated:– Decorticate response: flexion of arms, wrists, and

fingers with adduction in upper extremities; in lower extremities – extension, internal rotation, and plantar flexion

– Decerebrate response: all 4 extremities in rigid extension, hyperpronation of forearms and plantar extension of feet

– *P. 669, Figure 14-8

Increased Intracranial Pressure• Diagnostic Tests: – CT, MRI– Because acute increased intracranial pressure is a

medical emergency, there is little time for diagnostic tests [LP is contraindicated]• Frequent and careful observations and neurological

testing• The presence of even subtle changes can be very

significant.

– Internal measuring devices in postop or critically ill patients

Increased Intracranial Pressure

• Medical Management– Goal: identify and treat the underlying cause of

ICP– Mechanical decompression• Craniotomy• Craniectomy• Drain ventricles or subdural hematoma

– Medications: osmotic diuretics (e.g. Mannitol), corticosteroids(eg. Decadron), and anticonvulsants (eg. Dilantin)

Increased Intracranial Pressure

• Nursing Interventions– Therapeutic Measures (to reduce venous volume): • Elevating HOB 30-45 degrees• Neck in neutral position• Position pt. to avoid flexion of the hips, waist, and neck

(reduces intrabdominal and intrathoracic pressure that can increase ICP)• Instruct pt. to avoid isometric or resistive exercises

Increased Intracranial Pressure• Nursing Interventions/ Therapeutic Measures cont.– Restrict fluid intake– Measures to help pt. avoid Valsalva’s maneuver

(forced expiratory effort against a closed airway –e.g. straining to have a BM)

– Foley cath prn– Suction only prn– Administer O2– Hyperthermia blanket prn

Intracranial Tumors

Intracranial Tumors

• Etiology/pathophysiology• Benign (meningioma) or malignant (glioma)• Primary or metastatic• May affect any area of the brain; named for the

area from which they arise• Drug/environmental factors may play a role in

development

Intracranial Tumors• Assessment– Subjective Data: pt. understanding of diagnosis;

changes in personality or judgment; c/o abnormal sensations, visual problems, unusual odors; c/o headache, hearing loss, or inability to carry out ADLs

– Objective Data: motor strengths, gait, LOC, pupil status, speech abnormalities, cranial nerve abnormalities, s/sx of ICP, presence of seizures

Intracranial Tumors

• Diagnostic Tests: CT, MRI, PET, EEG• Medical Management– Surgical removal of tumor• Craniotomy• Intracranial endoscopy

– Radiation– Chemotherapy– Combination of above

Intracranial Tumors

• Nursing Interventions– Preoperative preparationBaseline neurological assessment

*Most Important with any patient– Postoperative care is determined by the pt.

condition• Assess for s/sx ICP

Intracranial Tumors

• Nursing Diagnoses (r/t, AEB: Nanda Approved)– Acute Pain– Disturbed Thought Processes– Disturbed Sensory Perception– Impaired Physical Mobility and Self-Care Deficit– Ineffective Coping

Epilepsy/Seizure Disorder

EPILEPSY/SEIZURE DISORDER

• A transitory disturbance in consciousness or motor, sensory, or autonomic function with or without loss of consciousness

• Associated with paroxysmal , uncontrolled electrical discharges in the neurons of the brain sudden, violent, involuntary contractions of a group of muscles

• Causes: hypoglycemia, infection, electrolyte imbalance, drug and alcohol withdrawal, and water intoxication

EPILEPSY/SEIZURE DISORDER

• Clinical Manifestations– Classifications:• Generalized tonic-clonic (grand mal)• Absence (petit mal)• Psychomotor (automatisms)• Jacksonian (focal)• Miscellaneous (myoclonic, akinetic)

– See Table 14-6 for more specifics • (p. 677-678)

EPILEPSY/SEIZURE DISORDER

• Clinical Manifestations cont.– Postictal Period: pt. usually feels groggy and acts

disoriented; sometimes c/o headache and muscle aches; often sleeps; may experience amnesia

– Status epilepticus • Medical emergency: continuous seizures or repeated

seizures in rapid succession for 30 minutes or more

EPILEPSY/SEIZURE DISORDER

• Assessment:– Subjective Data: pt. awareness of the disorder and

any precipitating factors; may c/o presence of an “aura” preceding a seizure• Aura: a sensation such as light or warmth that may

precede a migraine attack or seizure; may be psychic, sensory with olfactory, visual, auditory, or taste hallucinations

– Objective Data: # seizures occurring in a given time period; character of the seizures, behaviors noted, injuries incurred.

EPILEPSY/SEIZURE DISORDER

• Diagnostic Tests: EEG• Medical Management:– Medications (see Table 14-7 p. 679)– ADL – driving car, operating machinery, swimming

should be avoided until seizures are controlled

EPILEPSY/SEIZURE DISORDER

• Nursing Interventions: Care during a seizure– Primary goal: protection from aspiration and

injury; and observation and recording of the seizure activity

– DO NOT LEAVE PATIENT ALONE!– Support and protect the head– If possible, turn head to one side to maintain

airway.

EPILEPSY/SEIZURE DISORDER

• Nursing Interventions: Care during a seizure cont.– Loosen clothing around neckDO NOT RESTRAIN THE PATIENTDO NOT TRY TO PRY OPEN THE JAW TO INSERT

PADDED TONGUE BLADE OR OTHER OBJECT – Padded siderails may be used – esp. if seizure

activity at night

EPILEPSY/SEIZURE DISORDER

• Nursing Diagnoses may incude:– Ineffective airway clearance r/t mucus

accumulation in oropharyngeal area during seizure– Risk for injury r/t rapid onset of altered state of

consciousness and seizure activity

EPILEPSY/SEIZURE DISORDER

• Nursing Diagnosis and Patient Teaching• Ineffective Coping and Deficient Knowledge– Teach family and patient about the seizure

disorder, the therapy, & good follow-up care.– Teaching must be directed toward helping the

patient and family adjust to a chronic condition – Instruct re: use medic alert bracelet/necklace– Encourage questions and concerns– Explain restrictions

Vagus Nerve Stimulator• A generator, similar to a

pacemaker, is implanted under the skin on the patients chest. The electrodes (wires) are then wrapped around the vagus nerve.

• The generator sends electrical impulses to the vagus nerve, which carries those impulses to the CNS

• This impulses may stop a seizure or lessen the severity of a seizure