7/27/2019 Care of Patient With Brain Disorders

1/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Chapter 24

Care of Patients with Disorders of the Brain

7/27/2019 Care of Patient With Brain Disorders

2/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Theory Objectives

Describe the appropriate nursing actions

and observations to be carried out for a

patient experiencing a seizure.

Explain why seizure may be a

consequence of a stroke, tumor, or

infection in the brain.

Compare the subjective and objective

findings of thrombotic stroke and

intercerebral bleed.

7/27/2019 Care of Patient With Brain Disorders

3/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Theory Objectives (cont.)

Devise a nursing care plan for the patient

who has suffered a cerebrovascular

accident (CVA, stroke).

Discuss nursing actions to assist the

patient who has developed a complication

after a cerebrovascular accident.

Describe subjective and objective findings

indicative of a brain tumor.

7/27/2019 Care of Patient With Brain Disorders

4/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Theory Objectives (cont.)

Explain the pathophysiology behind the

symptoms of a brain tumor.

Diagram the mechanism by which

infection in the brain may cause increased

intracranial pressure.

Recall the signs of increasing intracranial

pressure from early to late signs.

7/27/2019 Care of Patient With Brain Disorders

5/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Theory Objectives (cont.)

Compare and contrast symptoms of

meningitis and encephalitis.

Explain the assessment data that

differentiate migraine headaches from

cluster headaches.

Compare the signs, symptoms, and

treatment of trigeminal neuralgia and Bells

palsy.

7/27/2019 Care of Patient With Brain Disorders

6/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Clinical Practice Objectives

Teach a teenage patient recently

diagnosed with epilepsy what he needs to

know about his disorder and care.

Perform neurologic checks on a patient

who is admitted with a suspected CVA.

Assist with the care of a patient who has

had intracranial surgery.

Devise a teaching plan for the patient who

has suffered a CVA and has right-sided

hemiplegia.

7/27/2019 Care of Patient With Brain Disorders

7/57Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Seizure Disorders and Epilepsy

Etiology

Brain injury, tumor, infection with high fever,

ESRD with uremia, eclampsia, drug

poisoning, epilepsy, tetanus, hypoxia, ETOHwithdrawal, metabolic disturbances, genetic

defects, increases in 60-80 yrs old, 4-8/1000

in US

7/27/2019 Care of Patient With Brain Disorders

8/57Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Seizure Disorders and Epilepsy

Pathophysiology

Chronic disturbance of nervous system

Recurrent spontaneous seizures

Unknown stimulus cause cell membranes to

depolarizeabnormal sensory or motor

activity may lead to unconciousness

Neurons have low threshold forexcitationspreads to surrounding cells in

brain

7/27/2019 Care of Patient With Brain Disorders

9/57Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Partial Seizures

Signs and symptoms

Partial seizures also are called simple orfocal seizures

and result from an abnormal localized cortical

discharge. Partial seizures with complex symptomatology may

also be called temporal lobe seizures because they

usually originate in the temporal lobe of the brain.

Partial seizures can be unilateral, with involvement ononly one side of the brain and activity only on one side

of the body.

7/27/2019 Care of Patient With Brain Disorders

10/57Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Seizure Disorders and Epilepsy

Signs and symptoms

Partial seizures

Consciousness not impaired

Motor, sensory, autonomic, psychological

symptoms

Complex partial seizures-some impairment

of consciousness, automatisms (lip-smacking etc), may become generalized

7/27/2019 Care of Patient With Brain Disorders

11/57Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Seizure Disorders and Epilepsy

Generalized seizures

bilateral, symmetrical, no local onset

Absence, myoclonic, clonic, tonic, tonic-clonic,

atonic, infantile spasms (d/t fever) Electrical discharges in brain (bilateral,

synchronous), whole brain affected

No warning or aura

Loss of consciousness lasting seconds to severalminutes

Absence or petit malfew seconds, no aura, no

post-ictal symptoms, 5-12 yrs disappear in puberty

7/27/2019 Care of Patient With Brain Disorders

12/57Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Generalized Seizures

Absence-lapse

Myoclonic-jerking, twitching of muscle

Clonic-rhythmic jerking, loss of conciousness

Tonic-continued contraction of muscles Tonic-clonic-jerking/contracting, starts focal, bilateral,

grand mal, loss of conciousness

Atonic seizures-

loss of muscle tone, nod head, weak knees Infantile spasms

(usually caused by increased temperature)

7/27/2019 Care of Patient With Brain Disorders

13/57Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Status Epilepticus

Prolonged partial or generalized seizure

without recovery between attacks

Rapid, unrelenting series of convulsive

seizures without intervening periods of

consciousness, and an absence of

respiration

Irreversible brain damage can occur if the

seizures are not controlled

7/27/2019 Care of Patient With Brain Disorders

14/57

7/27/2019 Care of Patient With Brain Disorders

15/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Treatment

Control or eliminate cause

Antiepileptic drugs and patient teaching

Ketogenic diet Biofeedback

Surgery

7/27/2019 Care of Patient With Brain Disorders

16/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Treatment of Status Epilepticus

Care is focused on supporting vital signs

and preventing injury

Intubation and respiratory support

7/27/2019 Care of Patient With Brain Disorders

17/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Observations to Make During a

Seizure Time the seizure began and the time itended

What the patient was doing just before the

seizure (Was the patient picking at

clothing?)

Where in the body the seizure began,

what parts of the body are involved

Which way eyes are moving, whether they

constrict or dilate, deviate to the right or

the left, or roll upward

7/27/2019 Care of Patient With Brain Disorders

18/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Observations to Make During a

Seizure (cont.) Which side the head turns toward Whether the patient cries out or screams

as the seizure begins

Whether there is evidence of repetitive

movements: lip smacking, chewing,

grimacing, tapping, or pill rolling

7/27/2019 Care of Patient With Brain Disorders

19/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Observations to Make During a

Seizure (cont.) Whether movements are bilateral andsymmetrical

Incontinence of urine or stool, vomiting,

frothing at the mouth, or bleeding

Whether the patient becomes apneic or

cyanotic

Changes in skin color or profuse

perspiration

7/27/2019 Care of Patient With Brain Disorders

20/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Postictal Assessment

After a patent airway is ensured

Length of time before regaining awareness

Presence of lethargy or confusion

Presence of headache

Presence of speech impairment

Presence of muscle soreness

Whether there was an aura before the seizure

began

Effects of the seizure on the patients vital

signs

7/27/2019 Care of Patient With Brain Disorders

21/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Planning and Implementation

Expected outcomes are written for the

individual patient and the type of seizure

disorder, possible triggers, and

manifestations

Safety considerations

Patient and family teaching

7/27/2019 Care of Patient With Brain Disorders

22/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Audience Response Question 1

Nursing care of a patient who had a recentseizure episode includes which nursingintervention(s)? (Select all that apply.)

1.Assess for injuries.2.Check the glucose level.

3.Reassure and reorient patient.

4.Provide uninterrupted periods of sleep andrest.

5.Provide a 24-hour sitter.

7/27/2019 Care of Patient With Brain Disorders

23/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Transient Ischemic Attack

Brief interruption in blood flow

Warnings of more serious neurologic

event

Symptoms generally last no more than an

hour and completely resolve without

residual deficits

Thorough history

7/27/2019 Care of Patient With Brain Disorders

24/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Transient Ischemic Attack

(cont.) Carotid duplex ultrasound Blood tests, MRI, and EEG

Angioplasty procedure with stentimplantation or a carotid endarterectomy

Diet, lifestyle modification, and medication

to prevent platelet aggregation

7/27/2019 Care of Patient With Brain Disorders

25/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Cerebrovascular Accident

(Stroke, Brain Attack) Etiology

Atherosclerosis

predispose to thrombus formation or plaque emboli

Risk factors-modifiable

Smoking, cocaine, ETOH >2 drinks/day, heart

dz, DM, HTN, High cholesterol, sedentary,

elevated RBC, TIAs, OCs, HRT,

7/27/2019 Care of Patient With Brain Disorders

26/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Cerebrovascular Accident

(Stroke, Brain Attack) Risk factors-non-modifiable

Age >65

Heredity

Asymptomatic carotid bruit

Prior CVA

African American-60%

Men-30%

7/27/2019 Care of Patient With Brain Disorders

27/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Cerebrovascular Accident

(Stroke, Brain Attack) Pathophysiology

Cerebral thrombosis-blood clot

Embolus-traveling clot

Intracerebral hemorrhage-ruptured blood

vessels

Pressure on a blood vessel-tumor

7/27/2019 Care of Patient With Brain Disorders

28/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Dangers of Cocaine or

Methamphetamine Use Caution people about the dangers of usingcocaine or methamphetamine

Both of these drugs can causevasoconstriction and brain ischemia

Cocaine may also cause hemorrhage

Using these drugs causes a fivefoldincrease in the incidence of stroke

The incidence of this type of stroke has

greatly increased in young adults

7/27/2019 Care of Patient With Brain Disorders

29/57

7/27/2019 Care of Patient With Brain Disorders

30/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Cerebral Aneurysm and

Arteriovenous Malformation Aneurysm

An abnormal ballooning of an artery wall

Arteriovenous malformation (AVM)

A congenital abnormality that is a tangled

mass of malformed, thin-walled, dilated

vessels that form an abnormal communicationbetween the arterial and venous systems

7/27/2019 Care of Patient With Brain Disorders

31/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Dissected Circle of Willis

Showing a Large Cerebral

Aneurysm

7/27/2019 Care of Patient With Brain Disorders

32/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Warning Signs of Stroke

Teach people to seek immediate medical

attention in an emergency department if

any of the following warning signs of

stroke appear Sudden weakness, numbness, tingling, or

loss of feeling in the face, arm, or leg

Sudden trouble seeing in one or both eyes;double vision

Sudden confusion, slurred speech, trouble

talking, or difficulty understanding what others

are saying

7/27/2019 Care of Patient With Brain Disorders

33/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Warning Signs of Stroke (cont.)

A sudden, severe headache for no known

reason

Sudden trouble walking, dizziness, or a

feeling of spinning around Loss of balance or coordination

Blackouts

7/27/2019 Care of Patient With Brain Disorders

34/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Warning Signs of Stroke (cont.)

Should any of the warning signs occur,

ask the person to

Smile

Shrug the shoulders

Repeat a sentence or saying what you say

first

Tell you who and where he or she is

7/27/2019 Care of Patient With Brain Disorders

35/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Stroke Signs and Symptoms

Location of the clot or bleed

Motor function deficits

Language disorders Emotional responses

Memory and judgment

Spatial-perceptual deficits Bladder and bowel incontinence

7/27/2019 Care of Patient With Brain Disorders

36/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Stroke Diagnosis

MRI or cerebral angiogram

EEG

Brain scans Transcranial Doppler flow studies

Carotid artery Doppler studies

Testing for blood levels of glutamate Lumbar puncture

7/27/2019 Care of Patient With Brain Disorders

37/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Stroke Treatment

Maintain an open airway

Fluids and antihypertensives

Temperature control Alteplase or systemic tissue plasminogen

activator and other medications

Surgical procedures

7/27/2019 Care of Patient With Brain Disorders

38/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Each Area of the Brain Controls

a Particular Activity

7/27/2019 Care of Patient With Brain Disorders

39/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Homonymous Hemianopsia

7/27/2019 Care of Patient With Brain Disorders

40/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Complications of Stroke

Extension of hemorrhage or rebleed

Seizures

Hydrocephalus

7/27/2019 Care of Patient With Brain Disorders

41/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Management of Stroke

Phase 1initial care

Phase 2rehabilitation efforts

Phase 3

continuity of care

7/27/2019 Care of Patient With Brain Disorders

42/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Phase I

Assessment

Nursing diagnosis

Planning Maintain an adequate airway

Establish baseline data regarding vital signs,

LOC, neuromuscular function, and neurologic

status

Preserve joint and muscle function

Prevent complications that may interfere with

rehabilitation

7/27/2019 Care of Patient With Brain Disorders

43/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Phase I (cont.)

Implementation

Amount of activity and cause of stroke

Dysphagia and speech therapy

Evaluation

7/27/2019 Care of Patient With Brain Disorders

44/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Comparison of Deficits

7/27/2019 Care of Patient With Brain Disorders

45/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Phase II

Plans for rehabilitation should begin the

moment the patient is admitted

Various members of the health care team

collaborate with the patient and family to

help resolve both psychosocial and

physical problems

The stroke patient can be prone to rapidmood swings and spontaneous weeping

7/27/2019 Care of Patient With Brain Disorders

46/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Phase III

Discharge and referrals

Visiting nurse

Continued rehabilitation

7/27/2019 Care of Patient With Brain Disorders

47/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Brain Tumor-pp.539

Etiology

Pathophysiology

Signs and symptoms

Diagnosis

Treatment

Surgery Radiation therapy

Chemotherapy

7/27/2019 Care of Patient With Brain Disorders

48/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Nursing Management of Brain

Tumors Routine neurologic assessments including

activities of daily living

Pain assessment and control

7/27/2019 Care of Patient With Brain Disorders

49/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Complications of Brain Tumors

Hydrocephalus

Intercerebral hemorrhage

7/27/2019 Care of Patient With Brain Disorders

50/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Bacterial Meningitis-pp.541

Etiology and pathophysiology

Meningitis immunization

Signs and symptoms

Brudzinskis sign

Kernigs sign

Diagnosis

7/27/2019 Care of Patient With Brain Disorders

51/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Bacterial Meningitis (cont.)

Treatment

Antibiotics

Dexamethasone

Anticonvulsive drugs

Analgesics

7/27/2019 Care of Patient With Brain Disorders

52/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Viral Meningitis

Signs and symptoms

Examination of the CSF

Nursing management

Assessment

Diagnosis

Planning (expected outcomes)

Implementation

Evaluation

7/27/2019 Care of Patient With Brain Disorders

53/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Viral Meningitis (cont.)

Expected outcomes

Conserve the strength of the patient

Prevent seizures

Promote healing

7/27/2019 Care of Patient With Brain Disorders

54/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Encephalitis-pp.544

Etiology and pathophysiology

Protect against mosquitoes and ticks

Signs and symptoms

Diagnosis

Treatment

Nursing management Complications

7/27/2019 Care of Patient With Brain Disorders

55/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Brain Disorders

Brain abscess

Headaches

Migraine headaches

Finding foods that trigger a migraine

headache

Complementary and alternative therapies

Cluster headaches

Tension headaches

7/27/2019 Care of Patient With Brain Disorders

56/57

Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

Trigeminal Neuralgia

(Tic Douloureux) Etiology Pathophysiology

Signs and symptoms

Diagnosis

Treatment

Nursing management

7/27/2019 Care of Patient With Brain Disorders

57/57

Bells Palsy

Etiology

Edema and ischemia of facial nerve

Herpes simplex virus

Stress

Exposure to cold

Pregnancy

Diagnosis

Treatment