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Cerebro-Vascular Disorders

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A ppt which features the nursing management for clients with Cerebrovascular disorders specifically CVA, HEAD INJURY and SPINAL INJURY.
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Management of Patients with Cerebrovascular Disorders Nelia B. Perez RN, MAEd, MSN PCU MJCN BSN 2012
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Page 1: Cerebro-Vascular Disorders

Management of Patients with Cerebrovascular Disorders

Nelia B. Perez RN, MAEd, MSNPCU MJCN

BSN 2012

Page 2: Cerebro-Vascular Disorders

Neurological System

Page 3: Cerebro-Vascular Disorders

Brain Anatomy• Cerebrum– Reasoning– Judgment– Concentration,– Motor, sensory, speech

• Cerebellum– Coordination

• Brainstem– Cranial nerves– Respiratory center– Cardiovascular center

Page 4: Cerebro-Vascular Disorders

Brain Anatomy Cont.

Page 5: Cerebro-Vascular Disorders

Cerebral Blood Flow

• 20% of CO• Cerebral tissues – Have no

oxygen or glucose reserves• Blood flows through Carotid

Arteries to Circle of Willis

Page 6: Cerebro-Vascular Disorders

Intracranial Pressure (ICP)

Composition• 80% brain tissue and water • 10% blood • 10% cerebrospinal fluid (CSF)

Increased ICP caused by:• Severe head injury/ Subdural

hematoma• Hydrocephalus• Brain tumor• Meningitis/Encephalitis• Aneurysm• Status epilepticus/Stroke

A medical emergency that can lead to:

Brain hypoxia, herniation, death

Clinical Manifestations• Vomiting • Headache • Blurred vision • Seizure • Changes in behavior • Loss of consciousness • Lethargy • Neurological symptoms

Page 7: Cerebro-Vascular Disorders

Neurological Assessment

• Rapid Neurological Assessment – Emergent situations– Sudden changes in neurologic status

1. LOC: first indicator of a decline in neurological function and increase in ICP (intracranial pressure); use the GCS

2. Pupils

Page 8: Cerebro-Vascular Disorders
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3. PUPILS

Pupils equal and react normally

Pupils react to light (slowly or blriskly)

Dilated pupil (compressed cranial nerve III)

Bilateral dilated, fixed (ominous sign)

Pinpoint pupils (pons damage or drugs)

Page 10: Cerebro-Vascular Disorders

Neuro-Diagnostic Tests• Routine labs• Radiology Tests– CT scan, MRI– Carotid ultrasound– Cerebral angiogram/ MRA

CT SCAN

MRA

Carotid US

Page 11: Cerebro-Vascular Disorders

Neuro-Diagnostic Tests: Lumbar Puncture

• Spinal needle inserted into SA

• L3/L4 or L-4 /L-5 using strict asepsis– Obtain CSF specimens and

pressure readings– To remove bloody or purulent

CSF– Administer spinal anesthesia

Page 12: Cerebro-Vascular Disorders

Cerebrovascular Disorders

• 53.6% Functional abnormality of the CNS that occurs when the blood supply is disrupted

• Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S.

• Stroke is the leading cause of serious long-term disability in the U.S.

• Direct and indirect costs of stroke are billion

Page 13: Cerebro-Vascular Disorders

Prevention• Nonmodifiable risk factors– Age (over 55), male gender, African American race

• Modifiable risk factors:– Hypertension: the primary risk factor

– Cardiovascular disease

– Elevated cholesterol or elevated hematocrit

– Obesity

– Diabetes

– Oral contraceptive use

– Smoking and drug and alcohol abuse

Page 14: Cerebro-Vascular Disorders

CEREBROVASCUL

AR ACCIDENTS

Page 15: Cerebro-Vascular Disorders

Stroke• “Brain attack”

• Sudden loss of function resulting from a disruption of the blood supply to a part of the brain

• Types of stroke:

– Ischemic (80% to 85%)

– Hemorrhagic (15% to 20%)

Page 16: Cerebro-Vascular Disorders

Ischemic Stroke• Disruption of the blood supply due to an

obstruction, usually a thrombus or embolism, that causes infarction of brain tissue

• Types– Large artery thrombosis

– Small penetrating artery thrombosis

– Cardiogenic embolism

– Cryptogenic

– Other

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Pathophysiology

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Manifestations of 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

Page 19: Cerebro-Vascular Disorders

R Hemiplegia/paresis

Impaired speech(Aphasias)

Impaired discrimination(R/L)

Slow performance,Cautious

Aware of deficitsDepression, Anxiety

Impaired comprehension & Memory R/T language and mathLeft -Sided CVA:

LEFT BRAIN DAMAGE R Hemianopsia

Page 20: Cerebro-Vascular Disorders

Right-sided CVA:RIGHT BRAIN DAMAGE Impaired judgment

Impulsive/Safetyproblems

Denies/Minimizesproblems

L hemiplegia/paresis

Left-sided neglect

Spatial-perceptual deficits

Rapid performanceShort attention

span

L Hemianopsia

Page 21: Cerebro-Vascular Disorders

Types of Paralysis

Page 22: Cerebro-Vascular Disorders

Abnormal Visual Fields

Page 23: Cerebro-Vascular Disorders

Cerebrovascular Terms

• Hemiplegia

• Hemiparesis

• Dysarthria

• Aphasia: expressive aphasia, receptive aphasia

• Hemianopsia

Page 24: Cerebro-Vascular Disorders

Transient Ischemic Attack (TIA)

• Temporary neurologic deficit resulting from a temporary impairment of blood flow

• “Warning of an impending stroke”

• Diagnostic work-up is required to treat and prevent irreversible deficits

Page 25: Cerebro-Vascular Disorders

Carotid Endarterectomy

Page 26: Cerebro-Vascular Disorders

Carotid Endarterectomy

Page 27: Cerebro-Vascular Disorders

Treatment of Stroke:Thrombotic Stroke

• Thrombolytic Therapy :• rtPA (recombinant tissue Plasminogen Activator-

Retavase)– A clot-buster delivered intravenously; breaks up the clot

allowing blood flow to return to the deprived area of the brain

– Must be administered within 3 hours of the onset of clinical signs of ischemic stroke

• Quick CT scan to see if stroke from clot or bleed

Page 28: Cerebro-Vascular Disorders

Treatment Cont:Acute phase:

• Anticoagulant - Heparin continuous infusion

• Osmotic Diuretics – to reduce brain swelling

• Anticoagulants contraindicated in Hemorrhagic Strokes

Long Term Drug TherapyTo Prevent Stroke:• Antiplatlet Drugs

• ASA, Ticlid, Persantine, Plavix• Anticoagulants– Coumadin– Lovenox

• Antiepileptics

Page 29: Cerebro-Vascular Disorders

Treatment Cont: Surgical Treatment For Bleeds (Interventional Radiology)

• Angiograms to see arteries and detect bleeding sites

• Aneurysm clips and coils

Page 30: Cerebro-Vascular Disorders

Surgical Removal:Hematoma

Page 31: Cerebro-Vascular Disorders

Preventive Treatment and Secondary Prevention

• Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease

• Carotid endarterectomy• Anticoagulant therapy • Antiplatelet therapy: aspirin, dipyridamole

(Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)

• Statins• Antihypertensive medications

Page 32: Cerebro-Vascular Disorders

Medical Management DuringAcute Phase of Stroke

• Prompt diagnosis and treatment

• Assessment of stroke: NIHSS assessment tool

• Thrombolytic therapy– Criteria for tissue plasminogen activator (tPA):

– IV dosage and administration

– Patient monitoring

– Side effects: potential bleeding

Page 33: Cerebro-Vascular Disorders

Medical Management DuringAcute Phase of Stroke (cont.)

• Elevate HOB unless contraindicated

• Maintain airway and ventilation

• Provide continuous hemodynamic monitoring and neurologic assessment

• See the guidelines in Appendix B

Page 34: Cerebro-Vascular Disorders

Hemorrhagic Stroke

• Caused by bleeding into brain tissue, the ventricles, or subarachnoid space

• May be due to spontaneous rupture of small vessels primarily related to hypertension; subarachnoid hemorrhage due to a ruptured aneurysm; or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants

Page 35: Cerebro-Vascular Disorders

Hemorrhagic Stroke (cont.)

• Brain metabolism is disrupted by exposure to blood

• ICP increases due to blood in the subarachnoid space

• Compression or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue

Page 36: Cerebro-Vascular Disorders

Manifestations

• Similar to ischemic stroke

• Severe headache

• Early and sudden changes in LOC

• Vomiting

Page 37: Cerebro-Vascular Disorders

Medical Management• Prevention: control of hypertension

• Diagnosis: CT scan, cerebral angiography, and lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage

• Care is primarily supportive

• Bed rest with sedation

• Oxygen

• Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding

Page 38: Cerebro-Vascular Disorders

Intracranial Aneurysms

Page 39: Cerebro-Vascular Disorders

NURSING MANAGEMENT• Improving Mobility and Preventing Joint

Deformities• Managing Sensory-Perceptual Difficulties• Attaining Bowel and Bladder Control• Improving Thought Processes• Improving Communication• Maintaining Skin Integrity• Improving Family Coping• Helping the Patient Cope with Sexual

Dysfunction

Page 40: Cerebro-Vascular Disorders

Nursing Process—Assessing the Patient Recovering From an Ischemic Stroke

• Acute phase

– Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: LOC and motor, speech, and eye symptoms

– Monitor for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation

• After the stroke is complete

– Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation

Page 41: Cerebro-Vascular Disorders

Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke

• Impaired physical mobility

• Acute pain

• Self-care deficits

• Disturbed sensory perception

• Impaired swallowing

• Urinary incontinence

Page 42: Cerebro-Vascular Disorders

Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke (cont.)

• Disturbed thought processes

• Impaired verbal communication

• Risk for impaired skin integrity

• Interrupted family processes

• Sexual dysfunction

Page 43: Cerebro-Vascular Disorders

Collaborative Problems/Potential Complications

• Decreased cerebral blood flow

• Inadequate oxygen delivery to brain

• Pneumonia

Page 44: Cerebro-Vascular Disorders

Nursing Process—Planning Patient Recovery After an Ischemic Stroke

• Major goals include: – Improved mobility – Avoidance of shoulder pain– Achievement of self-care – Relief of sensory and perceptual deprivation – Prevention of aspiration– Continence of bowel and bladder

Page 45: Cerebro-Vascular Disorders

Nursing Process—Planning Patient Recovery After an Ischemic Stroke (cont.)

• Major goals include (cont):– Improved thought processes– Achievement of a form of communication–Maintenance of skin integrity – Restoration of family functioning – Improved sexual function – Absence of complications

Page 46: Cerebro-Vascular Disorders

Interventions

• Focus on the whole person

• Provide interventions to prevent complications and to promote rehabilitation

• Provide support and encouragement

• Listen to the patient

Page 47: Cerebro-Vascular Disorders

Impaired Communication• Aphasia-loss of use

and comprehension

– Receptive aphasia- Wernicke’s area (sensory)

– Expressive aphasia – Broca’s area (motor)

– Global aphasia- mixed

• Nursing Interventions:

• Assess ability to speak and understand

• Provide + reinforcement

• Picture board• Repeat names of

objects routinely• Allow plenty of time

for client to answer

Page 48: Cerebro-Vascular Disorders

Picture Communication Board

Page 49: Cerebro-Vascular Disorders

Improving Mobility and Preventing Joint Deformities

• Turn and position the patient in correct alignment every 2 hours

• Use splints• Practice passive or active ROM 4 to 5 times day• Position hands and fingers• Prevent flexion contractures • Prevent shoulder abduction• Do not lift by flaccid shoulder

• Implement measures to prevent and treat shoulder problems

Page 50: Cerebro-Vascular Disorders

Positioning to Prevent Shoulder Abduction

Page 51: Cerebro-Vascular Disorders

Prone Positioning to Help Prevent Hip Flexion

Page 52: Cerebro-Vascular Disorders

Improving Mobility and Preventing Joint Deformities

• Perform passive or active ROM 4 to 5 times day• Encourage patient to exercise unaffected side• Establish regular exercise routine• Use quadriceps setting and gluteal exercises• Assist patient out of bed as soon as possible: assess

and help patient achieve balance and move slowly• Implement ambulation training

Page 53: Cerebro-Vascular Disorders

Interventions• Enhance self-care

– Set realistic goals with the patient– Encourage personal hygiene– Ensure that patient does not neglect the affected side– Use assistive devices and modification of clothing

• Provide support and encouragement

• Implement strategies to enhance communication: see Chart 62-4

• Encourage the patient with visual field loss to turn his head and look to side

Page 54: Cerebro-Vascular Disorders

Interventions (cont.)• Nutrition – Consult with speech therapist or nutritionist– Have patient sit upright to eat, preferably OOB– Use chin tuck or swallowing method– Feed thickened liquids or pureed diet

• Bowel and bladder control– Assess and schedule voiding– Implement measures to prevent constipation: fiber,

fluid, and toileting schedule– Provide bowel and bladder retraining

Page 55: Cerebro-Vascular Disorders

Nursing Process—Assessment of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm

• Complete an ongoing neurologic assessment: use neurologic flow chart

• Monitor respiratory status and oxygenation

• Monitor ICP

• Monitor patients with intracerebral or subarachnoid hemorrhage in the ICU

• Monitor for potential complications

• Monitor fluid balance and laboratory data

• Reported all changes immediately

Page 56: Cerebro-Vascular Disorders

Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/

Cerebral Aneurysm

• Ineffective tissue perfusion (cerebral)

• Disturbed sensory perception

• Anxiety

Page 57: Cerebro-Vascular Disorders

Collaborative Problems/Potential Complications

• Vasospasm

• Seizures

• Hydrocephalus

• Rebleeding

• Hyponatremia

Page 58: Cerebro-Vascular Disorders

Nursing Process—Planning Care of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm

• Goals may include: – Improved cerebral tissue perfusion – Relief of sensory and perceptual deprivation – Relief of anxiety – Absence of complications

Page 59: Cerebro-Vascular Disorders

Aneurysm Precautions

• Absolute bed rest

• Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusion

• Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or head

• Exhale through mouth when voiding or defecating to decrease strain

Page 60: Cerebro-Vascular Disorders

Aneurysm Precautions (cont.)

• Nurse provides all personal care and hygiene

• Provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio

• Prevent constipation

• Restrict visitors

Page 61: Cerebro-Vascular Disorders

Interventions

• Relieve sensory deprivation and anxiety• Keep sensory stimulation to a minimum for

aneurysm precautions• Implement reality orientation• Provide patient and family teaching• Provide support and reassurance• Implement seizure precautions• Implement strategies to regain and promote self-care

and rehabilitation

Page 62: Cerebro-Vascular Disorders

Home Care and Teaching for the Patient Recovering From a Stroke

• Prevention of subsequent strokes, health promotion, and implementation of follow-up care

• Prevention of and signs and symptoms of complications

• Medication teaching• Safety measures• Adaptive strategies and use of assistive devices for

ADLs

Page 63: Cerebro-Vascular Disorders

Home Care and Teaching for the Patient Recovering From a Stroke (cont.)

• Nutrition: diet, swallowing techniques, and tube feeding administration

• Elimination: bowel and bladder programs and catheter use

• Exercise and activities: recreation and diversion• Socialization, support groups, and community

resources• See Chart 62-6

Page 64: Cerebro-Vascular Disorders

STATUS EPILEPTICUS

Page 65: Cerebro-Vascular Disorders

SEIZURESeizures

sudden, excessive, disorderly electrical discharges of the neurons.

EFFECTS OF SEIZURE: alteration in the following mental status LOC sensory and speciual senses

motor funtion

Page 66: Cerebro-Vascular Disorders

TYPES OF SEIZURE

GRAND MALmost common type of seizure

The phases are as follows:

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POST-ICTAL PHASE

Cessation of tonic-clonic movementCharacterized by exhaustion, headache, drowsiness, deep sleep of 1-2, disorientation

TONIC – CLONIC PHASETonic phase- contraction

Clonic phase – jerking movementsAccompanied by dyspnea, drooling of saliva, urinary continence

AURA

(flashing light, smells, spots before eyes,dizziness)

Page 68: Cerebro-Vascular Disorders

PETIT MAL (Absence Seizure or Little Sickness)

o not preceeded by AURAo little or no toni-clonico charac blank facial expression, automatism like lip-

chewing, cheek smackingo regain of consciousness as rapid as it was lot for 10-

20secso usually occurs during childhood and adolescenceJACKSONIAN / FOCAL SEIZUREo common for patients with organic brain lesion like

frontal lobe tumoro aura is present(numbness, tingling, crawling feeling)o charac by tonic-clonic movements of group muscle

e.g. Hands, foot, or face then it proceeds toi grand mal seizureFEBRILE SEIZURE

o this is common for children <5yo, when temp. is rising

PSYCHOMOTOR SEIZUREo aura is present (hallucinations or illusion)o charac by mental clouding (being out of touch with the

envt)o appears intoxicatedo the client may commit violent or antisocial acts, e.g.

Going naked public, running

Page 69: Cerebro-Vascular Disorders

STATUS EPILEPTICUS

Page 70: Cerebro-Vascular Disorders

STATUS EPILEPTICUS(ACUTE PROLONGED SEIZURE ACTIVITY)

IS A SERIES OF GENERALIZED SEIZURE THAT OCCUR WITHOUT FULL RECOVERY OF CONSCIOUSNESS BETWEEN ATTACKS

THE TERM HAS BEEN BROADENED TO INCLUDE CONTINUOUS CLINICAL OR ELECTRICAL SEIZURES LASTING AT LEAST 30 MINUTES, EVEN WITHOUT IMPAIRMENT OF CONSCIOUSNESS.

A seizure is a sudden disruption of the brain's normal electrical activity, which can cause a loss of consciousness and make the body twitch and jerk. This condition is a medical emergency.

Page 71: Cerebro-Vascular Disorders

CAUSES

not taking anticonvulsant medication also caused by an underlying condition,

such as meningitis, sepsis, encephalitis, brain tumor, head trauma, extremely high fever, low glucose levels, or exposure to toxins.

Page 72: Cerebro-Vascular Disorders

SymptomsThe characteristic

symptom of status epilepticus is seizures occurring so frequently that they appear to be one continuous seizure. These seizures include severe muscle contractions and difficulty breathing. Permanent damage can occur to the brain and heart if treatment is not immediate. A person's symptoms can range from simply appearing dazed to the more serious muscle contractions, spasms, and loss of consciousness. The specific symptoms depend on the underlying type of seizure.

Page 73: Cerebro-Vascular Disorders

TWO CATEGORIES OF STATUS EPILEPTICUS

CONVULSIVEEpilepsia partialis continua is a variant it involve an hour, day or even week-long jerking. It is a consequence of vascular disease, tumor or encepalitis and drug resistant.

NONCONVULSIVEComplex Partial Status Epilepticus CPSE and absence status epilepticus are rare forms of the condition which are marked by nonconvulsive seizures. In the case of CPSE, the seizure is confined to a small area of the brain, normally the temporal lobe. But the latter, absence status epilepticus, is marked by a generalised seizure affecting the whole brain, and an EEG is needed to differentiate between the two conditions. This results in episodes characterized by a long-lasting stupor, staring and unresponsiveness.

Page 74: Cerebro-Vascular Disorders

HOW IT IS DIAGNOSED?

Status epilepticus is diagnosed according to its characteristics symptoms. The doctor will order test to look for the cause of the seizures. This may include

blood test

ECG to check for an abnormal heart rhythm

EEG to check electrical activity in the brain

MRI or CT scan to check for braing tumord or signs of damage to the brain tissue.

Page 75: Cerebro-Vascular Disorders

Nursing DiagnosisHigh Risk for Injury r/t Seizure Activity

Individual Coping r/t perceive social stigma, potential changes in employment

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MEDICATIONS diazepam (Valium)

this will stop motor movement

Phenytoin (Dilatin)

Phenobarbital (Barbita)

Paraldehyde

Thiopentahl sodium (Pentotal sodium)

General anesthesia may also be used as a treatment of last resort to stop seizure activity

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NURSING INTERVENTIONPREVENTING INJURY

IMPROVING COPING MECHANISMS

PROVIDING PATIENT AND FAMILY EDUCATION

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

TEACHING PATIENTS SELF-CARE

REDUCING FEARS OF SEIZURE

Page 78: Cerebro-Vascular Disorders

PREVENTING INJURY

injury prevention for the patient with seizure is a PRIORITY.

patient should be placed on the floor and remove any obstructive items

patient should never be forced into a position pad side rails

do not attempt to pry open jaws that are clenched in a spasm to insert anything.

if possible place the patient on one side with head flexed forward,

Page 79: Cerebro-Vascular Disorders

PATIENT EDUCACTION

TAKE MEDICATION AT REGULARBASIS

AVOID ALCOHOL. Lowers seizure threshold

ADEQUATE REST WELL-BALANCED DIET AVOID DRIVING, OPERATING MACHINES, SWIMMING UNTIL SEIZURES ARE WELL CONTROLLED.

LIVE AN ACTIVE LIFE

Page 80: Cerebro-Vascular Disorders

REDUCING FEARS OF SEIZURE

Fear that a seizure may occur unexpectedly can be reduced by the patients adherence to the prescribed treatment regimen. Cooperation of the patient and family and their trust in the prescribed regimen are essential for control of seizures

Periodic monitoring is necessary to ensure the adequacy of the treatment regimen and to prevent the side effects. back

Page 81: Cerebro-Vascular Disorders

IMPROVING COPING MECHANISMS

it has been noted that the social, psychological, and behavioral problems frequently accompanying the attack can be more handicap than the actual seizure.

Counselling assists the individual and family to understand the condition and the limitations imposed by it. Social and recreational opportunities are good for mental health . Nurses can improve the quality of life for patients with the disorder by educating them and their family about the symptom and also the management.

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PROVIDING PATIENT AND FAMILY EDUCATION

Ongoing education and encouragement should be given to patients to enable them to overcome these feelings. The patient and family should be educated about the medications as well as care during a seizure.perhaps the most valuable facets are

education and efforts to modify the attitudes of the patient and family toward the disorder.

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MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Patients should have plan to have serum drug levels drawn at regular intervals. The patient and family are instructed about the side effects and are given specific guidelines to assess and report signs and symptoms indicating medication overdose.

Page 84: Cerebro-Vascular Disorders

TEACHING PATIENTS SELF CARE

Like thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care

The patient is also instructed to inform all health care providers of the medication being taken because of the possibility of drug interactions. An individualized comprehensive teaching plan is needed to assist the patient and family to adjust to this chronic disorder.

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Head Injury

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INCIDENCES

Unknown, 9%

Assault, 11%

Struck, 19%

Traffic accident, 20%

Fall, 28%

Other , 7%

Bicycle, 3% Suicide, 1%Other transport, 2%

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1. Dura mater 2. Arachnoid 3. Venae sagittalis superiores cerebri 4. Sinus sagittalis superior and Falx cerebri

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Duramater

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Levels of consciousness

Level Description

Conscious Normal

ConfusedDisoriented; impaired thinking and

responses

DeliriousDisoriented; restlessness, hallucinations,

sometimes delusions

ObtundedDecreased alertness; slowed psychomotor

responses

StuporousSleep-like state (not unconscious);

little/no spontaneous activity

Comatose Cannot be aroused; no response to stimuli

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symptoms of mild head injury

– raised, swollen– bruise – small, superficial cut in the scalp – headache

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– confusion – loss of consciousness – blurred vision – severe headache – vomiting – loss of short-term memory,– slurred speech – difficult walking – dizziness – weakness in one side or area of

the body – sweating

–pale skin color –seizures –behavior

changes –blood or clear

fluid draining from the ears or nose

–one pupil looks larger than the other eye

–deep cut or laceration in the scalp

–open wound in the head

– foreign object penetrating the head

symptoms of moderate to severe head injury

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Prognosis

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Indication for admission• Minor head injury– Focal neurodeficit– Post traumatic seizure– Skull fracture

• Moderate head injury• Severe head injury

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Investigation

• Skull x-rays • CT scan of the head• Magnetic resonance imaging

–MRI may be used later for additional information about a brain injury.

• Other x-rays may be performed to look for other injuries

Imaging Studies

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• Initial blood tests– blood alcohol level for any patient who has an altered level of consciousness

–Coagulation abnormalities, a prothrombin time (PT), partial thromboplastin time (PTT), and a platelet count

– Bleeding time assessment may reveal platelet dysfunction.

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Urgent Scan in adult if any of–GCS <13 when first assessed –GCS<15 two hours after injury–Suspected open or depressed skull fracture –Signs of base of skull fracture**–Post-traumatic seizure–Focal neurological deficit–>1 episode of vomiting–Coagulopathy + any amnesia or LOC since

injury**Signs of basal skull fracture: 'panda' eyes, CSF leakage (ears or nose) or Battle's sign (bruising behind the ear in cases of basal skull

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8 hours after injury, a CT scan is also recommended

if there is either :– More than 30 minutes of amnesia of events

before impact– Or any amnesia or LOC since injury if• Aged ≥65 years• Coagulopathy or on warfarin• Dangerous mechanism of injury–RTA as pedestrian–RTA - ejected from car–Fall > 1m or >5 stairs

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Nursing Assessment

– History of Trauma – Time, cause, direction and force of the blow- Loss of consciousness, duration Assess LOC – Glasgow Coma Scale – Response to verbal commands or tactile stimuli- Pupillary response to light- Motor Function Vital Signs – Monitor for signs of increased ICPMotor Function- Move extremities, hand grasp, pedal push, speech

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Emergency Care

• First consideration is to ensure a clear airway• Keep spine straight; patient is carefully turned

to a lateral or semiprone position• Flexion or hypertension should be avoided in

case there is a cervical fracture• Keep patient covered, quiet and undistrubed

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General Care:

• Establish airway• Prevent aspiration pneumonia• Check for cardiovascular complications• Serach for new evidence of spinal injuries. Do not allow

the newly injured patient to move about even though he/she is conscious.

• Observe the skull and scalp injuries. cover open head wound with the cleanest material avaialble at the scene

• Prevent infection. Gove prophylactic dose for tetanus.

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General Care (Cont)

• Observe for CSF leakage – otorrhea, rhinorrhea, Battle’s sign-tenderness and eccymosis or mastoid bone especially for basilar skull fracture

• Obeserve for signs and symptoms of increased ICP; watch for nuclear rigidity.

• Control restlessness and pain. Narcotics are contraindicated following head injury, and are not given if ICP is prevent.

• Maintain fluid/electrolyte; acid-base balance and adequate nutrition. Record I & O.

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Management of Increased ICP• - True emergency requiring prompt treatment

- Monitor ICP- Intraventricular catheter, subarachnoid bolt, epidural catheter – Reduce Cerebral Edema – Osmotic diuretics (mannitol)- Corticosteroids ( dexamethasone)Maintain cerebral perfusion – Maintain cardiac output with fluids and dobutamine- Reduce CSF and blood volume – Drain CSF- Hyperventilation – results in vasoconstriction

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Management of ICP

• Control Fever – Fever increases cerebral metabolism and edema- Antipyretics, cooling blanket- Avoid shivering which increases ICP Reduce metabolic demands – Barbiturates decrease ICP- Muscle relaxants to paralyze patient

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Ineffective airway clearance related to accumulation of secretions and decreased LOC

• Maintain patient airway – Suction carefully- Discourage coughing (causes increase in ICP)- Elevate HOB 30 degrees- Guard against aspiration- Monitor ABGs to assess ventilation

Page 106: Cerebro-Vascular Disorders

Ineffective breathing pattern related to neurological dysfunction

• Monitor constantly for respiratory irregularities – Cheyne Stokes, hyperventilation,Effective suctioningHOB 30 degreesPosition patient lateral or semi prone

Page 107: Cerebro-Vascular Disorders

Altered cerebral tissue perfusion related to increased intracranial pressure

• Position patient to reduce ICP : – head in midline position to promote venous drainage- Elevate HOB 30 degrees- Avoid extreme rotation or flexion of neck- Avoid extreme hip flexion

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• Prevent straining - Stool Softeners- High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli

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Risk for fluid volume deficit related to dehydration procedures and decreased LOC

Monitor electrolytes- Brain damage can produce metabolic and hormonal dysfunctionsMonitor intake and outputMonitor IV fluids carefullyMonitor urine for acetone, osmolalityRecord daily weights

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Altered nutrition related to metabolic changes, inadequate intake.

• Start enteral feedings when patient stabilized- NG feeding unless CSF rhinorrhea- Elevate HOB 30 degrees- Aspirate for residual before feeding to prevent distention and aspiration- Use pump to regulate feeds

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Risk for injury related to disorientation, restlessness and brain damage.

•Assess for cause of restlessness- Often present as patient emerges from coma- May be due to hypoxia, fever, pain, full bladderUse padded side rails or wrap hands in mitts- Avoid restraints as straining against them increases ICPMinimize environmental stimuli- Low lights, limit visitors, speak calmly- Orient patient frequently

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Risk for altered body temperature related to damage to temperature -regulating mechanism

•Monitor temperature every 4 hrs.- Can be increased as result of:Damage to hypothalmusCerebral irritation from hemorrhageInfectionReduce temperature with acetaminophen and cooling blanketsIf infection suspected –- Culture potential sites- Start antibiotics

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Potential for impaired skin integrity related to bed rest, immobility, unconsciousness

•Assess all body surfaces every 8 hrs.Turn every 2-4 hrsProvide skincare every 4 hrsAssist patient to chair (if possible)

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Spinal Injury

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Spinal cord injuries:

• cause myelopathy or damage to nerve roots or myelinated fiber tracts that carry signals to and from the brain.

• Depending on its classification and severity, this type of traumatic injury could also damage the gray matter in the central part of the cord, causing segmental losses of interneurons and motorneurons.

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• Primary prevention important. – Drive slow, use seat belts & helmets, water safety, protective devices for athletes, prevent falls.

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Assessment Clinical manifestations depend on type and level of injury

– Below level of injury there is total loss of sensory and motor paralysis,

loss of bladder and bowel control, loss of sweating and vasomotor tone.

– Complains of acute pain in back or neck which may radiate along involved nerve.

– Respiratory problems (T1-T11 and diaphragm are used in breathing) – intercostal muscles. – above C4 – phrenic nerve – paralysis of diaphragm.

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• Respiratory status – observe respiratory pattern, strength of cough, auscultate lungs.

• Changes in motor or sensory function – Squeeze hand, spread fingers, move toes. – Pricking skin with dull item, start at shoulders.

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Signs of spinal shock

• – Complete loss of all reflexes, motor, sensory and autonomic below level of injury.

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Management of Spinal Cord Injuries

• High dose corticosteroids within 8 hrs of injury – Methylprednisolone, loading dose followed by infusion for 23 hrs.

• Oxygen, intubation if necessary• Skeletal reduction and traction

– Immediate immobilization – Reduction of dislocations (restore to normal position) – Stabilization of vertebral column. – Traction used in cervical fractures.

• Surgery.

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Nursing Interventions

• Promote adequate breathing and airway clearance. – Monitor pulse oximetry, ABGs. – Clear bronchial and pharyngeal secretions – Use suctioning cautiously – can stimulate vagus nerve causing bradycardia. - Chest Physiotherapy, breathing exercises. – Humidification. – Adequate hydration. – Assess for signs of respiratory infection. – Intubate and ventilate.

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Improve Mobility

• Maintain proper alignment at all times. • Reposition frequently. • Prevent foot drop – wear shoes. • Prevent external rotation of hip joints – trochanter rolls. • Prevent contractures – range of motion exercises 4 times daily. • If injury above midthoracic level, monitor BP when turning (loss of sympathetic control of peripheral vasoconstriction).

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Maintain Urinary and Bowel Function

• Intermittent or indwelling catheter to avoid overdistention of bladder. – Urinary retention results from bladder becoming atonic. • Intake and output. • Insert NG tube to relieve distention and prevent aspiration. – Paralytic ileus usually develops. – Bowel activity usually returns within 1 week. • High fibre, high protein diet. • Stool softener.

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Managing Potential Complications

• Thrombophlebitis and pulmonary embolism – Assess for symptoms (chest pain, dyspnea, ABGs) – Measure circumference of thighs and calves daily – Anticoagulation – low dose heparin – Pressure stockings. – Adequate hydration

• Orthostatic Hypotension – BP unstable and low for first 2 weeks. – Monitor closely when repositioning patient. – Reposition slowly, wear pressure stockings.

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Thank you!


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