Date post: | 13-Nov-2014 |
Category: |
Documents |
Upload: | nursereview |
View: | 1,649 times |
Download: | 0 times |
Medical-Surgical NursingA Review of Neurologic Concepts
Nurse Licensure Examination Review
Key to Success!
Confidence Test taking strategies Ample test preparation and study
habits Review of frequent board
examination topics Focus on your goals Above all- PRAYERS
Outline of Our Review Brief review of Anatomy and Physiology Application of the Nursing process in the
approach of neurologic problems: ASSESSMENT – relevant techniques and lab
procedures DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
Outline of the review
Trauma and related accidents Traumatic brain injury Spinal cord injury
Cerebrovascular Accidents
Outline of the review
Degenerative disorders- demyelinating Multiple sclerosis Guillain-Barre’ syndrome
Degenerative disorders- NON-demyelinating
Alzheimer’s disease Parkinson’s disease
Outline of the review
Motor dysfunction- CNS Epilepsy
Motor dysfunction- cranial nerve Bell’s palsy Trigeminal neuralgia
Motor dysfunction- peripheral Myasthenia gravis
Outline of the review
Infectious Disease Meningitis Brain abscess Encephalitis
Neoplastic disease
IMPLEMENTATION PHASE
Increased Intracranial pressure Altered level of consciousness Seizures Autonomic dysreflexia/hyperreflexia Spinal shock Cognitive impairment Bowel incontinence
IMPLEMENTATION PHASE
Impaired physical mobility Impaired swallowing Disturbed sensory perception
Anatomy and Physiology
Gross anatomy The nervous system is divided into
the central and peripheral nervous system
The Central nervous system consists of the BRAIN and the Spinal Cord
The peripheral nervous system consists of the Spinal nerves and the cranial nerves
Anatomy and Physiology
The brain is composed of lobes- Frontal lobe- personality, memory
and motor function Parietal lobe- sensory function Temporal lobe- hearing and
olfaction and emotion by the limbic system
Occipital lobe- vision
Anatomy and Physiology
The cerebellum is involved in coordination and equilibrium
The diencephalon consists of the : Thalamus- the relay center of all
sensory input Hypothalamus- center for endocrine
regulation, sleep, temperature, thirst, sexual arousal and emotional response
Anatomy and Physiology The brainstem is composed of the: MIDBRAIN- for visual and auditory
reflexes Pons- respiratory apneustic center,
nucleus of cranial nerves- 5,6,7,8 Medulla oblongata- respiratory and
cardiovascular centers, nucleus of cranial nerves 9,10,11,12
ASSESSMENT OF THE NEUROLOGIC SYSTEM
HISTORY A confused client becomes an
unreliable source of history
ASSESSMENT OF THE NEUROLOGIC SYSTEM
PHYSICAL EXAMINATION 5 categories:
1. Cerebral function- LOC, mental status
2. Cranial nerves 3. Motor function 4. Sensory function 5. Reflexes
ASSESSMENT OF THE NEUROLOGIC SYSTEM
Neuro Check Level of consciousness Pupillary size and response Verbal responsiveness Motor responsiveness Vital signs
CEREBRAL FUCTION Assess the degree of
wakefulness/alertness Note the intensity of stimulus to
cause a response Apply a painful stimulus over the
nailbeds with a blunt instrument Ask questions to assess orientation
to person, place and time
Cerebral function
Utilize the Glasgow Coma Scale An easy method of describing mental
status and abnormality detection Tests 3 areas- eye opening, verbal
response and motor response Scores are evaluated- range from 3-15 No ZERO score
Glasgow Coma Scale
Glasgow Coma Score Eye Opening (E) Verbal Response (V) Motor Response (M)
Glasgow Coma Scale
Glasgow Coma Score Eye Opening (E)
4=Spontaneous3=To voice2=To pain1=None (No response)
Glasgow Coma Scale
Glasgow Coma Score Verbal Response (V)
5=Normal/oriented4=Disoriented/CONFUSED3=Words, but incoherent/ inappropriate2=Incomprehensible/mumbled words1=None
Glasgow Coma Scale
Glasgow Coma Score Motor Response (M)
6=Normal- obeys command5=Localizes pain4=Withdraws to pain (Flexion)3=Decorticate posture2=Decerebrate posture
1=None (flaccid)
Cranial Nerve Function: Cranial Nerve 1- Olfactory
Check first for the patency of the nose
Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for
the identification Repeat with the other nostrils PROBLEM- ANOSMIA- “loss of smell”
Cranial Nerve Function: Cranial Nerve 2- Optic
Check the visual acuity with the use of the Snellen chart
Check for visual field by confrontation test
Check for pupillary reflex- direct and consensual
Fundoscopy to check for papilledema
Snellen chart
Cranial Nerve Function: Cranial Nerve 3, 4 and 6
Assess simultaneously the movement of the extra-ocular muscles
Deviations: Opthalmoplegia- inability to move
the eye in a direction Diplopia- complaint of double vision
Cranial Nerve Function: Cranial Nerve 5 -trigeminal
Sensory portion- assess for sensation of the facial skin
Motor portion- assess the muscles of mastication
Assess corneal reflex
Cranial Nerve Function: Cranial Nerve 7 -facial
Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water
Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids
Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory
Test patient’s hearing acuity Observe for nystagmus and
disturbed balance
Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal
Together with Cranial nerve 10 –vagus
Assess for gag reflex Watch the soft palate rising after
instructing the client to say “AH” The posterior one-third of the
tongue is supplied by the glossopharyngeal nerve
Cranial Nerve Function: Cranial Nerve 11- accessory
Press down the patient’s shoulder while he attempts to shrug against resistance
Cranial Nerve Function: Cranial Nerve 12- hypoglossal
Ask patient to protrude the tongue and note for symmetry
ASSESS Motor function
Assess muscle tone and strength by asking patient to flex or extend the extremities while the examiner places resistance
Grading of muscle strength
Assessing the motor function of the cerebellum
Test for balance- heel to toe Test for coordination- rapid
alternating movements and finger to nose test
ROMBERG’s is actually a test for the posterior spinothalamic tract
Assessing the motor function of the brainstem
Test for the Oculocephalic reflex- doll’s eye
Normal response- eyes appear to move opposite to the movement of the head
Abnormal- eyes move in the same direction
Assessing the motor function of the brainstem
Test for the Oculovestibular reflex Slowly irrigate the ear with cold
water and warm water Normal response- cOld- OppOsite,
wArM- sAMe
Assessing the sensory function Evaluate symmetric areas of the body Ask the patient to close the eyes while
testing Use of test tubes with cold and warm water Use blunt and sharp objects Use wisp of cotton Ask to identify objects placed on the hands Test for sense of position
Assessing the reflexes
Deep tendon reflexes Biceps Triceps Brachioradialis Patellar Assessing the sensory function
Achilles
Assessing the reflexes Superficial reflexes
Abdominal Cremasteric Anal
Pathologic reflex Babinski- stroke the lateral aspect of
the soles doing an inverted “J” (+)- DORSIFLEXION of the Big toe
with fanning out of the little toes
Grading of reflexes
Deep tendon reflex 0- absent + present but diminished ++ normal +++ increased ++++ hyperactive or clonicSuperficial reflex 0 absent +present
DIAGNOSTIC TESTS
EEG Withhold medications that may
interfere with the results- anticonvulsants, sedatives and stimulants
Wash hair thoroughly before procedure
DIAGNOSTIC TESTS
CT scan With radiation risk If contrast medium will be used-
ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected
DIAGNOSTIC TESTS
MRI Uses magnetic waves Patients with pacemakers,
orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure
DIAGNOSTIC TESTS
Cerebral arteriography Note allergies to dyes, iodine and
seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or
sandbag over punctured site
DIAGNOSTIC TESTS
Lumbar puncture Ensure consent, determine ability to
lie still Contraindicated in patients with
increased ICP Keep flat on bed after procedure Increase fluid intake after procedure
Increased Intracranial pressure
Intracranial pressure more than 15 mmHgBrunner= Normal intracranial pressure 10-20
mmHgCauses: Head injury Stroke Inflammatory lesions Brain tumor Surgical complications
Increased Intracranial pressure
Pathophysiology The cranium only contains the brain
substance, the CSF and the blood/blood vessels
MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other
Any increase or alteration in these structures will cause increased ICP
Increased Intracranial pressure
Pathophysiology Compensatory mechanisms: 1. Increased CSF absorption 2. Blood shunting 3. Decreased CSF production
Increased Intracranial pressure
PathophysiologyDecompensatory mechanisms: 1. Decreased cerebral perfusion 2. Decreased PO2 leading to brain
hypoxia 3. Cerebral edema 4. Brain herniation
Decreased cerebral blood flow
Vasomotor reflexes are stimulated initially slow bounding pulses
Increased concentration of carbon dioxide will cause VASODILATION increased flow increased ICP
Cerebral Edema
Abnormal accumulation of fluid in the intracellular space, extracellular space or both.
Herniation
Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem
Cerebral response to increased ICP
1. Steady perfusion up to 40 mmHg2. Cushing’s response
Vasomotor center triggers rise in BP to increase ICP
Sympathetic response is increased BP but the heart rate is SLOW
Respiration becomes SLOW
Increased Intracranial pressure
CLINICAL MANIFESTATIONSEarly manifestations: Changes in the LOC- usually
the earliest Pupillary changes- fixed, slowed
response Headache vomiting
Increased Intracranial pressure
CLINICAL MANIFESTATIONSlate manifestations: Cushing reflex- systolic
hypertension, bradycardia and wide pulse pressure
bradypnea Hyperthermia Abnormal posturing
Increased Intracranial pressure
Nursing interventions: Maintain patent airway 1. Elevate the head of the bed 15-
30 degrees- to promote venous drainage
2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levelsconstricts blood vesselsreduces edema
Increased Intracranial pressure
Nursing interventions 3. Administer prescribed
medications- usually Mannitol- to produce negative fluid
balance corticosteroid- to reduce edema anticonvulsants-p to prevent seizures
Increased Intracranial pressure
Nursing interventions 4. Reduce environmental stimuli 5. Avoid activities that can
increase ICP like valsalva, coughing, shivering, and vigorous suctioning
Increased Intracranial pressure
Nursing interventions 6. Keep head on a neutral position.
ACOID- extreme flexion, valsalva 7. monitor for secondary
complications Diabetes insipidus- output of >200
mL/hr SIADH
Altered level of consciousness
It is a function and symptom of multiple pathophysiologic phenomena
Causes: head injury, toxicity and metabolic derangement
Disruption in the neuronal transmission results to improper function
Altered level of consciousness
Assessment Orientation to time, place and
person Motor function
Decerebrate Decorticate
Sensory function
Altered level of consciousness Patient is not oriented Patient does not follow command Patient needs persistent stimuli to
be awake
COMA= clinical state of unconsciousness where patient is NOT aware of self and environment
Altered level of consciousness
Etiologic Factors1. Head injury 2. Stroke3. Drug overdose4. Alcoholic intoxication5. Diabetic ketoacidosis6. Hepatic failure
Altered level of consciousness
ASSESSMENT1. Behavioral changes initially2. Pupils are slowly reactive 3. Then , patient becomes
unresponsive and pupils become fixed dilated
Glasgow Coma Scale is utilized
Altered level of consciousness
Nursing Intervention1. Maintain patent airway Elevate the head of the bed to 30 degrees Suctioning2. Protect the patient Pad side rails Prevent injury from equipments, restraints
and etc.
Altered level of consciousness
Nursing Intervention3. Maintain fluid and nutritional
balance Input an output monitoring IVF therapy Feeding through NGT4. Provide mouth care Cleansing and rinsing of mouth Petrolatum on the lips
Altered level of consciousness
Nursing Intervention5. Maintain skin integrity Regular turning every 2 hours 30 degrees bed elevation Maintain correct body alignment by
using trochanter rolls, foot board6. Preserve corneal integrity Use of artificial tears every 2 hours
Altered level of consciousness
Nursing Intervention7. Achieve thermoregulation Minimum amount of beddings Rectal or tympanic temperature Administer acetaminophen as
prescribed8. Prevent urinary retention Use of intermittent catheterization
Altered level of consciousness
Nursing Intervention9. Promote bowel function High fiber diet Stool softeners and suppository10. Provide sensory stimulation Touch and communication Frequent reorientation
SEIZURES
Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons
A part or all of the brain may be involved
SEIZURES
PATHOPHYSIOLOGY An electrical disturbance in the
nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively
SEIZURES
ETIOLOGIC FACTORS1. Idiopathic2. Fever3. Head injury4. CNS infection5. Metabolic and toxic conditions
SEIZURES
Nursing InterventionsDuring seizure 1. remove harmful objects from the
patient’s surrounding 2. ease the client to the floor 3. protect the head with pillows 4. Observe and note for the duration,
parts of body affected, behaviors before and after the seizure
SEIZURES
Nursing InterventionsDuring seizure 5. loosen constrictive clothing 6. DO NOT restrain, or attempt
to place tongue blade or insert oral airway
SEIZURES
Nursing InterventionsPOST seizure 1. place patient to the side to drain
secretions and prevent aspiration 2. help re-orient the patient if confused 3. provide care if patient became
incontinent during the seizure attack 4. stress importance of medication
regimen
headache Cephalgia Primary headache- no organic cause Secondary headache- with organic
cause Migraine headache- periodic attacks
of headache due to vascular disturbance
Tension headache-the most common type- due to muscle tension
headache
Migraine1. Prodrome stage2. Aura phase3. Headache4. Recovery phase
headache
Nursing Interventions 1. Avoid precipitating factors 2. modify lifestyle 3. relieve pain by pharmacologic
measures Beta-blockers Serotonin antagonists- “triptan"
Autonomic Dysreflexia/hyperreflexia
Seen commonly in spinal cord injury above T6
An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation
Autonomic Dysreflexia/hyperreflexia
Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion
Autonomic Dysreflexia/hyperreflexia
NURSING INTERVENTIONS 1. Elevate the head of the bed
immediately 2. Check for bladder distention and
empty bladder with urinary catheter 3. Check for Fecal impaction and other
triggering factors like skin irritation, pressure ulcer
4. Administer antihypertensive medications- usually hydralazine
Spinal Shock
Pathophysiology The sudden depression of reflex
activity in the spinal cord below the level of injury
The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions
Spinal Shock
Nursing Interventions 1. Assist in chest physical therapy 2. Manage potential complication-
DVT
Cognitive Impairment
Nursing Interventions1. Assist or encourage the patient to
use eyeglass, hearing aid or assistive devices
2. Reorient the patient by calling his name frequently
3. Provide background information as to date, time, place, environment
Cognitive Impairment
Nursing Interventions4. Use large signs as visual cues5. Post patient's photo on the door6. Encourage family members to
bring personal articles and place them in the same area
Bowel and Bladder incontinence
Establish a regular pattern for bowel care
Maintain a dietary intake. Avoid foods that can cause excessive gas production
CONGENITAL DISORDERS:Hydrocephalus
Excessive CSF accumulation in the brain’s ventricular system
In infants, head enlarges In children and adults- brain
compression
CONGENITAL DISORDERS:Hydrocephalus
Non-communicating hydrocephalus results from CSF outflow obstruction
Communicating hydrocephalus results from faulty absorption or increased CSF production
CONGENITAL DISORDERS:Hydrocephalus
Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head,
thin scalp skin 4. sunset eyes
CONGENITAL DISORDERS:Hydrocephalus
DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography
CONGENITAL DISORDERS:Hydrocephalus
Nursing Intervention 1. monitor neurologic status 2. teach parents to watch for signs
of shunt malfunction, and periodic surgery to lengthen the shunt as child grows
CONGENITAL DISORDER- Spinal cord defects 1. Spina bifida occulta- incomplete
closure of one or more vertebrae without protrusion of the spinal cord or meninges
2. Spina bifida with meningocele- a sac contains meninges and CSF
3. Spina bifida with meningomyelocele- a sac contains spinal cord substance, meninges and CSF
CONGENITAL DISORDER: Spinal cord defects
Causes 1. environmental factors 2. radiation 3. folic acid deficiency in a
pregnant woman 4. possibly genetic
CONGENITAL DISORDER: Spinal cord defects
ASSESSMENT 1. a dimple or tuft of hair in the
vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography
CONGENITAL DISORDER: Spinal cord defects
NURSING INTERVENTION 1. cover the defect with sterile
dressing moistened with sterile saline
2. position the patient on prone or side to protect the fragile sac
3. place a diaper under the infant and change it often
CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 4. avoid the use of lotion 5. avoid frequent handling 6. Measure the child’s head
circumference daily 7. check anal reflex 8. support family members 9. prepare the parents for the possible
outcome of eh defect
CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 10. Post-operative care Position on abdomen Check post-operative dressings Place infant’s hips in abduction and feet
in neutral position Monitor intake and output Check for urine retention Asess infant frequently as he recovers
from the surgery
Traumatic brain injury
1. CONCUSSION Involves jarring of head without
tissue injury Temporary loss of neurologic
function lasting fore a few minutes to hours
Traumatic brain injury
2. CONTUSION Involves structural damage The patient becomes unconscious
for hours
Traumatic brain injury
3. Diffuse Axonal injury Involves widespread damage to
the neurons Patient has decerebrate and
decorticate posture
Traumatic brain injury
4. Intracranial hemorrhageEpidural Hematoma- blood collects
in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal arterySymptoms develop rapidly
Traumatic brain injury
4. Intracranial hemorrhageSubdural hematoma- a collection of
blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vesselsSymptoms usually develop slowly
Traumatic brain injury
4. Intracranial hemorrhageIntracerebral Hemorrhage and hematoma-
bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalitiesSymptoms develop insidiously, beginning with severe headache and neurologic deficits
Traumatic brain injury
MANIFESTATIONS 1. Altered LOC 2. CSF otorrhea 3. CSF rhinorrhea 4. Racoon eyes and battle sign
HALO SIGN- blood stain surrounded by a yellowish stain
Traumatic brain injury
NURSING MANAGEMENT1. Monitor for declining LOC- use
of Glasgow2. Maintain patent airway Elevate bed, suction prn,
monitor ABG
Traumatic brain injury
NURSING MANAGEMENT3. Monitor F and E balance Daily weights IVF therapy Monitor possible development
of DI and SIADH
Traumatic brain injury
4. Provide adequate nutrition5. Prevent injury Use padded side rails Minimize environmental stimuli Assess bladder Consider the use of
intermittent catheter
Traumatic brain injury
6. Maintain skin integrity Prolonged immobility will likely
cause skin breakdown Turn patient every 2 hours Provide skin care every 4
hours Avoid friction and shear forces
Traumatic brain injury
7. Monitor potential complications
Increased ICP Post-traumatic seizures Impaired ventilation
Spinal cord injury
The most frequent vertebrae – C5-C7, T12 and L1
Concussion Contusion Compression Transection
Spinal cord injury
Clinical manifestations 1. Paraplegia 2. quadriplegia 3. spinal shock
Spinal cord injury
DIAGNOSTIC TEST Spinal x-ray CT scan MRI
Spinal cord injury
EMERGENCY MANAGEMENT A-B-C Immobilization Immediate transfer to tertiary
facility
Spinal cord injury
NURSING INTERVENTION 1. Promote adequate breathing
and airway clearance 2. Improve mobility and proper
body alignment 3. Promote adaptation to sensory
and perceptual alterations 4. Maintain skin integrity
Spinal cord injury 5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage
complications Thromboplebhitis Orthostaic hypotension Spinal shock Autonomic dysreflexia
Spinal cord injury
9. Assists with surgical reduction and stabilization of cervical vertebral column
CEREBROVASCULAR ACCIDENTS
An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply
CEREBROVASCULAR ACCIDENTS
Can be divided into two major categories
1. Ischemic stroke- caused by thrombus and embolus
2. Hemorrhagic stroke- caused commonly by hypertensive bleeding
CEREBROVASCULAR ACCIDENTS
The stroke continuum 1. TIA- transient ischemic attack,
temporary neurologic loss less than 24 hours duration
2. Reversible Neurologic deficits 3. Stroke in evolution 4. Completed stroke
General manifestations
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus
RISKS FACTORS
Non-modifiable Advanced age Gender race
Modifiable Hypertension Cardio disease Obesity Smoking Diabetes mellitus hypercholesterolemia
Pathophysiology of ischemic stroke
Disruption of blood supply Anaerobic metabolism ensues Decreased ATP production leads to
impaired membrane function Cellular injury and death can occur
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
CLINICAL MANIFESTATIONS 1. Numbness or weakness 2. confusion or change of LOC 3. motor and speech
difficulties 4. Visual disturbance 5. Severe headache
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
Motor Loss Hemiplegia Hemiparesis
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
Communication loss Dysarthria= difficulty in speaking Aphasia= Loss of speech Apraxia= inability to perform a
previously learned action
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
Perceptual disturbances Hemianopsia
Sensory loss paresthesia
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS1. Improve Mobility and prevent joint
deformities Correctly position patient to
prevent contractures Place pillow under axilla Hand is placed in slight supination-
“C” Change position every 2 hours
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS2. Enhance self-care Carry out activities on the
unaffected side Prevent unilateral neglect Keep environment organized Use large mirror
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS3. Manage sensory-perceptual
difficulties Approach patient on the
Unaffected side Encourage to turn the head to the
affected side to compensate for visual loss
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS4. Manage dysphagia Place food on the UNAFFECTED
side Provide smaller bolus of food Manage tube feedings if
prescribed
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS5. Help patient attain bowel and
bladder control Intermittent catheterization is done
in the acute stage Offer bedpan on a regular schedule High fiber diet and prescribed fluid
intake
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS6. Improve thought processes Support patient and capitalize on
the remaining strengths
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS7. Improve communication Anticipate the needs of the patient Offer support Provide time to complete the sentence Provide a written copy of scheduled activities Use of communication board Give one instruction at a time
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS8. Maintain skin integrity Use of specialty bed Regular turning and positioning Keep skin dry and massage NON-
reddened areas Provide adequate nutrition
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS9. Promote continuing care Referral to other health care
providers
CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS10. Improve family coping11. Help patient cope with sexual
dysfunction
CVA: Hemorrhagic Stroke
Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP
Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage
CVA: Hemorrhagic Stroke
Sudden and severe headache Same neurologic deficits as
ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances
CVA: Hemorrhagic Stroke
DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no
increased ICP)
CVA: Hemorrhagic Stroke
NURSING INTERVENTIONS 1. Optimize cerebral tissue
perfusion 2. relieve Sensory deprivation and
anxiety 3. Monitor and manage potential
complications