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Management of Patients with
Cerebrovascular Disorders

       Nelia B. Perez RN, MAEd, MSN
                 PCU MJCN

                BSN 2012
Neurological System
Brain Anatomy
• Cerebrum
  –   Reasoning
  –   Judgment
  –   Concentration,
  –   Motor, sensory, speech
• Cerebellum
  – Coordination
• Brainstem
  – Cranial nerves
  – Respiratory center
  – Cardiovascular center
Brain Anatomy Cont.
• 20% of CO
                                 Cerebral Blood Flow
• Cerebral tissues – Have no
  oxygen or glucose reserves
• Blood flows through Carotid
  Arteries to Circle of Willis
Intracranial Pressure (ICP)
Composition                       A medical emergency that can
• 80% brain tissue and water         lead to:
                                  Brain hypoxia, herniation, death
• 10% blood
• 10% cerebrospinal fluid (CSF)
                                  Clinical Manifestations
Increased ICP caused by:          • Vomiting
• Severe head injury/ Subdural    • Headache
   hematoma                       • Blurred vision
                                  • Seizure
• Hydrocephalus                   • Changes in behavior
• Brain tumor                     • Loss of consciousness
• Meningitis/Encephalitis         • Lethargy
• Aneurysm                        • Neurological symptoms
• Status epilepticus/Stroke
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
Neuro diseases newest
3. PUPILS
             Pupils equal and react normally




            Pupils react to light (slowly or blriskly)




            Dilated pupil (compressed cranial nerve II




             Bilateral dilated, fixed (ominous sign)




             Pinpoint pupils (pons damage or drugs)
Neuro-Diagnostic Tests   CT SCAN

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

                Carotid US




                                      MRA
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
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
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
Neuro diseases newest
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%)
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
Pathophysiology
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
Impaired comprehension &
Left -Sided CVA:      Memory R/T language and math
LEFT BRAIN DAMAGE
                            R Hemianopsia

                          Impaired speech
                            (Aphasias)


                      Aware of deficits
                     Depression, Anxiety


                          R Hemiplegia
                            /paresis


                    Impaired discrimination
                            (R/L)

                                Slow performance,
                                    Cautious
Right-sided CVA:
                     Impaired judgment
RIGHT BRAIN DAMAGE
                                   L Hemianopsia

                                    Impulsive/Safety
                                       problems

                                      Rapid performance
                                       Short attention
                                             span


                                     L hemiplegia/paresis

                                    Denies/Minimizes
                                        problems

                                           Left-sided
                                            neglect
                      Spatial-perceptual
                            deficits
Types of Paralysis
Abnormal Visual Fields
Cerebrovascular Terms
• Hemiplegia

• Hemiparesis

• Dysarthria

• Aphasia: expressive aphasia, receptive
  aphasia

• Hemianopsia
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
Carotid Endarterectomy
Carotid Endarterectomy
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
Treatment Cont:
Acute phase:                Long Term Drug Therapy
                            To Prevent Stroke:
• Anticoagulant - Heparin   • Antiplatlet Drugs
  continuous infusion
                                   • ASA, Ticlid, Persanti
                                     ne, Plavix
• Osmotic Diuretics – to
  reduce brain swelling     • Anticoagulants
                               – Coumadin
• Anticoagulants               – Lovenox
  contraindicated in        • Antiepileptics
  Hemorrhagic Strokes
Treatment Cont:
Surgical Treatment
 For Bleeds (Interventional
Radiology)


   • Angiograms to see
     arteries and detect
     bleeding sites
   • Aneurysm clips and
     coils
Surgical Removal:
Hematoma
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
Medical Management During
           Acute 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
Medical Management During
        Acute 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
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
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
Manifestations
• Similar to ischemic stroke

• Severe headache

• Early and sudden changes in LOC

• Vomiting
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
Intracranial Aneurysms
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
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
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
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
Collaborative Problems/Potential
               Complications
• Decreased cerebral blood flow

• Inadequate oxygen delivery to brain

• Pneumonia
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
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
Interventions
• Focus on the whole person

• Provide interventions to prevent
  complications and to promote rehabilitation

• Provide support and encouragement

• Listen to the patient
Impaired Communication
• Aphasia-loss of use and    • Nursing Interventions:
  comprehension
                             • Assess ability to speak and
   – Receptive aphasia-        understand
     Wernicke’s area         • Provide + reinforcement
     (sensory)
                             • Picture board
   – Expressive aphasia –    • Repeat names of objects
     Broca’s area (motor)      routinely
                             • Allow plenty of time for
   – Global aphasia- mixed     client to answer
Picture Communication Board
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
Positioning to Prevent Shoulder Abduction
Prone Positioning to Help Prevent
           Hip Flexion
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
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
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
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
Nursing Process—Diagnosis of the Patient
        With a Hemorrhagic Stroke/
             Cerebral Aneurysm

• Ineffective tissue perfusion (cerebral)

• Disturbed sensory perception

• Anxiety
Collaborative Problems/Potential
               Complications
• Vasospasm

• Seizures

• Hydrocephalus

• Rebleeding

• Hyponatremia
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
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
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
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
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
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
STATUS

EPILEPTICUS
SEIZURE
Seizures
      sudden, excessive, disorderly electrical
discharges of the neurons.


EFFECTS OF SEIZURE: alteration in
the following
 mental status
 LOC
 sensory and speciual senses
 motor funtion
TYPES OF SEIZURE

GRAND MAL
  most common type of seizure

The phases are as
follows:
AURA
                 (flashing light, smells, spots before eyes,dizziness)




            TONIC – CLONIC PHASE
                              Tonic phase- contraction
                         Clonic phase – jerking movements
          Accompanied by dyspnea, drooling of saliva, urinary continence




                POST-ICTAL PHASE
                        Cessation of tonic-clonic movement
Characterized by exhaustion, headache, drowsiness, deep sleep of 1-2, disorientation
PETIT MAL (Absence Seizure or Little Sickness)

o       not preceeded by AURA
o       little or no toni-clonic
o       charac blank facial expression, automatism like lip-chewing,
        cheek smacking
o       regain of consciousness as rapid as it was lot for 10-20secs
o       usually occurs during childhood and adolescence
JACKSONIAN / FOCAL SEIZURE
o       common for patients with organic brain lesion like frontal
        lobe tumor
o       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 seizure
FEBRILE SEIZURE
o       this is common for children <5yo, when temp. is rising
PSYCHOMOTOR SEIZURE
o     aura is present (hallucinations or illusion)
o     charac by mental clouding (being out of touch with the envt)
o     appears intoxicated
o     the client may commit violent or antisocial acts, e.g. Going
      naked public, running
STATUS EPILEPTICUS
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.
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.
Symptoms
            The 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.
TWO CATEGORIES OF STATUS EPILEPTICUS

CONVULSIVE
Epilepsia 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.

NONCONVULSIVE
Complex 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.
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.
Nursing Diagnosis
 High Risk for Injury r/t Seizure
 Activity

 Individual Coping r/t perceive
 social stigma, potential changes
 in employment
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
NURSING INTERVENTION
   PREVENTING INJURY


   REDUCING FEARS OF SEIZURE


   IMPROVING COPING MECHANISMS


  PROVIDING PATIENT AND FAMILY EDUCATION



    MONITORING AND MANAGING POTENTIAL COMPLICATIONS


    TEACHING PATIENTS SELF-CARE
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,
PATIENT
    EDUCACTION
   TAKE MEDICATION AT REGULAR
    BASIS
   AVOID ALCOHOL. Lowers seizure
    threshold
   ADEQUATE REST
   WELL-BALANCED DIET
   AVOID DRIVING, OPERATING
    MACHINES, SWIMMING UNTIL SEIZURES
ARE WELL CONTROLLED.
   LIVE AN ACTIVE LIFE
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
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.
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.
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.
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.
Head Injury
Neuro diseases newest
INCIDENCES
                        Other transport, 2%
         Bicycle, 3%                          Suicide, 1%

          Other , 7%


                                                            Fall, 28%
   Unknown, 9%




Assault, 11%




                                                            Traffic accident,
               Struck, 19%                                         20%
1.   Dura mater
2.   Arachnoid
3.   Venae sagittalis superiores cerebri
4.   Sinus sagittalis superior and Falx cerebri
Duramater
Levels of consciousness
    Level                        Description
Conscious      Normal

Confused       Disoriented; impaired thinking and responses

               Disoriented; restlessness, hallucinations,
Delirious
                  sometimes delusions
               Decreased alertness; slowed psychomotor
Obtunded
                 responses
               Sleep-like state (not unconscious); little/no
Stuporous
                  spontaneous activity

Comatose       Cannot be aroused; no response to stimuli
symptoms of mild head injury
– raised, swollen
– bruise
– small, superficial cut in the scalp
– headache
symptoms of moderate to
          severe headpale skin color
– confusion
                    – injury
– loss of consciousness        – seizures
– blurred vision
– severe headache              – behavior changes
– vomiting                     – blood or clear fluid
– loss of short-term memory,
– slurred speech                 draining from the
– difficult walking              ears or nose
– dizziness
– weakness in one side or      – one pupil looks
  area of the body               larger than the
– sweating
                                 other eye
                               – deep cut or
                                 laceration in the
                                 scalp
                               – open wound in the
                                 head
Prognosis
Indication for admission
• Minor head injury
  – Focal neurodeficit
  – Post traumatic seizure
  – Skull fracture
• Moderate head injury
• Severe head injury
Investigation
Imaging
• Skull x-rays
Studies
• 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
• 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
Urgent Scan in adult if any of
  – GCS < when first assessed
  – GCS< two hours after injury
  – Suspected open or depressed skull
    fracture
  – Signs of base of skull fracture**
  – Post-traumatic seizure
  – Focal neurological deficit
  – > 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
8 hours after injury, a CT scan is also
             recommended
if there is either
   – More than     minutes of amnesia of events
     before impact
   – Or any amnesia or LOC since injury if
      • Aged ≥ years
      • Coagulopathy or on warfarin
      • Dangerous mechanism of injury
         –RTA as pedestrian
         –RTA - ejected from car
         –Fall > m or > stairs
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 ICP
Motor Function
- Move extremities, hand grasp, pedal push, speech
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
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.
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.
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
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
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
Ineffective breathing pattern related
         to neurological dysfunction
•
      Monitor constantly for respiratory
    irregularities
       – Cheyne Stokes, hyperventilation,
    Effective suctioning
    HOB 30 degrees
    Position patient lateral or semi prone
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
• Prevent straining
    - Stool Softeners
  - High Fibre diet
   Space Nursing activities
   Maintain calm atmosphere, reduce stimuli
Risk for fluid volume deficit related to
dehydration procedures and
decreased LOC
 Monitor electrolytes
 - Brain damage can produce metabolic and
 hormonal dysfunctions
 Monitor intake and output
 Monitor IV fluids carefully
 Monitor urine for acetone, osmolality
 Record daily weights
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
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 bladder
    Use padded side rails or wrap hands in mitts
    - Avoid restraints as straining against them increases
    ICP
    Minimize environmental stimuli
    - Low lights, limit visitors, speak calmly
    - Orient patient frequently
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 hypothalmus
    Cerebral irritation from hemorrhage
    Infection
    Reduce temperature with acetaminophen and cooling
    blankets
    If infection suspected –
    - Culture potential sites
    - Start antibiotics
Potential for impaired skin integrity
               related to bed
     rest, immobility, unconsciousness
•
    Assess all body surfaces every 8 hrs.
    Turn every 2-4 hrs
    Provide skincare every 4 hrs
    Assist patient to chair (if possible)
Neuro diseases newest
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.
• Primary prevention important.
    – Drive slow, use seat belts &
  helmets, water safety, protective devices for
  athletes, prevent falls.
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.
• 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.
Signs of spinal shock
•
      – Complete loss of all
    reflexes, motor, sensory and autonomic below
    level of injury.
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.
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.
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).
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.
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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Neuro diseases newest

  • 1. Management of Patients with Cerebrovascular Disorders Nelia B. Perez RN, MAEd, MSN PCU MJCN BSN 2012
  • 3. Brain Anatomy • Cerebrum – Reasoning – Judgment – Concentration, – Motor, sensory, speech • Cerebellum – Coordination • Brainstem – Cranial nerves – Respiratory center – Cardiovascular center
  • 5. • 20% of CO Cerebral Blood Flow • Cerebral tissues – Have no oxygen or glucose reserves • Blood flows through Carotid Arteries to Circle of Willis
  • 6. Intracranial Pressure (ICP) Composition A medical emergency that can • 80% brain tissue and water lead to: Brain hypoxia, herniation, death • 10% blood • 10% cerebrospinal fluid (CSF) Clinical Manifestations Increased ICP caused by: • Vomiting • Severe head injury/ Subdural • Headache hematoma • Blurred vision • Seizure • Hydrocephalus • Changes in behavior • Brain tumor • Loss of consciousness • Meningitis/Encephalitis • Lethargy • Aneurysm • Neurological symptoms • Status epilepticus/Stroke
  • 7. 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
  • 9. 3. PUPILS Pupils equal and react normally Pupils react to light (slowly or blriskly) Dilated pupil (compressed cranial nerve II Bilateral dilated, fixed (ominous sign) Pinpoint pupils (pons damage or drugs)
  • 10. Neuro-Diagnostic Tests CT SCAN • Routine labs • Radiology Tests – CT scan, MRI – Carotid ultrasound – Cerebral angiogram/ MRA Carotid US MRA
  • 11. 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
  • 12. 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
  • 13. 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
  • 15. 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%)
  • 16. 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
  • 18. 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
  • 19. Impaired comprehension & Left -Sided CVA: Memory R/T language and math LEFT BRAIN DAMAGE R Hemianopsia Impaired speech (Aphasias) Aware of deficits Depression, Anxiety R Hemiplegia /paresis Impaired discrimination (R/L) Slow performance, Cautious
  • 20. Right-sided CVA: Impaired judgment RIGHT BRAIN DAMAGE L Hemianopsia Impulsive/Safety problems Rapid performance Short attention span L hemiplegia/paresis Denies/Minimizes problems Left-sided neglect Spatial-perceptual deficits
  • 23. Cerebrovascular Terms • Hemiplegia • Hemiparesis • Dysarthria • Aphasia: expressive aphasia, receptive aphasia • Hemianopsia
  • 24. 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
  • 27. 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
  • 28. Treatment Cont: Acute phase: Long Term Drug Therapy To Prevent Stroke: • Anticoagulant - Heparin • Antiplatlet Drugs continuous infusion • ASA, Ticlid, Persanti ne, Plavix • Osmotic Diuretics – to reduce brain swelling • Anticoagulants – Coumadin • Anticoagulants – Lovenox contraindicated in • Antiepileptics Hemorrhagic Strokes
  • 29. Treatment Cont: Surgical Treatment For Bleeds (Interventional Radiology) • Angiograms to see arteries and detect bleeding sites • Aneurysm clips and coils
  • 31. 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
  • 32. Medical Management During Acute 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
  • 33. Medical Management During Acute 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
  • 34. 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
  • 35. 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
  • 36. Manifestations • Similar to ischemic stroke • Severe headache • Early and sudden changes in LOC • Vomiting
  • 37. 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
  • 39. 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
  • 40. 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
  • 41. 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
  • 42. 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
  • 43. Collaborative Problems/Potential Complications • Decreased cerebral blood flow • Inadequate oxygen delivery to brain • Pneumonia
  • 44. 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
  • 45. 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
  • 46. Interventions • Focus on the whole person • Provide interventions to prevent complications and to promote rehabilitation • Provide support and encouragement • Listen to the patient
  • 47. Impaired Communication • Aphasia-loss of use and • Nursing Interventions: comprehension • Assess ability to speak and – Receptive aphasia- understand Wernicke’s area • Provide + reinforcement (sensory) • Picture board – Expressive aphasia – • Repeat names of objects Broca’s area (motor) routinely • Allow plenty of time for – Global aphasia- mixed client to answer
  • 49. 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
  • 50. Positioning to Prevent Shoulder Abduction
  • 51. Prone Positioning to Help Prevent Hip Flexion
  • 52. 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
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/ Cerebral Aneurysm • Ineffective tissue perfusion (cerebral) • Disturbed sensory perception • Anxiety
  • 57. Collaborative Problems/Potential Complications • Vasospasm • Seizures • Hydrocephalus • Rebleeding • Hyponatremia
  • 58. 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
  • 59. 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
  • 60. 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
  • 61. 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
  • 62. 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
  • 63. 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
  • 65. SEIZURE Seizures sudden, excessive, disorderly electrical discharges of the neurons. EFFECTS OF SEIZURE: alteration in the following  mental status  LOC  sensory and speciual senses  motor funtion
  • 66. TYPES OF SEIZURE GRAND MAL most common type of seizure The phases are as follows:
  • 67. AURA (flashing light, smells, spots before eyes,dizziness) TONIC – CLONIC PHASE Tonic phase- contraction Clonic phase – jerking movements Accompanied by dyspnea, drooling of saliva, urinary continence POST-ICTAL PHASE Cessation of tonic-clonic movement Characterized by exhaustion, headache, drowsiness, deep sleep of 1-2, disorientation
  • 68. PETIT MAL (Absence Seizure or Little Sickness) o not preceeded by AURA o little or no toni-clonic o charac blank facial expression, automatism like lip-chewing, cheek smacking o regain of consciousness as rapid as it was lot for 10-20secs o usually occurs during childhood and adolescence JACKSONIAN / FOCAL SEIZURE o common for patients with organic brain lesion like frontal lobe tumor o 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 seizure FEBRILE SEIZURE o this is common for children <5yo, when temp. is rising PSYCHOMOTOR SEIZURE o aura is present (hallucinations or illusion) o charac by mental clouding (being out of touch with the envt) o appears intoxicated o the client may commit violent or antisocial acts, e.g. Going naked public, running
  • 70. 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.
  • 71. 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.
  • 72. Symptoms The 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.
  • 73. TWO CATEGORIES OF STATUS EPILEPTICUS CONVULSIVE Epilepsia 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. NONCONVULSIVE Complex 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.
  • 74. 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.
  • 75. Nursing Diagnosis High Risk for Injury r/t Seizure Activity Individual Coping r/t perceive social stigma, potential changes in employment
  • 76. 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
  • 77. NURSING INTERVENTION PREVENTING INJURY REDUCING FEARS OF SEIZURE IMPROVING COPING MECHANISMS PROVIDING PATIENT AND FAMILY EDUCATION MONITORING AND MANAGING POTENTIAL COMPLICATIONS TEACHING PATIENTS SELF-CARE
  • 78. 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,
  • 79. PATIENT EDUCACTION  TAKE MEDICATION AT REGULAR BASIS  AVOID ALCOHOL. Lowers seizure threshold  ADEQUATE REST  WELL-BALANCED DIET  AVOID DRIVING, OPERATING MACHINES, SWIMMING UNTIL SEIZURES ARE WELL CONTROLLED.  LIVE AN ACTIVE LIFE
  • 80. 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
  • 81. 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.
  • 82. 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.
  • 83. 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.
  • 84. 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.
  • 87. INCIDENCES Other transport, 2% Bicycle, 3% Suicide, 1% Other , 7% Fall, 28% Unknown, 9% Assault, 11% Traffic accident, Struck, 19% 20%
  • 88. 1. Dura mater 2. Arachnoid 3. Venae sagittalis superiores cerebri 4. Sinus sagittalis superior and Falx cerebri
  • 90. Levels of consciousness Level Description Conscious Normal Confused Disoriented; impaired thinking and responses Disoriented; restlessness, hallucinations, Delirious sometimes delusions Decreased alertness; slowed psychomotor Obtunded responses Sleep-like state (not unconscious); little/no Stuporous spontaneous activity Comatose Cannot be aroused; no response to stimuli
  • 91. symptoms of mild head injury – raised, swollen – bruise – small, superficial cut in the scalp – headache
  • 92. symptoms of moderate to severe headpale skin color – confusion – injury – loss of consciousness – seizures – blurred vision – severe headache – behavior changes – vomiting – blood or clear fluid – loss of short-term memory, – slurred speech draining from the – difficult walking ears or nose – dizziness – weakness in one side or – one pupil looks area of the body larger than the – sweating other eye – deep cut or laceration in the scalp – open wound in the head
  • 94. Indication for admission • Minor head injury – Focal neurodeficit – Post traumatic seizure – Skull fracture • Moderate head injury • Severe head injury
  • 95. Investigation Imaging • Skull x-rays Studies • 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
  • 96. • 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
  • 97. Urgent Scan in adult if any of – GCS < when first assessed – GCS< two hours after injury – Suspected open or depressed skull fracture – Signs of base of skull fracture** – Post-traumatic seizure – Focal neurological deficit – > 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
  • 98. 8 hours after injury, a CT scan is also recommended if there is either – More than minutes of amnesia of events before impact – Or any amnesia or LOC since injury if • Aged ≥ years • Coagulopathy or on warfarin • Dangerous mechanism of injury –RTA as pedestrian –RTA - ejected from car –Fall > m or > stairs
  • 99. 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 ICP Motor Function - Move extremities, hand grasp, pedal push, speech
  • 100. 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
  • 101. 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.
  • 102. 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.
  • 103. 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
  • 104. 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
  • 105. 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
  • 106. Ineffective breathing pattern related to neurological dysfunction • Monitor constantly for respiratory irregularities – Cheyne Stokes, hyperventilation, Effective suctioning HOB 30 degrees Position patient lateral or semi prone
  • 107. 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
  • 108. • Prevent straining - Stool Softeners - High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli
  • 109. Risk for fluid volume deficit related to dehydration procedures and decreased LOC Monitor electrolytes - Brain damage can produce metabolic and hormonal dysfunctions Monitor intake and output Monitor IV fluids carefully Monitor urine for acetone, osmolality Record daily weights
  • 110. 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
  • 111. 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 bladder Use padded side rails or wrap hands in mitts - Avoid restraints as straining against them increases ICP Minimize environmental stimuli - Low lights, limit visitors, speak calmly - Orient patient frequently
  • 112. 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 hypothalmus Cerebral irritation from hemorrhage Infection Reduce temperature with acetaminophen and cooling blankets If infection suspected – - Culture potential sites - Start antibiotics
  • 113. Potential for impaired skin integrity related to bed rest, immobility, unconsciousness • Assess all body surfaces every 8 hrs. Turn every 2-4 hrs Provide skincare every 4 hrs Assist patient to chair (if possible)
  • 115. 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.
  • 116. • Primary prevention important. – Drive slow, use seat belts & helmets, water safety, protective devices for athletes, prevent falls.
  • 117. 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.
  • 118. • 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.
  • 119. Signs of spinal shock • – Complete loss of all reflexes, motor, sensory and autonomic below level of injury.
  • 120. 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.
  • 121. 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.
  • 122. 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).
  • 123. 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.
  • 124. 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.