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Neurology Part 1 Neurology Part 1 Presentation Transcript

  • Medical-Surgical Nursing A Review of Neurologic Concepts Nurse Licensure Examination Review pinoynursing.webkotoh.com
  • 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=Spontaneous 3=To voice 2=To pain 1=None (No response)
  • Glasgow Coma Scale
    • Glasgow Coma Score
    • Verbal Response (V)
    • 5=Normal/oriented 4=Disoriented/ CONFUSED 3=Words, but incoherent/ inappropriate 2=Incomprehensible/mumbled words 1=None
  • Glasgow Coma Scale
    • Glasgow Coma Score
    • Motor Response (M)
    • 6=Normal- obeys command 5=Localizes pain 4=Withdraws to pain (Flexion) 3=Decorticate posture 2=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 clonic
    • Superficial 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 mmHg
    • Brunner= Normal intracranial pressure 10-20 mmHg
    • Causes:
    • 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
    • Pathophysiology
    • Decompensatory 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
    • Steady perfusion up to 40 mmHg
    • 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 MANIFESTATIONS
    • Early manifestations :
    • Changes in the LOC- usually the earliest
    • Pupillary changes- fixed, slowed response
    • Headache
    • vomiting
  • Increased Intracranial pressure
    • CLINICAL MANIFESTATIONS
    • late 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 levels  constricts blood vessels  reduces 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 Factors
    • Head injury
    • Stroke
    • Drug overdose
    • Alcoholic intoxication
    • Diabetic ketoacidosis
    • Hepatic failure
  • Altered level of consciousness
    • ASSESSMENT
    • Behavioral changes initially
    • Pupils are slowly reactive
    • Then , patient becomes unresponsive and pupils become fixed dilated
    • Glasgow Coma Scale is utilized
  • Altered level of consciousness
    • Nursing Intervention
    • 1. Maintain patent airway
    • Elevate the head of the bed to 30 degrees
    • Suctioning
    • 2. Protect the patient
    • Pad side rails
    • Prevent injury from equipments, restraints and etc.
  • Altered level of consciousness
    • Nursing Intervention
    • 3. Maintain fluid and nutritional balance
    • Input an output monitoring
    • IVF therapy
    • Feeding through NGT
    • 4. Provide mouth care
    • Cleansing and rinsing of mouth
    • Petrolatum on the lips
  • Altered level of consciousness
    • Nursing Intervention
    • 5. Maintain skin integrity
    • Regular turning every 2 hours
    • 30 degrees bed elevation
    • Maintain correct body alignment by using trochanter rolls, foot board
    • 6. Preserve corneal integrity
    • Use of artificial tears every 2 hours
  • Altered level of consciousness
    • Nursing Intervention
    • 7. Achieve thermoregulation
    • Minimum amount of beddings
    • Rectal or tympanic temperature
    • Administer acetaminophen as prescribed
    • 8. Prevent urinary retention
    • Use of intermittent catheterization
  • Altered level of consciousness
    • Nursing Intervention
    • 9. Promote bowel function
    • High fiber diet
    • Stool softeners and suppository
    • 10. 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 FACTORS
    • Idiopathic
    • Fever
    • Head injury
    • CNS infection
    • Metabolic and toxic conditions
  • SEIZURES
    • Nursing Interventions
    • During 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 Interventions
    • During seizure
    • 5. loosen constrictive clothing
    • 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway
  • SEIZURES
    • Nursing Interventions
    • POST 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
    • Migraine
    • Prodrome stage
    • Aura phase
    • Headache
    • 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 Interventions
    • Assist or encourage the patient to use eyeglass, hearing aid or assistive devices
    • Reorient the patient by calling his name frequently
    • Provide background information as to date, time, place, environment
  • Cognitive Impairment
    • Nursing Interventions
    • 4. Use large signs as visual cues
    • 5. Post patient's photo on the door
    • 6. 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 hemorrhage
    • Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery
    • Symptoms develop rapidly
  •  
  • Traumatic brain injury
    • 4. Intracranial hemorrhage
    • Subdural 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 vessels
    • Symptoms usually develop slowly
  •  
  • Traumatic brain injury
    • 4. Intracranial hemorrhage
    • Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities
    • Symptoms 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 MANAGEMENT
    • 1. Monitor for declining LOC- use of Glasgow
    • 2. Maintain patent airway
    • Elevate bed, suction prn, monitor ABG
  • Traumatic brain injury
    • NURSING MANAGEMENT
    • 3. Monitor F and E balance
    • Daily weights
    • IVF therapy
    • Monitor possible development of DI and SIADH
  • Traumatic brain injury
    • 4. Provide adequate nutrition
    • 5. 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 INTERVENTIONS
    • 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 INTERVENTIONS
    • 2. Enhance self-care
    • Carry out activities on the unaffected side
    • Prevent unilateral neglect
    • Keep environment organized
    • Use large mirror
  • CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
    • NURSING INTERVENTIONS
    • 3. 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 INTERVENTIONS
    • 4. Manage dysphagia
    • Place food on the UNAFFECTED side
    • Provide smaller bolus of food
    • Manage tube feedings if prescribed
  • CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
    • NURSING INTERVENTIONS
    • 5. 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 INTERVENTIONS
    • 6. Improve thought processes
    • Support patient and capitalize on the remaining strengths
  • CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
    • NURSING INTERVENTIONS
    • 7. 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 INTERVENTIONS
    • 8. 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 INTERVENTIONS
    • 9. Promote continuing care
    • Referral to other health care providers
  • CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
    • NURSING INTERVENTIONS
    • 10. Improve family coping
    • 11. 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
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