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Neurological System (includes Stroke)


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Neurological System (includes Stroke)

  1. 1. Neurological System
  2. 2. Brain Anatomy <ul><li>Cerebrum </li></ul><ul><ul><li>Reasoning </li></ul></ul><ul><ul><li>Judgment </li></ul></ul><ul><ul><li>Concentration, </li></ul></ul><ul><ul><li>Motor, sensory, speech </li></ul></ul><ul><li>Cerebellum </li></ul><ul><ul><li>Coordination </li></ul></ul><ul><li>Brainstem </li></ul><ul><ul><li>Cranial nerves </li></ul></ul><ul><ul><li>Respiratory center </li></ul></ul><ul><ul><li>Cardiovascular center </li></ul></ul>
  3. 3. Brain Anatomy Cont.
  4. 4. Cerebral Blood Flow <ul><li>20% of CO </li></ul><ul><li>Cerebral tissues – Have no oxygen or glucose reserves </li></ul><ul><li>Blood flows through Carotid Arteries to Circle of Willis </li></ul>
  5. 5. Intracranial Pressure (ICP) <ul><li>Composition </li></ul><ul><li>80% brain tissue and water </li></ul><ul><li>10% blood </li></ul><ul><li>10% cerebrospinal fluid (CSF) </li></ul><ul><li>Increased ICP caused by: </li></ul><ul><li>Severe head injury/ Subdural hematoma </li></ul><ul><li>Hydrocephalus </li></ul><ul><li>Brain tumor </li></ul><ul><li>Meningitis/Encephalitis </li></ul><ul><li>Aneurysm </li></ul><ul><li>Status epilepticus/Stroke </li></ul><ul><li>A medical emergency that can lead to: </li></ul><ul><li>Brain hypoxia, herniation, death </li></ul><ul><li>Clinical Manifestations </li></ul><ul><li>Vomiting </li></ul><ul><li>Headache </li></ul><ul><li>Blurred vision </li></ul><ul><li>Seizure </li></ul><ul><li>Changes in behavior </li></ul><ul><li>Loss of consciousness </li></ul><ul><li>Lethargy </li></ul><ul><li>Neurological symptoms </li></ul>
  6. 6. Neurological Assessment <ul><li>Rapid Neurological Assessment </li></ul><ul><ul><li>Emergent situations </li></ul></ul><ul><ul><li>Sudden changes in neurologic status </li></ul></ul><ul><ul><ul><li>LOC : first indicator of a decline in neurological function and increase in ICP (intracranial pressure); use the GCS </li></ul></ul></ul><ul><ul><ul><li>Pupils </li></ul></ul></ul>
  7. 8. 3. PUPILS Pupils equal and react normally Pupils react to light (slowly or blriskly) Dilated pupil (compressed cranial nerve III) Bilateral dilated, fixed (ominous sign) Pinpoint pupils (pons damage or drugs)
  8. 9. Neuro-Diagnostic Tests <ul><li>Routine labs </li></ul><ul><li>Radiology Tests </li></ul><ul><ul><li>CT scan, MRI </li></ul></ul><ul><ul><li>Carotid ultrasound </li></ul></ul><ul><ul><li>Cerebral angiogram/ </li></ul></ul><ul><ul><li>MRA </li></ul></ul>CT SCAN MRA Carotid US
  9. 10. Neuro-Diagnostic Tests: Lumbar Puncture <ul><li>Spinal needle inserted into SA </li></ul><ul><li>L3/L4 or L-4 /L-5 using strict asepsis </li></ul><ul><ul><li>Obtain CSF specimens and pressure readings </li></ul></ul><ul><ul><li>To remove bloody or purulent CSF </li></ul></ul><ul><ul><li>Administer spinal anesthesia </li></ul></ul>
  10. 11. Case Study: Introduction <ul><li>Nancy is a 66 year old female, came in to the ER with her daughter Gail. Gail states that her mother woke up in the middle of the night to go to the bathroom and fell to the ground because she was not able to control her right leg. </li></ul>
  11. 12. Case Study Subjective data <ul><li>R arm and leg weak and numb </li></ul><ul><li>Feeling depressed and fearful </li></ul><ul><li>Requires help with ADLs </li></ul><ul><li>Says she has not taken her meds for high cholesterol </li></ul><ul><li>History of brief episode of right sided weakness and tingling of the face, arm, and hand 3 months earlier, which totally resolved and for which she did not seek treatment </li></ul>
  12. 13. Case Study Objective Data <ul><li>Alert and oriented, and able to answer questions appropriately with mild slowness in responding </li></ul><ul><li>BP 180/110 </li></ul><ul><li>Global aphasia, facial drooping, dysphagia </li></ul><ul><li>Right sided paralysis </li></ul><ul><li>Decreased sensation to right side, particularly the hand </li></ul><ul><li>Right homonymous hemianopsia </li></ul><ul><li>Overweight </li></ul><ul><li>Incontinent of urine </li></ul>
  13. 14. Stroke: Brain Attack <ul><li>Cerebrovascular Accident (CVA) - loss of brain functions that occur when the blood supply to any part of the brain is interrupted. </li></ul><ul><li>Sudden onset of neurological deficits </li></ul><ul><li>Serious Medical Emergency- reduction in cerebral blood flow & tissue death </li></ul><ul><ul><li>Brain dependent on constant supply of oxygen and glucose </li></ul></ul>
  14. 15. Types of Stroke <ul><li>Ischemic- results from an occlusion of a cerebral artery by a thrombus or embolus </li></ul><ul><ul><li>Thrombotic Stroke </li></ul></ul><ul><ul><li>Embolic Stroke </li></ul></ul><ul><li>Hemorrhagic – bleeding into brain tissue </li></ul>
  15. 16. Ischemic: Thrombotic Stroke <ul><li>Atherosclerosis -most common cause </li></ul><ul><li>Thrombosis -clot forms at rough or narrowed artery </li></ul><ul><li>Complete blockage </li></ul><ul><li>Accounts for half of all strokes </li></ul>
  16. 17. Ischemic: Embolic Stroke <ul><ul><li>Accounts for 1/3 of all strokes </li></ul></ul><ul><ul><li>Embolism -emboli breaks off and travels to cerebral or carotid arteries (blood clot or fatty plaque released into circulation) </li></ul></ul><ul><ul><li>Often a fragment from a thrombosis or fatty plaque </li></ul></ul>
  17. 18. TIA: Transient Ischemic Attack or <ul><li>“ Silent stroke:/ mini stroke </li></ul><ul><li>Warning sign: Temporary onset of neurological symptoms often lasting 15 min but no longer than 24 hours </li></ul><ul><li>Needs prompt work-up: carotid U/S, brain and heart </li></ul><ul><li>Key features: </li></ul><ul><ul><li>Blurred vision, double vision, blindness one eye; Transient weakness, ataxia; Speech deficits </li></ul></ul>
  18. 19. Treatment Cont: Surgical Therapy <ul><li>Carotid Endarterectomy- for pts who have had TIAs or significant narrowing of carotid arteries </li></ul>
  19. 20. Hemorrhagic Stroke <ul><li>Rupture of weak vessel wall or cerebral aneurysm </li></ul><ul><li>Intracerebral or subarachnoid hemorrhage </li></ul><ul><li>Arteriovenous malformation </li></ul><ul><li>Bleeding into brain </li></ul><ul><li>or meninges </li></ul>
  20. 21. Risk Factors for Stroke <ul><li>Modifiable </li></ul><ul><li>Hypertension </li></ul><ul><li>Heart disease (MI, A Fib) </li></ul><ul><li>DM, Hyperlipidemia </li></ul><ul><li>Sedentary Lifestyle </li></ul><ul><li>Smoking/Alcohol </li></ul><ul><li>Obesity </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Illicit Drug Use; </li></ul><ul><li>cocaine </li></ul><ul><li>Nonmodiafiable </li></ul><ul><li>Age - People over 55 are </li></ul><ul><li>at high risk </li></ul><ul><li>family history </li></ul><ul><li>African american, hispanic, asian descent </li></ul>
  21. 22. Clinical Manifestations <ul><li>Depend on the extent of injury </li></ul><ul><ul><li>May be transient, mild or result in major neuro deficits </li></ul></ul><ul><ul><li>Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body </li></ul></ul><ul><ul><li>Sudden complete or partial loss of vision on one or both sides </li></ul></ul><ul><ul><li>Sudden confusion or trouble speaking or understanding </li></ul></ul><ul><ul><li>Sudden loss of balance, unsteadiness or an unexplained fall </li></ul></ul><ul><ul><li>Sudden vertigo, dizziness, swallowing difficulties or memory disturbances </li></ul></ul><ul><ul><li>Sudden, severe headache with no known cause </li></ul></ul><ul><li>Hemorrhagic </li></ul><ul><ul><li>Worst HA ever for bleeds </li></ul></ul>
  22. 23. R Hemiplegia /paresis Impaired speech (Aphasias) Impaired discrimination (R/L) Slow performance, Cautious Aware of deficits Depression, Anxiety Impaired comprehension & Memory R/T language and math Left -Sided CVA: LEFT BRAIN DAMAGE R Hemianopsia
  23. 24. Right-sided CVA: RIGHT BRAIN DAMAGE Impaired judgment Impulsive/Safety problems Denies/Minimizes problems L hemiplegia/paresis Left-sided neglect Spatial-perceptual deficits Rapid performance Short attention span L Hemianopsia
  24. 25. Impaired Swallowing Cognitive Changes Motor Deficits Sensory Changes Impaired Communication Altered Elimination Nancy Psychosocial
  25. 26. Impaired Swallowing <ul><li>Stroke -> dysphagia </li></ul><ul><li>Risk for airway obstruction/ aspiration </li></ul><ul><li>Nursing Interventions: </li></ul><ul><li>Maintain patent airway </li></ul><ul><ul><li>NPO until swallow eval (by ST) </li></ul></ul><ul><ul><li>Assess swallow, cough, gag reflex </li></ul></ul><ul><ul><li>Safe Feedings: High Fowler’s position with head flexed forward </li></ul></ul><ul><ul><li>Thickened liquids if impaired swallowing Instruct to position food on unaffected side in back of throat </li></ul></ul><ul><ul><li>Avoid distractions to reduce aspiration risks </li></ul></ul><ul><ul><li>Soft, semi-soft foods, pureed, baby food, dental diet </li></ul></ul><ul><ul><li>Suction as needed </li></ul></ul>
  26. 27. Cognitive Changes <ul><li>Change in LOC </li></ul><ul><li>Impaired judgment, memory, problem solving </li></ul><ul><li>Denial of illness </li></ul><ul><li>Inability to concentrate </li></ul><ul><ul><li>Nursing Interventions: </li></ul></ul><ul><ul><li>Frequent reorientation </li></ul></ul><ul><ul><li>Frequent safety instructions </li></ul></ul><ul><ul><li>Repeat directions on tasks by steps </li></ul></ul><ul><ul><li>Give time to process and respond </li></ul></ul>
  27. 28. Motor Deficits <ul><li>Loss of voluntary movement on contralateral (opposite) side of stroke </li></ul><ul><li>Weakness & paralysis </li></ul><ul><ul><li>Hemiplegia and/or Hemiparesis </li></ul></ul><ul><li>Gait changes </li></ul>
  28. 29. Motor Deficit Cont. <ul><li>Nursing Interventions: </li></ul><ul><li>Maintain optimal functioning and assist as necessary </li></ul><ul><li>Prevent contractures & atrophy </li></ul><ul><li>PT and OT eval/tx to promote independence </li></ul><ul><ul><li>Positioning- intermittent prone positions; elevate affected extremity </li></ul></ul><ul><ul><li>ROM exercises (passive: begin 1 st day of hosp; no ambulation with hemorrhagic stroke- limit mvmt to extremities only ) </li></ul></ul><ul><ul><li>Assist with ADLs (Self Care Deficit) </li></ul></ul><ul><ul><li>Use assistive devices (wide grip utensils, plate guards) </li></ul></ul><ul><ul><li>Rehab and use of ambulation devices </li></ul></ul>
  29. 30. Motor Deficit Cont. Splints, hand rolls, trochanter rolls
  30. 31. Assessment and Management Sensory Changes <ul><li>Contralateral sensory deficits </li></ul><ul><ul><li>Decreased sensation to touch </li></ul></ul><ul><li>Spatial dysfunction (kinesthesia/proprioception altered) </li></ul><ul><ul><li>↓ Awareness of position </li></ul></ul><ul><li>Neglect Syndrome – </li></ul><ul><ul><li>Ignore affected side due to altered perception and vision </li></ul></ul><ul><li>Visual Deficits (Hemianopsia) </li></ul><ul><li>Nursing Interventions : </li></ul><ul><ul><li>Teach client to touch and use both sides </li></ul></ul><ul><ul><li>Remind client to dress and bathe both sides </li></ul></ul><ul><ul><li>Place objects within patients field of vision </li></ul></ul><ul><ul><li>Approach patient from unaffected side </li></ul></ul>
  31. 32. Sensory Changes Cont. - Visual Deficits: Hemianopsia <ul><ul><li>Blindness in one side of visual field </li></ul></ul><ul><ul><li>Homonymous hemianopsia </li></ul></ul><ul><ul><ul><li>Blindness in in the same side of each visual field </li></ul></ul></ul>
  32. 33. Visual Deficits: Hemianopsia Cont. <ul><li>Nursing Interventions: </li></ul><ul><ul><li>Place objects in client’s visual field </li></ul></ul><ul><ul><li>Remove clutter </li></ul></ul><ul><ul><li>Teach patient to attend to the neglected side </li></ul></ul><ul><ul><ul><li>Teach scanning technique during ADLs </li></ul></ul></ul><ul><ul><li>Assess the neglected side (paralyzed or weak side) for trauma, adequacy of dressing and hygiene </li></ul></ul>
  33. 34. Impaired Communication <ul><li>Aphasia-loss of use and comprehension </li></ul><ul><ul><li>Receptive aphasia- Wernicke’s area (sensory) </li></ul></ul><ul><ul><li>Expressive aphasia – Broca’s area (motor) </li></ul></ul><ul><ul><li>Global aphasia- mixed </li></ul></ul><ul><li>Nursing Interventions: </li></ul><ul><li>Assess ability to speak and understand </li></ul><ul><li>Provide + reinforcement </li></ul><ul><li>Picture board </li></ul><ul><li>Repeat names of objects routinely </li></ul><ul><li>Allow plenty of time for client to answer </li></ul>
  34. 35. Picture Communication Board
  35. 36. Altered Elimination <ul><li>Temporary or permanent loss of bladder/bowel function </li></ul><ul><li>Constipation common </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Immobility </li></ul></ul><ul><li>Nursing Interventions: </li></ul><ul><ul><li>Increase fiber and fluids </li></ul></ul><ul><ul><li>Stool softeners </li></ul></ul><ul><ul><li>Digital stimulation/suppositories </li></ul></ul><ul><ul><li>bladder retraining </li></ul></ul><ul><ul><li>Straight cath to check residual </li></ul></ul>
  36. 37. Assessment and Management Problems R/T Imm obility <ul><li>Risk for atelectasis and pneumonia </li></ul><ul><li>Risk for impaired skin integrity and DVT </li></ul><ul><li>Nursing Interventions: </li></ul>
  37. 38. Assessment and Management: Psychosocial <ul><li>Emotional Support </li></ul><ul><ul><li>Depression a major problem </li></ul></ul><ul><li>Discharge planning </li></ul><ul><li>Care of the caregiver </li></ul>
  38. 39. Treatment of Stroke: Thrombotic Stroke <ul><li>Thrombolytic Therapy : </li></ul><ul><li>rtPA (recombinant tissue Plasminogen Activator-Retavase) </li></ul><ul><ul><li>A clot-buster delivered intravenously; breaks up the clot allowing blood flow to return to the deprived area of the brain </li></ul></ul><ul><ul><li>Must be administered within 3 hours of the onset of clinical signs of ischemic stroke </li></ul></ul><ul><li>Quick CT scan to see if stroke from clot or bleed </li></ul>
  39. 40. Treatment Cont: <ul><li>Acute phase: </li></ul><ul><li>Anticoagulant - Heparin continuous infusion </li></ul><ul><li>Osmotic Diuretics – to reduce brain swelling </li></ul><ul><li>Anticoagulants contraindicated in Hemorrhagic Strokes </li></ul><ul><li>Long Term Drug Therapy </li></ul><ul><li>To Prevent Stroke: </li></ul><ul><li>Antiplatlet Drugs </li></ul><ul><ul><ul><li>ASA, Ticlid, Persantine, Plavix </li></ul></ul></ul><ul><li>Anticoagulants </li></ul><ul><ul><li>Coumadin </li></ul></ul><ul><ul><li>Lovenox </li></ul></ul><ul><li>Antiepileptics </li></ul>
  40. 41. Treatment Cont: Surgical Treatment For Bleeds (Interventional Radiology) <ul><li>Angiograms to see arteries and detect bleeding sites </li></ul><ul><li>Aneurysm clips and coils </li></ul>
  41. 42. Surgical Removal: Hematoma