NurseReview.Org Neurology Part 1

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NurseReview.Org Neurology Part 1

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

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