neuro condition

1. NEUROLOGIC DISORDERS

2. The
Unconscious
Client

3. A. Descrip+on
•1. The unconscious client is in a state of depressed
cerebral functioning with unresponsiveness to
stimulation of sensory and motor function.
•2. Some causes include head trauma, cerebral toxins,
shock, hemorrhage, tumor, and infection.

4. B.
Assessment
• 1. Unarousable
• 2. Primitive or no
response to painful
stimuli
• 3. Altered respirations
• 4. Decreased cranial
nerve and reflex activity

5. C. Interventions Care of the Unconscious Client
• Assess patency of the airway and keep airway
and emergency equipment readily available.
• Monitor blood pressure, pulse, and heart
sounds.
• Assess respiratory and circulatory status.
• Do not leave the client unattended if
unstable.
• Assess lung sounds for the accumulation of
secretions; suction as needed.

6. C. Interventions Care of the Unconscious Client
• Maintain a patent airway and ven?la?on,
because a high carbon dioxide (CO2) level
increases intracranial pressure.
• Assess neurological status, including level of
consciousness, pupillary reac?ons, and
motor and sensory func?on, using a coma
scale.
• Place the client in a semi-Fowler’s posi?on.
• Change posi?on of the client every 2 hours,
avoiding injury when turning.
• Avoid Trendelenburg’s posi?on.

7. C. Interventions Care of the Unconscious Client
• Use side rails unless contraindicated
or according to agency protocol.
• Assess for edema.
• Monitor for dehydration.
• Monitor intake and output and daily
weight.
• Maintain NPO (nothing by mouth)
status until consciousness returns.

8. C. Interventions Care of the Unconscious Client
• Maintain nutrition as prescribed
(intravenous or enteral feedings) and
monitor fluid and electrolyte balance
(when consciousness returns, check
the gag and swallow reflex before
resuming a diet).
• Assess bowel sounds.
• Monitor elimination patterns.

9. C. Interventions Care of the Unconscious Client
• Monitor for constipation, impaction,
and paralytic ileus.
• Maintain urinary output to prevent
stasis, infection, and calculus
formation.
• Monitor the status of skin integrity.
• Initiate measures to prevent skin
breakdown.

10. C. Interventions Care of the Unconscious Client
• Provide frequent mouth care.
• Remove dentures and contact lenses.
• Assess the eyes for the presence of a
corneal reflex and irritation, and instill
artificial tears or cover the eyes with
eye patches.
• Monitor drainage from the ears or
nose for the presence of cerebrospinal
fluid.

11. C. Interventions Care of the Unconscious Client
• Assume that the unconscious client can
hear.
• Avoid restraints.
• Initiate seizure precautions if
necessary.
• Provide range-of-motion exercises to
prevent contractures.
• Use a footboard or high-topped
sneakers to prevent footdrop.

12. Increased Intracranial
Pressure (ICP)

13. A.
Description
• 1. Increased ICP may be caused by
trauma, hemorrhage, growths or
tumors, hydrocephalus, edema, or
inflammation.
• 2. Increased ICP can impede
circulation to the brain, impede the
absorption of CSF, affect the
functioning of nerve cells, and lead
to brainstem compression and
death.

14. B. Assessment
• 1. Altered level of
consciousness, which is
the most sensitive and
earliest indication of
increasing ICP
• 2. Headache
• 3. Abnormal respirations

15. Assessment of Respirations
Cheyne-Stokes
• Rhythmic, with
periods of apnea
• Can indicate a
metabolic
dysfunc<on or
dysfunc<on in the
cerebral hemisphere
or basal ganglia
Neurogenic
Hyperventilation
• Regular rapid and
deep sustained
respirations
• Indicates a
dysfunction in the
low midbrain and
middle pons
Apneustic
• Irregular respirations,
with pauses at the
end of inspiration
and expiration
• Indicates a
dysfunction in the
middle or caudal
pons

16. Assessment
of
Respirations
Totally irregular in rhythm and
depth
Indicates a dysfunction in the
medulla
Ataxic
Clusters of breaths with
irregularly spaced pauses
Indicates a dysfunction in the
medulla and pons
Cluster

17. B.
Assessment
• 4. Rise in blood pressure with widening pulse
pressure
• 5. Slowing of pulse
• 6. Elevated temperature
• 7. Vomiting
• 8. Pupil changes
• 9. Late signs of increased ICP include increased
systolic blood pressure, widened pulse pressure,
and slowed heart rate.
• 10. Other late signs include changes in motor
function from weakness to hemiplegia, a positive
Babinski’s reflex, decorticate or decerebrate
posturing, and seizures.

18. C. Interventions
• 1. Monitor respiratory status and prevent hypoxia.
• 2. Avoid the administration of morphine sulfate to prevent the
occurrence of hypoxia.
• 3. Maintain mechanical ventilation as prescribed; maintaining the
PaCO2 at 30 to 35 mm Hg (30 to 35 mm Hg) will result in
vasoconstriction of the cerebral blood vessels, decreased blood flow,
and therefore decreased ICP.
• 4. Maintain body temperature.

19. C. Interventions
• 5. Prevent shivering, which can increase ICP.
• 6. Decrease environmental stimuli.
• 7. Monitor electrolyte levels and acid–base balance.
• 8. Monitor intake and output.

20. C. Interventions
• 9. Limit fluid intake to 1200 mL/day.
• 10. Instruct the client to avoid straining activities, such as
coughing and sneezing.
• 11. Instruct the client to avoid Valsalva’s maneuver.
• For the client with increased ICP, elevate the head of the bed
30 to 40 degrees, avoid the Trendelenburg’s position, and
prevent flexion of the neck and hips.

21. D. Medications
• Antiseizure
• Seizures increase metabolic requirements and
cerebral blood flow and volume, thus
increasing intracranial pressure (ICP).
• Medications may be given prophylactically to
prevent seizures.
• Antipyretics and Muscle Relaxants
• Temperature reduction decreases metabolism,
cerebral blood flow, and thus ICP.
• Antipyretics prevent temperature elevations.
• Muscle relaxants prevent shivering.

22. D. Medications
• Blood Pressure Medication
• Blood pressure medication may be required to
maintain cerebral perfusion at a normal level.
• Notify the primary health care provider if the blood
pressure range is lower than 100 or higher than 150
mm Hg systolic.
• Corticosteroids
• Corticosteroids stabilize the cell membrane and
reduce leakiness of the blood- brain barrier.
• Corticosteroids decrease cerebral edema.
• A histamine blocker may be administered to
counteract the excess gastric secretion that occurs
with the corticosteroid.
• Clients must be withdrawn slowly from
corticosteroid therapy to reduce the risk of adrenal
crisis.

23. D. Medications
• Intravenous Fluids
• Fluids are administered intravenously via an infusion
pump to control the amount administered.
• Infusions are monitored closely because of the risk of
promoting additional cerebral edema and fluid overload.
• Hyperosmotic Agent
• A hyperosmotic agent increases intravascular pressure by
drawing fluid from the interstitial spaces and from the
brain cells.
• Monitor renal function.
• Diuresis is expected.

24. HYPERTHERMIA

25. A. Description
1. Temperature higher than
105° F (40.6° C), which
increases the cerebral
metabolism and increases
the risk of hypoxia
2. Causes include infection,
heat stroke, exposure to
high environmental
temperatures, and
dysfunction of the
thermoregulatory center.

26. B. Assessment
• 1. Temperature higher than
105° F (40.6° C)
• 2. Shivering
• 3. Nausea and vomiting

27. C. Interventions
• 1. Maintain a patent airway.
• 2. Initiate seizure precautions.
• 3. Monitor intake and output and assess the skin and mucous
membranes for signs of dehydration.
• 4. Monitor lung sounds.
• 5. Monitor for dysrhythmias.
• 6. Assess peripheral pulses for systemic blood flow.
• 7. Induce normothermia with fluids, cool baths, fans, or a
hypothermia blanket.

28. D. Inducement of normothermia
• 1. Prevent shivering, which will increase ICP and
oxygen consumption.
• 2. Administer medications as prescribed to prevent
shivering and to lower body temperature.
• 3. Monitor neurological status.
• 4. Monitor for infection and respiratory complications
because hyperthermia may mask the signs of
infection.

29. D. Inducement of normothermia
• 5. Monitor for cardiac dysrhythmias.
• 6. Monitor intake and output and fluid balance.
• 7. Prevent trauma to the skin and tissues.
• 8. Apply lotion to the skin frequently.
• 9. Inspect for frostbite if a hypothermia blanket is
used.

30. Traumatic Head Injury

31. A. Description
1. Head injury is trauma to the skull, resulting in mild to extensive
damage to the brain.
2. Immediate complications include cerebral bleeding, hematomas,
uncontrolled increased ICP, infections, and seizures.
3. Changes in personality or behavior, cranial nerve deficits, and any
other residual deficits depend on the area of the brain damage and
the extent of the damage.

32. B. Types of head
injuries
• Concussion
• Concussion is a jarring of the
brain within the skull; there may
or may not be a loss of
consciousness.
• Contusion
• Contusion is a bruising type of
injury to the brain tissue.
• Contusion may occur along with
other neurological injuries, such as
with subdural or extradural
collections of blood.

33. B. Types of head
injuries
• Skull Fractures
• Linear
• Depressed
• Compound
• Comminuted

34. C. Hematoma
• 1. Description:
• A collection of blood in the tissues that can
occur as a result of a subarachnoid
hemorrhage or an intracerebral hemorrhage.
• Epidural Hematoma
• The most serious type of hematoma,
epidural hematoma forms rapidly and results
from arterial bleeding.
• The hematoma forms between the dura and
skull from a tear in the meningeal artery.
• It is often associated with temporary loss of
consciousness, followed by a lucid period
that then rapidly progresses to coma.
• Epidural hematoma is a surgical emergency.

35. C. Hematoma
Subdural Hematoma
• Subdural hematoma forms slowly and results from
a venous bleed.
• It occurs under the dura as a result of tears in the
veins crossing the subdural space.
Intracerebral Hemorrhage
• Intracerebral hemorrhage occurs when a blood
vessel within the brain ruptures, allowing blood to
leak inside the brain.
Subarachnoid Hemorrhage
• A subarachnoid hemorrhage is bleeding into the
subarachnoid space. It may occur as a result of
head trauma or spontaneously, such as from a
ruptured cerebral aneurysm.

36. 2. Assessment
• a. Assessment findings depend on the injury.
• b. Clinical manifestations usually result from increased
ICP.
• c. Changing neurological signs in the client
• d. Changes in level of consciousness
• e. Airway and breathing pattern changes

37. 2. Assessment
• f. Vital signs change, reflecting increased ICP.
• g. Headache, nausea, and vomiting
• h. Visual disturbances, pupillary changes, and
papilledema
• i. Nuchal rigidity (not tested until spinal cord injury is
ruled out)
• j. CSF drainage from the ears or nose

38. 2. Assessment
• k. Weakness and paralysis
• l. Posturing
• m. Decreased sensation or absence of feeling
• n. Reflex activity changes
• o. Seizure activity

39. 2. Assessment
• p. CSF can be distinguished from other fluids by the
presence of concentric rings (bloody fluid surrounded by
yellowish stain; halo sign) when the fluid is placed on a
white sterile background, such as a gauze pad. CSF also
tests positive for glucose when tested using a strip test.

40. 3. Interventions
• a. Monitor respiratory status and maintain a patent airway, because
increased carbon dioxide (CO2) levels increase cerebral edema.
• b. Monitor neurological status and vital signs, including temperature.
• c. Monitor for increased ICP.
• d. Maintain head elevation to reduce venous pressure.
• e. Prevent neck flexion.

41. 3. Interventions
• f. Initiate normothermia measures for increased temperature.
• g. Assess cranial nerve function, reflexes, and motor and sensory
function.
• h. Initiate seizure precautions.
• i. Monitor for pain and restlessness.
• j. Morphine sulfate or opioid medication may be prescribed to
decrease agitation and control restlessness caused by pain for the
head-injured client on a ventilator; administer with caution because it
is a respiratory depressant and may increase ICP.

42. 3. Interventions
• k. Monitor for drainage from the nose or ears, because this fluid may
be CSF.
• l. Do not attempt to clean the nose, suction, or allow the client to
blow her or his nose if drainage occurs.
• m. Do not clean the ear if drainage is noted, but apply a loose, dry
sterile dressing.
• n. Check drainage for the presence of CSF.
• o. Notify the PHCP if drainage from the ears or nose is noted and if
the drainage tests positive for CSF.

43. 3. Interventions
• p. Instruct the client to avoid coughing because this increases ICP.
• q. Monitor for signs of infection.
• r. Prevent complications of immobility.
• s. Inform the client and family about the possible behavior changes
that may occur, including those that are expected and those that
need to be reported.

44. D. Craniotomy
• 1. Description
• a. Surgical procedure that involves an incision
through the cranium to remove accumulated
blood or a tumor
• b. Complications of the procedure include
increased ICP from cerebral edema,
hemorrhage, or obstruction of the normal flow
of CSF.
• c. Additional complications include
hematomas, hypovolemic shock,
hydrocephalus, respiratory and neurogenic
complications, pulmonary edema, and wound
infections.

45. D. Craniotomy
• d. Complications related to fluid and
electrolyte imbalances include
diabetes insipidus and inappropriate
secretion of antidiuretic hormone.
• e. Stereotactic radiosurgery (SRS)
may be an alternative to traditional
surgery and is usually used to treat
tumors and arteriovenous
malformations.

46. 2. Preoperative interventions
• a. Explain the procedure to the client and family.
• b. Prepare to shave the client’s head as prescribed (usually done
in the operating room) and cover the head with an appropriate
covering.
• c. Stabilize the client before surgery.

47. 3. Postoperative interventions
• Monitor vital signs and neurological status every 30 to 60 minutes.
• Monitor for increased intracranial pressure (ICP).
• Monitor for decreased level of consciousness, motor weakness or
paralysis, aphasia, visual changes, and personality changes.
• Maintain mechanical ventilation and slight hyperventilation for the
first 24 to 48 hours as prescribed to prevent increased ICP.
• Assess the primary health care provider’s (PHCP’s) prescription
regarding client positioning.

48. 3. Postoperative interventions
• Avoid extreme hip or neck flexion, and maintain the head in a
midline neutral position.
• Provide a quiet environment.
• Monitor the head dressing frequently for signs of drainage.
• Mark any area of drainage at least once each nursing shift for
baseline comparison.
• Monitor the drain, which may be in place for 24 hours; maintain
suction on the drain as prescribed.

49. 3. Postoperative interventions
• Measure drainage from the drain every 8 hours, and record the amount and
color.
• Notify the PHCP if drainage is more than the normal amount of 30 to 50 mL
per shift.
• Notify the PHCP immediately of excessive amounts of drainage or a saturated
head dressing.
• Record strict measurement of hourly intake and output.
• Maintain fluid restriction at 1500 mL/day as prescribed.

50. 3. Postoperative interventions
• Monitor electrolyte levels.
• Monitor for dysrhythmias, which may occur as a result of fluid or electrolyte
imbalance.
• Apply ice packs or cool compresses as prescribed; expect periorbital edema and
ecchymosis of 1 or both eyes.
• Provide range-of-motion exercises every 8 hours.
• Place antiembolism stockings on the client as prescribed.
• Administer antiseizure medications, antacids, corticosteroids, and antibiotics as
prescribed.
• Administer analgesics such as codeine sulfate or acetaminophen as prescribed for
pain.

51. 4. Postoperative positioning
• Client Positioning Following Craniotomy
• Positions prescribed following a craniotomy vary with the type of
surgery and the specific postoperative primary health care provider’s
(PHCP’s) prescription.
• Always check the PHCP’s prescription regarding client positioning.
• Incorrect positioning may cause serious and possibly fatal
complications.

52. • Removal of a Bone Flap for Decompression
• To facilitate brain expansion, the client should be turned from
the back to the nonoperative side, but not to the side on
which the operation was performed.
• Posterior Fossa Surgery
• To protect the operative site from pressure and minimize
tension on the suture line, position the client on the side,
with a pillow under the head for support, and not on the
back.

53. • Infratentorial Surgery
• Infratentorial surgery involves surgery below the tentorium of
the brain.
• The PHCP may prescribe a flat position without head
elevation or may prescribe that the head of the bed be
elevated at 30 to 45 degrees.
• Do not elevate the head of the bed in the acute phase of care
following surgery without an PHCP’s prescription.

54. • Supratentorial Surgery
• Supratentorial surgery involves surgery above the tentorium
of the brain.
• The PHCP may prescribe that the head of the bed be elevated
at 30 degrees to promote venous outflow through the jugular
veins.
• Do not lower the head of the bed in the acute phase of care
following surgery without a PHCP’s prescription.

55. Cerebral Aneurysm

56. A. Description:
• Dilation of the walls of a
weakened cerebral artery; can
lead to rupture

57. B.
Assessment
1. Headache and pain
2. Irritability
3. Visual changes
4. Tinnitus
5. Hemiparesis
6. Nuchal rigidity
7. Seizures

58. C. Interventions
• 1. Maintain a patent airway
(suction only with an PHCP’s
prescription).
• 2. Administer oxygen as prescribed.
• 3. Monitor vital signs and for
hypertension or dysrhythmias.
• 4. Avoid taking temperatures via
the rectum.

59. 5. Initiate
aneurysm
precautions
• Maintain the client on bed rest in a semi-
Fowler’s or a side-lying position.
• Maintain a darkened room (subdued lighting and
avoid direct, bright, artificial lights) without
stimulation (a private room is optimal).
• Provide a quiet environment (avoid activities or
startling noises); a telephone in the room is not
usually allowed.
• Reading, watching television, and listening to
music are permitted, provided that they do not
overstimulate the client.
• Limit visitors.

60. 5. Initiate
aneurysm
precautions
• Maintain fluid restrictions.
• Provide diet as prescribed; avoid stimulants in
the diet.
• Prevent any activities that initiate the Valsalva
maneuver (straining at stool, coughing); provide
stool softeners to prevent straining.
• Administer care gently (such as the bath, back
rub, range of motion). ▪ Limit invasive
procedures.
• Maintain normothermia.

61. 5. Initiate
aneurysm
precautions
• Prevent hypertension.
• Provide sedation.
• Provide pain control.'
• Administer prophylactic antiseizure medications.
• Provide deep vein thrombosis (DVT) prophylaxis
as prescribed

62. Seizures

63. A. Description
• 1. Seizures are an abnormal, sudden, excessive discharge of
electrical activity within the brain.
• 2. Epilepsy is a disorder characterized by chronic seizure activity and
indicates brain or CNS irritation.
• 3. Causes include genetic factors, trauma, tumors, circulatory or
metabolic disorders, toxicity, and infections.
• 4. Status epilepticus involves a rapid succession of epileptic spasms
without intervals of consciousness; it is a potential complication that
can occur with any type of seizure, and brain damage may result.

64. B. Types of
seizures
• Generalized Seizures
• Tonic-Clonic
• Tonic-clonic seizures may begin with an aura.
• The tonic phase involves the stiffening or rigidity of the muscles of the
arms and legs and usually lasts 10 to 20 seconds, followed by loss of
consciousness.
• The clonic phase consists of hyperventilation and jerking of the
extremities and usually lasts about 30 seconds.
• Full recovery from the seizure may take several hours.

65. • Absence
• A brief seizure that lasts seconds, and the individual may or
may not lose consciousness.
• No loss or change in muscle tone occurs.
• Seizures may occur several times during a day.
• The victim appears to be daydreaming.
• This type of seizure is more common in children.

66. • Myoclonic
• Myoclonic seizures present as a brief generalized
jerking or stiffening of extremities.
• The victim may fall from the seizure.

67. • Atonic or Akinetic (Drop Attacks)
• An atonic seizure is a sudden momentary loss of
muscle tone.
• The victim may fall as a result of the seizure.

68. • Partial Seizures
• Simple Partial
• ▪ The simple partial seizure produces sensory
symptoms accompanied by motor symptoms that
are localized or confined to a specific area.
• ▪ The client remains conscious and may report an
aura.

69. • Partial Seizures
• Complex Partial
• ▪ The complex partial seizure is a psychomotor seizure.
• ▪ The area of the brain most usually involved is the
temporal lobe.
• ▪ The seizure is characterized by periods of altered
behavior of which the client is not aware.
• ▪ The client loses consciousness for a few seconds.

70. C.
Assessment
• 1. Seizure history
• 2. Type of seizure
• 3. Occurrences before, during, and after the
seizure
• 4. Prodromal signs, such as mood changes,
irritability, and insomnia
• 5. Aura: Sensation that warns the client of the
impending seizure
• 6. Loss of motor activity or bowel and bladder
function or loss of consciousness during the
seizure
• 7. Occurrences during the postictal state, such as
headache, loss of consciousness, sleepiness, and
impaired speech or thinking

71. D.
Interventions
• Note: If the client is having a seizure,
maintain a patent airway. Do not force the
jaws open or place anything in the client’s
mouth.
• 1. Note the time and duration of the seizure.
• 2. Assess behavior at the onset of the seizure:
If the client has experienced an aura, if a
change in facial expression occurred, or if a
sound or cry occurred from the client.
• 3. If the client is standing or sitting, place the
client on the floor and protect the head and
body.
• 4. Support airway, breathing, and circulation.
• 5. Administer oxygen.

72. D.
Interventions
• 6. Prepare to suction secretions.
• 7. Turn the client to the side to allow
secretions to drain while maintaining the
airway.
• 8. Prevent injury during the seizure.
• 9. Remain with the client.
• 10. Do not restrain the client.
• 11. Loosen restrictive clothing.

73. D.
Interventions
• 12. Note the type, character, and progression
of the movements during the seizure.
• 13. Monitor for incontinence.
• 14. Administer intravenous medications as
prescribed to stop the seizure.
• 15. Document the characteristics of the
seizure.
• 16. Provide privacy.
• 17. Monitor behavior following the seizure,
such as the state of consciousness, motor
ability, and speech ability.

74. D.
Interventions
• 18. Instruct the client about the
importance of lifelong medication and the
need for follow-up determination of
medication blood levels.
• 19. Instruct the client to avoid alcohol,
excessive stress, fatigue, and strobe lights.
• 20. Encourage the client to contact
available community resources, such as
the Epilepsy Foundation of America.
• 21. Encourage the client to wear a
MedicAlert bracelet.

75. Stroke (Brain Attack)

76. A. Description
• 1. A stroke or brain attack manifests as a
sudden focal neurological deficit and is
caused by cerebrovascular disease.
• 2. Cerebral anoxia lasting longer than 10
minutes causes cerebral infarction with
irreversible change.
• 3. Cerebral edema and congestion cause
further dysfunction.
• 4. Diagnosis is determined by a CT scan,
electroencephalography, cerebral
arteriography, and MRI. In most facilities,
the type of stroke needs to be determined
within a certain time frame after arrival in
order for timely treatment to be initiated.

77. A. Description
• 5. Transient ischemic attack may be a warning sign of an
impending stroke.
• 6. The permanent disability cannot be determined until
the cerebral edema subsides.
• 7. The order in which function may return is facial,
swallowing, lower limbs, speech, and arms.
• 8. Carotid endarterectomy is a surgical intervention
used in stroke management; it is targeted at stroke
prevention, especially in clients with symptomatic
carotid stenosis.
• 9. The National Institutes of Health through the
National Institute of Neurological Disorders and Stroke
(NINDS) developed the Know Stroke: Know the Signs.
Act in Time campaign devised to help educate the
public about the symptoms of stroke and the
importance of getting to the hospital quickly.

78. B. Causes
• 1. Thrombosis
• 2. Embolism
• 3. Thrombotic and embolic strokes are classified as ischemic strokes.
• 4. Hemorrhage from rupture of a vessel; classified as a hemorrhagic
stroke
• 5. Manifestations of different types of stroke are similar and, therefore
it is critical to determine the type of stroke occurring; the type cannot
be determined solely based on manifestations, and the correct and
appropriate treatment for the stroke type must be initiated.

79. C. Risk factors
1.
Atherosclerosis
2. Hypertension
3.
Anticoagulation
therapy
4. Diabetes
mellitus
5. Stress 6. Obesity
7. Oral
contraceptives

80. D.
Assessment Frontal Lobe
• Broca’s area for
production of
speech
• Morals,
emotions,
reasoning and
judgment,
concentration,
and abstraction
Parietal Lobe
• Interpretation
of taste, pain,
touch,
temperature,
and pressure
• Spatial
perception
Temporal Lobe
• Auditory center
• Wernicke’s area
for
comprehension
of speech

81. D.
Assessment
Occipital Lobe
•Visual area
Limbic System
•Emotional and visceral
patterns for survival
•Learning and memory

82. Assessment
Findings
in
a
Stroke
Agnosia
• The inability to recognize familiar objects or
persons
Apraxia
• Called dyspraxia if the condition is mild
• Characterized by loss of ability to execute or
carry out skilled movements or gestures,
despite having the desire and physical ability
to perform them
Hemianopsia
• Blindness in half the visual field

83. Assessment
Findings
in
a
Stroke
Homonymous Hemianopsia
• Loss of half of the field of view on the same side
in both eyes
Neglect Syndrome (Unilateral Neglect)
• Client unaware of the existence of her or his
paralyzed side
Proprioception Alterations
• Altered position sense that places the client at
increased risk of injury
• Pyramid Point: With visual problems, the client
must turn the head to scan the complete range
of vision.

84. Assessment Findings in a Stroke
A critical factor in the early
intervention and treatment of stroke
is the accurate identification of
stroke manifestations and
establishing the onset of the
manifestations.
Stroke screening scales may be used
to identify stroke manifestations
quickly. Identification of the type of
stroke occurring is critical in
determining the appropriate
treatment, and this is usually done
using imaging such as a CT scan.

85. Assessment Findings
• 1. Assessment findings depend on the area of the brain affected;
stroke scales such as the NIH Stroke Scale may be used by the health
care facility for assessment.
• 2. Lesions in the cerebral hemisphere result in manifestations on the
contralateral side, which is the side of the body opposite the stroke.
• 3. Airway patency is always a priority.
• 4. Pulse (may be slow and bounding)
• 5. Respirations (Cheyne-Stokes)
• 6. Blood pressure (hypertension)

86. Assessment
Findings
7. Headache, nausea, and vomiting
8. Facial drooping
9. Nuchal rigidity
10. Visual changes
11. Ataxia
12. Dysarthria

87. Assessment
Findings
13. Dysphagia
14. Speech changes
15. Decreased sensation to pressure, heat, and
cold
16. Bowel and bladder dysfunctions
17. Paralysis

88. E. Aphasia
• 1. Expressive
• a. Damage occurs in Broca’s area of
the frontal brain.
• b. The client understands what is
said but is unable to communicate
verbally.
• 2. Receptive
• a. Injury involves Wernicke’s area
in the temporoparietal area.
• b. The client is unable to
understand the spoken and often
the written word.
• 3. Global or mixed: Language
dysfunction occurs in expression and
reception.

89. 4.
Interventions
for
aphasia • a. Provide repetitive directions.
• b. Break tasks down to 1 step at a time.
• c. Repeat names of objects frequently used.
• d. Allow time for the client to communicate.
• e. Use a picture board, communication board, or
computer technology.

90. F.
Interventions
during
the
acute
phase
of
stroke
• 1. Maintain a patent airway and administer oxygen as
prescribed.
• 2. Monitor vital signs.
• 3. Usually a blood pressure of 150/100 mm Hg is
maintained to ensure cerebral perfusion.
• 4. Suction secretions to prevent aspiration as
prescribed, but never suction nasally or for longer
than 10 seconds to prevent increased ICP.
• 5. Monitor for increased ICP, because the client is
most at risk during the first 72 hours following the
stroke.
• 6. Position the client on the side to prevent
aspiration, with the head of the bed elevated 15 to 30
degrees as prescribed.

91. F.
Interventions
during
the
acute
phase
of
stroke
• 7. Monitor level of consciousness, pupillary response,
motor and sensory response, cranial nerve function,
and reflexes.
• 8. Maintain a quiet environment.
• 9. Insert a urinary catheter as prescribed.
• 10. Administer intravenous fluids as prescribed.
• 11. Maintain fluid and electrolyte balance.
• 12. Prepare to administer anticoagulants, antiplatelets,
diuretics, antihypertensives, and antiseizure
medications as prescribed depending on the type of
stroke that has been diagnosed.
• 13. Establish a form of communication.

92. G. Interventions in
the post-acute
phase of a stroke
• 1. Continue with interventions from
the acute phase.
• 2. Position the client 2 hours on the
unaffected side and 20 minutes on
the affected side; the prone
position may also be prescribed.
• 3. Provide skin, mouth, and eye
care.
• 4. Perform passive range-of-motion
exercises to prevent contractures.
• 5. Place antiembolism stockings on
the client; remove daily to check
skin.

93. G. Interventions in
the post-acute
phase of a stroke
• 6. Monitor the gag reflex and ability
to swallow.
• 7. Provide sips of fluids and slowly
advance diet to foods that are easy
to chew and swallow.
• 8. Provide soft and semisoft foods
and flavored, cool or warm,
thickened fluids rather than thin
liquids, because the stroke client
can tolerate these types of food
better; speech therapists may do
swallow studies to recommend
consistency of food and fluids.

94. G. Interventions in
the post-acute
phase of a stroke
• 9. When the client is eating,
position the client sitting in a chair
or sitting up in bed, with the head
and neck positioned slightly forward
and flexed.
• 10. Place food in the back of the
mouth on the unaffected side to
prevent trapping of food in the
affected cheek.

95. H. Interventions in the chronic phase of
stroke
• 1. Neglect syndrome
• a. The client is unaware of the existence of her or his paralyzed side
(unilateral neglect), which places the client at risk for injury.
• b. Teach the client to touch and use both sides of the body.
• 2. Hemianopsia
• a. The client has blindness in half of the visual field.
• b. Homonymous hemianopsia is blindness in the same visual field of
both eyes.
• c. Encourage the client to turn the head to scan the complete range of
vision; otherwise, she or he does not see half of the visual field.

96. H. Interventions in the chronic phase of
stroke
• 3. Approach the client from the unaffected side.
• 4. Place the client’s personal objects within the visual field.
• 5. Provide eye care for visual deficits.
• 6. Place a patch over the affected eye if the client has diplopia.
• 7. Increase mobility as tolerated.
• 8. Encourage fluid intake and a high-fiber diet.
• 9. Administer stool softeners as prescribed.
• 10. Encourage the client to express her or his feelings.

97. H. Interventions in the chronic phase of
stroke
• 11. Encourage independence in activities of daily living.
• 12. Assess the need for assistive devices such as a cane, walker, splint, or
braces.
• 13. Teach transfer technique from bed to chair and from chair to bed.
• 14. Provide gait training.
• 15. Initiate physical and occupational therapy for assessment and the need for
adaptive equipment or other supports for self-care and mobility.
• 16. Refer client to a speech and language pathologist as prescribed.
• 17. Encourage the client and family to contact available community resources.