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PLANNING
IMPLEMENTATION
EVALUATION
Outline of the lecture
Cerebrovascular Accidents
Outline of the lecture
Degenerative disorders-
NON-demyelinating
Alzheimer’s disease
Parkinson’s disease
Outline of the lecture
Infectious Disease
Meningitis
Brain abscess
Encephalitis
IMPLEMENTATION PHASE
Seizures
Spinal shock
Cognitive impairment
Bowel incontinence
IMPLEMENTATION PHASE
Disturbed sensory
perception
A. CEREBRAL DISORDERS C. PERIPHERAL NERVOUS SYSTEM
Epilepsy DISORDERS
Seizures Lower Back Pain
Brain Tumors Trigeminal Neuralgia
Cerebrovascular Disease Bell’s Palsy
Brain Infections Vascular Spinal Cord Lesions
Headaches Disorders of the Peripheral Nerves
B. DEGENERATIVE NEUROLOGIC
DISORDERS
Dementia (Alzheimers)
D. NEUROLOGIC TRAUMA
Parkinson’s Disease Spinal Cord Injury
Creutzfeldt-Jakob Disease Head Injury
Huntington’s Disease
Multiple Sclerosis
Guillain Barre Syndrome
Myasthenia Gravis
Amyotrophic Lateral Sclerosis
Anatomy and Physiology
Gross anatomy
The nervous system is divided into the central and peripheral nervous
system
Control all motor, sensory, autonomic, cognitive and behavioral activities.
The Central nervous system consists of the BRAIN and the SPINAL
CORD
The peripheral nervous system consists of the SPINAL NERVES and
CEREBELLUM
Cerebrum
consists of the :
Thalamus- the relay center of all sensory input
Hypothalamus- center for endocrine regulation,
Includes:
Peripheral sensory nerves transmit stimuli from
sensory receptors in the skin, muscles, sensory
organs, & the viscera to the dorsal horn of the spinal
cord
The upper motor neurons of the brain & the lower
motor neurons of cell bodies in the ventral horn of
the spinal cord carry impulses that affect the
movement
Autonomic Nervous System
functions
Resposible for the rest & digest response
or nervous system is the body’s communication network
it coordinates and organizes the functions of all other body systems
NERVOUS SYSTEM
Sympathetic Nervous
Somatic Nervous Autonomic Nervous System
System System
Parasympathetic
Nervous System
the NEURON or NERVE CELL is the nervous system’s
fundamental unit
this highly specialized conductor cell receives and
transmits electrochemical nerve impulses
6. Enkephalin,endorphin
Major Neurotransmitters
NEUROTRANSMITTER SOURCE ACTION
HISTORY
Initial interview provides excellent opportunity
to explore the current condition and events
while observing appearance, mental status,
posture, movement and affect.
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
Verbal responsiveness
Motor responsiveness
Vital signs
CEREBRAL FUCTION
No ZERO score
Glasgow Coma Scale
4=Spontaneous
3=To voice
2=To pain
1=None (No response)
Glasgow Coma Scale
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)
identification
Repeat with the other nostrils
mastication
Assess corneal reflex
Cranial Nerve Function: Cranial Nerve 7 -
facial
CEREBRAL FUNCTION
Includes level of consciousness,
intellectual function, speech, speech,
memory, patterns of emotional
behavior, balance & coordination
DESCRIBING LEVEL OF CONCIOUSNESS
- responds to stimuli
CONFUSION – has short attention span & misinterpret
information
- disoriented to time, place, person & has trouble
following commands, but still responds to stumuli
DESCRIBING LEVEL OF CONSCIOUSNESS
confused
- stays awake only if he’s continously stimulated
LIGHT STUPOR – does not respond to stimuli, withdraws
quickly & forcefully from moderate pain which he can localize
DEEP STUPOR – responds only to a strong stimulus, when he
can’t localize
- may note decerebrate posture
DESCRIBING LEVEL OF CONSCIOUSNESS
direction
Assessing the motor function of the
brainstem
Brachioradialis
Patellar
Anal
Pathologic/primitive 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
Brudzinski & kernig’s sign – meningeal irritation in meningitis
Grading of reflexes
Deep tendon reflex
0- absent
+ present but diminished
++ normal
+++ increased
++++ hyperactive or clonic
Superficial reflex
0 absent
+present
DIAGNOSTIC TESTS
It takes 45 to 60 mins
Nursing interventions to patient undergoing
EEG
Assess the patient for allergy to iodine and shellfish because the agent
is iodine based
IV line is needed for the contrast flushing
Assess for the S/Sx of allergy like flushing, nausea & vomiting
DIAGNOSTIC TESTS
MRI
Uses magnetic waves
Cerebral arteriography
Note allergies to dyes, iodine and
seafood
Ensure consent
Cerebrospinal Analysis
Normal – clear & colorless
Cerebral contusion, laceration,
Stroke
Inflammatory lesions
Brain tumor
Surgical complications
Increased Intracranial pressure
Pathophysiology
The cranium only contains the brain substance (1400g), the
CSF (75mL) and the blood/blood vessels (75 ml)
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 ICP from any cause decrease cerebral perfusion,
stimulates further swelling and may shift brain tissue through
openings in the rigid dura, resulting herniation
Increased Intracranial pressure
Pathophysiology
Decompensatory mechanisms:
1. Decreased cerebral perfusion
2. Decreased O2 leading to brain hypoxia
3. Cerebral edema
4. Brain herniation
Decreased cerebral blood flow
CLINICAL PICTURE:
Subtle to dramatic changes in LOC; restlessness,
confusion, drowsiness, stupor, coma
Double or blurred vision, headache, nausea\ and
vomiting, photosensitivity
Decreased motor function
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
FOCUSED ASSESSMENT
Assess neuro status
Assess cranial nerves as condition allows
to 2 passes
Maintain O2 sat at 100%
Increased ICP
Nursing interventions
3. Administer prescribed medications- usually
Nursing interventions
4. Reduce environmental stimuli
Nursing interventions
6. Keep head on a neutral position. AvOID-
extreme flexion, valsalva
7. monitor for secondary complications
metabolic derangement
Disruption in the neuronal transmission
Assessment
Orientation to time, place and person
Motor function
Decerebrate
Decorticate
Sensory function
Altered level of consciousness
Etiologic Factors
1. Head injury
2. Stroke
3. Drug overdose
4. Alcoholic intoxication
5. Diabetic ketoacidosis
6. Hepatic failure
Altered level of consciousness
ASSESSMENT
1. Behavioral changes initially
Nursing Intervention
1. Maintain patent airway
Elevate the head of the bed to 30 degrees
Suctioning
etc.
Altered level of consciousness
Nursing Intervention
3. Maintain fluid and nutritional balance
Input and 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
LOC or disorientation
Cyanosis/apnea
CLINICAL PICTURE
Difficulty in arousing
ETIOLOGIC FACTORS
1. Idiopathic
2. Fever
3. Head injury
4. CNS infection
5. Metabolic and toxic conditions
SEIZURE
6 types of seizures:
Simple partial-sensory symptoms (flashing lights, smells,
auditory hallucinations)
Autonomic symptoms (sweating, flushing, pupil dilation)
Altered LOC
Amnesia
Absence seizure
A brief change in LOC indicated by blinking or rolling of the eyes,
a blank stare, and a slight mouth mov’t
SEIZURE
Myoclonic seizure
Brief involutary muscular jerks of the body or extremities
Nursing Interventions
During seizure
1. remove harmful objects from the patient’s
surrounding
2. ease the client to the floor
Nursing Interventions
During seizure
5. loosen constrictive clothing
Nursing Interventions
POST seizure
1. place patient to the side to drain
secretions and prevent aspiration
2. help re-orient the patient if confused
TYPES OF HEADACHE:
1. Primary headache- no organic cause
2. Secondary headache- with organic cause
3. Migraine headache/throbbing vascular headache-periodic attacks of
headache due to vascular disturbance
Affect 10% of Americans
Begin in childhood or adolescence & recur throughout adulthood
Tend to run in families w/c are common in women than men
4. Tension headache-the most common type- due to muscle tension
CAUSES OF HEADACHE
Emotional stress or fatigue
Menstruation
Glaucoma
Systemic disease
HPN
Head trauma/tumor
Intracranial bleeding
headache
“hatband” distribution
HEADACHE
INTRACRANIAL BLEEDING
Neuro deficits, such as paresthesia & muscle weakness
Unrelieved by opiods
HEADACHE
TUMOR
Pain that’s most severe when the patient is awake
headache
Nursing Interventions
1. Avoid precipitating factors
2. modify lifestyle
Beta-blockers
Serotonin antagonists- “triptan"
Autonomic Dysreflexia/hyperreflexia
Seen commonly in spinal cord injury
An exaggerated response by the
DIAGNOSTIC TESTS
1. Skull x-ray
2. ventriculography – x ray exam of the ventricles of the
brain after the introduction of the introduction of the contrast
medium, such as air or radiopaque material; has been
replaced by ct scan & MRI
CONGENITAL DISORDERS:
Hydrocephalus
Nursing Intervention
1. monitor neurologic status
minutes to hours
Traumatic brain injury
2. CONTUSION
Involves structural damage
2. CSF otorrhea
3. CSF rhinorrhea
IVF therapy
Assess bladder
Post-traumatic seizures
Impaired ventilation
Spinal cord injury
The most frequent vertebrae – C5-C7, T12 and L1
Concussion
Contusion
Compression
Transection
is trauma to the spinal cord which results
In complete (transection) or partial disruption
Nerve tracts & neurons
The level of cord involved dictates the
consequences of spinal cord injury
Risk factors:
• male
• High risk lifestyle activities
• Active in sports
• Age (teen to early 20’s)
• Alcohol and/or drug abuse
After an injury
Warm/dry extremities
2. quadriplegia
3. spinal shock
are classified according to cause, level of injury and degree of disruption produced
1. Glucocorticoids: Decadron
DIAGNOSTIC TESTS/LABORATORY 2. Vasopressors:
1. History & physical examination Norepinephrine,dopamine
2. X-rays 3. Muscle relaxants: methocarbamol
3. MRI 4. Anti-spasmodics:dantrolene
4. CT Scan sodium
5. Electromyography 5. Analgesics:opioid & non opioid
COMPLICATION
NSAIDS
1. Paralysis 6. Antidepressants
2. Autonomic dysreflexia 7. Histamine H2 receptor antagonists
3. Neurogenic shock (spinal shock) 8. Anticoagulant
4. Contractures 9. Stool softeners
5. Muscle atrophy 10. vasodilators
6. Pressure ulcers
7. Stool impaction
8. Death
NURSING MANAGEMENT
Communication loss
Dysarthria= difficulty in speaking
Aphasia= Loss of speech
Apraxia= inability to perform a previously learned action
CEREBROVASCULAR ACCIDENTS: Ischemic
Stroke
Perceptual disturbances
Hemianopia
Sensory loss
paresthesia
RISKS FACTORS
Non-modifiable Modifiable
Advanced age Hypertension
race Obesity
Smoking
Diabetes mellitus
hypercholesterolemia
CEREBROVASCULAR ACCIDENTS: Ischemic
Stroke
DIAGNOSTIC test
1. CT scan
2. MRI
3. Angiography
CEREBROVASCULAR ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
1. 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
2. Hemorrhagic: there is extravasation of blood in the brain; causes: are
intracerebral hemorrhage, subarachnoid hemorrhage,cerebral aneurysm &
arteriovenous malformation
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
Destruction (infarction) of brain cells caused by a reduction in
oxygen supply.
Symptoms depend on the area of the brain involved and extent of damage; may be
masked or delayed because of compensatory collateral circulation through the circle of
Willis.
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
General manifestations
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
Classified using the time course in the following manner:
1. Transient Ischemic Attack (TIA)
3. Stroke in evolution
This indicates no further progression of the hypoxic insult to the brain from this particular ischemic
attack
2. Objective:
a.Convulsions
b.Hemiplegia on side opposite the lesion (initially flaccid then spastic)
COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES
Left Hemispheric Stroke Right Hemispheric Stroke
Paralysis /weakness on R side Paralysis/weakness on L side of the body
of the body Left visual field deficit
Right visual field deficit Spatial-perceptual deficits
Aphasia (expressive,receptive, Increased distractibility
Or global) Impulsive behavior and poor judgment
Altered intellectual ability Lack of awareness of deficits
Slow, cautious behavior
CLINICAL FINDINGS OF CVD:
c. Aphasia: brain unable to fulfill its communicative functions because of damage to input,
integrative, or output centers.
f. Alterations in reflexes
g. Altered bladder and bowel function
3. Monitor vital signs; avoid using affected extremity for BP because it may produce falsely lowered
readings.
4.Maintain patency of the airway by positioning, suctioning, and inserting an artificial airway.
5.Provide for drainage and expansion of lungs with head turned to side; provide oxygen as necessary.
8. Assist client and family to set realistic goals; provide encouragement and praise.
9.Accept and explore feelings of fear, anger, and depression; accept mood swings and emotional
outburst.
10.Provide frequent oral hygiene; use artificial tears if blink reflex is
absent.
15.Provide tube feedings if swallowing and gag reflexes are depressed or absent.
16.Provide food in a form that is easily swallowed (mechanical soft, puree, thickening products);
encourage intake of nutrient- dense foods; when client is capable of chewing, introduce dietary fiber
to promote normal bowel function.
17. Assist with feeding (e.g. use a padded spoon handle; feed on the unaffected side of mouth; fed in
as close to a sitting position as possible)
21.Create environment that keeps sensory monotony to a minimum; orient to time and place,
increase social contacts, provide visual stimuli, extend environment.
22. Provide for self-esteem; encourage wearing own clothes, doing self-care activities, making
decisions.
23.Help with adjustment to altered body image and self-esteem.
THANK YOU!