Transcript Chapter 47

Care of Patients with Neurologic
Problems
Brain Injury, Intracranial
Pressure, CVA, and Seizures
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Brain Injury
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Blow or jolt to head
May be result of head penetration by foreign
object
May be classified as Primary or Secondary
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Primary Brain Injury
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Open vs. closed head injuries
Mild, moderate, severe classification
Fractures
Concussion
Laceration
Contusion
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Coup and Contrecoup Injury
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Acceleration-Deceleration Injury
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Secondary Brain Injury
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Negative patient outcomes
Physiologic, vascular, and biochemical
events
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Epidural Hematoma
(Arterial)
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Nursing Safety Priority
Critical Rescue
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After the initial interval, symptoms progress very
quickly with potentially life-threatening ICP
elevation and structural changes. Monitor the
patient suspected of epidural bleeding frequently
(every 5-10 minutes) for changes in neurologic
status. The patient can become quickly and
increasingly symptomatic and lose
consciousness.
An epidural hematoma is a neurosurgical
emergency! Notify the health care provider or
Rapid Response Team immediately if these
changes occur. Carefully document your
assessments
and the patient's overall condition.
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Subdural Hematoma (SDH)
(Venous)
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Venous bleeding into space beneath dura and above
arachnoid
Most commonly from tearing of bridging veins within
cerebral hemispheres or from laceration of brain
tissue
Bleeding occurs more slowly, symptoms mirror those
of epidural hematoma
Highest mortality rate because often unrecognized
Chronic SDH may be misdiagnosed as “dementia” in
the elderly (UCLA Neurosurgery, 2013)
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ICP
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Normal values: 0-15 mm Hg
Abnormal pressures can occur with brain
injury/trauma and Stroke
Edema
Brain Herniation (emergent)
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Key Features of ICP
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Decreased LOC
Behavioral changes
(restlessness, irritability,
confusion)
Headache
N&V
Change in speech pattern
including aphasia and slurring.
Changes in sensorimotor
status
Widened pulse pressure
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Dilated/non-reactive pupils or
constricted/non-reactive pupils
Cranial nerve dysfunction
Ataxia
Seizures
Cushings Triad (grave sign)
Bradycardia
Severe hypertension
Abnormal posturing
(decerebrate/extensor and/or
decorticate/flexion)
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Patient-Centered Care
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Assessments
-History
-Physical Exam
-VS
-Psychosocial
-Labs
-Imaging
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Nursing Management
Interventions
-Non-Surgical
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preventing and detecting ICP
drug therapy
inducing a barbiturate coma
maintaining fluid and electrolytes
maintain nutritional status
managing sensory, cognitive, and behavioral
changes
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Nursing Management
Interventions
-Surgical
• ICP Monitoring Device
• Craniotomy (Pre and Post-op Management)
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Community-Based Care
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Home care
Community services
Safety
Patient and Family education
Self-management
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Brain Death
FOUR PREREQUESITES (American Academy of Neurology,
2010):
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Coma of known cause as established by history,
clinical examination, laboratory testing, and
neuroimaging
Normal or near-normal core body temperature
(higher than 36° C)
Normal systolic blood pressure (higher than or
equal to 100 mm Hg)
At least one neurologic examination (some states
and health care systems require two on file)
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Stroke (Brain Attack)
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Change in normal blood supply to brain
Risk factors
Causative agents:
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Hypertension
Arteriovenous malformation
Injury insult
Types:
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Ischemic
Thrombolic
Embolic
Hemorrhagic
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Risk Factors (Modifiable)
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Risk Factors That Cannot Be
Changed
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Age: Risk for stroke increases as a person gets older.
Sex: Men have a 30% higher incidence of stroke, but
postmenopausal women are also at a significantly higher risk.
Family history: If a person has a stroke, it increases the risk for
stroke in other family members.
Race: African Americans have a higher risk for stroke because of
their increased incidence of high blood pressure, obesity, and
diabetes.
Myocardial infarction (MI): A history of an MI puts the patient at
increased risk for a stroke.
History of migraine headaches: Patients who suffer from migraines
may be at higher risk for ischemic strokes.
A prior stroke: Patients who have strokes are at risk for another
stroke.
Sickle cell disease: Patients with this type of disorder are at risk for
stroke at a younger age.
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Risk Factors Altered With
Collaborative Management
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High blood pressure (HBP): HBP can be managed with a
combination of drug therapy, diet, and exercise.
High cholesterol levels: Patients with high cholesterol can reduce
their stroke risk by 30% through lifestyle changes and drug
therapy.
Cardiovascular disease: Atherosclerosis and atrial fibrillation are
major risk factors for stroke, but if diagnosed early, they can be
controlled with drug therapy.
Diabetes: Consistent diabetic control is essential to decrease the
risk for strokes.
Blood clotting disorders: Patients with clotting problems are at high
risk for thrombotic stroke and require preventive anticoagulants.
Sleep apnea: Patients with sleep apnea have 3 to 6 times the risk
for stroke. Weight loss and/or using a breathing device at night
called a continuous positive airway pressure (CPAP) machine can
manage this problem.
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Types of Stroke
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Patient-Centered Care
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Assessment
-History
-Physical Exam
-Psychosocial
-Labs
-Imaging
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Nursing Management
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Interventions
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Non-surgical
• Fibrinolytic Therapy
• Endovascular
• Monitoring for ICP
• VS
• Routine Care Considerations (mobility,
swallowing/nutrition, communication, continence,
sensory perception, skin integrity)
• Ongoing Drug Therapy
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Nursing Management
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Interventions
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Surgical
• Carotid Endarectomy
• Stenting
• Craniotomy
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Reroute vessels from occlusion
Evacuate blood
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Community-Based Care
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Community
Home Care
Self-Care Teaching
Caregiver Support
Resources
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Seizures
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A seizure is an abnormal, sudden, excessive, uncontrolled
electrical discharge of neurons within the brain that may result
in a change in level of consciousness (LOC), motor or sensory
ability, and/or behavior. A single seizure may occur for no
known reason. Some seizures are caused by a pathologic
condition of the brain, such as a tumor. In this case, once the
underlying problem is treated, the patient is often
asymptomatic.
 Epilepsy is defined by the National Institute of Neurological
Disorders and Stroke as two or more seizures experienced by
a person. It is a chronic disorder in which repeated unprovoked
seizure activity occurs. It may be caused by an abnormality in
electrical neuronal activity; an imbalance of neurotransmitters,
especially gamma aminobutyric acid (GABA); or a combination
of both (McCance et al., 2010).
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Older Adult Seizure
Considerations
Complex partial seizures are most common among
older adults (Vacca & Olson, 2007).
These seizures are difficult to diagnose because
symptoms appear similar to dementia, psychosis, or
Alzheimer's disease (AD), especially in the postictal
stage (after the seizure).
New-onset seizures in older adults are typically
associated with conditions such as
hypertension, cardiac disease, diabetes mellitus,
stroke, and Alzheimer's disease.
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Seizure Risk Factors
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Primary or Idiopathic
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genetic
Secondary
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Lesion or tumor
 Trauma
 High fever
 Metabolic disorders and electrolyte imbalances
 Stroke
 Alcohol withdrawal and substance abuse
 Heart disease
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Patient-Centered Care
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Assessment
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History
Physical Exam
Imaging (CT or MRI) used to r/o other causes
Interventions
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Non-surgical
 Surgical
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Teaching Self-Management
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Medication
Community support groups
Family and Patient education
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Seizure Precautions
Nursing Safety Priority Action Alert!
 Seizure precautions include ensuring that
oxygen and suctioning equipment with an
airway are readily available. If the patient
does not have an IV access, insert a saline
lock, especially if he or she is at significant
risk for generalized tonic-clonic seizures.
The saline lock provides ready access if IV
drug therapy must be given to stop the
seizure.
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Nursing Focused Assessment for
Seizures
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How often does the seizure occur
Description of each seizure
Whether more than one type of seizure
occurs
Sequence of seizure progression
Observation of patient during seizure
How long the seizure lasts
When the last seizure took place
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Status Epilepticus
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A medical emergency and is a prolonged
seizure lasting longer than 5 minutes or
repeated seizures over the course of 30
minutes. It is a potential complication of all
types of seizures.
Seizures lasting longer than 10 minutes
can cause death! Common causes of
status epilepticus include:
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NURSING SAFETY: PRIORITY
RESCUE
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Convulsive status epilepticus must be treated promptly and
aggressively! Establish an airway and notify the health care
provider or Rapid Response Team immediately if this
problem occurs!
Establishing an airway is the priority for this patient's care.
Intubation by an anesthesia provider or respiratory therapist
(RT) may be necessary. Administer oxygen as indicated by
the patient's condition. If not already in place, establish IV
access with a large-bore catheter, and start 0.9% sodium
chloride. The patient is usually placed in the intensive care
unit for continuous monitoring and management.
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The spouse of a patient brought to the ED states that 6 hours ago
her husband began having difficulty finding words. The patient has
since become progressively worse. He has right hemiparesis. Upon
assessing the patient, you note that he is lying flat in a supine
position and has been incontinent of urine.
What is the priority nursing intervention for this patient at this time?
A. Provide perineal care
B. Assess for gag reflex
C. Elevate the head of bed
D. Perform a linen and gown change
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(cont’d)
An hour later after a CT scan, the patient is diagnosed
with a left hemisphere stroke.
Which manifestations would you expect? (Select all that
apply)
A. Disorientation to time, place, and person
B. Inability to discriminate words and letters
C. Constant smiling
D. Intellectual impairment
E. Neglect of left visual field
F. Deficits in the right visual field
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(cont’d)
1. The patient is admitted to the acute medical
unit after 7 hours. His wife asks if her
husband will receive IV thrombolytic therapy.
What is your best response?
2. Thirty minutes later, the wife asks for a glass
of water or juice because her husband is
thirsty. What is your best response?
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(cont’d)
The patient’s wife must leave her husband’s
bedside for 2 hours to run errands.
Which nursing action is appropriate to
contribute to patient safety while she is gone?
A. Apply restraints.
B. Maintain the bed in a low position.
C. Sit with the patient until his wife returns.
D. Place the call light in the patient’s right hand.
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(cont’d)
The patient needs assistance with feeding, but can
swallow well.
To whom would it be best to delegate this
responsibility?
A. Licensed practical nurse
B. Certified nursing assistant
C. Hospital volunteer
D. Student nurse doing first patient care experience
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NCLEX Questions
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Question 1
What is the greatest risk for a patient with dysfunction of
cranial nerves IX and X?
A.
B.
C.
D.
Dehydration
Aspiration pneumonia
Constipation
Weight loss
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Question 2
Which symptom is the earliest indicator of increased
intracranial pressure?
A.
B.
C.
D.
Increased pupil size
Elevated blood pressure
Agitation and confusion
Nausea and vomiting
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