NCLEX RN Preparation Program Neurologic Disorders Module 5, Part 1 of 3 Brain Attack (Cardiovascular Accident/CVA or Stroke) Thrombosis – most common Embolus Small vessel occlusion (lacunar) Hemorrhage Aneurysm Hypertension Blood thinners.
Download ReportTranscript NCLEX RN Preparation Program Neurologic Disorders Module 5, Part 1 of 3 Brain Attack (Cardiovascular Accident/CVA or Stroke) Thrombosis – most common Embolus Small vessel occlusion (lacunar) Hemorrhage Aneurysm Hypertension Blood thinners.
NCLEX RN Preparation Program Neurologic Disorders Module 5, Part 1 of 3 1 Brain Attack (Cardiovascular Accident/CVA or Stroke) Thrombosis – most common Embolus Small vessel occlusion (lacunar) Hemorrhage Aneurysm Hypertension Blood thinners (coumadin, heparin) 2 Clinical Manifestations Headache (25%) Nausea, Vomiting Aphasias Paresis Hemianopsia Dysarthria Dysphagia 3 Collaborative Care Aspirin? Vitamin K? Oxygen Anti-convulsants Blood pressure control Thrombolytics 4 Prevent Re-bleed (hemorrhage) 24-48 hours post hemorrhage 7-10 days post hemorrhage Keep BP low Head up Vitamin K (Aquamephyton)? 5 Clipping and Coiling Clipping: The most common surgical treatment for a cerebral aneurysm involves placing a metal clip around the neck of the aneurysm to prevent rupture Coiling: Endovascular therapy in which a neuroradiologist passes a catheter through an artery and deposits detachable platinum coils in the aneurysm. This prevents bleeding and protects against subarachnoid hemorrhage. Web resource: http://www.mayoclinic.org/cerebralaneurysm/treatment.html 6 Prevent Vasospasm Nimodipine (Nimotop) Triple H Therapy Hypertension Hypervolemia Hemodilution 7 Monitor Airway Aspiration pneumonia Cerebral edema Motor/Sensory changes Psychosocial Swallowing Skin, incontinence Monitor fluid/electrolyte balance 8 Intervene Position Activity Prevent complications Communication Environment 9 Teach Prevention Hypertension S&S Stroke Early treatment Healthy lifestyle Treat Transient Ischemic Attack (TIA) 10 Seizures Prodromal phase Aural phase Ictal phase Manifestations seen Postictal phase 11 Generalized Seizures Tonic/clonic Absence Myoclonic Atonic 12 Partial Seizures Complex AKA psychomotor AKA temporal lobe Simple 13 Nursing Care Onset Movements Airway Position Teach 14 Collaborative Management Anti-seizure medication Monitor serum levels Toxic effects Alcohol Status epilepticus Airway Lorazepam (Ativan) 15 Traumatic Brain Injury Open Closed Photo Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program, http://training.seer.cancer.gov/index.html 16 Open Head Injuries Linear skull fracture Depressed skull fracture Open fracture Basilar skull fracture 17 Basilar Skull Fracture Watch! Clear nasal or ear drainage Battle Sign Raccoon sign 18 Closed Head Injury - Concussion Signs & Symptoms Brief loss of consciousness Amnesia Headache Post-concussive syndrome Persistent headache Lethargy Personality/intellectual changes Decreased attention span 19 Brain Contusion Coup Contrecoup Signs 20 Brain Lacerations Epidural hematoma Brief loss of consciousness Period of lucidity Rapid decrease in LOC Watch! pupils, extremity movements Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp 21 Subdural Hematoma Acute Subacute Chronic Signs & Symptoms Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp 22 Cerebral Edema Brain tissue + Blood + CSF CPP = MAP - ICP Autoregulation Chemical autoregulation 23 Assessment for Edema LOC Orientation Pupils Motor Vital Signs 24 Diagnostic Tests CT scan EEG ABGs Electrolytes CBC Osmolality Lumbar Puncture? Photo Courtesy of the Indian Health Service/U.S. Department of Health and Human Services. 25 Craniotomy Postoperative assessment Peri-orbital edema, ecchymosis Strict I&O Positioning Dressing Drainage 26 Monitor Sodium Levels Low Na+ = salt wasting syndrome 3% saline High Na+ = Diabetes insipidus 0.45% saline 27 Postoperative Complications Increased ICP Hematomas Hydrocephalus Respiratory problems Wound infection Meningitis Fluid/electrolyte imbalances 28 Intracranial Pressure CSF leaks Head up Body in neutral alignment Control pCO2 Prevent hypoxia Suction airway? Sedation 29 Intracranial Pressure (continued) Intubated – paralytics Barbiturate coma Anticonvulsants Diuretic therapy Prevent hyperthermia Manage osmolality Ventricular drainage Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp 30 Spinal Cord Injury Prevention Common areas injured Photo Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD) http://images.niams.nih.gov/SearchResults.cfm?start=All 31 Types of Lesions Complete Incomplete Central cord syndrome Anterior cord syndrome Brown-Sequard syndrome Cauda equina 32 Area Cause Sensory Loss Central Cord Hyperextension pain & Upper temp below extremities injury Lower extremity motor Anterior Cord Flexion Pinprick, temp Complete motor loss Position, proprioception, vibration, deep pressure BrownKnife, Sequard bullet Complete loss opposite side Complete loss same side Bowel, bladder, walk with assist Cauda equina Perineal anesthesia Areflexic bowel, bladder Upper extremities, thorax 33 Lumbar disk herniation Motor Loss Intact Initial Assessment/Care Stabilize neck/back Watch! Respiratory failure C2-3 Assess Motor signs Assess Sensory signs Incontinence Superficial signs Pain 34 Spinal Shock Flaccid paralysis below injury Bradycardia Hypotension 35 Ongoing Assessment ABCs Bleeding Glasgow Coma Scale Motor/sensory status http://www.meddean.luc.edu/lumen/MedEd/ GrossAnatomy/learnem/dermat/main_der. htm 36 Glasgow Coma Scale 37 Collaborative Management Neurological Methylprednisolone (Solu-Medrol) Traction Log roll Treat spasticity, pain 38 Collaborative Mgmt - Circulation Bradycardia – atropine Hypotension – dopamine Fluids/blood products Vasovagal response Fluid/electrolyte imbalances Promote blood return 39 Collaborative Mgmt - Oxygen Lesions above C4 Pulmonary “toilet” Aspiration prevention Bronchodilators 40 Collaborative Mgmt - Nutrition Paralytic ileus Stress ulcers Histamine-2 blockers Total parenteral nutrition Constipation 41 Collaborative Mgmt Temperature Poikilothermia Control room temperature Warming measures Cooling measures 42 Collaborative Mgmt - Renal Bladder reflex loss Calcium stones Urinary tract infection 43 Skin-tissue Integrity Kinetic beds Inspect skin – Where? Protective devices Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp 44 Psychosocial Care What to expect Hope, reassurance Verbalize feelings Fear of the unknown: be accurate Touch areas with sensation Offer stimulation 45 Autonomic Dysreflexia Injuries above T6 Late complication Causes Signs, symptoms Prevention Treatment 46 Bacterial Meningitis Nuchal rigidity Brudzinski’s sign Kernig’s sign Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp 47 Meningitis Chills and high fever Vomiting Signs of increased intracranial pressure Photophobia Petechial rash Diplopia (double vision) Seizures 48 Diagnosis CSF: ↑ pressure, ↑ protein, cloudy, ↓ glucose High WBC Blood cultures Sodium 49 Collaborative Management Assess for neurologic deterioration Respiratory isolation x 24 hours Seizure precautions Antibiotics Dark room Headache Hydration 50 Monitor for Complications Septic emboli in circulation to hands Septic shock Coagulation disorders Prolonged temperature elevations 51 Parkinson Disease Bradykinesia Muscle rigidity Stooped posture Shuffling, propulsive gait Tremor 52 Collaborative Care Levodopa Carbidopa Amantadine Catechol Drug tolerance Drug holiday 53 Nursing Care Mobility Nutrition Aspiration precautions Assistive devices 54 Alzheimer’s Disease Chronic, progressive, degenerative brain disorder affecting: Memory Cognition Ability to care for self 55 Collaborative Management Aricept Reminyl Exelon Namenda 56 Nursing Care Cognitive stimulation Structure environment Prevent over-stimulation Provide consistency Promote independence Promote bowel, bladder continence Assist with facial recognition 57 Promote Communication Attract patient’s attention before talking Avoid environmental distractions Speak directly to patient, distinctly and in clear, short sentences Ask patient to perform one task at a time, giving plenty of time & breaking down into small steps 58 Myasthenia Gravis Varying levels of generalized weakness Extra-ocular muscle weakness: Diplopia Ptosis Weak eye closure 59 Diagnosis Acetylcholine receptor antibodies CT scan IV Tensilon and Prostigmin EMG 60 Collaborative Management Mestinon Prostigmin Cholinergic crisis Myasthenic crisis Teach 61 Guillain-Barré Syndrome Ascending weakness Acute respiratory failure Descending weakness? 62 Management Immune globulin Plasmapheresis Respiratory support Communication 63 Multiple Sclerosis Manifestations Fatigue Weakness Leg spasticity Intention tremor Dysmetria, dysdiadochokinesia Tinnitus, vertigo, hearing loss Vision changes 64 Manifestations (continued) Sensory: Hypalgesia (decreased sensitivity to pain), paresthesia, facial pain, decreased temperature sensation, numbness, tingling, burning or crawling sensations Psychosocial: Often anxious with emotional lability 65 Collaborative Management Medications to delay, decrease exacerbations Physical, speech therapy Warm packs, stretching Minimize fatigue Teach fall precautions 66 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery. 67