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Neurological Content Part 2
MS II
2013
Objectives
• Describe the etiology and pathophysiology of
selected neurologic disorders.
• Identify the clinical manifestations of selected
neurologic disorders.
• Explain the treatment of selected neurologic
disorders.
• Discuss the nursing priorities for managing a
patient with selected neurologic disorders.
MS II Neuro Presentation
2
Neurologic Disorders
• This chapter explores the most common
critical
care neurologic disorders as follows:
–
–
–
–
–
–
Etiology
Pathophysiology
Assessment
Diagnosis
Medical Management
Nursing Management
MS II Neuro Presentation
3
Coma
• Description
– Coma is a state of unconsciousness
• Both arousal and awareness are lacking
• Light coma
• Deep coma
• Coma is a symptom not a disease
• Need to discover underlying etiology
MS II Neuro Presentation
4
Coma
• Etiology:
• Structural Lesions / Metabolic
– Vascular Lesions, Trauma, Brain Tumors,
Abscesses, Increased ICP
– Overdoses, infections, endocrine, poisioning
MS II Neuro Presentation
5
Coma
• Etiology: Metabolic and Toxic Conditions
– Cardiopulmonary Decompensation
– Poisoning and Alcohol
– Hypertensive Encephalopathy
– Acute Hypertensive Crisis
– Meningitis
– Encephalitis
– Post-convulsion and Other
MS II Neuro Presentation
6
Coma
• Pathophysiology
– Diffuse dysfunction in cerebral hemispheres
– Diffuse or focal dysfunction in the reticular
activating system (RAS)
– Cerebral insults including:
• ischemia, infection, hypoxia, metabolic imbalance,
toxic exposure, structural disruption
– Comparable to stages of anesthesia
MS II Neuro Presentation
7
Coma
• Assessment and Diagnosis
– Diagnosis is clinical, based on LOC
– Neurological clinical assessment
– Diagnostic procedures:
• Skull x-rays, CT, MRI, LP
• Lab studies to rule out toxic or endocrine states
MS II Neuro Presentation
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Coma
• Medical Management
– Goal: identify and treat underlying cause
– Initial Management:
• Support vital functions:
– Airway, ventilation, CV function
• Prevent further neurologic deterioration
• If cause of coma not known administer:
– Thiamine
– Glucose
– Narcotic agonist
MS II Neuro Presentation
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Coma
• Medical Management
– Decision making with family
– Prognosis depends upon cause of coma
– Best prognosis seen with early arousal
MS II Neuro Presentation
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Coma
Nursing Management
 Eye care
 Temperature Control
 Coma stimulation therapy
 Monitoring for neurologic changes
 Nutrition
 Skin care
 Prevention of infection
 Maintenance of a clear airway
MS II Neuro Presentation
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Ineffective airway clearance
• Assess – high risk for airway obstruction due
to:____________________________
• __________________________________
• Inability to remove secretions-__________
• __________________________________
• Risk for atelectasis, pneumonia, aspiration,
hypoxia
MS II Neuro Presentation
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Airway - Interventions
Positioning ____________________
_
____________________
Suctioning
____________________
_________
Oxygenation____________________
____________________
_
Pulmonary hygieneMS II Neuro Presentation
13
Risk of Injury or Altered Protection
• Padded side rails
• Make sure IV lines,
drains are not
causing pressure
areas
• Meticulous skin care
MS II Neuro Presentation
14
Risk for injury
• Dignity
– Provide privacy
– Speak to the patient
during care
– Avoid negative
comments about the
patient’s condition
– Advocate for the
patient
– Do not carry on
personal conversations
around the patient
MS II Neuro Presentation
15
Risk for injury
• Avoid restraints
• If needed
– Physician’s order and
evaluation should be done
– Any form of restraint will
probably provoke
resistance from the patient
MS II Neuro Presentation
16
Fluid volume deficit
• Assess hydration____________________
• ____________________
______________
• IV fluids
• Management of a
gastrostomy tube
• Special consideration
needed!!!! r/t IV fluids or
blood transfusions____________________
MS II Neuro Presentation
17
Impaired Oral Cavity
• Assess mouth for
dryness/inflammatio
n/ and crusting
• Provide meticulous
oral care
• Risk of parotitis
• Keep lips
moist/apply
lubricant
MS II Neuro Presentation
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Risk for impaired skin
•
•
•
•
•
Regular turning
Positioning
Use splints/foam boots/trochanter rolls
Attention to heels
Apply early – air mattresses/specialty beds
MS II Neuro Presentation
19
Bowel incontinence
•
•
•
•
•
r/t neuro impairment & nutritional transitions
Assessment - _______________________
__________________________________
Problems - _________________________
__________________________________
MS II Neuro Presentation
20
Bowel Care
• Monitor _________ and ____________
• Perform ___________ examinations to assess
for _______________________
• Administer medications
• Stool softeners
• Glycerine suppository
• enemas
MS II Neuro Presentation
21
Impaired tissue integrity of cornea
r/t absent corneal
reflex or diminished
reflex
Assess for incomplete
eye closure
Interventions –
Cleanse with cotton
balls/sterile NS
Artificial tears q2h
Cold compresses
Avoid eye patches
MS II Neuro Presentation
22
Ineffective thermoregulation r/t
hypothalamic damage
•
•
•
•
•
•
•
Monitor for high fevers
Assess underlying cause and treat
Common causesMild temperature elevations-99 to 100________
Moderate – 100 – 102-________________
High – 102 and above-________________
Method of temperature monitoring-_________
MS II Neuro Presentation
23
Secondary Complications
•
•
•
•
•
•
Diabetes InsipidusWhat s/s would be watched for- _______
__________________________________
SIADH-_____________
What s/s would be watched for -________
_____________________________________
_______________________________
MS II Neuro Presentation
24
Disturbed sensory perception
•
•
•
•
Interventions
Maintain sense of daily rhythm
_________________________________
Stimulation – nurse and family establish
pattern of _________ and ___________
• Quality time at bedside – conversation,
reading books, music, aroma therapy
MS II Neuro Presentation
25
Disturbed sensory perception
•
•
•
•
Lightening of coma
Period of agitation normal
Good clinical sign
Educate family members about this
occurrence and significance
• Patient will be more aware, but still may be
unable to communicate or react appropriately
MS II Neuro Presentation
26
Disturbed sensory perception
•
•
•
•
•
Interventions
Support and protect client
Reorient patient
Provide paper materials for reorientation
Minimize stimulation – limit visitor to one at a
time
• Allow patient time to respond to verbal stimuli
MS II Neuro Presentation
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Disturbed sensory perception
• Client that is regaining consciousness
• Allow frequent rest and quiet times
• Videotapes of social events and family times
are useful for patient remember family
members, friends, and regain missed events
MS II Neuro Presentation
28
Interrupted family processes
• Assess needs/emotional state/coping ability
• Expect stages of grief and anxiety, remorse
• Prepare family, friends for patient status
during recovery, and non-curable deficits that
will have to be dealt with.
MS II Neuro Presentation
29
Brain herniation
• Cause of brain death
• Patient maintained
on life support
• Assess for organ
donation possiblity
• Clue with ICP
monitoring –
pressures will
decrease suddenly
MS II Neuro Presentation
30
Brain death
• Confusing to significant others
– Patient still has blood pressure, pulse, and some
bodily functions
– Definition – irreversible loss of all functions of the
brain including brain stem.
– This patient will have mechanical ventilation,
drugs to maintain blood pressure
MS II Neuro Presentation
31
Stroke (All Causes)
• Description
– Acute neurological deficit for > 24 hours
– Caused by interruption of blood flow to brain
– 3rd leading cause of death in USA
 Ischemic
 Hemorrhagic
 Subarachnoid hemorrhages (SAHs)
 Intracerebral hemorrhages (ICHs)
MS II Neuro Presentation
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Stroke
• Pathophysiology
– “Brain Attack” like “Heart Attack”
– Core of ischemic cells - may infarct
– Marginally perfused ischemic penumbra
– Relevant history
• TIA
• RIND
MS II Neuro Presentation
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Transient Ischemic Attacks
Transient or temporary
episode of neurologic
dysfunction, commonly
m/b sudden loss of
motor, sensory, or visual
function.
Duration: few seconds to
minutes, but no longer
than 24 hours
Complete recovery
usually occurs between
attacks
MS II Neuro Presentation
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TIA
• Warning sign of impending stroke
• Cause: temporary impairment of blood flow to
a specific region of the brain due to
atherosclerosis of the vessels, obstruction of
cerebral microcirculation by a small embolus,
decrease in cerebral perfusion pressure,
cardiac dysrhythmias
MS II Neuro Presentation
35
TIA
• Warning sign of impending stroke
• Cause: temporary impairment of blood flow to
a specific region of the brain due to
atherosclerosis of the vessels, obstruction of
cerebral microcirculation by a small embolus,
decrease in cerebral perfusion pressure,
cardiac dysrhythmias
MS II Neuro Presentation
36
TIA s/s correlating with location
• Amaurosis fugax(fleeting
blindness), occurs without
warning, sudden painless loss of
vision of one eye or dimming or
graying out of the field of vision
of one eye signifies retinal
ischemia. (insufficency of
homolateral ophthalmic or
carotid artery)
• Vertebral basilar system: vertigo,
diplopia, disturbances in LOC,
numbness extremeties
MS II Neuro Presentation
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Medical Management - TIA
• Anticoagulant
therapy
– Coumadin
• Platelet inhibiting
medication
– Plavix
– Aspirin
MS II Neuro Presentation
38
TIA Management - Surgical
Carotid Endarectomy:
removal of an
atherosclerotic plaque
or thrombus from the
carotid artery.
Nursing care s/p CE:
Neuro checks q1h,
q15min immed. Post
op. Neuro deficits such
as hemiparesis may
signify thrombus
formation at the site of
the endarectomy
MS II Neuro Presentation
39
Stroke
• Pathophysiology
– Cerebral edema
– Intracranial hypertension
– Complications
• Secondary hemorrhage
• Seizures
– Difference between “Focal” vs. “Global” insult
MS II Neuro Presentation
40
Pathophysiology of CVA
• Non-hemorrhagic
– Thrombosis
– Cerebral embolism
– ischemia
• Hemorrhagic
– Rupture of a cerebral blood
vessel with bleeding into
the tissue, or spaces
surrounding the brain
MS II Neuro Presentation
41
Ischemic Stroke
• Etiology
– Occlusion of a cerebral blood vessel
• Embolic
• Thrombotic
– Strokes are preventable
• Thrombotic (Atherosclerotic disease)
– Hypertension / Diabetes / Elevated blood lipids
• Embolic
– Cardiac valve disease / Atrial fibrillation
MS II Neuro Presentation
42
Ischemic Strokes
Large artery thrombotic
strokes
Small penetrating artery
thrombotic strokes
Cardiogenic embolic
strokes
Cryptogenic
MS II Neuro Presentation
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Characteristic sign of Ischemic
Stroke
• Sudden onset of focal neurological signs
lasting for more than 24 hours
• Location Clue: Brain stem or cerebellar
involvement may cause
• Seizures
• (Will occur within 24 hours of insult)
• Hypoxia
• With Symptoms such as stupor, coma, confusion
agitation
MS II Neuro Presentation
44
Hemorrhagic Strokes
• Bleeding into brain
tissue
• Causes
–
–
–
–
A-V Malformation
SAH
Aneursym Rupture
Anticoagulants,
amphetamines
– Uncontrolled hypertension
MS II Neuro Presentation
45
Stroke (Cont.)
• SAH (Cont.)
– Medical management
• Rebleeding
• Surgical clipping of
aneurysms
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imprint of Elsevier Inc.
46
Stroke (Cont.)
• SAH (Cont.)
– Medical management
(Cont.)
• Surgical excision of
AVMs
• Embolization
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imprint of Elsevier Inc.
47
Stroke (Cont.)
• SAH (Cont.)
– Medical management (Cont.)
• Cerebral vasospasm
– Hypertensive, hypervolemic, hemodilution (HHH)
therapy
– Nimodipine
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Hemorrhagic Strokes
• Epidural
• Bleeding causes acute
displacement of brain
tissue
• Tear of the middle
artery/meningeal artery
• Must be treated within hours
for survival
• Subdural
• Slower onset – bridging
vein is torn
• Most common cause is a
leaking aneurysm of the
brain
• Longer lucid interval till
neurological deficit occurs
MS II Neuro Presentation
49
Stroke (Cont.)

ICH (Cont.)

Medical management





Airway, breathing, and circulation management
Arterial blood pressure regulation
Vasopressor therapy
Fluid management
Surgical clot removal
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imprint of Elsevier Inc.
50
Stroke (Cont.)
• Nursing management
– Monitoring for changes in neurologic and
hemodynamic status
– Maintaining surveillance for complications
• Bleeding and vasospasm
• Increased ICP
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imprint of Elsevier Inc.
51
Assessment – Stroke Scale
• Developed by the national Institutes of health
• Tool to develop a score to determine the
degree of neurological hit
• The higher the score the greater the insult
MS II Neuro Presentation
52
Determination of Stroke throught
Diagnostics
• Non-contrast CT
• If that is negative stroke scale is used to
determine if patient is used for clinical
assessment
• LP will be used if the patient has the
symptoms of sub-arachnoid hemorrhage. If
CT scan is negative
• Big, Big headache will be involved which is
usually not present in ischemic strokes.
MS II Neuro Presentation
53
Neurologic Deficits - Stroke
• Homonymous
Hemianopsia
• Peripheral Vision Loss
• Diplopia
• Paresthesia
•
•
•
•
•
•
•
Hemiparesis
Ataxia
Hemiplegia
Dysarthria
Aphasia
Expressive
Receptive
MS II Neuro Presentation
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MS II Neuro Presentation
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MS II Neuro Presentation
56
Minimizing complications after stroke has
occurred
• Cerebral Hypoxia
• Adequate oxygenation
– Supplemental oxygen to maintain sat 92% or
greater
– Maintain hemoglobin/hematocrit within normal
limits
MS II Neuro Presentation
57
Minimizing Complications
• Maintain cerebral perfusion
– Related to blood pressure, cardiac output and
integrity of the cerebral blood vessels
– Adequate hydration
– Extremes of hypertension/hypotension should be
avoided.
MS II Neuro Presentation
58
Thrombolytic therapy
• Who qualifies –
• Things to know
• Must be given within 3 hours of the onset of
neurologic symptoms
• Why three hour time period?
MS II Neuro Presentation
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Administration of TPA
•
•
•
•
Done in a critical care setting
Patient is one on one
Monitoring is continuous
Should see resolution of symptoms within
hours if the TPA works
• Requires a permit before administration
• Physician must be present
MS II Neuro Presentation
60
TPA Dosing
• 0.9 mg/kg up to a maximum dose of 90 mg.
• 10% is administered as a bolus over one
minute
• Remaining 90% is given by IV infusion over the
next 60 minutes
• Urden page 350
MS II Neuro Presentation
61
TPA Dosing
• Patient weighs 80 kg
• Calculate the total dose of TPA(Concentration
100mg/100ml)
• Calculate how much the initial dose would be?
• Calculate the setting on the IV pump and the
amount you would be giving over the next
hour.
MS II Neuro Presentation
62
Post TPA Differences from the MI
Post TPA
• No anticoagulants of any kind for 24 hours
• Keep blood pressure lower than patient who
did not receive TPA.
• Below 180/105
• Support the patient – watch for those seizures
– Treat if they occur, no prophylaxis
MS II Neuro Presentation
63
Stroke victims – non qualifiers
• Maintain cerebral perfusion
• Diagnosis is PC – Decreased cerebral blood
flow
• Carpenito – PC – Increased intracranial
pressure
MS II Neuro Presentation
64
Acute care of the stroke patient
• Time of onset of symptoms till 24 to 72 hours
when patient deficits remain unchanged
• Vitals are stable
MS II Neuro Presentation
65
Maintaining cerebral perfusion
• Do not increase the patient’s intracranial
pressure
• Position very important!!!!!!!!!!!!!!!!!!!!!!!!
• Maintain oxygenation – Why
• Maintain blood pressure within parameters
• Systolic < 220 NON - TPA
• Diastolic < 120 (Urden page 352)
MS II Neuro Presentation
66
Temperature regulation
• Maintain normothermia 98.6 please
• Administer anti-pyretics as needed for
temperature > 99’F
• Warm baths to decrease temperature
• Avoid shivering of course
MS II Neuro Presentation
67
Maintain fluid volume WNL
• IV therapy –
• Fluid of choice is
always normal saline
• D5W is hypotonic
drawing water to itself
increasing cellular
volume – increases
cerebral edema
• Assess for fluid
volume deficit/excess
MS II Neuro Presentation
68
Stroke
• Nursing Management
– Early recognition of neurological changes
– Monitor for bleeding post thrombolytic therapy
– Monitor BP and use of antihypertensive drugs
• IV Labetelol
• IV Sodium Nitroprusside
– Monitor body temperature / blood glucose
– Patient education
MS II Neuro Presentation
69
Guillain-Barré Syndrome
• Description
– Acute inflammatory demyelinating
polyradiculoneuropathy (AIDP)
• Etiology
– Exact cause is unknown
– Immune-mediated response
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70
Guillain-Barré Syndrome (Cont.)
• Pathophysiology
– Segmental demyelination of peripheral nerves
• Assessment and diagnosis
– Clinical findings
– CSF analysis
– Nerve conduction studies
– Elevated CSF protein with normal cell count
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imprint of Elsevier Inc.
71
Guillain-Barré Syndrome (Cont.)
• Medical management
– Plasmapheresis
– Intravenous immune globulin (IVIG)
• Nursing management
– Support normal body functions
– Maintaining surveillance for complications
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imprint of Elsevier Inc.
72
Guillain-Barré Syndrome (Cont.)
• Nursing management (Cont.)
– Initiating rehabilitation
– Facilitating nutritional support
– Providing comfort and emotional support
– Educating the patient and family
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imprint of Elsevier Inc.
73
Craniotomy
• Types of surgery
• Preoperative care
– Patient health
– Assessment and documentation
– Screening
– Education
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74
Craniotomy (Cont.)
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75
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Copyright © 2014, 2010 by Mosby, an
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Craniotomy (Cont.)
 Postoperative medical management
 Intracranial hypertension
 Surgical hemorrhage
 Fluid imbalance
 CSF leak
 Deep vein thrombosis (DVT)
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78
Craniotomy (Cont.)
• Postoperative nursing management (Cont.)
– Preserving adequate cerebral perfusion
• Positioning
• Fluid management
• Avoidance of vomiting and fever
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79
Craniotomy (Cont.)
• Postoperative nursing management (Cont.)
– Promoting arterial oxygenation
– Providing comfort and emotional support
– Maintaining surveillance for complications
• Infection
• Corneal abrasions
• Injury
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80
Summary
• Coma
– Two main causes: structural and metabolic
– Deepest state of unconsciousness
– Medical management: identification and
treatment of underlying cause and support of vital
functions
– Nursing management: supporting body functions,
watching for complications, providing comfort and
emotional support, initiating rehabilitation
measures, and educating patient and family
Copyright © 2014, 2010 by Mosby, an
imprint of Elsevier Inc.
81
Summary (Cont.)
• Stroke
– Sudden onset of an acute neurologic deficit
persisting for more than 24 hours; caused by
interruption of blood flow to brain
– Classified as ischemic or hemorrhagic
– Nursing management: monitoring for neurologic
status changes, watching for complications,
providing comfort and emotional support,
initiating rehabilitation measures, and educating
patient and family
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imprint of Elsevier Inc.
82
Summary (Cont.)
• Ischemic stroke
– Two main causes: thrombosis and embolism;
results in neuronal tissue injury from decreased or
absent blood flow
– Characteristic sign: sudden onset of focal
neurologic signs persisting for more than 24 hours
– Medical management: preservation of brain tissue
through fibrinolytic therapy, management of
blood pressure, and treatment of complications
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imprint of Elsevier Inc.
83
Summary (Cont.)
• SAH
– Bleeding into subarachnoid space; usually caused
by rupture of a cerebral aneurysm or AVM
– Medical management: preservation of neurologic
function, support of vital functions, and treatment
of complications
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imprint of Elsevier Inc.
84
Summary (Cont.)
• ICH
– Bleeding directly into cerebral tissue; usually
caused by rupture of a small artery in brain
resulting from hypertension
– Medical management: preservation of neurologic
function, control of blood pressure, support of
vital functions, and management of intracranial
hypertension
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imprint of Elsevier Inc.
85
Summary (Cont.)
• Guillain-Barré syndrome
– Rapidly progressive, ascending peripheral nerve
dysfunction leading to paralysis that may produce
respiratory failure
– Medical management: support of vital functions and
administration of treatments to limit syndrome
duration
– Nursing management: watching for complications,
initiating rehabilitative measures, providing comfort
and emotional support, and educating patient and
family
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imprint of Elsevier Inc.
86
Summary (Cont.)
• Craniotomy
– Performed to gain access to CNS inside cranium
– Postoperative medical management: preventing
complications
– Nursing management: positioning patient’s head in
accordance with physician’s orders, monitoring
patient’s intake and output, administering
medications, promoting postoperative pulmonary
care, providing comfort and emotional support,
watching for complications, initiating rehabilitative
measures, and educating patient and family
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87
Summary (Cont.)
• Intracranial hypertension
– Early sign of increased ICP is decrease in level of
consciousness
– ICP can be measured using ICP monitor
– Medical and nursing management: reducing
volume of one or more of components within
intracranial vault
– Herniation of intracerebral contents results in
shifting of tissue from one brain compartment to
another and places pressure on cerebral vessels
and vital function centers of brain; if unchecked,
results in death
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88