Download Nurs2016NeuroLecture09

Caring for Individuals
Experiencing Neurologic
Challenges
NURS 2016
Chapters: 61-65
Cerebral Vascular Accidents
CVA
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Another name for CVA?
Thrombolytic
Hemorrhagic
Which is more common?
Clinical Manifestations
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numbness or weakness
confusion or change in mental status
trouble speaking
visual disturbances
loss of balance, difficulty walking
dizziness
sudden severe headache
Clinical Manifestations Cont’
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motor Loss
communication Loss
perceptual disturbance & sensory
loss
impaired cognitive & psychological
effects
bladder dysfunction
Assessment
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Change in level of responsiveness
Presence or absence of voluntary or
involuntary movements of extremities
Eyes
Quality & rates of pulse & respiration
Swallowing
Signs of bleeding
Facial droop
Assessment Cont’
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Glascow Coma Scale
Canadian Neurologic Scale
Goal of Stroke Care
Reduce amount of tissue damage resulting from
stroke
 Oxygen saturation: supplement if below 92%
 CBG: maintain less than 7mmol/l
 Positioning: functional, prevent breakdown. T&P
q2h
 Swallowing: speech/swallowing assessment ASAP.
NPO ‘til then
 Ambulation: Physio ASAP, active/passive ROM
immediately
 Bladder/bowel: assess, intermittent cath
Nursing Diagnosis
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Impaired physical mobility
Pain
Deficit self-care
Disturbed sensory perception
Impaired swallowing
Incontinence
Impaired thought processes
Impaired verbal communication
Risk for impaired skin integrity
Sexual dysfunction
Ineffective family processes
Nursing Interventions
Primarily supportive and rehabilitative
 Monitoring & managing potential
complications
 Improving mobility & preventing
deformities
 Establishing an exercise program
 Eating/drinking – swallowing
(“chipmunking”)
 Preparing for ambulation
 Preventing shoulder pain
Nursing Interventions
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Enhancing self-care
Managing sensory-perceptual difficulties
Attaining bowel & bladder control
Improving thought processes
• Hemianopsia (if they can’t see it…)
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Achieving communication
Maintaining skin integrity
Improving family coping through health
teaching
Regaining sexual function, promoting home &
community based care (special needs in home)
Unconscious Patient
Assessment
 Patient History
 Neurological exam
 Glasgow Coma Scale
 Subtle Changes
 Vomiting
 Monitor ICP
 Pupils changes (PERRL)
Nursing Diagnosis
 Ineffective airway clearance
 Ineffective cerebral tissue perfusion
 Ineffective breathing patterns
 Risk for fluid volume deficit
 Altered protection & risk for injury
 Risk for infection
 Altered oral mucous membranes
 Altered family processes related to
sudden crisis of unconsciousness
Nursing Interventions
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Maintain safety
Maintain a Patent airway
Attaining Normal Respiratory pattern
Preserving & Improving Cerebral Tissue
Perfusion
Maintain Negative Fluid Balance
Preventing Infection
Monitoring & Managing Potential
Complications
Spinal Cord Injury
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Concussion, contusion, laceration,
compression, transection
Cervical: 5th, 6th, 7th
Thoracic: 12th
Lumbar: 1st
Paraplegia
Quadriplegia
Management
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High-dose corticosteroid
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Respiratory therapy
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Skeletal reduction/traction
Nursing Assessment
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Respiratory status
Motor ability
Sensation
Spinal shock:depression of reflex
activity below injury
Temperature:risk of hyperthermia
(autonomic disruption)
Bladder: assess retention/distention
Nursing Interventions
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Promote adequate breathing &
airway
Improve mobility
Promoting adaptation to sensory &
perceptual alterations
Skin integrity
Bowel & bladder
Comfort measures
Complications
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Thrombophlebitis
Orthostatic hypotension
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Autonomic Hyperreflexia (dysreflexia)
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Headache
Hypertension
Diaphoresis
Nausea, nasal congestion
Bradycardia
Nursing Measures: Autonomic
Dysreflexia
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Sitting position
Identify trigger: bladder, bowel,
draft, skin irritation
Empty bladder, empty bowel, remove
restrictive clothing etc.
Administer ganglionic blocking agent
(Apresoling)
Patient education
Meningitis
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Inflammation of the meninges
Viral (aseptic), bacteria (septic), fungal
(tuberculous)
Bacterial
 Neisseria meningitides
 Streptococcus pnuemoniae
 Haemophilus influenzae
Clinical Manifestations
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Nuchal rigidity
Positive Kernig’s sign
Positive Brudzinski’s sign
Photophobia
Seizures & increased ICP
Rash
management
Diagnosis: culture CSF & blood
Pharmacological Treatment
 Antibiotics that cross blood brain
barrier
 Dexamethasone (corticosteriod)
Nursing Care
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VS & clinical status
Monitor I&O: Hydration vs overload
Precautions: Infection control
measure
Fever management
Multiple Sclerosis
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Degenerative progressive disease
Demyelination in brain & spinal cord
Clinical Manifestations
 Relapse – Remittance – varies
 Fatigue, weakness, depression
 Spasticity, ataxia, tremor
 Loss of control
Nursing Interventions
 Physical mobility
 Injury
 Bladder & bowel control
 Speech & swallowing difficulties
 Sensory & cognitive function
Huntington’s Disease
Chronic, progressive, hereditary
 Progressive involuntary choreiform
movement & dementia
 Autosomal dominant (each child of +ve
parent has 50%)
Prominent manifestations
 Chorea
 Intellectual decline
 Emotional disturbances
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Nursing Diagnosis
Potential for injury from falls
 Potential skin breakdown
Resulting from constant movement
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Psychological isolation
 Ineffective communication
Both resulting from excessive grimacing &
unintelligible speech
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Parkinson’s Disease
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Progressive neurologic movement
disorder
Dopamine: decrease dopamine
stores
Tremor, rigidity, bradykinesia
Nursing Diagnosis
 Impaired physical mobility
 Self-care deficits
 Altered nutrition
 Impaired verbal communication
Nursing Interventions
 Improving mobility
 Enhancing self-care & using assistive
devices
 Improving bowel function
 Improving swallowing & nutrition
 Supporting Coping Abilities
Seizure Disorders
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Episodes of abnormal motor, sensory,
autonomic or psychic activity
resulting from sudden excessive
discharge of cerebral neurons
May be loss of consciousness, excess
movement, or loss of muscle tone or
movement and disturbances in
behaviour, mood, sensation and
perception
Seizure vs Epilepsy
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What is the difference?
Seizures:
• sudden, abnormal electrical discharge
from the brain that results in changes in
sensation, behavior, movements,
perception, or consciousness
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Epilepsy:
• a chronic disorder of recurrent seizures.
A single seizure does not constitute
epilepsy.
Managing a Seizing Patient
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Ease patient to floor
Support airway (use nasopharyngeal
airway if necessary)
O2 and suction
Protect head
Move furniture
Don’t restrain
Loosen clothing
Provide privacy
Place on side (if possible)
Never place anything in the mouth
Take notes - make observation
Documenting a Seizure
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Describe situation before seizure
occurred
• Visual, auditory, olfactory, tactile
stimuli, emotional, sleep, etc…)
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Was there an aura?
The first thing the patient did when
they began to seize
• Where movement/stiffness started
• Eyes deviated?
Documenting a Seizure
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Type of movement (pull sheets down
to observe patient)
Pupil size, are the eyes open
Incontinence
Duration (sometimes 30 seconds can
seem like 3 minutes)
Postictal phase
• Unconscious, sleeping, confused,
paralysis, weakness, unable to speak
Status Epilepticus
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Emergency situation
continuous seizures in rapid succession
without regaining consciousness lasting
at least 30 minutes
Patient may remain comatose,
irreversible brain damage, or die
Most common cause is sudden
withdrawal from anticonvulsant
medication
Treatment of Status Epilepticus
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maintain airway
assess patient constantly
protect from injury
give emergency anticonvulsant
medication IV
Nursing Management
Assessment
Diagnosis
 Fear
 Ineffective coping
 Deficit knowledge
Nursing Interventions
 Care during seizures
 Controlling Seizures
 Improving coping mechanisms