NCLEX RN Preparation Program

1. NCLEX RN Preparation Program Neurologic Disorders Module 5, Part 1 of 3

2. Brain Attack (Cardiovascular Accident/CVA or Stroke) • Thrombosis – most common • Embolus • Small vessel occlusion (lacunar) • Hemorrhage • Aneurysm • Hypertension • Blood thinners (coumadin, heparin)

3. Clinical Manifestations • Headache (25%) • Nausea, Vomiting • Aphasias • Paresis • Hemianopsia • Dysarthria • Dysphagia

4. Collaborative Care • Aspirin? • Vitamin K? • Oxygen • Anti-convulsants • Blood pressure control • Thrombolytics

5. Prevent Re-bleed (hemorrhage) • 24-48 hours post hemorrhage • 7-10 days post hemorrhage • Keep BP low • Head up • Vitamin K (Aquamephyton)?

6. 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/cerebral-aneurysm/treatment.html

7. Prevent Vasospasm • Nimodipine (Nimotop) • Triple H Therapy • Hypertension • Hypervolemia • Hemodilution

8. Monitor Airway Aspiration pneumonia Cerebral edema Motor/Sensory changes Psychosocial Swallowing Skin, incontinence Monitor fluid/electrolyte balance

9. Intervene • Position • Activity • Prevent complications • Communication • Environment

10. Teach Prevention • Hypertension • S&S Stroke • Early treatment • Healthy lifestyle • Treat Transient Ischemic Attack (TIA)

11. Seizures • Prodromal phase • Aural phase • Ictal phase • Manifestations seen • Postictal phase

12. Generalized Seizures • Tonic/clonic • Absence • Myoclonic • Atonic

13. Partial Seizures • Complex • AKA psychomotor • AKA temporal lobe • Simple

14. Nursing Care • Onset • Movements • Airway • Position • Teach

15. Collaborative Management • Anti-seizure medication • Monitor serum levels • Toxic effects • Alcohol • Status epilepticus • Airway • Lorazepam (Ativan)

16. 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

17. Open Head Injuries • Linear skull fracture • Depressed skull fracture • Open fracture • Basilar skull fracture

18. Basilar Skull Fracture • Watch! • Clear nasal or ear drainage • Battle Sign • Raccoon sign

19. Closed Head Injury - Concussion • Signs & Symptoms • Brief loss of consciousness • Amnesia • Headache • Post-concussive syndrome • Persistent headache • Lethargy • Personality/intellectual changes • Decreased attention span

20. Brain Contusion • Coup • Contrecoup • Signs

21. 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

22. Subdural Hematoma • Acute • Subacute • Chronic • Signs & Symptoms Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp

23. Cerebral Edema • Brain tissue + Blood + CSF • CPP = MAP - ICP • Autoregulation • Chemical autoregulation

24. Assessment for Edema • LOC • Orientation • Pupils • Motor • Vital Signs

25. 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.

26. Craniotomy • Postoperative assessment • Peri-orbital edema, ecchymosis • Strict I&O • Positioning • Dressing • Drainage

27. Monitor Sodium Levels • Low Na+ = salt wasting syndrome • 3% saline • High Na+ = Diabetes insipidus • 0.45% saline

28. Postoperative Complications • Increased ICP • Hematomas • Hydrocephalus • Respiratory problems • Wound infection • Meningitis • Fluid/electrolyte imbalances

29. Intracranial Pressure • CSF leaks • Head up • Body in neutral alignment • Control pCO2 • Prevent hypoxia • Suction airway? • Sedation

30. 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

31. 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

32. Types of Lesions • Complete • Incomplete • Central cord syndrome • Anterior cord syndrome • Brown-Sequard syndrome • Cauda equina

34. Initial Assessment/Care • Stabilize neck/back • Watch! Respiratory failure C2-3 • Assess Motor signs • Assess Sensory signs • Incontinence • Superficial signs • Pain

35. Spinal Shock • Flaccid paralysis below injury • Bradycardia • Hypotension

36. Ongoing Assessment • ABCs • Bleeding • Glasgow Coma Scale • Motor/sensory status http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/learnem/dermat/main_der.htm

37. Glasgow Coma Scale

38. Collaborative Management - Neurological • Methylprednisolone (Solu-Medrol) • Traction • Log roll • Treat spasticity, pain

39. Collaborative Mgmt - Circulation • Bradycardia – atropine • Hypotension – dopamine • Fluids/blood products • Vasovagal response • Fluid/electrolyte imbalances • Promote blood return

40. Collaborative Mgmt - Oxygen • Lesions above C4 • Pulmonary “toilet” • Aspiration prevention • Bronchodilators

41. Collaborative Mgmt - Nutrition • Paralytic ileus • Stress ulcers • Histamine-2 blockers • Total parenteral nutrition • Constipation

42. Collaborative Mgmt - Temperature • Poikilothermia • Control room temperature • Warming measures • Cooling measures

43. Collaborative Mgmt - Renal • Bladder reflex loss • Calcium stones • Urinary tract infection

44. 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

45. Psychosocial Care • What to expect • Hope, reassurance • Verbalize feelings • Fear of the unknown: be accurate • Touch areas with sensation • Offer stimulation

46. Autonomic Dysreflexia • Injuries above T6 • Late complication • Causes • Signs, symptoms • Prevention • Treatment

47. 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

48. Meningitis • Chills and high fever • Vomiting • Signs of increased intracranial pressure • Photophobia • Petechial rash • Diplopia (double vision) • Seizures

49. Diagnosis • CSF: ↑ pressure, ↑ protein, cloudy, ↓ glucose • High WBC • Blood cultures • Sodium

50. Collaborative Management • Assess for neurologic deterioration • Respiratory isolation x 24 hours • Seizure precautions • Antibiotics • Dark room • Headache • Hydration