Care of Patients with Neurologic Problems

1. Care of Patients with Neurologic Problems Brain Injury, Intracranial Pressure, CVA, and Seizures

2. Brain Injury • Blow or jolt to head • May be result of head penetration by foreign object • May be classified as Primary or Secondary

3. Primary Brain Injury • Open vs. closed head injuries • Mild, moderate, severe classification • Fractures • Concussion • Laceration • Contusion

4. Coup and Contrecoup Injury

5. Acceleration-Deceleration Injury

6. Secondary Brain Injury • Negative patient outcomes • Physiologic, vascular, and biochemical events

7. Epidural Hematoma(Arterial)

8. Nursing Safety Priority Critical Rescue • 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.

9. Subdural Hematoma (SDH)(Venous) • 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)

10. ICP • Normal values: 0-15 mm Hg • Abnormal pressures can occur with brain injury/trauma and Stroke • Edema • Brain Herniation (emergent)

11. Key Features of ICP 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) • 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

12. Patient-Centered Care • Assessments -History -Physical Exam -VS -Psychosocial -Labs -Imaging

13. Nursing Management Interventions -Non-Surgical • preventing and detecting ICP • drug therapy • inducing a barbiturate coma • maintaining fluid and electrolytes • maintain nutritional status • managing sensory, cognitive, and behavioral changes

14. Nursing Management Interventions -Surgical • ICP Monitoring Device • Craniotomy (Pre and Post-op Management)

15. Community-Based Care • Home care • Community services • Safety • Patient and Family education • Self-management

16. Brain Death FOUR PREREQUESITES (American Academy of Neurology, 2010): • 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)

17. Stroke (Brain Attack) • Change in normal blood supply to brain • Risk factors • Causative agents: • Hypertension • Arteriovenous malformation • Injury insult • Types: • Ischemic • Thrombolic • Embolic • Hemorrhagic

18. Risk Factors (Modifiable)

19. Risk Factors That Cannot Be Changed • 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.

20. Risk Factors Altered With Collaborative Management • 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.

21. Types of Stroke

23. Patient-Centered Care • Assessment -History -Physical Exam -Psychosocial -Labs -Imaging

24. Nursing Management • Interventions • Non-surgical • Fibrinolytic Therapy • Endovascular • Monitoring for ICP • VS • Routine Care Considerations (mobility, swallowing/nutrition, communication, continence, sensory perception, skin integrity) • Ongoing Drug Therapy

25. Nursing Management • Interventions • Surgical • Carotid Endarectomy • Stenting • Craniotomy • Reroute vessels from occlusion • Evacuate blood

26. Community-Based Care • Community • Home Care • Self-Care Teaching • Caregiver Support • Resources

27. Seizures • 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).

28. 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.

29. Seizure Risk Factors • Primary or Idiopathic • genetic • Secondary • Lesion or tumor • Trauma • High fever • Metabolic disorders and electrolyte imbalances • Stroke • Alcohol withdrawal and substance abuse • Heart disease

30. Patient-Centered Care • Assessment • History • Physical Exam • Imaging (CT or MRI) used to r/o other causes • Interventions • Non-surgical • Surgical

31. Teaching Self-Management • Medication • Community support groups • Family and Patient education

32. 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.

33. Nursing Focused Assessment for Seizures • 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

34. Status Epilepticus • 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:

35. NURSING SAFETY: PRIORITY RESCUE • 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.

36. 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? • Provide perineal care • Assess for gag reflex • Elevate the head of bed • Perform a linen and gown change

37. (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) • Disorientation to time, place, and person • Inability to discriminate words and letters • Constant smiling • Intellectual impairment • Neglect of left visual field • Deficits in the right visual field

38. (cont’d) • 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? • Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is your best response?

39. (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? • Apply restraints. • Maintain the bed in a low position. • Sit with the patient until his wife returns. • Place the call light in the patient’s right hand.

40. (cont’d) The patient needs assistance with feeding, but can swallow well. To whom would it be best to delegate this responsibility? • Licensed practical nurse • Certified nursing assistant • Hospital volunteer • Student nurse doing first patient care experience

41. NCLEX Questions 41

42. Question 1 What is the greatest risk for a patient with dysfunction of cranial nerves IX and X? • Dehydration • Aspiration pneumonia • Constipation • Weight loss

43. Question 2 Which symptom is the earliest indicator of increased intracranial pressure? • Increased pupil size • Elevated blood pressure • Agitation and confusion • Nausea and vomiting