NUR 12O

1. NUR 12O Neurological Disorders Cerebrovascular Accident Seizures Glaucoma Cataracts Retinal Detachment Eye Trauma Ear Disorders

2. The Brain and its lobe/functions The cerebrum or cortex is the largest part of the human brain, associated with higher brain function such as thought and action. • Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving • Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli • Occipital Lobe- associated with visual processing • Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech.

3. The Brain and its lobe functions • Right hemisphere is associated with creativity and the left hemispheres is associated with logic abilities. The corpus callosum is a bundle of axons which connects these two hemispheres. • The Cerebellum - This structure is associated with regulation and coordination of movement, posture, and balance. • Limbic System - referred to as the "emotional brain", is found buried within the cerebrum. This system contains the thalamus, hypothalamus, amygdala, and hippocampus.

4. The Brain and its lobe/functions • Brain Stem - Underneath the limbic system is the brain stem. This structure is responsible for basic vital life functions such as breathing, heartbeat, and blood pressure. • The Amygdala • It's name is latin for almond which relates to its shape. It helps in storing and classifying emotionally charged memories. It plays a large role in producing our emotions, especially fear. It's been found to trigger responses to strong emotion such as sweaty palms, freezing, increased heart-beat/respiration and stress hormone release.

5. Cerebrovascular Accident • Also known as stroke • Involve a disruption in cerebral blood flow related to ischemia, hemorrhage or embolism. • Stroke affects 700,000 people every year and 160,000 Americans die of stroke each year • Stroke is the sudden stoppage of blood flow.

6. Description • Sudden loss of brain function resulting from a disruption in the blood supply to a part of a brain. CLASSIFICATION: • Thrombotic • Hemorrhagic

7. CNS involvement related to cause of CVA • Hemorrhagic – cause by a slow or fast hemorrhage into the brain tissue into the brain tissue: often related to hypertension. • Embolytic – caused by a clot that has broken away (embolus) from a vessel and has lodge in one of the arteries of the brain, blocking blood supply. It is often related to atherossclerosis.

8. CVA Pathophysiology • Brain cells need oxygen and nutrients to work properly. • This nourishment is provided from blood flowing through vessels in the brain. • When one of these vessels becomes clogged by a clot, or breaks open, the blood flow is suddenly stopped and the brain cells die. • This is a stroke.

9. Cerebrovascular Accident

10. Risk Factors • Hypertension • Atherosclerosis • Hyperlipidemia • Diabetes Millitus • Cocaine Use • Atrial fibrillation • Smoking • Use of Oral Contraceptives • Obesity • Hypercoagilability • Cerebral Aneurysm • Arteriovenous Malformation

11. What risk factors for stroke can't be changed? • Age — The chance of having a stroke approximately doubles for each decade of life after age 55.  • Heredity (family history) and race — Stroke risk is greater if a parent, grandparent, sister or brother has had a stroke.  • African Americans have a much higher risk of death from a stroke than Caucasians do.  • This is partly because blacks have higher risks of high blood pressure, diabetes and obesity. • Sex (gender) — Stroke is more common in men than in women.  • More men than women will have a stroke in a given year.  However, more than half of total stroke deaths occur in women.  • Use of birth control pills and pregnancy pose special stroke risks for women. • Prior stroke, TIA or heart attack — The risk of stroke for someone who has already had one is many times that of a person who has not.  

12. What stroke risk factors can be changed, treated or controlled? • High blood pressure — High blood pressure is the leading cause of stroke and the most important controllable risk factor for stroke.  • Cigarette smoking - The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system.  The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk. • Diabetes mellitus — Diabetes is an independent risk factor for stroke.    • Carotid or other artery disease — The carotid arteries in the neck supply blood to the brain.  A carotid artery narrowed by fatty deposits from atherosclerosis may become blocked by a blood clot.  Carotid artery disease is also called carotid artery stenosis. • Peripheral artery disease is the narrowing of blood vessels carrying blood to leg and arm muscles. It's caused by fatty buildups of plaque in artery walls. 

13. Other contributing factors • Atrial fibrillation —The heart's upper chambers quiver instead of beating effectively, which can let the blood pool and clot.  • Sickle cell disease (also called sickle cell anemia) — This is a genetic disorder that mainly affects African-American and Hispanic children. These cells tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke. • High blood cholesterol — People with high blood cholesterol have an increased risk for stroke.  • Poor diet — Diets high in saturated fat, trans fat and cholesterol can raise blood cholesterol levels.   Diets high in sodium (salt) can contribute to increased blood pressure.  • Physical inactivity and obesity — Being inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke.   • What are other, less well-documented risk factors? • Socioeconomic factors — There's some evidence that strokes are more common among low-income people than among more affluent people. • Alcohol abuse — Alcohol abuse can lead to multiple medical complications, including stroke.  • Drug abuse   Drugs that are abused, including cocaine, amphetamines and heroin, have been associated with an increased risk of stroke.  Strokes caused by drug abuse are often seen in a younger population.

14. Diagnostic Procedures • Magnetic Resonance Imaging • CT scan • Used to identify edema, ischemia and necrosis. • MR Angiography or Cerebral Angiography – used to identify the presence of cerebral hemorrhage, abnormal vessel structures, vessels ruptures, and regional perfusion of blood flow to the brain. • Lumbar Puncture- is used to assess for presence of blood in the cerebrospinal fluid. • Carotid Endarterectomy – performed to open the artery by removing atheroscleroyic plaque. • Interventional radiology is performed to treat cerebral aneurysm.

15. Assessments: • Symptoms will vary based on the area of the brain that is adequately supplied with oxygenated blood. • The left cerebral hemisphere is responsible for language, mathematic skills, and analytic thinking. - aphasia (language use or comprehension difficulty) - Alexia (reading difficulty) loss of ability to read - Agraphia (writing difficulty) loss of ability to write - Apraxia – inability to perform purposeful movement - Right hemiplegia or hemiparesis - Slow cautious behavior - Depression and quick frustration - Visual changes such ashemianopsia ( one side/eye unable to see. - Dysphagia – dysfunctional swallowing

16. Assessments: • He right hemisphere is responsible for visual and spatial awareness and proprioception. - unawareness of deficits (neglect syndrome, overestamation of abilities. - Loss of depth perception - Impulse-control difficulty - Disorientation - Poor judgment - Left hemiplegia or hemiparesis - Visual changes, such as hemianopsia

17. Location of Disruption in the Brain

18. Assess and Monitor: Nursing Assessment • Change in level of consciousness • Paresthesia, paralysis • Aphasia, agraphia, • Memory Loss • Visual Impairment • Bladder and Bowel dysfunction • Behavioral chnages • Airway patency • Swallowing ability/aspiration risk • Level of consciousness • Neurological status • Motor function • Sensory function • Cognitive function • Glasgow Coma scale score

19. Assessment of client’s functional abilities • Mobility • Activity of daily living • Elimination • Communication • Ability to swallow, eat, and drink without aspiration

20. Stroke Assessment • National Institutes of Health Stroke Scale • NIHSS • Developed in 1983 by NIH stroke research neurologists • A Systematic tool designed to measure neuro deficits most often seen with stroke • Designed to standardize and document reliable and valid neuro exam

21. NIHHS Stroke Scale • Need to be trained and certified to perform 11 items • Less than 10 minutes to perform • Range of scores 0 – 42 • Lower score indicate less impairment • Score reflects what the patient does!!!

22. NIHSS Stroke Scale • Helps to determine level of stroke severity • Get points for deficits • 0 -1 Normal • 1 - 4 Minor Stroke • 5 - 15 Moderate Stroke • 15 - 20 Moderately Severe Stroke • > 20 Severe Stroke

23. NIHSS Scale • Predicts outcome • <14 there is a 80% good outcome • >20 there is a 20% good outcome • Aids in planning rehabilitation needs • ≥ 14 Severe: long term care • 6 – 13 Adequate: acute inpatient rehab • ≤ 5 Mild: 80% discharged home

24. NIHSS Stroke Scale • Assessment Process General Instructions • Administer items in order listed • Follow directions for each exam • Do not coach patient • Record first answers after each subscale exam • Do not go back and change scores • 1a. LOC • 1b. LOC Questions • 1c. LOC Commands • 2. Best Gaze • 3. Visual fields • 4. Facial palsy • 5. Motor Arm • 6. Motor Leg • 7. Limb ataxia • 8. Sensory • 9. Best Language • 10. Dysarthria • 11. Extinction & Inattention

25. NIHSS Stroke Scale Level of Consciousness • Arousal • 0 = Alert • 1 = Not alert, but arousable • 2 = Not alert, repeated stimulation • 3 = Responds only with reflex motor to noxious stimuli LOC Questions • Awareness • Month & age • 0 = Answer both questions • 1 = Answer one • 2 = Answer neither

26. NIHSS Stroke Scale Open & close eyes, grip and release hand • 0 = Performs both correct • 1 = Performs one correct • 2 = Performs neither LOC Pearls • MOST IMPORTANT • Sensitive indicator of cortical function • Decreased LOC only if both hemispheres/brainstem dysfunction • Key predictor of outcome

27. NIHSS Stroke Scale Best Gaze • Horizontal eye movement • 0 = Normal • 1 = Partial gaze palsy (one or both eyes) • 2 = Forced deviation or total gaze paresis Best Gaze Pearls • CN VI longestintracranial course • Frequently involved • Double vision maybe experienced

28. NIHSS Stroke Scale Visual Fields • Finger counting or visual threat • 0 = No visual loss • 1 = Partial hemianopia • 2 = Complete hemianopia • 3 = Bilateral hemianopia (blindness) Visual Fields Pearls • Injury to Middle Cerebral Artery • Opposite side injury • Stand on the RIGHT for Left MCA • Stand on the LEFT for Right MCA

29. NIHSS Stroke Scale Facial Palsy • Show teeth, raise eyebrows, close eyes • 0 = Normal • 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling) • 2 = Partial paralysis (total/near total paralysis of lower face) • 3 = Complete paralysis, one or both sides (absence of movement in upper/lower face) Facial Palsy Pearls • Same side deficit • Eating is difficult • Damage cornea – unable to close eye

30. NIHSS Stroke Scale Motor Arm • Limb 45° supine, 90° sitting, drift if falls before 10 seconds • 0 = No drift • 1 = Drift (does not hit bed) • 2 = Some effort against gravity (drifts to bed) • 3 = No effort (limb falls) • 4 = No movement • UN = Untestable Motor Arm Pearls • Unilateral deficit common with anterior cerebral injury • Bilateral deficit common with brainstem injury • Unilateral arm drift common with MCA stroke

31. NIHSS Stroke Scale Motor Leg • Limb 30°, drift if falls before 5 seconds • 0 = No drift • 1 = Drift • 2 = Some effort against gravity • 3 = No effort • 4 = No movement • UN = Untestable Motor Leg Pearls • Unilateral deficit common with anterior cerebral injury • Bilateral deficit common with brainstem injury • Unilateral leg drift common with ACA stroke

32. NIHSS Stroke Scale Limb Ataxia • Finger-nose, heel shin • Scored only if present out of proportion to weakness • 0 = Absent (cannot understand, paralyzed) • 1 = Present in one limb • 2 = Present in two limbs • UN = Untestable Limb Ataxia Pearls • Deficit may indicate cerebellar injury

33. NIHSS Stroke Scale Sensory • Pinprick • Face, arms, trunk, legs • Bilateral testing • 0 = Normal • 1 = Mild – moderate loss (feels less sharp on affected side) • 2 = Severe – total loss (not aware of being touched). Sensory Pearls • Consider parietal lobe injury • Contralateral injury occurs • Unilateral neglect syndrome may be present

34. NIHSS Stroke Scale Best Language • Describe pictures • Read “You know how”, “ Down to earth”, “I got home from work”, “Near the table in the dining room”, “ They heard him speak on the radio last night”. Best Language • 0 = No aphasia • 1 = Mild-moderate aphasia (loss of fluency, can identify content from patient response) • 2 = Severe aphasia (fragmented expression, cannot identify content from patient response) • 3 = Mute, global aphasia

35. NANDA Nursing Diagnosis • Ineffective tissue perfusion (cerebral) • Disturbed sensory perception • Impaired physical mobility • Unilateral neglect • Risk for injury • Self-care Deficit • Impaired verbal communication • Impaired swallowing

36. Nursing Plans and Interventions Control hypertension to help prevent future CVA. Maintain proper body alignment while client is in bed. Use splints or other assistive devices. (including bed rolls and pillow) to maintain functional position. C. Position client to minimize edema, prevent contracture and maintain skin integrity. Perform full ROM exercises 4x a day. Follow up with program initiated by other team members. Instruct client to participate in or manage own personal care.

37. Nursing Interventions • Maintain a patent airway • Monitor for changes in client’s LOC ( s/s of Increased ICP). • Elevate the client’s head to reduce ICP and to promote venous drainage. Avoid extreme flexion or extension, maintain the head in the midline neutral, and elevate the head of the bed to 30 degrees. • Institute seizure precaution. • Maintain a non-stimulating environment. • Assist in communication skills if the client’s speech is impaired. Consult a SLP (therapist). • Assist with self-feeding - Assess swallowing reflexes, gag, cough before feeding. - The client’s liquid may need to be thickened to avoid aspiration. - Have the client eat in an upright position and swallow with the head and neck flexed slightly forward.

38. Nursing Interventions • Assist with feeding. • Place food in the back of the mouth on the unaffected side. • Suction on standby. • Maintain a distraction free environment during meals. • Maintain skin integrity. - Reposition the client frequently, use padding. - Monitor bony prominences, paying attention particular in affected extremities. • Encourage passive range motion exercises q 2 h to affec ted extremities and AROM q 2 h to the unaffected

39. Nursing Plans and Interventions • Set realistic goals; add new task daily. To prevent frustration on client that may lead to depression/grief ( loss of function) • Teach client that appropriate self-care activities for the hemiparetic client. • Instruct client to assist with dressing activities and modify them as necessary. • Analyze bladder elimination pattern. • Follow-up speech program initiated by the speech and language therapist. • Do not place client on sensory overload; give only one set of instructions at a time. • Encourage total family involvement in rehabilitation. • Encourage client and family to join a support group.

40. Nursing Plan and Intervention • Encourage family members to allow the client to perform self-care activities as outlined by the rehab team – This will prevent pt. from total loss of self-esteem. • Teach that swallowing modifications may include a soft diet ( pureed foods, thickened liquids) and head positioning.

41. Nursing Interventions • Elevate the affected extremities to promote venous return and to reduce swelling. • * Maintain a safe environment to reduce the risk of falls. Client have problem concerning spatial perception. • * Instruct the client to us scanning technique (turning head from side to side) when eating and ambulating to compensate for hemianopsia. • Provide care to prevent deep-vein thrombosis (sequential stockings, frequent position changes, mobilization.) • Administer medications as prescribed.

42. Medications • Systemic or catheter-directed thrombolytic therapy. Restores cerebral blood flow. It must be administered within hours of the onset of symptoms. It is C/I to treatment of hemorrhagic strokr and for clients with an increased bleeding . Rule out hemorrhagic stoke with MRI prior to initiation of thromboembolytic therapy. • Anticoagulants – Sodium Heparin, Warfarin (Coumadin). • Atiplatelets Aggregates – Ticlid (ticlopidine), clopidogrel (Plavix), ASA • Antiepileptic medications – Dilantin (phenytoin), Gabapentin (Neurontin). • Provide assistance with ADL as needed. Prevent complications of immobility. • Initiate referrals to social services(rehabilitation services)

43. Complications and Nursing Implications • Dysphagia and aspiration. - Suction client as needed. Pre-assess the client’s swallowing abilities. - Unilateral Neglect – loss of awareness of the side affected by CVA. This process poses great risk for injury and inadequate self-care. Instruc the client to dress the affected side first. Teach the client to care for both sides.

44. * Grief following CVA • Poststroke Depression • Etiology: • Organic: May be related to catecholamine depletion through lesion-induced damage to the frontal nonadrenergic, dopaminergic and serotonergic projections. • Reactive: Grief/psychological responses for physical and personal losses associated with stroke, loss of control that often accompany severe disability, etc. • Most prevalent six months to two years. • A psychiatric evaluation for DSM-IV criteria and vegetative signs may be a clinically useful diagnostic tool in stroke patients. • There may be higher risk for major depression in left frontal lesions (relationship still controversial) • Risk factors: prior psychiatric Hx, significant impairment in ADLs, high severity of deficits, female gender, nonfluent aphasia, cognitive impairment, and lack of social supports • Persistent depression correlates with delayed recovery and poorer outcome • Treatment: Active Tx should be considered for all patients with significant clinical depression • Psychosocial interventional program: psychotherapy • Medications: SSRIs preferred because of fewer side effects (compared to TCAs); methylphenidate has also been shown to be effective in poststroke depression • SSRIs and TCAs also been shown to be effective in poststroke emotional lability

45. Seizure Disorders • Seizures are abrupt, uncontrolled electrical brain discharges that cause alteration in level of consciousness and changes in motor and sensory behavior. • Epilepsy – is a group of syndrome characterized by recurring seizures. - it can be idiopathic or secondary caused by conditions such as brain tumor, acute alcohol withdrawal, and electrolyte imbalance. - it is not associated with alterations in intellectual capabilities.

46. * Seizures • Are classified as neurologic emergencies in all triage systems. Sustained untreated seizures can result to hypoxia, cardiac dysrhythmias, and lactic acidosis. • Risk Factors/Contributing Factors - Genetic predisposition - Acute febrile state - Head trauma - Cerebral edema - Abrupt cessation of antiepileptic drugs (AEDs) -Infections - Metabolic Disorder (hypoglycemia) - Exposure to toxins - Brain Tumor - Hypoxia - Acte Drug and alcohol withdrawal - Fluid and electrolyte imbalances.

47. Triggering Factors • Increased physical activity • Stress • Fatigue • Alcohol • Caffeine • Some chemicals

48. Diagnostics Procedures • Electroencephalogram (EEG) – records electrical activity and identifies the origin of seizure activity. Client instructions include: • No caffeine • Wash hair before the procedure ( no oils or spray) and after the procedure ( to remove electrode glue) • Maybe asked to take deep breaths and/or be exposed to flashes of a strobe light during the test. • Sleep may be with held prior to test and possibly induced during test. • Blood and urine culture test, MRI, CT/CAT, PET scan, CSF analysis, skull x-ray, electrolyte profile and drug screen may all be used to identify or rule out potential causes of seizures.

49. Assessments: • Assess and monitor: - Airway patency - Aspiration - Injury post seizure - If client experienced an aura ( warning sensation), possible indication of the origin of seizure. - Possible trigger factor ( e.g. fatigue). Nursing Diagnosis • Risk for injury • Risk for impaired spontaneous ventilation • Risk for ineffective tissue perfusion (cerebral).

50. Nursing Interventions • Protect the client from injury ( e.g move furnitures away). • Maintain a patent airway. • Be prepared to suction • Turn the pt to the side ( decreased the risk for aspiration) • Loosen clothing. • Do not attempt to restrain the client. • Do not attempt to open jaw during seizure activity (may damage the teeth, lips, and tongue). Do not use padded tongue blades. • Administer oxygen as prescribed. • Administer prescribed medications. ( anticonvulsants and sedatives). • Usual medications prescribed : anticonvulsants Keppra, Tegretol, Dilantin, Depakene/Depakote, Phenobarbital sedatives Valium ( Diazepam), Ativan (Lorazepam) • Document onset and duration of seizure and client findings/observations prior to during, and following the seizure (level of consciousness), apnea, cyanosis, motor activity, incontinenence).