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Neurological System

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Neurological System

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    1. Neurological System

    2. Brain Anatomy Cerebrum Reasoning Judgment Concentration, Motor, sensory, speech Cerebellum Coordination Brainstem Cranial nerves Respiratory center Cardiovascular center

    3. Brain Anatomy Cont.

    4. Cerebral Blood Flow 20% of CO Cerebral tissues – Have no oxygen or glucose reserves Blood flows through Carotid Arteries to Circle of Willis

    5. Intracranial Pressure (ICP) Composition 80% brain tissue and water 10% blood 10% cerebrospinal fluid (CSF) Increased ICP caused by: Severe head injury/ Subdural hematoma Hydrocephalus Brain tumor Meningitis/Encephalitis Aneurysm Status epilepticus/Stroke A medical emergency that can lead to: Brain hypoxia, herniation, death Clinical Manifestations Vomiting Headache Blurred vision Seizure Changes in behavior Loss of consciousness Lethargy Neurological symptoms

    6. Neurological Assessment Rapid Neurological Assessment Emergent situations Sudden changes in neurologic status LOC: first indicator of a decline in neurological function and increase in ICP (intracranial pressure); use the GCS Pupils

    9. Neuro-Diagnostic Tests Routine labs Radiology Tests CT scan, MRI Carotid ultrasound Cerebral angiogram/ MRA

    10. Neuro-Diagnostic Tests: Lumbar Puncture Spinal needle inserted into SA L3/L4 or L-4 /L-5 using strict asepsis Obtain CSF specimens and pressure readings To remove bloody or purulent CSF Administer spinal anesthesia

    11. Case Study: Introduction Nancy is a 66 year old female, came in to the ER with her daughter Gail. Gail states that her mother woke up in the middle of the night to go to the bathroom and fell to the ground because she was not able to control her right leg.

    12. Case Study Subjective data R arm and leg weak and numb Feeling depressed and fearful Requires help with ADLs Says she has not taken her meds for high cholesterol History of brief episode of right sided weakness and tingling of the face, arm, and hand 3 months earlier, which totally resolved and for which she did not seek treatment

    13. Case Study Objective Data Alert and oriented, and able to answer questions appropriately with mild slowness in responding BP 180/110 Global aphasia, facial drooping, dysphagia Right sided paralysis Decreased sensation to right side, particularly the hand Right homonymous hemianopsia Overweight Incontinent of urine

    14. Stroke: Brain Attack Cerebrovascular Accident (CVA) - loss of brain functions that occur when the blood supply to any part of the brain is interrupted. Sudden onset of neurological deficits Serious Medical Emergency- reduction in cerebral blood flow & tissue death Brain dependent on constant supply of oxygen and glucose

    15. Types of Stroke Ischemic- results from an occlusion of a cerebral artery by a thrombus or embolus Thrombotic Stroke Embolic Stroke Hemorrhagic – bleeding into brain tissue

    16. Ischemic: Thrombotic Stroke Atherosclerosis -most common cause Thrombosis-clot forms at rough or narrowed artery Complete blockage Accounts for half of all strokes

    17. Ischemic: Embolic Stroke Accounts for 1/3 of all strokes Embolism-emboli breaks off and travels to cerebral or carotid arteries (blood clot or fatty plaque released into circulation) Often a fragment from a thrombosis or fatty plaque

    18. TIA: Transient Ischemic Attack or “Silent stroke:/ mini stroke Warning sign: Temporary onset of neurological symptoms often lasting 15 min but no longer than 24 hours Needs prompt work-up: carotid U/S, brain and heart Key features: Blurred vision, double vision, blindness one eye; Transient weakness, ataxia; Speech deficits

    19. Treatment Cont: Surgical Therapy Carotid Endarterectomy- for pts who have had TIAs or significant narrowing of carotid arteries

    20. Hemorrhagic Stroke Rupture of weak vessel wall or cerebral aneurysm Intracerebral or subarachnoid hemorrhage Arteriovenous malformation Bleeding into brain or meninges

    21. Risk Factors for Stroke Modifiable Hypertension Heart disease (MI, A Fib) DM, Hyperlipidemia Sedentary Lifestyle Smoking/Alcohol Obesity Hyperlipidemia Illicit Drug Use; cocaine Nonmodiafiable Age - People over 55 are at high risk family history African american, hispanic, asian descent

    22. Clinical Manifestations Depend on the extent of injury May be transient, mild or result in major neuro deficits Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body Sudden complete or partial loss of vision on one or both sides Sudden confusion or trouble speaking or understanding Sudden loss of balance, unsteadiness or an unexplained fall Sudden vertigo, dizziness, swallowing difficulties or memory disturbances Sudden, severe headache with no known cause Hemorrhagic Worst HA ever for bleeds

    26. Impaired Swallowing Stroke ?dysphagia Risk for airway obstruction/ aspiration Nursing Interventions: Maintain patent airway NPO until swallow eval (by ST) Assess swallow, cough, gag reflex Safe Feedings: High Fowler’s position with head flexed forward Thickened liquids if impaired swallowing Instruct to position food on unaffected side in back of throat Avoid distractions to reduce aspiration risks Soft, semi-soft foods, pureed, baby food, dental diet Suction as needed

    27. Cognitive Changes Change in LOC Impaired judgment, memory, problem solving Denial of illness Inability to concentrate Nursing Interventions: Frequent reorientation Frequent safety instructions Repeat directions on tasks by steps Give time to process and respond

    28. Motor Deficits Loss of voluntary movement on contralateral (opposite) side of stroke Weakness & paralysis Hemiplegia and/or Hemiparesis Gait changes

    29. Motor Deficit Cont. Nursing Interventions: Maintain optimal functioning and assist as necessary Prevent contractures & atrophy PT and OT eval/tx to promote independence Positioning- intermittent prone positions; elevate affected extremity ROM exercises (passive: begin 1st day of hosp; no ambulation with hemorrhagic stroke- limit mvmt to extremities only ) Assist with ADLs (Self Care Deficit) Use assistive devices (wide grip utensils, plate guards) Rehab and use of ambulation devices

    30. Motor Deficit Cont.

    31. Assessment and Management Sensory Changes Contralateral sensory deficits Decreased sensation to touch Spatial dysfunction (kinesthesia/proprioception altered) ? Awareness of position Neglect Syndrome – Ignore affected side due to altered perception and vision Visual Deficits (Hemianopsia) Nursing Interventions: Teach client to touch and use both sides Remind client to dress and bathe both sides Place objects within patients field of vision Approach patient from unaffected side

    32. Sensory Changes Cont. - Visual Deficits: Hemianopsia Blindness in one side of visual field Homonymous hemianopsia Blindness in in the same side of each visual field

    33. Visual Deficits: Hemianopsia Cont. Nursing Interventions: Place objects in client’s visual field Remove clutter Teach patient to attend to the neglected side Teach scanning technique during ADLs Assess the neglected side (paralyzed or weak side) for trauma, adequacy of dressing and hygiene

    34. Impaired Communication Aphasia-loss of use and comprehension Receptive aphasia- Wernicke’s area (sensory) Expressive aphasia – Broca’s area (motor) Global aphasia- mixed Nursing Interventions: Assess ability to speak and understand Provide + reinforcement Picture board Repeat names of objects routinely Allow plenty of time for client to answer

    35. Picture Communication Board

    36. Altered Elimination Temporary or permanent loss of bladder/bowel function Constipation common Weakness Dehydration Immobility Nursing Interventions: Increase fiber and fluids Stool softeners Digital stimulation/suppositories bladder retraining Straight cath to check residual

    37. Assessment and Management Problems R/T Immobility Risk for atelectasis and pneumonia Risk for impaired skin integrity and DVT Nursing Interventions:

    38. Assessment and Management: Psychosocial Emotional Support Depression a major problem Discharge planning Care of the caregiver

    39. Treatment of Stroke: Thrombotic Stroke Thrombolytic Therapy : rtPA (recombinant tissue Plasminogen Activator-Retavase) A clot-buster delivered intravenously; breaks up the clot allowing blood flow to return to the deprived area of the brain Must be administered within 3 hours of the onset of clinical signs of ischemic stroke Quick CT scan to see if stroke from clot or bleed

    40. Treatment Cont: Acute phase: Anticoagulant - Heparin continuous infusion Osmotic Diuretics – to reduce brain swelling Anticoagulants contraindicated in Hemorrhagic Strokes Long Term Drug Therapy To Prevent Stroke: Antiplatlet Drugs ASA, Ticlid, Persantine, Plavix Anticoagulants Coumadin Lovenox Antiepileptics

    41. Treatment Cont: Surgical Treatment For Bleeds (Interventional Radiology) Angiograms to see arteries and detect bleeding sites Aneurysm clips and coils

    42. Surgical Removal: Hematoma

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