Critical Neurologic Problems

1. Critical Neurologic Problems

2. Stroke (Brain Attack) Disruption in the normal blood supply to the brain CVA Medical emergency Requires immediate treatment Third most common cause of death in US Primary cause of adult disability

3. Stroke: Pathophysiology Brain circulation: 1000 mL per minute Ischemia in brain tissue supplied by affected artery results in brain dysfunction Ischemia ? hypoxia/anoxia/hypoglycemia ? infarction or death of neurons, glia, and involved area of the brain Brain metabolism is affected in involved area as well as in the contralateral hemisphere Small lacunar infarcts� produce either a pure motor or pure sensory deficit

4. Types of Strokes Ischemic (occlusive) Caused by occlusion of cerebral artery by thrombus or embolus Thrombolic stroke Accounts for > 50% of all strokes Associated with atherosclerosis Lacunar stroke Embolic stroke Accounts for ~ 33% of all strokes Embolus/emboli travel to cerebral arteries via carotid artery Sources of emboli are cardiac

5. Types of Strokes Transient Ischemic Attack (TIA) Reversible Ischemic Neurologic Deficit (RIND) Hemorrhagic stroke Ruptured saccular (berry) aneurysm Ruptured arteriovenous malformation (AVM) Hypertension (most common)

6. Stroke: Risk Factors Hypertension Diabetes mellitus Heart disease Nonvalvular arterial fibrillation Smoking Sedentary lifestyle Substance abuse

7. Stroke: Assessments Accurate History Activity when stroke began Ischemic: sleep Hemorrhagic: activity Progression of Sx Level of Consciousness Current LOC Presence of deficits Medical History Head trauma HTN Heart disease Anemia Obesity Headache Current meds Anticoagulants ASA Vasodilators Illegal drugs

8. Stoke: Clinical Manifestations Cognitive changes Motor changes Sensory changes Cranial nerve intactness Cardiovascular assessment Psychosocial assessment

9. Stroke: Cognitive Changes Changes in LOC Neglect syndrome/hemiparesis Spatial and proprioceptive dysfunction Impairment of memory, judgment Problem-solving/decision-making abilities Decreased ability to concentrate/attend to tasks

10. Stroke: Cognitive Changes Right cerebral hemisphere Unaware of deficits Disoriented to time/place Impulsivity/poor judgment Left cerebral hemisphere Aphasia Alexia Agraphia Slow and cautious

11. Stroke: Motor Changes Motor nerve fibers cross in the medulla above spinal cord and periphery Hemiplegia/hemiparesis on opposite side Hypotonia or flaccidity Extremities feel heavy/muscle tone is inadequate Contractures/? ROM Proprioception (position sense) Uninhibited bladder/bowel function

12. Stroke: Sensory Changes Inability to write/read Agnosia/apraxia Neglect syndrome Visual ability Pupillary abnormalities Ptosis Visual field deficits Pallor/petechiae of conjunctiva Amaurosis fugax Hemianopsia Homonymous hemianopsia

13. Stroke: Nursing Diagnosis Impaired (cerebral) tissue perfusion Impaired physical mobility Disturbed sensory perception Unilateral neglect Impaired verbal communication Impaired swallowing Total urinary incontinence and bowel incontinence

14. Stroke: Interventions Drug therapy Thrombolytic therapy Anticoagulants/antiplatelets Antiepileptic drugs Calcium channel blockers Stool softeners/analgesics/antianxiety Aggressive rehabilitation NIC intracranial pressure monitoring Chart 48-6, p. 1038

15. Stroke: Interventions Glascow Coma Scale Monitoring for complications Surgical management Carotid endarterectomy Extracranial-intracranial bypass Management of arteriovenous malformations/ aneurysms Intracranial bleeding

16. Stroke: Impaired Verbal Communication Occurs in dominant hemisphere/majority in left hemisphere Dysarthria due to loss of motor function Aphasia caused by cerebral hemisphere damage Expressive (Broca�s or motor) aphasia Receptive (Wernicke�s or sensory) aphasia

17. Stroke: Expressive Aphasia Motor speech problems Understands but unable to communicate Difficulty with writing Frustration and anger

18. Stroke: Receptive Aphasia Unable to understand spoken and written word Neologisms Global or mixed aphasia Reading and writing equally affected

19. Left Frontal Stroke

20. Left Frontal Stroke (underside)

21. Right Sided Stroke

22. Right Sided Stroke

23. Traumatic Brain Injury (TBI) �Occurs as a result of an external force that produces a diminished or altered state of consciousness� (Iggy, p. 989) Can: Cause cognitive impairment Cause behavioral/emotional disturbances Be temporary or permanent Cause partial or total functional disability or psychosocial maladjustment

24. Traumatic Brain Injury (TBI) Primary brain injury Two classifications: Open head injury Linear fracture Depressed fracture Open fracture Comminuted fracture Basilar skull fracture Penetrating injury

25. Traumatic Brain injury Closed head injury Concussion Contusion Laceration Secondary brain injuries Any neurological damage that occurs after the initial injury

26. TBI: Types of Forces Acceleration injury Deceleration injury Shearing Straining Distortion of brain tissue Destruction of adjacent brain tissue

27. TBI: Secondary Brain Injury Increased intracranial pressure (ICP) Hemorrhage Epidural hemorrhage Subdural hematoma Intracerebral hemorrhage Loss of autoregulation Hydrocephalus Herniation

28. Increase Intracranial Pressure Response to edema, hemorrhage, hematoma formation, impaired auto-regulation, hydrocephalus Crainial components: Brain tissue Blood CSF ICP maintained through processes of accommodation and compliance

29. Increased Intracranial Pressure Monro-Kellie hypothesis Any ? in one component must be compensated for by a ? in one of the others First response to ? volume of any component is a shunting of CSF to the subarachnoid space or increasing rate of CSF absorption If necessary, cerebral blood flow is ? by displacement of blood to the sinuses

30. Increased Intracranial Pressure Normal ICP 10-15 mm Hg Leading cause of death from head trauma ? ICP = ? cerebral blood flow = ? serum pH and ? CO2 = cerebral vasodilation = edema = ? ICP = brain herniation = irreversible brain damage = death Edema Vasogenic (can cause ? ICP) Cytotoxic (can cause ? ICP) Interstitial (occurs in presence of acute brain swelling)

32. Hemorrhage Caused by vascular damage from shearing force Potentially life threatening Epidural: bleeding into space between the dura and inner table of the skull Subdural: venous bleeding into space beneath dura and above the arachnoid Intracerebral: accumulation of blood within the brain tissue

33. Loss of Autoregulation Causes cerebral blood flow to fluctuate passively with the systemic blood pressure Increases ICP and potential for vasogenic edema Hypoxemia and hypercapnia cause marked cerebral vasodilation

34. Hydrocephalus and Herniation Hydrocephalus Abnormal increase in CSF volume Results from impairment of CSF absorption or blockage of the CSF circulation pathway Herniation With ? ICP, brain tissue may shift and herniate downward Several herniation syndromes Uncal (transtentorial) herniation is life threatening

35. History Client may experience amnesia Client may be unconscious Obtain history from others Obtain information about events immediately after injury Determine whether client experienced seizure activity before or after the injury What were the circumstances of the fall Past medical history Allergies (esp. allergy to seafood)

36. Physical Assessment Goals of Nursing Assessment Establishment of baseline data Early detection and prevention of ? ICP, systemic hypotension, hypoxia, or hypercapnia Treat all head injuries as though they have a spinal injury Assess for indicators of spinal cord injury Loss of motor and sensory function Tenderness along spine and abnormal head tilt Respiratory difficulties Diminished or absent reflexes

37. Physical Assessments Airway and breathing pattern 1st priority ABG�s Vital signs Blood pressure and pulse Cushing reflex Neurological GCS or similar scale Neuro assessment (pupillary response, motor function, LOC, intactness of cranial nerves, signs of CSF leakage, posturing, papilledema)

38. Lab and Radiographic Assessment Lab No labs to diagnose, can be used to diagnose or prevent secondary brain insult ABG�s, CBC, and serum glucose, electrolytes and osmolality Radiographic CT scan Cervical spine and skull xray

39. TBI Interventions: Nonsurgical Goals are to prevent or detect ? ICP, promoting fluid and electrolyte balance, and monitoring effects of treatment and medications Vital Signs Monitor at least every 1-2 hours May need medication to maintain BP wnl Non-specific ST-segment or T-wave changes can occur Positioning Avoid extreme flexion or extension of neck, maintain head in the midline, neutral position Logroll HOB ? 30�

40. TBI Interventions: Nonsurgical Hyperventilation Avoided in first 20 hours post injury In acute deterioration used for brief periods to produce vasoconstriction which ? ICP Maintain PaCO2 at 27-35 mm Hg Induction of barbiturate coma Used when ICP not controlled by other means Reduces metabolic demands on the brain and cerebral blood flow Requires ventilator, hemodynamic and ICP monitoring

41. TBI Interventions: Nonsurgical Drug Therapy Glucocorticoids and steroids ineffective Mannitol (osmotic diuretic) to treat cerebral edema Furosemide as an adjunctive therapy Codeine and fentanyl to ?agitation and control restlessness of ventilated patients Fluid and Electrolyte management Risk for Diabetes Insipidus and SIADH May restrict fluids Monitor serum and urine osmolality frequently Monitor urine specific gravity every 1-4 hours

42. TBI Interventions: Nonsurgical Strategies for sensory/perceptual alterations Promotes pleasant environment at mealtime Position to maximize swallowing Provide hazard-free environment Sensory-stimulation program Pulmonary management Turn, cough, deep breath at frequent intervals Chest physiotherapy Suctioning as needed with particular attention to response of ICP

43. TBI Interventions: Nonsurgical Behavioral management Seizure precautions Observe and document behavior hourly Provide quiet environment and orient as needed Preventing complications of immobility Nutrition management May need enteral feedings Daily weight and calorie counts Monitor serum albumin, prealbumin and transferrin Assess for signs of dehydration

44. TBI: Interventions Surgical management Intracranial pressure monitoring Intraventricular catheter (can drain CSF) Subarachnoid screw or bolt (less invasive, CSF cannot be drained) Epidural catheter or sensor Subdural catheter Fiberoptic transducer tipped pressure sensor (most common device for ICP monitoring) Craniotomy

45. Brain Tumors Primary tumors Secondary tumors Signs and symptoms Cerebral edema Increased ICP Focal neurologic deficits Obstruction of flow of CSF

46. Brain Tumors: Complications Cerebral (vasogenic) edema/ ? ICP Herniation of brain tissue/ischemia of affected area Rupture/hemorrhage into brain tissue Seizure activity/hydrocephalus Pituitary dysfunctions/SIADH/diabetes insipidus Fluid and electrolyte imbalances

47. Brain Tumor: Classification Malignant/benign Location Gliomas Meningiomas Pituitary gland Acoustic neuromas

48. Brain Tumors: Symptoms Headaches (severe on awakening in am) Nausea and vomiting Visual symptoms Seizures Changes in mentation or personality Papilledema (swelling of the optic disk)

49. Brain Tumors: Interventions Nonsurgical Radiation/chemotherapy Blood brain barrier disruption Recombinant DNA Monoclonal antibodies Antineoplastic drugs Immunotherapy/hyperthermia Surgical Biopsy Craniotomy

50. Brain Tumors: Post-op Complications Increased ICP Hematomas Hydrocephalus Respiratory problems Neurogenic pulmonary edema Wound infection Meningitis Fluid/electrolyte imbalance