NEUROLOGIC DEFICITS

Nur-224

Identify the various types/causes of seizures.

Identify clinical manifestations for clients experiencing neurologic deficits.

Apply the principles of nursing management to care for the patient in the acute stage of ischemic stroke.

Use the nursing process as a framework to develop a plan of care for the client with neurological deficits.

OBJECTIVES

3rd leading cause of death in the US 800,000 people experience a stroke each year An emergency condition in which neurologic deficits

result from a sudden decrease in blood flow to a localized area of the brain.

Major loss of blood supply to the brain severe disability or death

Types of stroke Ischemic (80–85%) Hemorrhagic (15–20%)

CEREBROVASCULAR ACCIDENT

Risk Factors Hypertension Sickle cell anemia Atrial fibrillation Diabetes mellitus Smoking Hyperlipidemia Obesity Sedentary lifestyle TIA or “little stroke”

CEREBRAL VASCULAR ACCIDENT

Characterized by a gradual/rapid onset of neurologic deficits compromised cerebral blood flow

Stroke leads to a loss/impairment of sensorimotor functions on the opposite side the side of the brain that is damaged contralateral deficit.

Stroke in the (R) hemisphere of the brain is manifested by deficits in the (L) side of the body (and vice versa)

CVA

CEREBROVASCULAR ACCIDENT

Disruption of the blood supply to the brain due to an obstruction a thrombus or embolism, or from stenosis of a vessel resulting from a buildup of plaque

Types Large vessel stroke Small vessel stroke Cardiogenic embolism

ISCHEMIC STROKE

ISCHEMIC STROKE

Symptoms depend upon the location and size of the affected area

Numbness or weakness of face, arm, or leg, especially on one side

Confusion or change in mental status Trouble speaking or understanding speech Difficulty in walking, dizziness, or loss of

balance or coordination Sudden, severe headache Perceptual disturbances

ISCHEMIC STROKEClinical Manifestations

(L)/( R) HEMISPHERIC STROKE

L sided stroke R sided stroke

Paralysis/weakness on (R ) side of the body

(R ) visual field deficit Aphasia Altered intellectual

ability

Paralysis/weakness on the (L) side of the body

(L) visual field deficit Impulsive behavior

and poor judgment Lack of awareness of

deficits

Sensoriperceptual deficits

Cognitive and behavioral changes

Communication disorders

Motor deficits

Elimination disorders

COMPLICATIONS

Deficits may include Hemianopia Apraxia Neglect syndrome

SENSIORIPERCEPTUAL DEFICITS

Cognitive changes

Behavioral changes Emotional lability Loss of self-control

Intellectual changes

COGNITIVE /BEHAVIORAL CHANGES

Usually a result of the stroke affecting the dominant hemisphere

Aphasia Expressive Receptive Global

COMMUNICATION DISORDERS

Depending on the area of the brain involved strokes may cause:

Hemiplegia Hemiparesis Flaccidity Spasticity

MOTOR DEFICITS

Bladder elimination Bowel elimination

ELIMINATION DISORDERS

Mini-stroke Brief period of localized cerebral ischemia

that causes neurologic deficit lasting less than 24 hours

Sudden loss of motor, sensory, or visual function

Serves as a warning for impending stroke

Transient Ischemic Attack (TIA)

Acute phase diagnosis the type/cause of the stroke support cerebral circulation control/prevent further deficits

Focus minimize brain injury maximize patient recovery

Ischemic Stroke -Assessment

Complete history/careful physical assessment

CT scan DWI test PLAC tests

Ischemic Stroke – Diagnostic Findings

Prevention Antiplatelet- Aspirin, clopidogrel(Plavix),

ticlopidine(Ticlid)

Acute Stroke fibrinolytic therapy-tissue plasminogen

activator anticoagulant therapy

Antihypertensive medications

MEDICATIONS

Used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow to the brain.

Recombinant t-PA Rapid diagnosis of a stroke and initiation of

therapy (within 3 hours) decrease the size of the stroke and may improve functional abilities after 3 months

Bleeding most common side effect

Thrombolytic Therapy

Surgery (Carotid Endarectomy) Performed to prevent the occurrence of a

stroke Restore blood flow when a stroke has

occurred Repair vascular damage

RehabilitationPhysical therapyOccupational therapySpeech therapy

TREATMENTS

Position on the inoperative side –

Assess respirations/oxygen saturation - hemorrhage -respiratory distress - cranial nerve impairment -hypotension/hypertension

Carotid Endarterectomy Postoperative Care

Stroke prevention – esp known risk factors

Public awareness of signs of TIA/Stroke Sudden – - weakness/numbness - confusion, trouble speaking - trouble walking, dizziness, loss of balance - trouble with vision - severe headache without a cause

HEALTH PROMOTION

Risk for Ineffective Tissue Perfusion- Cerebral Impaired Verbal Communication Impaired Swallowing Impaired Physical Mobility Self-care deficits r/t (bathing, grooming,

hygiene)

Nursing Diagnosis/Interventions

Maintain correct position good body alignment avoid deformities

Change position every 2 hours – if sensation is impaired on one side – the amount of time spent on the affected should be limited.

Prevent pressure ulcers. Affected extremities – ROM exercises Prepare for ambulation ASAP/active

rehabilitation program

Nursing Interventions -Mobility

May swallowing problems (dysphagia). Swallowing difficulties place the patient at

the risk for aspiration, pneumonia, dehydration, and malnutrition.

Start patient on thick liquid/pureed foods easy to swallow

Patient unable to consume oral intake enteral feedings

Long-termed feedings gastrostomy tube

Nursing Interventions- Nutrition

Aphasia –receptive/expressive Face the patient and establish eye contact Develop strategies to make the atmosphere

conducive to communication Speak in a normal manner and tone, speak

slowly Use gestures, pictures, objects, writing, Use same words and gestures be

consistent

Nursing Interventions-Communication

At risk for skin and tissue breakdown Specialty bed Regular turning schedule Minimize shear/friction forces

Nursing Intervention – Skin Integrity

Recovery/rehabilitation may be prolonged and requires patience.

Community based support groups Depression – common /serious problem Caregivers need to be reminder to attend

their own health concerns/well-being respite care.

ISCHEMIC STROKE

Intracranial hemorrhage Cerebral blood vessel ruptures.

May be due to: Intracerebral hemorrhage Intracranial aneurysm AV malformation Subarachnoid hemorrhage

Hemorrhagic Stroke

HEMORRHAGIC STROKE

HEMORRHAGIC STROKE

Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting

Hemorrhagic Stroke –Clinical Manifestations

Maintain optimum tissue perfusion -aneurysm precautions Manage potential complications - vasospasms - hyponatremia - seizures Promote home and community-based care

HEMORRHAGIC STROKE Nursing Interventions

A single event of abnormal, sudden, electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function.

Epilepsy (seizure disorder) – - chronic disorder of abnormal, recurring excessive electrical discharges - recurring seizures accompanied by some type of behavioral change

SEIZURE DISORDERS

affect more than 3 million people strong genetic component

Precipitating factors birth defects head injury/trauma metabolic disorders/renal failure hyponatremia, IICP

The cause is unknown in 70% of all cases

SEIZURE DISORDERS

All people with epilepsy have seizures, but not all people who have a seizure have epilepsy.

Only after a person has two seizures dx. of epilepsy is made

Classification of seizures Partial seizures: begin in one part of the

brain Generalized seizures: involve both

hemispheres of the brain

Seizures

Messages from the body are carried by the neurons (nerve cells) by electrical discharges.

Impulses occur when a nerve cell has a task to perform.

Sometimes there is an excessive imbalance and the cell continues to fire after the task is completed.

Unwanted discharges cause the body to respond erratically.

SEIZURE DISORDERS/Pathophysiology

Consciousness is always impaired Absence seizures (petit mal) -sudden brief cessation of all motor activity accompanied by a blank stare and unresponsiveness. Tonic-clonic seizures (grand mal) - common type of seizures in adults - warning aura may precede generalized seizure activity

Generalized Seizures

Tonic Phase Begins with a sudden loss of consciousness,

sharp muscle contractions Patient may fall to the floor Urinary incontinence is common Breathing ceases and cyanosis develops Pupils are fixed and dilated Tonic phase may lasts – 15 seconds – 1

minute

TONIC-CLONIC SEIZURE

Clonic Phase Alternating contraction/relaxation of the

muscles in all extremities Eyes roll back and the patient froths at the

mouth Phase varies in duration and subsides

gradually Entire seizure generally lasts no more than

60-90 seconds

TONIC-CLONIC SEIZURE

Tonic – Clonic Seizures

Following clonic phase (postictal phase) Person remains unconscious /unresponsive to

stimuli Person is relaxed and breathes quietly Regains consciousness gradually May be confused/disoriented Headache muscle ache and fatigue may follow Amnesia of the seizure may follow

Because of lack of warning with tonic-clonic seizures, head injury, fractures, burns may occur secondary to seizure activity

TONIC-CLONIC SEIZURES

Can develop during seizure activity Seizure becomes continuous– with only short

periods of calm between intense and persistent seizures

Cumulative effect muscular contractions that interfere with respirations

Hypoxia, acidosis, hypoglycemia, hyperthermia and exhaustion may occur if the convulsive activity is not stoped.

medical emergency Goal – stop the seizure (ASAP) Establish and maintain airway is priority

Status Epilepticus

Diagnostic Assessment Confirm the diagnosis, determine any

treatable causes and precipitating factors

Diagnostic Testing MRI/CT Scan EEG Lab data – CBC, biochemistry

SEIZURE DISORDERS/Assessment

Pharmacologic therapy ( AEDs) controls rather than cures seizures

Medication blood levels should be monitored

Antiseizure drugs should not be discontinued abruptly because it can precipitate seizures

Protect the patient from harm, reduce/ prevent seizures activity without impairing cognitive function or producing undesirable side effects

SEIZURE DISORDERS/Medical Management

Phenytoin (Dilantin) Caramazepine ( Tegretol) Gabapentin (Neurotonin) Topiramate (Topamax) Valproate (Depakote,Depakene) Clonazepam (Klonopin) see page 1885

SEIZURE DISORDERS/Medications

Note CNS side effects: blurred vision, slurred speech, confusion

Patients on prolonged therapy may need a diet rich in Vitamin D

Maintain good oral hygiene – phenytoin Obtain liver functions Carry identification indicating type of

seizure -- being treated for

Antiepileptic Drugs

Nursing Diagnosis

Risk for Ineffective Airway Clearance Anxiety Risk for injury r/t seizure activity Readiness for Enhanced Knowledge

Nursing Process

Describe the mechanisms of injury, clinical manifestations, diagnostic testing, and treatment options for patients with brain and spinal cord injuries.

Use the nursing process as a framework for care of clients with brain and spinal cord injury

OBJECTIVES

Involves damage to the neural elements of the spinal cord.

Both sensory and motor function are often involved.

Major causes contusion, compression, laceration, hemorrhage and damage to the blood vessels in the spinal cord.

SPINAL CORD INJURY – (SCI)

A major health problem 200,000 persons in the U.S. live with

disability from SCI Injuries due to: MVAs, falls, acts of violence,

and sports injuries Males account for 82% of SCIs Young people ages 16–30 account for more

than half of all new SCIs African–Americans are at higher risk Risk factors include alcohol and drug use

SPINAL CORD INJURY/SCI

Spinal cord provides a two–way pathway for the conduction of impulses and information to and from the brain and the body

Ascending (sensory) pathways carry information pain, temperature, touch, Descending (motor) pathways carry information about movement

Involve damage to the vertebrae and supporting ligaments as well as the spinal cord.

SPINAL CORD INJURIES

Are the result of excessive force to the spinal column.

Most common causes -> acceleration and deceleration

Acceleration: external force is applied in a rear end collision

Deceleration: occurs in a head on collision

SPINAL CORD INJURIES

Vertebrae frequently Involved 1st, 2nd, and 4th to the 6th cervical vertebra. The 11 thoracic to 2nd lumbar vertebra.

SPINAL CORD INJURY/ SCI

Is determined by the amount of cord involvement

Paraplegia Quadriplegia

CLASSIFICATION of SCI

The patient requires emergency assessment and care and medications.

Initial care immobilization and extrication/stabilization of injuries. And possible surgery.

SCI affects every body system and function.

When injury is C1 to C4 respiratory paralysis is common and ventilator assistance is required

EMERGENCY MANAGEMENT

Neurological examinationDiagnostic x-rays ( cervical spine) CT /MRI ABG’s Trauma Screen

Fluids Medications – corticosteroids, vasopressors,

antispasmodics, NSAIDs, PPI, anticoagulants

Diagnostic Findings

Temporary loss of reflex function (areflexia) below the level of injury at the cervical and upper thoracic spinal cord.

As a result –SNS is interrupted and the PSNS is unopposed.

Muscles become completely paralyzed and flaccid/reflexes are absent

Loss of urinary bladder tone, intestinal peristalsis, perspiration

Recovery from spinal shock is gradual – usually 4-6 weeks.

Complications - Spinal Shock

Exaggerated sympathetic response affects persons with SCI at or above the T6 level.

Caused by visceral distention from distended bladder/impacted rectum

Pounding headache, hypertension, profuse sweating, bradycardia, piloerection (goosebumps)

HOB – high fowler’s, loosen tight clothing Asses bladder distention -catherization Fecal impaction – disimpact immediately

Complications –Autonomic Dysreflexia

Surgery – done to stabilize and support the spine

Stabilization/Immobilization – a type of traction or external fixation device to stabilize the vertebral column and prevent further damage to the cord.

TREATMENTS

SKELETAL FRACTURE REDUCTION/TRACTION

Impaired Gas Exchange Impaired Physical Mobility Impaired Urinary Elimination and

Constipation Sexual Dysfunction

Nursing Diagnosis

Long-term care rehabilitation is needed Learn strategies necessary to cope with

their alterations that the injury imposed on ADL’s

Care for the patient involves members of all health care disciplines

Psychologic support Goal of rehabilitation independence

HOME/COMMUNITY BASED CARE

Herniated intervertebral disk ( ruptured disc, slipped disk) is a rupture of the cartilage surrounding the intervertebral disk with protusion of the nucleus pulposus.

Most common cause of low back pain . May affect 2/3 of people at some point in

their lifetime. Most back problems are related to disk

disease

DEGENERATIVE DISK DISEASE

More common in men than women

Most patient are between the ages of 30-50

Majority of herniated disks occur in the lumbar region (L4 or L5 to S1), when disk herniate in the cervical region, they occur most often in the C6-C7 region

Herniation may be abrupt or gradual

HERNIATED INTERVERTEBRAL DISK

Intervertebral disk is a cartilaginous plate that forms a cushion between the vertebral bodies

Herniation of the intervertebral disk, causes the nucleus of the disk to protrude into the fibrous ring around the disk.

Immediate symptoms are short-lived, and those resulting from injury to the disk do not appear for months or years.

Continuous pressure may cause degenerative changes in the involved area

DEGENERATIVE DISK DISEASE

Pathophysiology

DISK DISEASE

Lumbar Disk recurrent episodes of lower back pain pain radiates across the buttocks and down

the posterior leg (sciatica)

Cervical Disk (C5-C6, C6-C7)Most herniations are the result of degeneration pain and stiffness neck, shoulders, arms pain dull, intermittent pain parethesia of upper extremities

DEGENERATIVE DISK DISEASEClinical Manifestations

Diagnostic findings MRI CT scan EMG Neurologic examination

DEGENERATIVE DISK DISEASEAssessment/Diagnostic Findings

Herniations of the cervical and lumbar disks are most common and are treated conservatively unless the patient is experiencing severe neurologic deficits.

Conservative Treatment Bedrest (no longer recommended) Patient is advised to continue with normal activities while

taking medication for pain, inflammation, and muscle spasms.

NSAID – ibuprofen (Motrin, Advil), naproxen (Naprosyn) Muscle relaxants – cycobenzaprine (Flexeril),

methocarbamol (Robaxin) Hot moist compresses

DEGENERATIVE DISK DISEASEMedical Management

Surgery is sometimes necessary Significant neurological deficit Continuing pain or sciatica Loss of sensory /motor function

Laminectomy-done to relieve the pressure on the nerves

Spinal fusion- insertion of a wedge-shaped piece of bone or bone chips between the vertebrae to stabilize them.

DEGENERATIVE DISK DISEASE

Craniotomy: opening of the skull Purposes: remove tumor, relieve elevated

ICP, evacuate a blood clot, control hemorrhage

Craniectomy: excision of portion of skill Cranioplasty: repair of cranial defect using a

plastic or metal plate Burr holes: circular openings for exploration

or diagnosis, to provide access to ventricles or for shunting procedures, to aspirate a hematoma or abscess, or to make a bone flap

Craniotomy

BURR HOLES

Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies

Medications are usually given to reduce risk of seizures

Corticosteroids, fluid restriction, hyperosmotic agent (mannitol), and diuretics may be used to reduce cerebral edema

Antibiotics may be administered to reduce potential infection

Diazepam may be used to alleviate anxiety

Preoperative Management-medical

Obtain baseline neurologic assessment Assess patient and family understanding of

and preparation for surgery. Provide information, reassurance, and

support

Preoperative -nursing

Intracranial Surgery

Postoperative care is aimed at detecting and reducing cerebral edema

relieving pain preventing seizures, monitor ICP The patient may be intubated and have

arterial and central venous lines.

Post operative

frequent monitoring of respiratory function including ABGs

monitor VS and LOC; noting any potential signs of increasing ICP

assess dressing and check for evidence of bleeding or CSF drainage

monitor for seizures; if seizures occur, carefully record and report these

monitor fluid status and laboratory data

Care of Patient -Assessment

Risk for imbalanced body temperature r/t damage to hypothalamus

Disturbed sensory perception r/t periorbital edema, head dressing

Body image disturbance r/t change in appearance or physical disabilities

Impaired communication (aphasia) r/t injury to brain tissue

Nursing Diagnosis

Strategies to control factors that increase ICP

Avoid extreme head rotation Head of bed may be flat or elevated 30° Suction or encourage coughing cautiously

as needed (suctioning and coughing increase ICP).

Humidification of oxygen may help loosen secretions.

Cerebral perfusion

Sensory deprivation Periorbital edema may impair vision, announce

presence to avoid startling the patient; cool compresses over eyes and elevation of HOB may be used to reduce edema if not contraindicated.

Enhancing self-image Encourage verbalization. Encourage social interaction and social support. Attention to grooming. Cover head with turban and, later, a wig.

Craniotomy- Nursing Interventions

What to expect after surgery medication is taken appropriately rehab – depending on post-op level of function physical therapy – residual weakness/mobility occupational therapy – self care concerns speech therapy – aphasic If prognosis is poor – discuss end of life

preferences

Home/Community based care