Neurologic Nursing 1- Jim

Medical-Surgical NursingThe Neurologic Concepts

JIMMELLEE ELLEN P. OLILANG, RN

References:BRUNNER & SUDDARTH’S TEXTBOOK OF MEDICAL-SURGICAL NURSING

Learning Objectiveson the completion of this chapter, the learner will be able to:

Describe the structure and functions of the central and peripheral nervous systems.

Differentiate between pathologic changes that affect motor control and those that affect sensory pathways.

Compare the functioning of the sympathetic and parasympathetic nervous systems.

Describe the significance of physical assessment to the diagnosis of neurologic dysfunction.

Describe changes in neurologic function associated with aging and their impact on neurologic assessment findings.

Describe diagnostic tests used for assessment of suspected neurologic disorders and the related nursing implications.

Outline of Our Lecture

Anatomy and Physiology Application of the Nursing process in the

approach of neurologic problems: ASSESSMENT – relevant techniques and lab procedures

DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Outline of the lecture

Trauma and related accidentsTraumatic brain injurySpinal cord injury

Cerebrovascular Accidents


Degenerative disorders- demyelinating Multiple sclerosis Guillain-Barre’ syndrome

Degenerative disorders- NON-demyelinating

Alzheimer’s disease Parkinson’s disease


Motor dysfunction- CNSEpilepsy

Motor dysfunction- cranial nerveBell’s palsyTrigeminal neuralgia

Motor dysfunction- peripheralMyasthenia gravis


Infectious DiseaseMeningitisBrain abscessEncephalitis

IMPLEMENTATION PHASE

Increased Intracranial pressureAltered level of consciousnessSeizuresAutonomic dysreflexia / hyperreflexiaSpinal shockCognitive impairmentBowel incontinence

IMPLEMENTATION PHASE

Impaired physical mobility

Impaired swallowingDisturbed sensory perception

A. CEREBRAL DISORDERS Epilepsy Seizures Brain Tumors Cerebrovascular Disease Brain Infections Headaches

B. DEGENERATIVE NEUROLOGIC DISORDERS Dementia (Alzheimers) Parkinson’s Disease Creutzfeldt-Jakob Disease Huntington’s Disease Multiple Sclerosis Guillain Barre Syndrome Myasthenia Gravis Amyotrophic Lateral Sclerosis

C. PERIPHERAL NERVOUS SYSTEM DISORDERS Lower Back Pain Trigeminal Neuralgia Bell’s Palsy Vascular Spinal Cord Lesions Disorders of the Peripheral Nerves

D. NEUROLOGIC TRAUMA Spinal Cord Injury Head Injury

Anatomy and Physiology

Gross anatomy The nervous system is divided into the central and peripheral

nervous system Control all motor, sensory, autonomic, cognitive and behavioral

activities. The Central nervous system consists of the BRAIN and the

SPINAL CORD The peripheral nervous system consists of the SPINAL NERVES

and the CRANIAL NERVES Can be further divided into the: SOMATIC OR VOLUNTARY NERVOUS

SYSTEM AND THE AUTONOMIC OR INVOLUNTARY NERVOUS SYSTEM

BRAIN - it collects, integrates, and interprets all

stimuli - it initiates & monitors voluntary & involuntary motor activity

CEREBRUM (cerbral cortex)BRAIN STEMCEREBELLUM

Cerebrum

-Gives us the ability to think & reason-enclosed in 3 membrane layers called meningesis composed of lobes- Frontal lobe- personality, memory and motor

function Parietal lobe- sensory function Temporal lobe- hearing and olfaction and

emotion by the limbic system Occipital lobe- vision


The cerebellum is involved in coordination and equilibrium

The diencephalon (a part of the cerebellum) consists of the : Thalamus- the relay center of all sensory input

Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response


The brainstem (beneath the diencephalon) Relays messages between the cerebrum &

diencephalon & spinal cord Regulates automatic body fxns e.g. HR, RR,

swallowing, & coughing is composed of: midbrain- for visual and auditory reflexes Pons- respiratory apneustic center, nucleus of cranial

nerves- 5,6,7,8 Medulla oblongata- respiratory and cardiovascular

centers, nucleus of cranial nerves 9,10,11,12

Peripheral Nervous System

Includes: Peripheral sensory nerves transmit stimuli

from sensory receptors in the skin, muscles, sensory organs, & the viscera to the dorsal horn of the spinal cord

The upper motor neurons of the brain & the lower motor neurons of cell bodies in the ventral horn of the spinal cord carry impulses that affect the movement

Autonomic Nervous System

Contains motor neurons that regulate visceral organs & innervate ( supply nerves to ) smooth & cardiac muscles & the glands

TWO PARTS OF ANS

1. sympathetic nervous system Controls the fight or flight response

2. parasympathetic nervous systrem Maintains the baseline of the body functions

Resposible for the rest & digest response

or nervous system is the body’s communication network it coordinates and organizes the functions of all other body systems NERVOUS SYSTEM

Central Nervous System Peripheral Nervous System

Brain Spinal Cord Motor (Efferent) Neurons

Sensory (Afferent )Neuron

Autonomic NervousSystem

Somatic NervousSystem

Sympathetic NervousSystem

ParasympatheticNervous System

the NEURON or NERVE CELL is the nervous system’s fundamental unitthis highly specialized conductor cell receives and transmits electrochemical nerve impulses

delicate, threadlike nerve fibers calledAXONS & DENDRITES extend from thecell body & transmit signals

Axons carry impulses away from the cell body;dendrites carry impulses to the cell body

this intricate network of interlockingreceptors & transmitters, along withthe brain & spinal cord, forms a livingcomputer that controls & regulates everymental and physical function

Each neuron communicates with eachother to a specific target tissue throughneurotransmitters

These neurotransmitters are produced& stored in the synaptic vesicles;theyenable conduction of impulses across thesynaptic cleft

The action of neurotransmitters is to potentiate, terminate or modulate a specific action & can either excite or inhibit the target cell’s activity.

MAJOR NEUROTRANSMITTERS:

1. Acetycholine2. Serotonin3. Dopamine

4. Norepinephrine5. Gamma-aminobutyric acid (GABA)6. Enkephalin,endorphin

Major NeurotransmittersNEUROTRANSMITTER SOURCE ACTION

ACETYLCHOLINE- (major transmitter of the parasympathetic nervous system)

Many areas of the brain; autonomic Nervous System

Usually excitatory; parasympathetic effects sometimes inhibitory (simulation of heart by vagal nerve)

SEROTONIN Brain stem, hypothalamus, dorsal horn of the spinal cord

Inhibtory, helps control mood and sleep, inhibits pain pathways

DOPAMINE Substantia Nigra and basal ganglia

Usually inhibits, affects behavior (attention, emotions, fine movements)

Major Neurotransmitters

NEUROTRANSMITTER SOURCE ACTION

ACETYLCHOLINE- (major transmitter of the parasympathetic nervous system)

Many areas of the brain; autonomic Nervous System

Usually excitatory; parasympathetic effects sometimes inhibitory (simulation of heart by vagal nerve)

SEROTONIN Brain stem, hypothalamus, dorsal horn of the spinal cord

Inhibtory, helps control mood and sleep, inhibits pain pathways

DOPAMINE Substantia Nigra and basal ganglia

Usually inhibits, affects behavior (attention, emotions, fine movements)

ENKEPHALIN, ENDORPHIN

Nerve terminals in the spine, brain stem, thalamus and hypothalamus, pituitary gland

Excitatory; pleasurable sensation, inhibits pain transmission

consists of the brain & the spinal cord that are protected by the bony skull and vertebrae, cerebrospinal fluid (CSF) and three membranes: the dura mater, the arachnoid membrane and the pia materThe brain is contained in the rigidskull, which protects it from injury;themajor bones of the skull are the frontal,temporal, parietal & occipital bones;These bones join at the suture lines The bones of the vertebral columnsurround & protect the spinal cord &normally consists of 7 cervical, 12thoracic, 5 lumbar vertebrae,sacrum &coccyx.

Scalp skin

Inner /Outer layers of the Skull

Dura mater (2 layers)

is a tough,fibrous, leatherlike tissue Composed of two layers:

1. Endosteal dura:forms the periosteum Of the skull & is continuous with the Lining of the vertebral canal

2. Meningeal dura: a thick membranecovers the brain, dipping between the brain tissue & providing support & protection

Arachnoid mater: is a thin, fibrousmembrane that hugs the brain &spinal cord

Pia mater: is a continuous layer of Connective tissue that covers & Contours the spinal tissue & brain

The epidural space lies between the skull & the dura mater

Between the dura mater & the arachnoid membrane is the subdural space Between the arachnoid membrane& the pia mater is the subarachnoidspace

Within the subarachnoid space & the brain’s four ventricles is CSF, aliquid composed of water & tracesof organic materials (especially CHON)glucose and minerals;this fluid protectsthe brain & spinal tissue from jolts &blows

ASSESSMENT OF THE NEUROLOGIC SYSTEM

HISTORY Initial interview provides excellent opportunity to explore the current condition and events while observing appearance, mental status, posture, movement and affect.

A confused client becomes an unreliable source of history


PHYSICAL EXAMINATION 5 categories:

1. Cerebral function- LOC, mental status 2. Cranial nerves 3. Motor function 4. Sensory function 5. Reflexes


Neuro CheckLevel of consciousnessPupillary size and responseVerbal responsivenessMotor responsivenessVital signs

CEREBRAL FUCTION

Assess the degree of wakefulness/alertness

Note the intensity of stimulus to cause a response

Apply a painful stimulus over the nailbeds with a blunt instrument

Ask questions to assess orientation to person, place and time

Cerebral function

Utilize the Glasgow Coma Scale An easy method of describing mental status and abnormality detection

Tests 3 areas- eye opening, verbal response and motor response

Scores are evaluated- range from 3-15 No ZERO score

Glasgow Coma Scale

Glasgow Coma ScoreEye Opening (E)Verbal Response (V)Motor Response (M)

Glasgow Coma Scale

Glasgow Coma ScoreEye Opening (E)

4=Spontaneous3=To voice2=To pain1=None (No response)

Glasgow Coma Scale

Glasgow Coma ScoreVerbal Response (V)

5=Normal/oriented4=Disoriented/CONFUSED3=Words, but incoherent/ inappropriate2=Incomprehensible/mumbled words1=None

Glasgow Coma Scale

Glasgow Coma Score Motor Response (M)

6=Normal- obeys command5=Localizes pain4=Withdraws to pain3=Decorticate posture2=Decerebrate posture

1=None (flaccid)

GLASGOW COMA SCALE

CONSCIOUS glasgow coma of 12 – 15

LIGHT STUPOROUS 9 – 11DEEP STUPOROUS 7 – 8LIGHT COMA 4 – 6 DEEP COMA 3

PUPILLARY CHANGES

Unilateral dilated (4mm)Fixed non-reactive

uncal herniationBrain stem compressionSubdural / epidural hematomaTentorial / herniation

Bilateral dilated (4mm) Fixed non-reactive

Severe midbrain damageCP arrest

Bilateral mid-sized (2mm)Fixed non-reactive

Midbrain involvement caused by edema, hemorrhage, infarction, lacerations, contusions

Pipillary Changes

Bilateral Pinpoint (<1mm)Non-reactive

Lesions of the pons

Unilateral, small (1.5mm)Non-reactive

Disruption of the SNS supply to the head due to spinal card lesion above T1

CRANIAL NERVES

Cranial Nerves

I olfactory smellII optic visionIII oculomotor Most eye mov’t, pupillary constriction,

upper eyelid elevationIV trochlear Down & in down mov’tV trigeminal Chewing, corneal reflex, face & scalp

sensationsVI abducen

tLateral eye movement

CRANIAL NERVES

Cranial Nerves

VI abducent Lateral eye movement VII facial Expressions in foreheadVIII acoustic Hearing & balanceIX glossopha

ryngealSwallowing, salivating, taste

X vagus Swallowing, gag reflex, talking, sensations of the throat, larynx & abd’l viscera, activities of thoracic & abd’l viscera, e.g. HR, & peristalsis

XI accessory Shoulder mov’t, head rotationXII hypoglossal Tongue mov’t

Cranial Nerve Function: Cranial Nerve 1- Olfactory

Check first for the patency of the nose Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for the identification

Repeat with the other nostrils PROBLEM- ANOSMIA- “loss of smell”

Cranial Nerve Function: Cranial Nerve 2- Optic

Check the visual acuity with the use of the Snellen chart

Check for visual field by confrontation test

Check for pupillary reflex- direct and consensual

Fundoscopy to check for papilledema

Snellen chart

Cranial Nerve Function: Cranial Nerve 3, 4 and 6

Assess simultaneously the movement of the extra-ocular muscles

Deviations:Opthalmoplegia- inability to move the eye in a directionDiplopia- complaint of double vision

Cranial Nerve Function: Cranial Nerve 5 -trigeminal

Sensory portion- assess for sensation of the facial skin

Motor portion- assess the muscles of mastication

Assess corneal reflex

Cranial Nerve Function: Cranial Nerve 7 -facial

Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water

Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory

Test patient’s hearing acuityObserve for nystagmus and disturbed balance

Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal

Together with Cranial nerve 10 –vagusAssess for gag reflexWatch the soft palate rising after instructing the client to say “AH”

The posterior one-third of the tongue is supplied by the glossopharyngeal nerve

Cranial Nerve Function: Cranial Nerve 11- accessory

Press down the patient’s shoulder while he attempts to shrug against resistance

Cranial Nerve Function: Cranial Nerve 12- hypoglossal

Ask patient to protrude the tongue and note for symmetry

NEUROLOGIC ASSESSMENT

CEREBRAL FUNCTIONIncludes level of consciousness, intellectual function, speech, speech, memory, patterns of emotional behavior, balance & coordination

DESCRIBING LEVEL OF CONCIOUSNESS

AWAKE – alert & completely oriented - responds to verbal & painful stimuli SLEEP – becomes alert & oriented when awakened - responds to stimuli CONFUSION – has short attention span & misinterpret

information - disoriented to time, place, person & has trouble

following commands, but still responds to stumuli

DESCRIBING LEVEL OF CONSCIOUSNESS

DELIRIUM – disoriented, agitated, & perhaps may have hallucinations, & responds to stimuli

OBTUNDED – remains drowsy when awakened, disoriented & confused

- stays awake only if he’s continously stimulated LIGHT STUPOR – does not respond to stimuli, withdraws

quickly & forcefully from moderate pain which he can localize

DEEP STUPOR – responds only to a strong stimulus, when he can’t localize

- may note decerebrate posture

DESCRIBING LEVEL OF CONSCIOUSNESS

COMA – doesn’t responds to any stimuli - vital signs may be stable - may note brain stem & spinal cord reflexes

- EEG shows activityCEREBRAL DEATH – vital signs must be

maintained artificially - has reflexes & no EEG activity - doesn’t responds to stimuli

ASSESS Motor function

Assess muscle tone and strength by asking patient to flex or extend the extremities over resistance

Grading of muscle strength

GRADING SCALE FOR MOTOR STRENGTH

5/5 movement against gravity with strong resistance

4/5 movement against gravity with some resistance

3/5 movement against gravity with out resistance

2/5 movement not against gravity1/5 trace movement0/5 no movement

Assessing the motor function of the cerebellum

Test for balance- heel to toe Test for coordination- rapid alternating movements and finger to nose test

ROMBERG’s is actually a test for the posterior spinothalamic tract

Assessing the motor function of the brainstem

Test for the Oculocephalic reflex- doll’s eye

Normal response- eyes appear to move opposite to the movement of the head

Abnormal- eyes move in the same direction

Assessing the motor function of the brainstem

Test for the Oculovestibular reflexSlowly irrigate the ear with cold water and warm water

Normal response- cOld- OppOsite, wArM- sAMe

Assessing the sensory function

Evaluate symmetric areas of the bodyAsk the patient to close the eyes while testingUse of test tubes with cold and warm waterUse blunt and sharp objectsUse wisp of cottonAsk to identify objects placed on the handsTest for sense of position

Assessing the reflexesDeep tendon/muscle-stretch reflexes – assymetrical – indicate paralysis

- brisk response – indicate localizing value - absent – deep coma

BicepsTricepsBrachioradialisPatellarAssessing the sensory function Achilles

Assessing the reflexes

Superficial /cutaneous reflexes Abdominal Cremasteric Anal

Pathologic/primitive reflex Babinski- stroke the lateral aspect of the soles doing an

inverted “J” (+)- DORSIFLEXION of the Big toe with fanning out of the

little toes Brudzinski & kernig’s sign – meningeal irritation in

meningitis

Grading of reflexes

Deep tendon reflex 0- absent + present but diminished ++ normal +++ increased ++++ hyperactive or clonicSuperficial reflex 0 absent +present

DIAGNOSTIC TESTS

EEG (electroencephalogram) – represents a record of electrical activity generated in the brain. It provides physiologic assessment of cerebral activity and determining brain death

Test diagnosing and evaluating Sz disorders, coma, or organic brain syndrome

Withhold medications that may interfere with the results- anticonvulsants, sedatives and stimulants

Wash hair thoroughly before procedure It takes 45 to 60 mins

Nursing interventions to patient undergoing EEG

Recommend the patient not to sleep the night before the procedure to increase the chances of recording Sz activities.

Anti Sz agents, tranquilizers, stimulants and depressants shld be withheld 24 to 48 hours before the test

DIAGNOSTIC TESTS

CT scan – makes use of a narrow x-ray beam to scan the body part in successive layers

With radiation risk If contrast medium will be used- ensure consent,

assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected. The injection of the water soluble iodinated contrast agent into the subarachnoid space through the lumbar puncture improves the visualization of the spinal and intracranial contents on these images.

Nursing interventions for patient undergoing CT scan

Teach the patient the need to lie quietly throughout the procedure

Sedation could be used if agitation and restlessness interfere with the successful study

For patient is to be using a contrast agent: Assess the patient for allergy to iodine and shellfish because

the agent is iodine based IV line is needed for the contrast flushing A period of fasting for 4 hours is needed

Assess for the S/Sx of allergy like flushing, nausea & vomiting

DIAGNOSTIC TESTS

MRIUses magnetic wavesPatients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure

DIAGNOSTIC TESTS

Cerebral arteriographyNote allergies to dyes, iodine and seafood

Ensure consentKeep patient at rest after procedureMaintain pressure dressing or sandbag over punctured site

DIAGNOSTIC TESTS

Lumbar puncture and examination of CSFEnsure consent, determine ability to lie stillContraindicated in patients with increased ICPKeep flat on bed after procedureIncrease fluid intake after procedureCSF pressure with the patient in lateral position is normally 70 – 200 mmH20.> 200 mm H20 = abnormal

Lumbar puncture (spinal tap)

It is performed to obtain CSF for examination, to measure and reduce CSF pressure, to determine presence or absence of blood in the CSF, to detect subarachnoid block, & to administer antibiotics intrathecally (into the spinal canal)

Queckenstedt’s Test – lumbar manometric test – compress the jugular veins on each side of the neck during the lumbar puncture Normal- CSF pressure is increased Slow rise and fall in pressure- indicates a partial block due to

a lesion compressing the spinal arachnoid pathways

Lumbar puncture (spinal tap)

Cerebrospinal AnalysisNormal – clear & colorlessCerebral contusion, laceration, subarachnoid hemorrhage - Pink, blood-tinged, or bloody CSF

Increased Intracranial pressure

Intracranial pressure more than 15 mmHgBrunner= Normal intracranial pressure 10-20 mmHgCauses: Head injury Stroke Inflammatory lesions Brain tumor Surgical complications


Pathophysiology The cranium only contains the brain substance (1400g),

the CSF (75mL) and the blood/blood vessels (75 ml) MONRO-KELLIE hypothesis- an increase in any one of the

components causes a change in the volume of the other Any increase or alteration in these structures will cause

increased ICP Increased ICP from any cause decrease cerebral

perfusion, stimulates further swelling and may shift brain tissue through openings in the rigid dura, resulting herniation


PathophysiologyDecompensatory mechanisms: 1. Decreased cerebral perfusion 2. Decreased O2 leading to brain hypoxia 3. Cerebral edema 4. Brain herniation

Decreased cerebral blood flow

Vasomotor reflexes are stimulated initially slow bounding pulses

Increased concentration of carbon dioxide will cause VASODILATION increased flow increased ICP

Cerebral Edema

Abnormal accumulation of fluid in the intracellular space, extracellular space or both.

Herniation

Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem

Cerebral response to increased ICP

1. Steady perfusion up to 40 mmHg2. Cushing’s response

Vasomotor center triggers rise in BP to increase ICP

Sympathetic response is increased BP but the heart rate is SLOW

Respiration becomes SLOW

Increased intracranial pressure

CLINICAL PICTURE:Subtle to dramatic changes in LOC; restlessness, confusion, drowsiness, stupor, coma

Double or blurred vision, headache, nausea\ and vomiting, photosensitivity

Decreased motor functionLate findings: Changes in vital signs (widening of pulse pressure, bradycardia, tachypnea)


CLINICAL MANIFESTATIONSEarly manifestations:Changes in the LOC- usually the earliest

Pupillary changes- fixed, slowed response Headache vomiting


CLINICAL MANIFESTATIONSlate manifestations: Cushing reflex- systolic hypertension, bradycardia and wide pulse pressure

bradycardia Hyperthermia Abnormal posturing

Increased Intracranial pressureNursing interventions: Maintain patent airway 1. Elevate the head of the bed 15-30 degrees- to

promote venous drainage Assess VS 2. assists in administering 100% oxygen or

controlled hyperventilation- to reduce the CO2 blood levelsconstricts blood vesselsreduces edema

Notify physicians of findings Keep head in neutral alignment Avoid flexion of the neck or hips

Increased Intracranial Pressure

minimize environmental stimuli document patient’s status, phone call to physician and physician response thereafter

Increased intracranial pressure

FOCUSED ASSESSMENT Assess neuro status Assess cranial nerves as condition allows Asses Oxygen saturation, cardiac rhythm Assess for signs of decreased oxygenation

STABILIZING & MONITORING Monitor neuro status & V/S Keep SBP bet. 100mmHg-160mmHg (check AP for parameters)g Limit suctioning (<10secs in duration, adm. O2 before hand; limit to 2

passes Maintain O2 sat at 100%

Increased ICP

Maintain & assess I&O Monitor ABG & electrolytes Insert oral / nasal airway if neccesary Maintain quiet environment; protect from injury Provide education/reassurance/comfort measures Document all findings & communicate to

physicians Obtain/perform chest physiotherapy as needed;

assess nutritional status; obtain consult as needed


Nursing interventions3. Administer prescribed medications- usually Mannitol- to produce negative fluid balance

corticosteroid- to reduce edema anticonvulsants- to prevent seizures


Nursing interventions4. Reduce environmental stimuli5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning


Nursing interventions6. Keep head on a neutral position. AvOID- extreme flexion, valsalva

7. monitor for secondary complicationsDiabetes insipidus- output of >200 mL/hrSIADH

Altered level of consciousness

It is a function and symptom of multiple pathophysiologic phenomena

Causes: head injury, toxicity and metabolic derangement

Disruption in the neuronal transmission results to improper function


AssessmentOrientation to time, place and person

Motor functionDecerebrateDecorticate

Sensory function


Patient is not orientedPatient does not follow commandPatient needs persistent stimuli to be awake

Inability to speakConfused, lethargic, obtunded, stuporous, or comatose


Etiologic Factors1. Head injury 2. Stroke3. Drug overdose4. Alcoholic intoxication5. Diabetic ketoacidosis6. Hepatic failure


ASSESSMENT1. Behavioral changes initially2. Pupils are slowly reactive 3. Then , patient becomes unresponsive

and pupils become fixed dilatedGlasgow Coma Scale is utilized


Nursing Intervention1. Maintain patent airway Elevate the head of the bed to 30 degrees Suctioning2. Protect the patient Pad side rails Prevent injury from equipments, restraints and etc.


Nursing Intervention3. Maintain fluid and nutritional balance Input and output monitoring IVF therapy Feeding through NGT4. Provide mouth care Cleansing and rinsing of mouth Petrolatum on the lips


Nursing Intervention5. Maintain skin integrity Regular turning every 2 hours 30 degrees bed elevation Maintain correct body alignment by using trochanter rolls,

foot board6. Preserve corneal integrity Use of artificial tears every 2 hours


Nursing Intervention7. Achieve thermoregulation Minimum amount of beddings Rectal or tympanic temperature Administer acetaminophen as prescribed8. Prevent urinary retention Use of intermittent catheterization


Nursing Intervention9. Promote bowel function High fiber diet Stool softeners and suppository10. Provide sensory stimulation Touch and communication Frequent reorientation

SEIZURES

Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons

A part or all of the brain may be involved

SEIZURES

PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain

section EMITS ELECTRICAL IMPULSES excessively CLINICAL PICTURE

Repetitive, jerky mov’t of all extremities Extreme muscle rigidity LOC or disorientation Tongue or eye deviation Cyanosis/apnea Urinary or fecal incontinence Blinking or repetitive behaviors (playing buttons)

SEIZURE

CLINICAL PICTUREDifficulty in arousingAura ( warning or recognition that seizures may occur)

SEIZURES

ETIOLOGIC FACTORS1. Idiopathic2. Fever3. Head injury4. CNS infection5. Metabolic and toxic conditions

SEIZURE

6 types of seizures: Simple partial-sensory symptoms (flashing lights, smells,

auditory hallucinations) Autonomic symptoms (sweating, flushing, pupil dilation) Psych symptoms ( dream states, anger, fear)

Complex partial seizure Altered LOC Amnesia

Absence seizure A brief change in LOC indicated by blinking or rolling of the eyes, a blank stare, and a slight mouth mov’t

SEIZURE Myoclonic seizure

Brief involutary muscular jerks of the body or extremities Generelized tonic-clonic seizure

Typically beginning with a loud cry Change in LOC Body stiffening, alternating between muscle spasm & relaxation Tongue biting, incontinence, labored breathing, apnea, cyanosis, Upon wakening, possible confusion & difficulty talking Drowsiness, fatigue, headache, muscle soreness, weakness

Atonic seizure General loss of postural tone Temporary loss of consciousness

SEIZURES

Nursing InterventionsDuring seizure 1. remove harmful objects from the patient’s surrounding

2. ease the client to the floor 3. protect the head with pillows 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure

SEIZURES

Nursing InterventionsDuring seizure5. loosen constrictive clothing6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

SEIZURES

Nursing InterventionsPOST seizure 1. place patient to the side to drain secretions and prevent aspiration

2. help re-orient the patient if confused 3. provide care if patient became incontinent during the seizure attack

4. stress importance of medication regimen

HEADACHE

Cephalgia-pain in the head 90% is caused by muscle contraction & vascular abnormalities Indicates underlying intracranial, systemic, psychological disorderTYPES OF HEADACHE:

1. Primary headache- no organic cause2. Secondary headache- with organic cause3. Migraine headache/throbbing vascular headache-periodic

attacks of headache due to vascular disturbance Affect 10% of Americans Begin in childhood or adolescence & recur throughout adulthood Tend to run in families w/c are common in women than men

4. Tension headache-the most common type- due to muscle tension

CAUSES OF HEADACHE Emotional stress or fatigue Menstruation Environmental stimuli (crowds, noise, bright lights) Glaucoma Inflammation of the eyes or nasal/paranasal sinus mucosa Disease of the scalp, teeth, external/middle ear Vasodilators (nitrates, alcohol, histamine) Systemic disease HPN Head trauma/tumor Intracranial bleeding

headache

Migraine-unilateral pulsating pain w/c become more generalized overtime lasting up to 2days

Stages of migraine

1. Prodrome stage – symptom indicating the onset2. Aura phase – a sensation that forewarns of an attack

- Usually affects the patient’s eyesight with brilliant flickering lights or blurring of vision, but may also result from numbness or weakness of limbs

3. Headache4. Recovery phase

OTHER TYPES OF HEADACHE

HEADACHE

Muscular contraction & traction- inflammatory vascular headache Dull, persistent ache or severe, unrelenting pain Tender spots on the head & neck Feeling of tightness around the head with a

characteristic “hatband” distribution

HEADACHE

INTRACRANIAL BLEEDING Neuro deficits, such as paresthesia & muscle

weakness Unrelieved by opiods

HEADACHE

TUMOR Pain that’s most severe when the patient is awake

headache

Nursing Interventions 1. Avoid precipitating factors 2. modify lifestyle 3. relieve pain by pharmacologic measures

Beta-blockers Serotonin antagonists- “triptan"

Autonomic Dysreflexia/hyperreflexiaSeen commonly in spinal cord injury

An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation

Autonomic Dysreflexia/hyperreflexia

SKELETAL SPINE


Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion


NURSING INTERVENTIONS 1. Elevate the head of the bed immediately 2. Check for bladder distention and empty bladder with

urinary catheter 3. Check for Fecal impaction and other triggering factors like

skin irritation, pressure ulcer 4. Administer antihypertensive medications- usually

hydralazine

Spinal Shock

Pathophysiology The sudden depression of reflex activity in the spinal

cord below the level of injury The muscles below the lesion are flaccid, the skin

without sensation and the reflexes are absent including bowel and bladder functions

Spinal Shock

Nursing Interventions 1. Assist in chest physical therapy 2. Manage potential complication- DVT

Cognitive Impairment

Nursing Interventions1. Assist or encourage the patient to use eyeglass,

hearing aid or assistive devices2. Reorient the patient by calling his name frequently3. Provide background information as to date, time,

place, environment

Cognitive Impairment

Nursing Interventions4. Use large signs as visual cues5. Post patient's photo on the door6. Encourage family members to bring personal articles

and place them in the same area

Bowel and Bladder incontinence

Establish a regular pattern for bowel care Maintain a dietary intake. Avoid foods that can cause

excessive gas production

CONGENITAL DISORDERS:Hydrocephalus

Excessive CSF accumulation in the brain’s ventricular system leading to their enlargement and swelling

In infants- head enlarges In children and adults- brain compression


Non-communicating hydrocephalus results from CSF outflow obstruction

Communicating hydrocephalus results from faulty absorption or increased CSF production


Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes – or setting sun; sclera is above the iris;

depressed eyes


DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography – x ray exam of the ventricles of

the brain after the introduction of the introduction of the contrast medium, such as air or radiopaque material; has been replaced by ct scan & MRI


GOAL OF Treatment: to minimize & prevent brain damage by improving CSF flow

Nursing Intervention 1. monitor neurologic status 2. teach parents to watch for signs of shunt

malfunction, and periodic surgery to lengthen the shunt as child grows

hydrocephalus

Shunting-surgical intervention to primary treat hydrocephalus It includes the direct removal of the obstruction with in

the brain so as to allow CSF to bypass the obstructed area, if the obstructed cannot be removed

Shunting of CSF to an outside of the brain Right atrium of the heart Abdominal peritoneum

Cautery – destruction by burning or removal of the parts of the ventricles that produce CSF may reduce CSF production

Traumatic brain injury

1. CONCUSSION Involves jarring of head without tissue injury Temporary loss of neurologic function lasting for a

few minutes to hours


2. CONTUSION Involves structural damage The patient becomes unconscious for hours


3. Diffuse Axonal injury Involves widespread damage to the neurons Patient has decerebrate and decorticate posture


4. Intracranial hemorrhageEpidural Hematoma- blood collects in the epidural

space between skull and dura mater. Usually due to laceration of the middle meningeal arterySymptoms develop rapidly


4. Intracranial hemorrhageSubdural hematoma- a collection of blood between the

dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vesselsSymptoms usually develop slowly


4. Intracranial hemorrhageIntracerebral Hemorrhage and hematoma- bleeding into the

substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalitiesSymptoms develop insidiously, beginning with severe headache and neurologic deficits


MANIFESTATIONS 1. Altered LOC 2. CSF otorrhea 3. CSF rhinorrhea 4. Racoon eyes and battle sign

HALO SIGN- blood stain surrounded by a yellowish stain


NURSING MANAGEMENT1. Monitor for declining LOC- use of Glasgow2. Maintain patent airway Elevate bed, suction prn, monitor ABG


NURSING MANAGEMENT3. Monitor F and E balance Daily weights IVF therapy Monitor possible development of DI and SIADH


4. Provide adequate nutrition5. Prevent injury Use padded side rails Minimize environmental stimuli Assess bladder Consider the use of intermittent catheter


6. Maintain skin integrity Prolonged immobility will likely cause skin

breakdown Turn patient every 2 hours Provide skin care every 4 hours Avoid friction and shear forces


7. Monitor potential complications Increased ICP Post-traumatic seizures Impaired ventilation

Spinal cord injury

The most frequent vertebrae – C5-C7, T12 and L1 Concussion Contusion Compression Transection

is trauma to the spinal cord which resultsIn complete (transection) or partial disruptionNerve tracts & neurons

The level of cord involved dictates theconsequences of spinal cord injury

most frequently vertebrae involved are:• 5th,6th, 7th cervical• 12th thoracic•1st lumbar

majority of spinal cord injury occur from car accidents, falls or sports injuries

Risk factors:• male• High risk lifestyle activities• Active in sports• Age (teen to early 20’s)• Alcohol and/or drug abuse

injuries may involve contusions, laceration,Or compression of the spinal cord

After an injury

Petechial hemorrhages in theCentral gray matter of the cord

ischemia

Edema results to Permanent damage

Spinal cord loses functionBelow the level of lesion

Spinal Shock: decrease reflexes flaccid paralsis

Neurogenic Shock: Sudden disruption of sympathetic nervous system

Hypotension

bradycardia

Hypothermia

Warm/dry extremities

Peripheral vasodilation that lead venous pooling

Decrease cardiac output

Spinal cord injury

Clinical manifestations 1. Paraplegia 2. quadriplegia 3. spinal shock

are classified according to cause, level of injury and degree of disruption produced

Central cord syndrome

•Characteristics: Motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved.•Cause: Injury or edema of the central cord, usually of the cervical area.

Anterior cord syndrome

•Characteristics: Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact.•Cause: The syndrome may be caused by acute disk herniation or hyperflexioninjuries associated with fracture-dislocation of vertebra. It also may occur as a result of injury to the anteriorspinal artery, which supplies the anteriortwo-thirds of the spinal cord.

Brown-Séquard syndrome (lateral cord syndrome)

•Characteristics: Ipsilateral paralysis or paresis, together with ipsilateral loss of touch, pressure, and vibration andcontralateral loss of pain & temperature.•Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, fracture/dislocation of a unilateral articular process, or possibly an acute ruptured disk.

DIAGNOSTIC TESTS/LABORATORY

1. History & physical examination2. X-rays3. MRI4. CT Scan5. ElectromyographyCOMPLICATION

1. Paralysis2. Autonomic dysreflexia3. Neurogenic shock (spinal shock)4. Contractures5. Muscle atrophy6. Pressure ulcers7. Stool impaction8. Death

PHARMACOLOGY

1. Glucocorticoids: Decadron2. Vasopressors: Norepinephrine,dopamine 3. Muscle relaxants: methocarbamol4. Anti-spasmodics:dantrolene sodium5. Analgesics:opioid & non opioid NSAIDS6. Antidepressants7. Histamine H2 receptor antagonists8. Anticoagulant9. Stool softeners10. vasodilators

NURSING MANAGEMENT

1. Assess/Monitor:a.Vital signsb.Neurological statusc. For signs of thrombophlebitisd. For spinal shocke. For autonomic dysreflexia:hypertension,bradycardia,flushed face & neck,severe headache,nasal stuffiness, dilated pupils,Blurred vision, sweating,nausea)f. Oxygen saturation levelsg. For bladder distentionh. For indications of altered body image/Self concept

2. Nursing activities:a.Maintain patent airwayb. Maintain mechanical ventilation asPrescribedc. Perform passive exercisesd. Encourage deep breathing exercisese. Encourage active exercisesf. Maintain skin integrityg. Assist with turning as neededh. Maintain adequate fluid intakei.Teach self-catheterizationj.Institute bowel retraining as neededk.Teach regarding sexual function/dysfunction

Spinal cord injury

DIAGNOSTIC TEST Spinal x-ray CT scan MRI

Spinal cord injury

EMERGENCY MANAGEMENT A-B-C Immobilization Immediate transfer to tertiary facility

Spinal cord injury

NURSING INTERVENTION 1. Promote adequate breathing and airway clearance 2. Improve mobility and proper body alignment 3. Promote adaptation to sensory and perceptual

alterations 4. Maintain skin integrity

Spinal cord injury

5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage complications

Thromboplebhitis Orthostaic hypotension Spinal shock Autonomic dysreflexia

Spinal cord injury

9. Assists with surgical reduction and stabilization of cervical vertebral column

is an umbrella term that refers to any functional abnormality of the CNS that occurs when the normal blood supply to the brain is disrupted

Modifiable risk factors include: A.Hypertension: major risk factor is the key to preventing strokeB.Cardiovascular disease: cerebral emboli may originate in the heart;atrial fibrillation, coronary artery disease, heart failure, left ventricular hypertrophy, MI, RHDC.High cholesterol levelsD.ObesityE. Elevated hematocrit:increases the risk of cerebral infarctionF. Diabetes mellitusG. Oral contraceptive useH. SmokingI. Drug abuseJ. Excessive alcohol consumption

CEREBROVASCULAR ACCIDENTS

Can be divided into two major categories 1. Ischemic stroke- caused by thrombus and

embolus 2. Hemorrhagic stroke- caused commonly by

hypertensive bleeding

It can be divided into two major categories:

1. Ischemic: vascular occlusion and significant hypoperfusion occur;causes: are large artery thrombosis, small penetrating artery thrombosis, cardiogenic embolic, cryptogenic (no known cause)

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus

Pathophysiology of ischemic stroke

Disruption of blood supply Decreased ATP production leads to impaired

membrane function Cellular injury and death can occur


Motor Loss Hemiplegia Hemiparesis


Communication loss Dysarthria= difficulty in speaking Aphasia= Loss of speech Apraxia= inability to perform a previously learned

action


Perceptual disturbances Hemianopia

Sensory loss paresthesia

RISKS FACTORS

Non-modifiable Advanced age Gender race

Modifiable Hypertension Cardio disease Obesity Smoking Diabetes mellitus hypercholesterolemia


DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography


NURSING INTERVENTIONS1. Improve Mobility and prevent joint deformities Correctly position patient to prevent contractures

Place pillow under axilla Hand is placed in slight supination- “C” Change position every 2 hours


NURSING INTERVENTIONS2. Enhance self-care Carry out activities on the unaffected side Prevent unilateral neglect Keep environment organized Use large mirror


NURSING INTERVENTIONS3. Manage sensory-perceptual difficulties Approach patient on the Unaffected side Encourage to turn the head to the affected side to

compensate for visual loss


NURSING INTERVENTIONS4. Manage dysphagia Place food on the UNAFFECTED side Provide smaller bolus of food Manage tube feedings if prescribed


NURSING INTERVENTIONS5. Help patient attain bowel and bladder control Intermittent catheterization is done in the acute

stage Offer bedpan on a regular schedule High fiber diet and prescribed fluid intake


NURSING INTERVENTIONS6. Improve thought processes Support patient and capitalize on the remaining

strengths


NURSING INTERVENTIONS7. Improve communication Anticipate the needs of the patient Offer support Provide time to complete the sentence Provide a written copy of scheduled activities Use of communication board Give one instruction at a time


NURSING INTERVENTIONS8. Maintain skin integrity Use of specialty bed Regular turning and positioning Keep skin dry and massage NON-reddened areas Provide adequate nutrition


NURSING INTERVENTIONS9. Promote continuing care Referral to other health care providers


NURSING INTERVENTIONS10. Improve family coping11. Help patient cope with sexual dysfunction

2. Hemorrhagic: there is extravasation of blood in the brain; causes: are intracerebral hemorrhage, subarachnoid hemorrhage,cerebral aneurysm & arteriovenous malformation

CVA: Hemorrhagic Stroke

Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP

Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage


Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances

Destruction (infarction) of brain cells caused by a reduction in oxygen supply.

Symptoms depend on the area of the brain involved and extent of damage; may be masked or delayed because of compensatory collateral circulation through the circle of Willis.


DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP)


NURSING INTERVENTIONS 1. Optimize cerebral tissue perfusion 2. relieve Sensory deprivation and anxiety 3. Monitor and manage potential complications

General manifestations

CEREBROVASCULAR ACCIDENTS

The stroke continuum 1. TIA- transient ischemic attack, temporary

neurologic loss less than 24 hours duration 2. Reversible Neurologic deficits 3. Stroke in evolution 4. Completed stroke

Classified using the time course in the following manner: 1. Transient Ischemic Attack (TIA)

Temporary episode of neurologic dysfunction manifested by a sudden loss of motor, sensory or visual functionIt may last a few seconds or minutes but no longer 24 hoursComplete recovery usually occurs between attacksServe as a warning of impending stroke which has its greatest incidence in the first month after the first attack

2. Reversible Ischemic Neurologic Deficits (RIND) Signs & symptoms are consistent with but more pronounced than a TIA and last more than 24 hours

Symptoms resolve in days with no permanent neurologic deficits

3. Stroke in evolution

Worsening of neurologic signs & symptoms over several minutes or hours; This is a progressing stroke

4. Complete Stroke

Stabilization of the neurologic signs and symptoms

This indicates no further progression of the hypoxic insult to the brain from this particular ischemic attack

CLINICAL FINDINGS OF CVD:

1. Subjective: syncope; headache; changes in level of consciousness; transient paresthesias (with TIAs); mood swings.

2. Objective:

a.Convulsionsb.Hemiplegia on side opposite the lesion (initially flaccid then spastic)

COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES

Left Hemispheric Stroke Right Hemispheric StrokeParalysis /weakness on R side Paralysis/weakness on L side of the body of the body Left visual field deficitRight visual field deficit Spatial-perceptual deficits Aphasia (expressive,receptive, Increased distractibility Or global) Impulsive behavior and poor judgment Altered intellectual ability Lack of awareness of deficitsSlow, cautious behavior


c. Aphasia: brain unable to fulfill its communicative functions because of damage to input, integrative, or output centers.

1.Expressive (motor or Broca’s) aphasia: difficulty making thoughts known to others; speaking and writing is most affected.

2. Receptive (sensory or Wernicke’s) aphasia: difficulty understanding what others is trying to communicate; interpretation of speech and reading is most affected.

3. Global aphasia: affects both expression and reception

d.Dysphagia

e.Sensory changes; hemianopia (loss of half of visual field)

f. Alterations in reflexes

g. Altered bladder and bowel function

h. CSF is bloody if cerebral or subarachnoid hemorrhage is present.


i. Abnormal EEG, CT scan, MRI

j.Cerebral Angiography may reveal vascular abnormalities such as aneurysms, narrowing or occlusions.

k.Signs of increased intracranial pressure

THERAPEUTIC INTERVENTIONS FOR CVD:1.Complete bed rest with sedation as needed.2.Maintenance of oxygenation by oxygen therapy or mechanical

ventilation.3. Maintenance of nutrition by parenteral route or nasogastric feedings if

the client is unable to swallow.4. Anticoagulant therapy if thrombus or embolus is present; antiplatelet

therapy.5. Antihypertensives and anticonvulsants if indicated.6. Glucocorticoids may be used to reduce cerebral edema and intacranial

pressure.

7.Surgical intervention.

a.To relieve pressure and control bleeding if hemorrhage is present.

b.Carotid endarterectomy to improve cerebral blood flow when carotid arteries are narrowed by arteriosclerotic patches

NURSING CARE OF CLIENTS WITH CVD:1. Assessment of:

a.Adequacy of airway and respiratory function.b.Neurologic statusc.Presence of signs of increased ICP.

2.Assist with lumbar puncture if performed; may be performed if subarachnoid hemorrhage is suspected.

3. Monitor vital signs; avoid using affected extremity for BP because it may produce falsely lowered readings.

4.Maintain patency of the airway by positioning, suctioning, and inserting an artificial airway.

5.Provide for drainage and expansion of lungs with head turned to side; provide oxygen as necessary.

6.Encouraged deep breathing; utilize mechanical ventilation if ordered.

7.Involve all members of the health team when planning care.

8. Assist client and family to set realistic goals; provide encouragement and praise.

9.Accept and explore feelings of fear, anger, and depression; accept mood swings and emotional outburst.

10.Provide frequent oral hygiene; use artificial tears if blink reflex is absent.

11.Institute seizure precautions.

12.Provide elastic or pneumatic stockings for both legs.

13.Prevent pressure ulcers.

14.Prevent muscle atrophy and contractures.a.Provide passive range- of- motion exercises; active range of motion and other exercises may be instituted later.b.Use devices to prevent footdrop, flexion of fingers, external rotation of hips, adduction of

shoulders and arms.

15.Provide tube feedings if swallowing and gag reflexes are depressed or absent.16.Provide food in a form that is easily swallowed (mechanical soft, puree, thickening products); encourage intake of nutrient- dense foods; when client is capable of chewing, introduce dietary fiber to promote normal bowel function.

17. Assist with feeding (e.g. use a padded spoon handle; feed on the unaffected side of mouth; fed in as close to a sitting position as possible)

18.Encourage the client with speech difficulties to communicate.

a.Be aware of own reactions to the speech difficulty.b.Evaluate extent of the client’s ability to understand and express self.a. Reinforce what has been learned in speech therapy.b. Convey that there is a problem with communication, not with intelligence, try to eliminate anxiety related to communication attempts.c. Avoid pushing to point of frustration.d. Keep distractions at a minimum, since they interfere with the reception and integration of messages.e. Speak slowly, clearly, and in short sentences, and do not raise voice.f. Use alternate means of communication.g. Involve client in a social interactions.Be alert for clues and gestures when speech is garbled.

19.Make a definite transition between tasks to prevent or reduce confusion.

20.Attempt to prevent fecal impaction and/or urinary tract problems.a.Provide adequate fluid intake.b.Provide a diet with enough roughage for sufficient quantity of bowel content and

proper consistency for evacuation; avoid straining at stool because it can raise ICP; administer stool softeners as ordered.

c.Avoid preoccupation with elimination; avoid encouragement of incontinence.d.Stimulate normal elimination by exercise and activity.e.Help develop regular bowel and bladder patterns.f.Respect the individual; provide for privacy and individually of routine.g.Utilize physical and psychologic techniques to stimulate elimination.

21.Create environment that keeps sensory monotony to a minimum; orient to time and place, increase social contacts, provide visual stimuli, extend environment.

22. Provide for self-esteem; encourage wearing own clothes, doing self-care activities, making decisions.23.Help with adjustment to altered body image and self-esteem.

THANK YOU!

Neurologic Nursing 1- Jim

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