Neurological Management KSU
Transcript of Neurological Management KSU
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Pathology
The pathology involving the CNS arises from
injuries, vascular insufficiency, tumors,infections and disorders from other diseases.Neurological medical problems are due tointerference with normal functioning of the
affected cells
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Nervous SystemAnatomy and Physiology
Review
The nervous system acts as a coordinatedunit both structurally and functionally
Communication network responsible forcoordinating and organizing the functions ofall body parts
The bodys link to the environment
Works with the endocrine system to maintainhomeostasis
Reacts in a split second
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Functions
1.Regulates system
2. Controls communication 3. Coordinates Activities of body system
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Divisions
Central nervous system ( CNS) : brain and
spinal cordinterprets incoming sensoryinformation and sends out instruction based onpast experiences
Peripheral nervous system ( PNS) : Cranial
and spinal nerves extending out from brain andspinal cord---carry impulses to and from brainand spinal cord
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Neurological Terms
Anesthesia- complete loss of sensation
Aphasia-loss of ability to use language
Auditory/receptive aphasia- loss of ability tounderstand
Expressive aphasia- loss of ability to use spoken orwritten word
Ataxia- uncoordinated movements Coma- state of profound unconsciousness
Convulsion- involuntary contractions and relaxation ofmuscles
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Neurological terms
Delirium- mental state characterized by
restlessness and disorientation Diplopia- double vision
Dyskeinesia- difficulty in voluntary movement
Flaccidd- without tone- limp
Neuralgia- intermittent, intense pain, along thecourse of a nerve
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Neurological terms
Neuritis- inflammation of a nerve or nerves
Nystagmus- involuntary, rapid movements ofthe eyeball
Paresthesia- abnormal sensation withoutobvious cause, with numbness and tingling
Stupor- state of impaired consciousness withbrief response only to vigorous and repeatedstimulation
Vertigo- dizziness
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Preparing a patient for a diagnostic
test
Answer question that thepatient may need clarification
Diet ordersNPO??? Special room or equipment
used
Special medications requiredfor test
An informed patient will bemore cooperative
Nursing assessment
Baseline vital signs and neurocks
Know level education todevelop an individualizedteaching plan
Determine awareness ofactual or potential medical
diagnosis Determine previous
experence with Dx test
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Diagnostic test/ methods
A. Computerized Tomography- CT or CAT scan
computer analysis of tissues as x-rays passthrough them; has replaced many of the usualtests: no special preparation or care after test
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CT scan
Nursing Interventions
Explain procedure will be enclosed tunel
Written consent
Assess allergies to iodine
Remove wigs hair pins or clips, partial denture plates
Assess for pacemakers
NPO 4 hours before if oral contrast is administered Encourage patient to drink fluids to avoid renal complications
and to promote excretion of the dye
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Diagnostic test/ methods
B. lumbar puncture- spinal tap
Done under local anesthesia a puncture is made atthe junction of the third and fourth lumbar vertebraeto obtain a specimen of cerebrospinal fluid (CSF)
CSF pressure measured
Used to inject medications- spinal anesthesia Used to inject diagnostic materialsair or dye-
myelogram
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Lumbar puncture
Nursing interventions Written consent
Monitor vital signs Have patient empty bowel and bladder
Position the patient
Label and number specimens
Keep patient supine 4-8 hours
Observe for headache and nuchal rigidity
Observe for mobility of extremities, pain, ability to void
Monitor site for leakage
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Diagnostic test/ methods
Cerebral Angiography- intraarterial injection of
radiopaque dye to obtain an xray film of thecerebrovascular circulation
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Cerebral angiography
Nursing interventions Written consent
Assess for allergy to iodine NPO past midnight
Administer preprocedure medications
Observe arterial puncture site
Monitor extremity for adequate circulation- pain tenderness
bleeding temperature and color Pedal pulses and vital signs q 1 hour
Provide ice pack to puncture site
Bedrest 12- 24 hours
Force fluids- to increase excretion of dye
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Diagnostic test/ methods
Electroencephalography (EEG)- electrodes are
placed on unshaven scalp with tiny needlesand electrode jelly
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EEG
Nursing Inventions Anticipate patients fears about electrocutions
Explain procedure Written consent
Hair should be clean
Do not give stimulants/ depressants before test /consult withM.D. about meds
Administer sedatives or hypnotics if ordered No smoking or caffeinated beverages before the test
Eat full meal before the testhypoglycemia may alter brainwaves
Stress need for restful sleep before the test sleep deprivation
may cause abnormal brain waves Wash hair and scal after test
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Diagnostic test/ methods
Brain Scan-after injection of a radioisotope,
abnormal brain tissue will absorb more rapidlythan normal tissue: this can be detected with aGeiger counter to diagnose brain tumors
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Brain Scan
Nursing interventions
NPO 4 hours before test Remove wigs, hair clips or pins,
Assess for iodine allergies
If ordered give sedation
Encourage fluids after test to increase excretion ofdye
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Diagnostic test/ methods
Magnetic Resonance Imaging- ( MRI)
uses combination of radio waves and a strongmagnetic field to view soft tissue ( does Notuse x-rays or dyes) ; produces a computerizedpicture that depicts soft tissues in high
contrast color
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MRI
Nursing interventions
Written consent Explain procedure- will have to remain perfectly still
in the narrow cylinder-shaped machine . No pain ordiscomfort but no room for movement
Assess for any metal contraindications-pacemaker,surgical clips, hair clips, belts
Empty bladder before test
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Diagnostic test/ methods
Myelogram- injection of a radiopaque dye into thesubarachnoidd space via a lumbar puncture:
performed to locate lesions of the spinal column orruptured vertebral disk
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Myleogram
Nursing interventions Written consent
Prepare for LP NPO for 4 hours before test
Positioning for LP
Vital signs
Observe for photophobia, fever stiff neck, occipital headaches,
nausea , dizziness, and possibly seizures Force fluids to promote dye excretion dehydration will result in
severe headache
Check with M.D. when withheld medications prior to test maybe restarted
Observe site for leakage of CSF Bedrest
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Nursing Diagnosis and
Interventions
Identify the patients needs
Neuro checks Assessment of history from family
Patient history
Nursing observations
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Impaired Physical Mobility
Neuro checks q2-4h
Explain the need for regular
exercise program ROM to all joints q2-4h
foundations pg 243-244
Use assistive devices
Protect the affect side from
injury
Protection from falling
Turn q2h
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Ineffective breathing pattern relatedto neuromuscular impairment
Maintain patent airway
Suction as needed
Elevate HOB 30-60-degrees
Have trach set ready
Provide O2 with humidity
V/S with neuro cks q2h Oral hygiene q2h
Lubricate lips
Maintain bed rest
Keep unconscious pt in
lateral position to allowsecretion drainage
Monitor for S/Spulmonary emboli Chest pain, SOB,
Monitor ability to swallow
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Risk for alteration in body
temperature
Asses rectal temp q2h
Use external heating orcooling blankets
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Risk for aspiration
Maintain NPO
Position Pt on side: turnq2h
Provide N/G feedings
Monitor IV fluid
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Altered patterns of urinary
elimination
1. Oligura-urinaryretention
Provide indwellingcatheter
Monitor I&O qh
2. Incontinence
Wash dry and inspect
skin Implement measures to
prevent decubitus ulcers
Implement bladdertraining
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Bowel incontinence/constipation
Incontinence
wash dry and inspectskin
Implement measures toprevent decubitus ulcers
Implement bowel training
Constipation
-Record bowel movements
-Provide stool softners,laxatives and enemas
-Check for impaction
-Increase fluid intake
-Increase Fiber in diet
-Increase activity
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Altered Nutrition: less than bodyrequirements related to dysphagia
and fatigue
Prepare for N/G
feedings Check gag reflex
Provide mouth care,clean and care for
dentures Place food in patients
visual field do patientcan see food
Diet low salt low
cholesterol consult dietary
Wt daily
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Impaired Communication
Assess communicationpatterns
Provide calm environmentwith minimal distraction
Use touch to increaseattention
Use familiar music to
enhance recall
Simple verbal commands
Communication boards
Pen and paper
Gestures eye blinks
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Fluid Volume deficit
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Inability to meet needs:Coma
COMA-Unconscious state in which the Pt isunresponsive to verbal or painful stimuli: thisoccurs with many primary diseases: the Ptdepends on the nurse for maintenance of allbasic human needs, nourishment, bathing,
elimination, respiration, prevention ofcomplications and assessment and provision ofcare for problems
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Coma : nursing interventions
Include family in nursing care and planning
Note LOC q15 minutes
Nero Ck q 15 minutes
Demonstrate respect for Pt presence
Provide quite restful environment
Speak to Pt, use proper name, introduce self,explain all care
Provide privacy
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Patient with paralysis
Paraplegia-paralysis of the lower extremities
There may be no motion or sensory function or reflexes
There may be uncontrollable muscle spasms
Perspiration ceases then becomes profuse
Loss of bowel and bladder control
Anxiety, fear, depression, anger, and embarrassment May be totally dependant
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Patient with paralysis
Quadriplegia- paralysis of all four extremities
Same problems as paraplegia
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Nursing interventions : Paralysis
Take measures to prevent complications of immobility
Bowel and bladder training
Prevent deformity: maintain joint mobility: correctalignment
Increase fluid intake
Provide high protein diet
Teach independence according to ability Work with health care team for rehabilitation
Include family in planning and care
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Increased intracranial pressure
( ICP)
Fluid accumulation or a lesion takes up spacein the cranial cavity, producing ICP: the brain isgradually compressed, or life-sustainingfunctions cease: may be sudden or progressslowly
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ICP
Causes
Tumors
Hematoma Edema from trauma
Abscesses from infection
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ICP
signs and symptoms
Headache, restless, anxiety
Vomiting,recurrent, projectile,
and not related to nausea ormeds
Change in pupil response tolight
Seizures
Respiratory difficulty;irregular, Cheyne-Stokes orKussmaul
BP elevates ,with wide pulsepressure
Pulse Increases at first thenslows to 40- 60
Alter LOC,lethargic, speechslows, confused, decreaselevel of response
Visual disturbances,diplopia
and blurred vision Progressive weakness or
paralysis
Loss of consciousness,comadeath
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ICP
Treatment
Depends on cause
Craniotomy Meds
Steroids
Anticonvulsants
Mannitol
dexamethasone
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ICP
Nursing interventions
Elevate HOB to semi-Fowlers
Never place in Trendelenburg
V/S and neuro cks q15 minutes Prevent aspiration
Place Pt on Side
Maintain airway- O2
Observe pupillary response ( usually unequal and maynot react to light)
Report changes in LOC immediately
Seizure precations
Provide care for Coma Pt
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Convulsive disorders
Frequently a convulsion or seizure is not adisease but a symptom of a neurologicdisorder:
Epilepsy is a disease characterized by adisposition for seizures;
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Types of seizures
Generalized or grand mal
Aura- There may be a premonition or sign
The Pt cries out Loss of consciousness
Enters tonic phase- the body is rigid and the jaw isclenched
Then the clonic phase- jerking movements ofmuscles
Cessation of respiration
Fecal and urinary incontinence
Lasts 1-2 minutes
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Types of seizures
Partial or petit Mal
Loss of consciousness that last 5- 30seconds
Normal activities may or may not ceas
There may be amnesia concerning the time
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Types of seizures
Jacksonian or Motor
A focal seizure that may precede a grand malseizure
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Convulsive Disorders
Causes
May be secondary to another condition
CVA, head injury, brain tumor, elevated temp,toxins, electrolyte imbalance
Epilepsy may have no known cause
Onset is usually during childhood or before age 30
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Convulsive Disorders
Diagnostic test
EEG
CT scan MRI
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Convulsive Disorders
Treatment
Treat and remove cause
Anticonvulsant drugs Surgery sterotactic- electrical stimulation to
locate and reset ( destroy) epileptogenic focus
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Convulsive Disorders
Nursing Interventions
Provide accurate observation and documentation
Aura
Time of onset Whether seizure is generalized or focal
Specific parts of body involved
Progression of seizure
Eye movements Loss of consciousness
Loss of bowel or bladder
Condition after seizure
Memory loss
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Convulsive Disorders
Nursing interventions
Encourage Pt to wear medical alert tag
Have suction available
During seizure maintain airway Prevent head injury
Place pt on side
Protect extremities from injury
Do not restrain Loosen clothing
Remove pillows
Maintain safety until fully conscious
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Transient Ischemic Attacks
TIA
Altered cerebral tissue perfusion related to atemporary neurologic disturbance
Manifested by sudden loss of motor or sensoryfunction
Lasts for a few minutes to a few hours
Caused by temporarily diminished blood supplyto an area of the brain
High risk for stroke
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TIA
Treatment
Control hypertension
Low sodium diet Possible anticoagulant therapy
Stop smoking
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Cerebrovascular Accident
CVA Stroke
Decreased blood supply to a part of the brain
caused by rupture , occlusion, or stenosis of the blood
vessels Onset may be sudden or gradual
Symptoms and patient problems depend on locationand size of area of brain with reduced or absent blood
supply right CVA results in Left side involvement often
associated with safety/ judgment
Left CVA results in Right side involvement oftenassociated with speech problems
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Cerebrovascular Accident
CVA Stroke
Symptoms related to location and size of brain areaaffected
Approximately 50% of survivors permanently disabled
High proportion experiencing recurrence within weeksto years
Chances for complete recovery depending an
circulation returning to normal soon after the initialstroke
Third most common cause of neurological disability
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Predisposing factors-CVA
History TIAs
Hypertension
Arrhythmias
Atherosclerosis
Rheumatic HeartDisease
MI
DM
High serum triglyceridelevels
Lack of exercise
Cigarette smoking
Family history
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CVA
Causes
Incidence increased with aging
Atherosclerosis Embolism
Thrombosis
Hemorrhage from ruptured cerebral aneurysm
hypertension
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CVA
Signs and Symptoms
Altered LOC
Change in mental status
Decreased attention span Decreased ability to think and reason
Difficulty following simple directions
Communication; motor and sensory aphasia difficulty
with reading ,writing, speaking, or understanding Bowel and bladder dysfunction retention impaction or
incontinence
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CVA
Signs and Symptoms
Seizures
Limited motor function; paralysis, dysphgia, weakness ,
hemiplegia, loss of function Loss of sensation/ perception
Headaches and syncope
Loss of temp regulation elevated TPR and BP
Absent of gag reflex ( aspiration) Unusual emotional responses; depression, anxiety,
anger, verbal outburst, and crying: emotional lability
Problems related with immobility
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CVA
Diagnostic test
Physical assessment
Pt and family history EEG
CT scan
Lunbar puncture
Cerebral angiogram
Carotid ultrasonogram
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CVA
Treatments
Remove cause, prevent complications, and maintainfunction, rehabilitation to restore function
Meds Antihypertensives
Anticoagulants
Stool softners
Surgical removal of clot, repair of aneurysm, carotidendarterectomy or balloon agioplasty
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CVA
Nursing Interventions
Patent airway
Maintain bedrest
Provide complete care Use turn sheet
Footboard
Firm mattress
Pillow and torchanter rolls
Maintain proper bodyalignment
Place items within reach
Reposition q2h
ROM passive and active
Place in chair
Flotation mattress orsheepskin
Skin assessment
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CVA
Nursing Interventions
O2 with humidity
C,T, DB q2h
Suction PRN
Keep head turned toside
Place in semi- fowlers
Assess nutrition daily withI&O, WT, %diet, calorie count
Provide N/G feedings ifneeded
Maintain IV fluids
Progress to soft diet prn
TPN as ordered
Aspiration precautions
Dietary consult & Speech forswallowing
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CVA
Nursing interventions
Establish means ofcommunication
Nonverbal gestures
Speak slowly
Explain all care
Speech therapy
Encourage familyparticipation
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CVA
Nursing Interventions
Assess LOC
Maintain safety
Use side rails
Restrain only asnecessary
Observe for ICP
V/S & Neuro CKS q 4 h
Seizure precations
Ensure elimination
Assess bowel sounds
Monitor bowelmovements
I & O
Indwelling catheter prn
Bowel and bladdertraining
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CVA
Nursing interventions
Family support
Begin discharge
teaching early
Physical therapy
Speech therapy
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Brain Tumor
A benign or malignant growth that grows a ndexerts pressure on vital centers of the braindecreasing function and causing increasedintracranial pressure
Cause is unknown
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Brain Tumor
Signs and Symptoms
Personality changes, fear and anxiety
H/A , dizziness and visual disturbances
Seizures
Pituitary dysfunction
ICP
Local paralysis or anesthia Aphsia
Problems with coordination
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Brain tumor
Diagnostic test
History
Physical exam
Neurologic assessment
EEG
CT
Angiogram
MRI
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Brain tumor
treatment
Surgical removalcraniotomy
Combination of radiation or chemotherapy
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Brain tumor
nursing interventions
Neuro cks q 1-4 hoursdepending on pt status
Safety
Seizure precautions
express fears andfeelings
POST OP care
Maintain airway
Seizure precautions Regulate body temp
Position on unoperated side
Elevate HOB ONLY underMD orders
Inspect dressing q30min V/S neuro cks q 15 min
progress to q4h
Coma care
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Head injuries
Trauma to scalp, skull, or brain. A fracture toskull may result either a simple break in the
bone or bone fragmentation that penetrates thebrain tissue, can also cause hemorrhage,concussion, or contusion
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Head injuries
Cerebral concussion- injury to the head, patientmay be dazed; or unconscious for a few
minutes: some function(memory) may beimpaired for as long as several weeks
Cerebral contusion- head injury causing
bruising of brain tissue> person experiencesstupor, confusion or loss of consciousness: ifsevere may go into coma
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Head injuries
Cerebral laceration- a break in continuity ofbrain tissue
Causes
Blow to head MVA
Fall
Head injuries
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Head injuriesSigns and Symptoms and
diagnostic test
Nausea & vomiting
Lethargic: increasing
loss of consciousness toimpending coma
Disorientation
Drainage of CSF from
ear or nose ICP
History and physicalexam
X-ray of head Angiogram, doppler
studies
CT head, MRI
PET
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Head injuries
Treatment
Anticonvulsulants
Corticosteriods
Mannitol
Maintain fluid balance
surgery
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Head injuries
Nursing interventions
Care for ICP
COMA care
Neuro cks & V/S q 15min to q1h
Maintain airway
Seizure precations
Observe ears and nosefor CSF
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Multiple Sclerosis
A chronic progressive disease of the brainandspinal cord: lesions cause degeneration of the
myelin sheath and interfere with conduction ofmotor nerve impulses: there are periods ofremissions and exacerbations: onset occuresin young adult: it has an unpredictableprogression
Cause: unknown< exacerbates with stress
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Multiple Sclerosis
Signs ands symptoms
Ataxia
Paresthesia
Weakness and loss ofmuscle tone
Loss of sense of position
Vertigo
Blurred visionprogressto blindness
Inappropriate emotions
Euphoria, apathy,
depression Dysphagia
Slurred speech
Bowel and bladder
dysfunction Sexual dysfunction
spasticity
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Multiple Sclerosis
Diagnostic test and treatments
History Physical exam
Neuro Cks
Ct
MRI
Exam of CSF
Treatment issymptomatic
Corticosteriods duringacute excerbation
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Multiple Sclerosis
Nursing interventions Prevent Complications of
immobility
Encourage independence Patient should participate in
plan of care
High calorie, vitamin, proteindiet
Family education
Bowel and bladder training
Safety
Express feelings regardingdependence and disabilities
Avoid precipitating factors forexacerbations
Fatigue, cold, heat, infections,stress
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Parkinsons Disease
A progressive , degenerative disease causingdestruction of nerve cells in the basal ganglia of the
brain caused by a deficiency of dopamine: limbsbecome rigid, fingers have characteristic pill rollingmovement, and head has to and for movement: thepatient has a bent position and walks in short, shufflingsteps: facial expressions become blank with wide openeyes and infrequent blinking ( parkinsons Mask)
Intelligence is NOT affected
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Parkinsons Disease
Signs and symptoms Tremor
Voluntary movement is slowand difficult
Coordination is poor- ataxia
Impaired chewing and eating
Excessive salivation anddrooling
Speech is slow
Patient is soft spoken
Written communication isdifficult
Excessive sweating
Emotional changes
Depression , confusion
dependency
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Parkinsons Disease
Dx test and treatments
History
Physical exam
Neuro cks
Many pt s respond todrug therapy and the
disease is controlled withmeds for the reminder oftheir lives
Others have no
response to meds -invalidism
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Parkinsons Disease
nursing interventions
Foster independenceADLs
Avoid social withdrawalinvolve in work, socialand diversional activities
Aviod embarrassmentwhile eating Use straws, wipe drool,
use bib, keep clothingclesn, use large handlegrips
Soft diet
Daily walkingsafety
Avoid fatigue Physical, Speech and
Occupational therapy
Avoid constipation-stool
softner
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Parkinsons Disease
nursing interventions
Bowel and bladdertraining
Be patient when patientis slow and clumsy
Establish a means ofcommunication
Reorientation Prevent pneumonia
Mouth care q4h
Family participation
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Spinal Cord Impairment
The vertebral column houses the spinal cord.A small cartilage disk acts as a cushion
between the vertebrae. All sensory and motornerves to the neck, trunk, and extremitiesbranch out from the spinal cord. The degree ofdisability and patient problems is related thepart of the body controlled by the injured ordisease nerves
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Spinal Cord Injuries
Trauma to spinal cord may cause complete orpartial severing of the spinal cord
If severing is complete there is permanentparalysis of body parts below site of injury
When there is partial damage edema may
cause a temporary paralysis
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Spinal Cord Injuries
Cause : accident ,MVA diving, shooting
S&S individual to site, respiratiory distress,paralysis
DX test: physical exam
Treatment: immobilization
Crutchfield tongs.halo traction.brace.body cast
Surgery corticosteroids, mannitol
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Spinal Cord Injuries
Nursing interventions
Care for paralysis patient
Observe for complications of spinal shock
Maintain airway and respiratory function