Caring for Individuals Caring for Individuals Experiencing Neurologic Experiencing Neurologic

ChallengesChallenges

NURS 2016NURS 2016

Chapters: 61-65Chapters: 61-65

Cerebral Vascular Accidents Cerebral Vascular Accidents CVACVA

Another name for CVA?Another name for CVA? ThrombolyticThrombolytic Hemorrhagic Hemorrhagic

Which is more common?Which is more common?

Clinical ManifestationsClinical Manifestations

numbness or weaknessnumbness or weakness confusion or change in mental statusconfusion or change in mental status trouble speakingtrouble speaking visual disturbancesvisual disturbances loss of balance, difficulty walkingloss of balance, difficulty walking dizzinessdizziness sudden severe headachesudden severe headache

Clinical Manifestations Cont’Clinical Manifestations Cont’

motor Lossmotor Loss communication Losscommunication Loss perceptual disturbance & sensory perceptual disturbance & sensory

lossloss impaired cognitive & psychological impaired cognitive & psychological

effectseffects bladder dysfunctionbladder dysfunction

AssessmentAssessment Change in level of responsivenessChange in level of responsiveness Presence or absence of voluntary or Presence or absence of voluntary or

involuntary movements of extremitiesinvoluntary movements of extremities EyesEyes Quality & rates of pulse & respirationQuality & rates of pulse & respiration SwallowingSwallowing Signs of bleedingSigns of bleeding Facial droopFacial droop

Assessment Cont’Assessment Cont’

Glascow Coma ScaleGlascow Coma Scale Canadian Neurologic ScaleCanadian Neurologic Scale

Goal of Stroke CareGoal of Stroke Care

Reduce amount of tissue damage resulting from Reduce amount of tissue damage resulting from strokestroke

Oxygen saturation: supplement if below 92%Oxygen saturation: supplement if below 92% CBG: maintain less than 7mmol/lCBG: maintain less than 7mmol/l Positioning: functional, prevent breakdown. T&P Positioning: functional, prevent breakdown. T&P

q2hq2h Swallowing: speech/swallowing assessment ASAP. Swallowing: speech/swallowing assessment ASAP.

NPO ‘til thenNPO ‘til then Ambulation: Physio ASAP, active/passive ROM Ambulation: Physio ASAP, active/passive ROM

immediatelyimmediately Bladder/bowel: assess, intermittent cathBladder/bowel: assess, intermittent cath

Nursing DiagnosisNursing Diagnosis

Impaired physical mobilityImpaired physical mobility PainPain Deficit self-careDeficit self-care Disturbed sensory perceptionDisturbed sensory perception Impaired swallowingImpaired swallowing IncontinenceIncontinence Impaired thought processesImpaired thought processes Impaired verbal communicationImpaired verbal communication Risk for impaired skin integrityRisk for impaired skin integrity Sexual dysfunctionSexual dysfunction Ineffective family processesIneffective family processes

Nursing InterventionsNursing Interventions

Primarily supportive and rehabilitativePrimarily supportive and rehabilitative Monitoring & managing potential Monitoring & managing potential

complicationscomplications Improving mobility & preventing Improving mobility & preventing

deformitiesdeformities Establishing an exercise programEstablishing an exercise program Eating/drinking – swallowing Eating/drinking – swallowing

(“chipmunking”)(“chipmunking”) Preparing for ambulationPreparing for ambulation Preventing shoulder painPreventing shoulder pain

Nursing InterventionsNursing Interventions Enhancing self-careEnhancing self-care Managing sensory-perceptual difficultiesManaging sensory-perceptual difficulties Attaining bowel & bladder controlAttaining bowel & bladder control Improving thought processesImproving thought processes

• Hemianopsia (if they can’t see it…)Hemianopsia (if they can’t see it…) Achieving communicationAchieving communication Maintaining skin integrityMaintaining skin integrity Improving family coping through health teachingImproving family coping through health teaching Regaining sexual function, promoting home & Regaining sexual function, promoting home &

community based care (special needs in home)community based care (special needs in home)

Unconscious PatientUnconscious Patient

AssessmentAssessment Patient HistoryPatient History Neurological examNeurological exam Glasgow Coma ScaleGlasgow Coma Scale Subtle ChangesSubtle Changes VomitingVomiting Monitor ICPMonitor ICP Pupils changes (PERRL)Pupils changes (PERRL)

Nursing DiagnosisNursing Diagnosis Ineffective airway clearanceIneffective airway clearance Ineffective cerebral tissue perfusionIneffective cerebral tissue perfusion Ineffective breathing patternsIneffective breathing patterns Risk for fluid volume deficit Risk for fluid volume deficit Altered protection & risk for injuryAltered protection & risk for injury Risk for infectionRisk for infection Altered oral mucous membranesAltered oral mucous membranes Altered family processes related to Altered family processes related to

sudden crisis of unconsciousnesssudden crisis of unconsciousness

Nursing InterventionsNursing Interventions

Maintain safetyMaintain safety Maintain a Patent airwayMaintain a Patent airway Attaining Normal Respiratory patternAttaining Normal Respiratory pattern Preserving & Improving Cerebral Tissue Preserving & Improving Cerebral Tissue

PerfusionPerfusion Maintain Negative Fluid BalanceMaintain Negative Fluid Balance Preventing InfectionPreventing Infection Monitoring & Managing Potential Monitoring & Managing Potential

ComplicationsComplications

Spinal Cord InjurySpinal Cord Injury

Concussion, contusion, laceration, Concussion, contusion, laceration, compression, transectioncompression, transection

Cervical: 5Cervical: 5thth, 6, 6thth, 7, 7thth

Thoracic: 12Thoracic: 12thth Lumbar: 1Lumbar: 1stst

ParaplegiaParaplegia QuadriplegiaQuadriplegia

ManagementManagement

High-dose corticosteroidHigh-dose corticosteroid

Respiratory therapyRespiratory therapy

Skeletal reduction/tractionSkeletal reduction/traction

Nursing AssessmentNursing Assessment

Respiratory statusRespiratory status Motor abilityMotor ability SensationSensation Spinal shock:depression of reflex Spinal shock:depression of reflex

activity below injuryactivity below injury Temperature:risk of hyperthermia Temperature:risk of hyperthermia

(autonomic disruption)(autonomic disruption) Bladder: assess retention/distentionBladder: assess retention/distention

Nursing InterventionsNursing Interventions

Promote adequate breathing & Promote adequate breathing & airwayairway

Improve mobilityImprove mobility Promoting adaptation to sensory & Promoting adaptation to sensory &

perceptual alterationsperceptual alterations Skin integritySkin integrity Bowel & bladderBowel & bladder Comfort measuresComfort measures

ComplicationsComplications

ThrombophlebitisThrombophlebitis Orthostatic hypotensionOrthostatic hypotension

Autonomic Hyperreflexia (dysreflexia)Autonomic Hyperreflexia (dysreflexia)• HeadacheHeadache• HypertensionHypertension• DiaphoresisDiaphoresis• Nausea, nasal congestionNausea, nasal congestion• BradycardiaBradycardia

Nursing Measures: Autonomic Nursing Measures: Autonomic DysreflexiaDysreflexia

Sitting positionSitting position Identify trigger: bladder, bowel, draft, Identify trigger: bladder, bowel, draft,

skin irritationskin irritation Empty bladder, empty bowel, remove Empty bladder, empty bowel, remove

restrictive clothing etc.restrictive clothing etc. Administer ganglionic blocking agent Administer ganglionic blocking agent

(Apresoling)(Apresoling) Patient educationPatient education

MeningitisMeningitis

Inflammation of the meningesInflammation of the meninges Viral (aseptic), bacteria (septic), fungal Viral (aseptic), bacteria (septic), fungal

(tuberculous)(tuberculous)

BacterialBacterial Neisseria meningitidesNeisseria meningitides Streptococcus pnuemoniaeStreptococcus pnuemoniae Haemophilus influenzaeHaemophilus influenzae

Clinical ManifestationsClinical Manifestations

Nuchal rigidityNuchal rigidity Positive Kernig’s signPositive Kernig’s sign Positive Brudzinski’s signPositive Brudzinski’s sign PhotophobiaPhotophobia Seizures & increased ICPSeizures & increased ICP RashRash

managementmanagement

Diagnosis: culture CSF & bloodDiagnosis: culture CSF & blood

Pharmacological TreatmentPharmacological Treatment Antibiotics that cross blood brain Antibiotics that cross blood brain

barrierbarrier Dexamethasone (corticosteriod)Dexamethasone (corticosteriod)

Nursing CareNursing Care

VS & clinical statusVS & clinical status Monitor I&O: Hydration vs overloadMonitor I&O: Hydration vs overload Precautions: Infection control Precautions: Infection control

measure measure Fever managementFever management

Multiple SclerosisMultiple Sclerosis

Degenerative progressive diseaseDegenerative progressive disease Demyelination in brain & spinal cordDemyelination in brain & spinal cord

Clinical ManifestationsClinical Manifestations Relapse – Remittance – variesRelapse – Remittance – varies Fatigue, weakness, depressionFatigue, weakness, depression Spasticity, ataxia, tremorSpasticity, ataxia, tremor Loss of controlLoss of control

Nursing InterventionsNursing Interventions Physical mobilityPhysical mobility InjuryInjury Bladder & bowel controlBladder & bowel control Speech & swallowing difficultiesSpeech & swallowing difficulties Sensory & cognitive functionSensory & cognitive function

Huntington’s DiseaseHuntington’s Disease

Chronic, progressive, hereditaryChronic, progressive, hereditary Progressive involuntary choreiform Progressive involuntary choreiform

movement & dementiamovement & dementia Autosomal dominant (each child of +ve Autosomal dominant (each child of +ve

parent has 50%)parent has 50%)

Prominent manifestationsProminent manifestations ChoreaChorea Intellectual declineIntellectual decline Emotional disturbancesEmotional disturbances

Nursing DiagnosisNursing Diagnosis

Potential for injury from falls Potential for injury from falls Potential skin breakdownPotential skin breakdown

Resulting from constant movementResulting from constant movement

Psychological isolationPsychological isolation Ineffective communicationIneffective communication

Both resulting from excessive grimacing & Both resulting from excessive grimacing & unintelligible speechunintelligible speech

Parkinson’s DiseaseParkinson’s Disease

Progressive neurologic movement Progressive neurologic movement disorderdisorder

Dopamine: decrease dopamine Dopamine: decrease dopamine storesstores

Tremor, rigidity, bradykinesiaTremor, rigidity, bradykinesia

Nursing DiagnosisNursing Diagnosis Impaired physical mobilityImpaired physical mobility Self-care deficitsSelf-care deficits Altered nutritionAltered nutrition Impaired verbal communicationImpaired verbal communicationNursing InterventionsNursing Interventions Improving mobilityImproving mobility Enhancing self-care & using assistive Enhancing self-care & using assistive

devicesdevices Improving bowel functionImproving bowel function Improving swallowing & nutritionImproving swallowing & nutrition Supporting Coping AbilitiesSupporting Coping Abilities

Seizure DisordersSeizure Disorders

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

May be loss of consciousness, excess May be loss of consciousness, excess movement, or loss of muscle tone or movement, or loss of muscle tone or movement and disturbances in movement and disturbances in behaviour, mood, sensation and behaviour, mood, sensation and perceptionperception

Seizure vs EpilepsySeizure vs Epilepsy

What is the difference?What is the difference? Seizures:Seizures:

• sudden, abnormal electrical discharge sudden, abnormal electrical discharge from the brain that results in changes in from the brain that results in changes in sensation, behavior, movements, sensation, behavior, movements, perception, or consciousnessperception, or consciousness

Epilepsy:Epilepsy:• a chronic disorder of recurrent seizures. A a chronic disorder of recurrent seizures. A

single seizure does not constitute epilepsy.single seizure does not constitute epilepsy.

Managing a Seizing PatientManaging a Seizing Patient Ease patient to floorEase patient to floor Support airway (use nasopharyngeal airway if necessary)Support airway (use nasopharyngeal airway if necessary) OO2 2 and suctionand suction Protect headProtect head Move furnitureMove furniture Don’t restrainDon’t restrain Loosen clothingLoosen clothing Provide privacyProvide privacy Place on side (if possible)Place on side (if possible) Never place anything in the mouthNever place anything in the mouth Take notes - make observation Take notes - make observation

Documenting a SeizureDocumenting a Seizure

Describe situation before seizure Describe situation before seizure occurred occurred • Visual, auditory, olfactory, tactile Visual, auditory, olfactory, tactile

stimuli, emotional, sleep, etc…)stimuli, emotional, sleep, etc…) Was there an aura?Was there an aura? The first thing the patient did when The first thing the patient did when

they began to seize they began to seize • Where movement/stiffness startedWhere movement/stiffness started• Eyes deviated?Eyes deviated?

Documenting a SeizureDocumenting a Seizure

Type of movement (pull sheets down Type of movement (pull sheets down to observe patient)to observe patient)

Pupil size, are the eyes openPupil size, are the eyes open IncontinenceIncontinence Duration (sometimes 30 seconds can Duration (sometimes 30 seconds can

seem like 3 minutes)seem like 3 minutes) Postictal phase Postictal phase

• Unconscious, sleeping, confused, Unconscious, sleeping, confused, paralysis, weakness, unable to speakparalysis, weakness, unable to speak

Status EpilepticusStatus Epilepticus

Emergency situationEmergency situation continuous seizures in rapid succession continuous seizures in rapid succession

without regaining consciousness lasting without regaining consciousness lasting at least 30 minutesat least 30 minutes

Patient may remain comatose, Patient may remain comatose, irreversible brain damage, or dieirreversible brain damage, or die

Most common cause is sudden Most common cause is sudden withdrawal from anticonvulsant withdrawal from anticonvulsant medicationmedication

Treatment of Status EpilepticusTreatment of Status Epilepticus

maintain airwaymaintain airway assess patient constantlyassess patient constantly protect from injuryprotect from injury give emergency anticonvulsant give emergency anticonvulsant

medication IVmedication IV

Nursing ManagementNursing Management

AssessmentAssessmentDiagnosisDiagnosis FearFear Ineffective copingIneffective coping Deficit knowledgeDeficit knowledgeNursing InterventionsNursing Interventions Care during seizuresCare during seizures Controlling SeizuresControlling Seizures Improving coping mechanismsImproving coping mechanisms