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1 NCLEX RN Preparation Program Neurologic Disorders Module 5, Part 1 of 3
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2 Brain Attack (Cardiovascular Accident/CVA or Stroke) Thrombosis – most common Embolus Small vessel occlusion (lacunar) Hemorrhage Aneurysm Hypertension Blood thinners (coumadin, heparin)
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3 Clinical Manifestations Headache (25%) Nausea, Vomiting Aphasias Paresis Hemianopsia Dysarthria Dysphagia
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4 Collaborative Care Aspirin? Vitamin K? Oxygen Anti-convulsants Blood pressure control Thrombolytics
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5 Prevent Re-bleed (hemorrhage) 24-48 hours post hemorrhage 7-10 days post hemorrhage Keep BP low Head up Vitamin K (Aquamephyton)?
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6 Clipping and Coiling Web resource: http://www.mayoclinic.org/cerebral- aneurysm/treatment.htmlhttp://www.mayoclinic.org/cerebral- aneurysm/treatment.html Clipping: The most common surgical treatment for a cerebral aneurysm involves placing a metal clip around the neck of the aneurysm to prevent rupture Coiling: Endovascular therapy in which a neuroradiologist passes a catheter through an artery and deposits detachable platinum coils in the aneurysm. This prevents bleeding and protects against subarachnoid hemorrhage.
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7 Prevent Vasospasm Nimodipine (Nimotop) Triple H Therapy Hypertension Hypervolemia Hemodilution
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8 Monitor Airway Aspiration pneumonia Cerebral edema Motor/Sensory changes Psychosocial Swallowing Skin, incontinence Monitor fluid/electrolyte balance
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9 Intervene Position Activity Prevent complications Communication Environment
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10 Teach Prevention Hypertension S&S Stroke Early treatment Healthy lifestyle Treat Transient Ischemic Attack (TIA)
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11 Seizures Prodromal phase Aural phase Ictal phase Manifestations seen Postictal phase
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12 Generalized Seizures Tonic/clonic Absence Myoclonic Atonic
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13 Partial Seizures Complex AKA psychomotor AKA temporal lobe Simple
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14 Nursing Care Onset Movements Airway Position Teach
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15 Collaborative Management Anti-seizure medication Monitor serum levels Toxic effects Alcohol Status epilepticus Airway Lorazepam (Ativan)
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16 Traumatic Brain Injury Open Closed Photo Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program, http://training.seer.cancer.gov/index.html http://training.seer.cancer.gov/index.html
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17 Open Head Injuries Linear skull fracture Depressed skull fracture Open fracture Basilar skull fracture
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18 Basilar Skull Fracture Watch! Clear nasal or ear drainage Battle Sign Raccoon sign
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19 Closed Head Injury - Concussion Signs & Symptoms Brief loss of consciousness Amnesia Headache Post-concussive syndrome Persistent headache Lethargy Personality/intellectual changes Decreased attention span
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20 Brain Contusion Coup Contrecoup Signs
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21 Brain Lacerations Epidural hematoma Brief loss of consciousness Period of lucidity Rapid decrease in LOC Watch! pupils, extremity movements Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp http://connection.lww.com/products/smeltzer9e/imagebank.asp
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22 Subdural Hematoma Acute Subacute Chronic Signs & Symptoms Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp http://connection.lww.com/products/smeltzer9e/imagebank.asp
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23 Cerebral Edema Brain tissue + Blood + CSF CPP = MAP - ICP Autoregulation Chemical autoregulation
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24 Assessment for Edema LOC Orientation Pupils Motor Vital Signs
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25 Diagnostic Tests CT scan EEG ABGs Electrolytes CBC Osmolality Lumbar Puncture? Photo Courtesy of the Indian Health Service/U.S. Department of Health and Human Services.
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26 Craniotomy Postoperative assessment Peri-orbital edema, ecchymosis Strict I&O Positioning Dressing Drainage
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27 Monitor Sodium Levels Low Na + = salt wasting syndrome 3% saline High Na + = Diabetes insipidus 0.45% saline
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28 Postoperative Complications Increased ICP Hematomas Hydrocephalus Respiratory problems Wound infection Meningitis Fluid/electrolyte imbalances
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29 Intracranial Pressure CSF leaks Head up Body in neutral alignment Control pCO 2 Prevent hypoxia Suction airway? Sedation
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30 Intracranial Pressure (continued) Intubated – paralytics Barbiturate coma Anticonvulsants Diuretic therapy Prevent hyperthermia Manage osmolality Ventricular drainage Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp http://connection.lww.com/products/smeltzer9e/imagebank.asp
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31 Spinal Cord Injury Prevention Common areas injured Photo Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD) http://images.niams.nih.gov/SearchResults.cfm?start=Allhttp://images.niams.nih.gov/SearchResults.cfm?start=All
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32 Types of Lesions Complete Incomplete Central cord syndrome Anterior cord syndrome Brown-Sequard syndrome Cauda equina
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33 AreaCauseSensory Loss Motor Loss Intact Central Cord Hyper- extension pain & temp below injury Upper extremities Lower extremity motor Anterior Cord FlexionPinprick, temp Complete motor loss Position, proprio- ception, vibration, deep pressure Brown- Sequard Knife, bullet Complete loss opposite side Complete loss same side Bowel, bladder, walk with assist Cauda equina Lumbar disk herniation Perineal anesthesia Areflexic bowel, bladder Upper extremities, thorax
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34 Initial Assessment/Care Stabilize neck/back Watch! Respiratory failure C2-3 Assess Motor signs Assess Sensory signs Incontinence Superficial signs Pain
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35 Spinal Shock Flaccid paralysis below injury Bradycardia Hypotension
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36 Ongoing Assessment ABCs Bleeding Glasgow Coma Scale Motor/sensory status http://www.meddean.luc.edu/lumen/MedEd/ GrossAnatomy/learnem/dermat/main_der. htm
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37 Glasgow Coma Scale
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38 Collaborative Management - Neurological Methylprednisolone (Solu-Medrol) Traction Log roll Treat spasticity, pain
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39 Collaborative Mgmt - Circulation Bradycardia – atropine Hypotension – dopamine Fluids/blood products Vasovagal response Fluid/electrolyte imbalances Promote blood return
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40 Collaborative Mgmt - Oxygen Lesions above C4 Pulmonary “toilet” Aspiration prevention Bronchodilators
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41 Collaborative Mgmt - Nutrition Paralytic ileus Stress ulcers Histamine-2 blockers Total parenteral nutrition Constipation
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42 Collaborative Mgmt - Temperature Poikilothermia Control room temperature Warming measures Cooling measures
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43 Collaborative Mgmt - Renal Bladder reflex loss Calcium stones Urinary tract infection
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44 Skin-tissue Integrity Kinetic beds Inspect skin – Where? Protective devices Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp http://connection.lww.com/products/smeltzer9e/imagebank.asp
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45 Psychosocial Care What to expect Hope, reassurance Verbalize feelings Fear of the unknown: be accurate Touch areas with sensation Offer stimulation
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46 Autonomic Dysreflexia Injuries above T6 Late complication Causes Signs, symptoms Prevention Treatment
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47 Bacterial Meningitis Nuchal rigidity Brudzinski’s sign Kernig’s sign Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp http://connection.lww.com/products/smeltzer9e/imagebank.asp
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48 Meningitis Chills and high fever Vomiting Signs of increased intracranial pressure Photophobia Petechial rash Diplopia (double vision) Seizures
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49 Diagnosis CSF: ↑ pressure, ↑ protein, cloudy, ↓ glucose High WBC Blood cultures Sodium
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50 Collaborative Management Assess for neurologic deterioration Respiratory isolation x 24 hours Seizure precautions Antibiotics Dark room Headache Hydration
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51 Monitor for Complications Septic emboli in circulation to hands Septic shock Coagulation disorders Prolonged temperature elevations
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52 Parkinson Disease Bradykinesia Muscle rigidity Stooped posture Shuffling, propulsive gait Tremor
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53 Collaborative Care Levodopa Carbidopa Amantadine Catechol Drug tolerance Drug holiday
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54 Nursing Care Mobility Nutrition Aspiration precautions Assistive devices
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55 Alzheimer’s Disease Chronic, progressive, degenerative brain disorder affecting: Memory Cognition Ability to care for self
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56 Collaborative Management Aricept Reminyl Exelon Namenda
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57 Nursing Care Cognitive stimulation Structure environment Prevent over-stimulation Provide consistency Promote independence Promote bowel, bladder continence Assist with facial recognition
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58 Promote Communication Attract patient’s attention before talking Avoid environmental distractions Speak directly to patient, distinctly and in clear, short sentences Ask patient to perform one task at a time, giving plenty of time & breaking down into small steps
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59 Myasthenia Gravis Varying levels of generalized weakness Extra-ocular muscle weakness: Diplopia Ptosis Weak eye closure
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60 Diagnosis Acetylcholine receptor antibodies CT scan IV Tensilon and Prostigmin EMG
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61 Collaborative Management Mestinon Prostigmin Cholinergic crisis Myasthenic crisis Teach
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62 Guillain-Barré Syndrome Ascending weakness Acute respiratory failure Descending weakness?
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63 Management Immune globulin Plasmapheresis Respiratory support Communication
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64 Multiple Sclerosis Manifestations Fatigue Weakness Leg spasticity Intention tremor Dysmetria, dysdiadochokinesia Tinnitus, vertigo, hearing loss Vision changes
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65 Manifestations (continued) Sensory: Hypalgesia (decreased sensitivity to pain), paresthesia, facial pain, decreased temperature sensation, numbness, tingling, burning or crawling sensations Psychosocial: Often anxious with emotional lability
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66 Collaborative Management Medications to delay, decrease exacerbations Physical, speech therapy Warm packs, stretching Minimize fatigue Teach fall precautions
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67 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.
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