1 NCLEX RN Preparation Program Neurologic Disorders Module 5, Part 1 of 3

2 Brain Attack (Cardiovascular Accident/CVA or Stroke) Thrombosis – most common Embolus Small vessel occlusion (lacunar) Hemorrhage Aneurysm Hypertension Blood thinners (coumadin, heparin)

3 Clinical Manifestations Headache (25%) Nausea, Vomiting Aphasias Paresis Hemianopsia Dysarthria Dysphagia

4 Collaborative Care Aspirin? Vitamin K? Oxygen Anti-convulsants Blood pressure control Thrombolytics

5 Prevent Re-bleed (hemorrhage) hours post hemorrhage 7-10 days post hemorrhage Keep BP low Head up Vitamin K (Aquamephyton)?

6 Clipping and Coiling Web resource: aneurysm/treatment.htmlhttp:// 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.

7 Prevent Vasospasm Nimodipine (Nimotop) Triple H Therapy Hypertension Hypervolemia Hemodilution

8 Monitor Airway Aspiration pneumonia Cerebral edema Motor/Sensory changes Psychosocial Swallowing Skin, incontinence Monitor fluid/electrolyte balance

9 Intervene Position Activity Prevent complications Communication Environment

10 Teach Prevention Hypertension S&S Stroke Early treatment Healthy lifestyle Treat Transient Ischemic Attack (TIA)

11 Seizures Prodromal phase Aural phase Ictal phase Manifestations seen Postictal phase

12 Generalized Seizures Tonic/clonic Absence Myoclonic Atonic

13 Partial Seizures Complex AKA psychomotor AKA temporal lobe Simple

14 Nursing Care Onset Movements Airway Position Teach

15 Collaborative Management Anti-seizure medication Monitor serum levels Toxic effects Alcohol Status epilepticus Airway Lorazepam (Ativan)

16 Traumatic Brain Injury Open Closed Photo Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program,

17 Open Head Injuries Linear skull fracture Depressed skull fracture Open fracture Basilar skull fracture

18 Basilar Skull Fracture Watch! Clear nasal or ear drainage Battle Sign Raccoon sign

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

20 Brain Contusion Coup Contrecoup Signs

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,

22 Subdural Hematoma Acute Subacute Chronic Signs & Symptoms Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank,

23 Cerebral Edema Brain tissue + Blood + CSF CPP = MAP - ICP Autoregulation Chemical autoregulation

24 Assessment for Edema LOC Orientation Pupils Motor Vital Signs

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.

26 Craniotomy Postoperative assessment Peri-orbital edema, ecchymosis Strict I&O Positioning Dressing Drainage

27 Monitor Sodium Levels Low Na + = salt wasting syndrome 3% saline High Na + = Diabetes insipidus 0.45% saline

28 Postoperative Complications Increased ICP Hematomas Hydrocephalus Respiratory problems Wound infection Meningitis Fluid/electrolyte imbalances

29 Intracranial Pressure CSF leaks Head up Body in neutral alignment Control pCO 2 Prevent hypoxia Suction airway? Sedation

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,

31 Spinal Cord Injury Prevention Common areas injured Photo Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD)

32 Types of Lesions Complete Incomplete Central cord syndrome Anterior cord syndrome Brown-Sequard syndrome Cauda equina

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

34 Initial Assessment/Care Stabilize neck/back Watch! Respiratory failure C2-3 Assess Motor signs Assess Sensory signs Incontinence Superficial signs Pain

35 Spinal Shock Flaccid paralysis below injury Bradycardia Hypotension

36 Ongoing Assessment ABCs Bleeding Glasgow Coma Scale Motor/sensory status GrossAnatomy/learnem/dermat/main_der. htm

37 Glasgow Coma Scale

38 Collaborative Management - Neurological Methylprednisolone (Solu-Medrol) Traction Log roll Treat spasticity, pain

39 Collaborative Mgmt - Circulation Bradycardia – atropine Hypotension – dopamine Fluids/blood products Vasovagal response Fluid/electrolyte imbalances Promote blood return

40 Collaborative Mgmt - Oxygen Lesions above C4 Pulmonary “toilet” Aspiration prevention Bronchodilators

41 Collaborative Mgmt - Nutrition Paralytic ileus Stress ulcers Histamine-2 blockers Total parenteral nutrition Constipation

42 Collaborative Mgmt - Temperature Poikilothermia Control room temperature Warming measures Cooling measures

43 Collaborative Mgmt - Renal Bladder reflex loss Calcium stones Urinary tract infection

44 Skin-tissue Integrity Kinetic beds Inspect skin – Where? Protective devices Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank,

45 Psychosocial Care What to expect Hope, reassurance Verbalize feelings Fear of the unknown: be accurate Touch areas with sensation Offer stimulation

46 Autonomic Dysreflexia Injuries above T6 Late complication Causes Signs, symptoms Prevention Treatment

47 Bacterial Meningitis Nuchal rigidity Brudzinski’s sign Kernig’s sign Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank,

48 Meningitis Chills and high fever Vomiting Signs of increased intracranial pressure Photophobia Petechial rash Diplopia (double vision) Seizures

49 Diagnosis CSF: ↑ pressure, ↑ protein, cloudy, ↓ glucose High WBC Blood cultures Sodium

50 Collaborative Management Assess for neurologic deterioration Respiratory isolation x 24 hours Seizure precautions Antibiotics Dark room Headache Hydration

51 Monitor for Complications Septic emboli in circulation to hands Septic shock Coagulation disorders Prolonged temperature elevations

52 Parkinson Disease Bradykinesia Muscle rigidity Stooped posture Shuffling, propulsive gait Tremor

53 Collaborative Care Levodopa Carbidopa Amantadine Catechol Drug tolerance Drug holiday

54 Nursing Care Mobility Nutrition Aspiration precautions Assistive devices

55 Alzheimer’s Disease Chronic, progressive, degenerative brain disorder affecting: Memory Cognition Ability to care for self

56 Collaborative Management Aricept Reminyl Exelon Namenda

57 Nursing Care Cognitive stimulation Structure environment Prevent over-stimulation Provide consistency Promote independence Promote bowel, bladder continence Assist with facial recognition

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

59 Myasthenia Gravis Varying levels of generalized weakness Extra-ocular muscle weakness: Diplopia Ptosis Weak eye closure

60 Diagnosis Acetylcholine receptor antibodies CT scan IV Tensilon and Prostigmin EMG

61 Collaborative Management Mestinon Prostigmin Cholinergic crisis Myasthenic crisis Teach

62 Guillain-Barré Syndrome Ascending weakness Acute respiratory failure Descending weakness?

63 Management Immune globulin Plasmapheresis Respiratory support Communication

64 Multiple Sclerosis Manifestations Fatigue Weakness Leg spasticity Intention tremor Dysmetria, dysdiadochokinesia Tinnitus, vertigo, hearing loss Vision changes

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

66 Collaborative Management Medications to delay, decrease exacerbations Physical, speech therapy Warm packs, stretching Minimize fatigue Teach fall precautions

67 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.