1. NEUROLOGIC DEFICITS
Nur-224

2. OBJECTIVES Identify the various types/causes of seizures.
Identify clinical manifestations for clients experiencing neurologic deficits.
Apply the principles of nursing management to care for the patient in the acute stage of ischemic stroke.
Use the nursing process as a framework to develop a plan of care for the client with neurological deficits.

3. CEREBROVASCULAR ACCIDENT
3rd leading cause of death in the US
800,000 people experience a stroke each year
An emergency condition in which neurologic deficits result from a sudden decrease in blood flow to a localized area of the brain.
Major loss of blood supply to the brain  severe disability or death
Types of stroke
Ischemic (80–85%)
Hemorrhagic (15–20%)

4. CEREBRAL VASCULAR ACCIDENT
Risk Factors
Hypertension
Sickle cell anemia
Atrial fibrillation
Diabetes mellitus
Smoking
Hyperlipidemia
Obesity
Sedentary lifestyle
TIA or “little stroke”

5. CVA
Characterized by a gradual/rapid onset of neurologic deficits  compromised cerebral blood flow
Stroke leads to a loss/impairment of sensorimotor functions on the opposite side the side of the brain that is damaged contralateral deficit.
Stroke in the (R) hemisphere of the brain is manifested by deficits in the (L) side of the body (and vice versa)

6. CEREBROVASCULAR ACCIDENT

7. ISCHEMIC STROKE
Disruption of the blood supply to the brain due to an obstruction  a thrombus or embolism, or from stenosis of a vessel resulting from a buildup of plaque
Types
Large vessel stroke
Small vessel stroke
Cardiogenic embolism

8. ISCHEMIC STROKE

9. ISCHEMIC STROKE Clinical Manifestations
Symptoms depend upon the location and size of the affected area
Numbness or weakness of face, arm, or leg, especially on one side
Confusion or change in mental status
Trouble speaking or understanding speech
Difficulty in walking, dizziness, or loss of balance or coordination
Sudden, severe headache
Perceptual disturbances

10. (L)/( R) HEMISPHERIC STROKE
Paralysis/weakness on (R ) side of the body
(R ) visual field deficit
Aphasia
Altered intellectual ability
Paralysis/weakness on the (L) side of the body
(L) visual field deficit
Impulsive behavior and poor judgment
Lack of awareness of deficits
L sided stroke
R sided stroke

11. COMPLICATIONS Sensoriperceptual deficits
Cognitive and behavioral changes
Communication disorders
Motor deficits
Elimination disorders

12. SENSIORIPERCEPTUAL DEFICITS
Deficits may include
Hemianopia
Apraxia
Neglect syndrome

13. COGNITIVE /BEHAVIORAL CHANGES
Cognitive changes
Behavioral changes
Emotional lability
Loss of self-control
Intellectual changes

14. COMMUNICATION DISORDERS
Usually a result of the stroke affecting the dominant hemisphere
Aphasia
Expressive
Receptive
Global

15. MOTOR DEFICITS
Depending on the area of the brain involved strokes may cause:
Hemiplegia
Hemiparesis
Flaccidity
Spasticity

16. ELIMINATION DISORDERS
Bladder elimination
Bowel elimination

17. Transient Ischemic Attack (TIA)
Mini-stroke
Brief period of localized cerebral ischemia that causes neurologic deficit lasting less than 24 hours
Sudden loss of motor, sensory, or visual function
Serves as a warning for impending stroke

18. Ischemic Stroke -Assessment
Acute phase
diagnosis the type/cause of the stroke
support cerebral circulation
control/prevent further deficits
Focus
minimize brain injury
maximize patient recovery

19. Ischemic Stroke – Diagnostic Findings
Complete history/careful physical assessment
CT scan
DWI test
PLAC tests

20. MEDICATIONS Prevention
Antiplatelet- Aspirin, clopidogrel(Plavix), ticlopidine(Ticlid)
Acute Stroke
fibrinolytic therapy-tissue plasminogen activator
anticoagulant therapy
Antihypertensive medications

21. Thrombolytic Therapy
Used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow to the brain.
Recombinant t-PA
Rapid diagnosis of a stroke and initiation of therapy (within 3 hours) decrease the size of the stroke and may improve functional abilities after 3 months
Bleeding most common side effect

22. TREATMENTS Surgery (Carotid Endarectomy)
Performed to prevent the occurrence of a stroke
Restore blood flow when a stroke has occurred
Repair vascular damage
Rehabilitation
Physical therapy
Occupational therapy
Speech therapy

24. Carotid Endarterectomy Postoperative Care
Position on the inoperative side –
Assess respirations/oxygen saturation
- hemorrhage
-respiratory distress
- cranial nerve impairment
-hypotension/hypertension

25. HEALTH PROMOTION Stroke prevention – esp known risk factors
Public awareness of signs of TIA/Stroke
Sudden –
- weakness/numbness
- confusion, trouble speaking
- trouble walking, dizziness, loss of balance
- trouble with vision
- severe headache without a cause

26. Nursing Diagnosis/Interventions
Risk for Ineffective Tissue Perfusion- Cerebral
Impaired Verbal Communication
Impaired Swallowing
Impaired Physical Mobility
Self-care deficits r/t (bathing, grooming, hygiene)

27. Nursing Interventions -Mobility
Maintain correct position  good body alignment  avoid deformities
Change position every 2 hours – if sensation is impaired on one side – the amount of time spent on the affected should be limited.
Prevent pressure ulcers.
Affected extremities – ROM exercises
Prepare for ambulation ASAP/active rehabilitation program

28. Nursing Interventions- Nutrition
May swallowing problems (dysphagia).
Swallowing difficulties place the patient at the risk for aspiration, pneumonia, dehydration, and malnutrition.
Start patient on thick liquid/pureed foods  easy to swallow
Patient unable to consume oral intake  enteral feedings
Long-termed feedings  gastrostomy tube

29. Nursing Interventions-Communication
Aphasia –receptive/expressive
Face the patient and establish eye contact
Develop strategies to make the atmosphere conducive to communication
Speak in a normal manner and tone, speak slowly
Use gestures, pictures, objects, writing,
Use same words and gestures  be consistent

30. Nursing Intervention – Skin Integrity
At risk for skin and tissue breakdown
Specialty bed
Regular turning schedule
Minimize shear/friction forces

31. ISCHEMIC STROKE
Recovery/rehabilitation  may be prolonged and requires patience.
Community based support groups
Depression – common /serious problem
Caregivers need to be reminder to attend their own health concerns/well-being  respite care.

32. Hemorrhagic Stroke Intracranial hemorrhage
Cerebral blood vessel ruptures.
May be due to:
Intracerebral hemorrhage
Intracranial aneurysm
AV malformation
Subarachnoid hemorrhage

33. HEMORRHAGIC STROKE

34. HEMORRHAGIC STROKE

35. Hemorrhagic Stroke – Clinical Manifestations
Similar to ischemic stroke
Severe headache
Early and sudden changes in LOC
Vomiting

36. HEMORRHAGIC STROKE Nursing Interventions
Maintain optimum tissue perfusion
-aneurysm precautions
Manage potential complications
- vasospasms
- hyponatremia
- seizures
Promote home and community-based care

37. SEIZURE DISORDERS
A single event of abnormal, sudden, electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function.
Epilepsy (seizure disorder) –
- chronic disorder of abnormal, recurring
excessive electrical discharges
- recurring seizures accompanied by some
type of behavioral change

38. SEIZURE DISORDERS affect more than 3 million people
strong genetic component
Precipitating factors
birth defects
head injury/trauma
metabolic disorders/renal failure hyponatremia,
IICP
The cause is unknown in 70% of all cases

39. Seizures
All people with epilepsy have seizures, but not all people who have a seizure have epilepsy.
Only after a person has two seizures  dx. of epilepsy is made
Classification of seizures
Partial seizures: begin in one part of the brain
Generalized seizures: involve both hemispheres of the brain

40. SEIZURE DISORDERS/Pathophysiology
Messages from the body are carried by the neurons (nerve cells) by electrical discharges.
Impulses occur when a nerve cell has a task to perform.
Sometimes there is an excessive imbalance and the cell continues to fire after the task is completed.
Unwanted discharges cause the body to respond erratically.

41. Generalized Seizures Consciousness is always impaired
Absence seizures (petit mal)
-sudden brief cessation of all motor activity
accompanied by a blank stare and
unresponsiveness.
Tonic-clonic seizures (grand mal)
- common type of seizures in adults
- warning aura may precede generalized
seizure activity

42. TONIC-CLONIC SEIZURE Tonic Phase
Begins with a sudden loss of consciousness, sharp muscle contractions
Patient may fall to the floor
Urinary incontinence is common
Breathing ceases and cyanosis develops
Pupils are fixed and dilated
Tonic phase may lasts – 15 seconds – 1 minute

43. TONIC-CLONIC SEIZURE Clonic Phase
Alternating contraction/relaxation of the muscles in all extremities
Eyes roll back and the patient froths at the mouth
Phase varies in duration and subsides gradually
Entire seizure generally lasts no more than seconds

44. Tonic – Clonic Seizures

45. TONIC-CLONIC SEIZURES
Following clonic phase (postictal phase)
Person remains unconscious /unresponsive to stimuli
Person is relaxed and breathes quietly
Regains consciousness gradually
May be confused/disoriented
Headache muscle ache and fatigue may follow
Amnesia of the seizure may follow
Because of lack of warning with tonic-clonic seizures, head injury, fractures, burns may occur secondary to seizure activity

46. Status Epilepticus Can develop during seizure activity
Seizure becomes continuous– with only short periods of calm between intense and persistent seizures
Cumulative effect  muscular contractions that interfere with respirations
Hypoxia, acidosis, hypoglycemia, hyperthermia and exhaustion may occur if the convulsive activity is not stoped.
medical emergency
Goal – stop the seizure (ASAP)
Establish and maintain airway is priority

47. SEIZURE DISORDERS/Assessment
Diagnostic Assessment
Confirm the diagnosis, determine any treatable causes and precipitating factors
Diagnostic Testing
MRI/CT Scan
EEG
Lab data – CBC, biochemistry

48. SEIZURE DISORDERS/Medical Management
Pharmacologic therapy ( AEDs)
controls rather than cures seizures
Medication blood levels should be monitored
Antiseizure drugs should not be discontinued abruptly because it can precipitate seizures
Protect the patient from harm, reduce/ prevent seizures activity without impairing cognitive function or producing undesirable side effects

49. SEIZURE DISORDERS/Medications
Phenytoin (Dilantin)
Caramazepine ( Tegretol)
Gabapentin (Neurotonin)
Topiramate (Topamax)
Valproate (Depakote,Depakene)
Clonazepam (Klonopin)
see page 1885

50. Antiepileptic Drugs
Note CNS side effects: blurred vision, slurred speech, confusion
Patients on prolonged therapy may need a diet rich in Vitamin D
Maintain good oral hygiene – phenytoin
Obtain liver functions
Carry identification indicating type of seizure -- being treated for

51. Nursing Process Nursing Diagnosis
Risk for Ineffective Airway Clearance
Anxiety
Risk for injury r/t seizure activity
Readiness for Enhanced Knowledge

52. OBJECTIVES
Describe the mechanisms of injury, clinical manifestations, diagnostic testing, and treatment options for patients with brain and spinal cord injuries.
Use the nursing process as a framework for care of clients with brain and spinal cord injury

53. SPINAL CORD INJURY – (SCI)
Involves damage to the neural elements of the spinal cord.
Both sensory and motor function are often involved.
Major causes  contusion, compression, laceration, hemorrhage and damage to the blood vessels in the spinal cord.

54. SPINAL CORD INJURY/SCI
A major health problem
200,000 persons in the U.S. live with disability from SCI
Injuries due to: MVAs, falls, acts of violence, and sports injuries
Males account for 82% of SCIs
Young people ages 16–30 account for more than half of all new SCIs
African–Americans are at higher risk
Risk factors include alcohol and drug use

55. SPINAL CORD INJURIES
Spinal cord provides a two–way pathway for the conduction of impulses and information to and from the brain and the body
Ascending (sensory) pathways carry information  pain, temperature, touch, Descending (motor) pathways carry information  about movement
Involve damage to the vertebrae and supporting ligaments as well as the spinal cord.

56. SPINAL CORD INJURIES
Are the result of excessive force to the spinal column.
Most common causes -> acceleration and deceleration
Acceleration: external force is applied in a rear end collision
Deceleration: occurs in a head on collision

57. SPINAL CORD INJURY/ SCI
Vertebrae frequently
Involved 1st, 2nd,
and 4th to the 6th
cervical vertebra.
The 11 thoracic to 2nd
lumbar vertebra.

59. CLASSIFICATION of SCI Is determined by the amount of cord involvement
Paraplegia
Quadriplegia

60. EMERGENCY MANAGEMENT
The patient requires emergency assessment and care and medications.
Initial care immobilization and extrication/stabilization of injuries. And possible surgery.
SCI affects every body system and function.
When injury is C1 to C4 respiratory paralysis is common and ventilator assistance is required

61. Diagnostic Findings Neurological examination
Diagnostic x-rays ( cervical spine)
CT /MRI
ABG’s
Trauma Screen
Fluids
Medications – corticosteroids, vasopressors, antispasmodics, NSAIDs, PPI, anticoagulants

62. Complications - Spinal Shock
Temporary loss of reflex function (areflexia) below the level of injury at the cervical and upper thoracic spinal cord.
As a result –SNS is interrupted and the PSNS is unopposed.
Muscles become completely paralyzed and flaccid/reflexes are absent
Loss of urinary bladder tone, intestinal peristalsis, perspiration
Recovery from spinal shock is gradual – usually 4-6 weeks.

63. Complications – Autonomic Dysreflexia
Exaggerated sympathetic response affects persons with SCI at or above the T6 level.
Caused by visceral distention from distended bladder/impacted rectum
Pounding headache, hypertension, profuse sweating, bradycardia, piloerection (goosebumps)
HOB – high fowler’s, loosen tight clothing
Asses bladder distention -catherization
Fecal impaction – disimpact immediately

64. TREATMENTS Surgery – done to stabilize and support the spine
Stabilization/Immobilization – a type of traction or external fixation device to stabilize the vertebral column and prevent further damage to the cord.

65. SKELETAL FRACTURE REDUCTION/TRACTION

66. Nursing Diagnosis Impaired Gas Exchange Impaired Physical Mobility
Impaired Urinary Elimination and Constipation
Sexual Dysfunction

67. HOME/COMMUNITY BASED CARE
Long-term care rehabilitation is needed
Learn strategies necessary to cope with their alterations that the injury imposed on ADL’s
Care for the patient involves members of all health care disciplines
Psychologic support
Goal of rehabilitation  independence

68. DEGENERATIVE DISK DISEASE
Herniated intervertebral disk ( ruptured disc, slipped disk) is a rupture of the cartilage surrounding the intervertebral disk with protusion of the nucleus pulposus.
Most common cause of low back pain .
May affect 2/3 of people at some point in their lifetime.
Most back problems are related to disk disease

69. HERNIATED INTERVERTEBRAL DISK
More common in men than women
Most patient are between the ages of 30-50
Majority of herniated disks occur in the lumbar region (L4 or L5 to S1), when disk herniate in the cervical region, they occur most often in the C6-C7 region
Herniation may be abrupt or gradual

70. DEGENERATIVE DISK DISEASE Pathophysiology
Intervertebral disk is a cartilaginous plate that forms a cushion between the vertebral bodies
Herniation of the intervertebral disk, causes the nucleus of the disk to protrude into the fibrous ring around the disk.
Immediate symptoms are short-lived, and those resulting from injury to the disk do not appear for months or years.
Continuous pressure may cause degenerative changes in the involved area

71. DISK DISEASE

72. DEGENERATIVE DISK DISEASE Clinical Manifestations
Lumbar Disk
recurrent episodes of lower back pain
pain radiates across the buttocks and down the posterior leg (sciatica)
Cervical Disk (C5-C6, C6-C7)
Most herniations are the result of degeneration
pain and stiffness  neck, shoulders, arms
pain  dull, intermittent pain
parethesia of upper extremities

73. DEGENERATIVE DISK DISEASE Assessment/Diagnostic Findings
MRI
CT scan
EMG
Neurologic examination

74. DEGENERATIVE DISK DISEASE Medical Management
Herniations of the cervical and lumbar disks are most common and are treated conservatively unless the patient is experiencing severe neurologic deficits.
Conservative Treatment
Bedrest (no longer recommended)
Patient is advised to continue with normal activities while taking medication for pain, inflammation, and muscle spasms.
NSAID – ibuprofen (Motrin, Advil), naproxen (Naprosyn)
Muscle relaxants – cycobenzaprine (Flexeril), methocarbamol (Robaxin)
Hot moist compresses

75. DEGENERATIVE DISK DISEASE
Surgery is sometimes necessary
Significant neurological deficit
Continuing pain or sciatica
Loss of sensory /motor function
Laminectomy-done to relieve the pressure on the nerves
Spinal fusion- insertion of a wedge-shaped piece of bone or bone chips between the vertebrae to stabilize them.

76. Craniotomy Craniotomy: opening of the skull
Purposes: remove tumor, relieve elevated ICP, evacuate a blood clot, control hemorrhage
Craniectomy: excision of portion of skill
Cranioplasty: repair of cranial defect using a plastic or metal plate
Burr holes: circular openings for exploration or diagnosis, to provide access to ventricles or for shunting procedures, to aspirate a hematoma or abscess, or to make a bone flap

77. BURR HOLES

78. Preoperative Management-medical
Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies
Medications are usually given to reduce risk of seizures
Corticosteroids, fluid restriction, hyperosmotic agent (mannitol), and diuretics may be used to reduce cerebral edema
Antibiotics may be administered to reduce potential infection
Diazepam may be used to alleviate anxiety

79. Preoperative -nursing
Obtain baseline neurologic assessment
Assess patient and family understanding of and preparation for surgery.
Provide information, reassurance, and support

80. Intracranial Surgery

81. Post operative
Postoperative care is aimed at detecting and reducing cerebral edema
relieving pain
preventing seizures,
monitor ICP
The patient may be intubated and have arterial and central venous lines.

82. Care of Patient -Assessment
frequent monitoring of respiratory function including ABGs
monitor VS and LOC; noting any potential signs of increasing ICP
assess dressing and check for evidence of bleeding or CSF drainage
monitor for seizures; if seizures occur, carefully record and report these
monitor fluid status and laboratory data

83. Nursing Diagnosis
Risk for imbalanced body temperature r/t damage to hypothalamus
Disturbed sensory perception r/t periorbital edema, head dressing
Body image disturbance r/t change in appearance or physical disabilities
Impaired communication (aphasia) r/t injury to brain tissue

84. Cerebral perfusion Strategies to control factors that increase ICP
Avoid extreme head rotation
Head of bed may be flat or elevated 30°
Suction or encourage coughing cautiously as needed (suctioning and coughing increase ICP).
Humidification of oxygen may help loosen secretions.

85. Craniotomy- Nursing Interventions
Sensory deprivation
Periorbital edema may impair vision, announce presence to avoid startling the patient; cool compresses over eyes and elevation of HOB may be used to reduce edema if not contraindicated.
Enhancing self-image
Encourage verbalization.
Encourage social interaction and social support.
Attention to grooming.
Cover head with turban and, later, a wig.

86. Home/Community based care
What to expect after surgery
medication is taken appropriately
rehab – depending on post-op level of function
physical therapy – residual weakness/mobility
occupational therapy – self care concerns
speech therapy – aphasic
If prognosis is poor – discuss end of life preferences