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Topic Outline
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Brief review of Anatomy and Physiology Application of the Nursing process in the approach of neurologic problems:
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ASSESSMENT relevant techniques and lab procedures DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
Topic Outline
Trauma and related accidents
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Cerebrovascular Accidents
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Infectious Disease
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Neoplastic disease
IMPLEMENTATION PHASE
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Increased Intracranial pressure Altered level of consciousness Seizures Autonomic dysreflexia/hyperreflexia Spinal shock Cognitive impairment Bowel incontinence
IMPLEMENTATION PHASE
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Gross anatomy
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The nervous system is divided into the central and peripheral nervous system The Central nervous system consists of the BRAIN and the Spinal Cord The peripheral nervous system consists of the Spinal nerves and the cranial nerves
The Cerebellum is involved in coordination and equilibrium The Diencephalon consists of the :
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Thalamus- the relay center of all sensory input Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response
5 categories:
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1. 2. 3. 4. 5.
Cerebral function- LOC, mental status Cranial nerves Motor function Sensory function Reflexes
Lethargy
Speak to the patient in a Appears drowsy but opens loud voice. e.g., call the the eye and looks at you, patients name or ask How responds to questions, and are you? then falls asleep.
CEREBRAL FUCTION
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Assess the degree of wakefulness/alertness Note the intensity of stimulus to cause a response Apply a painful stimulus over the nailbeds with a blunt instrument Ask questions to assess orientation to person, place and time
Cerebral function
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Utilize the Glasgow Coma Scale An easy method of describing mental status and abnormality detection Tests 3 areas- eye opening, verbal response and motor response Scores are evaluated- range from 3-15 No ZERO score
Glasgow Coma Score n Eye Opening (E) n Verbal Response (V) n Motor Response (M)
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Check first for the patency of the nose Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for the identification Repeat with the other nostrils PROBLEM- ANOSMIA- loss of smell
Check the Visual Acuity with the use of the Snellen chart Check for Visual Field by confrontation test Check for Pupillary Reflex- direct and consensual Fundoscopy to check for papilledema
Snellens Chart
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Confrontation test
Fundoscopy
Sensory portion- assess for sensation of the facial skin Motor portion- assess the muscles of mastication Assess Corneal Reflex
Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids
Test patients hearing acuity Observe for nystagmus and disturbed balance
Together with Cranial nerve 10 vagus Assess for gag reflex Watch the soft palate rising after instructing the client to say AH n The soft palate should rise symmetrically, the uvula should remain midline and the pharynx should constrict medially like a curtain. The posterior one-third of the tongue is supplied by the glossopharyngeal nerve
Press down the patients shoulder while he attempts to shrug against resistance
Assess muscle tone and strength by asking patient to flex or extend the extremities while the examiner places resistance
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Nystagmus
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Evaluate symmetric areas of the body Ask the patient to close the eyes while testing Use of test tubes with cold and warm water Use blunt and sharp objects Use wisp of cotton Ask to identify objects placed on the hands Test for sense of position
Superficial reflexes
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Abdominal Cremasteric Anal Babinski- stroke the lateral aspect of the soles doing an inverted J
Pathologic reflex
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(+)- DORSIFLEXION of the Big toe with fanning out of the little toes
A positive Babinski's sign is indicative of an upper motor neuron lesion affecting the lower extremity in question.
Grading of reflexes
Deep tendon reflex n 0- absent n + present but diminished n ++ normal n +++ increased n ++++ hyperactive or clonic Superficial reflex n 0 absent n +present
DIAGNOSTIC TESTS:
Electroencephalography - graphic recording of electrical activity of the brain by several small electrodes placed on the scalp. n evaluate level of brain function
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Electroencephalography
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Interventions:
Pretest Care: n Patient should be deprived of sleep before EEG n Withhold sedatives, tranquilizers, stimulants for 24 to 48 hrs of EEG n Coffee, tea, and cola drinks are omitted in the meal n Assure the client that the procedure is safe Postest Care:
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makes use of a narrow x-ray beam to scan the head in successive layers lesions in the brain are seen as variations in tissue density differing from the surrounding normal tissue
interventions:
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Preparation for the procedure and patient monitoring teaching the patient to lie quietly Relaxation technique for claustrophobic patient Detect for allergies for iodine based dye
DIAGNOSTIC TESTS
CT scan n With radiation risk n If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected
Interventions:
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Patient preparation ( relaxation technique ) All metal objects and credit cards are removed. Careful history taking: ( presence of aneurysm clips, orthopedic hardware etc.)
Cerebral arteriography
dye injected into the artery n vascular system of the brain is visualized Interventions:
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Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site
To To To To To
obtain CSF for examination measure and reduce CSF pressure( N 60-150 mm H20 ) determine the presence or absence of blood in the CSF detect spinal subarachnoid block administer antibiotics intrathecally
Contraindications: n Infection at site of puncture n Coagulopathies n Increased intracranial pressure n Cervical cord lesion n Suspected or known intracranial mass n Severe cardiovascular compromise
Complications of Lumbar Puncture: n Spinal headache n Iatrogenic infection n Bleeding n Backpain n Herniation
Pretest Have client empty bladder Position client in lateral recumbent position with head and neck flexed on to the chest and knees pulled up. Explain the need to remain still diring the procedure
Posttest Ensure labeling of CSF specimens in proper sequence. Keep client flat for 12-24 hours as ordered. Check puncture site for bleeding, leakage of CSF. Assess sensation and movement in lower extremities. Monitor Vital signs Administer analgesics for headache as ordered.
Vasomotor reflexes are stimulated initially slow bounding pulses Increased concentration of carbon dioxide will cause VASODILATION increased flow increased ICP
Cerebral Edema
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Herniation
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Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem
Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsants- to prevent seizures
Diabetes insipidus- output of >200 mL/hr Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)
It is a function and symptom of multiple pathophysiologic phenomena Causes: head injury, toxicity and metabolic derangement Disruption in the neuronal transmission results to improper function
Decerebrate Decorticate
Sensory function
Patient is not oriented Patient does not follow command Patient needs persistent stimuli to be awake COMA= clinical state of unconsciousness where patient is NOT aware of self and environment
Etiologic Factors Head injury Stroke Drug overdose Alcoholic intoxication Diabetic ketoacidosis Hepatic failure
SEIZURES
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Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons A part or all of the brain may be involved
SEIZURES
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PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively
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SEIZURES
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ETIOLOGIC FACTORS Idiopathic- BFC Fever Head injury CNS infection Metabolic and toxic conditions
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SEIZURES
Interventions During seizure n 1. remove harmful objects from the patients surrounding n 2. ease the client to the floor n 3. protect the head with pillows n 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure
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SEIZURES
Interventions During seizure n 5. loosen constrictive clothing n 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway
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SEIZURES
Interventions POST seizure n 1. place patient to the side to drain secretions and prevent aspiration n 2. help re-orient the patient if confused n 3. provide care if patient became incontinent during the seizure attack n 4. stress importance of medication regimen 4/23/12
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EPILEPSY
A group of syndromes characterized by recurring seizures CAUSES 1. idiopathic 6. brain tumors 2. Birth trauma 7. head Injury 3. perinatal infection 8. metabolic disorders 4. infectious disease 9. CVA 5. ingestion of toxins
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EPILEPSY
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Recurring seizures may be classified as GENERALIZED or PARTIAL SEIZURES Generalized Seizures- cause a generalized electrical abnormality within the brain Partial seizures- these seizures arise from a localized part of the brain and cause specific symptoms
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GENERALIZED SEIZURES
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1. General Tonic-Clonic seizure- ( Grand mal ) characterized by loss of consciousness and alternating movements of the extremities 2. Absence Seizure ( Petit mal )- common in children, begins with a brief change in the LOC, indicated by blinking, rolling of eyes and blank stares
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GENERALIZED SEIZURES
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3. Myoclonic seizure- characterized by brief, involuntary muscular jerks of body extremities 4. Akinetic seizure- general loss of postural tone and a temporary loss of consciousness- a drop attack
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PARTIAL SEIZURES
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1. Simple partial seizure- typically limited to one cerebral hemisphere 2. Complex partial seizure- begins with an aura, then with impaired consciousness, with purposeless behaviors like lip-smacking, chewing movements
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Epilepsy
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Epilepsy
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Medical treatment 1. Anticonvulsants- most commonly phenytoin, phenobarbital and carbamazepine Ethosuximide and valproic acid for absence seizure 2. surgery
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Epilepsy
Intervention n 1. Care of patients during seizure n 2. care of patients after seizures n 3. patient teaching
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SEIZURES
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PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively
SEIZURES
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ETIOLOGIC FACTORS Idiopathic Fever Head injury CNS infection Metabolic and toxic conditions
SEIZURES
Interventions During seizure n 1. remove harmful objects from the patients surrounding n 2. ease the client to the floor n 3. protect the head with pillows n 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure
SEIZURES
Interventions During seizure n 5. loosen constrictive clothing n 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway
SEIZURES
Interventions POST seizure n 1. place patient to the side to drain secretions and prevent aspiration n 2. help re-orient the patient if confused n 3. provide care if patient became incontinent during the seizure attack n 4. stress importance of medication regimen
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Prodromal period - from hours to days - drowsiness, dizziness, lack of coordination Aura warning before the seizure Reflects the portion of the brain which might be affected Smelling unpleasent odors ( temporal lobe)
- Flashing of lights ( occipital lobe) - Numbness of extremities ( parietal lobe ) - Cheshire cat grin ( Frontal lobe) 3. Tonic Stage all muscles of the body contract and the person falls to the ground - Body stiffens, face distorts - Lasts for 20 seconds - Contraction of throat muscles and muscles for respiration - Biting of the tongue
Blowing bubbles or saliva Incontinent of stool ad urine Lasts about 20 seconds 5. post ictal period coma
May be unresponsive for 1-4 hours then will be arousable to pain Awakens with severe headache and no memory of the seizure
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Absence Seizures
Myoclonic Seizure
Atonic/Akinetic Seizures
Status Epilepticus
Recovery Position
HEADACHE
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Cephalgia Primary headache- no organic cause Secondary headache- with organic cause Migraine headache- periodic attacks of headache due to vascular disturbance Tension headache- the most common typedue to muscle tension
HEADACHE
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HEADACHE
Interventions n 1. Avoid precipitating factors n 2. modify lifestyle n 3. relieve pain by pharmacologic measures
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Autonomic Dysreflexia/hyperreflexia
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Seen commonly in spinal cord injury above T6 An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation
Autonomic Dysreflexia/hyperreflexia
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Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion
Autonomic Dysreflexia/hyperreflexia
INTERVENTIONS n 1. Elevate the head of the bed immediately n 2. Check for bladder distention and empty bladder with urinary catheter n 3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer n 4. Administer antihypertensive medicationsusually hydralazine
Spinal Shock
Pathophysiology n The sudden depression of reflex activity in the spinal cord below the level of injury n The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions
Spinal Shock
Interventions n 1. Assist in chest physical therapy n 2. Manage potential complication- DVT
Cognitive Impairment
Interventions 1. Assist or encourage the patient to use eyeglass, hearing aid or assistive devices 2. Reorient the patient by calling his name frequently 3. Provide background information as to date, time, place, environment
Cognitive Impairment
Interventions 4. Use large signs as visual cues 5. Post patient's photo on the door 6. Encourage family members to bring personal articles and place them in the same area
Place the patient on potty every other day Use of stool softeners
Maintain a dietary intake. Avoid foods that can cause excessive gas production
Impaired Swallowing
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Elevate the head of the be 90 degrees during meals and 30 minutes after Serve foods that are soft and small sized Keep suction equipment on bedside Consult with rehabilitation team as to assistive devices that can be utilized
NEUROLOGICAL DISORDERS
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Excessive CSF accumulation in the brains ventricular system In infants, head enlarges In children and adults- brain compression
Non-communicating hydrocephalus results from CSF outflow obstruction Communicating hydrocephalus results from faulty absorption or increased CSF production
Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes
1. Spina bifida occulta- incomplete closure of one or more vertebrae without protrusion of the spinal cord or meninges 2. Spina bifida with meningocele- a sac contains meninges and CSF 3. Spina bifida with meningomyelocele- a sac contains spinal cord substance, meninges and CSF
Incomplete fusion of spinal cord Usually occurs in the lubosacral area (L5 and S1) There is positive tuft of hair or dimple over the affected area May result to progressive disturbance of gait with weak foot or bowel and bladder disturbances
Meningocele
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Hernial protrusion of a saclike cyst of meninges filled with spinal fluid Positive cystic swelling beneath the skin which contains CSF
Meningomyelocele
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Hernial protrusion of a saclike cyst containing meninges, spinal fluid and a portion of the spinal cord May result to either positive or negative neurologic deficits Usually seen with hydrocephalus and Arnold Chiari malformation
Encephalocele
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Cranial meningocele or myelomeningocele Occurs most often in the occipital area of the skull
Causes 1. environmental factors 2. radiation 3. folic acid deficiency in a pregnant woman 4. possibly genetic
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ASSESSMENT 1. a dimple or tuft of hair in the vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography
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The most frequent vertebrae C5-C7, T12 and L1 Concussion Contusion Compression Transection
5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage complications
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Causes
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Falls Diving VA Paralysis Loss of reflexes, sensory and motor function Autonomic dysfunction
Effects
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Cervical SCI
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Above C4 fatal Quadriplegia Respiratory muscle paralysis Bowel/bladder retention Paraplegia Poor control of upper trunk Bowel/bladder retention
Thoracic SCI
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Lumbar SCI
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Paraplegia flaccid Bowel/bladder retention Above S2 with erection, no ejaculation S2-S4 no erection with ejaculation Paraplegia Bowel / bladder INCONTINENCE
Sacral SCI
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COLLABORATIVE MANAGEMENT
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Respiratory function is the first priority especially in cervical SCI Immobilize in a flat, firm surface Cervical collar if cervical injury is suspected Transport patient as a unit Do not attempt to realign body parts Traction , cast, surgery
Complications of SCI
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Period of flaccid paralysis and a complete loss of all reflexes occurs Assessment
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Absence of sweating below the level of the lesion Bowel and bladder retention Hypotention Bradycardia
If the lumbosacral segments are undamaged, spinal shock wears off in 2-3 weeks
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First sign of wearing off is contraction of the quadriceps (hamstrings) and flexion and extention of toes on plantar flexion Bladder empties reflexively as in the infants Reflex defecation and sweating returns
Autonomic Dysreflexia
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Occurs with lesions above T6; most often in cervical injuries Causes
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Assessment
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Bradycardia Hypertension CVA, blindness Sweating above the lesion goose flesh Severe headache Nasal stuffiness
Collaborative Management
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Sitting position to decrease BP Check bladder distention, fecal impaction Ganglionic blocking agent (hexamethonium chloride) Vasodilators (Nitroprusside)
An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply
Cerebro-vascular Accident
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Disruption of blood supply to the brain The MCA most commonly affected Internal carotid artery second most frequently affected
Causes
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Thrombosis
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Most frequent cause of CVA Most common cause of cerebral thrombosis is atherosclerosis ; usually affecting elderly persons Occurs during sleep or soon after rising
Embolism
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Second most common cause of CVA Affecting younger people Cause by RHD and MI
Hemorrhage
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Temporary episodes of neurologic dysfunction Manifestations include contralateral weakness of the lower portion of the face, fingers, hands, arms and legs, sensory impairment Signs resolve within 24 hours
CEREBROVASCULAR ACCIDENTS
Can be divided into two major categories n 1. Ischemic stroke- caused by thrombus and embolus n 2. Hemorrhagic stroke- caused commonly by hypertensive bleeding
CEREBROVASCULAR ACCIDENTS
The stroke continuum n 1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration n 2. Reversible Neurologic deficits n 3. Stroke in evolution n 4. Completed stroke
General manifestations
Localization
Middle Cerebral Artery: n Aphasia n Dysphagia n HEMIPARESIS on the OPPOSITE sidemore severe on the face and arm than on the legs
Localization
Anterior Cerebral Artery: n Weakness n Numbness on the opposite side n Personality changes n Impaired motor and sensory function
Localization
Posterior Cerebral Artery: n Visual field defects n Sensory impairment n Coma n Less likely paralysis
There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus
RISKS FACTORS
Non-modifiable n Advanced age n Gender n race Modifiable n Hypertension n Cardio disease n Obesity n Smoking n Diabetes mellitus n hypercholesterolemia
Disruption of blood supply Anaerobic metabolism ensues Decreased ATP production leads to impaired membrane function Cellular injury and death can occur
Place pillow under axilla Hand is placed in slight supination- C Change position every 2 hours
Aspirin Diazepam to prevent seizures Thrombolytics Stool softeners Antihypertensives Analgesics, Muscle relaxants, STEROIDS
Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage
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Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances
DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP)
Collaborative Management
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Emergency Care
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Care of the patient with increased ICP TPN, NGT feeding, gastrostomy feeding Turn every hour, ROM exercises, prevent contractures I and O; Start urinary and bowel program
Promote nutrition
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Promote activity
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Promote elimination
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Promote communication
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Say one word at a time Identify one object at a time Give simple commands Anticipate needs Allow to verbalize no matter how long it takes him Speech therapy
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Approach from the unaffecte side Place articles on the unaffected side Teach scanning techniques. Turn head from side to side to see entire visual field
Rehabilitation Care
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Rehabilitation
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Learning to live to ones maximum potential with a chronic impairment and its resultant disability Promotes reintegration into the clients family and community Influenced by the client and clients motivation
Goals of Rehab
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Prevent complications Correction of deformities Restoration of function to achieve maximum independence Limitation of disability
DEMYELINATING DISEASES
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Topic Outline
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Multiple Sclerosis Guillian-Barre syndrome Alzheimers Disease Parkinsons Disease Epilepsy Bells palsy Trigeminal Neuralgia
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MULTIPLE SCLEROSIS
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An auto-immune mediated progressive demyelinating disease of the Central Nervous System (CNS) The myelin sheath is destroyed and replaced by sclerotic tissue (sclerosis)
MULTIPLE SCLEROSIS
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CAUSE- unknown Multiple factors- viral infection, environmental factors, geographic location and genetic predisposition Common in WOMEN ages 20-40
MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY n Sensitized T cells will enter the brain and promote antibody production that damages the myelin sheath n Plaques of sclerotic tissues appear on the demyelinated axons interrupting the neuronal transmission
MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY n The most common areas affected are
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MULTIPLE SCLEROSIS
CLINICAL MANIFESTATIONS n 1. visual problems such as diplopia, blurred vision and nystagmus n 2. motor dysfunction- mono/qudradiplegia n 3. Fatigue, sensory impairment n 4. Mental changes like mood swings, depression n 5. spasticity, ataxia
MULTIPLE SCLEROSIS
DIAGNOSTIC TESTS n 1. MRI- primary diagnostic study n 2. CSF Immunoglobulin G
MULTIPLE SCLEROSIS
NTERVENTIONS 1. Promote physical mobility n Exercise n Schedule activity and rest periods n Warm packs over the spastic area n Swimming and cycling are very useful
MULTIPLE SCLEROSIS
INTERVENTIONS 2. Prevent injuries n Wide stance walking n Use of walking aids n Wheelchair
MULTIPLE SCLEROSIS
3. Enhance bladder and bowel control n Set a voiding schedule n Intermittent bladder catheterization n Use of condom catheter n Adequate fluids, dietary fibers and bowel training program
MULTIPLE SCLEROSIS
4. Manage speech and swallowing difficulties n Careful feeding, proper positioning, suction machine availability n Speech therapist
MULTIPLE SCLEROSIS
5. Improve Sensory and Cognitive function n Vision- use eye patch for diplopia n Obtain large printed reading materials n Offer emotional support n Involve the family in the care
MULTIPLE SCLEROSIS
6. Strengthen coping mechanism n Alleviate the stress n Referral to the appropriate agencies
MULTIPLE SCLEROSIS
7. improve self-care abilities n Modify activities according to physical strength n Provide assistive devices
MULTIPLE SCLEROSIS
8. promote sexual functioning n Refer to sexual counselor
MULTIPLE SCLEROSIS
MEDICAL MANAGEMENT Pharmacotherapy
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Interferons Immunomodulators Corticosteroids BACLOFEN for muscle spasms NSAIDS for pain Antidepressants
Guillian-Barre Syndrome
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An auto-immune attack of the Peripheral Nervous System (PNS) Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves POTENTIALLY FATAL!
Guillian-Barre Syndrome
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Guillian-Barre Syndrome
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PATHOPHYSIOLOGY
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Cell-mediated immune attack to the myelin sheath of the peripheral nerves (PNS) Infectious agent may elicit antibody production that can also destroy the myelin sheath of the PERIPHERAL NERVES!!
GBS
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Because this syndrome causes inflammation and degenerative changes in the posterior and anterior nerve roots, MOTOR and SENSORY losses occur SIMULTANEOUSLY!
Guillian-Barre Syndrome
CLINICAL MANIFESTATIONS n 1. Ascending Weakness and Paralysis: Leg affected first n 2. diminished reflexes of the lower extremities n 3. paresthesia n 4. potential respiratory failure
Guillian-Barre Syndrome
LABORATORY EXAMINATION 1. CSF Protein level is INCREASED but the WBC remains normal in the CSF 2. EMG and nerve conduction velocity studies
Guillian-Barre Syndrome
INTERVENTIONS 1. Maintain respiratory function n. Chest physiotherapy and incentive spirometry n. Mechanical ventilator
Guillian-Barre Syndrome
INTERVENTIONS n 2. Enhance physical mobility
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Support paralyzed extremities Provide passive range of motion exercise Prevent DVT and pulmonary embolism Padding over bony prominences
Guillian-Barre Syndrome
INTERVENTIONS n 3. Provide adequate nutrition
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Guillian-Barre Syndrome
INTERVENTIONS n 4. Improve communication
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Guillian-Barre Syndrome
INTERVENTIONS n 5. Decrease fear and anxiety
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Provide Referrals Answer questions Provide diversional activities DVT, Urinary retention, pulmonary embolism, respiratory failure
Guillian-Barre Syndrome
MEDICAL MANAGEMENT n ICU admission n Mechanical Ventilation n TPN and IVF n PLASMAPHERESIS n IV IMMUNOGLOBULIN
ALZHEIMERS disease
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A Progressive Neurologic Disorder that affects the brain resulting in Cognitive Impairments
ALZHEIMERS disease
CAUSES: n Unknown n Potential factors- Amyloid plaques in the brain, Oxidative stress, neurochemical deficiencies
ALZHEIMERS disease
CLINCAL MANIFESTATIONS n 1. Forgetfulness n 2. Recent memory loss n 3. Difficulty learning n 4. Deterioration in personal hygiene n 5. Inability to concentrate
ALZHEIMERS disease
LATE CLINICAL MANIFESTATIONS n 1. Difficulty in abstract thinking n 2. Difficulty communicating n 3. Severe deterioration in memory, language and motor function n 4. repetitive action- perseveration n 5. personality changes
ALZHEIMERS disease
DIAGNOSTIC TEST n Neurologic examination n PET scan n EEG, CT and MRI n Other tests to rule out Vit B deficiencies and hypothyroidism n Autopsy is the most definitive
ALZHEIMERS disease
Drug therapy n 1. drugs to treat behavioral symptoms- antipsychotics n 2. anxiolytics n 3. Donepezil n 4. Tacrine
ALZHEIMERS disease
Interventions n 1. Support patients abilities n 2. Provide emotional support
ALZHEIMERS disease
Interventions 3. Establish an effective communication system with the patient and family n Use short simple sentences, words and gestures n Maintain a calm and consistent approach n Attempt to analyze behavior for meaning
ALZHEIMERS disease
4. protect the patient from injury n Provide a safe and structured environment n Requests a family member to accompany client if he wanders around n Keep bed in low position n Provide adequate lightning n Assign consistent caregivers
ALZHEIMERS disease
5. Encourage exercise to maintain mobility
PARKINSONs Disease
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A slowly progressing Neurologic Movement Disorder The degenerative idiopathic form is the most common form
PARKINSONs Disease
CAUSATIVE FACTORS: unknown n Potential factors: genetics, atherosclerosis, free radical stress, viral infection, head trauma and environmental factors
PARKINSONs Disease
Pathophysiology n Decreased levels of Dopamine due to destruction of pigmented neuronal cells in the Substantia Nigra in the basal ganglia n Clinical symptoms do not appear until 60% of the neurons have disappeared
PARKINSONs Disease
CLINICAL MANIFESTATIONS 1.Tremor: resting(Tremor at rest),pill-rolling" 2. Rigidity: Cog-wheel rigidity, Lead-pipe rigidity 3. Bradykinesia- abnormally slow movement 4. Dementia, depression, sleep disturbances and hallucinations 5. excessive sweating, paroxysmal flushing, orthostatic hypotension
PARKINSONs Disease
Medical management n 1. Anti-parkinsonian drugs- Levodopa, Carbidopa n 2. Anti-cholinergic therapy n 3. Antiviral therapy- Amantadine n 4. Dopamine Agonists- bromocriptine and Pergolide, Ropirinole anmd Pramipexole
PARKINSONs Disease
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PARKINSONs Disease
INTERVENTIONS n 1. Improve mobility n 2. Enhance Self- care activities n 3. Improve bowel elimination n 4. Improve nutrition n 5. Enhance swallowing n 6. Encourage the use of assistive devices
PARKINSONs Disease
INTERVENTIONS n 7. improve communication n 8. Support coping abilities
Myasthenia gravis
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A Sporadic, but Progressive Weakness and abnormal fatigability of striated muscles which are exacerbated by exercise and repetitive movements
Myasthenia gravis
ETIOLOGY n Autoimmune disease n Thymoma Women suffer at an earlier age and are more affected
Myasthenia gravis
Pathophysiology: n 1. Acetylcholine receptor antibodies interfere with impulse transmission n 2. Follows an unpredictable course of periodic exacerbations and remissions
Myasthenia gravis
CAUSE: autoimmune disorder that impairs transmission of nerve impulses ASSESSMENT FINDINGS 1. Gradually progressive skeletal muscle weakness and fatigue 2. Weakness that worsens during the day 3. Ptosis, diplopia and weak eye closure 4. Blank, mask-like facies 5. Difficulty chewing and swallowing 6. Respiratory difficulty
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Myasthenia gravis
DIAGNOSTIC TESTS n 1. EMG n 2. TENSILON TEST (Edrophonium) n 3. CT scan n 4. Serum anti-AchReceptor antibodies
Myasthenia gravis
MEDICAL THERAPY n Anticholinesterase drugspyridostigmine and neostigmine n Corticosteroids n Immunosuppresants n Plasmapheresis n Thymectomy
Myasthenia gravis
INTERVENTIONS n 1. Administer prescribed medication as scheduled n 2. Prevent problems with chewing and swallowing n 3. Promote respiratory function n 4. Encourage adjustments in lifestyle to prevent fatigue n 5.maximize functional abilities
Myasthenia gravis
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6. Prepare for complications like myasthenic crisis and cholinergic crisis 7. prevent problems associated with impaired vision resulting from ptosis of eyelids 8. provide client teaching 9. promote client and family coping
EPILEPSY
A group of syndromes characterized by recurring seizures CAUSES 1. idiopathic 6. brain tumors 2. Birth trauma 7. head Injury 3. perinatal infection 8. metabolic disorders 4. infectious disease 9. CVA 5. ingestion of toxins
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EPILEPSY
n
Recurring seizures may be classified as GENERALIZED or PARTIAL SEIZURES Generalized Seizures- cause a generalized electrical abnormality within the brain Partial seizures- these seizures arise from a localized part of the brain and cause specific symptoms
SEIZURES
n 1. 2. 3. 4. 5.
ETIOLOGIC FACTORS Idiopathic Fever Head injury CNS infection Metabolic and toxic conditions
GENERALIZED SEIZURES
n
characterized by loss of consciousness and alternating movements of the extremities common in children, begins with a brief change in the LOC, indicated by blinking, rolling of eyes and blank stares
GENERALIZED SEIZURES
n
3. Myoclonic seizuren
4. Akinetic seizuren
general loss of postural tone and a temporary loss of consciousness- a drop attack
PARTIAL SEIZURES
n
begins with an aura, then with impaired consciousness, with purposeless behaviors like lip-smacking, chewing movements
Epilepsy
n n n n n n
SEIZURES
Interventions During seizure n 1. remove harmful objects from the patients surrounding n 2. ease the client to the floor n 3. protect the head with pillows n 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure
SEIZURES
Interventions During seizure n 5. loosen constrictive clothing n 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway
SEIZURES
Interventions POST seizure n 1. place patient to the side to drain secretions and prevent aspiration n 2. help re-orient the patient if confused n 3. provide care if patient became incontinent during the seizure attack n 4. stress importance of medication regimen
Epilepsy
n n
Medical treatment 1. Anticonvulsants- most commonly phenytoin, phenobarbital and carbamazepine Ethosuximide and valproic acid for absence seizure 2. surgery
Epilepsy
Intervention n 1. Care of patients during seizure n 2. care of patients after seizures n 3. patient teaching
BELLS PALSY
Dysfunction of the facial nerve (CN 7)
n
BELLS PALSY
Causes n 1. infection n 2. hemorrhage n 3. tumor n 4. local traumatic injury n 5. Idiopathic
BELLS PALSY
MANIFESTATIONS 1 . Unilateral Facial Weakness 2. Mouth drooping 3. Distorted taste perception 4. Smooth forehead 5. Inability to close eyelid on the affected side 6. Incomplete eye closure 7. excessive tearing when attempting to close the eyes 8. Inability to raise eyebrows, puff out the
BELLS palsy
Diagnostic tests n EMG
BELLS palsy
Medical management n 1. Prednisone n 2. Artificial tears
BELLS palsy
Interventions n 1. Apply moist heat to reduce pain n 2. Massage the face to maintain muscle tone n 3. Give frequent mouth care n 4. Protect the eye with an eye patch. Eyelid can be taped at night n 5. instruct to chew on unaffected side
Trigeminal neuralgia
n n
Also called "Tic Douloureux Painful disorder that affects one or more branches of the fifth cranial nerve (Trigeminal nerve) CAUSES: repetitive pulsation of an artery as it exits the pons is the usual cause
Trigemial neuralgia
n
Nearly all cases of typical TN are caused by blood vessels compressing the trigeminal nerve root as it enters the brain stem. This neurovascular or microvascular compression at the trigeminal nerve root entry zone may be caused by arteries of veins, large or small, that may simply contact or indent the trigeminal nerve.
Trigeminal neuralgia
ASSESSMENT n 1. Pain history n 2. Searing or burning jabs of pain lasting from 1-15 minutes in an area innervated by the trigeminal nerve n DIAGNOSTIC TESTS Skull x-ray or CT scan
Trigeminal neuralgia
INTERVENTIONS n 1. provide emotional support n 2. encourage to express feelings n 3. provide adequate nutrition in small frequent meals at room temperature
Brain Abscess
n
A free or encapsulated collection of pus in the brain parenchyma Causes: usually secondary to another infection like- sinusitis, meningitis, dental abscess, mastoiditis, bacteremia and trauma
Encephalitis
n
Intense inflammation of the brain tisssue with lymphocytic infiltration, cerebral edema, degeneration of brain cells and diffuse nerve cell destruction
CNS infections
n n n n n n n
ASSESSMENT FINDINGS Meningitis 1. fever, headache, vomiting 2. positive meningeal sings Brain abscess 1. headache, N/V, seizures, changes in LOC 2. Focal neurologic deficits
CNS infections
n n n n n n n n
DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. EEG MEDICAL TREAMENT 1. Antibiotics 2. Surgical drainage 3. Drugs to reduce increased ICP
CNS infections
INTERVENTIONS n 1. Frequent monitoring of neurologic status n 2. Monitor intake and output n 3. Administer antibiotics n 4. Administer mild laxative to prevent constipation n 5. maintain quiet environment
Neoplastic diseases
n
A brain tumor is a localized intracranial lesion that occupies space within the skull Primary brain tumors originate from cells and structures within the brain.
Neoplastic disease
n n
The cause of brain tumors is unknown The only risk factor accepted is radiation exposure to ionization rays
Neoplastic disease
n n
Neoplastic disease
n n n n
Neoplastic disease
n n n n n
Neoplastic disease
n n n n
Neoplastic disease
INTERVENTIONS n 1. promote self-care independence n 2. improve nutrition n 3. relieve anxiety n 4. enhance family processes n 5. provide pre-operative and post-operative care n 6. manage pain
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