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Transcript of My neurological nursing
NEUROLOGICAL NURSING
Anatomy and Physiology
Neurological Nursing
Purpose: To understand the workings and functions of the human nervous system.
To successfully identify disease processes common to the human nervous system.
To provide proficient care to individuals afflicted with disease processes or injuries affecting the human nervous system.
Neurological Nursing
A & P of the Nervous System
Neurological Nursing
Neuron- The functional unit (cell) of the nervous system that conducts electrical impulses to the brain and to other areas of the body.
Sensory Neurons- Carry information from the distal parts of the body toward the central nervous system (CNS)
Motor Neurons- Carry motor information from the CNS to the periphery.
Neurological Nursing
Axon and dendrites branch off of the main body of the neuron.
Axon- Carry impulses away from the cell body
Dendrites – Carry impulses to the cell body.
Myelin- is a substance that sheaths many axons and dendrites. It enhances conduction along the nerve fiber (moves impulse very quickly) and gives the axons their white appearance.
Neurological Nursing
The Central Nervous System (CNS)
Made up of the BRAIN and the SPINAL CORD
The Peripheral Nervous System (PNS)
Made up of all of the peripheral of the body, including the spinal and cranial nerves
Neurological Nursing
Neurological Nursing
The Brain is divided into the Cerebrum, Cerebellum and the Brain Stem.
Cerebral Spinal Fluid (CSF) is composed of water, glucose, sodium chloride and protein.
Its FUNCTION is that it acts as a shock absorber for the brain and spinal cord.
Neurological Nursing
Neurological Nursing
The Spinal Cord
Extends from C1 to L2There are 31 pairs of spinal nerve roots that exit the spinal cord, each consisting of an afferent root (posterior sensory)and efferent root (anterior motor).These roots, along with the 12 cranial nerves make up the PERIPHERAL NERVOUS SYSTEM.
Neurological Nursing
Autonomic Nervous System
Controls the INVOLUNTARY activities of the viscera including smooth muscle, cardiac muscle and glands
Two major subdivisions: The SYMPATHETIC NERVOUS SYSTEM (SNS) and the PARASYMPATHETIC NERVOUS SYSTEM (PNS).
Cerebrum
Complex functions:
Initiation of movements, recognition of sensory input, higher-order thinking, regulating emotional behavior and endocrine and autonomic functions
Cerebrum
Divided into two halves: hemispheres
Each hemisphere controls the opposite side of the body: the right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body
The cortex of each is divided into the parietal, frontal, temporal, and occipital lobes; each has a different area of function
Cerebrum
Cerebrum
Brainstem
Includes midbrain, pons, medulla, and part of the reticular activating system
Controls vital, basic functions, including respiration, heart rate, and consciousness
Cerebellum
Uses information received from the cerebrum, muscles, joints, and inner ear to coordinate movement, balance, and posture
Unlike the cerebrum, the right side of the cerebellum controls the right side of the body, and the left side of the cerebellum controls the left side of the body
Circulation
Carotid System
Begins as one common artery; later divides into the external and internal carotid arteries
The external carotid arteries divide to supply blood to the face
The internal arteries further divide into the middle cerebral artery and the anterior cerebral artery to supply blood to the brain
Circulation
Carotid System
Begins as one common artery; later divides into the external and internal carotid arteries
The external carotid arteries divide to supply blood to the face
The internal arteries further divide into the middle cerebral artery and the anterior cerebral artery to supply blood to the brain
Circulation
Vertebral Arteries
Originate from the subclavian artery, travel up the anterior neck to merge and form the basilar artery at the brainstem
Second division forms posterior cerebral artery
Internal carotid and vertebrobasilar arteries unite to form the circle of Willis
Circulation
Neurological NursingPATHOPHYSIOLOGY
TYPES OF DISORDERS
Genetic/ Developmental Trauma Infection and Inflammation Neoplasms Degenerative processes Vascular Disorders Metabolic and Endocrine Disorders
Neurological NursingMigraine Headache
Thought to be caused by: Intracranial vasoconstriction followed be
vasodilation.
TRIGGERED BY: Menstruation Ovulation Alcohol consumption Some foods STRESS
Neurological NursingMigraine Headache
PAIN:
Usually unilateral Often begins in the temple or eye area VERY INTENSE Tearing and nausea and vomiting may occur Hypersensitivity to light and sound
Neurological NursingMigraine Headache
TREATMENT MEDICATIONS
Mild migraines: Acetaminophen or aspirin
Severe migraines: Ergotamine (Cafergot) Sumatriptan tablet (Imitrex) Sumatriptan autoinjector (for self injection)
Neurological Nursing Cluster Headache
Occur in a series of episodes followed by a long period with no symptoms.
Intensely painful and seem to be related to stress or anxiety.
Usually no warning symptoms.
Neurological Nursing Cluster Headache
TREATMENT MEDICATIONS
Cold application
Indomethacin (Indocin)
Tricyclic antidepressants (Elavil)
Neurological Nursing Tension Headache
Results from prolonged muscle contraction from anxiety, stress, or stimuli from other sources, such as brain tumor or an abscessed tooth.
Pain location may vary May have N/V Dizziness Tinnitus Tearing
Neurological Nursing Tension Headache
TREATMENT
Correction of known causes Psychotherapy Massage Heat application Relaxation techniques
Neurological Nursing Tension Headache
TREATMENT MEDICATIONS
Analgesics (usually non-opiod)
Benzodiazepines to relieve anxiety if severe.
SEIZURE DISORDERS
Electrical impulses in the brain are conducted in a highly chaotic pattern that yields abnormal activity and behavior.
Related to trauma, reduced cerebral perfusion, infection, electrolyte disturbances, poisoning, or tumors.
SEIZURE DISORDERS
MEDICAL DIAGNOSIS
Accurate history of the seizure disorder
Electroencephalogram (EEG)
SEIZURE DISORDERS Classification
Partial Seizure
SimplePart of one cerebral hemisphere; consciousness not impaired
ComplexConsciousness impaired; may exhibit
bizarre behavior
SEIZURE DISORDERS Classification
Generalized seizures Involves the whole brain Consciousness lost during the ictal (seizure) period
TYPES Tonic-Clonic (Grand Mal) Absence (Petit Mal) (Eye Blinking, Lip Smacking,
Daydreaming) generally identified in childhood. Myoclonic (brief jerking or stiffening of extremities) Atonic (Drop attacks) sudden loss of muscle tone
causes patient to collapse
SEIZURE DISORDERS Classification
Status EpilepticusMedical emergency. The continuous
seizure or repeated seizure in rapid succession for 30 minutes or more.
AuraDizziness, numbness, visual or hearing
disturbance, noting an offensive odor, or pain may precede a seizure
SEIZURE DISORDERS
MEDICAL TREATMENT
Resolution of the underlying condition
Anticonvulsant therapy If good seizure control is not accomplished with
one drug, combinations of drugs may be prescribed.
SEIZURE DISORDERS
SURGICAL TREATMENT
Removal of seizure foci in the temporal lobe and pallidotomy or vagal nerve stimulator.
SEIZURE DISORDERS
Assessment
Describe the seizure episode, INCLUDING the post-ictal period, and documenting drug therapy.
NURSING DIAGNOSES
Risk for Injury:
Nursing Interventions
Side rails Padded bed. Suction machine Bed in low position Remove objects away from the patient DO NOT attempt to restrain the patient
NURSING DIAGNOSES
Ineffective Coping and Knowledge Deficit
Nursing Interventions
Teach family and patient about seizure disorder and the therapy
Teaching must be directed toward helping the patient and family adjust to a chronic condition
Encourage questions and concerns
HEAD INJURIES
TYPES
Scalp Injuries Lacerations, contusions, abrasions, and
hematomas
ConcussionTrauma with no visible injury to the skull or
brain
ContusionBruising and bleeding in the brain tissue
HEAD INJURIES
TYPES
HematomaSubdural hematoma or epidural
hematoma
Intracerebral HemorrhageFrom lesions within the tissue of the brain
itself
Penetrating InjuriesSharp objects penetrate the skull and brain
tissue
HEAD INJURIES
Surgical Treatment
Directed at evacuating hematomas and debriding damaged tissue
NURSING DIAGNOSES
Ineffective Tissue Perfusion Ineffective Breathing Pattern Risk for Injury Risk for Infection Impaired Physical Mobility Disturbed Body Image Ineffective Role Performance
BRAIN TUMORS
Cause and Risk Factors
Some congenital; others may be related to heredity
Drug/environmental factors may play a role in development
BRAIN TUMORS
Signs and symptoms Directly related to area of brain invaded
by the tumor Visual disturbances and headache New-onset seizure activity Difficulties with balance and coordination
BRAIN TUMORS
Medical Treatment
Surgery often followed by radiation with or without chemotherapy
NURSING DIAGNOSES
Acute PainDisturbed Thought ProcessesDisturbed Sensory PerceptionImpaired Physical MobilitySelf-Care DeficitIneffective Coping
Meningitis
Cause and Risk Factors
Inflammation of the meningeal coverings of the brain and spinal cord caused by either viruses or bacteria
Meningitis
Signs and Symptoms
Headache, nuchal rigidity (stiffness of the back of the neck) irritability diminished level of consciousness photophobia (sensitivity to light) hypersensitivity seizure activity Positive Kernig sign Brudzinski sign
Positive Kernig Sign
Brudzinski Sign
Meningitis
Medical Treatment
Bacterial infections usually respond to antimicrobial therapy, but no specific drugs effective against most viral infections
Anticonvulsants used to control seizure activity if necessary
Meningitis
Assessment
Assess vital signs
Neurologic status frequently to determine further deterioration or onset of complications
NURSING DIAGNOSES
Ineffective Tissue PerfusionIneffective Breathing PatternAcute Pain Risk for InjuryDeficient Fluid Volume
Encephalitis
Cause and Risk FactorsInflammation of brain tissue caused by virus
Signs and SymptomsFever AgitationNuchal rigidity (stiff neck) HeadacheConfusion HemiparesisRestlessness Exhibit aphasiaDelirium Facial weaknessComatose Other alterations in motor activity
Encephalitis
Medical Treatment
Enhance patient comfort and increase strength
Because seizure activity is a potential problem, take appropriate safety precautions
NURSING DIAGNOSES
The nursing plan of care parallels that of the patient with meningitis
Guillain-Barré Syndrome
Cause and Risk Factors
Although specific cause unknown, it is believed to be an autoimmune response to a viral infection
Patients often report some recent viral infection or vaccination
Guillain-Barré Syndrome
Initial Phase
Symmetric muscle weakness: begins in lower extremities; ascends to trunk and upper extremities
Visual and hearing disturbances, difficulty chewing, and lack of facial expression
Mild paresthesias or anesthesia in feet and hands in a glove or stocking distribution pattern
Hypertension, orthostatic hypotension, cardiac dysrhythmias, profuse sweating, paralytic ileus, and urinary retention
Guillain-Barré Syndrome
Plateau PhaseRemains essentially unchangedNo further neurologic deterioration, but no improvement either
Recovery PhaseRemyelinization; muscle strength returns in a proximal-to-distal pattern (head to toes)
Guillain-Barré Syndrome
Medical Diagnosis
Characteristic onset and pattern of ascending motor involvement
Elevated protein level in the CSF
Nerve conduction velocity studies reveal slowed conduction speed in the involved nerves
Guillain-Barré Syndrome
Medical Treatment
Preserve vital function, particularly respiration
Respiratory status is closely monitored and mechanical ventilation initiated if vital capacity falls to 15 ml/kg of body weight
Massive doses of corticosteroids prescribed to suppress the inflammatory process
Plasmapheresis
Guillain-Barré Syndrome
Assessment
Health history describes the progression of symptoms
Note fears, coping strategies, and sources of support
Physical examination focuses on cranial nerve, motor, respiratory, and cardiovascular function
NURSING DIAGNOSES
Ineffective Breathing PatternDecreased Cardiac OutputRisk for Disuse SyndromeImbalanced Nutrition: Less Than Body Requirements AnxietyDeficient KnowledgeRehabilitation
Parkinson Syndrome
Cause and Risk Factors
Progressive degenerative disorder of the basal ganglia: an eventual loss of coordination and control over involuntary motor movement
Parkinson Syndrome
Signs and Symptoms
Tremor, rigidity, and bradykinesia
Loss of dexterity and power in affected limbs, aching, monotone voice, handwriting changes, drooling, lack of facial expression, rhythmic head nodding, reduced blinking, and slumped posture Depression common; dementia may develop
Clinical Manifestations of Parkinson Syndrome.
Parkinson Syndrome
Medical Diagnosis
From health history and physical examination
MRI to rule out other causes of the symptoms
Parkinson Syndrome
Medical Treatment
Control symptoms: physical therapy and drug therapy
Massage, heat, exercise, and gait retraining
Parkinson Syndrome
Medications
Dopamine receptor agonists: Pramipexole (Mirapex)
Ropinirole (Requip); L-dopa (L-dihydroxyphenylalanine); Carbidopa/levodopa (Sinemet)
Anticholinergic drugs:Trihexyphenidyl (Artane) Benztropine (Cogentin)
Parkinson Syndrome
Assessment
Weakness, fatigue, muscle cramps, sweating, dysphagia, constipation, difficulty voiding, and unusual movements
Note lack of facial expression, eyes fixed in one direction, drooling, slurred speech, tearing, tremors, muscle stiffness, and poor balance and coordination
NURSING DIAGNOSES
Impaired Physical Mobility Risk for InjuryImbalanced Nutrition: Less Than Body RequirementsIneffective Coping Deficient Knowledge
Multiple Sclerosis (MS)
Cause
Chronic, progressive degenerative disease
Attacks the protective myelin sheath around axons and disrupts the conduction of impulses through the CNS
Chronic, progressive MS: progresses steadily
Exacerbating-remitting MS: exacerbations and remissions
Multiple Sclerosis (MS)
Signs and Symptoms
Fatigue, weakness, and tingling in one or more extremities; visual disturbances; problems with coordination; bowel and bladder dysfunction; spasticity; and depression
Multiple Sclerosis (MS)
Relapsing-progressive MS: less stable periods than exacerbating-remitting
Stable MS: stable; no active disease for a year
Exact cause of MS is unknown; viral infections and autoimmune processes have been implicated
The lesions in multiple sclerosis: location and effects.
Multiple Sclerosis (MS)
Medical Diagnosis
Based on the physical examination and history of cyclic remission-exacerbation periods
Magnetic resonance imaging of the brain and spinal cord may reveal plaques characteristic of MS
Multiple Sclerosis (MS)
Medical TreatmentCorticosteroids
(ACTH, prednisone, methylprednisolone)
Interferon 1b (Betaseron) and interferon 1a (Avonex)
Glatiramer acetate (Copaxone) Immunosuppressants:
mitoxantrone (Novantrone)
Amantadine (Symmetrel)
Multiple Sclerosis (MS)
Urinary retention treated with cholinergics, such as bethanechol (Urecholine) or neostigmine (Prostigmine)
Multiple Sclerosis (MS)
Assessment
Onset and progression of symptoms, especially those that affect mobility, vision, eating, and elimination
Range of motion and strength, gait abnormalities, tremors, and muscle spasms
NURSING DIAGNOSES
Impaired Physical MobilityDisturbed Sensory PerceptionSelf-Care DeficitFunctional Urinary IncontinenceRisk for InfectionIneffective Coping Deficient Knowledge
Amyotrophic Lateral Sclerosis (ALS)
Cause
Also known as Lou Gehrig’s disease; a degenerative neurologic disease
Virus suspected, but exact cause unknown
Amyotrophic Lateral Sclerosis (ALS)
Pathophysiology
Degeneration of the anterior horn cells and the corticospinal tracts, so patient exhibits upper and lower motor neuron symptoms
Amyotrophic Lateral Sclerosis (ALS)
Signs and Symptoms
Weakness of voluntary muscles of the upper extremities, particularly the hands
Difficulty swallowing and speaking
Eventually, respirations shallow; difficulty clearing airway of pulmonary secretions
Death results from aspiration, respiratory infection, or respiratory failure
Amyotrophic Lateral Sclerosis (ALS)
Medical Diagnosis
History and physical examination findings
Electromyography
Amyotrophic Lateral Sclerosis (ALS)
Medical Treatment
Because no known cure or treatment, therapy is supportive; focuses on preventing complications and maintaining maximum function
Amyotrophic Lateral Sclerosis (ALS)
Assessment
Dyspnea, dysphagia, muscle cramps, weakness, twitching, joint stiffness, muscle atrophy, abnormal reflexes and gait, and paralysis
NURSING DIAGNOSES
Ineffective Airway ClearanceImpaired Physical MobilityImbalanced Nutrition: Less Than Body RequirementsImpaired Verbal CommunicationImpaired Skin IntegrityAnticipatory GrievingSituational Low Self-EsteemInterrupted Family Processes
Huntington Disease
Inherited degenerative neurologic disorder
Usually begins in middle adulthood with abnormal movements, emotional disturbance, and intellectual decline
Symptoms progress steadily: increasing disability and death in 15 to 20 years
Medical and nursing care are supportive only; there is no cure
Myasthenia Gravis
CauseMay have an autoimmune basis
Pathophysiology Insufficient receptor sites at the junction
of the motor nerve with the muscle With repeated stimulation, muscle
becomes exhausted; eventually unable to contract at all
If respiratory muscles involved, death from respiratory insufficiency or arrest possible
Myasthenia Gravis
Signs and Symptoms
Weakness of voluntary muscles, particularly those of chewing, swallowing, and speaking
Partial improvements of strength with rest
Dramatic improvement with the use of anticholinesterase drugs
Ptosis and diplopia commonly seen
Myasthenia Gravis
Medical Diagnosis
Administering edrophonium (Tensilon)
Muscle tone is markedly improved within 1 minute of injection; persists for 4 to 5 minutes
Myasthenia Gravis
Medical Treatment
Anticholinesterase drugs Neostigmine and pyridostigmine
(Mestinon) Corticosteroids Cytotoxic therapies Thymectomy Plasmapheresis
Myasthenia Gravis
Assessment
Health history describes the onset of symptoms: muscle weakness, diplopia, dysphagia, slurred speech, breathing difficulties, and loss of balance
NURSING DIAGNOSES
Ineffective Breathing Pattern
Impaired Physical Mobility and Self-Care Deficit
Impaired Swallowing
Deficient Knowledge
Nursing Assessment of Neurologic Function
Health History Note speech, behavior, coordination,
alertness, comprehension
Chief Complaint and history of present illness
Document what prompted the patient to seek medical attention
Describe any injuries If patient has pain, note the onset,
severity, location, and duration
Nursing Assessment of Neurologic Function
Past Medical History
Head injury, seizures, diabetes mellitus, hypertension, heart disease, and cancer
Record dates and types of immunizations
Nursing Assessment of Neurologic Function
Family History
Have immediate family members had heart disease, stroke, diabetes mellitus, cancer, seizure disorders, muscular dystrophy, or
Huntington disease?
Nursing Assessment of Neurologic Function
Review of Systems
Fatigue or weakness, headache, dizziness, vertigo, changes in vision/hearing, tinnitus, drainage from ears or nose, dysphagia, neck pain or stiffness, vomiting, bladder or bowel function, sexual dysfunction, fainting, blackouts, tremors, paralysis, incoordination, numbness or tingling, memory problems, mood changes
Nursing Assessment of Neurologic Function
Functional Assessment
Document whether present symptoms interfere with the patient’s usual activities and occupation Explore sources of stress, usual coping strategies, and sources of support
Nursing Assessment of Neurologic Function
Physical Examination
Level of consciousness, pupillary evaluation, neuromuscular response, and
vital signs
Cerebrovascular Accidents
Risk Factors for Stroke
Non-modifiable factors Risk factors that cannot be changed
Age, race, gender, and heredity
Modifiable factors Those that can be eliminated or controlled
Transient Ischemic Attack (TIA)
Temporary neurologic deficit caused by impairment of cerebral blood flow
Blood vessels occluded by spasms, fragments of plaque, or blood clots
Important warning signs for the individual experiencing a full stroke
Transient Ischemic Attack (TIA)
Signs and Symptoms
Dizziness, momentary confusion, loss of speech, loss of balance, tinnitus, visual disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling or numbness on one side of the body
Transient Ischemic Attack (TIA)
Medical Diagnosis
Health history, physical examination findings, and results of brain imaging studies
Laboratory studies, electrocardiography (ECG), duplex ultrasonography, and cerebral angiography
Transient Ischemic Attack (TIA)
Medical Diagnosis
Health history, physical examination findings, and results of brain imaging studies
Laboratory studies, electrocardiography (ECG), duplex ultrasonography, and cerebral angiography
Transient Ischemic Attack (TIA)
Medical Treatment
Depends on the location of the narrowed vessel and the degree of narrowing
Acetylsalicylic acid (aspirin)Ticlopidine hydrochloride (Ticlid) Extended-release dipyridamole (Aggrenox) Clopidogrel bisulfate (Plavix) decrease platelet clumping Warfarin (Coumadin) and heparin
Carotid endarterectomy and transluminal angioplasty
Transient Ischemic Attack (TIA)
Stroke
An abrupt impairment of brain function resulting in a set of neurologic signs and symptoms that are caused by impaired blood flow to the brain and last more than 24 hours
Stroke
PathophysiologyHemorrhagic stroke
Blood vessel in brain ruptures; bleeding into the brain occurs
Ischemic stroke Obstruction of blood vessel by atherosclerotic
plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain
Stroke
Stroke
Signs and Symptoms
Different signs and symptoms, depending on the type, location, and extent of brain injury
Hemorrhagic stroke Occurs suddenly; may include severe headache
described as “the worst headache of my life”
Other symptoms: stiff neck, loss of consciousness, vomiting, and seizures
Stroke
Signs and Symptoms
Embolic stroke
Appear without warning
One or more of the following signs and symptoms: one-sided weakness, numbness, visual problems, confusion and memory lapses, headache, dysphagia, and language problems
Age-Related Changes
The number of nerve cells decreases
Brain weight is reduced; ventricles increase in size
Lipofuscin: aging pigment deposited in nerve cells with amyloid, a type of protein
Increased plaques and tangled fibers in nerve tissue
Eye pupil often smaller; may respond to light more slowly
Age-Related Changes
Reflexes intact except for Achilles tendon jerk, which is often absent
Reaction time increases, especially complex reactions
Tremors in the head, face, and hands are common Some develop dizziness and problems with balance
Stroke
Stroke
Signs and Symptoms
Aphasia A defect in the use of language; speech,
reading, writing, or word comprehension
Dysarthria The inability to speak clearly
Dysphagia Swallowing difficulty
Stroke
Signs and Symptoms
Dyspraxia The partial inability to initiate
coordinated voluntary motor acts Hemiplegia Defined as paralysis of one side of the
body
Stroke
Stroke
Signs and Symptoms
Sensory impairment Unable to feel touch, pain, or
temperature in affected body parts
Unilateral neglect Do not recognize one side of the body
as belonging to them
Stroke
Signs and Symptoms
Homonymous hemianopsia Perceptual problem: involves loss of one side
of field of vision
Elimination disturbances Neurogenic bladder Flaccid bladder Bowel incontinence
Stroke
Medical Diagnosis
Blood studies, electrocardiogram (ECG), computed tomography, magnetic resonance imaging, carotid ultrasound studies, cerebral and carotid angiography, electrocardiography, positron-emission tomography, and single-photon emission computed tomography
Stroke
Complications
Constipation, dehydration, contractures, urinary tract infections, thrombophlebitis, decubitus ulcers, and pneumonia
Sensory losses put patient at risk for traumatic and thermal injuries
Swallowing difficulties place patient at risk for pulmonary complications, such as choking and aspiration pneumonia
Stroke
Prognosis
Prognosis for TIA or stroke increasingly hopeful
Critical variables for recovery: patient’s condition before the stroke, time between stroke and diagnosis, treatment and support in acute phase (usually the first 48 hours), severity of patient’s symptoms, and access to rehabilitative therapy
Stroke
Prognosis
Long-term recovery may depend on the care received immediately after the stroke
Most recovery takes place in the first 3 to 6 months, but progress often continues long after that
Stroke
Medical Treatment in the Acute Phase
Begins with the onset of signs and symptoms and continues until vital signs, particularly blood pressure and neurologic condition, stabilize
This phase usually lasts 24 to 48 hours Many medical management interventions are directed at minimizing complications and deterioration of the patient’s condition after a stroke
Stroke
Medical Treatment in the Acute Phase
Major focus areas Hypertension Oxygenation Hyperthermia Hyperglycemia
Drug therapy Tissue plasminogen activator (rt-PA, alteplase,
Activase) Given to dissolve clots in acute ischemic strokes
Stroke
Medical Treatment in the Acute Phase
Other Medications Mannitol Nimodipine (Nimotop) Phenytoin (Dilantin) and phenobarbital Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), Aggrenox, and clopidogrel (Plavix)
Stroke
Medical Treatment in the Acute Phase
Surgical intervention An option for some patients with hemorrhagic
strokes
Decisions about surgery are based on patient’s age, intracranial pressure, and location of the hemorrhage
Stroke
Medical Treatment in the Acute Phase
Fluids and Nutrition Intravenous fluids Dietary order based on patient’s
nutritional requirements and ability to eat Regular, soft, or pureed
Total parenteral nutrition may be ordered for the malnourished patient
Stroke
Medical Treatment in the Acute Phase
Urine Elimination
Indwelling catheter to manage urinary incontinence
Intermittent catheterization: controlling incontinence caused by a flaccid bladder
Stroke
Assessment
Evaluate type and extent of the stroke: time of onset, symptoms, other details
Cincinnati Pre-hospital Stroke Scale
Stroke
Health History
Chief complaint and history of present illness Medical history Family history Review of systems Functional assessment
Stroke
Physical Examination
Assess patient’s general appearance, responsiveness, and behavior
Record restlessness or agitation
Measure vital signs; weight and height if possible
Stroke
Physical Examination
Inspect the face for symmetry; mouth for moisture and drooling
Evaluate the alert patient’s ability to swallow
Inspect pupils for size, equality, and reaction to light
Stroke
Physical Examination
Conduct a gross vision assessment
Inspect skin color and palpate for moisture and turgor
Assess extremities for muscle tone and strength, sensation, and voluntary movement
Record evidence of incontinence or bladder distention
Frequently repeat neurologic checks: evaluating level of consciousness, pupil appearance and response to light, the patient’s ability to follow commands, and the movement and sensation of extremities
NURSING DIAGNOSES
Ineffective Airway Clearance and Ineffective Breathing Patterns Risk for Injury Deficient Fluid Volume or Excess Fluid VolumeImbalanced Nutrition Disturbed Sensory Perception Ineffective Thermoregulation Disturbed Thought Processes
NURSING DIAGNOSES
Impaired Verbal Communication
Impaired Physical Mobility
Total or Functional Urinary Incontinence
Constipation and/or Bowel Incontinence
Ineffective Coping
Interrupted Family Processes
Nursing Care in the Rehabilitation Phase
Assessment
Reassess patient’s abilities, expectations, knowledge, motivation, and resources
NURSING DIAGNOSES
Rehabilitation Phase
Self-Care Deficit Risk for Injury Ineffective Coping Impaired Verbal Communication Imbalanced Nutrition Impaired Physical Mobility ConstipationTotal and Functional Urinary Incontinence
REHAB
REHAB
REHAB
Discharge
Patients may be discharged to home or go to specialized rehabilitation centers for continued therapy
Outpatient therapy is an option for some patients
When able, patients are transitioned back into the home setting
Essential to include family, friends, and significant others in this process
Discharge
During and after the rehabilitation phase, patients and families need to be made aware of resources to help them deal with continuing disabilities
In rehabilitation, the patient is respectfully challenged to return to the highest level of function possible
Spinal Cord
Anatomy and Physiology
Consists of 33 vertebrae7 cervical (C1 through C7)12 thoracic (T1 through T12)5 lumbar (L1 through L5)5 sacral (S1 through S5)4 fused coccygeal
Spinal Cord
Spinal Cord
Vertebral Column