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Assess motor function Be descriptive of observed behavior,Gait,Coordination,Weakness (flaccid),Reflexes,Posture,Involuntary movements (spastic),Paralysis vs Paresis
CN 1 (olfactory) identification of common odors
CN 2 (optic) visual acuity and visual fields
CN III (oculomotor) Pupillary responses: size, shape, reactivity bilaterally
CN IV (trochlear) tested with CN III
CN V (trigeminal) Jaw strength, facial sensation, corneal reflex
CN VI (abducens) tested with CN III
CN VII (facial) Face moves in symmetry, identification of taste (sensory)
CN VIII (acoustic) hearing
CN IX (glossopharyngeal) taste
CN X (vagus) Gag reflex, movement of the uvula and soft palate
CN XI (spinal accessory) shoulder and neck movement
CN XII (hypoglossal) tongue movement
Assess sensory and perceptual status Pain, touch, temperature, Proprioception, Unilateral neglect, Hemianopia
Computed Tomography (CT) Scan 30-60 mins of lying still,IV line started if contrast medium planned, Claustrophobia, Allergy to iodine/seafood significant
MRI Remove watches, jewelry, any metal from clothing,Questioned about metal in the body,Noise
Lumbar puncture 10-15 mins,Slight pain and pressure,Sharp shooting pain down one leg common,Patient positioning on side with knee and head flexed,Slight bleeding at site,Patient to lie flat for several hours after to avoid headaches
Electroencephalography Patient must be quiet and rest before procedure,One hour to complete,Hair and scalp to be clean,Wash hair after to remove electrode paste,Must rest after procedure
Myelogram 2 hours to complete,Slight discomfort during procedure,May need to assume variety of positions,IV & check for allergies to contrast agents ,CT scan to follow,Headache, nausea, vomiting common after,Patient must rest after for a few hours
Angiography (Pre/intraprocedure) Oral intact restricted- NPO or clear fluids,Check for allergy to iodine,VS and neurological checks done,2-3 hours to complete,Discomfort in lying still that long,Hot flush feeling when dye injected,Bedrest ordered after procedure
Angiography (Post procedure) Bedrest ordered after procedure,Patient assessed routinely for VS, neuro checks, LOC, puncture site,High risk for CVA and/or IIP after procedure
Carotid Duplex Noninvasive probe on skin and moved along carotid
Digital Subtraction Angiography Same as angiogram
Electromyography 45 mins to complete,Discomfort when electrode inserted and when electrical current is used,Muscle ache after procedure,Assess for signs of bleeding,Provide analgesia
Echoencephalogram Same as a brain scan
Potential Nursing Diagnoses Knowledge deficit related to procedure,Anxiety related to procedure,Alteration in comfort related to procedure
traction inflammatory Occlusive vascular,Intracranial and extracranial causes structures,Infection,Temporal Arthritis
HEADACHES Cephalalagia-known as aching of the head,Common neurological complaint with variable clinical significance,Results from a variety of causes,Exact mechanism of head pain unknown
HEADACHES Skull and brain tissues contain no nerves and do not feel pain sensory,Pain arises from the scalp, it’s blood vessels and muscles, and from dura matter and its venous sinuses,Pain also comes from blood vessels at the base of the brain and cervical cranial
HEADACHES Classified as Vascular, Tension
Migraine,Cluster,Hypertensive Vascular
Psychological cause,Medical cause,Stress Tension
manifestations of Migraine Prodromal-Visual field defects,Disorientation,Paralysis of part of the body (rare),Familial
Manifestation During Migraine Nausea, vomiting,Sensitivity to light,Chills, diaphoresis,Irritability, fatigue,Edema
Migraine Contributing factors Emotional stress,Excess carbohydrates,Iodine rich foods,Alcohol,Chemical additives (MSG),Fatigue,Caffeine
Cluster Headaches Episodic-lasting 30 minutes to 2 hours,Occurring in clusters,2 to 10 headaches per day,Pain on one side of the head usually around or behind one eye,Very little time between onset and maximum pain
Cluster Headaches Attacks occur at the same time of day,Not Familial
Tension Headache Pain is described as a band of pressure encircling the head typically with a steady ache,Tension type headaches may also be chronic, occurring frequently or even every day
Tension Headache Response to: Emotional stress,Eyestrain,Maintaining a fixed position
Headache Subjective Precipitating factors,Relief measures,Site, frequency, pattern and nature of pain,Associated symptoms (before and during headache) Allergies
Headache Objective Behavior,Stress/anxiety,Ability to complete ADLs,Elevated body temperature,Sensory exam, Abnormal spinal reflexes, Vasomotor response
Headache Diagnostic Tests Neuro exam,CT,MRI or PET scan may also be done,A lumbar puncture (CT must be done 1st),X-ray,Brain scan
Headache Medical Management Dietary counseling reduction of foods that may cause or worsen headaches;Tyramine,nitrates or glutamates (MSG),Vinegar,Chocolate,Yogurt,Alcohol,Pork,Fermented or marinated foods,Cured sandwich meat
Headache Medical Management Psychotherapy,Relaxation techniques,Improve individual coping,Develop awareness of stress factors
Headache Nursing Interventions Medications,Relaxation and rest techniques,Diet restrictions,Identifying triggering factors,Comfort measures
Headache Comfort Measures Cold warm Packs,Pressure applied to temporal arteries,Stimuli reduction,Regular Physical exercise,Regular Physical exercise,Cluster care to allow for rest periods
Headache Pharmacological Management Non-Opioid=ibuprofen (Motrin). acetylsalicylic acid (Aspirin).acetaminophen (Tylenol). Opioids Agonist=propoxyphene/Darvon,propoxyphene/acetaminophen (darvocet-N).
Headache Pharmacological Management Vascular Headache Suppressants Ergot Derivatives,Serotonin Receptor Agonist,Beta-Blockers,
Vascular Headache Suppressants (Ergot derivatives) dihydroergotamine (Sandoz, Migranal),ergotamine (Cafergot),may be given in combination with caffeine, Phenobarbital and belladonna,reduce inflammation and pain transmission
Vascular Headache Suppressants(Ergot derivatives) Side effect include nausea, vomiting, changes in heart rate, numbness, tingling and muscle pain.
Vascular Headache Suppressants(Selective Serotonin receptor agonists) 5-HT Agonists produce vasoconstriction by acting as serotonin agonists(Sumatriptan= Imitrex,Zolmitriptan=Zomig)
Selective Serotonin receptor agonists Implementation: administer at first signs of headache Do not use in conjunction with Ergot derivatives.
Vascular Headache Suppressants Beta-Blockers: propranolol=Inderal,timolol=Blocadren,atenolol=tenormin,(MISCELLANEOUS)Depakote,Depakote ER,Depacon,Depakene
A patient has been complaining of headaches. the nurse would expect what if this were migraine headaches? They cause the patient to experience unusual smells or sounds before the pain begins.
Neurological Pain Disabling pain occurs because of a disorder within the nervous system or peripherally
Neurological Pain Pain receptors are not adaptable and are of pain only.May evolve from lesions
Neurological Pain Peripheral cutaneous nerves,Sensory nerve roots,The thalamus Central pain tract (AKA Lateral Spinothalamic)
Pain receptors can be activated by: Cellular damage,Innate chemicals (such as histamine),Heat/cold,Muscle spasms,Pruritus
Intractable Pain Pain that is unbearable and does not
Intractable Pain Chronic,Debilitating,Limits ability to perform ADLs
Intractable Pain (SUBJECTIVE) pain is highly SUBJECTIVE,Precipitating factors,Site/frequency/nature of painAssociated symptoms,Coping skills/ability when under stress
Intractable Pain (OBJECTIVE) signs of pain and/or stress,Change in ADLs,Muscle weakness/wasting,Vasomotor responses (flushing),Altered sensory exam,Abnormal spinal reflexes
Intractable Pain Diagnostic Test Electrical stimulation (used to define pain),Psychological testing,Myelogram(If back or neck pain is present)
Non Surgical Pain Control (TENS),Spinal cord stimulation,Acupuncture,Nerve block (used for intractable pain),Medications=Gabapentin is often useful controlling,Counseling
Surgical Pain Control Neurectomy,Rhizotomy,Cordotomy,Percutaneous cordotomy
Neurectomy nerve excision
Rhizotomy cut of a spinal nerve root
Cordotomy cutting a nerve in the spinal cord
Percutaneous cordotomy destruction of a nerve bundle by means of an electric current
Pain Nursing Interventions The most important nursing intervention is patient teaching(aimed at decreasing painful stimuli and enhancing proper positioning/improved function)
Pain Nursing Interventions Comfort measures, Counseling,Disuse syndrome risk for, related to lack of,Self care deficit, ADLs, related to pain
Increased ICP Potential complication in many neurological conditions,Often occurs suddenly and progresses rapidly,
Causes of increased ICP Space occupying lesions (tumors),Trauma,CSF excess (due to tumor or inability to drain),Cerebral Edema (due to tumor, trauma, hypoxia)
ICP (IICP) As pressure increases compensation occurs,Venous compression & displacement of CSF,Increased pressure = reduced cerebral blood flow,Increased pressure = reduced cerebral blood flow
Increased ICP (IICP) Increased Edema leads to increase in ICP,Further decrease in CBF= vicious cycle,Supratentorial Shift
Increased ICP (IICP) Herniation-Compression of Vasomotor center=BP, HR,Resp,Temperature control,Oculomotor nerve,Compression of RAS,Corticospinal nerve pathway,DEATH
Clinical Manifestations of IICP Imparitive that detection occur early while still reversible,Deterioration of LOC –(earliest sign)Pupillary dysfunction-ipsilaterat ,Visual Abnormalities Head Aache,Loss of motor function –late signs Alteration in blood pressure, pulse, resp
Subjective Manifestations of IICP May be present with little or no change in clinical presentation,Diplopia,Pain especially a headache (increases with cough, straining with stool or stooping)
Clinical Manifestations of IICP (Late signs-Brain stem involvement) Alteration in respirations,Cushing’s Response,Alteration in temperature,Loss of brain stem reflexes,Papilledema,Projectile vomiting,Singultus (hiccup)
The most important role for the nurse caring for the patient at risk for ICP is…. Detection of ICP early while it is still reversible
IICP Diagnosis General physical exam and, history, Neurological exam with frequent and careful observation,CT/MRI scan,CT/MRI scan(Intraventricular,Subarachnoid bolt or screw Epidural sensor)
IICP Treatment No single therapy for IICP,If tumor or mass surgical therapy is indicated ,Goal is to control I ICP and protect the brain from secondary injury(ischemia/hypoxia)
Treatment Medical Medical therapies can be categorized as Pharmacological,Mechanical,Adjunct
Pharmacological (IICP) Hyperosmotic agents, Sedation, Phenytoin, Paralytic agents
Mechanical (IICP) Craniotomy Craniectomy
(IICP)Hyperosmotic agents Mannitol(Draw water out of brain tissue by increasing osmolality of the blood,Begins effect in 15 minutes and last 5-6 hours,Lasix often used concomitantly; potentiates Mannitol,Monitor urine output, serum electrolytes,osmolarity.Maintain serum osmo
(IICP)Pain Management and Sedation Analgesics,Sedation reduces brain activity
Analgesics-IICP Treatments Morphine OR Fentanyl (short-acting agent)
Sedation reduces brain activity Usually wake patients up every 24 hours to assess neuro function for first few days after injury,Propofol (very short-acting agent),Midazolam (longer acting agent)
Phenytoin-IICP Treatments Maintain therapeutic dose for 7-10 days after injury to prevent seizures
Seizure-IICP Treatments significantly increase brain metabolism
Paralytic agents IICP Treatments ensure that patient receives adequate sedation and analgesics,Nothing is worse than being awake and paralyzed.=Vecuronium/Atracurium
Mechanical IICP Treatments. Craniotomy Bone flap removed and replaced (for example, removal of a tumor) Craniectomy Bone flap removed and not replaced (often used in trauma to allow brain to swell out of hole)
IICP Treatments Adjunct Endotracheal Intubation-Hypoxia produces cerebral vasoconstriction and is, therefore, avoided,PaO2 around 100mmHg. Hypercarbia (elevated PaCO2) causes cerebral vasodilatation. PCO2 within normal range
IICP Nursing Management Goals=Maintain cerebral perfusion,Prevent further neurologic ischemia
IICP Nursing Management Elevate HOB 30 – 45 degrees,Prevent hyperextension, flexion or rotation of head  Avoid flexion of the hips, waist, and neck Limit suctioning to 15 sec (hyperoxygenate before and after suctioning)Avoid valsalva
IICP Nursing Management Administration of pharmacological therapies Patient response to nursing interventions (particularly ICP) Neuro exams Emotional support Restrict fluids as ordered Foley Temperature control measures (MUST avoid shivering)
The goal of medical and nursing intervention on the IICP patient is To control ICP and protect the brain from secondary injury.
Motor Function Disturbance Results from damage to the nervous system Patients often have significant problems with mobility example is a patient with cerebral palsy
Motor Function Disturbance Manifestations Alteration in: Muscle strength Muscle tone - flaccid or hyperreflexic Reflex activity Manifestations differ according to neurological lesion
Motor Function Disturbance Assessment (Objective) Muscle strength and tone, to include atrophy Reflexes (presence of clonus or fasciculations) ADL ability Gait Coordination
Motor Function Disturbance Diagnostic Test -Electromyogram - Applying surface electrodes or inserting needle electrodes into a muscle to observe electrical activity -Detects various types of electrical activity and abnormal patterns seen in pathology
Motor Function Disturbance Medical Management Spasticity=Baclofen/Dantrium/Valium,Dysphagia Aspiration precautions Prefeeding and feeding exercises Paralysis –protect the affected site Eyes Limbs
Motor Function Disturbance Nursing Interventions Safety needs Activity needs Nutritional needs ADLs Psychological adjustment Medications Bowel and bladder training Assist family members in all teaching
Motor function disturbances result from? Results from damage to the nervous system
Alteration in Sensory and Perceptual Function Disruption in the sensory pathway from a lesion anywhere within the sensory system pathway-From the receptor to the sensory cortex,Alters transmission or perception of sensory information -Results in difficulty with ADLs
Alteration in Sensory and Perceptual Function Causes loss, decrease or increase in sensation of Pain Temperature Touch Proprioception Agnosia
Alteration in Sensory and Perceptual Function Medical Management Directed at symptomatology Dysphagia-aspiration precautions Paralysis-protect affected area
Alteration in Sensory and Perceptual FunctionNursing Interventions Protect patient from injury Frequent inspection Comfort measures Assist with the development of functioning senses to compensate for the lost one Patient teaching is the same as for a patient with a motor deficit
What is Agnosia? Total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage
Incidence of Epilepsy Occurs in all races. Men and women are affected equally with no apparent geographical distribution The onset of seizures is usually before 20 years of age, but can begin at any age. The incidence is about 1 in every 200-300 persons
Epilepsy Predisposing Factors High fever Electrolyte imbalances (Hypoglycemia, Hypocalcemia) Uremia Brain tumor Drug/Alcohol withdrawal Hypoxia Idiopathic Trauma/injury,
Tonic-Clonic (Grand Mal)Epilepsy The most common type,Usually proceeded by an aura,Characterized by a loss of consciousness Clinical signs: aura; tonic-clonic movements,incontinence,and the patient may fall/thrown to the ground Postictal period:may have a headache,sleep for 1-2 hours
Absence (Petit Mal)Epilepsy Usually occurs during childhood and adolescence(Usually decrease in frequency as a child gets older)sudden impairment in LOC with little or no tonic-clonic movement Clinical signs-sudden vacant facial expression with eyes focused straight ahead.
Psychomotor Epilepsy Occurs at any age,Similar to absence seizure but last longer,is associated with changes in awareness,a distortion of feeling and thinking,partially coordinated motor activity Clinical signs,Aura with complex hallucinations or illusions,Postictal period
Jacksonian (Local or Partial)Epilepsy Occurs almost entirely in patients with structural brain disease,Spasms of musculature that begin in a certain area of the body and move throughout a portion or all of the body,Commonly begins in hand, foot or face and may end in a grand mal seizure,Aura
Myoclonic Epilepsy May antedate grand mal by months or years. May be very mild or have rapid forceful movements Clinical signs include a sudden involuntary contraction of a muscle group, usually in extremity and no LOC No aura No postictal period.
Akinetic Epilepsy This type of seizure is uncommon Characterized by a peculiar generalized tonelessness Person falls in a flaccid state and is unconscious for a minute or two Rarely is there an aura No postictal period
Methods Used to Diagnose Epilepsy Patient history Electroencephalogram (EEG) Brain scan EEG and television monitoring of patient split screen method Serum electrolytes, serology
Epilepsy Medical Management Determine and treat underlying cause of seizures, if possible Prevent recurrence of seizures and therefore help the patient to live a normal life
Epilepsy Medical Management Institute and reinforce the importance of anticonvulsant drug therapy,Drug therapy is a means of control, not a cure,Initially, dosage may have to be changed to provide patients with maximum control with minimum side effects,Patients without seizures afte
Indications for Surgical Management of the Patient with Epilepsy/Seizures Brain tumors Brain abscesses Cysts Cortical scars due to cerebral trauma/birth injuries Treatment with drugs has been ineffective Intractable convulsive attacks with hemiplegia or increasing neurological deficits
Epilepsy/Seizures Nursing Interventions Give medication with milk or food to prevent gastric upset Monitor for and document any seizure activity Teach patient to avoid use of alcohol unless approved by the physician and carry ID indicating medication and epilepsy
Epilepsy/Seizures Nursing Interventions Do not use any non-prescription drugs unless approved by a physician,Explain the patient's prescribed medication,Encourage adequate rest,Encourage a balanced diet Instruct patient to wear a medical ID tag
Epilepsy/Seizures Nursing Interventions No alcohol use,Provide for frequent oral hygiene,Patients with seizure disorder should not drive or operate dangerous,equipment,Explain the importance of follow up care Refer to community resources as indicated by patient needs assessment
Medical Management During a Seizure The patient should be turned on their side Remove any objects that may obstruct breathing Restrictive clothing should be loosened, if possible It is necessary to protect the patient from injury but DO NOT restrain the patients
Medical Management After a Seizure The bed is kept flat and the patient turned on his side until they awaken,The room should be dim and noise kept to a minimum Restrictive clothing should now be loosened
Nursing Assessment During a Seizure First thing a patient does Type of movement of body parts involved Parts involved,Size of both pupils Incontinence of urine or feces Duration of each phase of the attack Unconsciousness if present, and duration Obvious paralysis
Epilepsy/Seizures Nursing Diagnosis Ineffective airway clearance related to mucus accumulation or vomiting during seizures Intervention Place patient in side lying position Suction as needed
Epilepsy/Seizures Nursing Diagnosis Risk for injury related to seizure activity Intervention Pad bed rails Assist patient to floor if out of bed Inform patient of seizure and re orient if needed
Epilepsy/Seizures Anti-Convulsant Agents Decrease incidence and severity of seizures due to various etiologies. More than one anticonvulsant is used to control seizures on a long-term basis. Many regimens are evaluated by monitoring serum levels.Depress abnormal neuronal discharges in the CNS
Epilepsy/Seizures Anti-Convulsant Agents Barbiturates.Benzodiazepines.Hydantoins.Valproates.Miscellaneous.
Barbiturates(Epilepsy/Seizures) generalized tonic-clonic (grand mal), partial, febrile seizures in children=pentobarbital (Nembutal). phenobarbital (Luminal).
Benzodiazepines(Epilepsy/Seizures) clonazepam (Clonopin)Prophylaxis: petit mal, petit mal variant, myoclonic, akinetic seizures.clorazepate (Gen-XENE, Tranxene, Tranxene-SD)Treatment of anxiety.diazepam (Valium)Treatment of status epilepticus/uncontrolled seizures.
Hydantoins(Epilepsy/Seizures) fosphenytoin (Cerebyx) Short-term parenteral (IV/IM) in acute generalized tonic-clonic seizures.Status epilepticus.Preventing and treating seizures occurring during neurosurgery/phenytoin (Dilantin, diphenylhydantoin, DPH, Phenytek):generaltonic-clonic
Valproates(Epilepsy/Seizures) Use: absence seizures. Examples: divalproex sodium (Depakote, Depakote ER). valproate sodium (Depacon). valproic acid (Depakene).
Miscellaneous(Epilepsy/Seizures) carbamazepine (Tegretol)focal, generalized tonic-clonic (Adults). gabapentin (Neurontin)indicated for partial seizures and for secondary generalized seizures.(Adjunctive therapy). lamotrigine (Lamictal)focal, generalized tonic-clonic (Adults).
Miscellaneous(Epilepsy/Seizures) levetiracetam (Keppra): indicated for partial seizures and for secondary generalized seizures. (Adjunctive therapy). oxcarbazepine (Trileptic) and tiagabine (Gabatril): indicated for partial seizures and for secondary generalized seizures. (Adjunctive
Anti-Convulsant Agents Contraindications/ Precautions: hypersensitivity/Severe hepatic or renal disease.Pregnancy.Lactation.Fetal hydantoin syndrome may occur in offspring of patients who receive phenytoin during pregnancy.
Anti-Convulsant Agents Contraindications/ Precautions: CNS: Nystagmus.Slurred speech.Mental confusion./EENT:gingival hyperplasia. GI:Nausea/vomiting.Constipation or diarrhea.Hematological changes.
Anti-Convulsant Agents Interactions Barbiturates stimulate the metabolism of other drugs that are metabolized by the liver, decreasing their effectiveness.Hydanoins are highly protein-bound and may displace or be displaced by other highly protein-bound drugs.
Anti-Convulsant Agents Interactions Lamotrigine tiagabine, and topiramate are capable of interacting with several other anticonvulsants.Many drugs are capable of lowering seizure threshold and may decrease the effectiveness of anticonvulsants, including tricyclic antidepressants and phenot
Anti-Convulsant Agents Lab Tests: Renal studies: BUN, creatinine, serum uric acid, urine creatinine clearance. Blood studies: RBC, HCT, HGB, Reticulocyte counts. Hepatic studies: AST, ALT, bilirubin, creatinine. Serum values for therapeutic dosage and monitor client for signs of toxicity
Anti-Convulsant Agents Nursing Assessment Assess for family history of seizures and recent drug therapy. Complete nursing health history. Obtain VS.
Anti-Convulsant Agents Implementation Administer around the clock. Abrupt discontinuation may precipitate status epilepticus. Implement seizure precautions. Administer with food to prevent GI distress. Oral forms of valproic acid should not be given with milk
Anti-Convulsant Agents Patient Teaching Do not omit, increase or decrease the prescribed dose. Monitor Blood levels at regular intervals. Avoid activities that require alertness.Avoid alcohol unless approved by health provider Carry ID indicating the drug used
Anticonvulsant therapy usually is started with A(n)__________agent that acts in different regions of the brain to decrease seizure activity Single, non-sedating
The actions of anticonvulsants are to _______ the seizure threshold, thereby regulating neuronal firing within the brain. increase
Trigeminal Neuralgia Etiology & Pathophysiology Specific peripheral nerve problem, Caused by degeneration of or pressure on the fifth cranial nerve,Etiology is unknown,Also known as Tic douloureux,Usually affects persons in middle or late adulthood,Slightly more common in women,Clinical Manifestations
Trigeminal Neuralgia Clinical Manifestations Characterized by excruciating, knifelike, or lightinglike shock in the lips, upper or lower gums, cheek, forehead, or side of nose, This pain can last a few seconds or minutes, Reoccurance unpredictable,several times a day or weeks or months apart.
Trigeminal Neuralgia Medical Management Drugs of choice for the treatment of trigeminal neuralgia pain: Tegretol (Carbamazepine), Dilantin (Phenytoin), Depakene (Valproate),Neurontin (Gabapentin)
Trigeminal Neuralgia Nursing Interventions Because of Pain: Patient may be undernourished and dehydrated, Patient may not have washed, shaved, or combed the hair for some time, Oral hygiene often has been neglected
Trigeminal Neuralgia Nursing Interventions, Keep room free of drafts, avoid walking briskly at bedside of patient, Place bed out of traffic area to prevent jarring of bed, Avoid touching the patient’s face, Do not urge patients wash/shave or to comb the hair,Avoid hot or cold liquids,
Bell’s Palsy (Peripheral Facial Paralysis) Is thought to be caused by an inflammatory process involving the facial nerve (VII), The exact etiology is not known, evidence that reactivated herpes simplex virus (HSV)involved in the majority of cases, The reactivation of the HSV for imflammation
Bell’s Palsy (Peripheral Facial Paralysis) Clinical Manifestations an abrupt onset of numbness or a feeling of stiffness or drawing sensation of the face, Unilateral weakness of the facial muscles is most common, inability to wrinkle the forehead, close the eyelid, pucker the lips, or retract the mouth on that sides
Bell’s Palsy (Peripheral Facial Paralysis) Clinical Manifestations The face appears asymmetric, with drooping of the mouth and cheek,Loss of taste,Reduction of saliva on affected side,Pain behind the ear,Ringing in ear or other hearing loss
Bell’s Palsy (Peripheral Facial Paralysis) Medical Management There is no specific therapy for Bell’s palsy, Electrical stimulation or warm moist heat along the course of the, nerve may help, Corticosteroids: especially Prednisone are started immediately, The best results are obtained if initiated before paralysis
Bell’s Palsy (Peripheral Facial Paralysis) Nursing Interventions Protection of the eye when the eyelid does not close use eye patch over eye and tear drops, Massage of the affected areas is recommended, Exercises may be prescribed for 5 minutes TID: Wrinkling the brow and forehead, closing eyes, puffing cheeks
Bell’s Palsy (Peripheral Facial Paralysis) Prognosis Approximately 85% of patients recover fully in weeks or months but may take as long as one year, Taste is usually the first sign of improvement, 15% of patients will continue to be bothered by asymmetrical movement of facial muscles
Intracranial Tumors Etiology & Pathophysiology Intracranial tumors include both benign and metastatic lesions, Metastic from a Primary site, or neoplasms, arise from the cells of brain tissue and associated structures, Gliomas, Meningiomas, Pituitary Tumors, Neuromas
Intracranial Tumors Subjective Data patient’s understanding of the diagnosis, changes in personality or judgement, presence of abnormal sensation or visual problems, Complaints of unusual odors may be present with tumors of the temporal lobe, Headaches, any hearing loss,
Intracranial Tumors Objective Data Motor strengths & gait, The level of alertness, consciousness & orientation, Pupils assessed for response and equality, presence of seizures, Speech abnormalities, cranial nerve abnormalities, signs and symptoms of, increased intracranial pressure
Intracranial Tumors Diagnostic Test No one procedure is entirely diagnostic of brain tumors, CT scan is often the basis for the diagnosis,
Intracranial Tumors Other tests that may be performed include: Brain scan, MRI,PET scans, EEG, Arteriography
Intracranial Tumors Medical and Surgical Management Surgical removal when feasible, Craniotomy a surgical opening through the skull. the bone is removed and carefully preserved,replaced at the end of surgery if there is no indication of infection or increased intracranial pressure. Craniectomy the surgical
Intracranial Tumors Medical and Surgical Management Osmotic diuretics/hyperosmolar drugs
Osmotic diuretics/hyperosmolar drugs Corticosteriods, Anticonvulsants are given to prevent seizures, Dilantin (most commonly used), Cerebyx, Opioids and other drugs that cause respiratory depression are used sparingly
Intracranial Tumors Nursing interventions A baseline neurological assessment is most important, Preoperative preparation of both the patient and the family is important, Treatments and procedures must be explained to prepare them ahead of time, Usually hair is shaved in the operating room,
Intracranial Tumors Nursing Diagnosis and Interventions Communication, impaired verbal, related to ischemic injury, Speak slowly and distinctly, Ask questions that can be answered by yes or no (or by signals), Try to anticipate patient needs, Provide call signal within reach of unaffected hand, speech therapy
Intracranial Tumors Nursing Diagnosis and Interventions Nutrition, imbalanced: less than body requirements, related to impaired ability to swallow, Provide IV fluids and tube feedings as prescribed during initial period, Assess ability to swallow before initiating feedings, Position patient with head elevated
Intracranial Tumors Nursing Diagnosis and Interventions Nutrition, imbalanced and Use training cup or feeding syringe for fluids as necessary, Inspect mouth for food trapped in cheek pockets, Be patient when feeding patient and provide directions for swallowing as needed, Encourage patient to feed self asap
Intracranial Tumors Nursing Diagnosis and Interventions Sensory perception, disturbed: visual, auditory, kinesthetic, tactile, related to compression/displacement of brain tissue, Maintain method of communication, Provide for social interaction, Maintain a safe environment, Provide orientation and appropriate
Intracranial Tumors Nursing Diagnosis and Interventions Thought processes, disturbed, related to altered circulation or destruction of brain tissue, Protect patient from self-injury, Provide soft safety reminder devices as indicated, Assist patient in self-care activities, Speak using short, simple phrases
Intracranial Tumors Nursing Diagnosis and Interventions Give one direction at a time, Relate date, time of day, and recent activities, Maintain a therapeutic environment, Keep equipment and personal possessions in same place, Encourage socialization
craniocerebral trauma Second most common cause of neurological injury Major cause of death between ages 1 and 35 The amount of obvious damage may not reflect the extent of injury Effects of injury can lead to cerebral edema, IICP and sensory and/or motor deficits
causes of head injury MVA’s Falls Sports Industrial accidents Assaults
open head injuries Linear Comminuted Depressed Compound Fractures at the base of the skull are more serious
linear incomplete break, typical line
depressed results from a blunt trauma to a flat bone-causing indentation
comminuted bone is shattered into two or more fragment or pieces
compound an open wound exist over the fracture site, often bone may be protruding through the skin
closed head injuries Laceration Concussion Contusion
laceration bleed profusely, is not always reflective of significant injury
concussion a violent jarring or shaking that results in a disturbance of brain function
contusion Damage to brain tissue and nerve fibers Bruising and possible hemorrhage Bruising at site of injury or on opposite side Permanent damage may result
hematoma Results from hemorrhage post-craniocerebral trauma Epidural Subdural Intracerebral Individuals at high risk for cerebral hematomas Receiving anticoagulants Have an underlying bleeding disorder
epidural hematoma Arterial bleeding between the dura and skull Initial unconsciousness-regains consciousness then lapses into coma Ipsilateral pupil changes Contralateral hemiparesis
subdural hematoma Venous bleeding between the dura & subarachnoid layers Usually slower bleed but more discrete in presentation Classified as acute, subacute or chronic bleed Progressive deterioration in LOC Ipsilateral pupil changes Decreased extraocular muscle
intracerebral hematoma Bleeding into the brain tissue Classic signs of IICP
head trauma s/s LOC,HA,Vomiting,Changes in VS,Pupil Changes,Posturing,Nausea,Abnormal,sensation,Rhinorrhea/Otorrhea
head trauma s/s Motor status,Seizure activity, Abnormal speech Signs of basilar skull fracture, Battle sign and raccoon eyes Cushing’s Triad or Cushing’s Response,Late sign,Increased systolic,BP,Widening pulse pressure,Bradycardia
basilar skull fracture diaganostic test/devices Detecting CSF in otorrhea and rhinorrhea drainage Dextrostick Halo sign CT scan and MRI Internal monitoring devices
basilar skull fracture signs battle signs and racoon eyes
basilar skull fracture medical/surgical management Lifesaving measures,Maintenance of body function until recovery Patent airway and adequate oxygenation,Do not suction via the,nose,Possible ETT and ventilator Adequate O2 levels,Control pH,Keep CO2 levels at the low end of normal Monitor ABGs closely
basilar skull fracture medical/surgical management Simple skull fracture Bed rest Observation for IICP Scalp lacerations
basilar skull fracture medical/surgical management Depressed skull fracture Surgical intervention to: Remove fragments or elevate depressed bone Repair damaged tissue and control bleeding Antibiotics Control IICP Anticonvulsants to treat or prevent seizures
basilar skull fracture medical/surgical management Scalp lacerations-Clean, debride and,suture/Concussion- Rest, Tylenol for analgesia, observe for complications/Contusion CT (and/or)MRI/Drug therapy-Assist ventilations as required
basilar skull fracture medical/surgical management Hematoma-Rapid change in LOC and increase in ICP is Medical Emergency Relieve pressure, stop bleeding, or-remove clot-Burr holes-Craniotomy-Craniectomy-Cranioplasty/Observe for possible post surgical complications
basilar skull fracture medical/surgical management Cerebral edema Infection Shock F&E imbalances Venous thrombosis IICP Seizures CFS leaks Stress ulcers Hemorrhage
basilar skull fracture medical/surgical management Reduce cerebral edema & IICP=Osmotic diuretics (Mannitol),Corticosteroids (Dexamethasone)/Anticonvulsants to treat or reduce seizures=Dilantin, Cerebyx/Analgesics that do not depress respirations=Non opioid drugs/Antipyretics
basilar skull fracture nursing management Obtain history Perform very thorough neurologic exam Examine head Closely Observe Elevate head of bed to 30-45 degrees Position patient to avoid IICP Closely monitor I&O-Fluid restriction if ordered
basilar skull fracture nursing management No Valsalva’s maneuver Foley catheter Perform suctioning only as necessary Administer oxygen Use a hypothermia blanket
basilar skull fracture nursing diagnosis Potential for infection Emotional support Breathing pattern ineffective Injury - risk for Social interaction impaired Communication impaired Nutrition imbalance
basilar skull fracture Medications Complications Rehabilitation Prognosis
Sequela of Strokes Classifications Strokes are usually classified according to their etiologic bases and are identified as ischemic or hemorrhagic. Ischemic strokes are thrombotic or embolic Account for 85% of all strokes Thrombotic stroke -most common of ischemic strokes
Sequela of Strokes Can lead to long term serious disabilities Hemiparesis,Inability to walk,Aphasia Complete or partial dependence in ADLs
Ischemic Stroke Risk factors for Thrombotic stroke use of oral contraceptives,coagulation disorders,polycythemia vera ,Arteritis, chronic hypoxia Dehydration
Ischemic Stroke Thrombi usually occur in larger vessels Associated with damage to vessel wall Readily develop when atherosclerotic plaques have narrowed vessel,Internal carotid arteries are common source
Ischemic Stroke Symptoms occur during sleep or soon after rising,S/S frequently worsen for the first few hours post stroke,typically peak within 72 hrs as edema increases in the affected area
Ischemic Stroke Embolic stroke is the 2nd most common cause of stroke Emboli usually originates from a thrombus in the endocardium cause by Rheumatic heart disease, Mitral stenosis, Atrial Fibrillation, MI, valvular prostheses or infective endocarditis. Less common
Embolic Stroke Embolus travels upward into cerebral Circulation & lodges in a bifurcation or Where the vessel narrows. Most often in the midcerebral artery
Hemorrhagic Strokes Account for 15% of all strokes Intracerebral-bleeding into the brain tissue Intracranial-bleeding into the subarachnoid space. Third most common cause of strokes Common causes of hemorrhagic strokes Hemorrhagic disease (leukemia, aplastic anemia)
Aneurysm Localized dilation of the wall of a blood vessel usually caused by atherosclerosis or HTN. Less often causes, Trauma, Infection, Congenital weakness in vessel
Aneurysm Vessel wall progressively weakens until it ruptures. Bleeding usually stops when fibrin & platelet plug forms
Aneurysm Begins to absorb within 3 weeks. High risk for recurrent rupture 7-10 days after initial bleed. Prognosis is poor -50% mortality. No forewarning. Peak incidence in the 35 to 60 year age group. More frequently affects women.
What is a Transient Ischemic Attack(TIA) An episode of cerebrovascular insufficiency with temporary episodes of neurological dysfunction,Lasting 15 minutes to 24 hours Most resolve within 3 hours Warning sign of an underlying pathological condition
S/S of Transient Ischemic Attack Most common deficit Contralateral weakness of the lower face, hands, arms, and legs Transient dysphasia Some sensory impairment Loss of vision, inability to speak 1/3 of TIA patients will have a stroke within 5 years
Transient Ischemic Attack Medical conditions,Hypertension, Atherosclerosis,Cardiac disease,Diabetes mellitus,Kidney disease,Peripheral vascular disease
causes of Transient Ischemic Attack (same as hypertension) Cigarette smoking,high cholesterol,Stress, Cocaine use,Sedentary lifestyle,Oral contraceptives,Obesity
Transient Ischemic Attack Signs and Symptoms Clinical picture will vary depending on area of brain involved.
Transient Ischemic Attack Subjective data; Time of onset,Presence of headache hemorrhagic stroke -HA is described as sudden & explosive,Sensory Impairment Inability to think clearly Numbness or tingling Visual problems Inability to speak/understand
Transient Ischemic Attack Objective data: Hemiparesis or hemiplegia,Change in LOC Signs of increased ICP,Respiratory problems Presence of aphasia or dysphagia,Impaired coordination,Auscultate the carotid artery for a bruit
Manifestations of strokes Contralateral hemiplegia or paresis Contralateral sensory loss,Spatial-perceptual deficits,Dysphasia or aphasia if dominant hemisphere is involved,Expressive aphasia-inability to speak,Receptive aphasia-inability to understand written/spoken language
Manifestations of strokes Confusion and emotional lability Impaired short term memory Impaired visual field Hemianopia-visual field defect inability to see the right (left sided stroke) or left (right sided stroke) half of an image.
strokes Diagnostic Test CT an MRI will reveal changes in density and differentiate between infarction or hemorrhage,Differentiate from other disorders such as brain tumors or cerebral edema,Shows the size and location of injury Position Emission Tomography (PET)
strokes Diagnostic Test Cerebral angiography shows displacement or blockage of blood vessels Ultrasonography - indicate size of blood vessels and direction of blood flow A lumbar puncture may be performed to check for blood in the CSF (only if ICP normal)
In the case of a TIA a Diagnostic Test cerebral angiogram,Doppler,computer tomographic angiography(CTA),magnetic resonance angiography (MRA)
Strokes Medical Treatment Strokes are a Medical Emergency. Triaged, transported and treated rapidly Treatment varies,Treatment directed by the cause
Strokes Medical Treatment Anticoagulation therapy is used in patients with thrombolytic stroke, contraindicated in hemorrhagic stroke,t-PA for the first 24 hours then Heparin,Coumadin,Lovenox
Strokes Medical Treatment Platelet antiaggregation medication (contraindicated in hemorrhagic stroke) ASA,Dipyridamole (Persantine)Ticlopidine (Ticlid),Clopidrogel (Plavix)
Strokes Medical Treatment Hemorrhagic strokes may require surgical intervention,Evacuate the clot,Aneurysm clipped or tied off
Strokes Medical Treatment Vasodialating agents(Osmotic diuretics)may be prescribed to reduce cerebral edema Dexamethasone (Decadron)to reduce IICP Fluids are usually restricted for the first few days,Suppositories, stool softness, laxatives
Strokes Medical Treatment Carotid endarterectomy: If atherosclerosis of the carotid artery is the cause,Crainiotomy: the treatment for aneurysm,Transluminal angioplasty
Strokes Medical Nursing Management Prevent Neurological deficits. Frequent Neuro assessments (at least once per shift.) Maintain accurate neurological flow sheet Observe the patient closely for signs of progression of the CVA; be particularly aware of change in LOC, motor ability,
Strokes Medical Nursing Management Assess ability to swallow Keeping accurate I&O record Intravenous fluids (until patient stabilizes),nasogastric tube feeding or oral feedings (depending upon patient's abilities) Suction equipment at bedside
Strokes Medical Nursing Management Maintain proper positioning/body alignment/skin integrity Prevent complications of bed rest decubiti, hypostatic pneumonia, contracture Apply footboard, sandbags, trochanter rolls and splints as necessary,Keep head of bed elevated 30 degrees,
Strokes Medical Nursing Management Maintain adequate elimination Foley catheter,bladder retraining (during rehabilitation) Stool softeners prevent constipation or straining which will increase intracranial pressure and encourage another hemorrhage
Strokes Medical Nursing Management Continually orient patient to person, place and time (day, month) even if patient remains in a coma Confusion possible result of just regaining consciousness or from neuro deficit the patient can hear you even if he/she cannot respond to you
Strokes Medical Nursing Management Place all objects requiring the patient's use in an area bound by his/her intact vision or movement limitations. Hemianopia,Unilateral neglect,Protect eye on the affected side if needed Instilling artificial Tears, as ordered
Hemianopia Nursing Management Include patient's family and significant others in plan of care to the extent possible Allow them to assist with care when feasible Keep them informed Help them to understand the patient's condition Home safety concerns rugs and electrical cords
Hemianopia Rehabilitation Multidisciplinary team approach Tasks faced by the patient include Compensation for impaired functions Independence in activities of daily living (ADL) Behavior patterns to prevent the recurrence of symptoms medications Stop smoking
Hemianopia Rehabilitation Individualized exercise program involving both affected and unaffected extremities. Speech therapy, as indicated by patient's condition.Counseling and support to family is an integral part of the rehabilitation process
Hemianopia Rehabilitation Counseling and support (cont) Hemiplegic patients may be easily confused, forgetful, withdrawn and dependent Be supportive and optimistic but firm and direct,Avoid doing things for the patient that they can do for themselves.
Hemianopia Nursing Diagnosis Communication impaired related to ischemic injury,Self care deficit related to loss of function Nutrition imbalance, less than body requirements, related to impaired ability to swallow.
Wwhat is the most common cause of cerebral thrombois? therosclerosis
Created by: SGT.MOSS