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Neurology Part 1 :: Medical Surgical Nursing :: Review For Nursing Licensure Examination Slide Transcript
Slide 1: Medical-Surgical Nursing A Review of Neurologic Concepts Nurse Licensure Examination Review
Slide 2: Key to Success! Confidence Test taking strategies Ample test preparation and study habits Review of frequent board examination topics Focus on your goals Above all- PRAYERS
Slide 3: Outline of Our Review Brief review of Anatomy and Physiology Application of the Nursing process in the approach of neurologic problems: ASSESSMENT – relevant techniques and lab procedures DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
Slide 4: Outline of the review Trauma and related accidents Traumatic brain injury Spinal cord injury Cerebrovascular Accidents
Slide 5: Outline of the review Degenerative disorders- demyelinating Multiple sclerosis Guillain-Barre’ syndrome Degenerative disorders- NON-demyelinating Alzheimer’s disease Parkinson’s disease
Slide 6: Outline of the review Motor dysfunction- CNS Epilepsy Motor dysfunction- cranial nerve Bell’s palsy Trigeminal neuralgia Motor dysfunction- peripheral Myasthenia gravis
Slide 7: Outline of the review Infectious Disease Meningitis Brain abscess Encephalitis Neoplastic disease
Slide 8: IMPLEMENTATION PHASE Increased Intracranial pressure Altered level of consciousness Seizures Autonomic dysreflexia/hyperreflexia Spinal shock Cognitive impairment Bowel incontinence
Slide 9: IMPLEMENTATION PHASE Impaired physical mobility Impaired swallowing Disturbed sensory perception
Slide 10: Anatomy and Physiology Gross anatomy 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
Slide 11: Anatomy and Physiology The brain is composed of lobes- Frontal lobe- personality, memory and motor function Parietal lobe- sensory function Temporal lobe- hearing and olfaction and emotion by the limbic system Occipital lobe- vision
Slide 12: Anatomy and Physiology The cerebellum is involved in coordination and equilibrium The diencephalon consists of the : Thalamus- the relay center of all sensory input Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response
Slide 13: Anatomy and Physiology The brainstem is composed of the: MIDBRAIN- for visual and auditory reflexes Pons- respiratory apneustic center, nucleus of cranial nerves- 5,6,7,8 Medulla oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12
Slide 14: ASSESSMENT OF THE NEUROLOGIC SYSTEM HISTORY A confused client becomes an unreliable source of history
Slide 15: ASSESSMENT OF THE NEUROLOGIC SYSTEM PHYSICAL EXAMINATION 5 categories: 1. Cerebral function- LOC, mental status 2. Cranial nerves 3. Motor function 4. Sensory function 5. Reflexes
Slide 16: ASSESSMENT OF THE NEUROLOGIC SYSTEM Neuro Check Level of consciousness Pupillary size and response Verbal responsiveness Motor responsiveness Vital signs
Slide 17: CEREBRAL FUCTION 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
Slide 18: Cerebral function 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
Slide 19: Glasgow Coma Scale Glasgow Coma Score Eye Opening (E) Verbal Response (V) Motor Response (M)
Slide 20: Glasgow Coma Scale Glasgow Coma Score Eye Opening (E) 4=Spontaneous 3=To voice 2=To pain 1=None (No response)
Slide 21: Glasgow Coma Scale Glasgow Coma Score Verbal Response (V) 5=Normal/oriented 4=Disoriented/CONFUSED 3=Words, but incoherent/ inappropriate 2=Incomprehensible/mumbled words 1=None
Slide 22: Glasgow Coma Scale Glasgow Coma Score Motor Response (M) 6=Normal- obeys command 5=Localizes pain 4=Withdraws to pain (Flexion) 3=Decorticate posture 2=Decerebrate posture 1=None (flaccid)
Slide 23: Cranial Nerve Function: Cranial Nerve 1- Olfactory 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”
Slide 24: Cranial Nerve Function: Cranial Nerve 2- Optic 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
Slide 25: Snellen chart
Slide 26: Cranial Nerve Function: Cranial Nerve 3, 4 and 6 Assess simultaneously the movement of the extra-ocular muscles Deviations: Opthalmoplegia- inability to move the eye in a direction Diplopia- complaint of double vision
Slide 28: Cranial Nerve Function: Cranial Nerve 5 -trigeminal Sensory portion- assess for sensation of the facial skin Motor portion- assess the muscles of mastication Assess corneal reflex
Slide 29: Cranial Nerve Function: Cranial Nerve 7 -facial 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
Slide 30: Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory Test patient’s hearing acuity Observe for nystagmus and disturbed balance
Slide 31: Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal Together with Cranial nerve 10 –vagus Assess for gag reflex Watch the soft palate rising after instructing the client to say “AH” The posterior one-third of the tongue is supplied by the glossopharyngeal nerve
Slide 32: Cranial Nerve Function: Cranial Nerve 11- accessory Press down the patient’s shoulder while he attempts to shrug against resistance
Slide 33: Cranial Nerve Function: Cranial Nerve 12- hypoglossal Ask patient to protrude the tongue and note for symmetry
Slide 34: ASSESS Motor function Assess muscle tone and strength by asking patient to flex or extend the extremities while the examiner places resistance Grading of muscle strength
Slide 35: Assessing the motor function of the cerebellum Test for balance- heel to toe Test for coordination- rapid alternating movements and finger to nose test ROMBERG’s is actually a test for the posterior spinothalamic tract
Slide 37: Assessing the motor function of the brainstem Test for the Oculocephalic reflex- doll’s eye Normal response- eyes appear to move opposite to the movement of the head Abnormal- eyes move in the same direction
Slide 38: Assessing the motor function of the brainstem Test for the Oculovestibular reflex Slowly irrigate the ear with cold water and warm water Normal response- cOld- OppOsite, wArM- sAMe
Slide 39: Assessing the sensory function 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
Slide 40: Assessing the reflexes Deep tendon reflexes Biceps Triceps Brachioradialis Patellar Assessing the sensory function Achilles
Slide 41: Assessing the reflexes Superficial reflexes Abdominal Cremasteric Anal Pathologic reflex Babinski- stroke the lateral aspect of the soles doing an inverted “J” (+)- DORSIFLEXION of the Big toe with fanning out of the little toes
Slide 42: Grading of reflexes Deep tendon reflex 0- absent + present but diminished ++ normal +++ increased ++++ hyperactive or clonic Superficial reflex 0 absent +present
Slide 43: DIAGNOSTIC TESTS EEG Withhold medications that may interfere with the results- anticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure
Slide 44: DIAGNOSTIC TESTS CT scan With radiation risk 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
Slide 45: DIAGNOSTIC TESTS MRI Uses magnetic waves Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure
Slide 46: DIAGNOSTIC TESTS Cerebral arteriography Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site
Slide 47: DIAGNOSTIC TESTS Lumbar puncture Ensure consent, determine ability to lie still Contraindicated in patients with increased ICP Keep flat on bed after procedure Increase fluid intake after procedure
Slide 48: Increased Intracranial pressure Intracranial pressure more than 15 mmHg Brunner= Normal intracranial pressure 10-20 mmHg Causes: Head injury Stroke Inflammatory lesions Brain tumor Surgical complications
Slide 49: Increased Intracranial pressure Pathophysiology The cranium only contains the brain substance, the CSF and the blood/blood vessels MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other Any increase or alteration in these structures will cause increased ICP
Slide 50: Increased Intracranial pressure Pathophysiology Compensatory mechanisms: 1. Increased CSF absorption 2. Blood shunting 3. Decreased CSF production
Slide 51: Increased Intracranial pressure Pathophysiology Decompensatory mechanisms: 1. Decreased cerebral perfusion 2. Decreased PO2 leading to brain hypoxia 3. Cerebral edema 4. Brain herniation
Slide 52: Decreased cerebral blood flow Vasomotor reflexes are stimulated initially slow bounding pulses Increased concentration of carbon dioxide will cause VASODILATION increased flow increased ICP
Slide 53: Cerebral Edema Abnormal accumulation of fluid in the intracellular space, extracellular space or both.
Slide 54: Herniation Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem
Slide 55: Cerebral response to increased ICP Steady perfusion up to 40 mmHg 1. Cushing’s response 2. Vasomotor center triggers rise in BP to increase ICP Sympathetic response is increased BP but the heart rate is SLOW Respiration becomes SLOW
Slide 56: Increased Intracranial pressure CLINICAL MANIFESTATIONS Early manifestations: Changes in the LOC- usually the earliest Pupillary changes- fixed, slowed response Headache vomiting
Slide 57: Increased Intracranial pressure CLINICAL MANIFESTATIONS late manifestations: Cushing reflex- systolic hypertension, bradycardia and wide pulse pressure bradypnea Hyperthermia Abnormal posturing
Slide 58: Increased Intracranial pressure Nursing interventions: Maintain patent airway 1. Elevate the head of the bed 15-30 degrees- to promote venous drainage 2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levelsconstricts blood vessels reduces edema
Slide 59: Increased Intracranial pressure Nursing interventions 3. Administer prescribed medications- usually Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsants-p to prevent seizures
Slide 60: Increased Intracranial pressure Nursing interventions 4. Reduce environmental stimuli 5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning
Slide 61: Increased Intracranial pressure Nursing interventions 6. Keep head on a neutral position. ACOID- extreme flexion, valsalva 7. monitor for secondary complications Diabetes insipidus- output of >200 mL/hr SIADH
Slide 62: Altered level of consciousness 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
Slide 63: Altered level of consciousness Assessment Orientation to time, place and person Motor function Decerebrate Decorticate Sensory function
Slide 64: Altered level of consciousness 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
Slide 65: Altered level of consciousness Etiologic Factors Head injury 2. Stroke 3. Drug overdose 4. Alcoholic intoxication 5. Diabetic ketoacidosis 6. Hepatic failure 7.
Slide 66: Altered level of consciousness ASSESSMENT Behavioral changes initially 2. Pupils are slowly reactive 3. Then , patient becomes unresponsive 4. and pupils become fixed dilated Glasgow Coma Scale is utilized
Slide 67: Altered level of consciousness Nursing Intervention 1. Maintain patent airway Elevate the head of the bed to 30 degrees Suctioning 2. Protect the patient Pad side rails Prevent injury from equipments, restraints and etc.
Slide 68: Altered level of consciousness Nursing Intervention 3. Maintain fluid and nutritional balance Input an output monitoring IVF therapy Feeding through NGT 4. Provide mouth care Cleansing and rinsing of mouth Petrolatum on the lips
Slide 69: Altered level of consciousness Nursing Intervention 5. Maintain skin integrity Regular turning every 2 hours 30 degrees bed elevation Maintain correct body alignment by using trochanter rolls, foot board 6. Preserve corneal integrity Use of artificial tears every 2 hours
Slide 70: Altered level of consciousness Nursing Intervention 7. Achieve thermoregulation Minimum amount of beddings Rectal or tympanic temperature Administer acetaminophen as prescribed 8. Prevent urinary retention Use of intermittent catheterization
Slide 71: Altered level of consciousness Nursing Intervention 9. Promote bowel function High fiber diet Stool softeners and suppository 10. Provide sensory stimulation Touch and communication Frequent reorientation
Slide 72: SEIZURES 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
Slide 73: SEIZURES PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively
Slide 74: SEIZURES ETIOLOGIC FACTORS Idiopathic 2. Fever 3. Head injury 4. CNS infection 5. Metabolic and toxic conditions 6.
Slide 75: SEIZURES Nursing Interventions During seizure 1. remove harmful objects from the patient’s surrounding 2. ease the client to the floor 3. protect the head with pillows 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure
Slide 76: SEIZURES Nursing Interventions During seizure 5. loosen constrictive clothing 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway
Slide 77: SEIZURES Nursing Interventions POST seizure 1. place patient to the side to drain secretions and prevent aspiration 2. help re-orient the patient if confused 3. provide care if patient became incontinent during the seizure attack 4. stress importance of medication regimen
Slide 78: headache 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 type- due to muscle tension
Slide 79: headache Migraine Prodrome stage 2. Aura phase 3. Headache 4. Recovery phase 5.
Slide 80: headache Nursing Interventions 1. Avoid precipitating factors 2. modify lifestyle 3. relieve pain by pharmacologic measures Beta-blockers Serotonin antagonists- “triptan"
Slide 81: Autonomic Dysreflexia/hyperreflexia 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
Slide 82: Autonomic Dysreflexia/hyperreflexia Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion
Slide 83: Autonomic Dysreflexia/hyperreflexia NURSING INTERVENTIONS 1. Elevate the head of the bed immediately 2. Check for bladder distention and empty bladder with urinary catheter 3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer 4. Administer antihypertensive medications- usually hydralazine
Slide 84: Spinal Shock Pathophysiology The sudden depression of reflex activity in the spinal cord below the level of injury The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions
Slide 85: Spinal Shock Nursing Interventions 1. Assist in chest physical therapy 2. Manage potential complication- DVT
Slide 86: Cognitive Impairment Nursing Interventions Assist or encourage the patient to use 2. eyeglass, hearing aid or assistive devices Reorient the patient by calling his 3. name frequently Provide background information as to 4. date, time, place, environment
Slide 87: Cognitive Impairment Nursing 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
Slide 88: Bowel and Bladder incontinence Establish a regular pattern for bowel care Maintain a dietary intake. Avoid foods that can cause excessive gas production
Slide 89: CONGENITAL DISORDERS: Hydrocephalus Excessive CSF accumulation in the brain’s ventricular system In infants, head enlarges In children and adults- brain compression
Slide 90: CONGENITAL DISORDERS: Hydrocephalus Non-communicating hydrocephalus results from CSF outflow obstruction Communicating hydrocephalus results from faulty absorption or increased CSF production
Slide 91: CONGENITAL DISORDERS: Hydrocephalus Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes
Slide 92: CONGENITAL DISORDERS: Hydrocephalus DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography
Slide 93: CONGENITAL DISORDERS: Hydrocephalus Nursing Intervention 1. monitor neurologic status 2. teach parents to watch for signs of shunt malfunction, and periodic surgery to lengthen the shunt as child grows
Slide 94: CONGENITAL DISORDER- Spinal cord defects 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
Slide 95: CONGENITAL DISORDER: Spinal cord defects Causes 1. environmental factors 2. radiation 3. folic acid deficiency in a pregnant woman 4. possibly genetic
Slide 96: CONGENITAL DISORDER: Spinal cord defects ASSESSMENT 1. a dimple or tuft of hair in the vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography
Slide 97: CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 1. cover the defect with sterile dressing moistened with sterile saline 2. position the patient on prone or side to protect the fragile sac 3. place a diaper under the infant and change it often
Slide 98: CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 4. avoid the use of lotion 5. avoid frequent handling 6. Measure the child’s head circumference daily 7. check anal reflex 8. support family members 9. prepare the parents for the possible outcome of eh defect
Slide 99: CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 10. Post-operative care Position on abdomen Check post-operative dressings Place infant’s hips in abduction and feet in neutral position Monitor intake and output Check for urine retention Asess infant frequently as he recovers from the surgery
Slide 100: Traumatic brain injury 1. CONCUSSION Involves jarring of head without tissue injury Temporary loss of neurologic function lasting fore a few minutes to hours
Slide 102: Traumatic brain injury 2. CONTUSION Involves structural damage The patient becomes unconscious for hours
Slide 104: Traumatic brain injury 3. Diffuse Axonal injury Involves widespread damage to the neurons Patient has decerebrate and decorticate posture
Slide 105: Traumatic brain injury 4. Intracranial hemorrhage Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery Symptoms develop rapidly
Slide 107: Traumatic brain injury 4. Intracranial hemorrhage Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels Symptoms usually develop slowly
Slide 109: Traumatic brain injury 4. Intracranial hemorrhage Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities Symptoms develop insidiously, beginning with severe headache and neurologic deficits
Slide 111: Traumatic brain injury MANIFESTATIONS 1. Altered LOC 2. CSF otorrhea 3. CSF rhinorrhea 4. Racoon eyes and battle sign HALO SIGN- blood stain surrounded by a yellowish stain
Slide 112: Traumatic brain injury NURSING MANAGEMENT 1. Monitor for declining LOC- use of Glasgow 2. Maintain patent airway Elevate bed, suction prn, monitor ABG
Slide 113: Traumatic brain injury NURSING MANAGEMENT 3. Monitor F and E balance Daily weights IVF therapy Monitor possible development of DI and SIADH
Slide 114: Traumatic brain injury 4. Provide adequate nutrition 5. Prevent injury Use padded side rails Minimize environmental stimuli Assess bladder Consider the use of intermittent catheter
Slide 115: Traumatic brain injury 6. Maintain skin integrity Prolonged immobility will likely cause skin breakdown Turn patient every 2 hours Provide skin care every 4 hours Avoid friction and shear forces
Slide 116: Traumatic brain injury 7. Monitor potential complications Increased ICP Post-traumatic seizures Impaired ventilation
Slide 117: Spinal cord injury The most frequent vertebrae – C5-C7, T12 and L1 Concussion Contusion Compression Transection
Slide 120: Spinal cord injury Clinical manifestations 1. Paraplegia 2. quadriplegia 3. spinal shock
Slide 122: Spinal cord injury DIAGNOSTIC TEST Spinal x-ray CT scan MRI
Slide 123: Spinal cord injury EMERGENCY MANAGEMENT A-B-C Immobilization Immediate transfer to tertiary facility
Slide 124: Spinal cord injury NURSING INTERVENTION 1. Promote adequate breathing and airway clearance 2. Improve mobility and proper body alignment 3. Promote adaptation to sensory and perceptual alterations 4. Maintain skin integrity
Slide 125: Spinal cord injury 5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage complications Thromboplebhitis Orthostaic hypotension Spinal shock Autonomic dysreflexia
Slide 126: Spinal cord injury 9. Assists with surgical reduction and stabilization of cervical vertebral column
Slide 127: CEREBROVASCULAR ACCIDENTS An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply
Slide 128: CEREBROVASCULAR ACCIDENTS Can be divided into two major categories 1. Ischemic stroke- caused by thrombus and embolus 2. Hemorrhagic stroke- caused commonly by hypertensive bleeding
Slide 131: CEREBROVASCULAR ACCIDENTS The stroke continuum 1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration 2. Reversible Neurologic deficits 3. Stroke in evolution 4. Completed stroke
Slide 132: General manifestations
Slide 133: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus
Slide 134: RISKS FACTORS Modifiable Non-modifiable Hypertension Advanced age Cardio disease Gender Obesity race Smoking Diabetes mellitus hypercholesterolemia
Slide 135: Pathophysiology of ischemic stroke Disruption of blood supply Anaerobic metabolism ensues Decreased ATP production leads to impaired membrane function Cellular injury and death can occur
Slide 136: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography
Slide 137: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke CLINICAL MANIFESTATIONS 1. Numbness or weakness 2. confusion or change of LOC 3. motor and speech difficulties 4. Visual disturbance 5. Severe headache
Slide 138: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke Motor Loss Hemiplegia Hemiparesis
Slide 139: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke Communication loss Dysarthria= difficulty in speaking Aphasia= Loss of speech Apraxia= inability to perform a previously learned action
Slide 140: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke Perceptual disturbances Hemianopsia Sensory loss paresthesia
Slide 141: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS Improve Mobility and prevent joint 2. deformities Correctly position patient to prevent contractures Place pillow under axilla Hand is placed in slight supination- “C” Change position every 2 hours
Slide 142: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 2. Enhance self-care Carry out activities on the unaffected side Prevent unilateral neglect Keep environment organized Use large mirror
Slide 143: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 3. Manage sensory-perceptual difficulties Approach patient on the Unaffected side Encourage to turn the head to the affected side to compensate for visual loss
Slide 144: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 4. Manage dysphagia Place food on the UNAFFECTED side Provide smaller bolus of food Manage tube feedings if prescribed
Slide 145: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 5. Help patient attain bowel and bladder control Intermittent catheterization is done in the acute stage Offer bedpan on a regular schedule High fiber diet and prescribed fluid intake
Slide 146: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 6. Improve thought processes Support patient and capitalize on the remaining strengths
Slide 147: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 7. Improve communication Anticipate the needs of the patient Offer support Provide time to complete the sentence Provide a written copy of scheduled activities Use of communication board Give one instruction at a time
Slide 148: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 8. Maintain skin integrity Use of specialty bed Regular turning and positioning Keep skin dry and massage NON- reddened areas Provide adequate nutrition
Slide 149: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 9. Promote continuing care Referral to other health care providers
Slide 150: CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 10. Improve family coping 11. Help patient cope with sexual dysfunction
Slide 151: CVA: Hemorrhagic Stroke 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
Slide 152: CVA: Hemorrhagic Stroke Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances
Slide 153: CVA: Hemorrhagic Stroke DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP)
Slide 154: CVA: Hemorrhagic Stroke NURSING INTERVENTIONS 1. Optimize cerebral tissue perfusion 2. relieve Sensory deprivation and anxiety 3. Monitor and manage potential complications
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