neurological system
TRANSCRIPT
Neurological System
Brain Anatomy
Cerebrum Reasoning Judgment Concentration, Motor, sensory, speech
Cerebellum Coordination
Brainstem Cranial nerves Respiratory center Cardiovascular center
Brain Blood Supply 20% of CO Cerebral tissues –
Have no oxygen or glucose reserves
Carotid Arteries to Circle of Willis
Intracranial Pressure (ICP)
Composition 80% brain tissue and water 10% blood 10% cerebrospinal fluid (CSF)
Increased ICP caused by: Severe head injury/ Subdural
hematoma Hydrocephalus Brain tumor Meningitis/Encephalitis Aneurysm Status epilepticus/Stroke
A medical emergency that can lead to:
Brain hypoxia, herniation, death
Clinical Manifestations Vomiting Headache Blurred vision Seizure Changes in behavior Loss of consciousness Lethargy Neurological symptoms
Neurological Assessment
Rapid Neurological Assessment Emergent situations Sudden changes in neurologic status
1. LOC: first indicator of a decline in neurological function and increase in ICP (intracranial pressure)
2. GCS
3. Pupils
2. Glasgow Coma Scale
3. PUPILS
Neuro-Diagnostic Tests Routine labs Radiology Tests
CT scan, MRI Carotid ultrasound Cerebral angiogram/
MRA
CT SCAN
MRA
Carotid US
Neuro-Diagnostic Tests: Lumbar Puncture Spinal needle
inserted into SA L3/L4 or L-4 /L-5
using strict asepsis Obtain specimens Measure pressure Anesthesia
Case Study: Introduction
Nancy came in to the ER with her daughter Gail. Gail states that her mother suddenly was unable to speak clearly and fell to the ground.
Stroke: Brain Attack
Cerebrovascular Accident (CVA) - loss of brain functions that occur when the blood supply to any part of the brain is interrupted.
Sudden onset of neurological deficits
Medical Emergency- reduction in cerebral blood flow & tissue death Brain dependent on constant supply of oxygen and
glucose
Types of Stroke
Ischemic Thrombotic Stroke Embolic Stroke
Hemorrhagic
Ischemic: Thrombotic Stroke
Atherosclerosis is the most common cause of vascular obstruction leading to thrombosis
Thrombosis-clot forms at rough or narrowed artery
Complete blockage Half of all strokes
Ischemic: Embolic StrokeEmbolism-blood clot or fatty plaque released
into circulationOften a fragment from a thrombosis or fatty
plaque
TIA: Transient Ischemic Attack Warning sign: Temporary onset of
neurological symptoms lasting from 1-24 hours
Needs prompt work-up: carotid U/S, brain and heart
Key features:Blurred vision, double vision, blindness one
eyeTransient weakness, ataxiaSpeech deficits
Treatment Cont: Surgical Therapy Carotid
Endarterectomy- for pts who have had TIAs or significant narrowing of carotid arteries
Hemorrhagic Stroke
Rupture of weak vessel wall or cerebral aneurysm
Arteriovenous malformation
Bleeding into brain or meninges
Risk Factors for Stroke
Hypertension Heart disease DM Lifestyle Smoking/Alcohol Obesity Hyperlipidemia Illicit Drug Use;
cocaine Age
Clinical Manifestations Depend on the extent of
injury May be transient, mild or
result in major neuro deficits
Embolic: sudden Hemorrhagic: sudden
Worse HA ever for bleeds
R Hemiplegia/paresis
Impaired speech(Aphasias)
Impaired discrimination(R/L)
Slow performance,Cautious
Aware of deficitsDepression, Anxiety
Impaired comprehension & Memory R/T language and mathLeft -Sided CVA:
LEFT BRAIN DAMAGE Hemianopsia
Right-sided CVA:RIGHT BRAIN DAMAGE Impaired judgment
Impulsive/Safetyproblems
Denies/Minimizesproblems
L hemiplegia/paresis
Left-sided neglect
Spatial-perceptual deficits
Rapid performanceShort attention
span
Hemianopsia
Impaired Swallowing
Cognitive Changes
Motor Deficits
Sensory Changes
Impaired Communication
Altered Elimination
Nancy
Psychosocial
Impaired Swallowing Stroke →dysphagia Risk for airway obstruction/ aspiration Nursing Interventions: Maintain patent airway
NPO until swallow eval (by ST) Assess swallow, cough, gag reflex Safe Feedings: High Fowler’s position with head
flexed forward Thickened liquids if impaired swallowing Instruct to
position food on unaffected side in back of throat Avoid distractions to reduce aspiration risks Soft, semi-soft foods, pureed, baby food, dental diet Suction as needed
Cognitive Changes
Change in LOC Impaired judgment,
memory, problem solving
Denial of illness Inability to
concentrate
Nursing Interventions: Frequent reorientation Frequent safety
instructions Repeat directions on
tasks by steps Give time to process
and respond
Motor Deficits
Loss of voluntary movement on contralateral (opposite) side of stroke
Weakness & paralysis Hemiplegia and/or
Hemiparesis Gait changes
Motor Deficit Cont.
Nursing Interventions: Maintain optimal functioning and assist as
necessary Prevent contractures & atrophy PT and OT eval/tx to promote independence
Positioning- intermittent prone positions; elevate affected extremity
ROM exercises (passive: begin 1st day of hosp; no ambulation with hemorrhagic stroke)
Assist with ADLs (Self Care Deficit) Use assistive devices (wide grip utensils, plate guards) Rehab and use of ambulation devices
Motor Deficit Cont.Splints, hand rolls, trochanter rolls
Assessment and Management Sensory Changes
Contralateral sensory deficits Decreased sensation to
touch Spatial dysfunction
Awareness of position Neglect Syndrome –
Ignore affected side due to altered perception and vision
Visual Deficits
Nursing Interventions: Teach client to touch and
use both sides Remind client to dress and
bathe both sides Place objects within
patients field of vision Approach patient from
unaffected side
Sensory Changes Cont. - Visual Deficits: Hemianopsia
Blindness in half of the visual field Homonymous hemianopsia
Blindness in in the same half of each visual field
Visual Deficits: Hemianopsia Cont. Nursing Interventions:
Place objects in client’s visual fieldRemove clutterTeach patient to attend to the neglected
side Teach scanning technique during ADLs
Assess the neglected side (paralyzed or weak side) for trauma, adequacy of dressing and hygiene
Impaired Communication Aphasia-loss of use
and comprehension
Receptive aphasia- Wernicke’s area (sensory)
Expressive aphasia – Broca’s area (motor)
Global aphasia- mixed
Nursing Interventions:
Assess ability to speak and understand
Provide + reinforcement Picture board Repeat names of
objects routinely
Picture Communication Board
Altered Elimination
Temporary or permanent loss of bladder/bowel function
Constipation common Weakness Dehydration Immobility
Nursing Interventions: Increase fiber and fluids Stool softeners Digital
stimulation/suppositories bladder retraining Straight cath to check
residual
Assessment and Management Problems R/T Immobility
Risk for atelectasis and pneumonia Risk for impaired skin integrity and DVT
Nursing Interventions:
Assessment and Management: Psychosocial Emotional Support
Depression major problem
Discharge planning
Care of the caregiver
Treatment of Stroke:Thrombotic Stroke Thrombolytic Therapy : rtPA (recombinant tissue Plasminogen Activator-
Retavase) A clot-buster delivered intravenously; breaks up the
clot allowing blood flow to return to the deprived area of the brain
Must be administered within 3 hours of the onset of clinical signs of ischemic stroke
Quick CT scan to see if stroke from clot or bleed
Treatment Cont:
Acute phase:
Anticoagulant - Heparin continuous infusion
Osmotic Diuretics – to reduce brain swelling
Anticoagulants contraindicated in Hemorrhagic Strokes
Long Term Drug TherapyTo Prevent Stroke: Antiplatlet Drugs
ASA, Ticlid, Persantine, Plavix
Anticoagulants Coumadin Lovenox
Antiepileptics
Treatment Cont: Surgical Therapy Carotid
Endarterectomy- for pts who have had TIAs or significant narrowing of carotid arteries
Treatment Cont: Surgical Treatment For Bleeds (Interventional Radiology)
Angiograms to see arteries and detect bleeding sites
Aneurysm clips and coils
Surgical Removal:Hematoma