requirement module ncm 104 and pharma

8/12/2019 Requirement Module Ncm 104 and Pharma

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Neurological Disorders

Cerebrovascular Diseases: Introduction

Cerebrovascular disease is one of the leading causes of death in the Philippines;

it is also the most prevalent neurologic disorder in terms of both morbidity and mortality.

The incidence of this disease increases with age, and the number of strokes is usually

projected to increase as the elderly population grows, with a doubling in stroke deaths

by the years to come.

Most cerebrovascular diseases are manifested by the abrupt onset of a focal

neurologic deficit, as if the patient was struck by the hand of !od. "#troke$ as it is

commonly called, is the clinical designation that applies to all these conditions,

particularly as symptoms begin acutely.

Cerebrovascular diseases include the e%pected three major categories,

thrombosis, embolism, and hemorrhage, with patient management differing between

groups. &rom the standpoint of pathophysiology and pathologic anatomy, it is

convenient to consider cerebrovascular disease as two processes'

( )ypo%ia, ischemia, and infarction resulting from impairment of blood supply

and o%ygenation of C*# tissue and

( )emorrhage resulting from rupture of C*# vessels

+n this module one must be able to appreciate all the facets of this disease which

will enable all of us to understand and make some adjustments that can be useful in

everyday living.

OBJECTIVES

. -escribe the incidence and social impact of cerebrovascular disorders.

. +dentify the risk factors for cerebrovascular disorders and related measures for

prevention.

/. Compare the various types of cerebrovascular disorders' their causes, clinical

manifestations, and medical management.

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0. 1pply the principles of nursing management to the care of a patient in the acute

stage of an ischemic stroke.

2. 3se the nursing process a framework for care of a patient recovering from an

ischemic stroke.

4. 3se the nursing process as a framework for care of a patient with a hemorrhagicstroke.

5. +dentify essential elements for family teaching and preparation for home care of the

patient who has had a stroke.

Clinical Description and Manifestations

1 stroke, or cerebrovascular accident, is defined by an abrupt onset of a

neurologic deficit that is attributable to a focal vascular cause. Thus, the definition of

stroke is clinical; and laboratory studies including brain imaging are used to support the

diagnosis.

#ome of the common risk factors for C61 include' a history positive for

cardiovascular disease, hypertension, diabetes mellitus, obesity, smoking,

hypercholesterolemia, arteriosclerotic disease of intra and e%tracranial vessels;

advancing age; and familial history.

The clinical manifestations of stroke are highly variable because of the comple%

anatomy of the brain and its vasculature. Cerebral ischemia is caused by a reduction in

blood flow that lasts longer than several seconds. *eurologic symptoms manifests

within seconds because neurons lack glycogen, so energy failure is rapid. +f the

cessation of flow lasts for more than a few minutes, infarction or death of brain tissue

results. 7hen blood flow is 8uickly restored, brain tissue can recover fully and the

patient9s symptoms are only transient' this is called a transient ischemic attack :T+1.

The standard definition of T+1 re8uires that all neurologic signs and symptoms resolve

within 0h regardless of whether there is imaging evidence of new permanent brain

injury; stroke has occurred if the neurologic signs and symptoms last for


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border =ones between the major cerebral artery distributions may develop. +n more

severe instances, global hypo%ia>ischemia causes widespread brain injury; the

constellation of cognitive se8uelae that ensues is called hypo%ic>ischemic

encephalopathy. &ocal ischemia or infarction, on the other hand, is usually caused by

thrombosis of the cerebral vessels themselves or by emboli from a pro%imal arterialsource or the heart.

+ntracranial hemorrhage is caused by bleeding directly into or around the brain; it

produces neurologic symptoms by producing a mass effect on neural structures, from

the to%ic effects of blood itself, or by increasing intracranial pressure.

#ymptoms vary tremendously depending on the si=e of the involved vessel and

the region of the brain that has been affected. ?n occasion, the vessel is tiny and

collateral circulation is present to compensate. +f this occurs, there may be few signs

and symptoms and a diagnosis of a C61 could be difficult to make. )owever,

neuromuscular deficits often occur. @ecause of the crossing of pyramidal nerve

pathways at the medulla, a C61 that occurs in the right hemisphere of the brain will

cause left>sided paralysis, while damage to the left side of the brain affects the right side

of the body. 1gain, loss of function depends on the si=e and location of the vessel

involved. Problems with swallowing, respiration, as well as receptive and e%pressive

communication can occur. Aoss of bowel and bladder control is usually transient, and

the patient should be involved in a bladder and bowel retraining regime as soon as

possible. Memory, judgment and spatial perception may be impaired. 3nilateral neglect

may occur; for e%ample, a patient may not recogni=e the paraly=ed body part as his own

and ignore all sensory input from the affected side or may have problems judging

distance.

Right brain damage Left brain damage:

(Paraly=ed left side (Paraly=ed right side

(@ehavioral style' 8uick,

impulsive

(@ehavior slow, cautions

(#patial perceptual deficits (#peech>language deficits

:if left brain is dominant

(-eficits in memory performance (Memory deficits' language

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(+ndifference to the disability (-istress and depression in

relation to the disability

Clinical 1ctivitiesB 1ssignments Aearning ?bjective

. Aist the parts of the brain and their

associated functions that have been

affected on your own patient.

. )ow do these affect the signs and

symptoms of your assigned patient will

be e%hibiting/. Complete a neurological assessment

on an assigned patient. *ote any

abnormalities and note for the

causesBreasons for these symptoms.

pproac! to t!e "atient: Cerebrovascular Disease

Dapid evaluation is essential for use of time>sensitive treatments such as

thrombolysis. )owever, patients with acute stroke often do not seek medical assistance

on their own, both because they are rarely in pain, as well as because they may lose the

appreciation that something is wrong :anosagnosia. +t is often a family member or a

bystander who calls for help, therefore, patients and their family members should be

counseled to call emergency medical services immediately if they e%perience or witness

the sudden onset of any of the following' loss of sensory andBor motor function on one

side of the body :nearly E2F of ischemic stroke patients have hemiparesis; change invision, gait, or ability to speak or understand; or if they e%perience a sudden, severe

headache.

There are several common causes of sudden>onset neurologic symptoms that

may mimic stroke, including sei=ure, intracranial tumor, migraine, and metabolic

encephalopathy. 1n ade8uate history from an observer that no convulsive activity

occurred at the onset reasonably e%cludes sei=ure. Tumors may present with acute

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neurologic symptoms due to hemorrhage, sei=ure, or hydrocephalus. #urprisingly,

migraine can mimic stroke, even in patients without a significant migraine history. 7hen

these develop without head pain :acephalgic migraine, the diagnosis of C61 may

remain elusive. Patients without any prior history of migraine may develop acephalgic

migraine even after age 42. 1 sensory disturbance is often prominent, and the sensorydeficit, as well as any motor deficits, tends to migrate slowly across a limb over minutes

rather than seconds as with stroke. The diagnosis of migraine becomes more secure as

the cortical disturbance begins to cross vascular boundaries or if typical visual

symptoms are present, such as scintillating scotomata. 1t times it may be difficult to

make the diagnosis until multiple episodes have occurred leaving behind no residual

symptoms and with a normal MD+ study of the brain. Classically, metabolic

encephalopathies produce fluctuating mental status without focal neurologic findings.

)owever, in the setting of prior stroke or brain injury, a patient with fever or sepsis may

manifest hemiparesis, which clears rapidly when the infection is remedied. The

metabolic process serves to unmask a prior deficit.

#e$ %istor$ Ele&ents

-ocument symptom:s onset or time last seen normal :without stroke symptoms or

at baseline.. This must be by a valid historian. 1lways document specifics since there

are precise time windows for therapies.

+n the history look for other causes of stroke like symptoms such as diabetes,

post>ictal state, and psychogenic factors.

/ Medications including anticoagulants :Coumadin, aspirin, plavi%, and cardiac

drugs like digo%in. +f possible bring all medications to the hospital.

0 Past Medical )istory including stroke, transient ischemic attack :T+1, diabetes,

hypertension, and cardiac disease. -ocument and convey to the receiving facility

any residual effects following the last C61. +f T+1, document and convey the

length of time effects lasted.

?nce the diagnosis of stroke is made, a brain imaging study is necessary to

determine if the cause of stroke is ischemia or hemorrhage. CT imaging of the brain is

the standard imaging modality to detect the presence or absence of intracranial

hemorrhage. +f the stroke is ischemic, administration of recombinant tissue plasminogen

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activator :rtP1 or endovascular mechanical thrombectomy may be beneficial in

restoring cerebral perfusion. Medical management to reduce the risk of complications

becomes the ne%t priority, followed by plans for secondary prevention. &or ischemic

stroke, several strategies can reduce the risk of subse8uent stroke in all patients, while

other strategies are effective for patients with specific causes of stroke such as cardiacembolus and carotid atherosclerosis. &or hemorrhagic stroke, aneurysmal subarachnoid

hemorrhage :#1) and hypertensive intracranial hemorrhage are two important causes.

Treat&ent:The treatment of C61 varies according to the cause of the condition. &or

patients who have suffered T+1s with no residual deficits and who demonstrate with

angiography that the T+1s are caused by carotid stenosis rather than cerebral

arteriosclerosis, carotid endarterectomy :removal of pla8ue from the artery might be

indicated. #ometimes )eparin or Coumadin are given because of the anticoagulation

effect if blood clots are a suspected cause. 1spirin or Persantine may be given to

reduce platelet aggregation and the potential for vessel blockage. 3nderlying disease

that may be contributing to the problem, such as cardiac problems, is treated. The

treatment for an actual C61 is symptomatic. The first priority is maintaining an airway.

+6 access is obtained and a &oley catheter is inserted. &luids and electrolytes are

monitored closely. +f there are signs of cerebral edema, +6 -ecadron andBor Mannitol,

!lycerol or urea solution may be given. +f the C61 has occurred because of cerebral

hemorrhage from an aneurysm :bulging of a weak arterial wall, surgery may be

attempted when the patient is stable. +f the patient is unable to take food orally, he or

she may receive tube feedings or total parenteral nutrition :TP*. To preserve function,

it is e%tremely important that the patient be actively involved in rehabilitation therapy as

soon as the acute phase has passed.

Clinical 1ssignments Aearning ?bjective

. -iscuss neurological tests completed on a patient in

your clinical unit. -istinguish the reasons for these

e%aminations and any diagnoses made.

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. Compare and contrast medical and surgical procedures

needed for the patient who suffered from C61.

*ursing management' *ursing management centers on combating the immobility which

makes this patient a candidate for all the attendant problems. Careful monitoring of

respiratory status and maintaining a patent airway are essential. &re8uent neurological

checks are indicated including level of consciousness :A?C, mental status, papillary

response, and ability to move e%tremities, perceive sensation, and demonstrate e8ual

strength bilaterally. Measures to prevent breakdown and contracture of the affected

joints are instituted early. The nurse needs to be aware that fle%ion contractures of

hand, wrist, and elbow are common, as is planter fle%ion of the foot. The shoulder tends

to adduct and the hip tends to rotate e%ternally. @e sure to test for a gag refle% before

feeding oral foods and fluids and have a suction set>up available. &ood should be

placed on the unaffected side of the mouth and when eating is completed, the affected

side of the mouth should be checked for retained food particles which the patient may

be unable to feel. Post>C61 care includes many components. +ncontinence often

re8uires bladder retraining. The patient should be offered a bedpan or urinal every two

hours to promote efforts at continence. #peech therapy should be instituted if the patient

has communication problems. Physical therapy and occupational therapy are key

aspects of post>C61 care. The nurse may need to act as coordinator for other team

members to see that the patient does in fact have sessions with each service. 1lso, the

nurse should be aware of the progress the patient is making and make every attempt to

reinforce the learning taking place. #upporting rehabilitation efforts tends to increase the

patientGs level of independence and self>esteem. The recovery period as well as the

acute stage will be a highly stressful time for the patient and family. &ear, frustration,

and grieving are common reactions. The nurse needs to take a prominent role in being

supportive to the patient and family.

Clinical 1ssignments Aearning ?bjective

. Complete a disease abstract of your patient and make a

comprehensive concept map putting emphasis on the

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nursing diagnosis and management to be done to your

patient.

. !et an article that is related to the concept then make a

summary and reaction in relation to what you have learned

in this module.

#uggested readings.

!uyton, 1rthur, )all, Hohn I. Te%tbook of Medical Physiology.

)arrison9s PD+*C+PAI# ?& +*TID*1A MI-+C+*I#eventeenth Idition

)ilton, Penelope 1nn, &undamental *ursing #kills, 7hurr Publishers,AondonBPhiladelphia, JJ2Aewis, #., )eitkemper, M. K -irksen, #. :JJ0. Medical>surgical nursing'

1ssessment and management of clinical problems. :4th ed. #t. Aouis' Mosby.Potter, P. K Perry, 1. :JJ &undamentals of nursing. :2th ed. #t. Aouis'Mosby.D?@@+*# 1*- C?TD1* P1T)?A?!+C @1#+# ?& -+#I1#I, EBI+#@*' L5E>>04J>/>2 Copyright JJ by #aunders, an imprint of Ilsevier +nc.#melt=er, #. K @are, @. :JJ0 @runner K #uddarthGs te%tbook of medical> surgicalnursing. :th ed. Phildelphia' Aippincott 7illiams K 7ilkins.

III' VSC()* DIST(*BNCES

Cerebrovascular ccident +CV,

Defers to any functional abnormality of theC*# related to disrupted blood supply.

' Isc!e&ic Stro-e :most common There is disruption of the cerebral blood flow due

to obstruction by embolus or thrombus.

Disk &actors

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. *on>modifiable :advanced age, gender, race.. Modifiable :hypertension, cardiovascular disease, obesity, smoking, diabetes mellitus,

hypercholesterolemia.

Pathophysiology of +schemic #troke

-isruption of blood supply.

1naerobic metabolism ensues.

-ecreased 1TP production leads to

impaired membrane function.

Cellular injury and death occur.

Clinical Manifestations

. #udden severe headache.. -ifficulty walking, di==iness or loss of balance or coordination.

/. Trouble speaking or understanding speech.0. 6isual disturbances.2. #udden weakness or numbness of the face, arm, or leg, especially on one side of

the body.4. Confusion or change in mental status.

-iagnostic Tests

. CT scan to determine if the event is ischemic or hemorrhagic.. IC! and Carotid 3ltrasound to identify source of thrombi or emboli./. 1ngiography visuali=es intracranial and cervical vessels.

*ursing +nterventions' :acute

. Insure patent airway.. Neep patient on lateral position./. Monitor 6# and !C#, pupil si=e.0. +6& is ordered but given with caution as not to increase +CP.2. *!T inserted.4. Medications' #teroids, mannitol, dia=epam.

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*ursing +nterventions' :)ospital

. +mprove mobility and prevent joint deformities.

Correctly position patient to prevent contractures.

Place pillow under a%illa.

)and is placed in slight supination> "C$.

Change position every hours.. Inhance #elf>care

Carry out activities on the unaffected side.

Prevent unilateral neglect> place some item on the affected side.

Neep environment organi=ed./. Manage #ensory>perceptual difficulties.

1pproach patient on the unaffected side.

Incourage to turn the head to the affected side to compensate for visual loss.

0. Manage -ysphagia.

Place food on the unaffected side.

Provide smaller bolus of food.

Manage tube feedings if prescribed.2. )elp patient attain bowel and bladder control.

+ntermittent catheteri=ation is done in the acute stage.

?ffer bedpan on a regular schedule.

)igh fiber diet and prescribed fluid intake.4. +mprove Thought processes.

#upport patient and capitali=e on the remaining strengths.5. +mprove Communication.

1nticipate the needs of the patient.

?ffer support.

Provide time to complete the sentence.

Provide a written copy of scheduled activities.

3se of communication board.

!ive one instruction at a time.E. Maintain #kin integrity.

3se of specialty bed :low>air>loss bed.

Degular turning and positioning.

Neep skin dry and massage non>reddened areas.

Provide ade8uate nutrition.L. Promote Continuing care.

Deferral to other health care providers.J. +mprove family coping.

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. )elp patient cope with se%ual dysfunction.

Medical Management

Pharmacologic'

. Platelet>inhibiting medication :aspirin.. 1nticonvulsant :dia=epam./. Thrombolytics :Tissue Plasminogen 1ctivator.0. Aa%atives.2. 1ntihypertensive.4. 1nalgesics, muscle rela%ants.5. #teroids.

B' %e&orr!agic Stro-e

*ormal brain metabolism is impaired by interruption of blood supply compressionand increased +CP.

Pathophysiology of )emorrhagic #troke

3sually due to rupture of intracranial

aneurysm, 16 malformation, subarachnoid

hemorrhage disrupting normal brain

metabolism.

#udden entry of blood into the subarachnoid space compressing and injuring brain

tissues.

Clinical Manifestations

. #udden severe headache.. -ifficulty walking, di==iness or loss of balance or coordination./. Trouble speaking or understanding speech.0. 6isual disturbances.2. #udden weakness or numbness of the face, arm, or leg, especially on one side of

the body4. Confusion or change in mental status.5. Aoss of consciousness.E. Meningeal irritation :nuchal rigidity.

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-iagnostic Tests

. CT scan to determine the si=e and location of the hematoma.. Cerebral 1ngiography to confirm diagnosis of an intracranial aneurysm or 16M.

*ursing +nterventions. ?ptimi=e cerebral tissue perfusion.

Placed on absolute bed rest in a 8uite, nonstressful environment.

)ead of bed elevated 2 to /J degrees to promote venous drainage.

1void 6alsalva maneuver, straining, snee=ing, pushing up in bed, and cigarettesmoking.

. Delieve sensory deprivation and an%iety.

Neep patient well informed of the plan of care for reassurance and minimi=ean%iety.

/. Monitor and manage potential complications.

6asospasm :headaches, confusion, and disorientation.

#ei=ure precaution.

)ydrocephalus.

Debleeding.

+6. M?6+I DI6+I7

T)I 171NI*+*!# Aearning ?bjective

. Complete discussion of the plot and the characters of

the movie.

. Aist down the all the signs and symptoms :put the

specific time where have you seen the signs and

symptoms related to the concept of neurology with the

possible disease condition and the scientific rationali=ation

of each sign.

/. -iscuss the treatments that have been done to the

patients in the movie. -o you agree with the said

modalities and relate to pathophysiological aspect of the

disease.

0. -iscuss the medication that has been given. )ow does

it affect the patients :P)1DM1C?N+*IT+C# 1*-

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P)1DM1C?-O*1M+C. 7hat is the impact of the effect of

the said drug to social aspects of the clients, medicine and

nursing.

#?**O 1. P3D1

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requirement module ncm 104 and pharma

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