Chapter 47

Chapter 47

Care of Patients with Neurologic Problems Brain Injury, Intracranial Pressure, CVA, and Seizures Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Brain Injury Blow or jolt to head May be result of head penetration by foreign object May be classified as Primary or Secondary

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 2 Primary Brain Injury Open vs. closed head injuries Mild, moderate, severe classification Fractures Concussion Laceration Contusion

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 3 Coup and Contrecoup Injury Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 4 Acceleration-Deceleration Injury Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 5 Secondary Brain Injury

Negative patient outcomes Physiologic, vascular, and biochemical events Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 6 Epidural Hematoma (Arterial) Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 7

Nursing Safety Priority Critical Rescue After the initial interval, symptoms progress very quickly with potentially life-threatening ICP elevation and structural changes. Monitor the patient suspected of epidural bleeding frequently (every 5-10 minutes) for changes in neurologic status. The patient can become quickly and increasingly symptomatic and lose consciousness. An epidural hematoma is a neurosurgical emergency! Notify the health care provider or Rapid Response Team immediately if these changes occur. Carefully document your

assessments and the patient's overall condition. Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 8 Subdural Hematoma (SDH) (Venous) Venous bleeding into space beneath dura and above arachnoid

Most commonly from tearing of bridging veins within cerebral hemispheres or from laceration of brain tissue Bleeding occurs more slowly, symptoms mirror those of epidural hematoma Highest mortality rate because often unrecognized Chronic SDH may be misdiagnosed as dementia in the elderly (UCLA Neurosurgery, 2013) Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 9 ICP

Normal values: 0-15 mm Hg Abnormal pressures can occur with brain injury/trauma and Stroke Edema Brain Herniation (emergent) Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 10 Key Features of ICP

Decreased LOC Behavioral changes (restlessness, irritability, confusion) Headache N&V Change in speech pattern including aphasia and slurring. Changes in sensorimotor status Widened pulse pressure

Dilated/non-reactive pupils or constricted/non-reactive pupils Cranial nerve dysfunction Ataxia Seizures Cushings Triad (grave sign) Bradycardia

Severe hypertension Abnormal posturing (decerebrate/extensor and/or decorticate/flexion) Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 11 Patient-Centered Care Assessments -History -Physical Exam -VS -Psychosocial -Labs

-Imaging Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 12 Nursing Management Interventions -Non-Surgical preventing and detecting ICP drug therapy

inducing a barbiturate coma maintaining fluid and electrolytes maintain nutritional status managing sensory, cognitive, and behavioral changes Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 13 Nursing Management Interventions -Surgical ICP Monitoring Device Craniotomy (Pre and Post-op Management) Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

14 Community-Based Care Home care Community services Safety Patient and Family education Self-management Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 15

Brain Death FOUR PREREQUESITES (American Academy of Neurology, 2010): Coma of known cause as established by history, clinical examination, laboratory testing, and neuroimaging Normal or near-normal core body temperature (higher than 36 C) Normal systolic blood pressure (higher than or

equal to 100 mm Hg) At least one neurologic examination (some states and health care systems require two on file) Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 16 Stroke (Brain Attack) Change in normal blood supply to brain Risk factors Causative agents:

Hypertension Arteriovenous malformation Injury insult Types: Ischemic Thrombolic Embolic Hemorrhagic Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

17 Risk Factors (Modifiable) Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 18 Risk Factors That Cannot Be Changed

Age: Risk for stroke increases as a person gets older. Sex: Men have a 30% higher incidence of stroke, but postmenopausal women are also at a significantly higher risk. Family history: If a person has a stroke, it increases the risk for stroke in other family members. Race: African Americans have a higher risk for stroke because of their increased incidence of high blood pressure, obesity, and diabetes. Myocardial infarction (MI): A history of an MI puts the patient at increased risk for a stroke.

History of migraine headaches: Patients who suffer from migraines may be at higher risk for ischemic strokes. A prior stroke: Patients who have strokes are at risk for another stroke. Sickle cell disease: Patients with this type of disorder are at risk for stroke at a younger age. Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 19 Risk Factors Altered With Collaborative Management

High blood pressure (HBP): HBP can be managed with a combination of drug therapy, diet, and exercise. High cholesterol levels: Patients with high cholesterol can reduce their stroke risk by 30% through lifestyle changes and drug therapy. Cardiovascular disease: Atherosclerosis and atrial fibrillation are major risk factors for stroke, but if diagnosed early, they can be controlled with drug therapy. Diabetes: Consistent diabetic control is essential to decrease the risk for strokes. Blood clotting disorders: Patients with clotting problems are at high risk for thrombotic stroke and require preventive anticoagulants.

Sleep apnea: Patients with sleep apnea have 3 to 6 times the risk for stroke. Weight loss and/or using a breathing device at night called a continuous positive airway pressure (CPAP) machine can manage this problem. Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 20 Types of Stroke Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 21 Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 22

Patient-Centered Care Assessment -History -Physical Exam -Psychosocial -Labs -Imaging Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 23 Nursing Management Interventions

Non-surgical Fibrinolytic Therapy Endovascular Monitoring for ICP VS Routine Care Considerations (mobility, swallowing/nutrition, communication, continence, sensory perception, skin integrity) Ongoing Drug Therapy Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 24 Nursing Management

Interventions Surgical Carotid Endarectomy Stenting Craniotomy Reroute vessels from occlusion Evacuate blood Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25

Community-Based Care Community Home Care Self-Care Teaching Caregiver Support Resources Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 26 Seizures

A seizure is an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness (LOC), motor or sensory ability, and/or behavior. A single seizure may occur for no known reason. Some seizures are caused by a pathologic condition of the brain, such as a tumor. In this case, once the underlying problem is treated, the patient is often asymptomatic. Epilepsy is defined by the National Institute of Neurological Disorders and Stroke as two or more seizures experienced by a person. It is a chronic disorder in which repeated unprovoked seizure activity occurs. It may be caused by an abnormality in electrical neuronal activity; an imbalance of neurotransmitters, especially gamma aminobutyric acid (GABA); or a combination of both (McCance et al., 2010). Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

27 Older Adult Seizure Considerations Complex partial seizures are most common among older adults (Vacca & Olson, 2007). These seizures are difficult to diagnose because symptoms appear similar to dementia, psychosis, or Alzheimer's disease (AD), especially in the postictal stage (after the seizure). New-onset seizures in older adults are typically associated with conditions such as hypertension, cardiac disease, diabetes mellitus, stroke, and Alzheimer's disease. Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 28

Seizure Risk Factors Primary or Idiopathic genetic Secondary

Lesion or tumor Trauma High fever Metabolic disorders and electrolyte imbalances Stroke Alcohol withdrawal and substance abuse Heart disease Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 29 Patient-Centered Care Assessment

History Physical Exam Imaging (CT or MRI) used to r/o other causes Interventions Non-surgical Surgical Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

30 Teaching Self-Management Medication Community support groups Family and Patient education Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 31 Seizure Precautions Nursing Safety Priority Action Alert! Seizure precautions include ensuring that

oxygen and suctioning equipment with an airway are readily available. If the patient does not have an IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 32 Nursing Focused Assessment for Seizures

How often does the seizure occur Description of each seizure Whether more than one type of seizure occurs Sequence of seizure progression Observation of patient during seizure How long the seizure lasts When the last seizure took place Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 33

Status Epilepticus A medical emergency and is a prolonged seizure lasting longer than 5 minutes or repeated seizures over the course of 30 minutes. It is a potential complication of all types of seizures. Seizures lasting longer than 10 minutes can cause death! Common causes of status epilepticus include: Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 34

NURSING SAFETY: PRIORITY RESCUE Convulsive status epilepticus must be treated promptly and aggressively! Establish an airway and notify the health care provider or Rapid Response Team immediately if this problem occurs! Establishing an airway is the priority for this patient's care. Intubation by an anesthesia provider or respiratory therapist (RT) may be necessary. Administer oxygen as indicated by the patient's condition. If not already in place, establish IV access with a large-bore catheter, and start 0.9% sodium chloride. The patient is usually placed in the intensive care unit for continuous monitoring and management.

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 35 The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine. What is the priority nursing intervention for this patient at this time? A. Provide perineal care B. Assess for gag reflex C. Elevate the head of bed D. Perform a linen and gown change Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 36

(contd) An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which manifestations would you expect? (Select all that apply) A. Disorientation to time, place, and person B. Inability to discriminate words and letters C. Constant smiling D. Intellectual impairment E. Neglect of left visual field F. Deficits in the right visual field Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 37 (contd) 1. The patient is admitted to the acute medical

unit after 7 hours. His wife asks if her husband will receive IV thrombolytic therapy. What is your best response? 2. Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is your best response? Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 38 (contd) The patients wife must leave her husbands bedside for 2 hours to run errands. Which nursing action is appropriate to

contribute to patient safety while she is gone? A. Apply restraints. B. Maintain the bed in a low position. C. Sit with the patient until his wife returns. D. Place the call light in the patients right hand. Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 39 (contd) The patient needs assistance with feeding, but can swallow well. To whom would it be best to delegate this responsibility? A. Licensed practical nurse B. Certified nursing assistant C. Hospital volunteer D. Student nurse doing first patient care experience

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 40 NCLEX Questions Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 41 Question 1 What is the greatest risk for a patient with dysfunction of cranial nerves IX and X? A. B. C. D.

Dehydration Aspiration pneumonia Constipation Weight loss Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 42 Question 2 Which symptom is the earliest indicator of increased intracranial pressure? A. B. C. D. Increased pupil size

Elevated blood pressure Agitation and confusion Nausea and vomiting Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 43

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