N220 3'2 Interventions for Critically Ill Clients with Neurologic Problems

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N220 3.2Interventions for Critically Ill Clients
with Neurologic Problems
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Traumatic Brain Injury (TBI)
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Clinical Application Head Injury

• Sam, 60
• No health problems, slipped and hit head
• Unconscious

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Eyes Open
(SAM-Opens eyes to pain)

• Spontaneously 4
• To Speech 3
• To pain 2
• None 1

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Best Verbal Response
(SAM-Moans to painful Stimuli)

• Oriented Converses know who he is where he is
  year month 5
• Confused Converses but disoriented in one or
  more spheres 4
• Inappropriate Words Words disorganized or
  inappropriate 3
• Incomprehensible- Makes sounds (moaning) but no
  recognizable words 2
• None No sounds even with painful stimuli 1
  

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Best Motor Response
(SAM - Appropriate w/d from pain)

• Obeys Commands 6
• Localizes Pain Does not obey, attempts to
  remove offending stimuli 5
• Flexion Withdrawal Flexes arm in response to
  pain without abnormal flexion posture 4
• Abnormal Flexion Flexes arm at elbow and
  pronates, makes a fist 3
• Abnormal Extension Extends arm at elbow, usually
  adducts and internally rotates are at shoulder
  2
• None 1

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Initial Neuro Assessment

• Hx
• LOC , N/V, mechanism of injury, medical Hx
• ABCs of trauma, VS, other injuries
• Assessment Bruises, fluids, eyes,
  posture/flaccidity, seizures

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Shaking Baby
Reticular Activating System
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Clinical Application Head Injury

• Head Injury Mechanisms
• Concussion -LOC
• Contusion
• Laceration

Interrupts the neuro, chemical, electrical
functions of the cortex and brain stem.
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Clinical Application Head Injury

• Sams type of bleed?
• Epidural -
• Subdural-
• Subarachnoid-
• Intracerebral-

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Clinical Application Head Injury

• Vital Signs
• Temperature
• Subnormal
• Elevated
• Pulse
• Tachycardia
• Bradycardia

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Clinical Application Head Injury

• Sams neurologic functions are decreasing
• You suspect increasing ICP
• What are other causes for increase ICP?

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Clinical Application Head Injury

• Edema
• Vasogenic
• Osmotic SIADH

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SIADH - Syndrome of Inappropriate ADH

• ADH release
• Water Reabsorption into circulation -
  Renal Tubules
• Extravascular Fluid
• Plasma Osmolality
• Glomerular Filtration Rate
• Serum Sodium Levels

CEREBRAL EDEMA
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Clinical Application Head Injury

• Edema
• Vasogenic
• Osmotic
• Cytotoxic
• Interstitial Cerebral edema

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Clinical Application Head Injury

• Factors that can contribute to increasing ICP
  besides space occupying lesions and edema?

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Clinical Application Head Injury

• CSF (increased production/blocked absorption)
• Chemicals (Dyes from tests)
• Metabolic coma
• Impaired Autoregulation
• Coughing
• Valsalva Maneuver

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Valsalva Maneuver

• Bedpan
• Increased Bp up 40 mm Hg over commode
• (Constipation 5X the frequency of straining)

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Valsalva Maneuver

• What is the most common isometric exercise a
  patient does?

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Sams Not doing well
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Clinical Application Head Injury

• Cushing Triad
• Increased systolic pressure (widening pulse
  pressure)
• Bradycardia
• Altered Respiratory pattern

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Cushing Triad
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Clinical Application Head Injury

• Treatment
• Sam taken for emergency surgery
• Post-op nursing management

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Cerebral Perfusion Pressure (CPP)

• Mean Arterial Pressure (MAP) Diastolic Bp 1/3
  Pulse Pressure
• CPP MAP - Intracranial Pressure
• Average 60- 100

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Clinical Application Head Injury

• What is the treatment for Sam if surgery not done
• Ventricular drainage
• Hyperventilation
• Osmotic Therapy
• Barbiturate therapy

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Treatment

• Conservative
• Bedrest/Positioning
• Environmental support
• Sedatives
• Control Bp
• Restrict fluids
• Anticonvulsants
• (Control the autonomic NS)

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Rehabilitation Problems

• Thinking (i.e., memory and reasoning)
• Sensation (i.e., touch, taste, and smell)
• Language (i.e., communication, expression, and
  understanding) and
• Emotion (i.e., depression, anxiety, personality
  changes, aggression, acting out, and social
  inappropriateness).

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Clinical Application Head Injury

• Back to Sam who suffered a stroke while he was in
  surgery

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Clinical Application Stroke

• Ischemic
• Thrombotic (50)
• Embolic (30)
• Hemorrhagic
• Intracerebral (10)
• Subarachnoid (10)

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Stroke Treatment

• Thromboltic therapy
• Airway Protection
• Blood Pressure Control
• Hyperthermia
• Hyperglycemia Treatment
• Control of Arrhythmias
• Anticoagulation

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Stroke Outcomes

• 10 Recover almost completely
• 25 Recover with minor impairments
• 40 Experience moderate to severe impairments
• 10 Require care in a long-tern care facility
• 15 die

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Stroke Problems for Nursing and Rehabilitation

• ID of impairment
• Agnosia, apraxia, dysphagia, Cognitive, visual,
  language
• Prevention of Complications
• Nutrition, Falls, Skin, Contractures,
  Deconditioning, DVT
• Education
• Medical, F/U, life style changes

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• Mental and Behavioral Health
• Depression (anxiety, anger, fear)
• Sexuality
• Medical Economics
• Rehab (inpatient or outpatient f/u)
• Resource Identification
• Locus of Control
• Self Esteem, respect, hope
• Isolation-Interdependance

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• Pain and Spasticity
• Neuropathic, musculoskeletal
• External aids
• Equipment, Assistive Devices, Home Modification
• Vocation
• Driving

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• Caregiver Burnout

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Transient Ischemic Attacks (TIAs)

• Brief episode of neuro deficit passes without
  residual deficits
• Last 2- 15 min to 24 hours
• Episodes tend to reoccur

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ABCD ABCD2

• A One point for age 60 or older,
• B One point for blood pressure at or above 140
  mmHg systolic or 90 mmHg diastolic,
• C Two points for unilateral weakness,
• One point for speech impairment without weakness,
  
• D Two points for TIA duration of 60 minutes or
  more,
• One point for TIA duration 10 to 59 minutes, and
  (D2) One point for diabetes.

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ABCD ABCD2

• ABCD Stroke Risk
• 7-DAY 30-DAY  
• 0 to 2 0 0
• 3 1.7 3.5
• 4 7.6 7.6
• 5 19.1 21.3
• 6 18.8 31.3

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• Predictions for 2, 7, and 90 days

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Reversible Ischemic Neurologic Deficit (RIND)

• Same as TIA except last longer than 24 hours with
  recovery within 1-3 weeks. No tissue death, but
  risk of complete infraction increased

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Transient Ischemic Attacks (TIAs) Reversible
Ischemic Neurologic Deficit (RIND)

• Symptoms depend on site of ischemia - Both cause
  damage to brain tissue
• Hemiplegia, weakness, paresthesia, paresis,
  ataxia, unilateral blindness, dizziness, syncope,
  headache, vertigo, transient dysphasia, ...

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Sports and Concussions
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REVIEW TIME

• Multiple Sclerosis
• Nerve demyelination of nerves in brain spinal
  cord
• Nerve impulse blocked or slowed
• Guillain-Barre
• Temp demyelination of nerves in peripheral NS
• Nerve impulse blocked or slowed

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• Myasthenia Gravis
• Autoimmune disease blocking ACh receptor sites
• Interference of nerve impulse across nerve
  junction on muscles
• Muscular Dystrophy
• Atrophy of voluntary muscles
• Wasting of voluntary muscles

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• Parkinson Disease
• Destruction of nerve cells in basel ganglia,
  Decrease Dopamine
• Excitatory mechanism unopposed
• Alzheimers Disease
• Degeneration of neurofibrils and plaques in brain
• Impairment of intellectual functioning

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• Huntingtons Chorea
• Degeneration of cerebral cortex and basal ganglia
  - Inherited
• Bizarre involuntary movements, dementia
• Amyotrophic Lateral Sclerosis
• Demyelination of motor neuron in spinal cord and
  brain
• Nerve impulse blocked or slowed

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• Bells Palsy
• Acute CNVII paralysis
• Effect control salivation, lacrimation or close
  eye
• Trigeminal Neuralgia
• CNV degeneration or pressure
• Facial pain, twitching