Neurological System

1
Neurological System
2
Brain Anatomy

• Cerebrum
• Reasoning
• Judgment
• Concentration,
• Motor, sensory, speech
• Cerebellum
• Coordination
• Brainstem
• Cranial nerves
• Respiratory center
• Cardiovascular center

3
Brain Anatomy Cont.
4
Cerebral Blood Flow

• 20 of CO
• Cerebral tissues Have no oxygen or glucose
  reserves
• Blood flows through Carotid Arteries to Circle of
  Willis

5
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

6
Neurological Assessment

• Rapid Neurological Assessment
• Emergent situations
• Sudden changes in neurologic status
• LOC first indicator of a decline in neurological
  function and increase in ICP (intracranial
  pressure) use the GCS
• Pupils

7
(No Transcript)
8
3. PUPILS
Pupils equal and react normally
Pupils react to light (slowly or blriskly)
Dilated pupil (compressed cranial nerve III)
Bilateral dilated, fixed (ominous sign)
Pinpoint pupils (pons damage or drugs)
9
Neuro-Diagnostic Tests
CT SCAN

• Routine labs
• Radiology Tests
• CT scan, MRI
• Carotid ultrasound
• Cerebral angiogram/
• MRA

Carotid US
MRA
10
Neuro-Diagnostic Tests Lumbar Puncture

• Spinal needle inserted into SA
• L3/L4 or L-4 /L-5 using strict asepsis
• Obtain CSF specimens and pressure readings
• To remove bloody or purulent CSF
• Administer spinal anesthesia

11
Case Study Introduction

• Nancy is a 66 year old female, came in to the ER
  with her daughter Gail. Gail states that her
  mother woke up in the middle of the night to go
  to the bathroom and fell to the ground because
  she was not able to control her right leg.

12
Case StudySubjective data

• R arm and leg weak and numb
• Feeling depressed and fearful
• Requires help with ADLs
• Says she has not taken her meds for high
  cholesterol
• History of brief episode of right sided weakness
  and tingling of the face, arm, and hand 3 months
  earlier, which totally resolved and for which she
  did not seek treatment

13
Case StudyObjective Data

• Alert and oriented, and able to answer questions
  appropriately with mild slowness in responding
• BP 180/110
• Global aphasia, facial drooping, dysphagia
• Right sided paralysis
• Decreased sensation to right side, particularly
  the hand
• Right homonymous hemianopsia
• Overweight
• Incontinent of urine

14
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
• Serious Medical Emergency- reduction in cerebral
  blood flow tissue death
• Brain dependent on constant supply of oxygen and
  glucose

15
Types of Stroke

• Ischemic- results from an occlusion of a cerebral
  artery by a thrombus or embolus
• Thrombotic Stroke
• Embolic Stroke
• Hemorrhagic bleeding into brain tissue

16
Ischemic Thrombotic Stroke

• Atherosclerosis -most common cause
• Thrombosis-clot forms at rough or narrowed artery
• Complete blockage
• Accounts for half of all strokes

17
Ischemic Embolic Stroke

• Accounts for 1/3 of all strokes
• Embolism-emboli breaks off and travels to
  cerebral or carotid arteries (blood clot or
  fatty plaque released into circulation)
• Often a fragment from a thrombosis or fatty
  plaque

18
TIA Transient Ischemic Attack or

• Silent stroke/ mini stroke
• Warning sign Temporary onset of neurological
  symptoms often lasting 15 min but no longer than
  24 hours
• Needs prompt work-up carotid U/S, brain and
  heart
• Key features
• Blurred vision, double vision, blindness one eye
  Transient weakness, ataxia Speech deficits

19
Treatment Cont Surgical Therapy

• Carotid Endarterectomy- for pts who have had TIAs
  or significant narrowing of carotid arteries

20
Hemorrhagic Stroke

• Rupture of weak vessel wall or cerebral aneurysm
• Intracerebral or subarachnoid hemorrhage
• Arteriovenous malformation
• Bleeding into brain
• or meninges

21
Risk Factors for Stroke

• Modifiable
• Hypertension
• Heart disease (MI, A Fib)
• DM, Hyperlipidemia
• Sedentary Lifestyle
• Smoking/Alcohol
• Obesity
• Hyperlipidemia
• Illicit Drug Use
• cocaine
• Nonmodiafiable
• Age - People over 55 are
• at high risk
• family history
• African american, hispanic, asian descent

22
Clinical Manifestations

• Depend on the extent of injury
• May be transient, mild or result in major neuro
  deficits
• Sudden numbness or weakness of the face, arm, or
  leg, especially on one side of the body
• Sudden complete or partial loss of vision on one
  or both sides
• Sudden confusion or trouble speaking or
  understanding
• Sudden loss of balance, unsteadiness or an
  unexplained fall
• Sudden vertigo, dizziness, swallowing
  difficulties or memory disturbances
• Sudden, severe headache with no known cause
• Hemorrhagic
• Worst HA ever for bleeds

23
Impaired comprehension Memory R/T language and
math
Left -Sided CVA LEFT BRAIN DAMAGE
R Hemianopsia
Impaired speech (Aphasias)
Aware of deficits Depression, Anxiety
R Hemiplegia /paresis
Impaired discrimination (R/L)
Slow performance, Cautious
24
Right-sided CVA RIGHT BRAIN DAMAGE
Impaired judgment
L Hemianopsia
Impulsive/Safety problems
Rapid performance Short attention span
L hemiplegia/paresis
Denies/Minimizes problems
Left-sided neglect
Spatial-perceptual deficits
25
Cognitive Changes
Psychosocial
Impaired Communication
Impaired Swallowing
Sensory Changes
Motor Deficits
Altered Elimination
Nancy
26
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 Fowlers 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

27
Cognitive Changes

• Nursing Interventions
• Frequent reorientation
• Frequent safety instructions
• Repeat directions on tasks by steps
• Give time to process and respond

• Change in LOC
• Impaired judgment, memory, problem solving
• Denial of illness
• Inability to concentrate

28
Motor Deficits

• Loss of voluntary movement on contralateral
  (opposite) side of stroke
• Weakness paralysis
• Hemiplegia and/or Hemiparesis
• Gait changes

29
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- limit mvmt
  to extremities only )
• Assist with ADLs (Self Care Deficit)
• Use assistive devices (wide grip utensils, plate
  guards)
• Rehab and use of ambulation devices

30
Motor Deficit Cont.
Splints, hand rolls, trochanter rolls
31
Assessment and Management Sensory Changes

• 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

• Contralateral sensory deficits
• Decreased sensation to touch
• Spatial dysfunction (kinesthesia/proprioception
  altered)
• ? Awareness of position
• Neglect Syndrome
• Ignore affected side due to altered perception
  and vision
• Visual Deficits (Hemianopsia)

32
Sensory Changes Cont. - Visual Deficits
Hemianopsia

• Blindness in one side of visual field
• Homonymous hemianopsia
• Blindness in in the same side of each visual
  field

33
Visual Deficits Hemianopsia Cont.

• Nursing Interventions
• Place objects in clients visual field
• Remove clutter
• Teach 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

34
Impaired Communication

• Nursing Interventions
• Assess ability to speak and understand
• Provide reinforcement
• Picture board
• Repeat names of objects routinely
• Allow plenty of time for client to answer

• Aphasia-loss of use and comprehension
• Receptive aphasia- Wernickes area (sensory)
• Expressive aphasia Brocas area (motor)
• Global aphasia- mixed

35
Picture Communication Board
36
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

37
Assessment and Management Problems R/T Immobility

• Risk for atelectasis and pneumonia
• Risk for impaired skin integrity and DVT
• Nursing Interventions

38
Assessment and Management Psychosocial

• Emotional Support
• Depression a major problem
• Discharge planning
• Care of the caregiver

39
Treatment of StrokeThrombotic 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

40
Treatment Cont

• Acute phase
• Anticoagulant - Heparin continuous infusion
• Osmotic Diuretics to reduce brain swelling
• Anticoagulants contraindicated in Hemorrhagic
  Strokes

• Long Term Drug Therapy
• To Prevent Stroke
• Antiplatlet Drugs
• ASA, Ticlid, Persantine, Plavix
• Anticoagulants
• Coumadin
• Lovenox
• Antiepileptics

41
Treatment Cont Surgical Treatment For Bleeds
(Interventional Radiology)

• Angiograms to see arteries and detect bleeding
  sites
• Aneurysm clips and coils

42
Surgical RemovalHematoma