Lecture 13 Neurology - Porterville College

Report
Medical Surgical Nursing
Lecture 13
Neurology
The nervous system consists of:
• Brain
• Spinal Cord
• Peripheral Nerves
• Divided system
– Central Nervous System
(CNS)
• Brain & Spinal
Cord
– Peripheral Nervous
System (PNS)
• Nerves (peripheral
& Cranial)
Nervous System
• Controls and
coordinates all parts of
the body
• By transmission of
electrical impulses
Purpose of the Nervous System
•
•
•
•
Control
Coordinate
Communication
Stimulation of
Movement
Purpsose of the Nervous System
• Maintains Homeostasis
– Along with the what
system?
• Endocrine
Neuron
• Basic functional unit
Synaptic Junction
• Neuron connect to each
other end to end
– Synaptic junction
– Synapse
Central Nervous System
• Brain
• Spinal Cord
• Control center for
entire system
Protection
• Brain:
– Encased by the Skull
• Spinal Cord
– Encased in vertebral
column
The Meninges
• Function
– Support
– Protect
– Nourish
• Dura mater
• Arachnoid
– Cerebral Spinal Fluid
• Pia Mater
Brain – 3 main areas
• Cerebrum
– Coordination of stimuli
• Cerebellum
– Control muscle movement
• Brainstem
– Vital Reflexes
Brainstem
• Connects brain with spinal
cord
– Vital reflexes
– Relay for sight and
hearing
Cerebellum
• “Lesser brain”
• Controls skeletal muscles
 coordinated
Spinal Cord – CNS
• Continuous with brain
stem
• Extend to L-1orL-2
• Lumbar Punctures 
– L3-4
Peripheral Nervous System
• Contains
– Cranial nerves
– Spinal nerves
• Location
• Function
– Sensory impulses from PNS
 CNS
– Motor response from CNS
 PNS
• Key word:
– Nerves
PNS  Somatic & Autonomic NS
• Somatic Nervous System
– Conscious activities
• Autonomic Nervous System
– Connects CNS to visceral organs
– Unconscious activities
– Divided
• Sympathetic nervous system
– Fight or flight
• Parasympathetic nervous system
– Rest & digest
History
•
•
•
•
•
•
Family member present
Vaccination
Major injuries
Childhood illnesses
Family
Present illness
Complaints specific to neurology
• Pain
–
–
–
–
–
–
–
Location
Quality
Severity
Duration
Precipitating factors
Assoc. symptoms
Exasperation / diminished
pain
– Onset
Pain assessment: The 5th vital sign
Headaches
• Multiple causes
• Not a good indicator
of neuro trouble
Vertigo
• Sensation of moving
around in space or
objects moving around
them
Paresthesia
• Definition
– Unusual sensation
• Examples
– Numbness
– Tingling
– Burning
• Assessment
– ? Weak
– ? Intermittent or
constant
Vision Dysfunction
• Diplopia
– Double vision
• Clarity
• Nystagmus
– Eye twitching
Disturbances in…
• Thinking
• Memory
• Personality
Nausea and vomiting
• Projectile
Assessing Cerebral Function - PE
•
•
•
•
•
•
•
Mental status
Intellectual function
Thought content
Emotional status
Perception
Motor ability
Language ability
Level of Consciousness
• Alert
– Open eyes
spontaneously
• Lethargic
– Opens eyes to verbal
stimuli
– Slow to respond, but
appropriate
• Stupor
– Responds to physical
stimuli with moans and
groans
• Semi Comatose
– Responds to painful
stimuli
• Coma
– Unresponsive except
to severe pain
– Absent Protective
reflexes
Types of Stimuli  response
•
•
•
•
•
Voice
Touch
Shaking
Voice + Shaking
Noxious/painful stimuli
Nature of response
•
•
•
•
Eye opens
Remove stimuli
Abnormal posturing
No response
Glasgow Coma Scale
• Eye Opening
–
–
–
–
Spontaneous – 4
To speech – 3
To pain – 2
Nil – 1
Glasgow Coma Scale
• Best Motor Response
–
–
–
–
–
–
Obeys -6
Localizes – 5
Withdraws – 4
Abnormal flexion – 3
Extension response – 2
Nil - 1
Glasgow Coma Scale
• Verbal response
–
–
–
–
Oriented – 5
Confused conversation – 4
Inappropriate words – 3
Incomprehensible sounds –
2
– Nil - 1
Glasgow Coma Scale
A strong predictor of
outcome
 13: mild brain injury
 9-12: Moderate brain
injury
 < 8: Severe brain injury
(coma)
Sample Question
•
The nurse is caring for an adult client who was
admitted unconscious. The initial assessment utilized
the Glasgow Coma Scale. The nurse knows that the
Glasgow Coma Scale is a systemic neurological
assessment tool that evaluates all of the following
EXCEPT
A. Eye opening
B. Motor response
C. Pupillary reaction
D. Verbal performance
What is the lowest score you can get
on the GCS?
A. 0
B. 1
C. 3
D. 5
E. None of the above
What is the highest score you can get
on a GCS?
A. 0
B. 3
C. 13
D. 15
E. None of the above
Orientation
• x3
– Person
– Place
– Time
General Appearance
• How do they look?
–
–
–
–
–
Grooming
Dress
Aids
Eye deviation
Skin
Vital Signs
• Temperature
– With head trauma 
increased
Vital Signs
• Pulse
– Increased ICP 
• Bradycardia
Vital Signs
• Respirations
– Ataxic
• Damage to medulla
– Cheyne-stokes
• Lesion deep in cerebral
cortex
– Hyperventilation
• Metabolic problems
Vital Signs
• Blood Pressure
– Orthostatic
hypotension
• > 20mmHg 
• cerebral ischemia
Vital Signs
• Pulse Pressure formula:
– Systolic – diastolic
120
-----80
=
?
Vital Signs
• Pulse Pressure
180
160
140
120
100
80
60
40
20
0
0
70
0
90
0
0
11
0
0
13
0
0
15
– Systolic – diastolic
120
-----=
40
80
– Normal Pulse pressure
= 40
– Widening pulse
pressure = Increased
ICP
Neuro Checks
• LOC
• Pupils
– PERRLA
•
•
•
•
•
•
Pupils
Equal
Round
Reactive to
Light
Accommodation
Neuro Check
• Pupils
– Anisocoria
• Inequality in the size of
the pupils
– Nystagmus
– Progressive dilation
•  Increase ICP
– Fixed & dilated
• Poor prognosis
Computer Tomography Scan - CT
•
•
X-rays
Distinguishes tissue
density
– Tumors
Computer Tomography Scan - CT
• Nursing Considerations
– Explain procedure
• 30-60 minutes
• Lying still
– If contrast medium is used
• P for iodine & shellfish
allergies
• NPO
• Push fluids after
procedure
• watch for S&S of hICP
Magnetic Resonance Imaging: MRI
Description
•
Magnetic field + radio
waves
•
Used to ID:
–
–
–
Edema
Hemorrhage
Tumors
Magnetic Resonance Imaging: MRI
Nursing Considerations
• Remove all metal
• Relaxation techniques /
• Claustrophobia
• Duration:
– 45-60 min
• Lay flat & motionless
Nervous System
• Controls and
coordinates all parts of
the body
• By transmission of
electrical impulses
Cerebral Cortex / Cerebrum
•
CNS produces electrical waves
Electroencephalography (EEG)
•
Measures electrical
impulses of the brain
–
•
•
Electrodes applied to the
scalp
Used to diagnosis
–
–
–
•
Seizures
Coma
Brain death
Obtain an baseline
–
•
brain waves
Quiet & dark
Stimulation
–
Flashing lights
Electroencephalography (EEG)
• Duration: 1 hour
• h seizures
– sleep deprivation
• Hold meds
–
–
–
–
anti seizure meds
Tranquilizers
Stimulants
depressants
• No caffeine
• OK to eat
Lumbar Puncture
Description
•
Into Subarachnoid space
•
@ L 3-4 level
•
Used to
–
–
–
Extract CSF
Test Spinal fluid pressure
Introduce
•
•
•
antibiotics
dyes
anesthesia
Lumbar Puncture
Nursing Considerations
• Pre-procedure
– Side lying with legs
pulled close to chin
– Do not move
– Painful – pressure
– Shooting pain down
leg
– 10 minutes
Lumbar Puncture
• Post-procedure
– Bed rest
– h Fluid (unless…)
– Observe for S/E
I-ICP
• I-ICP Cycle
–
–
–
–
–
–
I-ICP 
h pressure
i cerebral perfusion 
Ischemia 
h edema 
Death
I-ICP
• Early S&S
– #1 Alt LOC
• h restlessness or
confusion
– H/A
– Pupil changes
– Weakness on one side
I-ICP - Late S&S
• Stupor  coma
• Pulse
–i
• Resp
– i & Erratic
• BP
–h
• Temp
–h
• Projectile vomiting
I-ICP
• Late S&S
– Abnormal posturing
– Loss of protective
reflexes
Goals of I-ICP management
• Decrease the Pressure
–i
edema
I-ICP management
• Decrease Edema
– Osmotic diuretic
I-ICP management
• Decrease edema
– Corticosteroids
• Anti-inflammatory
I-ICP management
• Decreasing edema
– Fluids
• i
– HOB
• h
– Oxygen
• h
Seizures
• Definition
– Abnormal motor,
sensory autonomic or
psychic activity resulting
from sudden excessive
discharge from cerebral
neurons
Seizure video in bed
• http://www.youtube.com/w
atch?feature=player_detailp
age&v=Nds2U4CzvC4
• http://vimeo.com/3428474
• http://www.google.com/url
?url=http://www.healthgur
u.com/content/video/watch
/100663/10_Truths_About_
Epilepsy%3FHG_Google_Vid
eo_Sitemap%3D&rct=j&sa=
X&ctbm=vid&ei=PZbITt7cLs
3diAKU_PzADw&ved=0CGc
QuAIwBDge&q=seizure+ton
ic+clonic&usg=AFQjCNGdre
dGS6dFX9kRopvQ9nC91kBK
rw&cad=rja
Seizures
• Classification
– Partial
– Seizure that begins in one part of the brain
• Simple
– Awareness
– Memory
– Consciousness
Seizures
• Classification
– Partial
• Simple
• Complex
– Loss of
» Awareness
» Memory
» Consciousness
Seizures
• Classification
– Generalized
– Seizure that involves electrical discharges in the whole brain
• Absence Seizure
– Period of staring
• Tonic-Clonic Seizure
Seizures
• Seizure activity
– Tonic Phase
• Rigidity
– Clonic phase
• Jerking
Seizures
• Characteristics
– Post-seizure / postictal
• Recover period
• Deep sleep
Nausea
Weak
Depression
Muscle
soreness
Head
ache
Tired
Seizures
• Medical management
– Anti-convulsants
Seizures
• Nrs Management w/ anticonvulsants
– Do not stop abruptly  seizures
– Monitor levels
– Take regularly
– Alcohol only in moderation
Seizures
• Before Seizure
– At risk for injury
• Padded side rails
• Suction machine in room
Seizures
During a seizure
• Safety
–
–
–
–
–
Ease to floor
Protect the head
Turn to side
Loosen clothing
In bed?
• Remove pillow
• Side rails up
– Do not
• Insert anything in mouth
• restrain
– Stay with pt
• Support client
– Privacy
Seizures
• Observe & document
– 1st
– Movement
– Duration
– Unconsciousness
– Post seizure behavior
Seizures
• After a seizure
– Document
– At risk for Aspiration
• Vomiting
Seizures
–
–
–
–
VS
Check mouth
Clean client
Allow to “sleep it off”
• Post Seizure Nursing care
– Side lying
– Padded side rails
– i stimulation
• Dim lights
• Noise i
Cerebrovascular accident
AKA
• CVA
• Stroke
• Brain attack
CVA: Pathophysiology
• Disruption of blood flow to
part of the brain 
• Ischemia 
• Infarction 
• h ICP
CVA: Common Causes
• Ischemic
– Thrombi
– Emboli
CVA: Etiology
• Hemorrhage
– Rupture of the
cerebral blood
vessel
• D/T:
–HTN
CVA: Risk Factors
Changeable
• Smoking
• Obesity
• HTN
• Sedentary life
• Stress
• h fat diet
• h Na diet
• Substance abuse
• Diabetes mellitus
Non-changeable
• Age
• Gender
• Family history
• Race
CVA: Risk Factors
Which is the most important risk factor for a stroke?
A. Smoking
B. Weight
C. Diet
D. HTN
E. Stress
F. Substance Abuse
CVA: Risk Factors
What is the number one cause of CVA in a younger
patient?
A. Smoking
B. Weight
C. Diet
D. HTN
E. Stress
F. Substance Abuse
CVA: Clinical manifestations
S&S depend on:
1. Location
2. Size
CVA: Clinical Manifestations
•
•
•
•
•
•
•
Alt. LOC
H/A
Aphasia
Seizures
Vision disturb
Labile emotion
Hemiparesis
– Weakness
• Hemiplegia
– Paralysis
Hemorrhagic Stroke
• Usually more severe with a longer recovery
period than ischemic stroke
Hemorrhagic Stroke
• Common Cause
– HTN
CVA: diagnostic findings
• CT / MRI
CVA: Medical Management
Focus on Cause & Control
• #1 cause =
– Hypertension
– Anti-hypertensives
CVA: Rx - HTN
• Beta-blockers
– Action
• Block sympathetic
response
CVA: Medical Management
• Diet
– Sodium
• i
– Fat
• i
– Potassium
• h
– Stimulants
• i
– Fluids
• i
CVA: Medical Management
• Prevent clot formation
– Meds / anticoagulants
CVA: Medical Management
• Prevent clot formation
– Non-Rx
• Ted hose
• ROM
• Isometric exercise
CVA: Medical Management
• Thrombolytic agents
– Action
• Break down thrombi
– S/E
• Hemorrhage
CVA: Medical Management
• Prevent Seizures
– Anti-convulsants
– Precaution
– i stimuli
CVA: Medical Management
•
i ICP
– O2
• h
– Position
• HOB h
– Activity
• Rest
– Meds
• Diuretics
• Glucocorticoids
– Monitor
• BP
CVA: Medical Management
• Nutrition
– NGT
CVA: Medical Management
• Monitor for complications
– VS
– I&O
– Labs
• Na & K
• Glucose
• PT/PTT
– Pulse oximetry
CVA: Medical Management
Prevent complications
• ROM
• Isometric exercise
• Pain Control
CVA: NRS management
Risk for injury
•
•
•
•
r/t seizures
r/t repeat CVA
r/t unilateral neglect
r/t falls
–
–
–
–
–
–
–
–
Padded side rails
Call light
Assist w. amb.
Suction
Items w/in reach
Clear path
H2O temps
Turn & position
• q2hr
CVA: NRS management
Alt. nutrition
•
•
•
r/t impaired swallowing
Motor deficits
Impaired judgment
– SLP
–
–
–
–
–
–
Swallow eval
HOB high fowlers
Straws – no
Thick liquids
Swallow twice
P pocketing food
– Talk & eat – NO
–
–
–
–
Unaffected side of tongue
P gag
Small meals
High texture food
CVA: NRS management
Alt. Mobility
• r/t neuro deficits
– Begin on admit
– Turn q2hr
– ROM
–
–
–
–
–
Splints
Footboards
Built-up utensils
Raised toilet
Exercises
CVA: NRS management
Impaired Communication
• r/t aphasia
–
–
–
–
–
–
SLP
Give the client Time
Anticipate needs
Call bell
Face patient
Eye contact
–
–
–
–
Yes/No ?
ID methods
Gestures
Visual aids
CVA: NRS management
Self-Care Deficit
• Eating
–
–
–
–
Non-skid mats
Stabilizer plates
Plate guards
Wide grip utensils
CVA: NRS management
Self-Care Deficit
• Bathing & Grooming
–
–
–
–
–
–
Long handle sponge
Grab bars
Non-skid mats
Hand held showers
Electric razor
Shower seat
CVA: NRS management
Self-Care Deficit
• Toileting
– Raised seat
– Grab bars
CVA: NRS management
Self-Care Deficit
• Dressing
– Velcro
– Elastic shoelaces
– Long-handle shoehorn
CVA: NRS management
Self-Care Deficit
• Mobility
–
–
–
–
Canes
Walkers
Wheelchair
Transfer devices
CVA: NRS management
Unilateral neglect
• Unaffected side
– Personal items
– Approach
– Door face
TIA: Transient Ischemic Attack
• Short reversible ischemic
event
• Duration
– < 24 hrs
• No permanent neuro
deficit
• Warning!

similar documents