Nursing Care of Clients with Altered Perception PDF

Nursing Care of Clients with Altered Perception mlg  Neurologic Emergencies 1. Traumatic Brain Injury TBI - is physical injury to brain tissue that temporarily or permanently impairs brain function. mlg  Leading Cause of Traumatic...

Nursing Care of Clients with Altered Perception mlg  Neurologic Emergencies 1. Traumatic Brain Injury TBI - is physical injury to brain tissue that temporarily or permanently impairs brain function. mlg  Leading Cause of Traumatic Brain Injury 1. Falls – usually young children and older adults 2. Blunt Force trauma 3. Vehicular-related collisions 65% are the result of car accidents. 15-20% are the result of motorcycle accidents. 10% are from bicycle accidents. mlg  Leading Cause of Traumatic Brain Injury 4. Assaults including child abuse Violence – gunshot wound 5. Others: Sports injuries – soccer, boxing, football or any extreme sports mlg  TBI Severity Occurrence Location Mild Primary Focal Moderate Secondary Diffuse Severe mlg Assessment for Traumatic Brain Injury The Glasgow Coma Scale (GCS) - which is determined when the person first arrives at the hospital. Loss of consciousness (LOC) Post-Traumatic Amnesia (PTA) - which is a state of confusion and memory loss right after a TBI. - PTA occurs because there is an impairment in attention and concentration. mlg  Classification System For Post Traumatic Brain Injury Classification Duration of Glasgow Post- Unconsciousness Coma Scale Traumatic Amnesia Mild < 30 minutes 13 – 15 < 24 hrs. 30 mins – 24 Moderate hrs. 9 – 12 1 – 7 days Severe > 24 hrs. 3-8 > 7 days mlg Signs and symptoms of Mild TBI Loss of consciousness for a few seconds to a few minutes Memory or concentration problems Headaches Dizziness or loss of balance Nausea or vomiting Difficulty sleeping mlg Signs & symptoms of Moderate to Severe TBI Loss of consciousness from several minutes to hours Slurred speech Inability to awaken from sleep Weakness or numbness in fingers and toes Loss of coordination Persistent headache or headache that worsens mlg  Classification according to Occurrence 1. Primary injury is the initial damage to the brain that results from the traumatic event. may include contusions, lacerations, and torn blood vessels from impact, acceleration/deceleration, or foreign object penetration 2. Secondary injury may occur hours or even days after the initial injury and is due primarily to brain swelling or ongoing bleedingmlg Classification according to Occurrence mlg Classification according to Location 1. Focal brain injury – usually due to contact and causing scalp injury, it might present as skull fracture, contusions and or intracranial hemorrhage. mlg Classification according to Location 2. Diffuse brain Injury – usually due to acceleration and concussion resulting in diffuse axonal injury and brain swelling. The tearing of the nerve tissue disrupts the brain’s regular communication metabolic processes. mlg Types of TBI 1. Closed Brain injury – without the skull being broken or penetrated and the brain has not been exposed. Ex: rapid movement of the head backward and forward causes the brain to move inside the skull and slam against its inner bone mlg Types of TBI 2. Open brain injury – open or penetrating head injury - a TBI can be focal or diffuse, meaning damage maybe isolated to one specific area of the brain in focal injuries or widespread in the case of diffuse injuries. mlg 2. Brain Injury The most important consideration in any head injury Even seemingly minor injury can cause significant brain damage due to obstructed blood flow and decreased tissue perfusion. The brain cannot store oxygen and glucose to any significant degree. The cerebral cells need an uninterrupted blood supply to obtain nutrients irreversible brain damage and cell death occur when the blood supply is interrupted for even a few minutes. mlg  3. Cerebral Contusion Contusion is any injury that causes blood to collect under the skin. A more severe injury in which the brain is bruised, with possible surface hemorrhage. The patient is unconscious for few seconds or minutes. Clinical signs and symptoms depend on the size of the contusion and the amount of associated cerebral edema. Often there is involuntary evacuation in bowels and bladder. The patient may lie motionless, v/s are subnormal, cool, pale skin and the picture is somewhat similar to shock. mlg  Cerebral Concussion A concussions are specific to injuries that affect the brain and may not involve visible bruises or any apparent structural damage. This is a temporary loss of neurologic function which involves period of unconsciousness lasting from a few seconds to a few minutes. Concussion effects varied depending on its location and severity. If the brain tissue in the frontal lobe is affected, the patient may exhibit bizarre irrational behavior. Temporal lobe involvement can produce temporary amnesia or disorientation. mlg  4. Intracranial Hemorrhage/Hematomas It is the most serious brain injuries, most common cause of death and clinical deterioration after TBI A hematoma (collections of blood) may be; a. epidural (above the dura) b. subdural (below the dura) c. intracerebral (within the brain) Major symptoms are frequently delayed until the hematoma is large enough to cause distortion of the brain and increased ICP. mlg 5. Epidural Hematoma Extradural Hematoma or Hemorrhage After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura. This can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery, the artery that runs between the dura and the skull inferior to a thin portion of temporal bone. Hemorrhage from this artery causes rapid pressure on the brain. mlg 6. Subdural Hematoma It is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of fluid. The most common cause of subdural hematoma is trauma, but it may also occur from coagulopathies or rupture of an aneurysm. A subdural hematoma may be acute, subacute, or chronic, depending on the size of the involved vessel and the amount of bleeding present. mlg  Management of Brain Injuries Assessment and diagnosis of the extent of injury are accomplished by the initial physical and neurologic examinations. CT Scan, MRI and Positron emission tomography (PET scan) Any individual with a head injury is presumed to have a cervical spine injury until proven otherwise. From the scene of the injury, the patient is transported on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained mlg  Treatment of Increased Intracranial Pressure As the damaged brain swells with edema, a rise in ICP occurs and requires aggressive treatment. Initial management is based on the principle of preventing secondary injury and maintaining adequate cerebral oxygenation. ICP; if increased - elevate the head of the bed, and maintaining normal blood volume. Devices to monitor ICP or drain CSF can be inserted during surgery or at the bedside using aseptic technique. The patient is cared for in the ICU, where expert nursing care and medical treatment are readily available. mlg  Treatment of Increased Intracranial Pressure Surgical Management: Surgery is required for evacuation of blood clots, debridement and elevation of depressed fractures of the skull, and suture of severe scalp lacerations. Medications: Diuretics – given IV to reduce intracranial pressure. Anti-seizure drugs – given during first week to avoid any additional brain damage might caused by seizure. Coma-inducing drugs – sometimes use this drugs to put people into temporary comas because comatose brain needs less oxygen to function. mlg Nursing Management Goal of Nursing Care: Maintain normal physiologic parameters Prevent secondary brain injury Provide emotional and psychological support to patient and families maximize recovery and rehabilitative outcomes mlg Nursing Management Assessment /Monitoring: History Mechanism of injury Pre-existing Medical condition Medications Physical Exam Reflexes Signs of fracture mlg Nursing Management Assessment /Monitoring: Level of consciousness mlg Nursing Management Assessment /Monitoring: Pupils size and reactivity mlg Nursing Management Assessment /Monitoring: Muscle tone and Posturing mlg Nursing Management Assessment /Monitoring: Vital Signs - BP – target SBP > 100mmHg - CVP – (8-10cm H20) - ICP – target is (< 20mmHg) Intake and Output monitoring - Use of Indwelling catheters mlg Nursing Management Respiratory care: Target ABG values - PaO2 > 60mmHg - PaCO2 35 – 45mmHg - pH 7.35 – 7.45 Suctioning Use of PEEP Aspiration precautions mlg Nursing Management Hemodynamic/Fluid Management Avoid Hypotension - Use of Isotonic fluids - Use of Vasoactive drugs Osmotherapy - Use of Mannitol - Use of hypertonic Saline Monitoring of volume status Maintain electrolyte Balance mlg Nursing Management Maintain normothermia and Analgesia Temperature – 35 to 37℃ - Sponge bath - Cooling blanket - Cold saline solution Anti-pyretic medications - Analgesic to avoid increase ICP -Kept at minimum requirement to allow neurologic exam mlg Nursing Management Positioning and Nutrition: Elevate heat of bed at 30 ͦ Head and neck in neutral alignment Ensure ET tube ties, cervical collar do not compress the neck Enteral feeding should be initiated within 72hrs of injury or as prescribed Full caloric requirement must be given Maintain normal blood glucose level mlg Nursing Management Prevention of Complications: Seizure precaution and management Minimize noxious stimuli Prevent secondary Infections - VAP/HAP Prevent pressure injuries - Good skin care and pressure reduction DVT precautions - ROM exercise mlg Nursing Management Rehabilitation and Family Support: Physical Therapy Occupational therapy Speech therapy Cognitive therapy Social worker referral Religious and spiritual support mlg ACUTE ISCHEMIC STROKE mlg  Etiology, Risk Factors, and Pathophysiology Stroke is the layman's term for a cerebrovascular accident. This refers to brain dysfunction that is caused by brain cell damage and death as a result of inadequate blood flow to the brain. Stroke - is a leading cause of death and disability world-wide. mlg  Etiology, Risk Factors, and Pathophysiology Ischemic Stroke The blood clot formation are usually the cause of blockage in blood vessel to the brain that causes ischemic stroke. The affected part no longer receives enough blood or oxygen. Because the brain cannot store oxygen or glucose and therefore requires a constant flow of blood to supply these nutrients. That part of the brain without blood flow dies mlg Etiology, Risk Factors, and Pathophysiology The blood supply to the brain can be altered through several different processes: a. Embolism or thrombus formation accounts for approximately 85% of all ischemic strokes. b. Hemorrhage c. Compression or spasm of the vessels mlg  Etiology, Risk Factors, and Pathophysiology Edema occurs in the area of ischemic or infarcted tissue and contributes to further neuronal cell death. If ischemia is not reversed, neuronal cell death and infarction of brain tissue occurs. The penumbra is an area of tissue that surrounds the core ischemic area. The penumbra receives some blood flow from adjacent vessels but perfusion is marginal. If Cerebral Blood Flow is improved, the penumbra may recover. mlg Risk factors: 1. Hypertension 3. Diabetes 2. Cardiac disease 4. Increased age a. coronary artery disease 5. Male gender b. heart failure 6. Prior stroke c. atrial fibrillation 7. Hypercoagulability d. endocarditis a. cancer e. patent foramen ovale b. pregnancy f. myocardial infarction c. high RBCs, g. carotid artery disease d. sickle cell mlg Risk factors: 8. Family history 9. Dyslipidemia 10. Race (African American) 11. Smoking 12. Obesity 13. Physical inactivity 14. Alcohol or illicit drugs 15. Hormone therapy. mlg  Transient ischemic attack (TIA) This is an important warning sign for stroke. The patient develops stroke symptoms but may resolve without tissue infarction. The pathophysiology of stroke varies based on the precipitating event. Thrombosis and embolism formation result in acute ischemic stroke. mlg  Thrombosis It is the most common cause of ischemic stroke and is usually due to atherosclerosis and the formation of plaque within an artery. Thrombotic comes from thrombus, which is a blood clot A thrombus then forms at the site of the plaque and causes brain tissue ischemia along the course of the affected vessel, which results in infarct if not quickly reversed. mlg  Thrombosis Edema often develops, further increasing ischemia by compressing areas surrounding the infarct. Patients with a history of atherosclerosis or arteritis are at highest risk for thrombotic strokes. Thrombotic strokes tend to develop during periods of sleep or inactivity, or when blood flow is less brisk. mlg  Embolism It refers to the occlusion of a cerebral vessel, most often by a blood clots, infectious particles, fat, air, or tumor fragments. Embolism is often associated with heart disease that results in bacterial vegetations or blood clots that are easily detached from the wall or valves of the heart and then travel to the brain, lodging in a cerebral vessel. mlg  Embolism Chronic atrial fibrillation, valvular disease, prosthetic valves, cardiomyopathy, and atherosclerotic lesions of the proximal aorta are common causes of embolism. The fragmented substance easily lodges at the bifurcation of the middle cerebral artery, breaking apart and traveling further into the cerebral vascular system. The onset of an embolic occlusion is rapid, with symptoms that develop without warning. mlg Clinical Presentation Symptoms of stroke Common signs and symptoms include: 1. weakness in an extremity or on one side of the body 2. sensory changes 3. difficulty speaking or understanding speech 4. facial droop 5. headache 6. visual changes. Clinical presentation of stroke varies based on the area of ischemia or infarction. mlg Diagnostic Tests The goal of initial diagnostic testing in acute stroke is to rule out intracranial hemorrhage (ICH). evidence of ischemia may not appear or may be very subtle on standard CT scanning until 12 to 24 hours after symptom onset. mlg Diagnostic Tests Specialized MRI scan detect areas of ischemia before they are apparent on CT. CT Angiogram - detects areas of vascular abnormalities. Angiogram mlg Management of Acute Ischemic Stroke Stroke is a medical emergency and is treated with the same urgency as acute myocardial infarction. The goals of treatment are to restore circulation to the brain when possible, stop the ongoing ischemic process, and prevent secondary complications. mlg  Management principles include the following: 1. Evaluation of Conditions - that Mimic Acute Ischemic Stroke hypoglycemia may cause stroke-like symptoms and is easily detected by using a bedside monitor to check blood glucose toxic or metabolic disorders migraines seizures mass lesions such as brain tumors or abscesses psychological disorders mlg  Management principles include the following: 2. Fibrinolytic Therapy must be administered to restore perfusion to the affected area IV administration of (rtPA) Recombinant tissue plasminogen activator can be treated within 3 hours of the onset of symptoms recommended dose for rtPA is 0.9 mg/kg, with 10% of the total dose given as a bolus over 1 to 2 minutes followed by the remainder of the dose as an infusion over 1 hour Vital signs and neurologic checks are done every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, and then hourly until 24 hours following initial treatment mlg Management principles 3. Endovascular Treatment 4. Blood pressure management 5. Management of increase intracranial pressure 6. Glucose management 7. Preventing and treating secondary complications 8. Preventing recurrent stroke mlg  TERMINOLOGIES Increased ICP – the pressure inside the skull increases; it is a medical emergency when this occurs suddenly Autonomic dysreflexia - a life-threatening emergency in spinal cord injury patients that causes a hypertensive emergency; also called autonomic hyperreflexia Brain injury - an injury to the skull or brain that is severe enough to interfere with normal functioning Transient ischemic attack – a warning sign of stroke mlg  Brain injury, closed (blunt) - occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura Brain injury, open - occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain mlg  Concussion - a temporary loss of neurologic function with no apparent structural damage to the brain Contusion - bruising of the brain surface Penumbra is an area of tissue that surrounds the core ischemic area Thrombus is a formation of plaque within an artery Embolus refers to the occlusion of a cerebral vessel, most often by a blood clot mlg mlg  Spinal Cord Injury occurs when a force is exerted on the vertebral column, resulting in damage to the spinal cord. Damage to any part of the spinal cord or nerves at the end of the spinal canal often causes permanent changes in strength, sensation and other body functions below the site of the injury. mlg  SCIs can be separated into two categories: 1. Primary injuries - are the result of the initial insult or trauma and are usually permanent. 2. Secondary injuries - are usually the result of a contusion or tear injury, in which the nerve fibers begin to swell and disintegrate. mlg  - ischemia, hypoxia, Primary Secondary edema, hemorrhagic lesions, which in turn injuries injuries result in destruction of myelin and axons These secondary reactions, believed to be the principal causes of spinal cord degeneration at the level of injury, are now thought to be reversible 4 to 6 hours after injury mlg  traumatic blow to the spine causing fractures, dislocation, crushing or compression of one or more of the vertebrae Penetrating gunshot or knife wound Diseases/Conditions: Arthritis, cancer, inflammation, infections or disk degeneration of the spine mlg mlg  Severity Classification: 1. Complete – if all sensory and all motor functions are lost below the spinal cord injury 2. Incomplete – if some motor or sensory functions below the affected area are still present; there are varying degrees of incomplete injury. mlg mlg mlg mlg mlg mlg mlg IMPORTANT! For suspected back or neck injury, DO NOT move the injured person (permanent paralysis and other serious complications may result). Keep the person still. Place heavy towels on both sides of the neck to prevent from moving mlg  Emergency signs and symptoms 1. Extreme back pain or pressure in neck, head or back 2. Weakness, incoordination or paralysis in any part of the body 3. Numbness, tingling or loss of sensation in the hands, fingers, feet or toes 4. Loss of bladder or bowel control 5. Difficulty with balance and walking 6. Impaired breathing after injury 7. An oddly positioned or twisted neck or back mlg mlg mlg mlg Seizure a sudden, abnormal, excessive discharge of electrical activity within the brain that disrupts the brain’s usual system for nerve conduction mlg mlg Classification of Seizure 1. Absence (petit mal) - An absence seizure causes an individual to blank out or stare into space for a few seconds. Absence seizures are most common in children and typically don’t cause any long-term problems. Petit mal mlg Classification of Seizure 2. Atonic - are a type of seizure that causes sudden loss of muscle strength. These seizures are also called akinetic seizures drop attacks or drop seizures. Atonic mlg Classification of Seizure 3. Tonic-Clonic - means sustained rhythmical jerking. During a Clonic seizure, jerking of the body or parts of the body are the main symptom. They can begin in one area (focal motor) or affect both sides of the brain (generalized Clonic). Clonic seizure movements cannot be stopped by restraining the person. mlg Classification of Seizure 4. Myoclonic - are brief shock-like jerks of a muscle or group of muscles. They occur in a variety of epilepsy syndromes that have different characteristics. During a myoclonic seizure, the person is usually awake and able to think clearly. mlg Classification of Seizure 5. Idiopathic (unclassified seizures) - Epileptic seizures are defined as transient signs due abnormal excessive or synchronous neuronal activity in the brain, and epilepsy refers to at least two unprovoked seizures more than 24 hours apart. The term idiopathic means a disease of unknown cause. mlg Diagnostics: 1. Electroencephalography (EEG) – definitive test to diagnose seizure activity 2. SPECT scan – scan of choice for a diagnostic evaluation of certain types of CNS disorders Treatment: 1. Medication therapy – hallmark of seizure management 2. Surgery – respective procedures or palliative corpus callosotomy 3. Seizure precautions 4. Oxygen and suction equipment at bedside 5. Re-orient client upon waking mlg mlg mlg mlg Status Epilepticus potential complication of all types of seizures. This is a seizure that lasts longer than 5 minutes, or more than 1 seizure within a 5-minute period, without returning to normal level of consciousness between episodes. Hence, this is a medical emergency that may lead to permanent brain damage or death. mlg Status Epilepticus Causes: Diagnostic: Stroke EEG Low blood glucose levels CT Too much alcohol, MRI withdrawal symptoms LP mlg Status Epilepticus Principle of Management: Goal: control seizure as quickly as possible, preventing recurrence, maintaining patient safety and identifying the underlying cause. Medications: 1. Lorazepam (Ativan) – induces respiratory depression 2. Flumazenil (Romazicon) – decrease respiratory depression 3. Phenytoin via central venous line 4. Phenobarbital (Luminal) mlg Patient education on DOs ✓Ease the person to the floor. ✓Turn the person gently onto one side. This will help the person breathe. ✓Clear the area around the person of anything hard or sharp. This can prevent injury. ✓Put something soft and flat, like a folded jacket, under his or her head. ✓Remove eyeglasses. ✓Loosen ties or anything around the neck that may make it hard to breathe. ✓Time the seizure. mlg Patient education on DON’Ts 1. Do not hold the person down or try to stop his or her movements. 2. Do not put anything in the person’s mouth. This can injure teeth or the jaw. A person having a seizure cannot swallow his or her tongue. 3. Do not try to give mouth-to-mouth breaths (like CPR). People usually start breathing again on their own after a seizure. 4. Do not offer the person water or food until he or she is fully alert….. mlg References Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis: Elsevier Mosby. pp 504-593 Torregrossa, F. Salli, M., and Grasso, G. (2020 August). Emerging Therapeutic Strategies for Traumatic Spinal Cord Injury, World Neurosurgery, vol. 140. Retrieved from https://www.sciencedirect.com/science/article/pii /S1878875020306707 Centers for Disease Control and Prevention (CDC) (n.d.). https://www.cdc.gov Department of Health (Kagawaran ng Kalusugan). (n.d). https://www.doh.gov.ph Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis: Elsevier Mosby mlg Thank You mlgonzales