Neurological Emergencies PDF

NEUROLOGICAL EMERGENCIES Florence B. Grageda, M.D. Lecturer  NEUROLOGICAL EMERGENCIES § Increase ICP § Traumatic Brain Injury / Traumatic Head Injury § Spinal Cord Injury (SCI) § Spinal Shock /Neurogenic Shcok § Autonomic Dysreflexia § Cerebral Aneurysm § Sei...

NEUROLOGICAL EMERGENCIES Florence B. Grageda, M.D. Lecturer  NEUROLOGICAL EMERGENCIES § Increase ICP § Traumatic Brain Injury / Traumatic Head Injury § Spinal Cord Injury (SCI) § Spinal Shock /Neurogenic Shcok § Autonomic Dysreflexia § Cerebral Aneurysm § Seizure § Stroke  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Skull and spinal radiography § CT Scan § MRI § Lumbar Puncture § Cerebral Angiography § ElectroEncephalography (EEG)  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Skull and spinal radiography § Description § Radiographs of the skull § Spinal radiographs identify; reveals; § Fractures § the size and shape of the § Dislocation skull bones § Compression § suture separation in infants § Curvature § fractures or bony defects § Erosion § Erosion § narrowed spinal cord § calcification. § degenerative processes  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Skull and spinal radiography § Preprocedure interventions § Provide nursing support for the; § Confused § Combative § ventilator-dependent client. § Maintain immobilization of the neck if a spinal fracture is suspected. § Remove metal items from the client. § If the client has thick and heavy hair, this should be documented, because it could affect interpretation of the x-ray film. § Postprocedure intervention: § Maintain immobilization until results are known.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Skull and spinal radiography § Always check with the client about the possibility of pregnancy before any radiographic procedures are done.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Computed Tomography (CT) § A type of brain scanning that may or may not require injection of a dye. § used to detect; § intracranial bleeding § space-occupying lesions § cerebral edema § Infarctions § Hydrocephalus § cerebral atrophy § shifts of brain structures. NEUROLOGICAL EMERGENCIES: Diagnostic Tests § CT Scan § An informed consent is needed for any invasive procedure, including those that use a contrast medium (dye).  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § CT Scan § Preprocedure interventions: § Assess for allergies to iodine, contrast dyes, or shellfish if a dye is used § Assess renal function § Instruct the client of the need to lie still and flat during the test § Instruct the client to hold breath when requested § Initiate an intravenous line with the appropriate gauge size if prescribed  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § CT Scan § Preprocedure interventions: § Remove objects from the head § wigs, barrettes, earrings, and hairpins § Assess for claustrophobia § Inform the client of; § possible mechanical noises as the scanning occurs § there may be a hot, flushed sensation and a metallic taste in the mouth when the dye is injected § Note that some clients may be given the dye even if they report an allergy § they may be treated with an antihistamine and corticosteroids before the injection to reduce the severity of a reaction NEUROLOGICAL EMERGENCIES: Diagnostic Tests § CT Scan § Assess the need to withhold metformin if iodinated contrast dye is used for a diagnostic procedure § lactic acidosis NEUROLOGICAL EMERGENCIES: Diagnostic Tests § CT Scan § Assess the need to withhold metformin if iodinated contrast dye is used for a diagnostic procedure because of the risk for metformin- induced lactic acidosis.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § CT Scan § Postprocedure interventions: § Provide replacement fluids because diuresis from the dye is expected § Monitor for an allergic reaction to the dye § Assess the dye injection site for; § bleeding or hematoma § Monitor the extremity for; § Color § Warmth § presence of distal pulses  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Magnetic Resonance Imaging ( MRI ) § A noninvasive procedure that identifies; § Tissues § Tumors § vascular abnormalities § It is similar to CT scanning but provides more detailed pictures § An informed consent is needed for any invasive procedure, including those that use a contrast medium (dye).  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Magnetic Resonance Imaging ( MRI ) § Preprocedure interventions § Remove all metal objects from the client § Determine whether the client has a; § pacemaker § implanted defibrillator § metal implants such as a hip prosthesis or vascular clips § Insert an intermittent infusion device (saline lock) to all intravenous accesses prior to the procedure (intravenous fluid pumps are not allowed in the MRI room) § Provide precautions for the client who is attached to a pulse oximeter because it can cause a burn during testing if coiled around the body or a body part  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Magnetic Resonance Imaging ( MRI ) § Preprocedure interventions § Provide an assessment of the client with claustrophobia (may not be necessary if an open MRI machine is used) § Administer medication as prescribed for the client with claustrophobia § Determine whether a contrast agent is to be used and follow the prescription related to the administration of food, fluids, and medications § Verify allergies and renal function prior to administration § Instruct the client that he or she will need to remain still during the procedure.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Magnetic Resonance Imaging ( MRI ) § An MRI is contraindicated in a pregnant § Because the increase in amniotic fluid temperature that occurs during the procedure § maybe harmful to the fetus  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Magnetic Resonance Imaging ( MRI ) § Postprocedure intervention: § The client may resume normal activities § Increase fluid intake ??? § expect diuresis if a contrast agent is used.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Lumbar puncture § Insertion of a spinal needle through the L3–L4 interspace into the lumbar subarachnoid space to; § obtain CSF § measure CSF fluid or pressure § instill air, dye, or medications § The test is contraindicated in clients with increased intracranial pressure (ICP) § will cause a rapid decrease in pressure in the CSF around the spinal cord § leading to brain herniation.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Lumbar puncture § Preprocedure Interventions: § Have the client empty the bladder § During the procedure Interventions: § Position the client in a lateral recumbent position and have the client draw the knees up to the abdomen and the chin onto the chest; the prone position may be required for radiologically guided punctures § Assist with the collection of specimens (label the specimens in sequence) § Maintain strict asepsis.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Lumbar puncture § Postprocedure Interventions: § Monitor VS and neurological signs to check for the presence of; § leakage of CSF § monitor for headache § Position the client flat as prescribed § Encourage fluids to replace CSF obtained from the specimen collection or from leakage § Monitor intake and output  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Cerebral Angiography § Injection of a contrast material usually through the femoral artery (or another artery) into the carotid arteries to visualize the cerebral arteries and assess for lesions § Preprocedure interventions § Assess the client for allergies to iodine and shellfish. Assess renal function § Assess for a medication history of anticoagulation therapy; withhold the anticoagulant medication prior to the procedure as prescribed. § Encourage hydration for 2 days before the test  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Cerebral Angiography § Preprocedure interventions § Maintain the client on NPO (nothing by mouth) status 4 to 6 hours before the test as prescribed § Perform a neurological assessment § serves as a baseline for postprocedure assessments § Mark the peripheral pulses § Remove metal items from the hair § Administer premedication as prescribed  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Cerebral Angiography § Postprocedure interventions § Monitor neurological status, vital signs, and neurovascular status of the affected extremity frequently until stable § Monitor for swelling in the neck and for difficulty swallowing; notify a health care provider (HCP) if these symptoms occur § Maintain bed rest for 12 hours as prescribed. d. Elevate the head of the bed 15 to 30 degrees only if prescribed § Keep the bed flat, as prescribed, if the femoral artery is used § Assess peripheral pulses  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Cerebral Angiography § Postprocedure interventions § Apply sandbags or another device to immobilize the limb and a pressure dressingto the injection site to decrease bleeding as prescribed § Place ice on the puncture site as prescribed § Encourage fluid intake.  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Electroencephalography § Graphic recording of the electrical activity of the superficial layers of the cerebral cortex § Preprocedure interventions § Wash the client’s hair § Inform the client that electrodes are attached to the head and that electricity does not enter the head § Withhold stimulants for 24 to 48 hours before the test; § coffee, tea, and caffeine beverages § Antidepressants, tranquilizers § antiseizure medications  NEUROLOGICAL EMERGENCIES: Diagnostic Tests § Electroencephalography § Graphic recording of the electrical activity of the superficial layers of the cerebral cortex § Preprocedure interventions § Allow the client to have breakfast if prescribed § Premedicate for sedation as prescribed § Postprocedure interventions § Wash the client’s hair § Maintain safety precautions, if the client was sedated.  NEUROLOGICAL EMERGENCIES: Neurological Assessment § Assessment of Risk Factors § Trauma § Hemorrhage § Tumors § The most sensitive § Infection indicator of § Toxicity neurological status § Metabolic disorders § Hypoxic conditions § LOC § Hypertension § Cigarette smoking § Stress § Aging process § Chemicals, either ingestion or environmental exposure  NEUROLOGICAL EMERGENCIES: Neurological Assessment § Assessment of Risk Factors § Assessment of Vital Signs § Monitor for BP or pulse changes § indicates inc ICP  NEUROLOGICAL EMERGENCIES: Neurological Assessment § Assessment of Risk Factors § Assessment of Respirations § Cheyne-Stokes § metabolic dysfunction § dysfunction in the cerebral hemisphere or basal ganglia § Neurogenic Hyperventilation § dysfunction in the low midbrain and middle pons § Apneustic § dysfunction in middle or caudal pons § Ataxic § dysfunction in medulla § Cluster § Dysfunction in the medulla and pons  NEUROLOGICAL EMERGENCIES: Neurological Assessment § Assessment of Risk Factors § Assessment of Temperature § An elevated temperature; § increases the metabolic rate of the brain § dysfunction of the hypothalamus or brainstem § A slow rise in temperature § infection  NEUROLOGICAL EMERGENCIES: Neurological Assessment § Assessment of Risk Factors § Assessment of PUPILS:  NEUROLOGICAL EMERGENCIES: Anatomy & Physiology § CPP = § cerebral metabolic need = cerebral blood flow depends on CPP depends on ICP NEUROLOGICAL EMERGENCIES: Anatomy & Physiology  I. Increase ICP § Description § Causes: § Trauma § Hemorrhage § growths or tumors § Hydrocephalus § Results: § Edema § Impedes; § inflammation. § circulation to the brain § absorption of CSF § affect the functioning of nerve cells § brainstem compression § death  I. Increase ICP § the most sensitive and earliest indication of increasing ICP § Altered LOC  I. Increase ICP § Assessment § Abnormal respirations § Rise in blood pressure with widening pulse pressure § Slowing of pulse § Elevated temperature § Vomiting § Pupil changes  I. Increase ICP § Assessment: § Late signs of increased ICP include; § increased systolic BP § widened pulse pressure § slowed heart rate  I. Increase ICP § Assessment: § Other late signs include changes in motor function; § weakness to hemiplegia § a positive Babinski’s reflex § decorticate or decerebrate posturing, and seizures.  I. Increase ICP § Intervention 1. Monitor respiratory status and prevent hypoxia. 2. Avoid the administration of morphine sulfate § to prevent the occurrence of hypoxia. 3. Maintain mechanical ventilation as prescribed; § maintaining the PaCO2 at 30 to 35 mm Hg § vasoconstriction of the cerebral blood vessels § decreased blood flow à decreased ICP 4. Maintain body temperature 5. Prevent shivering § can increase ICP  I. Increase ICP § Intervention 6. Monitor; § electrolyte levels § acid–base balance § I and O 7. Limit fluid intake to 1200 mL/day. 8. Instruct the client to avoid straining activities § coughing § sneezing 9. Instruct the client to avoid Valsalva’s maneuver.  I. Increase ICP Note: § For the client with increased ICP; § elevate the HOB at 30 to 40 degrees § avoid the Trendelenburg’s position § prevent flexion of the neck and hips.  I. Increase ICP § Medications: 1. Antiseizure = Seizure à increase metabolic requirements à cerebral blood flow and volume à increasing ICP = Medications may be given prophylactically to prevent seizures. 2. Antipyretics and Muscle Relaxants = Fever à increases metabolism, cerebral blood flow à increasing ICP. = Antipyretics prevent temperature elevations. = Muscle relaxants prevent shivering.  I. Increase ICP § Medications: 3. Antihypertensive = may be required to maintain cerebral perfusion at a normal level. = notify the PHC provider if the BP < 100 mm Hg systolic or > 150 mm Hg systolic. 4. IV Fluids = via an infusion pump to control the amount administered. = Infusions are monitored closely because of the risk of promoting; ü additional cerebral edema ü fluid overload.  I. Increase ICP § Medications: 5. Corticosteroids § antiinflammatory § stabilize the cell membrane and reduce leakiness of the BBB § decrease cerebral edema § Histamine blocker § counteract the excess gastric secretion that occurs with the corticosteroid § withdraw slowly from corticosteroid therapy to § reduce the risk of adrenal crisis.  I. Increase ICP § Medications: 6. Hyperosmotic Agent = increases IV pressure by drawing fluid from the interstitial spaces and from the brain cells = monitor renal function = diuresis is expected ICF ICF Interstitial fluid ICF ICF Interstitial fluid ICF  I. Increase ICP § Surgical Intervention: VENTRICULOPERITONEAL SHUNT § Description: § diverts CSF from the ventricles to the peritoneum § Postprocedure Interventions: § Position client supine and turn from the back to the nonoperative side § Monitor for signs of increasing ICP resulting from shunt failure § Monitor for signs of infection  II. Traumatic Brain Injury ( TBI ) § Description § Head injury is trauma to the skull, resulting in mild to extensive damage to the brain. § Immediate complications; § cerebral bleeding § Hematomas § uncontrolled increased ICP § Infections § seizures. § Changes in personality or behavior, cranial nerve deficits, and any other residual deficits depend on the area of the brain damage and the extent of the damage.  II. Traumatic Brain Injury ( TBI ) § B. Types of Head Injuries § Open § Scalp lacerations § Fractures in the skull § Interruption of the dura mater  II. Traumatic Brain Injury ( TBI ) § B. Types of Head Injuries: § Closed § Concussions § jarring of the brain § Contusions § bruising type of injury to the brain tissue § Fractures  II. Traumatic Head Injury § C. Hematoma § A collection of blood in the tissues that can occur as a result of a subarachnoid hemorrhage or an intracerebral hemorrhage § Assessment: § Assessment findings depend on the injury. § Clinical manifestations usually result from increased ICP. § Changing neurological signs in the client § Changes in LOC § Airway and breathing pattern changes § VS change, reflecting increased ICP  II. Traumatic Head Injury § Hematoma § Assessment: § Headache, N/V § Visual disturbances, pupillary changes, and papilledema § Nuchal rigidity § not tested until spinal cord injury is ruled out § CSF drainage from the ears or nose § Weakness and paralysis § Posturing § Decreased sensation or absence of feeling § Reflex activity changes § Seizure activity  II. Traumatic Head Injury § CSF can be distinguished from other fluids § presence of concentric rings § bloody fluid surrounded by yellowish stain; § halo sign § CSF also tests positive for glucose when tested using a strip test.  II. Traumatic Head Injury § Interventions: § Monitor; § respiratory status and maintain a patent airway § increased carbon dioxide (CO2) levels à increase cerebral edema § Neuro status and VS, including temperature. § increased ICP § Maintain head elevation § to reduce venous pressure § Prevent neck flexion.  II. Traumatic Head Injury § Interventions: § Initiate seizure precautions. § Monitor for pain and restlessness. § Morphine sulfate § to decrease agitation and control restlessness caused by pain for the head-injured client on a ventilator § administer with caution § it is a respiratory depressant à may increase ICP § Monitor for drainage from the nose or ears § fluid may be CSF  II. Traumatic Head Injury § Do not attempt to clean the nose, suction, or allow the client to blow her or his nose if drainage occurs § Do not clean the ear if drainage is noted § apply a loose, dry sterile dressing § Check drainage for the presence of CSF § Notify the PHCP if drainage from the ears or nose is noted and if the drainage tests positive for CSF II. Traumatic Head Injury § Instruct the client to avoid coughing § increases ICP § Monitor for signs of infection. § Prevent complications of immobility. § Inform the client and family about the possible behavior changes  III. Spinal Cord Injury (SCI) § Description: § Trauma to the spinal cord § Causes; § partial § complete disruption of the nerve tracts and neurons § Involves; § Contusion § Laceration § compression of the cord  III. Spinal Cord Injury (SCI) § Causes: § motor vehicle crashes § Falls § sporting and industrial accidents § gunshot or stab wounds § Result: § Spinal cord edema § compromised capillary circulation and venous return § SC necrosis  III. Spinal Cord Injury (SCI) § Sequela: § Loss of; § motor function § Sensation reflex activity § bowel and bladder control § Complications: § respiratory failure § autonomic dysreflexia § spinal shock § further cord damage § death III. Spinal Cord Injury (SCI) III. Spinal Cord Injury (SCI) § Most frequently involved vertebrae § C5, C6 and C7 § T 12 § L1  III. Spinal Cord Injury (SCI) § Spinal Cord Syndromes: § Anterior cord Syndrome § damage to the anterior portion of the gray and white matter of the spinal cord § Motor function, pain, and temperature sensation § lost below the level of injury § sensations of position, vibration, and touch § remain intact § Spinal Cord Syndromes: III. Spinal Cord Injury (SCI) § Brown - Sequard Syndrome § Results from penetrating injuries that cause hemisection of the spinal cord or injuries that affect half of the cord § Contralateral § Loss of nociceptive & thermal sensations below the level of lesion § Ipsilateral § Loss of discriminative tactile, vibratory, and position sense below level of lesion § Ipsilateral § Paralysis of the leg or leg and arm, depending on level of hemisection III. Spinal Cord Injury (SCI) Cervical injuries Injury at; C2 to C3 fatal C4 major innervation to the diaphragm by the phrenic nerve III. Spinal Cord Injury (SCI) Cervical injuries Injury at; above C4 respiratory difficulty paralysis of all four extremities C5 and C7 movement in the shoulder decrease respiratory reserve.  III. Spinal Cord Injury (SCI) § Thoracic level injuries § Loss of movement of the chest, trunk, bowel, bladder, and legs may occur, depending on the level of injury § Paraplegia § Autonomic dysreflexia § lesions or injuries above T6 and in cervical lesions may occur § Visceral distention from noxious stimuli such as a distended bladder or an impacted rectum may cause reactions such as sweating, bradycardia, hypertension, nasal stuffiness, and goose flesh. III. Spinal Cord Injury (SCI) § Lumbar and Sacral level injuries § Loss of movement and sensation of the lower extremities may occur § S2 and S3 center on micturition § below this level, the bladder will contract but not empty (neurogenic bladder) § Injury above S2 in males § SNS nerve damage § (+) erection § (-) ejaculation § Injury between S2 and S4 § SNS and PNS damage § (-) erection § (-) ejaculation  III. Spinal Cord Injury (SCI) § Always suspect SCI when trauma occurs until this injury is ruled out. § Immobilize the client on a spinal backboard with the head in a neutral position § to prevent an incomplete injury from becoming complete.  III. Spinal Cord Injury (SCI) § Emergency Interventions: § Emergency management is critical § improper movement can cause further damage and loss of neurological function § Assess the respiratory pattern and maintain a patent airway § Prevent head flexion, rotation, or extension § During immobilization § maintain traction and alignment on the head by placing hands on both sides of the head by the ears  III. Spinal Cord Injury (SCI) § Emergency Interventions: § Maintain an extended position § Logroll the client § No part of the body should be twisted or turned, and the client is not allowed to assume a sitting position § In the ER, a cervical fracture should be placed immediately in skeletal traction via skull tongs or halo traction § to immobilize the cervical spine and reduce the fracture and dislocation  IV. Spinal and Neurogenic Shock § Spinal Shock § A complete but temporary loss of motor, sensory, reflex, and autonomic function that occurs immediately after injury as the cord’s response to the injury § usually lasts less than 48 hours but can continue for several weeks § Neurogenic Shock § occurs most commonly in clients with injuries above T6 and usually is experienced soon after the injury § Massive vasodilation occurs, leading to; § pooling of the blood in blood vessels § tissue hypoperfusion § impaired cellular metabolism.  IV. Spinal and Neurogenic Shock § Assessment: § Neurogenic Shock § Hypotension § Bradycardia § Spinal Shock § Flaccid paralysis § Loss of reflex activity below the level of the injury § Bradycardia § Hypotension § Paralytic ileus  IV. Spinal and Neurogenic Shock § Interventions: § Monitor for; § signs of shock following a spinal cord injury § hypotension and bradycardia § reflex activity § Bowel and urinary retention § Return of reflexes § Assess bowel sounds § Provide supportive measures as prescribed, based on the presence of symptoms  V. Autonomic Dysreflexia § Description: § Also known as autonomic hyperreflexia § It generally occurs; § after the period of spinal shock is resolved § injuries above T6 and in cervical lesions § Triggers; § visceral distention § distended bladder or § impacted rectum § It is a neurological emergency § Sequela: § hypertensive stroke  V. Autonomic Dysreflexia § Assessment: § Sudden onset § severe throbbing headache § Severe hypertension and bradycardia § Flushing above the level of the injury § Pale extremities below the level of the injury § Nasal stuffiness § Nausea § Dilated pupils or blurred vision § Sweating § Piloerection (goose bumps) § Restlessness and a feeling of apprehension  V. Autonomic Dysreflexia q Nursing Priority Actions: 1. Raise the HOB and ask that the health care provider (HCP) be notified 2. Loosen tight clothing on the client 3. Check for bladder distention or other noxious stimulus 4. Administer an antihypertensive medication 5. Document the occurrence, treatment, and response.  VI. Cerebral Aneurysm § Description: § Dilation of the walls of a weakened cerebral artery; can lead to rupture § Assessment 1. Headache and pain 2. Irritability 3. Visual changes 4. Tinnitus 5. Hemiparesis 6. Nuchal rigidity 7. Seizures  VI. Cerebral Aneurysm § Description: § Interventions 1. Maintain a patent airway (suction only with an HCP’s prescription) 2. Administer oxygen as prescribed 3. Monitor vital signs and for hypertension or dysrhythmias 4. Avoid taking temperatures via the rectum 5. Initiate aneurysm precautions  VI. Cerebral Aneurysm § Aneurysm Precautions: § Maintain the client on bed rest in a semi-Fowler’s or a side-lying position. § Maintain a darkened room (subdued lighting and avoid direct, bright, artificial lights) without stimulation (a private room is optimal) § Provide a quiet environment (avoid activities or startling noises); a telephone in the room is not usually allowed § Reading, watching television, and listening to music are permitted, provided that they do not overstimulate the client § Limit visitors § Maintain fluid restrictions § Provide diet as prescribed; avoid stimulants in the diet.  VI. Cerebral Aneurysm § Aneurysm Precautions: § Prevent any activities that initiate the Valsalva maneuver § straining at stool § coughing § Provide stool softeners to prevent straining § Administer care gently (such as the bath, back rub, range of motion) § Limit invasive procedures § Maintain normothermia § Prevent hypertension § Provide sedation § Provide pain control § Administer prophylactic antiseizure medications § Provide deep vein thrombosis (DVT) prophylaxis as prescribed.  VII. Seizures § Description: § Seizures § abnormal, sudden, excessive discharge of electrical activity within the brain. § Epilepsy § chronic seizure activity § indicates brain or CNS irritation.  VI. Seizures § Description: § Causes: § genetic factors § Trauma § Tumors § Hypoglycemia § Toxicity § infections. § Status epilepticus § rapid succession of epileptic spasms without intervals of consciousness § a potential complication § brain damage  VII. Seizures § Assessment: § Seizure history § Type of seizure § Occurrences before, during, and after the seizure § Prodromal signs, such as mood changes, irritability, and insomnia § Aura: Sensation that warns the client of the impending seizure § Loss of motor activity or bowel and bladder function or loss of consciousness during the seizure § Occurrences during the postictal state, such as headache, loss of consciousness, sleepiness, and impaired speech or thinking  VII. Seizures § Types of Seizures: § Tonic-Clonic § may begin with an aura § Tonic phase § involves the stiffening or rigidity of the muscles of the arms and legs § usually lasts 10 to 20 seconds, followed by loss of consciousness § Clonic phase § hyperventilation and jerking of the extremities § lasts about 30 seconds § Full recovery may take several hours  VII. Seizures § Types of Seizures: § Absence § A brief seizure that lasts seconds § may or may not lose consciousness § No loss or change in muscle tone occurs § may occur several times during a day § victim appears to be daydreaming § more common in children § Myoclonic Myoclonic § a brief generalized jerking or stiffening of extremities § victim may fall from the seizure  VII. Seizures § Types of Seizures: § Partial Seizure § Simple Partial § produces sensory symptoms accompanied by motor symptoms that are localized or confined to a specific area. The client remains conscious and may report an aura. § Complex Partial § is a psychomotor seizure. § The area of the brain most usually involved is the temporal lobe. § The seizure is characterized by periods of altered behavior of which the client is not aware. § The client loses consciousness for a few seconds. Seizures § Interventions: § If the client is having a seizure, maintain a patent airway. § Do not force the jaws open or place anything in the client’s mouth  VII. Seizures § Interventions: 1. Note the time and duration of the seizure 2. Assess behavior at the onset of the seizure: ü if the client has experienced an aura ü if a change in facial expression occurred ü if a sound or cry occurred from the client. 3. If the client is standing or sitting, place the client on the floor and protect the head and body. 4. Support Airway, Breathing, and Circulation. 5. Administer oxygen.  VII. Seizures § Interventions: 6. Prepare to suction secretions. 7. Turn the client to the side to allow secretions to drain while maintaining the airway. 8. Prevent injury during the seizure. 9. Remain with the client. 10. Do not restrain the client. 11. Loosen restrictive clothing. 12. Note the type, character, and progression of the movements during the seizure. § Interventions: VII. Seizures 13. Monitor for incontinence. 14. Administer IV anti seizure. 15. Document the characteristics of the seizure. 16. Provide privacy. 17. Monitor behavior following the seizure, such as the state of consciousness, motor ability, and speech ability. 18. Instruct the client about the importance of lifelong medication and the need for follow-up determination of medication blood levels. 19. Instruct the client to avoid alcohol, excessive stress, fatigue, and strobe lights. 20. Encourage the client to wear a MedicAlert bracelet.  VIII. Stroke ( Brain Attack ) § Description: 1. A sudden focal neurological deficit and is caused by cerebrovascular disease. 2. Cerebral anoxia lasting longer than 10 minutes ü causes cerebral infarction with irreversible change. 3. Cerebral edema and congestion cause further dysfunction. 4. Diagnosis; ü CT scan ü Electroencephalography ü cerebral arteriography ü MRI 5. Transient ischemic attack ( TIA ) ü a warning sign of an impending stroke.  VIII. Stroke ( Brain Attack ) § Description: 6. The permanent disability cannot be determined until the cerebral edema subsides. 7. The order in which function may return ; ü Facial ü Swallowing ü lower limbs ü Speech ü arms. 8. Carotid endarterectomy = a surgical intervention used in stroke management = targeted at stroke prevention, especially in clients with symptomatic carotid stenosis. § Causes: VIII. Stroke ( Brain Attack ) 1. Ischemic Stroke § Thrombosis § Embolism 2. Hemorrhagic stroke § from rupture of a vessel q Manifestations of different types of stroke are similar ü it is critical to determine the type of stroke occurring ü type cannot be determined solely based on manifestations ü the correct and appropriate treatment for the stroke type must be initiated.  VIII. Stroke ( Brain Attack ) § Risk Factors: 1. Atherosclerosis 2. Hypertension 3. Anticoagulation therapy 4. Diabetes mellitus 5. Stress 6. Obesity 7. Oral contraceptives  VIII. Stroke ( Brain Attack ) § Assessment: q A critical factor in the early intervention and treatment of stroke; ü accurate identification of stroke manifestations ü establishing the onset of the manifestations. q Stroke screening scales may be used to identify stroke manifestations quickly. q Identification of the type of stroke ü critical in determining the appropriate treatment ü done using a CT scan.  VIII. Stroke ( Brain Attack ) § Clinical Manifestations of Stroke Based on Type: Type Thrombotic Stroke Embolic Stroke Hemorrhagic Stroke Typically, there is no decreased Sudden, severe symptoms Sudden onset of symptoms level of consciousness within the first 24 hours. Symptoms get progressively Warning signs are less Symptoms progress over worse as the infarction and common. minutes to hours due to edema increase. ongoing bleeding Client remains conscious and may have a headache.  VIII. Stroke ( Brain Attack ) § Assessment: § depend on the area of the brain affected § Lesions in the cerebral hemisphere result in manifestations on the contralateral side § Nursing priority § airway § Pulse (may be slow and bounding) § Respirations (Cheyne-Stokes) § Hypertension § Headache, nausea, and vomiting  VIII. Stroke ( Brain Attack ) § Assessment: § Facial drooping § Nuchal rigidity § Visual changes § Ataxia § Dysarthria § Dysphagia § Speech changes § Decreased sensation to pressure, heat, and cold § Bowel and bladder dysfunctions § Paralysis  VIII. Stroke ( Brain Attack ) § Aphasia: § Expressive § Damage occurs in Broca’s area of the frontal brain. § The client understands what is said but is unable to communicate verbally. § Receptive § Injury involves Wernicke’s area in the temporoparietal area. § The client is unable to understand the spoken and often the written word. § Global or mixed: § Language dysfunction occurs in expression and reception.  VIII. Stroke ( Brain Attack ) § Aphasia: Intervention § Provide repetitive directions. § Break tasks down to 1 step at a time. § Repeat names of objects frequently used. § Allow time for the client to communicate. § Use a; § picture board § communication board § computer technology.  VIII. Stroke ( Brain Attack ) § Intervention: Acute Phase § Maintain a patent airway and administer oxygen as prescribed. § Monitor VS § Usually a BP of 150/100 mm Hg § maintained to ensure cerebral perfusion. § Suction secretions § to prevent aspiration as prescribed § never suction nasally or for longer than 10 seconds § to prevent increased ICP. § Monitor for increased ICP § most at risk during the first 72 hours following the stroke. § Position the client on the side to prevent aspiration, with HOB elevated 15 to 30 degrees as prescribed.  VIII. Stroke ( Brain Attack ) § Intervention: Acute Phase § Monitor LOC, pupillary response, motor and sensory response, cranial nerve function, and reflexes. § Maintain a quiet environment. § Insert a urinary catheter as prescribed. § Administer IV as prescribed. § Maintain fluid and electrolyte balance. § Prepare to administer; § Anticoagulants § Antiplatelets § Diuretics § Antihypertensives § Antiseizure § Establish a form of communication.  VIII. Stroke ( Brain Attack ) § Intervention : Postacute phase § Continue with interventions from the acute phase. § Position: § 2 hours on the unaffected side § 20 minutes on the affected side § the prone position may also be prescribed. § Provide skin, mouth, and eye care. § Perform passive ROM exercises § to prevent contractures. § Place antiembolism stockings on the client § remove daily to check skin. § Monitor the gag reflex and ability to swallow.  VIII. Stroke ( Brain Attack ) § Intervention : Postacute phase § Provide sips of fluids and slowly advance diet to foods that are easy to chew and swallow. § Provide diet that is ; § soft and semisoft foods § flavored § cool or warm § thickened fluids § stroke client can tolerate these types of food better § Eating position; § in a chair or sitting up in bed § with the head and neck positioned slightly forward and flexed. § Place food in the back of the mouth on the unaffected side § to prevent trapping of food in the affected cheek.  VIII. Stroke ( Brain Attack ) § Intervention : Chronic phase § Neglect syndrome ü The client is unaware of the existence of his or her paralyzed side (unilateral neglect), which places the client at ü risk for injury. ü Teach the client to touch and use both sides of the body.  VIII. Stroke ( Brain Attack ) § Intervention : Chronic phase § Hemianopsia ü The client has blindness in half of the visual field. ü Homonymous hemianopsia ü is blindness in the same visual field of both eyes. ü Encourage the client to turn the head to scan the complete range of vision; otherwise, he or she does not see half of the visual field  VIII. Stroke ( Brain Attack ) § Intervention : Chronic phase § Approach the client from the unaffected side. § Place the client’s personal objects within the visual field. § Provide eye care for visual deficits. § Place a patch over the affected eye if the client has diplopia. § Increase mobility as tolerated. § Encourage fluid intake and a high-fiber diet. § Administer stool softeners as prescribed. § Encourage the client to express her or his feelings. § Encourage independence in ADL.  VIII. Stroke ( Brain Attack ) § Intervention : Chronic phase § Assess the need for assistive devices § Cane § Walker § Splint § braces. § Teach transfer technique from bed to chair and from chair to bed. § Provide gait training. § Initiate physical and occupational therapy for assessment and the need for adaptive equipment or other supports for self-care and mobility. § Refer client to a speech and language pathologist as prescribed.