Neurological Content Part 2 MS II 2013 Objectives

Neurological Content Part 2 MS II 2013

Objectives • Describe the etiology and pathophysiology of selected neurologic disorders. • Identify the clinical manifestations of selected neurologic disorders. • Explain the treatment of selected neurologic disorders. • Discuss the nursing priorities for managing a patient with selected neurologic disorders. MS II Neuro Presentation 2

Neurologic Disorders • This chapter explores the most common critical care neurologic disorders as follows: – Etiology – Pathophysiology – Assessment – Diagnosis – Medical Management – Nursing Management MS II Neuro Presentation 3

Coma • Description – Coma is a state of unconsciousness • Both arousal and awareness are lacking • Light coma • Deep coma • Coma is a symptom not a disease • Need to discover underlying etiology MS II Neuro Presentation 4

Coma • Etiology: • Structural Lesions / Metabolic – Vascular Lesions, Trauma, Brain Tumors, Abscesses, Increased ICP – Overdoses, infections, endocrine, poisioning MS II Neuro Presentation 5

Coma • Etiology: Metabolic and Toxic Conditions – Cardiopulmonary Decompensation – Poisoning and Alcohol – Hypertensive Encephalopathy – Acute Hypertensive Crisis – Meningitis – Encephalitis – Post-convulsion and Other MS II Neuro Presentation 6

Coma • Pathophysiology – Diffuse dysfunction in cerebral hemispheres – Diffuse or focal dysfunction in the reticular activating system (RAS) – Cerebral insults including: • ischemia, infection, hypoxia, metabolic imbalance, toxic exposure, structural disruption – Comparable to stages of anesthesia MS II Neuro Presentation 7

Coma • Assessment and Diagnosis – Diagnosis is clinical, based on LOC – Neurological clinical assessment – Diagnostic procedures: • Skull x-rays, CT, MRI, LP • Lab studies to rule out toxic or endocrine states MS II Neuro Presentation 8

Coma • Medical Management – Goal: identify and treat underlying cause – Initial Management: • Support vital functions: – Airway, ventilation, CV function • Prevent further neurologic deterioration • If cause of coma not known administer: – Thiamine – Glucose – Narcotic agonist MS II Neuro Presentation 9

Coma • Medical Management – Decision making with family – Prognosis depends upon cause of coma – Best prognosis seen with early arousal MS II Neuro Presentation 10

Coma �Nursing Management �Eye care �Temperature Control �Coma stimulation therapy �Monitoring for neurologic changes �Nutrition �Skin care �Prevention of infection �Maintenance of a clear airway MS II Neuro Presentation 11

Ineffective airway clearance • Assess – high risk for airway obstruction due to: ______________ • _________________ • Inability to remove secretions-_____ • _________________ • Risk for atelectasis, pneumonia, aspiration, hypoxia MS II Neuro Presentation 12

Airway - Interventions �Positioning ___________ �__________ �Suctioning �__________ �Oxygenation___________ �Pulmonary hygiene- MS II Neuro Presentation 13

Risk of Injury or Altered Protection • Padded side rails • Make sure IV lines, drains are not causing pressure areas • Meticulous skin care MS II Neuro Presentation 14

Risk for injury • Dignity – Provide privacy – Speak to the patient during care – Avoid negative comments about the patient’s condition – Advocate for the patient – Do not carry on personal conversations around the patient MS II Neuro Presentation 15

Risk for injury • Avoid restraints • If needed – Physician’s order and evaluation should be done – Any form of restraint will probably provoke resistance from the patient MS II Neuro Presentation 16

Fluid volume deficit • Assess hydration__________ • __________ • IV fluids • Management of a gastrostomy tube • Special consideration needed!!!! r/t IV fluids or blood transfusions__________ MS II Neuro Presentation 17

Impaired Oral Cavity • Assess mouth for dryness/inflammatio n/ and crusting • Provide meticulous oral care • Risk of parotitis • Keep lips moist/apply lubricant MS II Neuro Presentation 18

Risk for impaired skin • • • Regular turning Positioning Use splints/foam boots/trochanter rolls Attention to heels Apply early – air mattresses/specialty beds MS II Neuro Presentation 19

Bowel incontinence • • • r/t neuro impairment & nutritional transitions Assessment - _____________________________ Problems - ______________________________ MS II Neuro Presentation 20

Bowel Care • Monitor _____ and ______ • Perform ______ examinations to assess for ____________ • Administer medications • Stool softeners • Glycerine suppository • enemas MS II Neuro Presentation 21

Impaired tissue integrity of cornea �r/t absent corneal reflex or diminished reflex �Assess for incomplete eye closure �Interventions – �Cleanse with cotton balls/sterile NS �Artificial tears q 2 h �Cold compresses �Avoid eye patches MS II Neuro Presentation 22

Ineffective thermoregulation r/t hypothalamic damage • • Monitor for high fevers Assess underlying cause and treat Common causes. Mild temperature elevations-99 to 100____ Moderate – 100 – 102 -________ High – 102 and above-________ Method of temperature monitoring-_____ MS II Neuro Presentation 23

Secondary Complications • • • Diabetes Insipidus. What s/s would be watched for- _____________________ SIADH-_______ What s/s would be watched for -______________________________ MS II Neuro Presentation 24

Disturbed sensory perception Interventions Maintain sense of daily rhythm _________________ Stimulation – nurse and family establish pattern of _____ and ______ • Quality time at bedside – conversation, reading books, music, aroma therapy • • MS II Neuro Presentation 25

Disturbed sensory perception Lightening of coma Period of agitation normal Good clinical sign Educate family members about this occurrence and significance • Patient will be more aware, but still may be unable to communicate or react appropriately • • MS II Neuro Presentation 26

Disturbed sensory perception Interventions Support and protect client Reorient patient Provide paper materials for reorientation Minimize stimulation – limit visitor to one at a time • Allow patient time to respond to verbal stimuli • • • MS II Neuro Presentation 27

Disturbed sensory perception • Client that is regaining consciousness • Allow frequent rest and quiet times • Videotapes of social events and family times are useful for patient remember family members, friends, and regain missed events MS II Neuro Presentation 28

Interrupted family processes • Assess needs/emotional state/coping ability • Expect stages of grief and anxiety, remorse • Prepare family, friends for patient status during recovery, and non-curable deficits that will have to be dealt with. MS II Neuro Presentation 29

Brain herniation • Cause of brain death • Patient maintained on life support • Assess for organ donation possiblity • Clue with ICP monitoring – pressures will decrease suddenly MS II Neuro Presentation 30

Brain death • Confusing to significant others – Patient still has blood pressure, pulse, and some bodily functions – Definition – irreversible loss of all functions of the brain including brain stem. – This patient will have mechanical ventilation, drugs to maintain blood pressure MS II Neuro Presentation 31

Stroke (All Causes) • Description – Acute neurological deficit for > 24 hours – Caused by interruption of blood flow to brain – 3 rd leading cause of death in USA �Ischemic �Hemorrhagic �Subarachnoid hemorrhages (SAHs) �Intracerebral hemorrhages (ICHs) MS II Neuro Presentation 32

Stroke • Pathophysiology – “Brain Attack” like “Heart Attack” – Core of ischemic cells - may infarct – Marginally perfused ischemic penumbra – Relevant history • TIA • RIND MS II Neuro Presentation 33

Transient Ischemic Attacks �Transient or temporary episode of neurologic dysfunction, commonly m/b sudden loss of motor, sensory, or visual function. �Duration: few seconds to minutes, but no longer than 24 hours �Complete recovery usually occurs between attacks MS II Neuro Presentation 34

TIA • Warning sign of impending stroke • Cause: temporary impairment of blood flow to a specific region of the brain due to atherosclerosis of the vessels, obstruction of cerebral microcirculation by a small embolus, decrease in cerebral perfusion pressure, cardiac dysrhythmias MS II Neuro Presentation 35

TIA • Warning sign of impending stroke • Cause: temporary impairment of blood flow to a specific region of the brain due to atherosclerosis of the vessels, obstruction of cerebral microcirculation by a small embolus, decrease in cerebral perfusion pressure, cardiac dysrhythmias MS II Neuro Presentation 36

TIA s/s correlating with location • Amaurosis fugax(fleeting blindness), occurs without warning, sudden painless loss of vision of one eye or dimming or graying out of the field of vision of one eye signifies retinal ischemia. (insufficency of homolateral ophthalmic or carotid artery) • Vertebral basilar system: vertigo, diplopia, disturbances in LOC, numbness extremeties MS II Neuro Presentation 37

Medical Management - TIA • Anticoagulant therapy – Coumadin • Platelet inhibiting medication – Plavix – Aspirin MS II Neuro Presentation 38

TIA Management - Surgical �Carotid Endarectomy: removal of an atherosclerotic plaque or thrombus from the carotid artery. �Nursing care s/p CE: Neuro checks q 1 h, q 15 min immed. Post op. Neuro deficits such as hemiparesis may signify thrombus formation at the site of the endarectomy MS II Neuro Presentation 39

Stroke • Pathophysiology – Cerebral edema – Intracranial hypertension – Complications • Secondary hemorrhage • Seizures – Difference between “Focal” vs. “Global” insult MS II Neuro Presentation 40

Pathophysiology of CVA • Non-hemorrhagic – Thrombosis – Cerebral embolism – ischemia • Hemorrhagic – Rupture of a cerebral blood vessel with bleeding into the tissue, or spaces surrounding the brain MS II Neuro Presentation 41

Ischemic Stroke • Etiology – Occlusion of a cerebral blood vessel • Embolic • Thrombotic – Strokes are preventable • Thrombotic (Atherosclerotic disease) – Hypertension / Diabetes / Elevated blood lipids • Embolic – Cardiac valve disease / Atrial fibrillation MS II Neuro Presentation 42

Ischemic Strokes �Large artery thrombotic strokes �Small penetrating artery thrombotic strokes �Cardiogenic embolic strokes �Cryptogenic MS II Neuro Presentation 43

Characteristic sign of Ischemic Stroke • Sudden onset of focal neurological signs lasting for more than 24 hours • Location Clue: Brain stem or cerebellar involvement may cause • Seizures • (Will occur within 24 hours of insult) • Hypoxia • With Symptoms such as stupor, coma, confusion agitation MS II Neuro Presentation 44

Hemorrhagic Strokes • Bleeding into brain tissue • Causes A-V Malformation SAH Aneursym Rupture Anticoagulants, amphetamines – Uncontrolled hypertension – – MS II Neuro Presentation 45

Stroke (Cont. ) • SAH (Cont. ) – Medical management • Rebleeding • Surgical

Stroke (Cont. ) • SAH (Cont. ) – Medical management (Cont. ) • Surgical

Stroke (Cont. ) • SAH (Cont. ) – Medical management (Cont. ) • Cerebral vasospasm – Hypertensive, hypervolemic, hemodilution (HHH) therapy – Nimodipine Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 48

Hemorrhagic Strokes • Epidural • Bleeding causes acute displacement of brain tissue • Tear of the middle artery/meningeal artery • Must be treated within hours for survival • Subdural • Slower onset – bridging vein is torn • Most common cause is a leaking aneurysm of the brain • Longer lucid interval till neurological deficit occurs MS II Neuro Presentation 49

Stroke (Cont. ) ICH (Cont. ) Ø Medical management Airway, breathing, and circulation management Arterial blood pressure regulation Vasopressor therapy Fluid management Surgical clot removal Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 50

Stroke (Cont. ) • Nursing management – Monitoring for changes in neurologic and hemodynamic status – Maintaining surveillance for complications • Bleeding and vasospasm • Increased ICP Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 51

Assessment – Stroke Scale • Developed by the national Institutes of health • Tool to develop a score to determine the degree of neurological hit • The higher the score the greater the insult MS II Neuro Presentation 52

Determination of Stroke throught Diagnostics • Non-contrast CT • If that is negative stroke scale is used to determine if patient is used for clinical assessment • LP will be used if the patient has the symptoms of sub-arachnoid hemorrhage. If CT scan is negative • Big, Big headache will be involved which is usually not present in ischemic strokes. MS II Neuro Presentation 53

Neurologic Deficits - Stroke • Homonymous Hemianopsia • Peripheral Vision Loss • Diplopia • Paresthesia • • Hemiparesis Ataxia Hemiplegia Dysarthria Aphasia Expressive Receptive MS II Neuro Presentation 54

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Minimizing complications after stroke has occurred • Cerebral Hypoxia • Adequate oxygenation – Supplemental oxygen to maintain sat 92% or greater – Maintain hemoglobin/hematocrit within normal limits MS II Neuro Presentation 57

Minimizing Complications • Maintain cerebral perfusion – Related to blood pressure, cardiac output and integrity of the cerebral blood vessels – Adequate hydration – Extremes of hypertension/hypotension should be avoided. MS II Neuro Presentation 58

Thrombolytic therapy • Who qualifies – • Things to know • Must be given within 3 hours of the onset of neurologic symptoms • Why three hour time period? MS II Neuro Presentation 59

Administration of TPA Done in a critical care setting Patient is one on one Monitoring is continuous Should see resolution of symptoms within hours if the TPA works • Requires a permit before administration • Physician must be present • • MS II Neuro Presentation 60

TPA Dosing • 0. 9 mg/kg up to a maximum dose of 90 mg. • 10% is administered as a bolus over one minute • Remaining 90% is given by IV infusion over the next 60 minutes • Urden page 350 MS II Neuro Presentation 61

TPA Dosing • Patient weighs 80 kg • Calculate the total dose of TPA(Concentration 100 mg/100 ml) • Calculate how much the initial dose would be? • Calculate the setting on the IV pump and the amount you would be giving over the next hour. MS II Neuro Presentation 62

Post TPA Differences from the MI Post TPA • No anticoagulants of any kind for 24 hours • Keep blood pressure lower than patient who did not receive TPA. • Below 180/105 • Support the patient – watch for those seizures – Treat if they occur, no prophylaxis MS II Neuro Presentation 63

Stroke victims – non qualifiers • Maintain cerebral perfusion • Diagnosis is PC – Decreased cerebral blood flow • Carpenito – PC – Increased intracranial pressure MS II Neuro Presentation 64

Acute care of the stroke patient • Time of onset of symptoms till 24 to 72 hours when patient deficits remain unchanged • Vitals are stable MS II Neuro Presentation 65

Maintaining cerebral perfusion • Do not increase the patient’s intracranial pressure • Position very important!!!!!!!!!!!! • Maintain oxygenation – Why • Maintain blood pressure within parameters • Systolic < 220 NON - TPA • Diastolic < 120 (Urden page 352) 352 MS II Neuro Presentation 66

Temperature regulation • Maintain normothermia 98. 6 please • Administer anti-pyretics as needed for temperature > 99’F • Warm baths to decrease temperature • Avoid shivering of course MS II Neuro Presentation 67

Maintain fluid volume WNL • IV therapy – • Fluid of choice is always normal saline • D 5 W is hypotonic drawing water to itself increasing cellular volume – increases cerebral edema • Assess for fluid volume deficit/excess MS II Neuro Presentation 68

Stroke • Nursing Management – Early recognition of neurological changes – Monitor for bleeding post thrombolytic therapy – Monitor BP and use of antihypertensive drugs • IV Labetelol • IV Sodium Nitroprusside – Monitor body temperature / blood glucose – Patient education MS II Neuro Presentation 69

Guillain-Barré Syndrome • Description – Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) • Etiology – Exact cause is unknown – Immune-mediated response Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 70

Guillain-Barré Syndrome (Cont. ) • Pathophysiology – Segmental demyelination of peripheral nerves • Assessment and diagnosis – Clinical findings – CSF analysis – Nerve conduction studies – Elevated CSF protein with normal cell count Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 71

Guillain-Barré Syndrome (Cont. ) • Medical management – Plasmapheresis – Intravenous immune globulin (IVIG) • Nursing management – Support normal body functions – Maintaining surveillance for complications Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 72

Guillain-Barré Syndrome (Cont. ) • Nursing management (Cont. ) – Initiating rehabilitation – Facilitating nutritional support – Providing comfort and emotional support – Educating the patient and family Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 73

Craniotomy • Types of surgery • Preoperative care – Patient health – Assessment and

Craniotomy (Cont. ) Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc.

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Craniotomy (Cont. ) �Postoperative medical management �Intracranial hypertension �Surgical hemorrhage �Fluid imbalance �CSF leak �Deep vein thrombosis (DVT) Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 78

Craniotomy (Cont. ) • Postoperative nursing management (Cont. ) – Preserving adequate cerebral perfusion • Positioning • Fluid management • Avoidance of vomiting and fever Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 79

Craniotomy (Cont. ) • Postoperative nursing management (Cont. ) – Promoting arterial oxygenation – Providing comfort and emotional support – Maintaining surveillance for complications • Infection • Corneal abrasions • Injury Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 80

Summary • Coma – Two main causes: structural and metabolic – Deepest state of unconsciousness – Medical management: identification and treatment of underlying cause and support of vital functions – Nursing management: supporting body functions, watching for complications, providing comfort and emotional support, initiating rehabilitation measures, and educating patient and family Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 81

Summary (Cont. ) • Stroke – Sudden onset of an acute neurologic deficit persisting for more than 24 hours; caused by interruption of blood flow to brain – Classified as ischemic or hemorrhagic – Nursing management: monitoring for neurologic status changes, watching for complications, providing comfort and emotional support, initiating rehabilitation measures, and educating patient and family Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 82

Summary (Cont. ) • Ischemic stroke – Two main causes: thrombosis and embolism; results in neuronal tissue injury from decreased or absent blood flow – Characteristic sign: sudden onset of focal neurologic signs persisting for more than 24 hours – Medical management: preservation of brain tissue through fibrinolytic therapy, management of blood pressure, and treatment of complications Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 83

Summary (Cont. ) • SAH – Bleeding into subarachnoid space; usually caused by rupture of a cerebral aneurysm or AVM – Medical management: preservation of neurologic function, support of vital functions, and treatment of complications Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 84

Summary (Cont. ) • ICH – Bleeding directly into cerebral tissue; usually caused by rupture of a small artery in brain resulting from hypertension – Medical management: preservation of neurologic function, control of blood pressure, support of vital functions, and management of intracranial hypertension Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 85

Summary (Cont. ) • Guillain-Barré syndrome – Rapidly progressive, ascending peripheral nerve dysfunction leading to paralysis that may produce respiratory failure – Medical management: support of vital functions and administration of treatments to limit syndrome duration – Nursing management: watching for complications, initiating rehabilitative measures, providing comfort and emotional support, and educating patient and family Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 86

Summary (Cont. ) • Craniotomy – Performed to gain access to CNS inside cranium – Postoperative medical management: preventing complications – Nursing management: positioning patient’s head in accordance with physician’s orders, monitoring patient’s intake and output, administering medications, promoting postoperative pulmonary care, providing comfort and emotional support, watching for complications, initiating rehabilitative measures, and educating patient and family Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 87

Summary (Cont. ) • Intracranial hypertension – Early sign of increased ICP is decrease in level of consciousness – ICP can be measured using ICP monitor – Medical and nursing management: reducing volume of one or more of components within intracranial vault – Herniation of intracerebral contents results in shifting of tissue from one brain compartment to another and places pressure on cerebral vessels and vital function centers of brain; if unchecked, results in death Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 88