Care of the client with alterations in neurological integrity

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The NCLEX questions will be taken from

• B CVA DBears

• A AD DBears

• D All of the above

• C CVA AD

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The NCLEX questions will be taken from

• B

• A

• D

• C CVA AD

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Care of the client with alterations in
neurological integrity

• NUR 108
• Spring 2007

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Pathophysiology of the CNS

• Constant blood flow is required to provide the
  brain with
• Oxygen
• Glucose
• Metabolism The chemical processes occurring
  within a living cell or organism that are
  necessary for the maintenance of life.
• Complete interruption of blood flow
• Metabolism change in 30 seconds
• Cessation of metabolism in 2 minutes
• Cellular death in 4-5 minutes
• Protection
• Cerebral autoregulation processes that maintain
  a generally constant physiological state in a
  cell or organism

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Causes of altered cognitive function

• Inadequate blood flow
• Altered nutrition
• Fluid/electrolyte imbalance
• Infectious process
• Inadequate sleep and rest
• Environmental stress
• Pharmacological agents

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Effects of aging on the Nervous System

• CNS
• Loss of neurons
• ? of cerebral blood flow
• ? in CSF production
• PNS
• Degenerative changes in myelin ??in nerve
  conduction
• Cellular degeneration ?death of neurons
• Neurons are electrically excitable cells in the
  nervous system that function to process and
  transmit information.

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Acute Neurological Alterations

• Transient Ischemic Attack (TIA)
• Cerebrovascular Disease (Stroke)
• Amyotropic Lateral Sclerosis (ALS)

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Mini Strokes
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TIA Transient Ischemic Attack

• Definition temporary focal loss of neurological
  function caused by ischemia to one vascular area
  of the brain
• Lasts lt 24 hours
• Most resolve in 3 hours
• Warning sign of progressive cerebrovascular
  disease

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What causes a transient ischemic attack?

• TIAs occur when a blood clot temporarily clogs an
  artery, and part of the brain doesn't get the
  blood it needs. The symptoms occur rapidly and
  last a relatively short time. Most TIAs last less
  than five minutes. The average is about a minute.
  Unlike stroke, when a TIA is over, there's no
  injury to the brain.

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TIA

• Signs and symptoms are dependent on which area of
  the brain was affected
• Sudden numbness or weakness of the face, arm or
  leg, especially on one side of the body
• Sudden confusion, trouble speaking or
  understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of
  balance or coordination
• Sudden, severe headache with no known cause
• CT scan is the most important initial diagnostic
  tool
• Rx antiplatelet aggregation agents and
  anticoagulant drugs

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antiplatelet aggregation agents
and anticoagulant drugs
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• Plavix

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Carotid endarterectomy.
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Carotid endarterectomy.
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CVA/Stroke

• Definition ischemia to a portion of the brain OR
  bleeding into the brain both of which causes
  cellular death
• most common cause of death
• Approx 25 die within one year
• Incidence increases with age
• Doubling each decade after age 55

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StrokeStroke killed 157,804 people in
2003.One of the largest cause of death, ranking
behind "diseases of the heart" and all forms of
cancer. Stroke is a leading cause of serious,
long-term disability in the United States.
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Classification

• Thrombotic
• Ischemic
• Embolic
• Intracerebral
• Hemorrhagic
• Subarachnoid

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Definitions

• Ischemia
• Thrombotic or embolic occlusion of cerebral
  vessels
• Progresses over hours to days
• Hemorrhage
• Bleeding into the brain
• Abrupt onset of headache
• High mortality rate

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Major types of Stroke

• Thrombus - atherosclerosis of carotids/brain
  gradual, during sleep or early am, preceded by
  TIAs
• Embolus - cardiac clot, rapid onset, during day
  activity, falling
• Hemorrhage - intracerebral or subarachnoid worse
  headache of my life lose consciousness

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Subarachnoid Hemorrhage
Intracerebral Hemorrhage
Hemorrhage either within the brain itself
(intracerebral) or in the space surrounding the
brain (subarachnoid) is a cause of
cerebrovascular accident or brain attack.
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Coil is used to occlude an aneurysmal sac
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Manifestation of R-brain L-BrainStroke
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Spatial and Perceptual deficits in
Stroke Homonymous
hemianopsia
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Risk Factors

• MODIFIABLE
• Diabetes
• Heavy alcohol
• Hypercoagulability
• Hyperlipidemia
• HTN
• Obesity
• Sedentary lifestyle
• smoking

• NONMODIFIABLE
• Age
• Gender
• Ethnicity
• Heredity

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Diagnostic Tests

• History and neuro exam
• Blood tests
• CT scan
• doppler studies
• EKG
• MRI
• Angiography/DSA (digital subtraction angiography)
• PET Positron emission tomography
• TCD Transcranial Doppler ultrasonography
• Lumbar Puncture
• CXR

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Warning signs of stroke

• Sudden weakness, paralysis, or numbness of face,
  arm or leg
• Especially on one side of the body
• Sudden dimness or loss of vision
• Sudden loss of speech, confusion or difficulty
  speaking
• Unexplained sudden dizziness, loss of balance or
  coordination
• Sudden severe headache

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Goals of acute care following CVA

• Preserve life
• Prevent further damage
• ?disability

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Anticoagulant therapy Acute phase

• Treat aggressively - Clot Busters
  Thrombolitic Drug tissue plasminogen activator
  (tPA)
• Window of opportunity is 3 hours Timing
• Only for Ischemic Stroke
• Heparin is initiated immediately IV with goal to
  be 2 -2 1/2 times the control
• Can not use if cause is hemorrhage
• Coumadin 1 1/2 times for 3 months
• After 3 months - Platelet antiaggregation therapy
  - ASA or Persantine

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tissue plasminogen activator (tPA)

• is a fibrin specific thrombolytic agent for the
  therapy of thromboembolic diseases such as
  myocardial infarction, pulmonary embolism, stroke
  and deep venous thrombosis.
• Naturally occurring substance in the body tissues
  that activates the enzyme plasmin that is able to
  dissolve blood clots

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Medical Management

• Treatment of predisposing conditions
• Control of hypertension
• Anticoagulant therapy
• Surgical Intervention - Carotid endarterectomy

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Rehabilitation

• Following stabilization, goal of care shifts from
  preservation of life to ?disability and attaining
  optimal function

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Rehabilitation Team

• Multidisciplinary approachindividual /
  familynurse / physicianphysical / occupational
  registered dietitiansocial worker / vocational
  counselorrecreation therapist / speech therapy
  clergy

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Recovery

• Most significant recovery from a CVA occurs
  during the first 6 weeks after the event

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Nursing Diagnosis

• Impaired physical mobility
• Impaired verbal communication
• Unilateral neglect
• Ineffective health maintenance
• Altered nutrition
• Self-esteem

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Amyotrophic Lateral Sclerosis

• Lou Gehrigs Disease

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amyotrophic lateral sclerosis

• The official name comes from these
• Greek words
• "a" for without
• "myo" for muscle
• "trophic" for nourishment
• "lateral" for side (of the spinal cord)
• "sclerosis" for hardening or scarring

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Lou Gehrig's Farewell Speech

• Lou Gehrig's Farewell Speech
• "Fans, for the past two weeks you have been
  reading about the bad break I got. Yet today I
  consider myself the luckiest man on the face of
  the earth. I have been in ballparks for 17 years
  and have never received anything but kindness and
  encouragement from you fans. Look at these grand
  men. Which of you wouldn't consider it the
  highlight of his career just to associate with
  them for even one day? Sure I'm lucky. Who
  wouldn't consider it an honor to have known Jacob
  Ruppert? Also, the builder of baseball's greatest
  empire, Ed Barrow? To have spent six years with
  that wonderful little fellow, Miller Huggins?
  Then to have spent the next nine years with the
  best manager in baseball today, Joe McCarthy?
  Sure I'm lucky. When the New York Giants, a team
  you would give your right arm to beat, and vice
  versa, sends you a gift - that's something. When
  everybody down to the groundskeepers and those
  boys in white coats remember you with trophies -
  that's something. When you have a wonderful
  mother-in-law who takes sides with you in
  squabbles with her own daughter - that's
  something. When you have a father and a mother
  who work all their lives so you can have an
  education and build your body - it's a blessing.
  When you have a wife who has been a tower of
  strength and shown more courage than you dreamed
  existed - that's the finest I know. So I close in
  saying that I may have had a tough break, but I
  have an awful lot to live for.
• --Lou GehrigGehrig's immortal words of
  thanks on July 4, 1939, Lou Gehrig Appreciation
  Day at Yankee Stadium

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ALS

• Definition rare, progressive neurological
  disorder characterized by loss of motor neurons
• Motor neurons in brain and spinal cord gradually
  degenerate
• Leads to death within 2-6yrs of diagnosis
• More common in men than women by ratio of 21

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Clinical Manifestations

• Typical initial symptoms
• Upper extremity weakness
• Dysarthria difficulty is speech
• Dysphagia
• Death is usually the result of respiratory
  infection secondary to compromised respiratory
  status

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Collaborative Care

• There is no cure for ALS
• Treating signs and symptoms
• Riluzole (Rilutek)
• Slows the progression of ALS increases life by a
  few months
• Cognition is intact with physical wasting
• Support the patients cognitive emotional
  functions

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Definitions

• agnosia - inability to recognize familiar
  objects
• alexia - inability to read or word blindness
• anosognosia - denial and inattention of affected
  side. May harm self by not protecting affected
  side
• aphasia - absence or impairment of the ability to
  communicate through speech, writing, or signs
• apraxia - inability to perform a learned movement
  voluntarily - put toothpaste on a comb
• ataxia - defective muscular coordination esp that
  manifested when voluntary muscle movements are
  attempted
• diplopia - double vision
• dysarthria - difficulty in speech due to motor
  function of the tongue
• dyskinesia - inability to perform voluntary
  movements
• paresis - partial or incomplete paralysis

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Definitions

• dysnomia - condition in which the patient forgets
  words or has difficulty finding words for written
  or oral expression
• dysopia - defective vision
• dysphagia - inability to swallow or difficulty in
  swallowing
• dysphasia - impairment of speech resulting from a
  brain lesion
• hemianopia - blindness in one half of the visual
  field
• hemianosmia - loss of sense of smell in one
  nostril
• hemiapraxia - incapacity to exercise purposeful
  movements on one side of the body
• hemiataxia - impaired muscular coordination
  causing awkward movements of the affected side of
  the body.
• hemiparesis - paralysis
• hemiparesthia - numbness of one side of the body
• hemiplegia - paralysis of only one side of the
  body

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Any Questions ????
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Any Questions !!!
By Leandro A. Resurreccion