Neuro Flashcards
Headache
Priority is to determine underlying cause of headache prior to treatment
Thorough history and physical
*Distinguish what causes it; is there an aura?
Headache: Nursing Assessment
Health History
Seizures, cancer, stroke, trauma, asthma or allergies, mental illness, stress, menstruation (where are they in their menstruation/pregnancy?), exercise, food (nuts, chocolates, wines, MSG), bright lights (low light: not enough lighting; eyes could be straining), noxious stimuli
Medications (What are they using?)
Surgery and other treatments (cranial/facial could be manifestation)
Headache: Nursing Assessment
Objective Data
Anxiety or apprehension
Diaphoresis, pallor, unilateral flushing with cheek edema, conjunctivitis
*Migraines can often mean something more severe
Migraine Headache
Recurring
Characterized by unilateral or bilateral throbbing pain
Triggering event or factor
Family history
Migraine Headache: Drug Therapy
Goal is to terminate or decrease symptoms
Mild to moderate headache can obtain relief with aspirin or acetaminophen
One in progress may need narcotics (narcotics can cause onset; stopping treatment can result in withdrawal)
Antiemetics
Migraine Headache: Drug THerapy
Serotonin receptor agonists Alpha- and beta-adrenergic blockers Tricyclic antidepressants Calcium channel blockers (common) Antiseizure drugs
Migraine Headache: Drug Therapy
Propanolol (prevents dilation of cerebral blood vessels)
Verapamil (controls cerebral vasospams)
Amitriptyline (blocks uptake of serotonin and catecholamines)
Methysergide maleate (dec. serotonin action)
Ergomar or Cafergot (helps to dec. severity; Can be given by supp.)
Imitrex and Zomig (act rapidly to stop migraine; Self-injection)
Tension-Type Headache: Drug Therapy
Non-narcotic analgesic used alone or in combination with a sedative, muscle relaxant, tranquilizer, or codeine
*Tylenol, Ibuprofen. Combine with muscle relaxant. Heat and cold therapy may help
Cluster Headache: Treatment
Similar meds as migraines may control these
Oxygen (10-20 min. continuous flow)
Ergotamine tartrate give HS rectally)
*Look at changing the triggers - Fall (season) and alcohol intake
Tension-Type Headache: Diagnostic Studies
Careful history taking
Electromyography may be performed (may reveal sustained contraction of neck, scalp, or facial muscles)
Tension Headache: Drug Therapy
Nonnarcotic analgesics (Aspirin/ Tylenol) Elavil may be given at bedtime
Cluster Headavhe: Diagnostic Studies
Primarily history
CT, MRI, or MRA may be performed to rule out aneurysm, tumor, or infection
Cluster Headache: Drug Therapy
Alpha-adrenergic blockers
Vasoconstrictors
Acute treatment is inhalation of 100% oxygen delivered at a rate of 7-9L/min for 15-20 minutes
Headache
Can be first symptom of a more serious illness
Can accompany subarachnoid hemorrhage; brain tumours; other intracranial masses; arteritis; vascular abnormalities; trigeminal neuralgia; diseases of the eyes, nose, and teeth; and systemic illness
Headache: Collaborative Care
If no systemic underlying disease is found, therapy is directed toward functional type of headache
Includes drugs, medication, yoga, biofeedback, cognitive-behavioural therapy, and relaxation training
Headache: Nursing Diagnoses
Acute pain
Anxiety
Hoplessness
Headache: Planning
Have reduced or no pain
Experience increased comfort and decreased anxiety
Demonstrate understanding of triggering events and treatment strategies
Use positive coping strategies to deal with chronic pain
Experience increased quality of life
Headache: Nursing Implementation
Daily exercise, relaxation periods, and socializing help decrease recurrence and should be encouraged
Suggest alternative pain management such as relaxation, meditation, yoga, and self-hypnosis
Help client examine lifestyle, recognize stressful situations, and learn to cope with them more appropriately
Headache: Nursing Iplementation
Massage and heat packs can help with tension-type
Client should make a written note to prevent accidental overdose
Teach client about prophylactic treatment
Dietary counselling for food triggers
Avoid smoking and smoke exposure and other environmental triggers
Meningitis
Inflammation of the meninges: brain and spinal cord
Bacterial: 100 cases a year in Canada - 21% due to pneumococcal
Viral: Less severe, shorter course
Meningitis: Clinical Manifestations (Assessment)
Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia Seizures & Increased ICP Rash
Meningitis: Management
Diagnosis: Lumbar puncture culture CSF & blood
Pharmacological Treatment: Antibiotics that cross blood brain barrier (BBB); Dexamethasone (corticosteroid)
Meningococcemia
Spread airborne droplets
Highly contagious
Death can occur 10-12 hours after fever and petechial rash
Due to overwhelming septicaemia, vascular collapse and adrenal hemorrhage
Public Health Issues
Since highly contagious individuals exposed are placed on prophylactic antibiotics
Rifampin and ciprofloxacin
Must be reported to health dept.
Preventative vaccination program
Meningitis: Treatment
Viral: Focuses on relieving symptoms. Antipyretics and analgesics. No need for isolation
Bacterial: Rapid diagnosis. Antibiotic therapy immediately; IV penicillin, cephalosporins, more specific with C&S- high doses to cross BBB. Airborne isolation precautions
Encephalitis: Treatment
Antiviral medications (Vudarabine and acyclovir) No need for isolation as not transmitted from person to person
Brain Abscess
Treatment focuses on prompt antibiotic therapy
Treatment of symptoms
Surgical interventions (when antibiotics not effective): Drainage of abscess, craniotomy to remove encapsulated abscess
Brain Infections: Nursing Care
Assessment: VS/LOC Changes in vision/hearing Brudzinski's and Kernig's signs Seizures/restlessness or agitation Petechial rash Exposure to mosquitoes or ticks Hx of head injury, brain surgery, otitis media or bacterial endocarditis
Brain Infections: Nursing Care
Diagnoses: Risk for Ineffective Tissue Persion: Cerebral; Hyperthermia; Acute pain
Evaluation: Afebrile; Absence of headache/ signs of IICP; Knowledge of anti-infective therapy
Relief of other symptoms
Anticonvulsants Antipyretics Analgesics Osmotic diuretics Corticosteroids Antiemetics IV fluids
Brain Infections: Nursing Care
VS & clinical status
Monitor I&O: Hydration vs overload
Precautions: Infection control measure
Fever management
MS: Nursing Assessment
Health Hx: Viral infections or vaccnations Residence in cold or temperate climates Physical and emotional stress Medications Elimination problems Weight loss, dysphagia
MS: Nursing Assessment
Muscle weakness or fatigue, tingling or numbness, muscle spasms
Blurred or lost vision, diplopia, vertigo, tinnitus
Decreased libido, impotence
Anger, depression, euphoria, isolation
MS: Nursing Assessment (Objective Data)
Aptahy, inattentiveness
Pressure Ulcers
Scanning speech, tremor, nystagmus, ataxia, spasticity, hyperreflexia, decreased hearing
Muscular weakness, paresis, paralysis, foot dragging, dysarthria
MS: Drug Therapy
Corticosteroids
Treat acute exacerbations by reducing edema and inflammation at the site of demyelination
Do not affect the ultimate outcome or degree of residual neurological impairment from exacerbation
MS: Immunosuppressive Therapy
Beneficial effects in clients with progressive-relapsing, secondary-progressive, and primary-progressive MS
Potential benefits counterbalanced against potentially serious side effects
MS: Immunomodulators
Interferon ß-1b (Betaseron) Interferon ß-1a (Avonex, Rebif) Glatiramer (Copaxone) Natalizumab (Antegren) Mitoxaantrone (Novantrone)
MS: Collaborative Care
Antispasmotics
CNS stimulants
Anticholinergics
Tricyclic antidepressants and anti seizure drugs
Urinary retention treated with cholinergics such as bethanechol (Urecholine) or neostigmine (Prostigmine)
MS: Collaborative Care
Surgery
Dorsal-column electrical stimulation
Intrathecal baclofen pump
Physical therapy helps: Relieve spasticity; Increase coordination; Train the client to substitute unaffected muscles for impaired ones
Nutritional therapy includes megavitamins and diets consisting of low-fat, gluten-free food, and raw vegetables
High-protein diet with supplementary vitamins is often prescribed
MS: Nursing Diagnoses
Impaired physical mobility Dressing/grooming self-care deficit Risk for impaired skin integrity Impaired urinary elimination pattern Sexual dysfunction Interrupted family processes
MS: Nursing Planning
Maximize neuromuscular function
Maintain independence in activities of daily living for as long as possible
Optimize psychosocial well-being
Adjust to the illness
Reduce factors that precipitate exacerbations
MS: Nursing Implementation
Help client identify triggers and develop ways to avoid them or minimize their effects
Reassure client during diagnostic phase
Assist client in dealing with anxiety caused by diagnosis
Prevent major complications of immobility
MS: Nursing Implementation
Focus teaching on building general resistance to illness (Avoiding fatigue, extremes of hot and cold, exposure to infection)
Teach good balance of exercise and rest, nutrition, avoidance of hazards of immobility)
Teach self-catheterization if necessary
Teach adequate intake of fibre to promote regular bowel habits
Increased Intracranial Pressure (IICP): Complications
Inadequate cerebral perfusion
Cerebral herniation
IICP: Diagnostic Studies
MRI CT Cerebral angiography Transcranial Doppler studies Near-infrared spectroscopy PET and SPECT
IICP: Collaborative Care
Normothermia Adequate oxygenation PaO2 maintenance at 100 mm Hg or greater ABG analysis guides the oxygen therapy May require mechanical ventilator
IICP: Drug therapy
Mannitol Loop Diuretics Corticostroids Barbiturates Antiseizure drugs Antipyretics
IICP: Nutrtional Therapy
Client is in hyper metabolic and hyper catabolic state
^ need for glucose
Keep client normovolemic (IV 0.45% or 0.9% NaCl)
IICP: Nursing Assessment
Subjective data from client or family members
Glasgow Coma Scale (GCS)
Neurological assessment
IICP: Nursign Diagnoses
Ineffective airway clearance
ineffective tissue perfusion
Impaired skin integrity
Self-care deficit
IICP: Planning
Overall goals: ICP normalized Maintain patent airway Normal fluid and electrolyte balance No complications secondary to immobility
IICP: Nursing Implementation
Respiratory function Fluid and electrolyte balance Monitoring of intracranial pressure Body position maintained in head-up position Protection from injury Psychological considerations Family support
Seizures: Nursing Assessment
Birth defects or injuries, anoxic episodes, CNS trauma, tumors, metabolic disorders, alcoholism, exposure to renal failure
Compliance with anti seizure medications, barbiturate or alcohol withdrawal, cocaine/amphetamines
Seizures: Nursing Assessment
Family Hx
Headaches, aura, mood or behavioural changes before seizure
Anxiety, depression, loss of self-esteem, social isolation
Decreased sexual drive, ED
Seizures: Nursing Assessment
Metabolic acidosis or alkalosis, hyperkalemia, hypoglycemia, dehydration, water intoxication
Bitten tongue, soft tissue damage, cyanosis
Abnormal respiratory rate, apnea (ictal), absent or abnormal breath sounds, airway occlusion
Seizures: Nursing Assessment
Hypertension, tachy/bradycardia
Bowel/urinary incontinence, excessive salivation
Weakness, paralysis, ataxia (postical)
Abnormal CT, MRI, EEG
Seizures: Nursing Assessment
Tonic-clonic: loss of consciousness, muscle tightening then jerking, dilated pupils, hyperventilation then apnea, post-octal somnolence
Absence: altered consciousness, minor facial motor activity
Seizures: Nursing Assessment
Simple: aura; focal sensory, motor, cognitive or emotional phenomena; unilateral “marching”; motor seizure
Complex: altered consciousness with inappropriate behaviours, amnesia of event
Seizures: Complications
Status epilepticus is a state of constant seizure or a condition in which seizures recur in rapid succession without return to consciousness between seizures
Neurological emergency
Can involve any type of seizure
Seizure: Complications
Tonic-clonic status epilepticus is most dangerous because it can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis
Trauma during seizures can cause severe injury and death
Seizures: Complications
Social stigma: Interferes with values of self-control, conformity, and independence
Discrimination in employment and education
Driving sanctions
Seizures: Collaborative Care
Drug therapy aimed at prevention:
Stabilize nerve cell membranes and prevent spread of epileptic discharge
70% of clients controlled with medication
Monitor drug serum levels
Seizure: Collaborative Care
Primary drugs for treatment of generalized tonic-clonic and partial seizures:
Older: Dilantin, Tegretol, phenobarbital, and Depakote
Newer: Neurontin, Lamictal, Topamax, Gabitril, Keppra, and Zonegram
Seizure: Collaborative Care
For absence, akinetic, and myoclonic: Zarontin, Depakote, Klonopin
Status eplipeticus treated with IV ativan and Valium: Must be followed with long-acting drugs
Seizure: Collaborative Care
Antiseizure drugs should not be discontinued abruptly; abrupt discontinuation can precipitate seizures
Toxic side effects include diplopia, drowsiness, ataxia, and mental slowing
Seizure: Collaborative Care
Neurological assessment involves testing for nystagmus, hand and gait coordination, cognitive functioning, and general alertness
Side effects outside of CNS include rashes, hyperplasia of gingiva, blood dyscrasias and effects on liver and kidneys
Seizure: Collaborative Care
Surgical removal of epileptic focus or prevent spread of epileptic activity in brain: Removal of one lobe (usually temporal), cortex, or separation of two hemispheres (corpus collostomy)
Seizure: Collaborative Care
Benefits of surgery are reduction in frequency or cessation of seizures
Not all types benefit
Requirements for surgery: Diagnosis of epilepsy confirmed; Adequate trial with drug therapy without satisfactory results; Electroclinical syndrome defined
Seizure: Collaborative Care
Vagal nerve stimulation gives intermittent stimulation to brain to reduce frequency and intensity of seizures
Biofeedback teaches client to maintain certain brain-wave frequency that is refractory to seizure activity (experimental)
Seizure: Nursing Diagnoses
Ineffective breathing pattern
Risk for injury
Ineffective coping
Ineffective therapeutic regimen management
Seizure: Planning
Overall goals are that client will:
Be free from injury during seizure
Have optimal mental and physical functioning while taking anti seizure medications
Have satisfactory psych social functioning
Seizure: Nursing Implementation
Wearing helmet if risk for head injury
General health habits (diet, exercise)
Assist to identify events or situations precipitating seizures and avoidance if possible
Instruct to avoid excessive alcohol, fatigue, and loss of sleep
Seizure: Nursing Implementation
Observation and treatment of seizure: Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor; May require suctioning or oxygen after seizure
Assess level of understanding
Seizure: Nursing Implementation
Instruct on importance of adherence to medication, not to adjust dose without physician
Keep regular appointments
Teach family members emergency management
Seizure: Nursing Implementation
Emotional support and identification of coping mechanisms
Medic-Alert bracelets
Referrals to agencies and organizations
Seizues: Evaluation
Appropriate HR/ rhythm, depth of respirations
No injury
Verbalization of knowledge of potential injury
Arrangement of environment to minimize injury
Seizure: Evaluation
Acceptance of disorder
Acknowledgement seizure has occurred
Therapeutic drug levels
Compliance with therapeutic regimen
Head Injury: Nursing Assessment
GCS score Neurological status Presence of CSF leak Body position Temperature management Management of pain and sedation
Head Injury: Nursing Diagnoses
Ineffective tissue perfusion Hyperthermia Acute pain Anxiety Impaired physical mobility
Head Injury: Planning
Overall goals:
Maintain normal ICP
Maintain adequate cerebral perfusion
Remain normothermic
Be free from pain, discomfort, and infection
Attain maximal cognitive, motor, and sensory function
Head Injury: Nursing Implementation
Health Promotion:
Injury prevention awareness
Safety helmets
Seatbelts
Acute Intervention:
Maintain cerebral perfusion and prevent secondary cerebral ischema
Monitor for changes in neurological status
Head Injury: Nursing Implementation
Ambulatory and Home Care: Nutrition Bowel and bladder management Spasticity Dysphagia Seizure disorders Family participation and education
Head Injury: Evaluation
Expected outcomes:
Maintain normal cerebral perfusion pressure
Achieve maximal cognitive, motor, and sensory function
Experience no infection, hyperthermia, or pain
Head Injury: Diagnostic Studies and Collaborative Care
CT scan considered the best diagnostic test to determine craniocerebral trauma
MRI
Angiography
GCS monitoring
Head Injury: Diagnostic Studies and Collaborative Care
Craniotomy
Craniectomy
Cranioplasty
Burr-hole
Craniotomy
Preoperative Care: Routine preoperative care/teaching Assess understanding of procedure Assess anxiety level Postoperative appearance
Craniotomy
Postoperative Care: Monitoring: VS, resp. status, O2 status; IICP, CSF leak, manifestations of meningitis, seizures Pain control, antibiotic therapy Positioning Care of the wound/incision
ICP: Complications
Two major complications of uncontrolled IICP:
Inadequate cerebral perfusion
Cerebral herniation
IICP: Diagnostic Studies
Aimed at identifying the underlying cause:
MRI
CT
Cerebral angiography
IICP: Collaborative Care
Normothermia
Adequate oxygenation: PaO2 maintenance at 100 mm Hg or greater, ABG analysis guides the oxygen therapy, May require mechanical ventilator
IICP: Drug Therapy
Mannitol Loop diuretics Corticosteroids Barbiturates Antiseizure drugs Antipyretics
IICP: Nutritional therapy
Client is hyper metabolic and hyper catabolic state
^ need for glucose
Keep client normovolemic (IV 0.45% or 0.9% NaCl)
IICP: Nursing Assessment
Subjective data from client or family members
GCS
Neurological assessment
IICP: Nursing Diagnoses
Ineffective airway clearance
Ineffective tissue perfusion
Impaired skin integrity
Self-are deficit
IICP: Planning
Overall goals: ICP normalized Maintain patent airway Normal fluid and electrolyte balance No complications secondary to immobility
IICP: Nursing Implementation
Resp. function F&E balance Monitoring ICP Body position maintained in head-up position Protection from injury Psychological considerations Family support
Stroke: Prevention
Health management for the well individual
Education and management of modifiable risk factors to prevent a stroke
F - face
A- asphagia
S- slurred speech
T- time
Stroke: Prevention
Antiplatelet drugs are usually the chosen treatment to prevent further stroke in clients who have had a TIA
Aspirin is the most frequently used anti platelet drug
Stroke: Prevention
Surgical interventions for the client with TIAs from carotid disease include: Carotid endarterectomy (remove plaque from arteries), Transluminal angioplasty (if clot is small enough, can remove), Stenting
Stroke: Post-op care
HOB 30º and had aligned straight
Support head while turning
Patency of drains
Monitoring: Hemorrhage, cranial nerve impairment, confusion, dizziness, slurred speech or hemiparesis; VS: hypertension inc. risk CVA, hypotension inc. risk myocardial ischemia
Stroke: Acute Care
Goals for collaborative care during the acute phase are: Preserving life (limit disability), Preventing further brain damage, Reducing disability
Stroke: Acute Care (Assessment findings)
Altered level of consciousness Weakness, numbness, or paralysis Speech or visual disturbances Severe headache (hemorrhage) ^ or decrease HR Resp. distress Unequal pupils (which side event is occurring) Hypertension (significant ^; 300's) Facial drooping on affected side Difficulty swallowing Seizures Bladder or bowel incontinence N/V Vertigo Blood sugar (hypoglycaemia can mimic signs of stroke)
Stroke: Initial Interventions
Ensure client airway
Remove dentures (choke risk))
Perform pulse oximetry (at least 92%)
Maintain adequate oxygenation
IV access with normal saline (neutral; won’t cross BBB)
Maintain BP according to guidelines (140-160 in stroke patients)
Stroke: Initial Intervention
Remove clothing (constricting; anticipating crash)
Obtain CT scan immediately (could be hemorrhagic)
Perform baseline lab tests (cardiac, chemistry, clotting factors)
Position head midline (Avoid potential obstruction)
Elevate HOB 30º if no symptoms of shock or injury
Institute seizure precautions
Anticipate thrombolytic therapy for ischemic stroke
Stroke: Ongoing Interventions
Monitor VS and neurologic status LOC Motor and sensory function Pupil size and reactivity O2 saturation Cardiac rhythm
Stroke: Acute care
Recombinant tissue plasminogen activator (tPA) is used to re-establish blood flow through a blocked artery to prevent cell death in clients with acute onset of ischemic stroke symptoms
Stroke: Acute Care
Thrombolytic therapy given within 3 hours of the onset of symptoms decreases disability but at the expense of ^ in deaths within the first 7-10 days and ^ in intracranial hemorrhage
Stroke: SUrgical Interventions
Surgical interventions for stroke include immediate evacuation of:
Aneurysm-induced hematomas
Cerebellar hematomas
Stroke: Rehabilitation Care
After the stroke has stabilized for 12-24 hours, collaborative care shifts from preserving life to lessening disability and attaining optimal functioning
Client may be transferred to a rehab unit
Stroke: Nursing Assessment
If client is stable, obtain:
Description of the current illness with attention to initial symptoms
Hx of similar symptoms previously experienced
Current medications
Hx of risk factors and other illnesses
Family Hx of stroke of cardiovascular disease
Stroke: Nursing Assessment
Include a comprehensive neurologic examination: LOC Cognition Motor abilities Cranial nerve function Sensation Proprioception Cerebellar function Deep tendon reflexes
Stroke: Nursing Diagnoses
Ineffective tissue perfusion Ineffective airway clearance Impaired physical mobility Impaired verbal communication Unilateral neglect Impaired urinary elimination Impaired swallowing Situational low self-esteem
Stroke: Planning
Goals are that the client will:
Maintain a stable or improved level of consciousness
Attain maximum physical functioning
Attain maximum self-care abilities and skills
Maximize communication abilities
Maintain adequate nutrition
Avoid complications of stroke
Maintain effective personal and family coping
Stroke: Nursing Implementation (Health promotion)
Teaching clients and families about early symptoms associated with stroke or TIA and when to seek health care for symptoms
Stroke: Nursing Implementation (Resp. System)
Management of the reps. system is a nursing priority
Risk for aspiration pneumonia
Risk for airway obstruction
May require endotracheal intubation and mechanical ventilation
Stroke: Nursing Implementation (Neuro. System)
Monitor closely to detect changes suggesting: Extension of the stroke IICP Vasospasm Recovery from stroke symptoms
Stroke: Nursing Implementation (Cardio. System)
Monitoring VS frequently
Monitoring cardiac rhythms
Calculating I&O, noting imbalances
Regulating IV infusions
Stroke: Nursing Implementation (Musculoskeletal System)
Trochanter roll at hip to prevent external rotation
Hand cones to prevent hand contractors
Arm supports with slings and lap boards to prevent shoulder displacement
Avoidance of pulling the client by the arm to avoid shoulder displacement
Posterior leg splints, footboards or high-topped tennis shoes to prevent foot drop
Hand splints to reduce spasticity
Stroke: Nursing Implementation (Integument. System)
Pressure relief by position changes, special mattresses, or wheelchair cushions
Good skin hygiene (keep warm and moist)
Emollients applied to dry skin
Early mobility
Position client on the weak or paralyzed side for only 30 min. (No sensation; can’t tell if there’s too much pressure)
Stroke: Nursing Implementation (GI System)
After careful assessment of swallowing, chewing, gag reflex, and pocketing, oral feedings can be initiated
Feedings must be followed by scrupulous oral hygiene
Constipation is the most common bowel problem for the client who has had a stroke
Physical activity also promotes bowel function
laxatives, suppositories, or additional stool softeners may be ordered
Stroke: Nursing Implementation (Urinary system)
In the acute stage poor bladder control is the primary urinary problem, resulting in incontinence
Efforts should be made to promote normal bladder function and avoid the use of in-dwelling catheters
Stroke: Nursing Implementation (Communication)
Nurse’s role in meeting psychological needs of the client is primarily supportive
Client is assessed both for the ability to speak and the ability to understand
Speak slowly and calmly, using simple words or sentences
Stroke: Nursing Implementation (Sensory- Perceptual Alterations)
Blindness in the same half of each visual field is a common problem after stroke
Other visual problems may include diplopia (double vision), loss of the corneal reflex, and ptosis (drooping eyelid)
Stroke: Nursing Implementation (Coping)
Client’s family should be given a careful, detailed explanation of what has happened to the client
Family members usually have not had time to prepare for the illness, social services referral is often helpful
Stroke: Nursing Implementation (Ambulatory and Home Care)
The rehab nurse assesses the client and family with:
Rehab potential of the client
Physical status of all body systems
Presence of complications caused by the stroke or other chronic conditions
Cognitive status of the client
Family resources and support
Expectations of the client and family related to the rehab program
Stroke: Nursing Implementation (Ambulatory and Home Care)
The nurse initially emphasizes the musculoskeletal functions of:
Eating, Toileting, Walking
After the acute phase, a dietician can assist in determining the appropriate daily caloric intake based on the clients:
Size, Weight, Activity Level
Stroke: Nursing Implementation (Ambulatory and Home Care)
Interventions to promote self-feeding include:
Using the unaffected upper extremity to eat
Employing assistive devices such as rocker knives, plate guards, and non-slip pads for dishes
Removing uneccessary items from the tray or table, which can reduce spills
Providing a non-distracting environment to decrease sensory overload and distraction
Stroke: Nursing Implementation (ambulatory and Home Care)
Recognition of behavioural change resulting from neurological deficits that are not changeable
Responses to multiple losses both by the client and the family
Behaviours that may have been reinforced during the earlystages of stroke as continued dependency
A person who has had a stroke may be concerned about the loss of sexual function
Common concerns about sexual activity are impotence and the occurrence of another stroke during sex
Spinal Cord Injury: Initial Goals
Sustain life
Prevent further cord damage
Rehabilitation
Systemic and neurogenic shock must be treated to maintain blood pressure
Spinal Cord Injury: Emergent care
ABC Pain; sensation (dermatones) Immobilization: neck, spine Oxygenation needs IV fluids
Hx
How accident occurred
Extent of injury as perceived by client immediately after accident
Spinal Cord Injury: Assessment
Sensory examination (dermatones, reflexes)
Brain injury
Musculoskeletal injuries
Damage to internal organs
Loss of strength, movement, and sensation below level of injury
Pain at or above injury: numbness, twitching of extremities
Spinal Cord Injury: Early management
Stabilization/ immobilization: Braces (thoracic, lumbar) Body casts (thoracic, lumbar) Cervical tongs/ traction (cervical) Halo vest (stable cervical or thoracic)
Spinal Cord Injury: Surgical Interventions
Spinal infusion
Decompression laminectomy
Insertion of rods
Spinal Cord Injury: Drug therapy
Greater recovery of neurologic function with early administration of methylprednisone:
Given within 8 hours of injury
IV drip for 48 hours
Improves blood flow
Reduces edema
Vasopressor agents used as adjuvants in acute phase maintain mean arterial pressure to improve perfusion to spinal cord
Spinal Cord Injury: Effects of methylprednisone
Reduction post-trauma ischemia Improvement of energy balance Restoration of extracellular calcium Improvement in impulse conduction Repression of free fatty acid release
Spinal Cord Injury: Pharmacotherapy
Histamine blockers, PPI’s
Antispasmodics
Anticoagulants (use TED stockings)
Stool softeners (T6: bowel and bladder)
Spinal Cord Injury: Nursing Assessment
Resp. status (ABC)
Motor ability
Sensation (constantly monitor with pins/ice)
Spinal shock: depression of reflex activity below injury
Temperature: risk of hyperthermia (autonomic disruption)
Bladder: assess retention/ distention
Spinal Cord Injury: Nursing Interventions
Promote adequate breathing and airway Improve mobility Promoting adaptation to sensory and perceptual alterations skin integrity bowel and bladder Comfort measures
Spinal Cord Injury: Planning
Client with spinal cord injury will:
Maintain optimal level of neurological functioning
Have minimal or no complications of immobility
Learn new skills, behaviours, self-care or successfully direct others to do so
Return home with optimal level of functioning
Spinal Cord Injury: Nursing Implementation (Impaired Gas Exchange)
Intubation or tracheostomy and mechanical ventilation initiated with injuries above C3 or with inadequate oxygenation/ ventilation Aggressive Chest physio Adequate oxygenation Proper pain management Regularly Assess: Breath sounds, breathing patterns ABGs Tidal volume, vital capacity Skin colour Subjective comments Amount and colour of sputum
Spinal Cord Injury: Nursing Implementation (Impaired Gas Echange)
Assisted coughing to stimulate ineffective abdominal muscles Tracheal suctioning for crackles, wheezes Incentive spirometry Resp. Rehab.: Diaphragmatic pacemaker Ventilator care Assisted coughing Incentive spirometry Deep breathing
Spinal Cord Injury: Nursing Implementation (Decreased Cardiac Output)
Frequent VS
Administration of anticholinergic for bradycardia
Temporary pacemaker
Vasopressor and fluid replacement for hypoension
Assess for DVT every shift
Prophylactic heparin
Hgb, Hct level monitoring with blood loss
Monitor for signs of hypovolemic shock secondary to hemorrhage
Spinal Cord Injury: Nursing Implementation (Decreased Cardiac Output)
Stool/ gastric contents tested daily for blood related to stress ulcer
Antacids/ food with corticosterods
Prophylactic histamine H2 blockers or proton pump inhibitors
Compression stocking for venous return and prevention of DVT (remove q8hr for skin care)
Pneumatic compression devices
Range-of-motion exercises and regular stretching
Spinal Cord Injury: Nursing Implementation (Constipation)
Bowel training program:
Laxatives, suppository or mini-enema daily at the same time of day; or eery other day; or 3 times per week schedule
Follow by digital stimulation of manual evacuation until evacuation is complete
Upright position on padded commode chair
Spinal Cord Injury: Nursing Implementation (Constipation)
Neurogenic bowel: High-fibre diet Adequate fluid Suppositories Small-volume enemas Digital stimulation
Spinal Cord Injury: Nursing Implementation (Constipation)
Stool softeners
Valsalva manoeuvre with lower motor neurone lesions
Timing
Record frequency, amount, and consistency of bowel movements
Spinal Cord Injury: Nursing Implementation (Impaired urinary function)
Indwelling catheter: Frequency inspection and irrigation Aseptic technique Intermittent catheterization: 1800-2000 mL/day restriction Closely monitor output
Spinal Cord Injury: Nursing Implementation (Impaired urinary function)
Neurogenic bladder:
Drainage method according to dysfunction; In-dwelling, intermittent, or external catheter, bladder reflex training, surgery
Adequate fluid intake and catheter changes q1 week to 1 month
Intermittent catheterization q4hr on average
Surgery with recurrent UTIs
Spinal Cord Injury: Nursing Implementation (Impaired urinary function)
Anticholinergics to suppress contraction
∂-adrenergic blockers to decrease outflow resistance
Antispasmotics to decrease spasticity of pelvic floor muscles
Spinal Cord Injury: Nursing Implementation (Impaired skin integrity)
Proper immobilization of neck to stabilize cervical spine : Always correctly aligned, turning with client as unit
Traction maintained at all times with cervical injuries: Cleansing sites BID
Special Beds: Kinetic therapy using slow rotation, decreases likelihood of pressure ulcers and cardiopulmonary complications
“Body jacket” or Jewett brace for thoracic or lumbar injuries
Meticulous skin care
Spinal Cord Injury: Risk for autonomic dysreflexia
Elevate HOB at 45º to sit upright Notify physicna Identify trigger and correct: bladder, bowel, draft, skin irritation Immediate catheterization for bladder distention Bowel for evacuation for impaction Removal of all skin stimuli Management of BP - Apresoline patient education
Spinal Cord Injury: Risk for ineffective coping
Grief and depression: Regression at different stages Expect wide fluctuation of emotions Allow mourning Assist in obtaining control during anger phase Promotion of independence
Spinal Cord Injury: Imbalanced nutrition (less than)
NG tube if GI motility ceases in first 48-72 hours following injury:
Monitor electrolytes
Gradual introduction of fluids and food once motility returns
Swallowing must be evaluated
High -calorie, high protein diet or TPN
Spinal Cord Injury: Imbalanced nutrition (less than)
Evaluate if client is not eating: Make contract with client for increased sense of control Pleasant eating environment Allow adequate time to eat Encourage family to bring special foods Calorie count Daily weight Increased dietary fibre
Spinal Cord Injury: Impaired physical Mobility
Perform ROM
Use of splints, braces
Wheelchair
