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NEUROLOGIC DEFICITS

NEUROLOGIC DEFICITS. Nur-224. OBJECTIVES. Identify the various types/causes of seizures. Identify clinical manifestations for clients experiencing neurologic deficits. Apply the principles of nursing management to care for the patient in the acute stage of ischemic stroke.

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NEUROLOGIC DEFICITS

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  1. NEUROLOGIC DEFICITS Nur-224

  2. OBJECTIVES • Identify the various types/causes of seizures. • Identify clinical manifestations for clients experiencing neurologic deficits. • Apply the principles of nursing management to care for the patient in the acute stage of ischemic stroke. • Use the nursing process as a framework to develop a plan of care for the client with neurological deficits.

  3. CEREBROVASCULAR ACCIDENT • 3rd leading cause of death in the US • 800,000 people experience a stroke each year • An emergency condition in which neurologic deficits result from a sudden decrease in blood flow to a localized area of the brain. • Major loss of blood supply to the brain  severe disability or death Types of stroke • Ischemic (80–85%) • Hemorrhagic (15–20%)

  4. CEREBRAL VASCULAR ACCIDENT Risk Factors • Hypertension • Sickle cell anemia • Atrial fibrillation • Diabetes mellitus • Smoking • Hyperlipidemia • Obesity • Sedentary lifestyle • TIA or “little stroke”

  5. CVA • Characterized by a gradual/rapid onset of neurologic deficits  compromised cerebral blood flow • Stroke leads to a loss/impairment of sensorimotor functions on the opposite side the side of the brain that is damaged contralateral deficit. • Stroke in the (R) hemisphere of the brain is manifested by deficits in the (L) side of the body (and vice versa)

  6. CEREBROVASCULAR ACCIDENT

  7. ISCHEMIC STROKE • Disruption of the blood supply to the brain due to an obstruction  a thrombus or embolism, or from stenosis of a vessel resulting from a buildup of plaque Types • Large vessel stroke • Small vessel stroke • Cardiogenic embolism

  8. ISCHEMIC STROKE

  9. ISCHEMIC STROKEClinical Manifestations • Symptoms depend upon the location and size of the affected area • Numbness or weakness of face, arm, or leg, especially on one side • Confusion or change in mental status • Trouble speaking or understanding speech • Difficulty in walking, dizziness, or loss of balance or coordination • Sudden, severe headache • Perceptual disturbances

  10. (L)/( R) HEMISPHERIC STROKE • Paralysis/weakness on (R ) side of the body • (R ) visual field deficit • Aphasia • Altered intellectual ability • Paralysis/weakness on the (L) side of the body • (L) visual field deficit • Impulsive behavior and poor judgment • Lack of awareness of deficits L sided stroke R sided stroke

  11. COMPLICATIONS • Sensoriperceptual deficits • Cognitive and behavioral changes • Communication disorders • Motor deficits • Elimination disorders

  12. SENSIORIPERCEPTUAL DEFICITS Deficits may include • Hemianopia • Apraxia • Neglect syndrome

  13. COGNITIVE /BEHAVIORAL CHANGES Cognitive changes Behavioral changes • Emotional lability • Loss of self-control Intellectual changes

  14. COMMUNICATION DISORDERS • Usually a result of the stroke affecting the dominant hemisphere Aphasia • Expressive • Receptive • Global

  15. MOTOR DEFICITS Depending on the area of the brain involved strokes may cause: • Hemiplegia • Hemiparesis • Flaccidity • Spasticity

  16. ELIMINATION DISORDERS • Bladder elimination • Bowel elimination

  17. Transient Ischemic Attack (TIA) • Mini-stroke • Brief period of localized cerebral ischemia that causes neurologic deficit lasting less than 24 hours • Sudden loss of motor, sensory, or visual function • Serves as a warning for impending stroke

  18. Ischemic Stroke -Assessment Acute phase • diagnosis the type/cause of the stroke • support cerebral circulation • control/prevent further deficits Focus • minimize brain injury • maximize patient recovery

  19. Ischemic Stroke – Diagnostic Findings • Complete history/careful physical assessment • CT scan • DWI test • PLAC tests

  20. MEDICATIONS Prevention • Antiplatelet- Aspirin, clopidogrel(Plavix), ticlopidine(Ticlid) Acute Stroke • fibrinolytic therapy-tissue plasminogen activator • anticoagulant therapy Antihypertensive medications

  21. Thrombolytic Therapy • Used to treat ischemic stroke by dissolving the blood clot that is blocking blood flow to the brain. • Recombinant t-PA • Rapid diagnosis of a stroke and initiation of therapy (within 3 hours) decrease the size of the stroke and may improve functional abilities after 3 months • Bleeding most common side effect

  22. TREATMENTS Surgery (Carotid Endarectomy) • Performed to prevent the occurrence of a stroke • Restore blood flow when a stroke has occurred • Repair vascular damage Rehabilitation • Physical therapy • Occupational therapy • Speech therapy

  23. Carotid Endarterectomy Postoperative Care • Position on the inoperative side – • Assess respirations/oxygen saturation - hemorrhage -respiratory distress - cranial nerve impairment -hypotension/hypertension

  24. HEALTH PROMOTION • Stroke prevention – esp known risk factors • Public awareness of signs of TIA/Stroke • Sudden – - weakness/numbness - confusion, trouble speaking - trouble walking, dizziness, loss of balance - trouble with vision - severe headache without a cause

  25. Nursing Diagnosis/Interventions • Risk for Ineffective Tissue Perfusion- Cerebral • Impaired Verbal Communication • Impaired Swallowing • Impaired Physical Mobility • Self-care deficits r/t (bathing, grooming, hygiene)

  26. Nursing Interventions -Mobility • Maintain correct position  good body alignment  avoid deformities • Change position every 2 hours – if sensation is impaired on one side – the amount of time spent on the affected should be limited. • Prevent pressure ulcers. • Affected extremities – ROM exercises • Prepare for ambulation ASAP/active rehabilitation program

  27. Nursing Interventions- Nutrition • May swallowing problems (dysphagia). • Swallowing difficulties place the patient at the risk for aspiration, pneumonia, dehydration, and malnutrition. • Start patient on thick liquid/pureed foods  easy to swallow • Patient unable to consume oral intake  enteral feedings • Long-termed feedings  gastrostomy tube

  28. Nursing Interventions-Communication • Aphasia –receptive/expressive • Face the patient and establish eye contact • Develop strategies to make the atmosphere conducive to communication • Speak in a normal manner and tone, speak slowly • Use gestures, pictures, objects, writing, • Use same words and gestures  be consistent

  29. Nursing Intervention – Skin Integrity • At risk for skin and tissue breakdown • Specialty bed • Regular turning schedule • Minimize shear/friction forces

  30. ISCHEMIC STROKE • Recovery/rehabilitation  may be prolonged and requires patience. • Community based support groups • Depression – common /serious problem • Caregivers need to be reminder to attend their own health concerns/well-being  respite care.

  31. Hemorrhagic Stroke • Intracranial hemorrhage • Cerebral blood vessel ruptures. May be due to: • Intracerebral hemorrhage • Intracranial aneurysm • AV malformation • Subarachnoid hemorrhage

  32. HEMORRHAGIC STROKE

  33. HEMORRHAGIC STROKE

  34. Hemorrhagic Stroke –Clinical Manifestations • Similar to ischemic stroke • Severe headache • Early and sudden changes in LOC • Vomiting

  35. HEMORRHAGIC STROKE Nursing Interventions • Maintain optimum tissue perfusion -aneurysm precautions • Manage potential complications - vasospasms - hyponatremia - seizures • Promote home and community-based care

  36. SEIZURE DISORDERS • A single event of abnormal, sudden, electrical discharge in the brain resulting in an abrupt and temporary altered state of cerebral function. • Epilepsy (seizure disorder) – - chronic disorder of abnormal, recurring excessive electrical discharges - recurring seizures accompanied by some type of behavioral change

  37. SEIZURE DISORDERS • affect more than 3 million people • strong genetic component Precipitating factors • birth defects • head injury/trauma • metabolic disorders/renal failure hyponatremia, • IICP • The cause is unknown in 70% of all cases

  38. Seizures • All people with epilepsy have seizures, but not all people who have a seizure have epilepsy. • Only after a person has two seizures  dx. of epilepsy is made Classification of seizures • Partial seizures: begin in one part of the brain • Generalized seizures: involve both hemispheres of the brain

  39. SEIZURE DISORDERS/Pathophysiology • Messages from the body are carried by the neurons (nerve cells) by electrical discharges. • Impulses occur when a nerve cell has a task to perform. • Sometimes there is an excessive imbalance and the cell continues to fire after the task is completed. • Unwanted discharges cause the body to respond erratically.

  40. Generalized Seizures • Consciousness is always impaired • Absence seizures (petit mal) -sudden brief cessation of all motor activity accompanied by a blank stare and unresponsiveness. • Tonic-clonic seizures (grand mal) - common type of seizures in adults - warning aura may precede generalized seizure activity

  41. TONIC-CLONIC SEIZURE Tonic Phase • Begins with a sudden loss of consciousness, sharp muscle contractions • Patient may fall to the floor • Urinary incontinence is common • Breathing ceases and cyanosis develops • Pupils are fixed and dilated • Tonic phase may lasts – 15 seconds – 1 minute

  42. TONIC-CLONIC SEIZURE Clonic Phase • Alternating contraction/relaxation of the muscles in all extremities • Eyes roll back and the patient froths at the mouth • Phase varies in duration and subsides gradually • Entire seizure generally lasts no more than 60-90 seconds

  43. Tonic – Clonic Seizures

  44. TONIC-CLONIC SEIZURES • Following clonic phase (postictal phase) • Person remains unconscious /unresponsive to stimuli • Person is relaxed and breathes quietly • Regains consciousness gradually • May be confused/disoriented • Headache muscle ache and fatigue may follow • Amnesia of the seizure may follow • Because of lack of warning with tonic-clonic seizures, head injury, fractures, burns may occur secondary to seizure activity

  45. Status Epilepticus • Can develop during seizure activity • Seizure becomes continuous– with only short periods of calm between intense and persistent seizures • Cumulative effect  muscular contractions that interfere with respirations • Hypoxia, acidosis, hypoglycemia, hyperthermia and exhaustion may occur if the convulsive activity is not stoped. • medical emergency • Goal – stop the seizure (ASAP) • Establish and maintain airway is priority

  46. SEIZURE DISORDERS/Assessment Diagnostic Assessment • Confirm the diagnosis, determine any treatable causes and precipitating factors Diagnostic Testing • MRI/CT Scan • EEG • Lab data – CBC, biochemistry

  47. SEIZURE DISORDERS/Medical Management • Pharmacologic therapy ( AEDs) controls rather than cures seizures • Medication blood levels should be monitored • Antiseizure drugs should not be discontinued abruptly because it can precipitate seizures • Protect the patient from harm, reduce/ prevent seizures activity without impairing cognitive function or producing undesirable side effects

  48. SEIZURE DISORDERS/Medications • Phenytoin (Dilantin) • Caramazepine ( Tegretol) • Gabapentin (Neurotonin) • Topiramate (Topamax) • Valproate (Depakote,Depakene) • Clonazepam (Klonopin) see page 1885

  49. Antiepileptic Drugs • Note CNS side effects: blurred vision, slurred speech, confusion • Patients on prolonged therapy may need a diet rich in Vitamin D • Maintain good oral hygiene – phenytoin • Obtain liver functions • Carry identification indicating type of seizure -- being treated for

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