Learning Objectives
1.Describe the incidence and social impact of cerebrovascular
disorders.
2.Identify the risk factors for cerebrovascular disorders and
related measures for prevention.
3.Compare the various types of cerebrovascular disorders: their
causes, clinical manifestations, and medical management.
4.Apply the principles of nursing management to the care of a
patient in the acute stage of an ischemic stroke.
5.Use the nursing process as a framework for care of a patient
recovering from an ischemic stroke.
6.Use the nursing process as a framework for care of a patient
with a hemorrhagic stroke.
7.Identify essential elements for family teaching and
preparation for home care of the patient who has had a stroke.
Cerebrovascular Disorders
Functional abnormality of the CNS
that occurs when the blood supply is
disrupted
Stroke is the primary cerebrovascular
disorder and the third leading cause
of death in the U.S.
Stroke is the leading cause of serious
long-term disability in the U.S.
Prevention
Nonmodifiable risk factors
Cardiovascular disease
Obesity
Diabetes
Stroke
Brain attack
Sudden loss of function resulting
from a disruption of the blood
supply to a part of the brain
Types of stroke
Ischemic (8085%)
Hemorrhagic (1520%)
Ischemic Stroke
Disruption of the blood supply due to an
obstruction, usually a thrombus or
embolism, that causes infarction of brain
tissue
Types
Large artery thrombosis
Small penetrating artery thrombosis
Cardiogenic embolism
Cryptogenic
Other
Manifestations of Ischemic
Stroke
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
Terms:
Hemiplegia
Hemiparesis
Dysarthria
Aphasia: expressive aphasia,
receptive aphasia
Hemianopsia
Carotid Endarterectomy
Patient monitoring
Hemorrhagic Stroke
Caused by bleeding into brain tissue, the ventricles,
or subarachnoid space.
May be due to spontaneous rupture of small vessels
primarily related to hypertension; subarachnoid
hemorrhage due to a ruptured aneurysm; or
intracerebral hemorrhage related to amyloid
angiopathy, arterial venous malformations (AVMs),
intracranial aneurysms, or medications such as
anticoagulants.
Brain metabolism is disrupted by exposure to blood.
ICP increases due to blood in the subarachnoid space.
Compression or secondary ischemia from reduced
perfusion and vasoconstriction causes injury to brain
tissue.
Manifestations
Similar to ischemic stroke
Severe headache
Early and sudden changes in (LOC)
Level of Consciousness
Vomiting
Medical Management
Prevention: control of hypertension
Diagnosis: CT scan, cerebral angiography,
lumbar puncture if CT is negative and ICP is not
elevated to confirm subarachnoid hemorrhage
Care is primarily supportive
Bed rest with sedation
Oxygen
Treatment of vasospasm, increased ICP,
hypertension, potential seizures, and prevention
of further bleeding
Nursing Process:
The Patient Recovering from an Ischemic Stroke
Assessment
Acute phase
Ongoing/frequent monitoring of all systems including
vital signs and neurologic assessmentLOC, motor
symptoms, speech, eye symptoms
Monitor for potential complications including
musculoskeletal problems, swallowing difficulties,
respiratory problems, and signs and symptoms of
increased ICP and meningeal irritation
Nursing Process:
The Patient Recovering from an Ischemic Stroke
Diagnoses
Potential
Problems/Complications
Decreased cerebral blood flow
Inadequate oxygen delivery to brain
Pneumonia
Nursing Process:
The Patient Recovering from an Ischemic Stroke
Planning
Interventions
Focus on the whole person
Provide interventions to prevent
complications and to and promote
rehabilitation
Provide support and encouragement
Listen to the patient
Interventions
Enhancing self-care
Interventions
Nutrition
Nursing Process:
The Patient with a Hemorrhagic StrokeAssessment
Potential
Problems/Complications
Vasospasm
Seizures
Hydrocephalus
Rebleeding
Hyponatremia
Aneurysm Precautions
Absolute bed rest
Elevate HOB 30 to promote venous drainage or flat
to increase cerebral perfusion
Avoid all activity that may increase ICP or BP;
Valsalva maneuver, acute flexion or rotation of neck
or head
Exhale through mouth when voiding or defecating to
decrease strain
Nurse provides all personal care and hygiene
Nonstimulating, nonstressful environment; dim
lighting, no reading, no TV, no radio
Prevent constipation
Visitors are restricted
Interventions
Relieving sensory deprivation and anxiety
Keep sensory stimulation to a minimum
for aneurysm precautions
Realty orientation
Patient and family teaching
Support and reassurance
Seizure precautions
Strategies to regain and promote selfcare and rehabilitation
Question
What are expected patient outcomes
for a patient recovering from a
hemorrhagic stroke?
A. Exhibits absence of vasospasm
B. Residual aphasia
C. One to four seizures
D.Complains of visual changes
Answer
A
Expected patient outcomes for a
patient recovering from a
hemorrhagic stroke include absence
of vasospasm, no seizures, normal
speech patterns, and no visual
changes
Learning Objectives
On completion of this chapter, the learner should be able to:
1.Describe the mechanisms of injury, clinical signs and symptoms,
diagnostic testing, and treatment options for patients with
traumatic
brain and spinal cord injuries.
2.Describe the nursing management of patients with brain injury.
3.Use the nursing process as a framework for care of patients with
traumatic brain injury.
4.Identify the population at risk for spinal cord injury.
5.Describe the clinical features and management of the patient with
neurogenic shock.
6.Discuss the pathophysiology of autonomic dysreflexia and describe the
appropriate nursing interventions.
7.Use the nursing process as a framework for care of patients with spinal
cord injury.
Adult Nursing 2
Management of Patients
With
Neurologic Trauma
Head Injury
A broad classification that includes injury to the
scalp, skull, or brain
1.4 million people receive head injuries every year
in the U.S.
The most common cause of death from trauma
Most common cause of brain trauma is MVA
Group at highest risk group for brain trauma is
males age 1524
Those younger than 5 years and the elderly are
also at increased risk
Prevention
Pathophysiology of Brain
Damage
Primary injury: due to the initial
damage
Contusions, lacerations, damage to
blood vessels, acceleration/deceleration
injury, or due to foreign object
penetration
Manifestations
Manifestations depend upon the
severity and location of the injury
Scalp wounds
Skull fractures
Manifestations of Brain
Injury
Altered LOC
Pupillary abnormalities
Sudden onset of neurologic deficits
and neurologic changes; changes in
sense, movement, reflexes
Changes in vital signs
Headache
Seizures
Brain Injury
Brain Injury
Diffuse axonal injury: widespread axon
damage in the brain seen with head
trauma. Patient develops immediate
coma.
Intracranial bleeding
Epidural hematoma
Subdural hematoma
Acute and subacute
Chronic
Concussion
Patient may be admitted for observation
or sent home
Observation of patients after head
trauma; report immediately
Observe for any changes in LOC
Difficulty in awakening, lethargy, dizziness,
confusion, irritability, anxiety
Difficulty in speaking or movement
Severe headache
Vomiting
Epidural Hematoma
Blood collection in the space between the skull and
the dura.
Patient may have a brief loss of consciousness with
return of lucid state then as hematoma expands
increased ICP will often suddenly reduce LOC.
An emergency situation!
Treatment include measures to reduce ICP, remove
the clot and stop bleedingburr holes or
craniotomy.
Patient will need monitoring and support of vital
body functions; respiratory support.
Subdural Hematoma
Collection of blood between the dura and the
brain
Acute/Subacute
Chronic
Intracerebral Hemorrhage
Hemorrhage occurs into the substance of
the brain
May be due to trauma or a nontraumatic
cause
Treatment
Supportive care
Control of ICP
Administration of fluids, electrolytes, and
antihypertensive medications
Craniotomy or craniectomy to remove clot and
control hemorrhage; this may not be possible
due the location or lack of circumscribed area of
hemorrhage
Diagnostic Evaluation
Supportive Measures
Respiratory support; intubation and
mechanical ventilation
Seizure precautions and prevention
NG to manage reduced gastric
motility and prevent aspiration
Fluid and electrolyte maintenance
Pain and anxiety management
Nutrition
Potential Problems/Complications
Interventions
Ongoing assessment and monitoring is
vital
Maintenance of airway
Positioning to facilitate drainage of oral secretions
with HOB usually elevated 30 to decrease venous
pressure
Suctioning with caution
Prevention of aspiration and respiratory insufficiency
Monitor ABGs, ventilation, and mechanical ventilation
Monitor for pulmonary complications, potential ARDS
Interventions
I&O and daily weights
Monitor blood and urine electrolytes and
osmolality and blood glucose
Measures to promote adequate nutrition
Strategies to prevent injury
Assessment of oxygenation
Assessment of bladder and urinary output
Assessment for constriction due to dressings
and casts
Pad side-rails
Mittens to prevent self-injury; avoid
restraints
Interventions
Strategies to prevent injury
Interventions
Support of cognitive function
Support of family
Neurogenic shock
Autonomic Dysreflexia
Acute emergency!
Occurs after spinal shock has resolved and may
occur years after the injury.
Occurs in persons with a SC lesion above T6.
Autonomic nervous system responses are
exaggerated.
Symptoms include severe pounding headache,
sudden increase in blood pressure, profuse
diaphoresis, nausea, nasal congestion and
bradycardia.
Triggering stimuli include distended bladder (most
common cause), distention or contraction of
visceral organs (such as constipation), or
stimulation of the skin.
Nursing Interventions
Place patient in seated position to lower BP
Rapid assessment to identify and eliminate
cause
Empty the bladder using a urinary catheter or
irrigate/change indwelling catheter
Examine rectum for fecal mass
Examine skin
Examine for any other stimulus
Improving Mobility
Maintain proper body alignment
Turn only if spine is stable and as
indicated by physician
Monitor blood pressure with position
changes
PROM at least four times a day
Use neck brace or collar, as
prescribed, when patient is mobilized
Move gradually to erect position
Interventions
Strategies to compensate for sensory and
perceptual alterations
Measures to maintain skin integrity
Temporary indwelling catherization or
intermittent catherization
NG tube to alleviate gastric distention
High-calorie, high-protein, high-fiber diet
Bowel program and use of stool softeners
Traction pin care
Hygiene and skin care related to traction
devices
Adult 2
Management of Patients With
Neurologic Infections,
Autoimmune Disorders, and
Neuropathies
Learning Objectives
On completion of this chapter, the learner will be able to:
1.Differentiate among the infectious disorders of the nervous
system according to causes, manifestations, medical care,
and nursing management.
2.Describe the pathophysiology, clinical manifestations, and
medical and nursing management of multiple sclerosis,
myasthenia gravis, and Guillain-Barr syndrome.
3.Use the nursing process as a framework for care of
patients with multiple sclerosis and Guillain-Barr syndrome.
4.Describe disorders of the cranial nerves, their
manifestations, and indicated nursing interventions.
5.Develop a plan of nursing care for the patient with a
cranial nerve disorder.
Infectious Neurologic
Disorders
Meningitis
Brain abscesses
Encephalitis
Creutzfeldt-Jakob disease and variant
Creutzfeldt-Jakob disease
Meningitis
Inflammation of the membranes and the fluid space
surrounding the brain and spinal cord
Types
Septic due to bacteria (Streptococcus pneumoniae,
Neisseria meningitidis)
Aseptic due viral infection, lymphoma, leukemia, or
brain abscess
N. meningitidis is transmitted by secretions or aerosol
contamination and infection is most likely in dense
community groups such as college campuses
Manifestations include headache, fever, changes in LOC,
behavioral changes, nuchal rigidity (stiff neck), positive
Kernig's sign, positive Brudzinskis sign, and photophobia
Brudzinskis Sign
Medical Management
Prevention by vaccination against
Haemophilus influenzae and S.
pneumoniae for all children and all
at-risk adults
Early administration of high doses of
appropriate IV antibiotics for
bacterial meningitis
Dexamethasone
Treatment dehydration, shock, and
seizures
Nursing Management
Frequent/continual assessment including VS and
LOC
Protect patient form injury related to seizure
activity or altered LOC
Monitor daily weight, serum electrolytes, urine
volume, specific gravity, and osmolality
Prevent complications associated with immobility
Infection control precautions
Supportive care
Measures to facilitate coping of patient and family
Brain Abscess
Collection of infectious material within brain tissue
Risk is increased in immunocompromised patient
Prevent by treating otitis media, mastoiditis,
sinusitis, dental infections, and systemic infections
promptly
Manifestations may include headache that is usually
worse in the morning, fever, vomiting, neurologic
deficits, signs and symptoms of increased ICP
Diagnosis by MRI or CT
CT-guided aspiration is used to identify the causative
organisms
Brain Abscess
Medical management
Control ICP
Drain abscess
Administer appropriate antibiotic therapy.
Corticosteroids may be used to treat
cerebral edema
Nursing management
Encephalitis
Supportive care
Autoimmune Neurologic
Disorders
Multiple sclerosis
Myasthenia gravis
Guillain-Barr syndrome
Myasthenia Gravis
Autoimmune disorder affecting the myoneural
junction
Antibodies directed at acetylcholine at the
myoneural junction impair transmission of
impulses
Manifestations
Myasthenia gravis, a motor disorder
Initially symptoms involve ocular muscles; diplopia
and ptosis
Weakness of facial muscles, swallowing and voice
impairment (dysphonia), generalized weakness
Myasthenia Gravis
Medical Management
Pharmacologic therapy
Cholinesterase inhibitor: pyrostigmine
bromide (Mestinon)
Immunomodulating therapy
Plasmapheresis
Thymectomy
Myasthenic Crisis
Result of disease exacerbation or
precipitating event, most commonly
a respiratory infection.
Severe generalized muscle weakness
with respiratory and bulbar
weakness.
Patient may develop respiratory
compromise failure.
Cholinergic Crisis
Caused by overmedication with
cholinesterase inhibitors
Severe muscle weakness with
respiratory and bulbar weakness
Patent may develop respiratory
compromise and failure
Management of Myasthenic
Crisis
Patient instruction in signs and symptoms of
myasthenic crisis and cholinergic crisis.
Assuring adequate ventilation; intubation
and mechanical ventilation may be needed.
Assessment and supportive measures
include:
Measures to ensure airway and respiratory
support
ABGS, serum electrolytes, I&O, and daily weight
If patient cannot swallow, nasogastric feeding
may be required
Avoid sedatives and tranquilizers
Guillain-Barr Syndrome
Autoimmune disorder with acute attack of
peripheral nerve myelin
Rapid demyelination may produce respiratory failure
and autonomic nervous system dysfunction with CV
instability
Most often follows a viral infection
Manifestations are variable and may include
weakness, paralysis, paresthesias, pain, and
diminished or absent reflexes starting with the lower
extremities and progressing upward; bulbar
weakness; cranial nerve symptoms; tachycardia;
bradycardia; hypertension; or hypotension
Guillain-Barr Syndrome
Medical management
Requires intensive care management
with continuous monitoring and
respiratory support
Plasmapheresis and IVIG are used to
reduce circulating antibodies
Potential Complications
Respiratory failure
Autonomic dysfunction
Deep vein thrombosis (DVT)
Pulmonary embolism
Urinary retention
Interventions
Enhancing physical mobility and prevention of
DVT
Support limbs in functional position
Passive ROM at least twice daily
Frequent position changes at least every 2 hours
Elastic compression hose and/or sequential
compression boots
Adequate hydration
Interventions
Develop a plan for communication
individualized to patient needs
Decreasing fear and anxiety
Provide information and support
Referral to support group
Relaxation measures
Maintain positive attitude and atmosphere to
promote a sense of well-being
Diversional activities
Question
What is dysphonia?
A. Double vision or the awareness of two
images of the same object occurring in one
or more eyes.
B. Impaired ability to execute voluntary
movements.
C. Difficulty swallowing and causing the
patient to be at risk for aspiration.
D.Voice impairment or altered voice
production.
Answer
Diplopia is double vision or the
awareness of two images of the
same object occurring in one or more
eyes. Dyskinesia is impaired ability to
execute voluntary movements.
Dysphagia is difficulty swallowing
and causing the patient to be at risk
for aspiration. Dysphonia is voice
impairment or altered voice
production.
Process of Demyelination
Interventions
Utilize a collaborative approach
Coordinate and refer as needed to health
care services; social services, speech
therapy, physical therapy, counseling
services, home care services, etc.
Activity and rest
Program of activity and daily exercise
Relaxation, coordination exercises, walking,
muscle stretching exercises
Avoid very strenuous activity and extreme fatigue
Interventions
Bowel and bladder control
Interventions
Interventions to minimize stress
Maintenance of temperate
environmentair conditioning to
avoid excessive heat and avoidance
of exposure to extreme cold
Use assistive devices and
modifications for home care
management and independence in
ADLs
Support of coping
Medical Management
Antiseizure medications such as
carbamazepine (Tegretol), gabapentin
(Neurontin), phenyltoin, or antispasmodic
medication baclofen (Lioresal)
Surgical treatment
Microvascualr decompression of the
trigeminal nerve
Radiofrequency thermal coagulation
Percutaneous balloon microcompression
Nursing Interventions
Patient teaching related to pain prevention and
treatment regimen
Measures to reduce and prevent pain; avoidance
of triggers
Care of the patient experiencing chronic pain
Measures to maintain hygienewashing face,
oral care
Strategies to ensure nutrition; soft food, chew on
unaffected side, avoid hot and cold food
Recognize and provide interventions to address
anxiety, depression, insomnia
Bell Palsy
Facial paralysis due to unilateral
inflammation of the 7th cranial nerve
Manifestationsunilateral facial
muscle weakness or paralysis with
facial distortion, increased lacrimation,
and painful sensations in the face, may
have difficulty with speech and eating
Most patients recover completely in 3
5 weeks and the disorder rarely recurs.
Management
Medical
Nursing
Learning Objectives
On completion of this chapter, the learner will be able to:
1.Identify the pathophysiologic processes responsible for oncologic disorders.
2.Describe brain and spinal cord tumors: their classification, clinical
manifestations, diagnosis, and medical and nursing management.
3.Use the nursing process as a framework for care of patients with cerebral
metastases or inoperable brain tumors.
4.Identify the pathophysiologic processes responsible for various
degenerative neurologic disorders.
5.Use the nursing process as a framework for care of patients with
Parkinsons disease.
6.Identify resources for patients and families with oncologic and degenerative
neurologic disorders.
7. Use the nursing process as a framework for care of patients following a
cervical diskectomy.
Question
What is akathisia?
A. Restlessness, urgent need to move
around, and agitation.
B. Very slow voluntary movements and
speech.
C. Impaired ability to execute voluntary
movements.
D.A sensation of numbness, tingling, or
a pins and needles sensation
Answer
A
Akathisia is restlessness, urgent need to
move around and agitation. Bradykinesia is
very slow voluntary movements and
speech. Dyskinesia is impaired ability to
execute voluntary movements. Paresthesia
is a sensation of numbness, tingling, or a
pins and needles sensation.
Pathophysiologic Results of
Neurologic Oncologic Disorders
Manifestations depend upon the
tissues infiltrated and compressed by
the neoplasm
Pathophysiologic events may include:
Increase ICP
Seizures
Hydrocephalus
Altered pituitary function
Question
Is the following statement True or
False?
Brain tumor classification is based upon
location and histological characteristics.
Answer
True
Brain tumor classification is based upon
location and histological characteristics.
Oncologic Tumors
Brain tumors
Benign or malignant
Classification is based upon location and
histological characteristics
Brain Tumors
Symptoms are dependent upon the location
and size of the lesion and the compression
of associated structures
Manifestations:
Localized or generalized neurologic
symptoms
Symptoms of increased ICP
Headache
Vomiting
Visual disturbances
Hormonal effects with pituitary adenoma
Loss of hearing, tinnitus, and vertigo with
acoustic neuroma
Diagnostic Evaluation
Neurologic examination
CT scan
MRI
PET scan
EEG
Cytological study of cerebral spinal
fluid
Biopsy
Medical Management
Specific treatment depends upon the type,
location, and accessibility of the tumor
Surgery
Goal is removal of tumor without increasing
neurologic symptoms or to relieve symptoms
by decompression
Craniotomy, transspenoidal surgery,
stereotactic procedures
Radiation therapy
Chemotherapy
Self-care deficit
Imbalanced nutrition
Anxiety
Interrupted family processes
Interventions
Encourage independence for as long as
possible
Measures to improve cognitive function
Allow patient to participate in decision making
Allow patient to express fears and concerns
Presence of family, friends, spiritual advisor,
and health care personnel may be supportive
Referral to counselor, social worker, home
health care, support groups
Referral for hospice care
Improving Nutrition
Oral hygiene before meals
Plan meals for times when patient is
comfortable and well rested
Measures to make mealtime as pleasant
as possible
Offer preferred foods
Dietary supplements
Daily weight
Record dietary intake
Question
Is the following statement True or
False?
Parkinsons disease is a slowly
progressing neurologic movement
disorder that eventually leads to
disability.
Answer
True
Parkinsons disease is a slowly
progressing neurologic movement
disorder that eventually leads to
disability.
Parkinsons Disease
Associated with decreased levels of dopamine due
to destruction of cells in the substantia nigra in the
basal ganglia; this effects the neurotransmission of
impulses
Manifestations: tremor, rigidity, bradykinesia,
postural instability, depression and other
psychiatric changes, dementia, autonomic
symptoms, sleep disturbances,
Medical management
Pharmacologic treatment
Surgical procedures
Other therapies
Pathophysiology of Parkinsons
Disease
Improving Mobility
Interventions
Alzheimer's Disease
AKA senile dementia
The most common cause of
dementia
A chronic, progressive, degenerative
brain disorder that effects 4.5 million
people in the United States
Research suggests oxidative stress
plays a role in the pathophysiology of
this disease
Amyotrophic Lateral
Sclerosis (ALS)
Lou Gehrigs disease
Loss of motor neurons in the anterior
horn of the spinal cord, and loss of
motor nuclei in the brainstem, cause
progressive weakness and atrophy of
the muscles of the extremities and
trunk. Weakness of the bulbar
muscles impairs swallowing and
talking. Respiratory function is also
impaired
Muscular Dystrophies
Incurable disorders characterized by
progressive weakening and wasting
of skeletal and voluntary muscles
Most are inherited disorders
Duchenne muscular dystrophy is the
most common and inherited as a
sex-linked trait
Relieving pain
Improving mobility
Monitoring and managing potential
complications
Promoting home and communitybased care