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Cerebro-Vascular Disorders

A ppt which features the nursing management for clients with Cerebrovascular disorders specifically CVA, HEAD INJURY and SPINAL INJURY.

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Cerebro-Vascular Disorders

  1. 1. Management of Patients withCerebrovascular Disorders Nelia B. Perez RN, MAEd, MSN PCU MJCN BSN 2012
  2. 2. Neurological System
  3. 3. Brain Anatomy• Cerebrum – Reasoning – Judgment – Concentration, – Motor, sensory, speech• Cerebellum – Coordination• Brainstem – Cranial nerves – Respiratory center – Cardiovascular center
  4. 4. Brain Anatomy Cont.
  5. 5. • 20% of CO Cerebral Blood Flow• Cerebral tissues – Have no oxygen or glucose reserves• Blood flows through Carotid Arteries to Circle of Willis
  6. 6. Intracranial Pressure (ICP)Composition A medical emergency that can• 80% brain tissue and water lead to: Brain hypoxia, herniation, death• 10% blood• 10% cerebrospinal fluid (CSF) Clinical ManifestationsIncreased ICP caused by: • Vomiting• Severe head injury/ Subdural • Headache hematoma • Blurred vision • Seizure• Hydrocephalus • Changes in behavior• Brain tumor • Loss of consciousness• Meningitis/Encephalitis • Lethargy• Aneurysm • Neurological symptoms• Status epilepticus/Stroke
  7. 7. Neurological Assessment• Rapid Neurological Assessment – Emergent situations – Sudden changes in neurologic status 1. LOC: first indicator of a decline in neurological function and increase in ICP (intracranial pressure); use the GCS 2. Pupils
  8. 8. 3. PUPILS Pupils equal and react normally Pupils react to light (slowly or blriskly) Dilated pupil (compressed cranial nerve II Bilateral dilated, fixed (ominous sign) Pinpoint pupils (pons damage or drugs)
  9. 9. Neuro-Diagnostic Tests CT SCAN• Routine labs• Radiology Tests – CT scan, MRI – Carotid ultrasound – Cerebral angiogram/ MRA Carotid US MRA
  10. 10. Neuro-Diagnostic Tests: Lumbar Puncture• Spinal needle inserted into SA• L3/L4 or L-4 /L-5 using strict asepsis – Obtain CSF specimens and pressure readings – To remove bloody or purulent CSF – Administer spinal anesthesia
  11. 11. Cerebrovascular Disorders• 53.6% 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.• Direct and indirect costs of stroke are billion
  12. 12. Prevention• Nonmodifiable risk factors – Age (over 55), male gender, African American race• Modifiable risk factors: – Hypertension: the primary risk factor – Cardiovascular disease – Elevated cholesterol or elevated hematocrit – Obesity – Diabetes – Oral contraceptive use – Smoking and drug and alcohol abuse
  13. 13. 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 (80% to 85%) – Hemorrhagic (15% to 20%)
  14. 14. 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
  15. 15. Pathophysiology
  16. 16. 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
  17. 17. Impaired comprehension &Left -Sided CVA: Memory R/T language and mathLEFT BRAIN DAMAGE R Hemianopsia Impaired speech (Aphasias) Aware of deficits Depression, Anxiety R Hemiplegia /paresis Impaired discrimination (R/L) Slow performance, Cautious
  18. 18. Right-sided CVA: Impaired judgmentRIGHT BRAIN DAMAGE L Hemianopsia Impulsive/Safety problems Rapid performance Short attention span L hemiplegia/paresis Denies/Minimizes problems Left-sided neglect Spatial-perceptual deficits
  19. 19. Types of Paralysis
  20. 20. Abnormal Visual Fields
  21. 21. Cerebrovascular Terms• Hemiplegia• Hemiparesis• Dysarthria• Aphasia: expressive aphasia, receptive aphasia• Hemianopsia
  22. 22. Transient Ischemic Attack (TIA)• Temporary neurologic deficit resulting from a temporary impairment of blood flow• “Warning of an impending stroke”• Diagnostic work-up is required to treat and prevent irreversible deficits
  23. 23. Carotid Endarterectomy
  24. 24. Carotid Endarterectomy
  25. 25. Treatment of Stroke: Thrombotic Stroke• Thrombolytic Therapy :• rtPA (recombinant tissue Plasminogen Activator- Retavase) – A clot-buster delivered intravenously; breaks up the clot allowing blood flow to return to the deprived area of the brain – Must be administered within 3 hours of the onset of clinical signs of ischemic stroke• Quick CT scan to see if stroke from clot or bleed
  26. 26. Treatment Cont:Acute phase: Long Term Drug Therapy To Prevent Stroke:• Anticoagulant - Heparin • Antiplatlet Drugs continuous infusion • ASA, Ticlid, Persantine, Plavix• Osmotic Diuretics – to reduce brain swelling • Anticoagulants – Coumadin• Anticoagulants – Lovenox contraindicated in • Antiepileptics Hemorrhagic Strokes
  27. 27. Treatment Cont:Surgical Treatment For Bleeds (InterventionalRadiology) • Angiograms to see arteries and detect bleeding sites • Aneurysm clips and coils
  28. 28. Surgical Removal:Hematoma
  29. 29. Preventive Treatment and Secondary Prevention• Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease• Carotid endarterectomy• Anticoagulant therapy• Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid)• Statins• Antihypertensive medications
  30. 30. Medical Management During Acute Phase of Stroke• Prompt diagnosis and treatment• Assessment of stroke: NIHSS assessment tool• Thrombolytic therapy – Criteria for tissue plasminogen activator (tPA): – IV dosage and administration – Patient monitoring – Side effects: potential bleeding
  31. 31. Medical Management During Acute Phase of Stroke (cont.)• Elevate HOB unless contraindicated• Maintain airway and ventilation• Provide continuous hemodynamic monitoring and neurologic assessment• See the guidelines in Appendix B
  32. 32. 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
  33. 33. Hemorrhagic Stroke (cont.)• 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 injures brain tissue
  34. 34. Manifestations• Similar to ischemic stroke• Severe headache• Early and sudden changes in LOC• Vomiting
  35. 35. Medical Management• Prevention: control of hypertension• Diagnosis: CT scan, cerebral angiography, and 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
  36. 36. Intracranial Aneurysms
  37. 37. NURSING MANAGEMENT•Improving Mobility and Preventing Joint Deformities•Managing Sensory-Perceptual Difficulties•Attaining Bowel and Bladder Control•Improving Thought Processes•Improving Communication•Maintaining Skin Integrity•Improving Family Coping•Helping the Patient Cope with Sexual Dysfunction
  38. 38. Nursing Process—Assessing the Patient Recovering From an Ischemic Stroke• Acute phase – Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: LOC and motor, speech, and eye symptoms – Monitor for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation• After the stroke is complete – Focus on patient function; self-care ability, coping, and teaching needs to facilitate rehabilitation
  39. 39. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke• Impaired physical mobility• Acute pain• Self-care deficits• Disturbed sensory perception• Impaired swallowing• Urinary incontinence
  40. 40. Nursing Process—Diagnosis of the Patient Recovering From an Ischemic Stroke (cont.)• Disturbed thought processes• Impaired verbal communication• Risk for impaired skin integrity• Interrupted family processes• Sexual dysfunction
  41. 41. Collaborative Problems/Potential Complications• Decreased cerebral blood flow• Inadequate oxygen delivery to brain• Pneumonia
  42. 42. Nursing Process—Planning Patient Recovery After an Ischemic Stroke• Major goals include: – Improved mobility – Avoidance of shoulder pain – Achievement of self-care – Relief of sensory and perceptual deprivation – Prevention of aspiration – Continence of bowel and bladder
  43. 43. Nursing Process—Planning Patient Recovery After an Ischemic Stroke (cont.)• Major goals include (cont): – Improved thought processes – Achievement of a form of communication – Maintenance of skin integrity – Restoration of family functioning – Improved sexual function – Absence of complications
  44. 44. Interventions• Focus on the whole person• Provide interventions to prevent complications and to promote rehabilitation• Provide support and encouragement• Listen to the patient
  45. 45. Impaired Communication• Aphasia-loss of use and • Nursing Interventions: comprehension • Assess ability to speak and – Receptive aphasia- understand Wernicke’s area • Provide + reinforcement (sensory) • Picture board – Expressive aphasia – • Repeat names of objects Broca’s area (motor) routinely • Allow plenty of time for – Global aphasia- mixed client to answer
  46. 46. Picture Communication Board
  47. 47. Improving Mobility and Preventing Joint Deformities• Turn and position the patient in correct alignment every 2 hours• Use splints• Practice passive or active ROM 4 to 5 times day• Position hands and fingers• Prevent flexion contractures• Prevent shoulder abduction• Do not lift by flaccid shoulder• Implement measures to prevent and treat shoulder problems
  48. 48. Positioning to Prevent Shoulder Abduction
  49. 49. Prone Positioning to Help Prevent Hip Flexion
  50. 50. Improving Mobility and Preventing Joint Deformities• Perform passive or active ROM 4 to 5 times day• Encourage patient to exercise unaffected side• Establish regular exercise routine• Use quadriceps setting and gluteal exercises• Assist patient out of bed as soon as possible: assess and help patient achieve balance and move slowly• Implement ambulation training
  51. 51. Interventions• Enhance self-care – Set realistic goals with the patient – Encourage personal hygiene – Ensure that patient does not neglect the affected side – Use assistive devices and modification of clothing• Provide support and encouragement• Implement strategies to enhance communication: see Chart 62-4• Encourage the patient with visual field loss to turn his head and look to side
  52. 52. Interventions (cont.)• Nutrition – Consult with speech therapist or nutritionist – Have patient sit upright to eat, preferably OOB – Use chin tuck or swallowing method – Feed thickened liquids or pureed diet• Bowel and bladder control – Assess and schedule voiding – Implement measures to prevent constipation: fiber, fluid, and toileting schedule – Provide bowel and bladder retraining
  53. 53. Nursing Process—Assessment of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm• Complete an ongoing neurologic assessment: use neurologic flow chart• Monitor respiratory status and oxygenation• Monitor ICP• Monitor patients with intracerebral or subarachnoid hemorrhage in the ICU• Monitor for potential complications• Monitor fluid balance and laboratory data• Reported all changes immediately
  54. 54. Nursing Process—Diagnosis of the Patient With a Hemorrhagic Stroke/ Cerebral Aneurysm• Ineffective tissue perfusion (cerebral)• Disturbed sensory perception• Anxiety
  55. 55. Collaborative Problems/Potential Complications• Vasospasm• Seizures• Hydrocephalus• Rebleeding• Hyponatremia
  56. 56. Nursing Process—Planning Care of the Patient With a Hemorrhagic Stroke/Cerebral Aneurysm• Goals may include: – Improved cerebral tissue perfusion – Relief of sensory and perceptual deprivation – Relief of anxiety – Absence of complications
  57. 57. Aneurysm Precautions• Absolute bed rest• Elevate HOB 30° to promote venous drainage or keep the bed flat to increase cerebral perfusion• Avoid all activity that may increase ICP or BP; implement Valsalva maneuver, acute flexion, and rotation of the neck or head• Exhale through mouth when voiding or defecating to decrease strain
  58. 58. Aneurysm Precautions (cont.)• Nurse provides all personal care and hygiene• Provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV, and no radio• Prevent constipation• Restrict visitors
  59. 59. Interventions• Relieve sensory deprivation and anxiety• Keep sensory stimulation to a minimum for aneurysm precautions• Implement reality orientation• Provide patient and family teaching• Provide support and reassurance• Implement seizure precautions• Implement strategies to regain and promote self-care and rehabilitation
  60. 60. Home Care and Teaching for the Patient Recovering From a Stroke• Prevention of subsequent strokes, health promotion, and implementation of follow-up care• Prevention of and signs and symptoms of complications• Medication teaching• Safety measures• Adaptive strategies and use of assistive devices for ADLs
  61. 61. Home Care and Teaching for the Patient Recovering From a Stroke (cont.)• Nutrition: diet, swallowing techniques, and tube feeding administration• Elimination: bowel and bladder programs and catheter use• Exercise and activities: recreation and diversion• Socialization, support groups, and community resources• See Chart 62-6
  63. 63. SEIZURESeizures sudden, excessive, disorderly electricaldischarges of the neurons.EFFECTS OF SEIZURE: alteration inthe following mental status LOC sensory and speciual senses motor funtion
  64. 64. TYPES OF SEIZUREGRAND MAL most common type of seizureThe phases are asfollows:
  65. 65. AURA (flashing light, smells, spots before eyes,dizziness) TONIC – CLONIC PHASE Tonic phase- contraction Clonic phase – jerking movements Accompanied by dyspnea, drooling of saliva, urinary continence POST-ICTAL PHASE Cessation of tonic-clonic movementCharacterized by exhaustion, headache, drowsiness, deep sleep of 1-2, disorientation
  66. 66. PETIT MAL (Absence Seizure or Little Sickness)o not preceeded by AURAo little or no toni-clonico charac blank facial expression, automatism like lip-chewing, cheek smackingo regain of consciousness as rapid as it was lot for 10-20secso usually occurs during childhood and adolescenceJACKSONIAN / FOCAL SEIZUREo common for patients with organic brain lesion like frontal lobe tumoro aura is present(numbness, tingling, crawling feeling)o charac by tonic-clonic movements of group muscle e.g. Hands, foot, or face then it proceeds toi grand mal seizureFEBRILE SEIZUREo this is common for children <5yo, when temp. is risingPSYCHOMOTOR SEIZUREo aura is present (hallucinations or illusion)o charac by mental clouding (being out of touch with the envt)o appears intoxicatedo the client may commit violent or antisocial acts, e.g. Going naked public, running
  69. 69. CAUSES not taking anticonvulsant medication also caused by an underlying condition, such as meningitis, sepsis, encephalitis, brain tumor, head trauma, extremely high fever, low glucose levels, or exposure to toxins.
  70. 70. Symptoms The characteristic symptom of statusepilepticus is seizures occurring so frequently that theyappear to be one continuous seizure. These seizuresinclude severe muscle contractions and difficultybreathing. Permanent damage can occur to the brain andheart if treatment is not immediate. A personssymptoms can range from simply appearing dazed to themore serious muscle contractions, spasms, and loss ofconsciousness. The specific symptoms depend on theunderlying type of seizure.
  71. 71. TWO CATEGORIES OF STATUS EPILEPTICUSCONVULSIVEEpilepsia partialis continua is a variant it involve an hour, dayor even week-long jerking. It is a consequence of vasculardisease, tumor or encepalitis and drug resistant.NONCONVULSIVEComplex Partial Status Epilepticus CPSE and absence statusepilepticus are rare forms of the condition which are markedby nonconvulsive seizures. In the case of CPSE, the seizure isconfined to a small area of the brain, normally the temporallobe. But the latter, absence status epilepticus, is marked by ageneralised seizure affecting the whole brain, and an EEG isneeded to differentiate between the two conditions. Thisresults in episodes characterized by a long-lasting stupor,staring and unresponsiveness.
  72. 72. HOW IT IS DIAGNOSED? Status epilepticus is diagnosed according to itscharacteristics symptoms. The doctor will order test tolook for the cause of the seizures. This may include blood test ECG to check for an abnormal heart rhythm EEG to check electrical activity in the brain MRI or CT scan to check for braing tumord orsigns of damage to the brain tissue.
  73. 73. Nursing Diagnosis High Risk for Injury r/t Seizure Activity Individual Coping r/t perceive social stigma, potential changes in employment
  74. 74. MEDICATIONS diazepam (Valium) this will stop motor movement Phenytoin (Dilatin) Phenobarbital (Barbita) Paraldehyde Thiopentahl sodium (Pentotal sodium) General anesthesia may also be used as a treatment of last resort to stop seizure activity
  76. 76. PREVENTING INJURYinjury prevention for the patient with seizure is a PRIORITY.  patient should be placed on the floor and remove any obstructive items  patient should never be forced into a position  pad side rails  do not attempt to pry open jaws that are clenched in a spasm to insert anything.  if possible place the patient on one side with head flexed forward,
  78. 78. REDUCING FEARS OF SEIZUREFear that a seizure may occur unexpectedlycan be reduced by the patients adherence tothe prescribed treatment regimen.Cooperation of the patient and family andtheir trust in the prescribed regimen areessential for control of seizuresPeriodic monitoring is necessary to ensurethe adequacy of the treatment regimen andto prevent the side effects. back
  79. 79. IMPROVING COPING MECHANISMSit has been noted that the social,psychological, and behavioral problemsfrequently accompanying the attack can bemore handicap than the actual seizure.Counselling assists the individual and family tounderstand the condition and the limitationsimposed by it. Social and recreationalopportunities are good for mental health .Nurses can improve the quality of life forpatients with the disorder by educating themand their family about the symptom and alsothe management.
  80. 80. PROVIDING PATIENT AND FAMILY EDUCATIONOngoing education and encouragementshould be given to patients to enable them toovercome these feelings. The patient andfamily should be educated about themedications as well as care during a seizure. perhaps the most valuable facets are education and efforts to modify the attitudes of the patient and family toward the disorder.
  81. 81. MONITORING AND MANAGING POTENTIAL COMPLICATIONSPatients should have plan to haveserum drug levels drawn at regularintervals. The patient and family areinstructed about the side effects andare given specific guidelines toassess and report signs andsymptoms indicating medicationoverdose.
  82. 82. TEACHING PATIENTS SELF CARELike thorough oral hygiene after eachmeal, gum massage, daily flossing, andregular dental care The patient is also instructed to informall health care providers of themedication being taken because of thepossibility of drug interactions. Anindividualized comprehensive teachingplan is needed to assist the patient andfamily to adjust to this chronic disorder.
  83. 83. Head Injury
  84. 84. INCIDENCES Other transport, 2% Bicycle, 3% Suicide, 1% Other , 7% Fall, 28% Unknown, 9%Assault, 11% Traffic accident, Struck, 19% 20%
  85. 85. 1. Dura mater2. Arachnoid3. Venae sagittalis superiores cerebri4. Sinus sagittalis superior and Falx cerebri
  86. 86. Duramater
  87. 87. Levels of consciousness Level DescriptionConscious NormalConfused Disoriented; impaired thinking and responses Disoriented; restlessness, hallucinations,Delirious sometimes delusions Decreased alertness; slowed psychomotorObtunded responses Sleep-like state (not unconscious); little/noStuporous spontaneous activityComatose Cannot be aroused; no response to stimuli
  88. 88. symptoms of mild head injury– raised, swollen– bruise– small, superficial cut in the scalp– headache
  89. 89. symptoms of moderate to severe headpale skin color– confusion – injury– loss of consciousness – seizures– blurred vision– severe headache – behavior changes– vomiting – blood or clear fluid– loss of short-term memory,– slurred speech draining from the– difficult walking ears or nose– dizziness– weakness in one side or – one pupil looks area of the body larger than the– sweating other eye – deep cut or laceration in the scalp – open wound in the head
  90. 90. Prognosis
  91. 91. Indication for admission• Minor head injury – Focal neurodeficit – Post traumatic seizure – Skull fracture• Moderate head injury• Severe head injury
  92. 92. InvestigationImaging• Skull x-raysStudies• CT scan of the head• Magnetic resonance imaging –MRI may be used later for additional information about a brain injury.• Other x-rays may be performed to
  93. 93. • Initial blood tests – blood alcohol level for any patient who has an altered level of consciousness –Coagulation abnormalities, a prothrombin time (PT), partial thromboplastin time (PTT), and a platelet count – Bleeding time assessment may
  94. 94. Urgent Scan in adult if any of – GCS < when first assessed – GCS< two hours after injury – Suspected open or depressed skull fracture – Signs of base of skull fracture** – Post-traumatic seizure – Focal neurological deficit – > episode of vomiting – Coagulopathy + any amnesia or LOC since injury**Signs of basal skull fracture: panda eyes, CSF leakage (ears or nose) orBattles sign (bruising behind the ear in cases of basal skull
  95. 95. 8 hours after injury, a CT scan is also recommendedif there is either – More than minutes of amnesia of events before impact – Or any amnesia or LOC since injury if • Aged ≥ years • Coagulopathy or on warfarin • Dangerous mechanism of injury –RTA as pedestrian –RTA - ejected from car –Fall > m or > stairs
  96. 96. Nursing Assessment – History of Trauma – Time, cause, direction and force of the blow- Loss of consciousness, duration Assess LOC – Glasgow Coma Scale – Response to verbal commands or tactile stimuli- Pupillary response to light- Motor Function Vital Signs – Monitor for signs of increased ICPMotor Function- Move extremities, hand grasp, pedal push, speech
  97. 97. Emergency Care• First consideration is to ensure a clear airway• Keep spine straight; patient is carefully turned to a lateral or semiprone position• Flexion or hypertension should be avoided in case there is a cervical fracture• Keep patient covered, quiet and undistrubed
  98. 98. General Care:• Establish airway• Prevent aspiration pneumonia• Check for cardiovascular complications• Serach for new evidence of spinal injuries. Do not allow the newly injured patient to move about even though he/she is conscious.• Observe the skull and scalp injuries. cover open head wound with the cleanest material avaialble at the scene• Prevent infection. Gove prophylactic dose for tetanus.
  99. 99. General Care (Cont)• Observe for CSF leakage – otorrhea, rhinorrhea, Battle’s sign-tenderness and eccymosis or mastoid bone especially for basilar skull fracture• Obeserve for signs and symptoms of increased ICP; watch for nuclear rigidity.• Control restlessness and pain. Narcotics are contraindicated following head injury, and are not given if ICP is prevent.• Maintain fluid/electrolyte; acid-base balance and adequate nutrition. Record I & O.
  100. 100. Management of Increased ICP• - True emergency requiring prompt treatment - Monitor ICP - Intraventricular catheter, subarachnoid bolt, epidural catheter – Reduce Cerebral Edema – Osmotic diuretics (mannitol) - Corticosteroids ( dexamethasone) Maintain cerebral perfusion – Maintain cardiac output with fluids and dobutamine - Reduce CSF and blood volume – Drain CSF - Hyperventilation – results in vasoconstriction
  101. 101. Management of ICP• Control Fever – Fever increases cerebral metabolism and edema - Antipyretics, cooling blanket - Avoid shivering which increases ICP Reduce metabolic demands – Barbiturates decrease ICP - Muscle relaxants to paralyze patient
  102. 102. Ineffective airway clearance related to accumulation of secretions and decreased LOC• Maintain patient airway – Suction carefully - Discourage coughing (causes increase in ICP) - Elevate HOB 30 degrees - Guard against aspiration - Monitor ABGs to assess ventilation
  103. 103. Ineffective breathing pattern related to neurological dysfunction• Monitor constantly for respiratory irregularities – Cheyne Stokes, hyperventilation, Effective suctioning HOB 30 degrees Position patient lateral or semi prone
  104. 104. Altered cerebral tissue perfusion related to increased intracranial pressure• Position patient to reduce ICP : – head in midline position to promote venous drainage - Elevate HOB 30 degrees - Avoid extreme rotation or flexion of neck - Avoid extreme hip flexion
  105. 105. • Prevent straining - Stool Softeners - High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli
  106. 106. Risk for fluid volume deficit related todehydration procedures anddecreased LOC Monitor electrolytes - Brain damage can produce metabolic and hormonal dysfunctions Monitor intake and output Monitor IV fluids carefully Monitor urine for acetone, osmolality Record daily weights
  107. 107. Altered nutrition related to metabolic changes, inadequate intake.• Start enteral feedings when patient stabilized - NG feeding unless CSF rhinorrhea - Elevate HOB 30 degrees - Aspirate for residual before feeding to prevent distention and aspiration - Use pump to regulate feeds
  108. 108. Risk for injury related todisorientation, restlessness and braindamage.• Assess for cause of restlessness - Often present as patient emerges from coma - May be due to hypoxia, fever, pain, full bladder Use padded side rails or wrap hands in mitts - Avoid restraints as straining against them increases ICP Minimize environmental stimuli - Low lights, limit visitors, speak calmly - Orient patient frequently
  109. 109. Risk for altered body temperature related to damage to temperature - regulating mechanism• Monitor temperature every 4 hrs. - Can be increased as result of: Damage to hypothalmus Cerebral irritation from hemorrhage Infection Reduce temperature with acetaminophen and cooling blankets If infection suspected – - Culture potential sites - Start antibiotics
  110. 110. Potential for impaired skin integrity related to bed rest, immobility, unconsciousness• Assess all body surfaces every 8 hrs. Turn every 2-4 hrs Provide skincare every 4 hrs Assist patient to chair (if possible)
  111. 111. Spinal cord injuries:• cause myelopathy or damage to nerve roots or myelinated fiber tracts that carry signals to and from the brain.• Depending on its classification and severity, this type of traumatic injury could also damage the gray matter in the central part of the cord, causing segmental losses of interneurons and motorneurons.
  112. 112. • Primary prevention important. – Drive slow, use seat belts & helmets, water safety, protective devices for athletes, prevent falls.
  113. 113. AssessmentClinical manifestations depend on type and level of injury – Below level of injury there is total loss of sensory and motor paralysis, loss of bladder and bowel control, loss of sweating and vasomotor tone.– Complains of acute pain in back or neck which may radiate along involved nerve. – Respiratory problems (T1-T11 and diaphragm are used in breathing) – intercostal muscles. – above C4 – phrenic nerve – paralysis of diaphragm.
  114. 114. • Respiratory status – observe respiratory pattern, strength of cough, auscultate lungs.• Changes in motor or sensory function – Squeeze hand, spread fingers, move toes. – Pricking skin with dull item, start at shoulders.
  115. 115. Signs of spinal shock• – Complete loss of all reflexes, motor, sensory and autonomic below level of injury.
  116. 116. Management of Spinal Cord Injuries• High dose corticosteroids within 8 hrs of injury – Methylprednisolone, loading dose followed by infusion for 23 hrs.• Oxygen, intubation if necessary• Skeletal reduction and traction – Immediate immobilization – Reduction of dislocations (restore to normal position) – Stabilization of vertebral column. – Traction used in cervical fractures.• Surgery.
  117. 117. Nursing Interventions • Promote adequate breathing and airway clearance. – Monitor pulse oximetry, ABGs. – Clear bronchial and pharyngeal secretions – Use suctioning cautiously – can stimulate vagus nerve causing bradycardia. - Chest Physiotherapy, breathing exercises. – Humidification. – Adequate hydration. – Assess for signs of respiratory infection. – Intubate and ventilate.
  118. 118. Improve Mobility• Maintain proper alignment at all times.• Reposition frequently.• Prevent foot drop – wear shoes.• Prevent external rotation of hip joints – trochanterrolls.• Prevent contractures – range of motion exercises 4times daily.• If injury above midthoracic level, monitor BP whenturning (loss of sympathetic control of peripheralvasoconstriction).
  119. 119. Maintain Urinary and Bowel Function • Intermittent or indwelling catheter to avoid overdistention of bladder. – Urinary retention results from bladder becoming atonic. • Intake and output. • Insert NG tube to relieve distention and prevent aspiration. – Paralytic ileus usually develops. – Bowel activity usually returns within 1 week. • High fibre, high protein diet. • Stool softener.
  120. 120. Managing Potential Complications • Thrombophlebitis and pulmonary embolism – Assess for symptoms (chest pain, dyspnea, ABGs) – Measure circumference of thighs and calves daily – Anticoagulation – low dose heparin – Pressure stockings. – Adequate hydration• Orthostatic Hypotension – BP unstable and low for first 2 weeks. – Monitor closely when repositioning patient. – Reposition slowly, wear pressure stockings.