Tca 3

TCA 3

STROKE (CVA) - 3RD LEADING CAUSE OF DEATH IN THE U.S. - #1 CAUSE OF LONG-TERM DISABILITY - OVER 700,000 STROKES PER YEAR…1/3 DIE AS A RESULT - $40 BILLION IN MEDICAL COSTS AND LOST PRODUCTIVITY - 4.7 MILLION STROKE SURVIVORS ALIVE TODAY – MANY OF THEM REQUIRE SOME ASSISTANCE WITH THEIR ADL’S WHAT IS A STROKE? - BLOOD FLOW TO THE BRAIN IS SUDDENLY INTERRUPTED - BRAIN CELLS IN THE IMMEDIATE AREA DIE - LOSS OF BRAIN FUNCTION IN THAT AREA - CAN LEAD TO DISABILITY (WILL DEPEND ON THE AREA OF AND HOW MUCH OF THE BRAIN IS INVOLVED) STROKE ISCHEMIC – LOW BLOOD FLOW STROKES (MOST COMMON - ACCOUNTS FOR 85% OF STROKES) O THROMBOTIC – CLOT FORMED WITHIN THE BRAIN CAUSES OCCLUSION OF BLOOD TO THE BRAIN – ATHROSCLEROTIC PLAQUE FORMS WITHIN THE WALL AND IT BREAKS OFF. O EMBOLIC – CLOT FORMED SOMEWHERE ELSE IN THE BODY (SUCH AS DVT, ATRIAL FIB) CAUSES

TYPES OF

-

OCCLUSION OF BLOOD TO THE BRAIN

-

HEMORRHAGIC –

USUALLY OCCURS DUE TO

HTN (MAIN

CAUSE), AND

CEREBRAL ATHROSCLEROSIS (PATIENTS – BECAUSE THE TISSUE DEATH IN AN WITH A HEMORRHAGIC STROKE). WITH A

THAT SUFFER THIS TYPE OF STROKE TYPICALLY HAVE POORER OUTCOMES ISCHEMIC STROKE HAPPENS AT A MUCH SLOWER RATE THAN HEMORRHAGIC STROKE, THERE IS A RAPID INCREASE IN O

INTRACEREBRAL – HEMORRHAGE

ICP.

WITHIN BRAIN TISSUE

–

A VESSEL WITHIN THE ACTUAL BRAIN TISSUE

THAT RUPTURES AND BEGINS TO BLEED. O

SUBARACHNOID – HEMORRHAGE IN HYDROCEPHALUS DUE TO BLOCKAGE RUPTURED ANEURISM.

SUBARACHNOID

LAYER

OF VILLI THAT DRAIN

RISK FACTORS FOR STROKE - AGE – RISK DOUBLES EVERY DECADE AFTER 50 - SEX – MALES MORE LIKELY TO HAVE BUT FEMALES

OF

THE

CSF) –

BRAIN

(ALSO

CAN

CAUSE

MOST OFTEN CAUSED BY A

BECAUSE THEY HAVE THEM MUCH LATER IN LIFE ARE MORE

LIKELY TO DIE FROM A STROKE

-

-

-

RACE – AFRICAN AMERICAN HEREDITY – HAVE FOUND GENETIC MARKERS HYPERTENSION – BIGGEST RISK FACTOR – ABOUT 90% OF STROKE PATIENTS HAVE A HISTORY OF HTN HISTORY OF A PRIOR STROKE TIA (TRANSIENT ISCHEMIC ATTACK) SMOKING (DOUBLES RISK FOR ISCHEMIC STROKE) DIABETES CAROTID ARTERY DISEASE – THE CAROTID ARTERIES RUN ALONG THE NECK AND SUPPLY BLOOD TO THE BRAIN. HEART DISEASE HIGH CHOLESTEROL OBESITY AND INACTIVITY SOCIOECONOMIC STATUS – DECREASED ACCESS TO HEALTH CARE GEOGRAPHY – SOUTHEAST IS THE STROKE BELT OF THE UNITED STATES ALCOHOL ABUSE ILLICIT DRUG USE – COCAINE PHENYLPROPANOLAMINE (PPA) USE (HEMORRHAGIC STROKE) – FOUND IN DIMETAPP 1

TCA 3

LIFESPAN CONSIDERATIONS - ELDERLY AT GREATEST RISK - CHILDREN WITH SICKLE CELL AT RISK – THEIR RBC’S ARE MISHAPED AND THEY HAVE CLOTTING ISSUES - ANYONE WITH NUMEROUS RISK FACTORS PATHO OF STROKE (VARIES DEPENDING UPON WHAT TYPE OF STROKE THAT IT IS) - ISCHEMIC (LOW BLOOD FLOW TO THE BRAIN) O THE ARTERIES – BLOCK DUE TO ATHEROSCLEROSIS, CAN NARROW WITH AGE O THE HEART – DIAGNOSIS OF A FIB, VALVE DISEASE, SEPTAL DEFFECTS OR ANYTHING THAT CAN CAUSE A CLOT TO FORM AND TRAVEL TO THE BRAIN CAUSING OCCLUSION OF BLOOD FLOW. HEART FAILURE CAN LEAD TO A LOW BLOOD FLOW ISCHEMIC STROKE – IF YOU ARE NOT HAVING ENOUGH CARDIAC OUTPUT TO PERFUSE THE BRAIN. O THE BLOOD – SICKLE CELL, DIC, LOW BLOOD VOLUME, ANYTHING THAT CAUSES OXYGEN DEPRIVATION TO THE BRAIN BY BLOCKING BLOOD FLOW. ANYTHING THAT IS GOING TO CAUSE THE BLOOD TO BE MORE PRONE TO CLOTTING. LOW BLOOD VOLUME FROM TRAUMA WHERE YOU ARE NOT GETTING ENOUGH BLOOD FLOW AND PERFUSION TO THE BRAIN CAN LEAD TO AN ISCHEMIC STROKE. O

-

COMBINATION

HEMORRHAGIC O HIGH BLOOD PRESSURE (UNCONTROLLED HYPERTENSION), ATHEROSCLEROSIS, VESSEL DEFECTS  BY FAR UNCONTROLLED HYPERTENSION IS THE MAJOR CAUSE OF A HEMORRHAGIC STROKE. ABOUT 80% OF THE TIME THE HEMORRHAGIC STROKE IS DUE TO A SMALL VESSEL RUPTURE FROM UNCONTROLLED HYPERTENSION. THE OTHERS ARE CAUSED BY RUPTURE OF THOSE ARTERIOVENOUS MALFORMATIONS (DEVELOP IN THE FETAL STAGE BUT MAY NOT MANIFEST FOR YEARS).  AVM RUPTURE AND INTRACRANIAL INTRACEREBRAL ANEURISM RUPTURE ARE OTHER THINGS THAT CAN LEAD TO HEMORRHAGIC STROKE.  VESSEL RUPTURE  BLEEDING  INCREASED ICP  VASOSPASM  YOU HAVE VESSEL RUPTURE, YOU HAVE HEMORRHAGING INTO THE BRAIN, IT LEADS TO INCREASED INTRACRANIAL PRESSURE AND AS A DEFENSE MECHANISM WITH THE VESSEL RUPTURE, THE BODY’S ATTEMPT TO CONTROL THE HEMORRHAGE IS VASOSPASMS.

THE

VESSELS ACTUALLY CLAMP DOWN WITHIN THE BRAIN TO TRY TO CONTROL THE BLEED, BUT THIS CAN LEAD TO ISCHEMIC STROKE (CUTTING OFF BLOOD SUPPLY TO THE BRAIN)



IN

AN ATTEMPT TO SAVE ITSELF THE VESSELS SPASM TO STOP BLEEDING WHICH ENDS UP

CAUSING AN ISCHEMIC STROKE DUE TO BLOCKAGE



VERY POOR PROGNOSIS WITH A HEMORRHAGIC STROKE

SYMPTOMS OF STOKE - SUDDEN NUMBNESS OR WEAKNESS OF THE FACE, ARM OR LEG – ESPECIALLY ALL ON ONE SIDE - SUDDEN CONFUSION, TROUBLE SPEAKING, OR TROUBLE UNDERSTANDING SPEECH (EXPRESSIVE OR RECEPTIVE APHASIA) - SUDDEN TROUBLE SEEING IN ONE OR BOTH EYES - SUDDEN TROUBLE WALKING, DIZZINESS, LOSS OF BALANCE OR COORDINATION - SUDDEN SEVERE HEADACHE WITH NO KNOWN CAUSE (ESPECIALLY WITH HEMORRHAGIC STROKE). PEOPLE WITH INTRACRANIAL ANEURISM RUPTURES OR SOME OTHER TYPE OF INTRACEREBRAL HEMORRHAGE OR HEMORRHAGIC

I HAVE EVER HAD. THEY VERY QUICKLY BECOME THIS CAN BE VERY LIFE THREATENING AND GET FATAL VERY QUICKLY.

STROKE WILL STATE THAT THIS IS THE WORST HEADACHE THAT UNCONSCIOUS AND UNRESPONSIVE.

PRIMARY STOKE PREVENTION 2

TCA 3

-

AS

NURSES WE KNOW THAT PRIMARY PREVENTION IS WHAT WE WOULD LIKE TO SEE.

PREVENT STROKES BEFORE THEY HAPPEN.

-

WE WOULD THIS IS GOING TO FOCUS ON COMMUNITY EDUCATION:

LIKE TO

KNOW RISK FACTORS PRACTICE HEALTHY EATING HABITS EXERCISE REGULARLY LIMIT ALCOHOL AVOID CIGARETTES AND ILLICIT DRUGS DON’T DO ANYTHING THAT CAN SEVERELY OR CONSISTENTLY VASOCONSTRICT YOUR VESSELS SEE PHYSICIAN REGULARLY FOR MANAGEMENT OF CHRONIC DISEASE’S (HTN, DIABETES, CVD). MANAGEMENT OF ALL OF THESE DISEASES THAT CAN LEAD TO STROKE IS CONSIDERED PRIMARY PREVENTION.

STARTING

TO CHARACTERIZE STROKES AS BRAIN ATTACKS SO THE PUBLIC WILL POSSIBLY BETTER UNDERSTAND THE

URGENCY OF THE SITUATION.

ENDARECTOMY FOR PREVENTION OF ISCHEMIC STROKE - INDICATION FOR CLIENTS THAT HAVE HAD A TIA – STENOSIS. - PROCEDURE – GO INTO THE CAROTID ARTERY AND

SMALL ISCHEMIC STROKE

–

DUE TO CAROTID ARTERY

REMOVE ATHEROSCLEROTIC TISSUE FROM THE VESSEL

WALLS

-

POTENTIAL

COMPLICATIONS

– STROKE,

HEMORRHAGE, CRANIAL NERVE INJURY, HYPERPERFUSION, INFECTION,

HEMATOMA AT THE SITE WHICH WOULD MEAN WE WOULD HAVE TO WORRY ABOUT AIRWAY PROBLEMS (WE WANT TO KEEP A TRACH TRAY CLOSE BY) O

USUALLY

THESE CLIENTS WILL BE IN

THESE CLIENTS GO HOME WITHIN

ICU. THERE

ICU

24

OVERNIGHT

-

DUE TO POSSIBLE COMPLICATIONS

HOURS AFTER SURGERY.

SOME

–

MOST OF

GO HOME DIRECTLY FROM THE

ARE SERIOUS COMPLICATIONS THAT CAN OCCUR FROM THIS SURGERY, BUT USUALLY IF

THEY ARE GOING TO OCCUR, THEY OCCUR DURING SURGERY AND IT IS EASILY RECOGNIZED RIGHT AFTER SURGERY.

SO

ONCE THEY HAVE GOTTEN THROUGH THE

24

HOUR PERIOD, MANY TIMES THEY

WILL GO ON HOME O

HYPERPERFUSION

SYNDROME

–

STOPPED UP CAROTID ARTERY.

BECAUSE THE BRAIN IS USED TO HAVE A LOW BLOOD FLOW FROM A

THE

VESSELS BECOME DILATED AND IN ORDER TO TRY TO GET AS

MUCH BLOOD FLOW AS THEY CAN FROM THE CAROTID ARTERY THAT IS STOPPED UP. OPEN UP THE CAROTID ARTERY AND GET GOOD BLOOD FLOW GOING BACK. HAVE A HARD TIME ADJUSTING AND THEY REMAIN DILATED.

YOU

WELL WHEN THEY SOMETIMES THESE VESSELS

CAN HAVE ACTUAL VESSEL RUPTURE

DUE TO THIS SUDDEN INCREASE IN BLOOD PRESSURE/BLOOD FLOW ON THAT SIDE.

-

NURSING MANAGEMENT O MONITOR B/P –

KEEP NORMOTENSIVE

–

DON’T WANT THIS PERSON TO HAVE HIGH OR LOW BLOOD

PRESSURE O O

TELEMETRY – MUST WATCH FOR DYSRHYTMIAS DUE TO OTHER DISEASE PROCESS (CAD) NEURO CHECKS - ↓ LOC (1ST SIGN OF PROBLEMS) – NOTIFY THE NEUROSURGEON IMMEDIATELY IF THEY BEGIN TO HAVE A DECREASE IN THEIR LOC AFTER THIS SURGERY. IT MIGHT INDICATE THAT THEY ARE HAVING A STROKE OR THAT THEY HAVE DEVELOPED HYPERPERFUSION SYNDROME AND HAVE BEGUN TO HEMORRHAGE OR SOME OTHER SERIOUS COMPLICATION.

O

O

MONITOR FOR CRANIAL NERVE DAMAGE – MOVEMENT OF EYES. WATCH HOARSE, HAS SOME FACIAL ASSYMETRY, OR SWALLOWING PROBLEMS. AIRWAY PATENCY

TO SEE IF THE CLIENT IS

SECONDARY PREVENTION - KNOW SIGNS AND SYMPTOMS OF STOKE - CALL 911 IF SYMPTOMS OCCUR 3

TCA 3

-

-

INITIAL DIAGNOSTIC TEST = CT SCAN (DETERMINES THE TYPE OF STROKE) PROMPT TREATMENT IMPROVES CHANCES FOR RECOVERY

CLINICAL MANIFESTATIONS OF STROKES --- PG 1890 (CHART) - MOTOR LOSS O HEMIPLEGIA – PARALYSIS OF 1 SIDE O HEMIPARESIS – WEAKNESS OF 1 SIDE O ATAXIA – INCOORDINATION OF MOVEMENT, SUCH AS AN UNSTEADY GAIT (UPPER EXTREMITIES MAY ALSO BE ATAXIC) O DYSPHASIA – DIFFICULTY SWALLOWING - COMMUNICATION LOSS O DYSARTHRIA – DIFFICULTY FORMING THE WORDS DUE TO MUSCLE WEAKNESS OR PARALYSIS O APHASIA – DIFFICULTY EXPRESSING OR RECEPTION OF THOUGHTS – DIFFICULTY FINDING THE WORDS THAT THEY WANT TO USE DUE TO THE BRAIN INVOLVEMENT OF THE SPEECH CENTER. O APRAXIA – INABILITY TO PERFORM PREVIOUSLY LEARNED ACTION OR MOVEMENT - SENSORY/PERCEPTION LOSS O VISUAL  HOMONYMOUS HEMIANOPSIA – LOSS OF ½ OF VISUAL FIELD (USUALLY VISUAL DEFICIT IS ON THE SAME SIDE AS WEAKNESS AFFECTED) – FOR INSTANCE, IF YOU HAVE A RIGHT HEMISPHERIC STROKE, THE WEAKNESS WILL BE ON THE LEFT SIDE, THE VISUAL DEFECT WILL ALSO BE ON THE LEFT SIDE

– PATIENT NEGLECTS AFFECTED SIDE DUE TO THE FACT ESPECIALLY IF THAT SIDE HAPPENS TO BE WEAK AND PARALYZED AND THERE IS NO SENSATION THERE. IF THEY DON’T FEEL IT AND THEY DON’T SEE IT, THEN THERE CAN VERY LIKELY BE NEGLECT TO THAT SIDE. THIS IS A BIG SAFETY ISSUE. DIPLOPLIA – DOUBLE VISION PERIPHERAL VISION LOSS VISUAL-SPATIAL DISTURBANCES – TROUBLE JUDGING DISTANCES – FOR INSTANCE IF SOMETHING IS SITTING ON THEIR TRAY, THEY MAY OVERREACH OR UNDERREACH FOR IT. •

THIS

CAN LEAD TO NEGLECT

THAT THEY CAN’T SEE IT.



  O

-

-

SENSATION  PARESTHESIA – TINGLING, NUMBNESS  PROPRIOCEPTION DIFFICULTIES – PROBLEMS PERCIEVING POSITION OF EXTREMIITES (BODY PARTS). YOU HAVE A MOTOR DEFICIT OR PARALYSIS OR SENSORY LOSS; IT IS GOING TO BE HARD FOR THIS PATIENT TO KNOW WHERE THEIR LEG IS IN THE BED.

COGNITIVE DEFICITS O MEMORY O ATTENTION SPAN O CONCENTRATION O ABSTRACT REASONING O JUDGMENT EMOTIONAL DEFICITS (USUALLY A R SIDE AFFECTED STROKE) O EMOTIONAL LABILITY O O O

O

LOSS OF SELF CONTROL

REDUCED TOLERANCE TO STRESS DEPRESSION, WITHDRAWAL, ISOLATION FEAR, HOSTILITY, ANGER 4

TCA 3 O

SOME

OF THESE EMOTIONAL THINGS CAN OCCUR DUE TO THE AREA OF THE BRAIN THAT IS INVOLVED,

PARTICULARLY RIGHT HEMISPHERIC STROKES. O

BUT ALSO JUST BECAUSE IT IS

A SUDDEN ADJUSTMENT THAT THEY ARE HAVING TO MAKE.

SOMEONE THAT WAS COMPLETELY INDEPENDENT AND NOW THEY HAVE SEVERE BE A LOT OF HOSTILITY AND ANGER.

MIGHT

IF YOU HAVE DEFICITS. THERE CAN

EVEN SEE GRIEVING PROCESS BECAUSE OF SUCH A

SEVERE LOSS OF FUNCTION.

DIAGNOSTIC TESTS - CT SCAN –

DONE IMMEDIATELY UPON ARRIVAL IF STROKE IS SUSPECTED

–

THIS IS GOING TO CONFIRM THE

PRESENCE OF THE STROKE AND WILL DETERMINE WHETHER THEY ARE HAVING HEMORRHAGE.

YOU

CANNOT

MAKE ANY TREATMENT DECISIONS UNTIL THIS TEST IS DONE.

-

MRI

WILL SHOW SPECIFICS ABOUT THE STROKE SUCH AS DAMAGE, INTENSITY, ETC…GET A MORE EXACT

PICTURE OF THE EXACT LOCATION AND SIZE OF THE PROBLEM THAT IS GOING ON.

-

CEREBRAL ANGIOGRAPHY/ARTERIOGRAM – SHOW SPECIFICS ABOUT THE STROKE – IT WILL ALLOW YOU TO LOOK AT THE ACTUAL VESSELS INVOLVED

-

DOPPLER

FLOW STUDIES

–

MACHINE THAT ACTUALLY WATCHES BLOOD FLOW THROUGH THE VESSELS

-

HELPS

LOOK FOR BLOCKAGE

-

EKG – CHECKING FOR DYSRHYTHMIAS – A CLIENT CAN COME IN WITH A DIAGNOSIS OF A STROKE AND OBTAIN A NEW DIAGNOSIS OF ATRIAL FIBRILLATION. THEY HAVE NEVER BEEN ON COUMADIN BECAUSE THEY DID NOT KNOW THAT THEYHAD ATRIAL FIB AND THEY COME IN AND THEY HAVE HAD AN ISCHEMIC STROKE AND WE FIND A

EKG – SO WE HAVE NOW FOUND THE CAUSE OF THE STROKE. MUST ALSO TREAT THE ATRIAL FIB. (TREATMENT OF A FIB CONSISTS OF COUMADIN, POSSIBLY DIGOXIN TO HELP WITH THEIR RHYTHM). ECHOCARDIOGRAM – CHECKS FOR SEPTAL DEFECTS, VALVE PROBLEMS, ETC…. FIB ON THE

-

“TIME IS BRAIN” REMEMBER THAT THE FASTER THAT THE STROKE VICTIM RECEIVES TREATMENT, THE BETTER THE OUTCOME IS GOING TO BE, THE FEWER DEFICITS THEY ARE GOING TO HAVE. USUALLY WITH A STROKE WHEN THEY COME IN WITH SYMPTOMS LIKE COMPLETE PARALYSIS ON ONE SIDE. ALL OF THAT MAY NOT BE PERMANENT. THERE IS AN AREA AROUND THE ISCHEMIA THAT CAN BE SALVAGED IF THE PATIENT IS GIVEN PROMPT TREATMENT. SO IF YOU CAN GET IN THERE AND GET THEM ON EARLY TREATMENT (ANTICOAGULANTS, SOMETHING TO GET THE BLOOD FLOW RESTORED), THEN THE SYMPTOMS ARE GOING TO IMPROVE. TREATMENT OF ACUTE STROKE - ISCHEMIC O T-PA (TISSUE PLASMINOGEN ACTIVATOR) – CLOT BUSTER, DISSOLVES CLOTS – BELONGS TO A CLASS OF DRUGS KNOWN AS THROMBOLYTICS. THIS IS THE ONLY CLASS OF MEDICATION THAT IS ACTUALLY GOINGTO GO IN THERE AND DISSOLVE THE BLOOD CLOT.  MUST MEET CERTAIN CRITERIA FOR ADMINISTRATION •

MUST KNOW WHEN SYMPTOMS STARTED BECAUSE THIS DRUG NEEDS TO BE GIVEN WITHIN

3

HOURS OF THE ONSET OF SYMPTOMS.

HAVE

TO BE IN THE

ER

WITHIN

3

HOURS FROM WHEN SYMPTOMS STARTED IN ORDER TO RECEIVE T-PA

• • • •

18 YEARS OF AGE OR OLDER AND MANY MORE

ABOUT 95% OF PATIENTS DO NOT GET TO THE HOSPITAL IN TIME TO RECEIVE T-PA THERE IS BIG RISK FOR HEMORRHAGE (16%) WITH THIS DRUG, SO THE CLIENT NEEDS TO BE IN A CRITICAL CARE SETTING AND THEY REALLY NEED TO WEIGH THE RISKS VERSUS THE BENEFITS

O

ANTICOAGULANTS 5

TCA 3



DEPENDING

UPON THE CAUSE OF THE STROKE AND THE SEVERITY, YOU WILL SEE THESE

PATIENTS ON DIFFERENT ANTICOAGULANTS)



WILL HAVE

IV

HEPARIN INFUSION

(MUST

KNOW HEPARIN PROTOCOL), WILL HAVE ORDERS

SOMEWHERE IN THE CHART AS TO HOW OFTEN THE UPON THE RESULTS OF THE

PTT

PTT

HAS TO BE DRAWN

–

DEPENDING

WHAT TO DO WITH THE RATE OF THE HEPARIN.

BE

SURE

THAT AS THE PRIMARY NURSE FOR THIS CLIENT MAKE SURE THAT WHEN YOU ARE GETTING REPORT THAT YOU FIND OUT WHEN THE LAST HEPARIN NOW? AND

WHEN

PTT

WAS DRAWN?

WHAT IS THE RATE OF THE GET THIS INFORMATION

IS THE NEXT ONE DUE TO BE DRAWN?

QUICKLY.



COUMADIN WITH LOVENOX UNTIL INR IS PT AND INR. THE THERAPEUTIC RANGE

ALSO MAY BE ON

THERAPUETIC.

WITH

COUMADIN

OF THE INR WITH COUMADIN IS 2 TO 3. PLAVIX (ANTIPLATELET AGENT), ASA PREVENT CLOTS FROM FORMING, PREVENT ADDITIONAL CLOTTING AROUND THAT AREA, BUT THEY DO NOT DISSOLVE THE BLOOD CLOT. VERY COMMONLY WILL BE ON COUMADIN IF IT IS AN EMBOLIC STROKE FROM ATRIAL FIB OR IF THEY HAVE A DVT OR SOMETHING LIKE THAT SHOULD NOT SEE HEPARIN AND LOVENOX GIVEN TOGETHER. THERE SHOULD BE SEVERAL HOURS BETWEEN BEFORE YOU DISCONTINUE ONE AND START THE OTHER. YOU CHECK THE AROUND



  

OTHER TREATMENT MEASURES  ELEVATE HOB (TO PROMOTE VENOUS DRAINAGE)  SECURE AIRWAY  MONITOR HEMODYNAMICS – B/P (KEEP NORMOTENSIVE) → IF BP IS TOO LOW, YOU ARE NOT GOING TO GET ENOUGH BLOOD FLOW TO THE BRAIN. IF THE BP IS TOO HIGH THERE WILL BE TOO MUCH PRESSURE ON THE CEREBRAL VESSELS.  MONITOR FOR NEURO CHANGES – 1ST SIGN IS ↓ LOC HEMORRHAGIC – CT TO DIAGNOSE, MAY MONITOR IF SMALL BLEED O OF COURSE WITH BLEEDING, WE ARE NOT GOING TO BE GIVING THIS PATIENT ANTICOAGULANTS O EMERGENCY SUGERY (IF POSSIBLE) – IF IT IS AN INTRACEREBRAL HEMORRHAGE AND IF IT IS WITHIN THE DEEP WITHIN THE TISSUE OF THE BRAIN, OFTEN TIMES THOSE HEMORRHAGES ARE INOPERABLE. THEY HAVE TO HOPE THAT THE HEMORRHAGE STOPS ON ITS OWN, THEY MONITOR IT CLOSELY. THEY MAY DO A CT SCAN EVERY DAY FOR A FEW DAYS TO MONITOR PROGRESSION. SOMETIMES THERE IS ABSOLUTELY NOTHING THAT THEY CAN DO. O MANAGE/PREVENT VASOSPASM  NIMOTOPINE – CALCIUM CHANNEL BLOCKERS (STOPS VASOSPAMS) – NIMOTOP. USUALLY GIVE CALCIUM CHANNEL BLOCKERS FOR HYPERTENSION. THEREFORE WHEN WE GIVE NIMOTOP, THE BLOOD PRESSURE IS GOING TO DECREASE. IF YOU HAVE A PATIENT THAT HAS A LOW BLOOD PRESSURE, YOU WOULD NOT GIVE THE NIMOTOP TO PREVENT VASOSPASMS BECAUSE IT WILL FURTHER BOTTOM OUT THE BLOOD PRESSURE. OUR GOAL IS TO KEEP THE PATIENT NORMOTENSIVE. O

-

STROKE REHABILITATION - MOBILIZE AS EARLY

AS POSSIBLE

(ISCHEMIC

STROKE CAN BE MOBILE QUICKER THAN HEMORRHAGIC).

WITH

A

HEMORRHAGIC STROKE, THESE CLIENTS ARE USUALLY MAINTAINED ON BEDREST AND WE DECREASE THE STIMULI UNTIL THE RISK OF HEMORRHAGE IS GONE.

-

CONFIRM THE CLIENTS ACTIVITY LEVEL IN THE PHYSICIANS ORDERS. PT, OT, SPEECH THERAPY – TO RELEARN CERTAIN MOVEMENTS, AND LANGUAGE SKILLS TREAT DEPRESSION – IF THE CLIENT IS DEPRESSED THEY WILL NOT BE AS LIKELY TO PARTICIPATE IN THEIR TREATMENT AND REHABILITATION. EDUCATE CLIENT AND CAREGIVERS 6

TCA 3

-

DETERMINE PLACEMENT OPTIONS – NEED A PLACE IN CASE NOT ABLE TO RETURN HOME

NURSING DIAGNOSIS RELATED TO STROKE - IMPAIRED PHSICAL MOBILITY - ACUTE PAIN (PAINFUL SHOULDER) - SELF CARE DEFICITS - DISTURBED SENSORY PERCEPTION - IMPAIRED SWALLOWING - INCONTINENCE - DISTURBED THOUGHT PROCESSES - IMPAIRED VERBAL COMMUNICATION - RISK FOR IMPAIRED SKIN INTEGRITY - INTERRUPTED FAMILY PROCESSES - SEXUAL DYSFUNCTION COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS - DECREASED CEREBRAL BLOOD FLOW – IF YOU HAVE

A CLIENT THAT HAS HAD A STROKE, USUALLY ONE OF THE

TOP THREE NURSING DIAGNOSIS SHOULD BE ALTERED CEREBRAL TISSUE PERFUSION.

THIS

IS WHAT IS REALLY

GOING ON WITH THAT CLIENT AND WE REALLY NEED TO MONITOR FOR IT.

-

INADEQUATE OXYGEN DELIVERY TO THE BRAIN PNEUMONIA – ASPIRATION IS MAIN CAUSE ALSO BR OR IMMOBILITY

NURSING INTERVENTIONS: STROKE - IMPROVING MOBILITY AND PREVENTING JOINT DEFORMITIES O PROPER POSITIONING TO PREVENT CONTRACTURES O ELEVATE TO PREVENT SWELLING – (ELEVATE THE PARALYZED ARM SO THAT THE FINGERS ARE A LITTLE BIT HIGHER THAN THE WRIST AND THE WRIST IS A LITTLE BIT HIGHER THAN THE ELBOW). KEEP FINGERS OUT, SLIGHTLY FLEXED O SHOULDER ADDUCTION PREVENTED BY PILLOW UNDER AXILLA OF THE ARM TO KEEP IT FROM DRAWING IN SO CLOSE TO THE BODY ON THE PARALYZED SIDE (PG 1897 PROPER POSISTIONING) O PASSIVE ROM O SHOULDER PAIN – CONTROL SO THEY CAN PARTICIPATE IN CARE, PUT IN SLING WHEN AMBULATING O CHANGE POSTION EVERY 2 HOURS O

LIMIT TURNING THEM ON THE AFFECTED SIDE

MIGHT NEED ADAPTIVE EQUIPMENT (WALKER, ETC.) ENCOURAGE AMBULATION AS SOON AS IT IS SAFELY POSSIBLE (WITH ISCHEMIC IT MIGHT BE VERY SOON, WITH HEMORRHAGIC IT MAY TAKE LONGER BEFORE THEY GET TO AMBULATE) O SHOULDER PAIN OCCURS IN ABOUT 70% OF STROKE PATIENTS SO IT REALLY IS A BIG PROBLEM. WITH THE ARM IN SUCH A DEPENDENT POSITION, GRAVITY IS PULLING ON THE JOINT AT THE SHOULDER. THIS CAN CAUSE DISLOCATION OF THE SHOULDER JOINT. IT WILL BE VERY PAINFUL AND STIFF. WITH THESE CLIENTS BE SURE WHEN YOU GET THEM UP; MAKE SURE THAT THEY WEAR A SLING OR SOME MEANS OF SUPPORT AROUND THAT ARM. ENHANCING SELF-CARE O PROMOTE INDEPENDENCE O PROMOTE USE OF AFFECTED SIDE MANAGING SENSORY-PERCEPTUAL DIFFICULTIES O APPROACH THEM ON SIDE THAT IS NOT AFFECTED (IF THEY HAVE HOMONYMOUS HEMIANOPSIA) O O

-

-

7

TCA 3 O

O

O

-

-

-

-

–

CAN BE VERY DIFFICULT IF THERE ARE PERSONALITY

O

SKIN ASSESSMENT ESPECIALLY ON THE AFFECTED SIDE

O

NUTRITIONAL STATUS

O

-

CLIENT AND FAMILY

CHANGES AFTER A STROKE, THIS MAY BE VERY DIFFICULT FOR FAMILY MEMBERS TO HANDLE. IMPROVING COMMUNICATION O COMMUNICATION BOARD (EXPRESSIVE APHASIA) O SLATE BOARD (DYSARTHRIA) O USE SHORT PHRASES (RECEPTIVE APHASIA) O USING GESTURES, FACE THEM WHEN SPEAKING TO THEM (RECEPTIVE APHASIA) O DON’T RUSH THEM O DON’T PUT WORDS IN THEIR MOUTH MAINTAINING SKIN INTEGRITY O FREQUENT TURNING

O

-

ALTERATE MODIFICATION TO THEIR CLOTHING IF THEY HAVE PARALYSIS ON ONE SIDE

IMPROVING THOUGHT PROCESS O SUPPORTIVE ROLE FOR

O

-

ADEQUATE LIGHTING

MANAGING DYSPHASIA O MUST ASSESS ABILITY TO SWALLOW O IF UNABLE TO SWALLOW SMALL ABOUT OF H2O MUCH CONSULT SPEECH THERAPY O HAVE THEM ON A PUREED DIET WITH A THICKENER FOR THIN LIQUIDS. THIN LIQUIDS ARE VERY DIFFICULT TO MANIPULATE IN THE MOUTH. THEY ARE ALMOST IN THE BACK OF THE MOUTH BEFORE THE PERSON CAN GET CONTROL OF THEM. IF THEY HAVE DYSPHAGIA THE MUSCLE MOVEMENTS ARE SLOW. THEY NEED SOMETHING THICK SO THEY CAN GAIN CONTROL OF IT BEFORE IT GETS TO THE BACK OF THEIR THROAT AND THEY ARE SWALLOWING IT. THIS IS ANOTHER REASON THAT WE DO NOT USE STRAWS WITH A CLIENT THAT HAS DYSPHAGIA. ATTAINING BOWEL AND BLADDER CONTROL O MAY HAVE INCONTINENCE O MAY BE CONFUSED O MAY BE IMPAIRED COMMUNICATION, NOT ABLE TO TELL YOU WHAT THEY NEED O MAY NEED ASSISTIVE DEVICES O NEED A BARRIER FREE ACCESS TO THE TOILET O

-

PUT THINGS RELATED TO ORIENTATION (FOR INSTANCE THE CLOCK, TV) WITHIN THEIR FIELD OF VISION. THIS IS FOR SAFETY – EVENTUALLY WE ARE GOING TO ENCOURAGE THEM TO PAY ATTENTION TO THE SIDE THAT THEY CANNOT SEE FROM. MUST ACKNOWLEDGE AFFECTED SIDE (EVEN IF IT IS NOT A VISUAL PROBLEM, MAY BE NUMBNESS OR DECREASED SENSATION). THEY COULD HAVE THEIR AFFECTED ARM STUCK IN THE BED RAIL AND THEY WOULD NOT BE ABLE TO FEEL THIS.

GOOD HYGIENE MIGHT NEED SPECIALTY MATTRESS OR BED SKIN CARE

IMPROVING FAMILY COPING O SOME CLIENTS MAY BE ANGRY, CONFUSED, AND COMBATIVE O SUPPORT FAMILY MEMBERS, BUT DO NOT GIVE THEM FALSE HOPE, YET BE AS OPTIMISTIC AS WE CAN ADDRESSING SEXUAL DYSFUNCTION O MAY BE NEUROLOGICAL DAMAGE, PARALYSIS, DEPRESSION, MOTOR DEFICITS OR MEDICATION INDUCED O

KEEP OPEN MIND

O

MAY HAVE TO TRY ALTERNATE POSITONS

PROMOTING HOME AND COMMUNITY-BASED CARE 8

TCA 3

O

CAREGIVER ROLE STRAIN MUST BE SUPPORTIVE AND INVOLVE THE CLIENT

O

FAMILY MEMBERS MIGHT NOT BE ABLE TO PROVIDE THE NEEDED CARE

O

HEALTH CARE TEAM) GENTLY EDUCATE THEM ON THIS PROCESS.

TRY

–

YOU WANT TO

(ALONG

WITH

TO IDENTIFY SUPPORT SERVICES

THAT MAY HELP THEM OUT.

INTRACRANIAL ANEURYSM (HEMORRHAGIC STROKE WHEN BURST) - LOCALIZED DILATION OF A CEREBRAL ARTERY RESULTING AND CAUSE A HEMORRHAGE)

IN WEAKNESS IN THE ARTERIAL WALL

(CAN

RUPTURE

CAUSES OF INTRACRANIAL ANEURYSM - ATHEROSCLEROSIS - CONGENITAL VESSEL DEFECTS - HYPERTENSION - HEAD TRAUMA - ADVANCING AGE – ELDERLY VESSEL WALL BALLOONS OUT, WHICH PUTS IT AT AN INCREASED RISK TO RUPTURE. PATHOPHYSIOLOGY - ARTERY ENLARGES

AND PRESSES ON CRANIAL NERVES OR BRAIN TISSUE

–

HOPEFULLY WILL START TO HAVE

SYMPTOMS THAT WILL START BEFORE RUPTURE

-

ANEURYSM

MAY RUPTURE, SPILLING BLOOD INTO THE BRAIN

(SUBARACHNOID

HEMORRHAGE

–

TYPE OF

HEMORRHAGIC STROKE)

-

IF YOU HAVE AN ANEURYSM RUPTURE, YOU WILL HAVE: O NORMAL BRAIN METABOLISM IS DISRUPTED O INCREASED ICP – DUE TO BLEEDING INTO THE BRAIN TISSUE (EXTRA BLOOD) AND BLOCKAGE OF VILLI THAT ABSORB CSF (WHEN THESE VILLI ARE CLOGGED WITH BLOOD CELLS IT CAN LEAD TO HYDROCEPHALUS) O ISCHEMIA DUE TO REDUCED PERFUSION AND VASOSPASM (DEVELOP VASOSPASM WITH HEMORRHAGIC STROKE, IT IS THE BODY’S ATTEMPT TO STOP HEMORRHAGING, BU THEN YOU CAN HAVE A SECONDARY ISCHEMIC STROKE)

CLINICAL MANIFESTATIONS – OF RUPTURED ANEURYSM - SUDDEN SEVERE HEADACHE – “WORST HEADACHE THAT I HAVE EVER HAD” - LOSS OF CONSCIOUSNESS - NUCHAL RIGIDITY – NECK STIFFNESS DUE TO MENNINGAL IRRITATION FROM THE BLOOD - DIZZINESS, TINNITUS (RINGING IN THE EAR) - SYMPTOMS OF STROKE (MOTOR, COGNITIVE, VISUAL, PERCEPTUAL DEFICITS) - SIGNS OF INCREASED ICP (CHANGE IN LOC, RESTLESSNESS, LETHARGY, VS CHANGES – SLOW BOUNDING PULSE, SYSTOLIC ↑, DIASTOLIC REMAINS THE SAME) - ANEURYSM MAY LEAK , CLOT OFF AND HAVE NO SYMPTOMS - UP TO 50% MORTALITY FROM SUBARACHNOID HEMORRHAGE - AN ANEURYSM RUPTURE IS AN EMERGENCY SITUATIONS – THEY WILL MOST LIKELY NEED EMERGENCY SURGERY TO SAVE THEIR LIFE

DIAGNOSTIC TESTS: ANEURYSM 9

TCA 3

-

CT SCAN – TO CONFIRM BLEED – THIS IS THE FIRST THING THAT WILL BE DONE CEREBRAL ANGIOGRAPHY/ARTERIOGRAM – SHOWS SIZE AND LOCATION (IF THE ANEURYSM IS RUPTURED THEY WILL PROBABLY NOT TAKE THE TIME TO DO AN ARTERIOGRAM. IF IT IS JUST LEAKING THEY MIGHT GO DO ONE). LUMBAR PUNCTURE – BLOOD FOUND IN CSF IF THERE IS A SUBARACHNOID HEMORRHAGE (LP NOT TYPICALLY DONE DUE TO INCREASED ICP) LUMBAR PUNCTURE IS ONLY DONE IF THE CT SCAN IS NEGATIVE FOR HEMORRHAGE AND THERE ARE NO SIGNS OF INCREASED ICP.

MEDICAL MANAGEMENT - RECOVER FROM THE INITIAL BLEED, PREVENT RE-BLEED O PUT ON ABSOLUTE BEDREST, DECREASE STIMULI, ICP NURSING CARE O READ ABOUT ANEURYSM PRECAUTIONS IN BRUNNER - CONTROL VASOSPASM – GIVE CA CHANNEL BLOCKERS (PROCARDIA, NIMOTOPINE) – CHECK THE BLOOD PRESSURE BEFORE ADMINISTERING CALCIUM CHANNEL BLOCKERS. WE DO NOT WANT THIS PATIENT’S BLOOD PRESSURE TO GET REAL LOW. WE WANT TO KEEP THEM NORMOTENSIVE OR A LITTLE TINY BIT HIGHER THAN NORMAL. IF THE BLOOD PRESSURE GETS TOO LOW THEN THERE WILL BE INADEQUATE PERFUSION TO THE BRAIN AND THIS PATIENT ALREADY HAS COMPROMISED CEREBRAL PERFUSION. - CONTROL HYPERTENSION – GOAL SYSTOLIC IS 150 TO ENSURE ADEQUATE PERFUSION TO BRAIN (MAY GIVE DOPAMINE, OR VASOPRESSOR IF B/P IS TOO LOW). IF WE GET IT MUCH HIGHER THAN 150 THIS WILL PUT THE PATIENT AT RISK FOR REBLEEDING. - MONITOR FOR AND TREAT INCREASED ICP – WE TREAT ICP WITH MANNITOL (OSMOTIC DIURETIC), DECADRON, WE GIVE LASIX WITH MANNITOL TO TRY TO DECREASE THE INTRAVASCULAR FLUID VOLUME – TRY TO GET THE KIDNEYS TO EXCRETE URINE. WE GIVE DECADRON TO DECREASE CEREBRAL EDEMA. WE WILL MONITOR THEIR FLUID INTAKE VERY CAREFULLY. SURGICAL MANAGEMENT OF ANEURYSM - DO NOT ALWAYS IMMEDIATELY OPERATE

ON AN ANEURYSM THAT IS NOT RUPTURED.

THEY

MAY JUST MONITOR

IT DEPENDING UPON ITS SIZE AND LOCATION AND JUST SEE WHAT IT DOES.

-

ANEURYSM CLIPPING, WRAPPING, OR TRAPPING O THESE ARE IN AN EFFORT TO ISOLATE THE ANEURYSM FROM THE LONGER GOING), OR REINFORCE THE VESSEL O TRAPPING ACTUALLY ISOLATES IT FROM CIRCULATION SO THAT

CIRCULATION

(BLOOD

FLOW IS NO

BLOOD FLOW NO LONGER GOES

THROUGH THAT AREA O

WRAPPING OF THE ANEURYSM IS ACTUALLY WRAPPING SOME SYNTHETIC MATERIAL AROUND THAT SECTION OF THE VESSEL WALL SO THAT IT IS NO LONGER BULGING OUT AND CAUSING A PROBLEM.

-

CAROTID ARTERY CLAMP – DONE ON OPERATIVE SIDE (CAN CAUSE ISCHEMIC STROKE) INTERVENTIONAL NEURORADIOLOGY – COILING – INSERT TO ISOLATE FROM CIRCULATION. THIS

IS PREFERRED

IF YOU CAN GO IN AND GET TO THE FEMORAL ARTERY AND FIX THIS ANEURYSM WITHOUT ACTUALLY HAVING TO DO A CRANIOTOMY.

NOT

ALL ANEURYSMS CAN BE COILED.

WITH

ANEURYSM COILING, THEY GO IN JUST AS IF

THEY ARE DOING AN ARTERIOGRAM, THEY GO UP TO THE ACTUAL AREA WHERE THE ANEURYSM IS AND THEY CAN INSERT A LITTLE SPRING TYPE LOOKING COIL THAT THEY COIL INSIDE THE ANEURYSM AND IT ISOLATES IT FROM

(BLOOD FLOW IS NO LONGER GOING THROUGH THERE), SO IT IS NOT DEPENDING UPON THE SIZE AND SHAPE OF THE ANEURYSM, IT MAY OR MAY

CIRCULATION

AT RISK FOR RUPTURE ANY

MORE.

NOT HOLD A COIL INSIDE OF

THERE.

-

STROKE, HEMORRHAGE AND BLOOD CLOTS CAN HAPPEN AS A RESULT OF THESE PROCEDURES.

NURSING DIAGNOSIS R/T ANEURYSM - INEFFECTIVE CEREBRAL TISSUE PERFUSION (PRIORITY) - DISTURBED SENSORY PERCEPTION - ANXIETY 10

TCA 3

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS - VASOSPASM - SEIZURES - HYDROCEPHALUS - RE-BLEEDING NURSING INTERVENTIONS - OPTIMIZING CEREBRAL TISSUE PERFUSION O ANEURYSM PRECAUTIONS (HOB ↑, DECREASE STIMULI, ABSOLUTE BEDREST, ETC.) O SEE CARE PLAN FOR INCREASED ICP - RELIEVING SENSORY DEPRIVATION AND ANXIETY O

-

EXPLAIN TO PATIENT AND FAMILY THE IMPORTANCE OF DECREASED STIMULI

MONITORING AND MANAGING POTENTIAL COMLICATIONS O VASOSPASM – HAPPENS 4-14 DAYS AFTER HEMORRHAGE (ANEURYSM RUPTURE)  RE-BLEEDING CAN OCCUR DUE TO VASOSPASM • SYMPTOMS OF RE-BLEEDING – THESE S/S DEPEND ON WHERE BRAIN, MAY BE DIFFERENT AT DIFFERENT PARTS O WORSENING HEADACHE O INCREASED ICP O ALTERED LOC, NEURO DEFICITS

THIS OCCURS IN THE

DIFFERENT DEFICITS DEPENDING UPON WHERE THE VASOSPASM IS OCCURING.

O

IT

IS GOING TO MIMIC A STROKE, BECAUSE THAT IS REALLY WHAT IT CAN

CAUSE IS AN ISCHEMIC STROKE. O

SEIZURES  SEIZURES

ARE NOT REAL COMMON, BUT THEY ARE VERY DANGEROUS FOR SOMEONE THAT HAS

AN ANEURYSM.

 O

MIGHT PUT THE PATIENT ON PROPHYLACTIC ANTISEIZURE MEDICATION.

HYDROCEPHALUS  CAN OCCUR

(DILANTIN)

VERY QUICKLY AFTER ANEURYSM RUPTURE OR IT CAN BE WEEKS AFTER THE

ANEURYSM RUPTURES O

REBLEEDING  NOT

VERY COMMON, BUT IT IS OFTEN FATAL.

THEY

ARE GOING TO HAVE THE RECURRENT

SYMPTOMS OF THAT ANEURYSM RUPTURE OR OF A STROKE. NUCHAL RIGIDITY AGAIN.

THEY

THEY

MIGHT DEVELOP THAT

MAY HAVE A SUDDEN SEVERE HEADACHE AND THEN SYMPTOMS

OF A STROKE (DEPENDING UPON THE AREA OF THE BRAIN INVOLVED).



THE

BEST WAY TO PREVENT REBLEEDING IS TO KEEP THESE PATIENT’S BLOOD PRESSURE

UNDER CONTROL.

WE WANT TO KEEP THEM NORMOTENSIVE, NO MORE THAN A SYSTOLIC 150. THIS WILL HELP PREVENT THE CHANCES OF REBLEEDING. PROMOTING HOME AND COMMUNITY-BASED CARE O TEACHING SELF CARE – S/S OF ICP, S/S OF STROKE  CHANGE IN LOC – THIS IS THE BIGGY. IF THE CLIENT SEEMS LIKE THEY ARE SLEEPING MORE THAN USUAL, THEY ARE HARD TO WAKE UP OR THEY BECOME MORE AGITATED OR CONFUSED.  HEADACHES  STIFF NECK  SIGNS AND SYMPTOMS OF STROKE (DIFFICULTY WALKING, DIFFICULTY SEEING, DIFFICULTY SPEAKING, NUMBNESS, WEAKNESS) PRESSURE OF

-

11

TCA 3



TEACHING

ABOUT MEDICATIONS

–

THEY MIGHT GO HOME ON DILANTIN OR ON OTHER

MEDICATIONS



IF

– WE NEED INFECTIONS, DRAINAGE

THEY HAVE HAD SURGERY

AND SYMPTOMS OF

TO TEACH POST OP INSTRUCTIONS SUCH AS SIGNS THAT THEY NEED TO WATCH OUT FOR, WE WANT TO

TELL THEM AFTER THEY GO HOME TO NOTIFY THEIR NEUROSURGEON IF THEY HAVE EXCESSIVE O O

DRAINAGE FROM THE WOUND (EVEN IF THE DRAINAGE IS CLEAR) MAY NEED HOME EQUIPMENT OR MODIFICATIONS MUST FOLLOW UP WITH NEURO SURGEON

REVIEW OF THE CEREBROSPINAL FLUID THE CSF IS PRODUCED AND REABSORBED IN THE ARACHNOID LAYER OF THE BRAIN. IT IS CONTAINED IN 4 VENTRICLES. REMEMBER THAT THE 4 VENTRICLES ARE KIND OF IN THE CENTER OF THE CRANIAL VAULT UNDER THE CEREBRAL HEMISPHERES. THE CSF CIRCULATES AROUND THE BRAIN AND THE SPINAL CORD. IT HAS THREE MAJOR FUNCTIONS. ONE OF THE FUNCTIONS OF CSF IS TO ACT AS A SHOCK ABSORBER FOR THE BRAIN AND THE SPINAL CORD. ANOTHER IS TO DELIVERY NUTRIENTS TO THE BRAIN AND TO REMOVE WASTE. THE THIRD IS THAT IT FLOWS BETWEEN THE CRANIUM AND THE SPINE TO COMPENSATE FOR CHANGES IN INTRACRANIAL BLOOD VOLUME. IF YOU HAVE AN INJURY OR SOME OTHER CAUSE OF INCREASED ICP, CSF IS ONE OF THE THINGS THAT CAN BE EASILY DISPLACED. CSF CAN BE MORE RAPIDLY REABSORBED OR THE PRODUCTION CAN SLOW DOWN OR IT CAN BE DISPLACED TO THE BASE OF THE

ICP. THE AVERAGE ADULT PRODUCES ABOUT ½ OF A LITER OF CSF EVERY DAY AND ALL BUT ABOUT 125 TO 150 IS REABSORBED BACK INTO THE BLOOD STREAM. WE REALLY DO NOT HAVE MORE THAN ABOUT 150 CIRCULATING. HYDROCEPHALUS OCCURS WHEN YOU HAVE AN IMBALANCE IN THE RATE OF PRODUCTION AND THE RATE OF ABSORPTION OF CSF. WHEN THE PRODUCTION IS TOO GREAT OR THE REABSORPTION SLOWS DOWN AND IT IS NOT ADEQUATE, CSF ACCUMULATES IN THOSE VENTRICLES USUALLY UNDER INCREASED PRESSURE PRODUCING DILATION OF THE VESSELS OF THE BRAIN. SKULL TO MAKE MORE ROOM FOR WHATEVER IS CAUSING THE INCREASE IN

HYDROCEPHALUS OVERVIEW: CEREBROSPINAL FLUID (CSF) - PRODUCED AND REABSORBED IN THE ARACHNOID LAYER OF THE BRAIN - CONTAINED IN 4 VENTRICLES AND CIRCULATES AROUND THE BRAIN AND SPINAL CORD - FUNCTIONS O ACTS AS A “SHOCK ABSORBER” FOR THE BRAIN AND SPINAL CORD O DELIVERS NUTRIENTS TO THE BRAIN AND REMOVES WASTE O FLOWS BETWEEN THE CRANIUM AND SPINE TO COMPENSATE FOR CHANGES IN THE INTRACRANIAL BLOOD VOLUME - AVERAGE ADULT PRODUCES 500ML OF CSF PER DAY….. ALL BUT 125-150ML IS REABSORBED WHAT IS HYDROCEPHALUS? - A CONDITION CAUSED

BY AN IMBALANCE IN THE RATES OF PRODUCTION AND ABSORPTION OF

VENTRICULAR SYSTEM OF THE BRAIN.

CSF

IN THE

WHEN PRODUCTION IS TOO GREAT OR ABSORPTION IS INADEQUATE, CSF USUALLY UNDER INCREASED PRESSUE, PRODUCING DILATION OF

ACCUMULATES IN THE VENTRICULAR SYSTEM, THE VENTRICLES OF THE BRAIN,

-

A SYMPTOM

ILLNESS (FOR HYDROCEPHALUS AS A RESULT OF SUBARACHNOID HEMORRHAGE) OF

AN

UNDERLYING

NEUROLOGICAL

EXAMPLE

YOU

CAN

DEVELOP

TYPES OF HYDROCEPHALUS - CONGENITAL O ABNORMAL FETAL DEVELOPMENT – STRUCTURAL DEFECT O GENETIC PREDISPOSITION - ACQUIRED 12

TCA 3

OCCURS DURING OR AFTER BIRTH O CAUSED BY AN INJURY, INFECTION, TUMOR, OR HEMORRHAGE OTHER TYPES OF HYDROCEPHALUS O HYDROCEPHALUS EX-VACUO – FROM INJURY (STROKE), BRAIN TISSUE SHRINKS, CSF ↑ • OCCURS UNDER NORMAL PRESSURE. THIS CAN OCCUR FROM BRAIN INJURY OR STROKE. THIS IS WHERE YOUR ACTUAL BRAIN TISSUE CAN SHRINK AND ATROPHY. YOU HAVE EXTRA CSF TAKING ITS PLACE SO IT IS NOT AN INCREASE IN PRESSURE, BUT IT IS AN INCREASE IN THE AMOUNT OF CSF AND DILATION OF THE VENTRICLES. O NORMAL PRESSURE HYDROCEPHALUS (NPH) – CAUSE OF DEMENTIA, GRADUAL BLOCKAGE OF CSF O

-

DRAINAGE SYSTEM

• NPH IS USUALLY SEEN IN THE ELDERLY • NPH IS A GRADUAL BLOCKAGE OF THE CSF DRAINAGE

SYSTEM.

IT

CAN OCCUR AS RESULT

OF INFECTION OR HEMORRHAGE, BUT SOMETIMES THEY CANNOT IDENTIFY THE CAUSE OF THAT.

• NORMAL PRESSURE HYDROCEPHALUS, YOU DO NOT IMMEDIATELY HAVE THE INCREASE IN ICP. IF

IT GOES ON AND ON, YOU CAN BEGIN TO HAVE THE SYMPTOMS, BUT AT FIRST IT IS UNDER

NORMAL PRESSURE THAT IT OCCURS.

•

SYMPTOMS ARE VERY GRADUAL AND OFTEN THEY ARE MISTAKEN FOR DEMENTIA.

PATHOPHYSIOLOGY - 2 TYPES O COMMUNICATING  CSF FLOW IS RESTRICTED AFTER IT EXITS THE VENTRICLES O NON-COMMUNICATING (OBSTRUCTIVE)  CSF FLOW IS RESTRICTED IN THE VENTRICLES (THERE IS SOMETHING VENTRICLES WHERE THE CSF IS NOT CIRCULATING PROPERLY) CLINICAL MANIFESTATIONS OF HYDROCEPHALUS - INFANTS AND YOUNG CHILDREN O RAPID HEAD GROWTH, BULGING PROJECTILE), “SETTING SUN” SIGN O CLOSED SUTURES MAY RE-OPEN -

WRONG WITHIN THE

FONTANELS, SEPARATED CRANIAL SUTURES, VOMITTING

4

(OFTEN

10-12 YEARS OLD IN THE PRESENCE OF HYDROCEPHALUS OR OTHER REASONS FOR INCREASE ICP. O LATER: IRRITABILITY, CHANGE IN LOC, SEIZURES OLDER CHILDREN AND ADULTS O “WET (URINARY INCONTINENCE), WOBBLE (ATAXIC GAIT), WEIRD (COGNITIVE CHANGES)”. THESE ARE THREE CLASSIC SIGNS. O HEADACHE (WORSE WHEN THEY LIE DOWN), NAUSEA, PAPILLEDEMA, BLURRED VISION, DIPLOPIA, “SETTING SUN” SIGN, ATAXIC GAIT, POOR COORDINATION, URINARY INCONTINENCE, DEVELOPMENTAL DELAYS (CHILDREN), CHANGES IN LOC, IRRITABILITY, PERSONALITY CHANGES, COGNITIVE CHANGES O

IN CHILDREN UNDER

A HEADACHE IN A CLIENT WITH HYDROCEPHALUS IS WORSE AS SOON AS THEY WAKE UP IN THE MORNING.

IT

GETS BETTER WHEN THEY SIT UPRIGHT BECAUSE GRAVITY IS CAUSING THE DRAINAGE OF

CSF, THEREFORE THE HEADACHE AND THE PRESSURE GETS BETTER. DIAGNOSTIC TESTS RELATED TO HYDROCEPHALUS - INFANTS – HEAD CIRCUMFERENCE - DAILY - CT SCAN - MRI - CISTERNOGRAM 13

TCA 3 O O

MULTI-STEP TEST FLOW AND UPTAKE

OF

CSF IS

MONITORED (WITHIN THE VENTRICULAR SYSTEM AND ALSO AROUND THE

BRAIN AND SPINAL CORD WHERE THE

CSF

IS CIRCULATING AND THE WAY THAT IT IS REABSORBED

THROUGH THE VILLI) SPACE.

THEY

HAVE A

VP

SHUNT OR THE

MEDICAL MANAGEMENT - MEDICATIONS TO TREAT INCREASED ICP – OSMOTIC DIURETICS, POSSIBLY STEROIDS - LUMBAR PUNCTURE OR VENTRICULOSTOMY - TO DRAIN EXCESS CSF. THIS IS A TEMPORARY

FIX, BUT IF THEY

O

O O

DYE

(RADIOACTIVE ISOTOPE) INTO THE SUBARACHNOID THROUGH A LUMBAR PUNCTURE. LOOK AT SEVERAL TIMES OVER A PERIOD OF DAYS THIS HELPS TO DETERMINE WHETHER IT WOULD BE EFFECTIVE TO PLACEMENT OF IT. IS INSERTED

WILL DO THIS

DETERMINE THAT THEY HAVE HYDROCEPHALUS AND THEY DETERMINE THAT THERE IS INCREASED MIGHT DO CAREFUL ONE TIME.

CSF

DRAINAGE.

THEY

ICP,

THEY

WOULD NOT BE ABLE TO REMOVE A RAPID OR LARGE AMOUNT AT

THIS WILL RELIEVE SOME OF THE PRESSURE.

SURGICAL MANAGEMENT - DIRECT REMOVAL OF THE OBSTRUCTION (SUCH AS TUMOR) - VENTRICULOPERITNEAL (VP) SHUNT – MOST OFTEN DONE – FLEXIBLE TUBE IS INSERTED INTO THE VENTRICLE, USUALLY ON THE NON-DOMINANT SIDE OF THE BRAIN. THERE IS A ONE WAY VALVE THAT CONTROLS THE RATE OF EMPTYING. THE TUBE IS INSERTED INTO THE VENTRICLE AND IT IS FED UP UNDER THE SKIN INTO THE PERITONEAL CAVITY. IT EMPTIES THE CSF INTO THE PERITONEAL CAVITY WHERE IT IS REABSORBED INTO THE BODY. - ENDOSCOPIC THIRD VENTRICULOSTOMY – SMALL HOLE S/T VENTRICLES TO ALLOW FOR FLOW OF CSF – CAN BE USED IF THERE IS OBSTRUCTIVE HYDROCEPHALUS. FROM FILM (NPH) - VENTRICULOPERITNEAL SHUNT – NEUROSURGEONS INSERT A TUBE CALLED A SHUNT INTO THE BRAIN. THE TUBE DRAINS THE EXCESS FLUID FROM THE BRAIN AND MOVES IT TO THE BELLY WHERE IT CAN BE ABSORBED. THE SHUNT MAY NEED TO BE ADJUSTED BECAUSE REMOVING TOO MUCH OR TOO LITTLE FLUID CAN BE DANGEROUS. THE ADJUSTMENT IS DONE PAINLESSLY WITH A MAGNENT IN THE DOCTOR’S OFFICE. - PATIENT’S AND THEIR FAMILIES SHOULD KNOW THAT IF SOMEONE IS AGING AND THEIR GAIT IS WORSENING, THEIR MENTAL THOUGHT PROCESSES ARE BECOMING LESS CLEAR AND/OR THEY HAVE URINARY INCONTINENCE, THEY NEED A CT SCAN/MRI. NURSING MANAGEMENT - CARE PLAN: INCREASED ICP - ROUTINE CRANIOTOMY CARE POST-OP O POSITION DICTATED BY SURGEON –

USUALLY

HOB

ELEVATED

(30°)

TO ALLOW FOR DRAINAGE

–

THE

ONLY EXCEPTION TO THIS IS AN INFANT/SMALL CHILD; THEY ARE OFTEN KEPT FLAT TO AVOID RAPID CHANGES IN THEIR INTRACRANIAL PRESSURE. O

OBSERVE

FOR INFECTION

–

SYMPTOMS OF MENNIGITIS

(STIFF

NECK, HEADACEH), SYMTOMS OF

PERITONITIS (RIGGID STIFF BOARDLIKE ABDOMEN, DISTENSION), WE ARE GOING TO WATCH FOR FEVER THIS IS USUALLY ONE OF THE FIRST INDICATORS OF A SHUNT INFECTION.

–

SOMETIMES YOU CAN SEE

REDNESS FOLLOWING THE SHUNT TRACT. O

OBSERVE

– INCREASED ICP IF NOT WORKING (SHUNT IS BLOCKED); IF TOO MUCH IS BEING DRAINED WILL HAVE VERY BAD HEADACHE WHILE SITTING UP BECAUSE THE BLOOD VESSELS THAT ATTACH THE BRAIN TO THE OUTER COVERING GET PULLED ON. IF YOU DUMP OUT TOO MUCH CSF AT ONE TIME – THE ULTIMATE COMPLICATION WOULD BE THAT THE BRAIN CAN HERNIATE. FOR SHUNT MALFUNCTION

14

TCA 3 O

OBSERVE

FOR

CSF

LEAKAGE

–

POCKET UNDER SKIN OF THE SCALP,

MIGHT LEAK OUT OF THE INCISION SITE, MAY DEVELOP A MUSH

HA WORSE WHILE SITTING UP

LONG-TERM MANAGEMENT - CONSIDERATIONS FOR CHILDREN O ABOUT 1/3 OF THESE CHILDREN HAVE NO INTELLECTUAL OR NEUROLOGICAL DEFICITS. O CONDITION IS LIFE-LONG O WE NEED TO ENCOURAGE PARENTS TO MAKE LIFE AS NORMAL AS POSSIBLE – NEED TO AVOID CONTACT SPORTS O

IF

THE CHILD HAS TO HAVE A

VP

SHUNT, THIS IS GOING TO BE A LIFELONG THING.

THERE MAY BE SHUNT MALFUNCTIONS.

-

THERE

PREPARE

THAT

WILL PROBABLY NEED TO HAVE REVISIONS OF THE

SHUNT AS THE CHILD GROWS. PROGNOSIS DEPENDS ON 1. CAUSE – IF THEY CAN FIX THE CAUSE, THEN THE PROGNOSIS IS BETTER 2. RATE THAT IT DEVELOPED – RAPID DEVELOPMENT = NEURO DAMAGE 3. NUMBER OF COMPLICATIONS – INFECTIONS, REVISIONS OF SHUNT, BLOCKAGE OF SHUNT

FYI: THERE ARE ONLY TWO TIMES THAT WE KEEP THE HEAD OF THE BED FLAT AFTER CRANIAL PROCEDURES. ONE IS THE INFANT/SMALL CHILD AFTER RECEIVING A VP SHUNT. THE OTHER IS WITH INFRATENTORIAL SURGERY (HOB FLAT OR NO MORE THAN 10°). CASE STUDY #1 A CLIENT THAT IS 73 YEARS OLD, ADMITTED TO NEURO UNIT WITH DIAGNOSIS OF TIA, 23 HOUR ADMIT, SHOWING ATRIAL FIB ON TELEMETRY, WITH A RATE OF 160. HAD AN EPISODE TODAY FOR 15 MINUTES, SO HE COULD NOT SPEAK, WAS HARD TO GET TO RESPOND TO VERBAL COMMANDS, HAD RIGHT SIDED WEAKNESS IN THE UPPER AND LOWER EXTREMETIES FOR 2 HOURS. WAS BROUGHT TO THE ER, IMMEDIATELY, BUT NOW IS ORIENTED X 3, MOVES ALL EXTREMITIES AND HAS NOT DEFICITS. WHY IS HIS DIAGNOSIS TIA? BECAUSE HE RECOVERED, THERE IS A CHART IN THE BOOK. HOURS FOR IT TO BE CONSIDERED A

TIA. WITH

A

TIA,

IF

THEY HAVE SYMPTOMS FOR LESS THAN

24

IT IS TRANSIENT AND ALL OF THE SYMPTOMS

RESOLVE IN LESS THAN 24 HOURS. WHAT DIAGNOSTIC TESTS WILL MOST LIKELY BE SCHEDULED FOR HIM? TELEMETRY, CT, MRI, CP DONE RIGHT WHEN THEY COME INTO CEREBRAL ARTERIOGRAM. IF THEY FIND A BLOCKAGE, WHAT IS THE TREATMENT FOR THAT

THE DOOR, MAY OR MAY NOT DO

ENDARDARECTOMY

WHAT NURSING CARE IS RELATED TO ENDARDARECTOMY? OBSERVE FOR AIRWAY, HEMORRHAGE, CRANIAL NERVE INJURY, HYPERPERFUSION SYNDROME, IF THERE IS A CHANGE IN LOC WE WILL CALL THE DOCTOR.

SIGNS AND SYMPTOMS OF STROKE,

A CLOT FROM A FIB WAS PROBABLY THIS CLIENTS REASON FOR HAVING A TIA. THE CLOT PROBABLY DISLODGED ITSELF AND WENT SOMEWHERE ELSE AND DID NOT CAUSE A STROKE. CASE STUDY #2 ADMITTED TO THE ER WITH A DIAGNOSIS

OF A LEFT HEMISPHERIC

NEXT MORNING HER HUSBAND SAID SHE HAD WEAKNESS ON HER

CVA, SHE WENT TO BE THE NIGHT BEFORE AND THE RIGHT SIDE AND WAS UNABLE TO TALK. HE RUSHED 15

TCA 3 HER TO THE HOSPITAL, SHE STILL HAS RIGHT SIDED WEAKNESS, DIFFICULTY FORMING WORDS AND HEMIANOPSIA, SHE HAD DIABETES AND HIGH BLOOD PRESSURE,

HOMONYMOUS

AND SHE IS ON A SOFT DIET.

WHAT ARE 5 ASSESSMENTS THAT THE NURSE SHOULD MAKE? LOC, MUSCLE STRENGTH AND COORDINATION (MAKE SURE WEAKNESS DOESN’T GET WORSE), WE WANT TO GET A GOOD BASELINE ASSESSMENT AND CONTINUE TO MONITOR IT, MAKE SURE THAT HER SYMPTOMS DO NOT GET WORSE AND MAKE SURE THAT SHE DOES NOT DEVELOP ANY FURTHER SIGNS OF STROKE. WAS THIS PATIENT A CANDIDATE FOR T-PA (ACTIVATE) IN THE ER? SHE HAD GONE TO BE NORMAL THE NIGHT BEFORE AND DID NOT KNOW WHEN THE SYMPTOMS STARTED. THIS DRUG HAS TO BE ADMINISTERED WITHIN 3 HOURS OF INITIAL SYMPTOMS AND IT IS NOT KNOWN WHEN HER INITIAL SYMPTOMS STARTED IN THE NIGHT. WHAT ARE THEY GOING TO DO IN THE ACUTE CARE FOR THIS PATIENT? THE FIRST THINGS IS ABC’S. DIAGNOSTICALLY, THEY ARE GOING TO DO A CT SCAN IMMEDIATELY AND PROBABLY AN MRI NOT LONG AFTER THAT. THE CT SCAN IS GOING TO SHOW WHAT TYPE OF STROKE THAT SHE HAS HAD. THIS CLIENT HAS PROBABLY HAD AN ISCHEMIC STROKE, SHE IS A DIABETIC, HAS HIGH BLOOD PRESSURE. THESE ARE RISKS FOR AN ISCHEMIC STROKE. CASE STUDY #3 THE SAME LADY HAS A LEFT HEMISPHERIC STROKE WITH RIGHT SIDED WEAKNESS, SOME DIFFICULTIES FORMING WORDS (EXPRESSIVE APHASIA); SHE IS NOW GOING TO REHAB. WHO IS GOING TO BE ON THE HEALTH CARE TEAM AND WHAT ARE THEIR RESPONSIBILITIES? DIABETIC COUNSELOR PT – GAIT TRAINING AND AMBULATION OT – REGAIN SOME FUNCTIONING IN THE EXTREMITIES, PERFORMANCE OF ADL’S SPEECH THERAPY – VERY IMPORTANT, CAN BE VERY IMPORTANT FOR CLIENT WITH EXPRESSIVE APHASIA CARDIOLOGIST NEUROLOGIST WHAT ARE GOING TO BE SOME BARRIERS TO HER BEING ABLE TO HAVE A SUCCESSFUL REHABILITATION? THE CASE STUDY SAID THAT SHE LIVED IN A SMALL TOWN, REHAB FACILITY WILL BE FAR FROM HOME, FAMILY MIGHT NOT BE ABLE TO SEE HER AS OFTEN, THIS MAY GIVE HER FEELINGS OF ISOLATION AND DEPRESSION, HER PHYSICAL LIMITATIONS WITH HER CHRONIC ILLNESSES (DIABETES, HYPERTENSION) CASE STUDY #4 MISS ANDREWS HAD

A CEREBRAL ANEURYSM THAT RUPTURED AND SHE HAD A SUBARACHNOID HEMORRHAGE.

SHE

HAS

AN INCISION WITH NO REDNESS OR DRAINAGE, NIMOTOP IS ORDERED.

WHAT ARE THE DIFFERENCES IN THE SIGNS AND SYMTOMS OF A HEMORRHAGIC AND AN ISCHEMIC STROKE? HEMORRHAGIC STROKE – RAPID ONSET, SUDDEN SEVERE HEADACHE, LOSS OF CONSCIOUSNESS, NUCHAL RIGIDITY ISCHEMIC STOKE

– SLOWER ONSET

HOW WOULD YOU DIAGNOSE A SUBARACHNOID HEMORRHAGE? WITH A CT SCAN OR AN MRI WHAT ARE THE COMPLICATIONS FOR A SUBARACHNOID HEMORRHAGE AND HOW DO WE TREAT THOSE? VASOSPASMS – CALCIUM CHANNEL BLOCKERS SEIZURES – ANTISEIZURE MEDS (DILANTIN) HYDROCEPHALUS – POSSIBLE SHUNT RE-BLEEDING - MONITOR THEIR BLOOD PRESSURE AND KEEP IT UNDER CONTROL 16

TCA 3

CASE STUDY #5 THE LADY IN CASE STUDY #4 HAS DEVELOPED HYDROCEPHALUS WHAT IS THE PATHO OF HER HYDROCEPHALUS? SHE HAS COMMUNICATING – THE CSF FLOW IS RESTRICTED AFTER IT EXITS THE VENTRICLES. HER CSF FLOW WAS RESTRICTED IN THE ABSORPTION (WHEN IT GETS TO THAT SUBARACHNOID LAYER AND THE VILLI THAT ARE SUPPOSE TO ABSORB THE CSF HAVE BEEN BLOCKED WITH RBC’S) WHAT SURGICAL PROCEDURE MIGHT SHE NEED? VP SHUNT – A FLEXIBLE TUBE WITH A ONE WAY VALVE IS INSERTED INTO THE VENTRICLE AND IT DRAINS DOWN INTO THE PERITONEAL CAVITY WHERE IT CAN BE ABSORBED BACK INTO THE BODY. WHAT IS THE DIFFERENCE AFTER SURGERY IN AN INFANT AND IN AN ADULT AFTER THIS VP SHUNT PLACEMENT? WILL LAY THE INFANT FLAT (TO PREVENT ANY RAPID CHANGES IN INTRACRANIAL PRESSURE) AND YOU WILL HAVE THE HOB LIFTED 30° FOR THE ADULT

17

TCA 3

NEUROLOGIC DEFICITS OF STROKE: MANIFESTATIONS AND NURSING IMPLICATIONS NEUROLOGICAL MANIFESTATION NURSING IMPLICATIONS/PATIENT TEACHING APPLICATIONS DEFICIT VISUAL FIELD DEFICITS HOMONYMOUS UNAWARE OF PERSONS OR PLACE OBJECTS WITHIN INTACT FIELD OF VISION. HEMIANOPSIA OBJECTS ON SIDE OF VISUAL APPROACH PATIENT FROM SIDE OF INTACT FIELD OF VISION. LOSS. INSTRUCT/REMIND THE PATIENT TO TURN HEAD IN THE DIRECTION OF NEGLECT OF ONE SIDE OF VISUAL LOSS TO COMPENSATE FOR LOSS OF VISUAL FIELD. THE BODY. ENCOURAGE THE USE OF EYEGLASSES IF AVAILABLE DIFFICULTY JUDGING DISTANCES. LOSS OF PERIPHERAL DIFFICULTY SEEING AT WHEN TEACHING THE PATIENT, DO SO WITHIN PATIENT’S INTACT VISUAL VISION NIGHT. FIELD. UNAWARE OF OBJECTS OR AVOID NIGHT DRIVING OR OTHER RISKY ACTIVITIES IN THE DARKNESS. THE BORDERS OF OBJECTS. ENCOURAGE THE USE OF A CANE OR OTHER OBJECT TO IDENTIFY OBJECTS IN THE PERIPHERY OF THE VISUAL FIELD. EXPLAIN TO THE PATIENT THE LOCATION OF AN OBJECT WHEN PLACING IT NEAR THE PATIENT. CONSISTENTLY PLACE PATIENT CARE ITEMS IN THE SAME LOCATION. NEUROLOGICAL MANIFESTATION NURSING IMPLICATIONS/PATIENT TEACHING APPLICATIONS DEFICIT MOTOR DEFICITS HEMIPARESIS

WEAKNESS OF THE FACE, INSTRUCT THE PATIENT TO EXERCISE AND INCREASE THE STRENGTH ON ARM, AND LEG ON THE SAME THE UNAFFECTED SIDE SIDE. PLACE OBJECTS WITHIN PATIENT’S REACH ON THE NONAFFECTED SIDE.

HEMIPLEGIA

PARALYSIS OF THE FACE, PLACE OBJECTS WITHIN PATIENT’S REACH ON THE NONAFFECTED SIDE. ARM, AND LEG ON THE SAME PROVIDE IMMOVILIZATION AS NEEDED TO THE AFFECTED SIDE SIDE. MAINTAIN BODY ALIGNMENT IN FUNCTIONAL POSITION. EXERCISE UNAFFECTED LIMB TO INCREASE MOBILITY, STRENGTH, AND USE. STAGGERING, UNSTEADY SUPPORT PATIENT DURING THE INITIAL AMBULATION PHASE. GAIT. PROVIDE SUPPORTIVE DEVICE FOR AMBULATION (WALKER, CANE). UNABLE TO KEEP FEET INSTRUCT THE PATIENT NOT TO WALK WITHOUT ASSISTANCE OR TOGETHER; NEEDS A BROAD SUPPORTIVE DEVICE. VASE TO STAND. DIFFICULTY IN FORMING PROVIDE THE PATIENT WITH ALTERNATIVE METHODS OF COMMUNICATING. WORDS ALLOW THE PATIENT SUFFICIENT TIME TO RESPOND TO VERBAL COMMUNICATION. SUPPORT PATIENT AND FAMILY TO ALLEVIATE FRUSTRATION RELATED TO DIFFICULTY IN COMMUNICATING. DIFFICULTY IN SWALLOWING TEST THE PATIENT’S PHARYNGEAL REFLEXES BEFORE OFFERING FOOD OR FLUIDS. ASSIST THE PATIENT WITH MEALS. PLACE FOOD ON THE UNAFFECTED SIDE OF THE MOUTH. ALLOW AMPLE TIME TO EAT. MANIFESTATION NURSING IMPLICATIONS/PATIENT TEACHING APPLICATIONS

ATAXIA

DYSARTHRIA

DYSPHAGIA

NEUROLOGICAL DEFICIT SENSORY DEFICITS PARESTHESIA

NUMBNESS AND EXTREMITY. DIFFICULTY

TINGLING OF

PROPRIOCEPTION.

INSTRUCT

THE PATIENT TO AVOID USING THIS EXTREMITY AS THE

DOMINANT LIMB DUE TO ALTERED SENSATION. WITH

PROVIDE

RANGE

OF

MOTION

TO

AFFECTED

AREAS

AND

APPLY

CORRECTIVE DEVICES AS NEEDED.

18

TCA 3

VERBAL DEFICITS EXPRESSIVE APHASIA

USABLE

TO

FORM

WORDS

ENCOURAGE PATIENT TO REPEAT SOUNDS OF THE ALPHABET

THAT ARE UNDERSTANDABLE; MAY BE ABLE TO SPEAK IN SINGLE-WORD RESPONSES

RECEPTIVE APHASIA

UNABLE THE

TO

SPOKEN

COMPREHEND

SPEAK

WORD;

SOUNDS.

CAN

SLOWLY AND CLEARLY TO ASSIST THE PATIENT IN FORMING THE

SPEAK BUT MAY NOT MAKE SENSE

GLOBAL APHASIA COGNITIVE DEFICITS

COMBINATION

OF

BOTH

CLEARLY

AND

IN

SIMPLE

SENTENCES;

USE

GESTURES

PICTURES WHEN ABLE.

APHASIA

ESTABLISH ALTERNATIVE MEANS OF COMMUNICATION. REORIENT PATIENT TO TIME, PLACE, AND SITUATION FREQUENTLY USE VERBAL AND AUDITORY CUES TO ORIENT PATIENT. PROVIDE FAMILIAR OBJECTS USE NONCOMMPLICATED LANGUAGE MATCH VISUAL TASKS WITH VERBAL CUES MINIMIZE DESTRACTING NOISES WHEN TEACHING THE PATIENT REPEAT AND REINFORCE INSTRUCTIONS FREQUENTLY

SHORT

AND

LONG

TERM

MEMORY LOSS

DECREASED

ATTENTION

SPAN

IMPAIRED

ABILITY

TO

CONCENTRATE

EMOTIONAL DEFICITS

SPEAK

RECEPTIVE AND EXPRESSIVE

POOR ABSTRACT REASONING ALTERED JUDGMENT LOSS OF SELF-CONTROL. EMOTIONAL LABILITY. DECREASED TOLERANCE TO STRESSFUL SITUATIONS. DEPRESSION WITHDRAWAL FEAR, HOSTILITY, AND ANGER

SUPPORT

PATIENT DURING UNCONTROLLABLE OUTBURSTS

THE DISEASE

IS

OR

DUE TO

PROCESS.

ENCOURAGE PATIENT TO PARTICIPATE IN GROUP ACTIVITY. PROVIDE STIMULATION FOR THE PATIENT. CONTROL STRESSFUL SITUATIONS, IF POSSIBLE. PROVIDE A SAFE ENVIROMENT. ENCOURAGE PATIENT TO EXPRESS FEELINGS AND FRUSTRATIONS RELATED TO DISEASE PROCESS.

FEELINGS OF ISOLATION

19