Neurologic Deficits-Lecture 1 and 2
Created By: Janet Maloney MSM/HM
Definition- a condition in which the patient is unresponsive to and unaware of environmental stimuli.
Coma: clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods.
Akinetic mutism: Do not response to the environment. Patient makes no movement or sound but sometimes opens eyes.
Persistent vegetative states: patient is described as wakeful but has no cognitive or affective mental function.
Unconsciousness itself is not a disease or a diagnoses but rather a manifestation of a large number of pathophysiological processes, including trauma, metabolic disturbances, mass lesions, and infections.
RAS is a network of nerve fibers and cell bodies in the central part of the brainstem that has connections to many parts of the nervous system.
An intact RAS can maintain a state of wakefulness. Any interruption of RAS impulses or alteration of the cerebral hemispheres can cause unconsciousness,
Causes Of Unconsciousness
Psychiatric disorders depression, catatonia and schizophrenia.
Supertentorial Mass- epidural hematoma, cerebral infarction, brain tumor, brain abscess
Subtentorial Lesions- brainstem infarction, brainstem hemorrhage, cerebellar hemorrhage.
Aspiration (gastric feeding)
Defined by behavior and pattern of brain activity by an EEG.
Deepest state dose not respond to painful stimuli, corneal and pupillary responses are absent. No swallowing or cough reflex and incontinent of urine and feces.
EEG pattern demonstrate decreased or absent neuronal activity. Pt in a coma
Planning and goals
Maintenance of a clear airway
Protection form injury
Attainment of fluid volume balance
Achievement of intact oral mucus membranes
Maintenance of normal skin integrity
Absence of corneal irritation
Absence of complications
Planning and goals
Attainment of thermoregulation
Absence of urinary retention and infection
Absence of diarrhea or fecal impaction
Maintenance of intact family or support system
Maintaining the airway
Protecting the patient and maintaining safety
Maintaining fluid and nutritional balance
Providing mouth care
Maintaining skin integrity
Preserving corneal integrity
Preventing urinary retention (observe urine)
Promoting bowel function
Providing sensory stimulation
Supporting the family
Monitoring and managing potential complications
Appropriate breath sounds
Maintain adequate fluid status
Maintain skin integrity
No corneal irritation
No urinary retention
Family copes with crisis
Head injury includes any trauma to scalp, skull or brain. Includes an alteration in consciousness.
Types of Head Injury scalp Lacerations, Skull fractures, Minor Head trauma , Major head Trauma and Diffuse Axonal Injury.
Types of head injuries
Scalp Lacerations: Most minor of the head traumas. Because your scalp contains many blood vessels with poor constructive abilities, most scalp lacerations are associated with profuse bleeding. The major compilation is INFECTION.
Skull Fractures: Frequently occurs with head trauma. There are several ways to describe skull fractures: P. 1624
a)Linear (occurs at the base of the skull) or depressed (inward indentation)
b)Simple, comminuted, or compound
c) Closed or open
Fractures may be closed or open, depending on the presence of a scalp laceration or extension of the fracture in the he air sinus or dura.
The type and severity of a skull fracture depends on the velocity, momentum, the direction of injuring agent, and the site of impact.
The location of the fracture alters the presentation of the clinical signs and symptoms.
a) Frontal fracture: Exposure of brain to contaminants through frontal air sinus. CSF Rhinorrhea (CSF leakage from the nose) or otorrhea (from the ear). This usually confirms that the fracture has transverse the dura.
b) Orbital fracture: raccoon eyes (periorbital ecchymosis).
c) Temporal Fracture: Battle sign. Oval shaped bruise behind the ears.
d) Parietal Fracture: Deafness, CSF or brain otorrhea, facial paralysis, loss of taste; battle sign.
e) Posterior fossa fracture: Occipital bruising resulting in blindness, visual field defects, rare appearance of ataxia.
f) Basilar skull fracture: CSF or brain otorrhea, bulging of tympanic membrane caused be CSF or blood, battle sign, tinnitus or hearing difficulty, facial paralysis, vertigo.
The postconcussion syndrome: is seen anywhere from 2 weeks to 2 months after the concussion.
Minor head injury
Minor head trauma:
Brain injuries are categorized as being minor or major. Concussion (a sudden transient mechanical head injury with disruption of neural activity and a change of LOC) . The patient may not loss total consciousness with this injury.
Signs: Brief LOC, amnesia (of incident), and headache.
If the unconsciousness lasted less than 5 minutes the patient is usually sent home with instructions of when to notify MD.
Testing CSF fluids
TWO WAYS TO TEST FOR CSF LEAKAGE.
1)Test with a dextrostix or tes-tape strip to determine whether glucose is present. CSF gives a positive reading for glucose. IF blood is present however, testing for the presence of glucose is unreliable because blood contains glucose.
2)If this occurs look for the Halo or ring sign. To perform this test, the nurse allows the leaking fluid to drip on a white pad (4 X 3) or towel and observes the drainage. Within a few minutes the blood moves to the center and a yellowish ring encircles the blood is CSF is present. Note the amount, color and appearance because both tests can give false positive results.
Minor head injury
Signs: persistent headache, lethargy, personality and behavior changes, shortened attention span, decreased short-term memory, and changes in intellectual ability.
Although a concussion is generally considered benign and usually resolves spontaneously, the symptoms may be beginning signs of a more serious problem.
Very important to give patient and families instructions of all the above so they can seek help if needed.
Major head trauma
Major Head Trauma: Includes contusions (bruising of the brain tissue within a focal area that maintains the integrity of the pia mater and arachnoid layers) and lacerations.
A contusion develops area of necrosis, infarction, hemorrhage and edema. Usually occurs at the site of the fracture. Bleeding at the site is usually minimal and the blood is reabsorbed slowly. Seizures are a common complication of brain contusion.
Lacerations: Involve actual tearing of the brain tissue and occur frequently in association with depressed and compound fractures and penetrating injuries. Tissue damage is severe and surgical repair of the laceration is impossible because of the texture of the brain tissue.
Signs and symptoms: Hemorrhage, hematoma formation, seizures, and cerebral edema.
Prognosis is usually very poor when a patient has a hemorrhage.
Blunt MVA, Pedestrian event, fall, assault, sports injury
Penetrating gun shot wound, arrow
Chronic subdural hematoma
Diagnostic Studies and Collaborative care
Skull x-rays r/o skull fx and facial fx
CT scan and MRI r/o cranialcerebral trauma, Allows for rapid dxs
PET differentiates head injuries
Transcranial Doppler allow for measurement of cerebral blood flow velocity
Collaborative Care cont
Ensure patent airway
Establish IV access
Monitor V/S, LOC, O2 sat, cardiac rhythm, GCS, pupil size & reactivity
Skull Fracture , craniotomy or craniectomy maybe necessary
Collaborative Care cont
Maintain body temperature
Maintain skin integrity
Prevent sleep disturbance
Ineffective airway clearance and ventilation r/t hypoxia.
Fluid volume deficit r/t disturbances of consciousness and hormonal dysfunction
Altered nutrition r/t metabolic changes, fluid restriction, and inadequate intake.
Risk for injury r/t disorientation, restlessness, and brain damage.
Pain r/t headache, nausea and vomiting
Self-esteem disturbance r/t altered appearance of head and face
Maintain adequate cerebral perfusion; remain normthermic; be free from pain and infection and maintain max cognitive, motor and sensory function
Health Promotion- to Prevent head injuries promote safety driving, use of seat belts and helmets.
Avoid driving while under the influence of alcohol
Educate parents on the proper use of seat belts and restraints for their children
Patient and Family Teaching
Home Care Notify MD if pt with s/s of:
Worsen HA or stiff neck
Glasgow Coma Scale
GCS- uses three indicators of response are evaluated.
Opening of the eyes, the best verbal response and the best motor response.
Specific behaviors are seen and given a numeric value and can be plotted on a graph.
The higher the scores, the higher the level of brain functioning
Normal ICP is the pressure exerted by total volume from 3 components within the skull: brain tissue, blood, and CSF. HOB @ 30 ICP 0-15 mm hg.
Normal compensatory adaptations
Dispensability of dura, increased venous outflow, decreased CSF production, changes in intracranial blood volume via constriction & dilation & slight compression of brain tissue
Cerebral Blood Flow
CBF is the amt of blood in ML passing through 100 g of brain tissue in 1 min. CBF 50 ml/min
Brain requires 20% of the bodys oxygen and 25% of its glucose
Autoregulation Ensures a consistent CBF to provide for metabolic needs to maintain cerebral perfusion pressure.
Normal MAP 50 mm hg, below this CBF decreases s/s cerebral ischemia, I.e, syncope & blurred vision.
The systemic arterial pressure that autoregulation is effective is 150 mm hg. When this pressure is exceeded, vessels are constricted.
Resulting in an increase ICP
Oxygen tension, carbon dioxide tension and hydrogen ion concentration affect cerebral tone.
-Cerebral edema results in an increase in tissue volume that may increase ICP.
-3 types of cerebral edema, vasogenic cerebral edema, cytotoxic and interstitial cerebral edema
-Conditions assoc. w/ CE see p 1613 table-54-4 & Fig 54.4
Major complications are cerebral herniation, if unrelieved respiratory arrest may occur.
Clinical manifestation change in LOC, change in V.S, ocular signs, decrease in major function, headache and vomiting
Loss of consciousness confuses clinical s/s of increased ICP
· Identifying the underlying cause of >ICP.
· MRI, CT, cerebral angiography, EEG, cerebral blood flow, transcranial Doppler studies.
Preventing secondary injury to brain
Oxygenation to support brain function, Pao2 @ 100 mm hg or>
ET or tracheostomy to maintain ventilation/ Mechanical ventilation
If cause by mass lesion I.e, tumor or hematoma, surgical removal of mass maybe necessary
· Osmotic diuretics
· Loop diuretics
· Corticosteroids therapy
· High dose barbiturates e.g., pentobarbital and thiopental
· Hyperventilation therapy
· Nutritional therapy
· Subjective & objective data
· GCS data
·Mental status, cranial nerve functioning, motor functioning, sensory status, cerebellar functioning and reflexes
· Pupil size & response
· Altered cerebral tissue perfusion r/t cerebral tissue swelling AEB MS ICP> 20 mm Hg
· Risk of infection r/t immobility
· Risk for impaired skin integrity r/t nutritional deficit and immobility
Client will (1) have decreased ICP to within normal limits (2) maintain patent airway, and (3) demonstrate normal fluid and electrolyte balance
Types Tumors arise from tissues within the brain or secondary from metastasis from a malignancy else where in the body.
Tumors arise from brain tissue Gliomas or vascular tumors
Tumors arising outside the brain substance – meningiomas or cranial nerve tumors
Because obstruction of CSF, increased ICP, displacement of structures, & edema
Slight decrease in mental acuity, mental deterioration or a seizure
S/S depends on the location of tumor & the functions controlled by affected the area
If tumor obstructs Ventricles or an outlet surgical TX is done to relieve pressure and placement of a shunt drains CSF to right atrium or peritoneum.
Pt instructed to avoid contact sports
Call MD if s/s of decreasing LOC, N/V, H.A., blurred vision or stiff neck
· H & P
· CT scan
· Skull x-rays
· Brain scan
· Myleogram and lumbar puncture
· Surgical Therapy
· Radiation & Chemotherapy
·Therapy currently under Investigation are Radium implants into tumor bed, local hyperthermia and biologic therapy
Causes brain tumor, CNS infection, vascular abnormal, craniocerebral trauma, epilepsy and intractable pain
Types of cranial surgery Burr hole, Craniotomy, craniectomy, Cranioplasty, stereotaxis and Shunt procedures
· CT scan: to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement.
·MRI: provides information similar to that of the CT scan and examines the lesion in other planes
·Angiography: used to study the tumors blood supply or give information about vascular lesions.
·Transcranial Doppler: studies are used to evaluate the blood flow of
·intracranial blood flow.
Complications of intracranial surgery
· Increased ICP, infection and neurologic defiects.
·Increased ICP may develop as a result of cerebral edema or swelling and is treated with mannitol and use of paralyzing agents.
· Anticonvulsant medication before surgery to reduce the risk of poet-op seizures. Steroids (Dexamethasone) may be administered to reduce cerebral edema.
· Fluids may be restricted.
·Hypertonic solutions such as as mannitol and a diuretic lasix may be given IV immediately before and sometimes during surgery if the patient tends to retain fluids.
· Altered cerebral tissue perfusion r/t to cerebral edema.
·Potential for ineffective thermoregualtion r/t damage to the hypothalamus, dehydration, and infection.
· Potential for gas exchange
· Increased ICP
· Bleeding and hypovolemic shock
· Fluid and electrolyte disturbances
· Arterial line and a venous line may be placed to monitor blood pressure and central venous pressure. The patient may be intubated and may receive supplemental o2 therapy.
· Reduce cerebral edema
· Relieving pain and [preventing seizures
· Monitoring ICP
· Pt w/ cranial surgery will return to normal consciousness, be free from pain & discomfort, maximize neuromuscular functioning and be rehabilitated to maximum ability
· Achieving neurologic homestasis
· Regulating temp.
· Improving gas exchange
· Managing sensory deprivation
· Enhancing self-image
· Monitoring and managing potential complications
A seizure is a uncontrolled discharge of neurons in the brain that interrupts normal function. Seizures are frequently symptoms of an underlying illness.
Epilepsy is a condition in which a person has spontaneously recurring seizures caused by a chronic underlying condition.
Etiology & Pathphysiology
· Most common cause 1st 6 mos of life are congenital defects from birth injury.
· 2 – 20 y.o. infection, trauma & genetic factors
· 20 – 30 y.o. structural lesions I.e., trauma, brain tumors or vascular disease
· After 50 y.o primary cause are cerebrovascular lesions & metastic brain tumors
· Phases of seizures:
· The prodromal phase w/ signs activity, which precede a seizure
· The aural phase w/ a sensory warning
· The ictal phase w/ full seizure
· Postictal phase, which is the period of recovery after the seizure
Partial seizures are focal in origin and affect only part of the brain. Here maybe a finger or hand shakes. Maybe the mouth jerks. The person may talk unintelligibly, may be dizzy and may experience unusual or unpleasant sights, sounds, odors, or taste, but without loss of consciousness. (AURA)
SIMPLE Partial seizures: elementary symptoms, generally without impairment of consciousness.
COMPLEX partial seizures: generally with impairment of consciousness.
Generalized Seizures the entire brain is affected at the onset, there is no warning or aura, lost of consciousness for sec to min.
Tonic-Clonic seizures most common loss of consciousness & falls, stiffening of body (tonic phase)10-20 sec & jerking of extremities (clonic phase) for 30-40 seconds
Physical Status epilepticus rapid succession of seizures. Pt. dose not regain consciousness a neurologic emergency
Tonic-Clonic- ventilatory insuffiency, hypoxemia, cardiac arrhythmias, hyperthermia & systemic acidosis.
-Severe injury and even death from trauma can occur during a seizure
-Epileptic pts who lose consciousness are at risk, death can result from a head injury incurred in a fall, drowning in a tub or from severe burns
· Psychosocial :
· Social stigma
· Ineffective method of coping
· Electrolytes, creatinine, fasting blood
· Lumbar puncture
· CT, MRI, Pet scan
· Antiseizure medication
· Vagal nerve stimulation
· Psychosocial counseling
· Alternative therapy – biofeedback
· Subjective & objective data
·Planning: Pt will be free from injury during a seizure, have optimal mental and physical functioning while taking antiseizure medication, and have satisfactory psychosocial functioning
Nursing Care Plan
· Ineffective method of coping
· Risk for injury
· Ineffective airway clearance
· Ineffective mgt of therapeutic regimen r/t lack of knowledge
· Self-esteem disturbance r/t diagnoses of epilepsy
· Health Promotion: general safety,practice good health habits
·Acute Intervention: observation, treatment of seizure, education and psychosocial intervention
Ambulatory and Home Care
· Medication taken regularly
· Do not adjust dose w/o MD
· Educate family members re: emergency management
· Wear a medic alert bracelet or ID card
· Avoid excessive alcohol, fatigue and loss of sleep
· Regular meals & snacks in between if faint, shaky or hungry
TIA Transient Ischemic Attack
· Is a temporary episode of neurological dysfunction, commonly manifested by a sudden loss of motor. Sensory, or visual function.
· May last few seconds or minutes but does not last longer than 24 hours.
· Complete recovery usually occurs.
· TIA can follow a stroke. This occurs in about 10% of patients. This however, is considered a warning sign to a stroke (usually within the first 3 years).
·Reversible ischemic neurological deficits (RIND) symptoms that are consistent with TIA but last longer than 24 hours and resolved within 21 days without any deficits.
Risk Factors for TIA
· DM Type 1
· History of smoking
· Family HX
· Chronic alcoholism
· Temporary impairment of blood flow top a specific region of the brain fro various reason, such as arthrosclerosis, obstruction of cerebral microcirculation by a small embolus, a decrease in CPP, or cardiac dysrhythmias.
Assessment and DX finding
· Carotid artery: May hear a bruit (this is considered interference with normal blood flow).
·Carotid phonoangiography: this involves auscultation, direct visualization and photographic recording of the bruits.
· Carotid Angiogram: allows you to see the intracranial and cervical vessels.
· Carotid endarterectomy Removal of plaque or thrombus from the carotid artery.
·Carotid angioplasty (a balloon is inserted in the artery to compress the plaque against the arterial wall and thereby improve blood flow).
· Neuro flow sheet
· If deficits occur the neuro surgeon is identified.
· If a thrombus is present then surgery will be rescheduled.
· Primary complications of endarterectomy: stroke, cranial nerve injuries, infection or hematoma of the wound, and carotid nerve injuries.
·It is important to maintain adequate blood pressure levels in the immediate post-op period.
Hypotension (try to avoid this, it could cause thrombosis and cerebral ischemia)
· Uncontrolled hypertension (can cause hemorrhage, edema).
· Difficulty in swallowing, hoarseness.
· Brain attack
·Sudden loss of brain function resulting from disruption of the blood supply to a part of the brain.
· Nonhemorrhagic (85%)
· Hemorrhagic (15%)
Nonhemorrhagic: can occur from
· Thrombosis (a clot within a blood vessel or the brain or neck).
·Cerebral embolism: a blood clot or other material carried to the brain from another part of the body.
· Ischemia: decrease blood flow to an area of the brain.
· Is a cerebral hemorrhage: rupture of a blood vessel with bleeding into the brain tissue or spaces surrounding the brain.
Divided into 5 different types:
· Large thrombosis (20%)
· Small penetrating artery thrombosis (25%).
· Cardiogenic embolic stroke (20%)
· Cryptogenic (30%)
· Other (5%)
· Result from bleeding into the brain tissue or into a space such as a subarachnoid space.
· Can be caused by aneurysm, certain drugs or uncontrolled HTN.
· Epidural hemorrhage is a neurological emergency.
·Usually follows skull fracture with a tear of the middle artery or other meningeal artery.
· Pt. Must be treated within hours or the pt. will die.
· Is basically the same as an epidural hemorrhage, except that it is usually a vein that is torn.
· So a hematoma takes longer to form and cause pressure to the brain.
· Some patients may not even exhibit s/s.
· Hemorrhaged in the Subarachnoid space.
·May result due to trauma or HTN, but the most common use is a leaking aneurysm in the circle of Willis and congenital arterio-venous malformation of the brain.
· Bleeding into the brain substance, is most common in patients with HTN, and cerebral atherosclerosis because of degenerative changes from these disease cause rupture of the vessel.
·Bleeding is usually arterial and occurs most commonly in a portion of the basal ganglia and adjacent internal capsule and the thalamus.
· Numbness or weakness of the face, arm, or leg.
· Confusion or change in mental status.
· Trouble speaking or understanding speech
· Visual disturbances.
· Difficulty walking, dizziness, loss of balance or coordination.
· Sudden severe headache.
· Motor loss
· Communication loss
· Perceptual disturbances
· Sensory loss
· Cognitive impairment
· Carotid US
· Best approach
· Control of AF
· Cartoid endo
· Cerebral hypoxia (minimize by providing adequate O2 of blood to the brain).
· Administer O2 and maintain H/H at acceptable.
· Adequate IVF (reduce blood thickness and improve cerebral blood flow).
Thrombolytic therapy for the patient with an ischemic stroke.
· Rapid dx of stroke and initiation of thrombolytic therapy in patients with ischemic stoke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
· Patients are given t-PA (tissue plasminogen activator), a clot dissolving medication, within 3 hours of the onset of symptoms.
·Pt.s who are receiving anticoagulants or bleeding disorders are not candidates for t-PA.
· Window is 3 hours
·Delays are a problem because revascularization of necrotic tissue (which develops after 3 hours) occurs. This increases the risk of cerebral edema and hemorrhage.
· CT scan (once it has been determined if patient meets criteria t-PA will be started and no anticoagulant therapy.
· Recombinant t-PA binds to fibrin and converts plasminogen to plasmin, stimulating fibrinolysis of the atherosclerotic lesion.
· Once this is determined the patient is weighted and t-PA is started.
· Minimum dose is 0.9mg/kg the maximum dose is 90 mg.
·The loading dose is 10% of the calculated dose and is administered over 1 minute.
·The remain dose is administered over 1 hour via infusion pump, after the infusion is completed, the line is flushed with 20cc of NS to ensure that all the medication is administered to the patient.
· Then the patient is transferred to ICU, where cardiac monitoring is done.
· Vital signs done q 15m for the first 2 hours., every 30M for the next 6 and then every 16 hours.
· Bleeding is the most common side effect.
Patients not receiving t-PA
· Heparin or low-molecular weight heparin.
·Management of patient with hemorrhagic stroke is focused on management of increased ICP and its associated problems.
· Administer osmotic diuretics (Mannitol).
·Elevate the HOB 30 degrees to promote venous drainage and to lower increased ICP.
· Incubation with an ETT to establish secure airway.
· Continuous EEG and VS.
· Neuro checks
During acute phase monitor for:
· Change in LOC or responsiveness.
· Presence or absence of voluntary or involuntary movement of the ext.
· Stiffness or flaccidity
· Eye opening, size of pupils, reactions to light.
· Color pf the face and ext.
· Quality and rates of pulse and respiration; ABG
· Ability to speak
· Volume of fluids
· Presence of bleeding
· Maintenance of BP
· Impaired physical mobility
· Self care deficits
· Impaired swallowing
· Altered though process
· Improve mobility and prevent contractures
· Prevent shoulder adduction
· Positioning the hand and fingers
· Changing positions
· Establish an exercise routine
· Prepare for ambulation
· Enhance self care
· Mange sensory-perceptual difficulties
· Manage dysphasia (swallowing problems).
· Manage tube feedings
· Attain bowel and bladder control
· Improve thought process
· Improve communication
· Maintain skin integrity
· Improve family coping
· Help the patient cope with sexual dysfunction
· Receptive aphasia: inability to understand what someone else is saying; often associated with damage to the temporal lobe area
·Expressive aphasia: inability to express oneself; often associates with the lift frontal lobe.
·Paraphasia: uses wrong words, word substitutions, grammatical errors, faults in word usage in both written or verbal.
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