Chapter 41 Care of Critically Ill Patients with Neurologic Problems Copyright © 2021, Elsevier Inc. All Rights Reserved. Concepts The priority concepts in this chapter are Perfusion Cognition The interrelated concepts in this chapter are Mobility Sensory Perception Copyright © 2021, Elsevier Inc. All Rights Reserved. Transient Ischemic Attack (TIA) “Warning sign” Temporary neurologic dysfunction Brief interruption in cerebral blood flow Often caused by carotid stenosis ABCD2 assessment tool Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke (Brain Attack) Pathophysiology Overview Interruption of perfusion to any part of the brain Medical emergency Types Acute ischemic stroke (AIS) • Thrombolic • Embolic Hemorrhagic • Intracerebral hemorrhage (ICH) • Subarachnoid hemorrhage (SAH) • Aneurysm • Arteriovenous malformation (AVM) Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Etiology and Genetic Risk Genetic First-degree relative with history of hypertension, atherosclerotic disease, aneurysm Leading causes Smoking Obesity Hypertension Diabetes mellitus Elevated cholesterol Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Incidence and Prevalence Fifth leading cause of death in U.S. Women have higher incidence than men (likely because women live longer) “Stroke belt” Many stroke survivors Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Health Promotion and Maintenance ABCDs Aspirin use when appropriate Blood pressure control Cholesterol management Smoking cessation Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Assessment: Recognize Cues (1 of 2) History First priority is to ensure patient is transported to stroke center Other history can be taken after this Physical Assessment/Signs & Symptoms Neurologic examination NIHSS Psychosocial Assessment Emotional lability Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Assessment: Recognize Cues (2 of 2) Laboratory assessment Elevated H&H, WBC Blood glucose Hemoglobin A1C PT, INR, aPTT Imaging assessment CTP and/or CTA MRA US Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Analysis: Analyze Cues & Prioritize Hypotheses Inadequate perfusion to the brain due to interruption of arterial blood flow and a possible increase in ICP Decreased mobility and possible need for assistance to perform ADLs due to neuromuscular or impaired cognition Aphasia and/or dysarthria due to decreased circulation in the brain (aphasia) or facial muscle weakness (dysarthria) Sensory perception deficits due to altered neurologic reception and transmission Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Planning and Implementation: Generate Solutions & Take Action Improving cerebral perfusion Monitoring for increased intracranial pressure Promoting mobility and ADL ability Managing changes in sensory perception Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Care Coordination and Transition Management Home care management Self-management education F.A.S.T. pneumonic Health care resources Copyright © 2021, Elsevier Inc. All Rights Reserved. Stroke: Evaluation: Evaluate Outcomes The expected outcomes are that the patient: Has adequate cerebral perfusion to avoid long-term disability Maintains blood pressure and blood glucose within a safe, prescribed range Performs self-care and mobility activities independently, with or without assistive devices Learns to adapt to sensory perception changes, if present Communicates effectively or develops strategies for effective communication as needed Has adequate nutrition and avoids aspiration Copyright © 2021, Elsevier Inc. All Rights Reserved. Traumatic Brain Injury (TBI) Damage to the brain from an external mechanical force Not caused by neurodegenerative or congenital conditions Copyright © 2021, Elsevier Inc. All Rights Reserved. Acceleration–Deceleration Injury The image to the right identifies head movement during acceleration— deceleration injury, which is typically seen in motor vehicle crashes (MVCs). Copyright © 2021, Elsevier Inc. All Rights Reserved. Types Primary brain injury Happens at time of injury Focal or diffuse Open or closed Mild, moderate, severe Secondary brain injury Occurs after the initial injury and worsens outcomes E.g., post-concussion syndrome, hypotension and hypoxia, increased ICP, hemorrhage, etc. Copyright © 2021, Elsevier Inc. All Rights Reserved. Epidural Hematoma The image above identifies the location of an epidural hematoma (outside the dura mater of the brain), subdural hematoma (under the dura mater), and intracerebral hemorrhage (within the brain tissue). Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma Venous bleeding into space beneath dura and above arachnoid Occurs from tearing of bridging veins within cerebral hemispheres Bleeding occurs more slowly than from an epidural hematoma Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Etiology Fall Motor vehicle crashes Colliding with stationary or moving object Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Incidence and Prevalence 1.7 million annually in US Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Health Promotion and Maintenance Safe driving practices Avoid alcohol, drugs, marijuana Use helmets Environmental factors Fall prevention strategy Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Assessment: Recognize Cues (1 of 2) History Physical Assessment/Signs & Symptoms Amnesia, LOC, or seizure? Physical findings • Protect airway and spine Cognitive findings Sleep disturbances Psychosocial Assessment Emotional lability Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Assessment: Recognize Cues (2 of 2) Imaging assessment CT MRI Functional MRI Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Analysis: Analyze Cues & Prioritize Hypotheses Potential for decreased cerebral tissue perfusion Potential for decreased cognition, sensory perception, and/or mobility Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Planning and Implementation: Generate Solutions & Take Action Maintaining cerebral perfusion Prevent and detect secondary brain injury Maintaining cognition, sensory perception, and mobility Cognitive rehabilitation Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Care Coordination and Transition Management Home care management Self-management education Health care resources Copyright © 2021, Elsevier Inc. All Rights Reserved. Subdural Hematoma: Evaluation: Evaluate Outcomes Expected outcomes are that the patient: Maintains cerebral tissue perfusion Learns to adapt to altered mobility and sensory perception changes, if any Has minimal alterations in cognition or understands how to compensate for cognition changes when necessary Copyright © 2021, Elsevier Inc. All Rights Reserved. Brain Tumors Pathophysiology Overview Primary tumors originate within central nervous system (CNS) Secondary tumors result from metastasis in other areas of the body Classification • Benign • Malignant • Metastatic Copyright © 2021, Elsevier Inc. All Rights Reserved. Brain Tumors: Assessment: Recognize Cues Common symptoms Headaches Nausea and vomiting Seizures Impaired sensory perception Loss of balance or dizziness Weakness or paralysis Difficulty thinking, speaking, or articulating words Changes in cognition, mentation, or personality Copyright © 2021, Elsevier Inc. All Rights Reserved. Brain Tumors: Interventions: Take Action Nonsurgical management Drug therapy Stereotactic radiosurgery Surgical management Craniotomy Copyright © 2021, Elsevier Inc. All Rights Reserved. Brain Tumors: Care Coordination and Transition Management Accessibility Follow-up appointments American Brain Tumor Association or National Brain Tumor Foundation – U.S. Brain Tumor Foundation – Canada Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (1 of 5) The spouse of a client brought to the ED reports that 6 hours ago, her husband began having difficulty finding words. The client has since become progressively worse. Upon assessment, you note right hemiparesis and urine incontinence 1. What is the priority nursing intervention for this client at this time? A. B. C. D. Provide perineal care. Assess for gag reflex. Elevate the head of the bed. Perform a linen and gown change. Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 1 ANS: C The airway must be protected. Elevating the head of the bed prevents swallowing concerns and allows for an open airway. The client should then be assessed for a gag reflex, perineal care should be provided, and linens changed. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (2 of 5) 2. An hour later after a CT scan, the client is diagnosed with a left hemisphere stroke. Which assessment findings does the nurse anticipate? (Select all that apply.) A. Constant smiling B. Intellectual impairment C. Deficits in the right visual field D. Disorientation to time, place, and person E. Inability to discriminate words and letters Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 2 ANS: B, C, E Clients experiencing a left hemisphere stroke display an inability to discriminate words and letters, intellectual impairment, and deficits in the right visual field. Disorientation, constant smiling, and neglect of left visual field are manifestation of a right hemisphere stroke. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (3 of 5) 3a. The client is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV fibrinolytic therapy. What is the appropriate nursing response? 3b. Thirty minutes later, the wife asks for a glass of water because her husband is thirsty. How will the nurse respond? Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 3 ANS: 3a. Clients must meet strict eligibility criteria for fibrinolytic (thrombolytic) therapy, including giving the drug ideally within 3 hours after the first stroke symptoms. The client’s symptoms began well before 3 hours. 3b. Before the client is given any liquids, food, or medications, he must be screened for the ability to swallow. Also his gag and cough reflexes must be checked. After he has a swallowing screen and it is determined that he can tolerate liquids or food without aspirating, fluids and food will be provided. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (4 of 5) 4. The client’s wife must leave her husband’s bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to client safety while she is gone? A. Apply restraints. B. Maintain the bed in a low position. C. Sit with the client until his wife returns. D. Place the call light in the client’s right hand. Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 4 ANS: B Restraints should not be applied until all alternate methods have been attempted. Sitting with a client for 2 hours is impractical for the nurse. Placing a call light in the client’s right hand would not be effective because he has deficits in his right visual field and may have right field neglect. Copyright © 2021, Elsevier Inc. All Rights Reserved. Case Study (5 of 5) 5. The client needs assistance with feeding, but can swallow well. To whom should the nurse delegate this responsibility? A. Hospital volunteer B. Assistive personnel C. Licensed practical nurse D. Student nurse doing first client care experience Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Case Study Question 5 ANS: B Feeding clients falls within the scope of practice of an assistive personnel member. Copyright © 2021, Elsevier Inc. All Rights Reserved. Chapter 41 Audience Response System Questions Copyright © 2021, Elsevier Inc. All Rights Reserved. Question 1 A client with a TBI has nonreactive and dilated pupils. What finding does the nurse anticipate? A. Loss of vision B. Intense headache C. Projectile vomiting D. Brain stem herniation Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Question 1 ANS: D Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are treated as herniation of the brain from increased ICP until proven differently. Pupils that are fixed (nonreactive) and dilated are a poor prognostic sign. clients with this problem are sometimes referred to as having “blown” pupils. Copyright © 2021, Elsevier Inc. All Rights Reserved. Question 2 The nurse is caring for a client with a head injury. Which finding requires immediate nursing intervention? A. Increased pupil size B. Nausea and vomiting C. Agitation and confusion D. Elevated blood pressure Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Question 2 ANS: C The first sign of increased intracranial pressure (ICP) is a declining or changing level of consciousness (LOC); therefore the nurse must assess the client immediate when this symptom is present. Clients may be agitated and slightly confused before progressing to difficult to arouse as an early assessment variable of increased ICP. Changes in vital signs, nausea and vomiting, and pupillary response occur as ICP increases. Copyright © 2021, Elsevier Inc. All Rights Reserved. Question 3 A client has experienced a stroke in the left cerebral hemisphere. What clinical presentation does the nurse expect? (Select all that apply.) A. Aphasia B. Agraphia C. Decreased proprioception D. Disoriented to time and place E. Difficulty with math calculation Copyright © 2021, Elsevier Inc. All Rights Reserved. Answer to Question 3 ANS: A, B, E The right cerebral hemisphere is more involved with visual and spatial awareness and proprioception (sense of body position). A person who has a stroke involving the right cerebral hemisphere is often unaware of any deficits and may be disoriented to time and place. Personality changes include impulsivity (poor impulse control) and poor judgment. The left cerebral hemisphere is the center for language, mathematic skills, and analytic thinking. Therefore a left hemisphere stroke may result in: Aphasia: inability to speak or comprehend language Alexia or dyslexia: difficulty with reading Agraphia: difficulty with writing Acalculia: difficulty with mathematic calculation Copyright © 2021, Elsevier Inc. All Rights Reserved.
