Nur-224
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Identify the various types/causes of seizures.
Identify clinical manifestations for clients
experiencing neurologic deficits.
Apply the principles of nursing management
to care for the patient in the acute stage of
ischemic stroke.
Use the nursing process as a framework to
develop a plan of care for the client with
neurological deficits.
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3rd leading cause of death in the US
800,000 people experience a stroke each year
An emergency condition in which neurologic
deficits result from a sudden decrease in blood
flow to a localized area of the brain.
Major loss of blood supply to the brain  severe
disability or death
Types of stroke
 Ischemic (80–85%)
 Hemorrhagic (15–20%)
Risk Factors
 Hypertension
 Sickle cell anemia
 Atrial fibrillation
 Diabetes mellitus
 Smoking
 Hyperlipidemia
 Obesity
 Sedentary lifestyle
 TIA or “little stroke”
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Characterized by a gradual/rapid onset of
neurologic deficits  compromised cerebral
blood flow
Stroke leads to a loss/impairment of
sensorimotor functions on the opposite side
the side of the brain that is damaged
contralateral deficit.
Stroke in the (R) hemisphere of the brain is
manifested by deficits in the (L) side of the
body (and vice versa)
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Disruption of the blood supply to the brain
due to an obstruction  a thrombus or
embolism, or from stenosis of a vessel
resulting from a buildup of plaque
Types
 Large vessel stroke
 Small vessel stroke
 Cardiogenic embolism
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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
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Paralysis/weakness on
(R ) side of the body
(R ) visual field deficit
Aphasia
Altered intellectual
ability
L sided stroke
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Paralysis/weakness on
the (L) side of the body
(L) visual field deficit
Impulsive behavior and
poor judgment
Lack of awareness of
deficits
R sided stroke
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Sensoriperceptual deficits
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Cognitive and behavioral changes
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Communication disorders
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Motor deficits
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Elimination disorders
Deficits may include
 Hemianopia
 Apraxia
 Neglect syndrome
Cognitive changes
Behavioral changes
 Emotional lability
 Loss of self-control
Intellectual changes
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Usually a result of the stroke affecting the
dominant hemisphere
Aphasia
 Expressive
 Receptive
 Global
Depending on the area of the brain involved
strokes may cause:
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Hemiplegia
Hemiparesis
Flaccidity
Spasticity
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Bladder elimination
Bowel elimination
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Mini-stroke
Brief period of localized cerebral ischemia
that causes neurologic deficit lasting less
than 24 hours
Sudden loss of motor, sensory, or visual
function
Serves as a warning for impending stroke
Acute phase
 diagnosis the type/cause of the stroke
 support cerebral circulation
 control/prevent further deficits
Focus
 minimize brain injury
 maximize patient recovery
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Complete history/careful physical assessment
CT scan
DWI test
PLAC tests
Prevention
 Antiplatelet- Aspirin, clopidogrel(Plavix),
ticlopidine(Ticlid)
Acute Stroke
 fibrinolytic therapy-tissue plasminogen
activator
 anticoagulant therapy
Antihypertensive medications
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Used to treat ischemic stroke by dissolving
the blood clot that is blocking blood flow to
the brain.
Recombinant t-PA
Rapid diagnosis of a stroke and initiation of
therapy (within 3 hours) decrease the size
of the stroke and may improve functional
abilities after 3 months
Bleeding most common side effect
Surgery (Carotid Endarectomy)
 Performed to prevent the occurrence of a
stroke
 Restore blood flow when a stroke has
occurred
 Repair vascular damage
Rehabilitation
 Physical therapy
 Occupational therapy
 Speech therapy
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Position on the inoperative side –
Assess respirations/oxygen saturation
- hemorrhage
-respiratory distress
- cranial nerve impairment
-hypotension/hypertension
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Stroke prevention – esp known risk factors
Public awareness of signs of TIA/Stroke
 Sudden –
- weakness/numbness
- confusion, trouble speaking
- trouble walking, dizziness, loss of balance
- trouble with vision
- severe headache without a cause
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Risk for Ineffective Tissue Perfusion- Cerebral
 Impaired Verbal Communication
 Impaired Swallowing
 Impaired Physical Mobility
 Self-care deficits r/t (bathing, grooming,
hygiene)
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Maintain correct position  good body
alignment  avoid deformities
Change position every 2 hours – if sensation
is impaired on one side – the amount of time
spent on the affected should be limited.
Prevent pressure ulcers.
Affected extremities – ROM exercises
Prepare for ambulation ASAP/active
rehabilitation program
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May swallowing problems (dysphagia).
Swallowing difficulties place the patient at the
risk for aspiration, pneumonia, dehydration,
and malnutrition.
Start patient on thick liquid/pureed foods 
easy to swallow
Patient unable to consume oral intake 
enteral feedings
Long-termed feedings  gastrostomy tube
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Aphasia –receptive/expressive
Face the patient and establish eye contact
Develop strategies to make the atmosphere
conducive to communication
Speak in a normal manner and tone, speak
slowly
Use gestures, pictures, objects, writing,
Use same words and gestures  be consistent
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At risk for skin and tissue breakdown
Specialty bed
Regular turning schedule
Minimize shear/friction forces
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Recovery/rehabilitation  may be prolonged
and requires patience.
Community based support groups
Depression – common /serious problem
Caregivers need to be reminder to attend
their own health concerns/well-being 
respite care.
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Intracranial hemorrhage
Cerebral blood vessel ruptures.
May be due to:
 Intracerebral hemorrhage
 Intracranial aneurysm
 AV malformation
 Subarachnoid hemorrhage
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Similar to ischemic stroke
Severe headache
Early and sudden changes in LOC
Vomiting
Maintain optimum tissue perfusion
-aneurysm precautions
 Manage potential complications
- vasospasms
- hyponatremia
- seizures
 Promote home and community-based care
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A single event of abnormal, sudden,
electrical discharge in the brain resulting in
an abrupt and temporary altered state of
cerebral function.
Epilepsy (seizure disorder) –
- chronic disorder of abnormal, recurring
excessive electrical discharges
- recurring seizures accompanied by some
type of behavioral change
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affect more than 3 million people
strong genetic component
Precipitating factors
 birth defects
 head injury/trauma
 metabolic disorders/renal failure
hyponatremia,
 IICP
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The cause is unknown in 70% of all cases
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All people with epilepsy have seizures, but
not all people who have a seizure have
epilepsy.
Only after a person has two seizures  dx. of
epilepsy is made
Classification of seizures
 Partial seizures: begin in one part of the brain
 Generalized seizures: involve both
hemispheres of the brain
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Messages from the body are carried by the
neurons (nerve cells) by electrical discharges.
Impulses occur when a nerve cell has a task
to perform.
Sometimes there is an excessive imbalance
and the cell continues to fire after the task is
completed.
Unwanted discharges cause the body to
respond erratically.
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Consciousness is always impaired
Absence seizures (petit mal)
-sudden brief cessation of all motor activity
accompanied by a blank stare and
unresponsiveness.
Tonic-clonic seizures (grand mal)
- common type of seizures in adults
- warning aura may precede generalized
seizure activity
Tonic Phase
 Begins with a sudden loss of consciousness,
sharp muscle contractions
 Patient may fall to the floor
 Urinary incontinence is common
 Breathing ceases and cyanosis develops
 Pupils are fixed and dilated
 Tonic phase may lasts – 15 seconds – 1 minute
Clonic Phase
 Alternating contraction/relaxation of the
muscles in all extremities
 Eyes roll back and the patient froths at the
mouth
 Phase varies in duration and subsides
gradually
 Entire seizure generally lasts no more than
60-90 seconds
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Following clonic phase (postictal phase)
Person remains unconscious /unresponsive to
stimuli
Person is relaxed and breathes quietly
Regains consciousness gradually
May be confused/disoriented
Headache muscle ache and fatigue may follow
Amnesia of the seizure may follow
Because of lack of warning with tonic-clonic
seizures, head injury, fractures, burns may occur
secondary to seizure activity
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Can develop during seizure activity
Seizure becomes continuous– with only short
periods of calm between intense and
persistent seizures
Cumulative effect  muscular contractions
that interfere with respirations
Hypoxia, acidosis, hypoglycemia,
hyperthermia and exhaustion may occur if the
convulsive activity is not stoped.
medical emergency
Goal – stop the seizure (ASAP)
Establish and maintain airway is priority
Diagnostic Assessment
 Confirm the diagnosis, determine any
treatable causes and precipitating factors
Diagnostic Testing
 MRI/CT Scan
 EEG
 Lab data – CBC, biochemistry
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Pharmacologic therapy ( AEDs)
controls rather than cures seizures
Medication blood levels should be monitored
Antiseizure drugs should not be discontinued
abruptly because it can precipitate seizures
Protect the patient from harm, reduce/ prevent
seizures activity without impairing cognitive
function or producing undesirable side effects
Phenytoin (Dilantin)
 Caramazepine ( Tegretol)
 Gabapentin (Neurotonin)
 Topiramate (Topamax)
 Valproate (Depakote,Depakene)
 Clonazepam (Klonopin)
see page 1885
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Note CNS side effects: blurred vision, slurred
speech, confusion
Patients on prolonged therapy may need a
diet rich in Vitamin D
Maintain good oral hygiene – phenytoin
Obtain liver functions
Carry identification indicating type of seizure
-- being treated for
Nursing Diagnosis
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Risk for Ineffective Airway Clearance
Anxiety
Risk for injury r/t seizure activity
Readiness for Enhanced Knowledge
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Describe the mechanisms of injury, clinical
manifestations, diagnostic testing, and
treatment options for patients with brain and
spinal cord injuries.
Use the nursing process as a framework for
care of clients with brain and spinal cord
injury
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Involves damage to the neural elements of
the spinal cord.
Both sensory and motor function are often
involved.
Major causes  contusion, compression,
laceration, hemorrhage and damage to the
blood vessels in the spinal cord.
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A major health problem
200,000 persons in the U.S. live with
disability from SCI
Injuries due to: MVAs, falls, acts of violence,
and sports injuries
Males account for 82% of SCIs
Young people ages 16–30 account for more
than half of all new SCIs
African–Americans are at higher risk
Risk factors include alcohol and drug use
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Spinal cord provides a two–way pathway for
the conduction of impulses and information
to and from the brain and the body
Ascending (sensory) pathways carry
information  pain, temperature, touch,
Descending (motor) pathways carry
information  about movement
Involve damage to the vertebrae and
supporting ligaments as well as the spinal
cord.
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Are the result of excessive force to the spinal
column.
Most common causes -> acceleration and
deceleration
Acceleration: external force is applied in a
rear end collision
Deceleration: occurs in a head on collision
Vertebrae frequently
Involved 1st, 2nd,
and 4th to the 6th
cervical vertebra.
The 11 thoracic to 2nd
lumbar vertebra.
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Is determined by the amount of cord
involvement
Paraplegia
Quadriplegia
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The patient requires emergency assessment
and care and medications.
Initial care immobilization and
extrication/stabilization of injuries. And
possible surgery.
SCI affects every body system and function.
When injury is C1 to C4 respiratory
paralysis is common and ventilator assistance
is required
Neurological examination
Diagnostic x-rays ( cervical spine)
 CT /MRI
 ABG’s
 Trauma Screen
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Fluids
Medications – corticosteroids, vasopressors,
antispasmodics, NSAIDs, PPI, anticoagulants
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Temporary loss of reflex function (areflexia)
below the level of injury at the cervical and
upper thoracic spinal cord.
As a result –SNS is interrupted and the PSNS
is unopposed.
Muscles become completely paralyzed and
flaccid/reflexes are absent
Loss of urinary bladder tone, intestinal
peristalsis, perspiration
Recovery from spinal shock is gradual –
usually 4-6 weeks.
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Exaggerated sympathetic response affects
persons with SCI at or above the T6 level.
Caused by visceral distention from distended
bladder/impacted rectum
Pounding headache, hypertension, profuse
sweating, bradycardia, piloerection
(goosebumps)
HOB – high fowler’s, loosen tight clothing
Asses bladder distention -catherization
Fecal impaction – disimpact immediately
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Surgery – done to stabilize and support the
spine
Stabilization/Immobilization – a type of
traction or external fixation device to
stabilize the vertebral column and prevent
further damage to the cord.
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Impaired Gas Exchange
Impaired Physical Mobility
Impaired Urinary Elimination and
Constipation
Sexual Dysfunction
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Long-term care rehabilitation is needed
Learn strategies necessary to cope with their
alterations that the injury imposed on ADL’s
Care for the patient involves members of all
health care disciplines
Psychologic support
Goal of rehabilitation  independence
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Herniated intervertebral disk ( ruptured disc,
slipped disk) is a rupture of the cartilage
surrounding the intervertebral disk with
protusion of the nucleus pulposus.
Most common cause of low back pain .
May affect 2/3 of people at some point in
their lifetime.
Most back problems are related to disk
disease
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More common in men than women
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Most patient are between the ages of 30-50
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Majority of herniated disks occur in the
lumbar region (L4 or L5 to S1), when disk
herniate in the cervical region, they occur
most often in the C6-C7 region
Herniation may be abrupt or gradual
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Intervertebral disk is a cartilaginous plate
that forms a cushion between the vertebral
bodies
Herniation of the intervertebral disk, causes
the nucleus of the disk to protrude into the
fibrous ring around the disk.
Immediate symptoms are short-lived, and
those resulting from injury to the disk do not
appear for months or years.
Continuous pressure may cause degenerative
changes in the involved area
Lumbar Disk
 recurrent episodes of lower back pain
 pain radiates across the buttocks and down
the posterior leg (sciatica)
Cervical Disk (C5-C6, C6-C7)
Most herniations are the result of degeneration
 pain and stiffness  neck, shoulders, arms
 pain  dull, intermittent pain
 parethesia of upper extremities
Diagnostic findings
 MRI
 CT scan
 EMG
 Neurologic examination
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Herniations of the cervical and lumbar disks are most
common and are treated conservatively unless the
patient is experiencing severe neurologic deficits.
Conservative Treatment
 Bedrest (no longer recommended)
 Patient is advised to continue with normal activities
while taking medication for pain, inflammation, and
muscle spasms.
 NSAID – ibuprofen (Motrin, Advil), naproxen
(Naprosyn)
 Muscle relaxants – cycobenzaprine (Flexeril),
methocarbamol (Robaxin)
 Hot moist compresses
Surgery is sometimes necessary
 Significant neurological deficit
 Continuing pain or sciatica
 Loss of sensory /motor function
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Laminectomy-done to relieve the pressure on
the nerves
Spinal fusion- insertion of a wedge-shaped
piece of bone or bone chips between the
vertebrae to stabilize them.
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Craniotomy: opening of the skull
Purposes: remove tumor, relieve elevated ICP,
evacuate a blood clot, control hemorrhage
Craniectomy: excision of portion of skill
Cranioplasty: repair of cranial defect using a
plastic or metal plate
Burr holes: circular openings for exploration
or diagnosis, to provide access to ventricles
or for shunting procedures, to aspirate a
hematoma or abscess, or to make a bone flap
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Preoperative diagnostic procedures may
include CT scan, MRI, angiography, or
transcranial Doppler flow studies
Medications are usually given to reduce risk
of seizures
Corticosteroids, fluid restriction,
hyperosmotic agent (mannitol), and diuretics
may be used to reduce cerebral edema
Antibiotics may be administered to reduce
potential infection
Diazepam may be used to alleviate anxiety
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Obtain baseline neurologic assessment
Assess patient and family understanding of
and preparation for surgery.
Provide information, reassurance, and
support
Postoperative care is aimed at detecting and
reducing cerebral edema
relieving pain
preventing seizures,
monitor ICP
 The patient may be intubated and have
arterial and central venous lines.
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frequent monitoring of respiratory function
including ABGs
monitor VS and LOC; noting any potential
signs of increasing ICP
assess dressing and check for evidence of
bleeding or CSF drainage
monitor for seizures; if seizures occur,
carefully record and report these
monitor fluid status and laboratory data
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Risk for imbalanced body temperature r/t
damage to hypothalamus
Disturbed sensory perception r/t periorbital
edema, head dressing
Body image disturbance r/t change in
appearance or physical disabilities
Impaired communication (aphasia) r/t injury
to brain tissue
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Strategies to control factors that increase ICP
Avoid extreme head rotation
Head of bed may be flat or elevated 30°
Suction or encourage coughing cautiously as
needed (suctioning and coughing increase
ICP).
Humidification of oxygen may help loosen
secretions.
Sensory deprivation
 Periorbital edema may impair vision, announce
presence to avoid startling the patient; cool
compresses over eyes and elevation of HOB may
be used to reduce edema if not contraindicated.
Enhancing self-image
 Encourage verbalization.
 Encourage social interaction and social support.
 Attention to grooming.
 Cover head with turban and, later, a wig.
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What to expect after surgery
medication is taken appropriately
rehab – depending on post-op level of function
physical therapy – residual weakness/mobility
occupational therapy – self care concerns
speech therapy – aphasic
If prognosis is poor – discuss end of life
preferences