Neurological Disorders Part 1

UNIT 3
ADULT NURSING II
 Objectives
2

By the end of this unit each student she be able to:

1. Define nervous disorders.
2. Describe the aetiology, pathophysiology, and possible
complications of the common nervous disorders.
3. Identify common diagnostic and laboratory tests used in the
evaluation of selective nervous disorders.
4. Discuss the relevant medical and/or surgical management for
nervous disorders.
5. Discuss the nursing interventions (with rationale), nursing
diagnoses and expected outcomes for nervous disorders
6. Discuss the discharge planning for the client
 Nervous System
3

The Nervous System is:

 Responsible for coordinating body functions;
 Responding to changes, stimuli in the internal and
external environments
 Brain; Spinal cord; Peripheral nerves
 Basic Structure
 Neuron: Sensory; Motor
 Neuronal Anatomy
4

Three Characteristic –
Excitability (generate)
Conductivity (transmit)
Influence (other cells to transmit nerve impulses)
 Glial Cells
5

Provide support, nourishment, and protection to neurons

 Nervous System
6

 The Nervous System is divided in to two

Anatomic Divisions
 Central Nervous System (CNS)
brain, spinal cord, cranial nerves I and II
 Peripheral Nervous System (PNS)
cranialnerves III to XII, spinal nerves, and the
peripheral components of the autonomic
nervous system (ANS)
Nervous System
7
 Peripheral Nervous System
8
 Cranial Nerves: 12 pairs  VIII: Vestibulocochlear
 I: Olfactory nerve  IX: Glossopharyngeal

 II: Optic nerve nerve

 III: Oculomotor nerve  X: Vagus nerve

 IV: Trochlear nerve  XI: Accessory nerve

 V: Trigeminal nerve  XII: Hypoglossal nerve

 VI: Abducens nerve

 VII: Facial nerve

NB.
These cranial nerves some are only
sensory, some only motor, and some
both. Unlike spinal nerves.
Peripheral Nervous System
9
 Peripheral Nervous System
10

 Spinal Nerves
 31 pairs (Both sensory & motor)
 8 cervical,
 12 thoracic,
 5 lumbar
 5 sacral,
 1 coccygeal
 Two roots
 Dorsal (afferent – sensory)
 Ventral (efferent – motor)
 Dermatome distribution
Dermatomes
11
 Peripheral Nervous System
12

 Autonomic Nervous System

 Sympathetic nervous system
 Expenditure of energy
 Catecholamines: Epinephrine; Norepinephrine;
Dopamine

 Parasympathetic nervous system

 Conservation of energy
 Acetylcholine
Assessment
13
 Assessment
14

 History
 Symptoms of present illness;
 Pain
 Seizures
 Dizziness (abnormal sense of imbalance or movement) and vertigo
(loss of equilibrium, light headiness. Nausea, vomiting)
 Visual Disturbance
 Muscle weakness
 Abnormal Sensation

 Trauma; Medications; Allergies; Personal, Family

medical history
 Assessment
15

 Physical Examination
A neurologic assessment is divided into five
components: consciousness and cognition, cranial
nerves, motor system, sensory system, and reflexes.
 Vital Signs
 Spinal cord injury classic triad – hypotension, bradycardia,
hypothermia
 Late stages of increased ICP – Cushing response ( systolic
BP, widening pulse pressure, bradycardia; changes in rate
and rhythm of respiration will be the result of ICP in the
brain stem)
 Assessment
16

 Consciousness and cognition

 Level of consciousness (alertness and ability to follow
commands): Use words such as Conscious or alert;
Somnolent or lethargic; Stuporous; Semi-comatose;
Comatose.
 Glasgow Coma Scale and Pupillary response
 Mental Status; orientation, memory, mood and affect,
intellectual functioning, judgement and insight, and
language and communication.

 Head, Neck, Back

 Cranial nerves (only when level of consciousness is
decreased)
 Assessment
17

 Motor function
 Muscle size,
 Tone (abnormal tone - spasticity (increased muscle
tone), rigidity (resistance to passive stretch), and
flaccidity
 Strength (ability to flex or extend the extremities
against resistance)
 Coordination and balance (romberg test)
 Motor Function - Strength Scale
18

 +5 - full ROM, full strength

 +4 - full ROM, less than normal strength
 +3 - can raise extremity but not against resistance
 +2 - can move extremity but not lift it
 +1 - slight movement
 0 - no movement
 Assessment
19

 Sensory function (with eyes closed)

 Tactile
Sensation, Superficial pain, Temperature,
Vibration, and Position sense (proprioception)

 Reflexes
 Normal (superficial and deep tendon)
 Abnormal
 Superficial reflex
20

 The plantar reflex is the only superficial reflex that's

commonly assessed and should be tested in
comatose patients and in those with suspected injury
to the lumbar 4 – 5 or sacral 1– 2 areas of the spinal
cord.
 Stimulate the sole of the foot with a tongue blade or the handle
of a reflex hammer. Begin at the heel and move up the foot, in
a continuous motion, along the outer aspect of the sole and
then across the ball to the base of the big toe.
 The normal response is plantar flexion (curling under) of the toes.
Extension of the big toe—Babinski's sign—is abnormal, except in
children younger than 2 years.
 Assessing deep tendon reflexes
21

 Deep tendon reflexes are tested with a reflex hammer. Test

each of the following, grading them from 0 to 5+, with 0
being no reflex, 2+ being normal, and 5+ being
hyperreflexia with clonus (repeated rhythmic contractions):
 Biceps. The patient's arm should be flexed slightly with the
palm facing up. Hold the arm with your thumb in the
antecubital space over the biceps tendon. Strike your thumb
with the hammer; the arm should flex slightly.

 Triceps. The patient's arm should be flexed 90 degrees.

Support the arm and strike it just above the elbow, between
the epicondyles; the arm should extend at the elbow.
 Assessing deep tendon reflexes
22

 Brachioradialis. The patient's arm should be flexed slightly

and resting on the lap with the palm facing down. Strike the
outer forearm about two inches above the wrist; the palm
should turn upward as the forearm rotates laterally.

 Patellar. With the patient's legs dangling (if possible), place

your hand on one thigh and strike the leg just below the
kneecap; the leg should extend at the knee.

 Achilles tendon. With the patient's foot in slight

dorsiflexion, lightly strike the back of the ankle, just above the
heel; the foot should plantar flex.
 Assessing Reflexes
23

 Reflex responses:
 0 no response

 1+ diminished, low normal

 2+ average, normal

 3+ brisker than normal

 4+ very brisk, hyperactive

 Lower motor neuron disease is associated with 0 or

1+, upper motor neuron disease is associated with 3+
or 4+.
 Diagnostic Tests
24

 Diagnostic Tests
 Imaging procedures
 Computed Tomography (CT Scan); Magnetic
Resonance Imaging (MRI); Electroencephalogram
(EEG)
 Positron Emission Tomography PET; Single photon
emission CT
 Electromyography; Nerve conduction studies
 Echoencephalography
 Lumbar puncture
 Laboratory Test
 Nursing Process: Diagnostic Testing
25

 Assessment
 Level of comprehension; Allergies; Weight; Vital signs
 Diagnosis, Planning, and Interventions
 Knowledge deficit: Unfamiliarity with diagnostic
procedures
 Allergy to contrast dye

 Meningeal irritation (nuchal rigdity, nausea, blurred

vision, photophobia and sudden violet headache)
 Evaluation of Expected Outcome
 Comprehension of procedure, purpose; Reduced
complications
 Abnormal Findings
26

Abnormal Sensation Abnormal Movement

 Analgesia - Loss of pain sensation  Apraxia - Inability to perform

 Anesthesia - Absence of learned movements despite having
sensation desire and physical ability to perform
them
 Paresthesia -Alteration in
 Ataxia - Lack of coordination of
sensation
movement
 Astereognosis - Inability to
 Dyskinesia - Impairment of
recognize form of object by touch voluntary movement, resulting in
 Hypoesthesia - Reduced sense fragmentary or incomplete
of pain movements
 Hemiplegia - Paralysis on one side
 Nystagmus - Jerking or bobbing of
eyes as they track moving object
Neurological Disorders Part 1
27

INCREASED INTRACRANIAL PRESSURE

ALTERED LEVEL OF CONSCIOUSNESS

CEREBROVASCULAR ACCIDENT (CVA)

 Normal Intracranial Pressure
28

 Intracranial pressure (ICP) is the hydrostatic

force measured in the brain CSF compartment.

 A balance among the three components (brain tissue,

blood, CSF) maintains the ICP.

 Normal ICP ranges from 5 to 15 mmHg

 Normal Intracranial Pressure
29

 Factors influences ICP include:

 (1) arterial pressure; (2) venous pressure;

(3) intraabdominal and intrathoracic pressure; (4) posture;

(5) temperature; and (6) blood gases, particularly carbon
dioxide levels.

 The degree of their influence on ICP is based on the

brain adaptation abilities.
Increased Intracranial Pressure
30
 Increased Intracranial Pressure
31

 The skull is a closed box with three essential components:

 Brain tissue (84%)
 Blood (4%)
 CSF (12%
 As volume in the compartment increases pressure
increases.
 A significant increase without compensation 
Increased Intracranial Pressure
 Increased Intracranial Pressure
32
 Pathophysiology and  Factors increasing edema
Etiology  Hypercapnia
 A Mass  Cerebral Acidosis

 Braintumors  Systemic Hypertension

 Hematoma  Impaired Auto-regulation

 Hypoxia
 Abscess

 Cerebral Edema
 Head trauma
 Infectious
 Inflammatory disorders
 Increased Intracranial Pressure
33

 Signs and Symptoms

 Decreasing LOC

 Headache

 Vomiting (without nausea)

 Ocular Changes

 Papilledema (edema of the optic disc)

 Late signs: Cushing’s triad; Cheyne-Stokes respirations

 Changes in vital signs
 Cushing traid ((systolic hypertension with a widening pulse
pressure, bradycardia with a full and bounding pulse, and
irregular respirations)
 Monro-Kellie Doctrine
34

 If one of the three components in the cranial vault,

(brain tissue, blood, CSF), increases in volume, at least
one of the other two must decrease in volume, or the
pressure increases.
 It causes displacement of the brain, this causes
restriction of blood flow to the brain, decreasing
oxygen delivery and waste removal.
 Cells within the brain become anoxic and cannot
metabolize properly, producing ischemia, infarction,
irreversible brain damage, and, eventually, brain death
 Increased Intracranial Pressure
35

Complications
 Complications of increased ICP include:
 Brain stem herniation,
 Results from an excessive increase in ICP in which the
pressure builds in the cranial vault and the brain tissue
presses down on the brain stem.
 Diabetes Insipidus,
 Result of decreased secretion of antidiuretic hormone
(ADH).
 Syndrome of inappropriate antidiuretic hormone
(SIADH).
 Result of increased secretion of ADH.
Intracranial Herniations
36
 Sustained increases in
ICP result in brainstem
compression and
herniation of the brain
from one compartment
to another.
 Herniation of brain
tissue can cause a
potentially reversible
process to become
irreversible.

Major types of intracranial herniations

 Increased Intracranial Pressure
37

 Diagnostic Findings
 CT; MRI; Lumbar puncture; Cerebral angiography; Skull
radiography
 Lab Studies including CBC, coagulation profile, electrolytes,
serum creatinine, ABGs, ammonia level, drug and toxicology
screen, CSF analysis for protein, cells, glucose
 Medical and Surgical Management
 Immediate goal: Decrease ICP by relieving cause

 Goals
 Maintain BP
 Prevent hypoxia
 Ensure cerebral perfusion
 Increased Intracranial Pressure
38

 Drug Therapy
 Osmotic diuretic – Mannitol (Osmitrol 25%)

 Hypertonic saline solution

 Corticosteroids (e.g., dexamethasone [Decadron]) are used

to treat vasogenic edema surrounding tumors and
abscesses.
 Antipyretics (for fever or other fever reducing strategies to
maintain temp 36° to 37° C)
 Barbiturates decrease cerebral metabolism, causing a
decrease in ICP and a reduction in cerebral edema
 Increased Intracranial Pressure
39

 Nursing Management
 Nursing diagnoses for the patient with increased ICP
include, but are not limited to, the following:
 Decreased intracranial adaptive capacity related to decreased
cerebral perfusion or increased ICP
 Risk for ineffective cerebral tissue perfusion related to
reduction of venous and/or arterial blood flow and cerebral
edema
 Risk for disuse syndrome related to altered LOC, immobility,
and altered nutritional intake
 Increased Intracranial Pressure
40

 Nursing Interventions are aimed at achieving these

overall goals for the patient with increased ICP:
1. Maintain a patent airway;

2. Have ICP within normal limits;

3. Have normal fluid, electrolyte, and nutritional balance; and

4. Prevent complications secondary to immobility and

decreased LOC.
Altered Level of Consciousness
41
 Altered Level of Consciousness
42

 Consciousness is a state of being that has two

important aspects:
1. wakefulness
2. awareness of self, environment and time.

 An altered level of consciousness (LOC) is

apparent in the patient who is not oriented, does
not follow commands, or needs persistent stimuli to
achieve a state of alertness.
 Altered Level of Consciousness
43

Continuum of LOC
 Alert - awake, looks about and responds in a
meaningful manner to verbal instructions or gestures

 Drowsy - oriented when awake but if left alone will

sleep

 Confused:
 Disoriented to time, place, or person
 Memory difficulty is common
 Has difficulty with commands
 Exhibits alteration in perception of stimuli, may be agitated
 Altered Level of Consciousness
44

 Stuporous:
 Generally unresponsive except to vigorous stimulation
 May make attempt at verbalization to vigorous/repeated stimuli
 Opens eyes to deep pain

 Comatose:
 Unarousable and unresponsive
 Some localization or movement may be acceptable within the
comatose category depending on the coma definitions e.g. light coma
to deep coma
 Does not open eyes to deep pain

 Unconsciousness - abnormal state of complete or

partial unawareness of self or environment.
 Altered Level of Consciousness
45

 Altered Level of Consciousness is a result of multiple

pathophysiologic phenomena. The cause may be:
 Neurologic (head injury, stroke),
 Toxicologic (drug overdose,
 Alcohol intoxication),
 Metabolic (hepatic or renal failure, diabetic ketoacidosis)

 A complete assessment is performed, with

particular attention to the neurologic system.
 Altered Level of Consciousness
46

 Medical Management
 Obtain and maintain a patent airway to maintain adequate
oxygenation and ventilation
 The circulatory status (blood pressure, heart rate) is monitored
to ensure adequate perfusion to the body and brain
 Nutritional support

 Determine and treat the underlying causes of altered LOC

 Prevention of complications.
 Altered Level of Consciousness
47

Nursing Management
 Possible Nursing Diagnosis (Chap 61)
 Ineffective airway clearance related to altered LOC
 Risk of injury related to decreased LOC
 Deficient fluid volume related to inability to take fluids by
mouth
 Impaired oral mucous membrane related to mouth breathing,
absence of pharyngeal reflex, and altered
 fluid intake
 Risk for impaired skin integrity related to prolonged
immobility
 Altered Level of Consciousness
48

 Impaired tissue integrity of cornea related to diminished or

absent corneal reflex
 Ineffective thermoregulation related to damage to
hypothalamic center
 Impaired urinary elimination (incontinence or retention)
related to impairment in neurologic sensing and control
 Bowel incontinence related to impairment in neurologic
sensing and control and also related to changes in nutritional
delivery methods
 Disturbed sensory perception related to neurologic
impairment
 Interrupted family processes related to health crisis
 Altered Level of Consciousness
49

 Possible Nursing Intervention Headings (Chap 61)

 Maintaining the Airway

 Protecting the Patient

 Maintaining Fluid Balance and Managing Nutritional Needs

 Providing Mouth Care

 Maintaining Skin and Joint Integrity

 Preserving Corneal Integrity

 Altered Level of Consciousness
50

 Possible Nursing Intervention Headings (Chap 61)

 Maintaining Body Temperature

 Preventing Urinary Retention

 Promoting Bowel Function

 Providing Sensory Stimulation

 Monitor and Management of Complications
 Pneumonia, aspiration, and respiratory failure, pressure ulcers,
DVT
Head Injury
51
 Head Injury
52

 Is a broad classification that includes injury to the

scalp, skull, or brain.

 A head injury may lead to conditions ranging from

mild concussion to coma and death; the most serious
form is known as a traumatic brain injury
(TBI)
 The most common causes of TBIs are:
 falls, motor vehicle crashes, being struck by objects,
and assaults.
 Head Injury
53

 Primary injury is the initial damage to the

brain that results from the traumatic event.
 This may include contusions, lacerations, and torn blood
vessels due to impact, acceleration/ deceleration, or foreign
object penetration.

 Secondary injury evolves over the ensuing

hours and days after the initial injury and results
from inadequate delivery of nutrients and oxygen to
the cells.
 Head Injury-Scalp Injury
54

 Isolated scalp trauma is generally classified as a

minor injury
 Trauma may result in an:
 Abrasion (brush wound), Contusion, Laceration, or
Hematoma beneath the layers of tissue of the scalp
(subgaleal hematoma).
 Diagnosis of a scalp injury is based on physical
examination, inspection, and palpation.
 Head Injury-Scalp Injury
55

 Scalp wounds are potential portals of entry for

organisms that cause intracranial infections.
 Treatment:
 Irrigation of the area before the laceration is sutured, to
remove foreign material and to reduce the risk for
infection.
 Subgaleal hematomas (hematomas below the outer
covering of the skull) usually reabsorb and do not require
any specific treatment.
 Head Injury-Skull Fractures
56

 Pathophysiology, Etiology
 Head injuries: Open; Closed

 Skull fractures: Simple; Depressed; Basilar

A simple (linear) fracture is a break in the continuity of the
bone.
 A comminuted skull fracture refers to a splintered or multiple
fracture line.
 Depressed skull fractures occur when the bones of the skull are
forcefully displaced downward and can vary from a slight
depression to bones of the skull being splintered and embedded
within brain tissue.
 A fracture of the base of the skull is called a basilar skull
fracture
Types of Fracture
57
 Head Injury-Skull Fractures
58

 Assessment Findings: Signs and Symptoms

 Localized headache; Bump, bruise, or laceration;
Hemiparesis; Shock
 Rhinorrhea; Otorrhea
 Periorbital ecchymosis; Battle’s sign
 Conjunctival hemorrhages; Seizures
Basilar Fracture
59
 Head Injury- Skull Fractures
60

 Diagnostic Findings: Skull radiographs; CT scan;

MRI
 Medical and Surgical Management
 Simple fracture: Bed rest; Observation for IICP
 Lacerated scalp: Clean, débride, and suture (within 24
hours of injury)
 Depressed skull fracture

 Craniotomy; Antibiotics
 Osmotic diuretics; Anticonvulsants
 Head Injury- Skull Fractures
61

 Nursing Management
 Signs of head trauma

 Drainage from the nose or ear

 Halo sign
 Neurologic assessments
 Hourly: LOC; Pupil, motor, and sensory status
 Every 15 to 30 minutes: Vital signs
 Prepare for the possibility of seizures
Brain Injury
62
 Brain Injury
63

 Closed (blunt) brain injury occurs when the head

accelerates and then rapidly decelerates or collides with
another object (eg, a wall, the dashboard of a car) and brain
tissue is damaged but there is no opening through the skull
and dura.
 Open brain injury occurs when an object
penetrates the skull, enters the brain, and damages the
soft brain tissue in its path (penetrating injury), or when
blunt trauma to the head is so severe that it opens the scalp,
skull, and dura to expose the brain.
 Pathophysiology of traumatic brain injury.

64
 Concussion
65

 Pathophysiology, Etiology
 Blow to the head that jars the brain

 Temporary neurologic impairment

 Assessment Findings
 Brief lapse of consciousness; Disorientation

 Headache; Blurred or double vision

 Emotional irritability; Dizziness

 Diagnostic Findings: Skull radiography, CT scan,

MRI
 Concussion
66

 Medical Management
 Temporary inactivity

 Mild analgesia

 Observation for neurologic complications

 Nursing Management
 Neurologic assessment

 Close observation: Signs of Increase ICP

 Client instruction: Contact physician, return to ED if

symptoms of IICP occur
 Contusion
67

 Pathophysiology, Etiology
 Coup and contrecoup injury
 Cerebral edema
 Assessment Findings
 Hypotension; Rapid, weak pulse; Shallow respirations; Pale, clammy
skin
 Temporary amnesia
 Effects of permanent brain damage
 Effects of injury (hemorrhage and edema) peak after about 18 to
36 hours.
 Diagnostic Findings: Skull radiography; CT scan; MRI
Coup and Contrecoup Injury
68
 Contusion
69

 Medical Management
 Drug therapy; Mechanical ventilation

 Nursing Management
 Periodically monitor

 LOC; Neurologic changes; Respiratory distress; Signs

of Increase ICP; Vital signs
 Head injury prevention

 Seatbelts; Infant car seats; Protective headgear; Neck

restraints; No alcohol or drugs while driving
 Cerebral Hematomas
70

 Pathophysiology, Etiology
 Head trauma

 Cerebral vascular disorders

 Types: Epidural; Subdural; Intracerebral

 Assessment Findings
 Location dependent; Bleeding rate; Hematoma size;
Autoregulation
 Diagnostic Findings: MRI; CT scan; ICP
monitoring
 Cerebral Hematomas
71

Diagram - Location of epidural, subdural, and intracerebral hematomas

 Cerebral Hematomas
72

 Medical Management
 Indications of surgical emergency: Rapid change in LOC;
Signs of uncontrolled Increase ICP
 Surgical Management
 Burr holes

 Intracranial surgery: Craniotomy, craniectomy, and

cranioplasty
 Surgical approaches

 Supratentorial
 Infratentorial
 Cerebral Hematomas
73

 Nursing Management
 Allhead injuries are emergencies
 Nurse’s role

History; Neurologic examination; Vital signs;

LOC
Limb movement; Pupil reactions
 Trauma

Head examination; Respiratory status

Neurologic changes
 Cerebral Hematomas
74

 Nursing Management
 Preoperative nursing care

 Hair removal; Vital signs; Neurologic assessment;

Antiembolism stockings
 Restrict: Fluids
 Post-operative nursing care

 Supine or side-lying position

 Regular monitoring; Observe for Increase ICP
 Control thrombus or embolus; Cerebral edema
Cerebrovascular Accident (CVA)
75

STROKE
 76

 The brain is divided into left and right hemispheres.

Each hemisphere controls its own unique set of
activities or tasks.
 The right side of the brain tends to be more
dominant in creative activities, while the left side of
the brain tends to be more dominant in logical or
analytical activities
77
 78
Right Side Left Side

• Judging the position • Understanding and

of things in space use of language
• Knowing body (listening, reading,
position speaking and writing)
• Understanding and • Memory for spoken
remembering things and written messages
we do and see • Detailed analysis of
• Putting bits of information
information together • Controls the right side
to make an entire of the body
picture
• Controls the left side
of the body
 Cerebrovascular Accident (Stroke)
79

 A stroke is is a sudden loss of function resulting from

disruption of the blood supply to a part of the brain.
 Pathophysiology, Etiology
 Ischemic strokes
Is disruption of the cerebral blood flow due to obstruction of a
blood vessel.
 Thrombotic;
 Embolic

 Hemorrhagic strokes
Hemorrhagic strokes are caused by bleeding into the brain
tissue, the ventricles, or the subarachnoid space.
 Cerebrovascular Accident (Stroke)
80

 Warning Signs:
 Sudden numbness, weakness, paralysis of the face, arm, or leg,
especially on one side of the body
 Sudden confusion, trouble speaking or understanding
 Slurred speech
 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of balance or
coordination
 Sudden, severe headache with no known cause
 Cerebrovascular Accident (Stroke)
81

A stroke can affect many body functions, including

motor activity, bladder and bowel elimination,
intellectual function, spatial-perceptual alterations,
personality, affect, sensation, swallowing, and
communication. The functions affected are directly
related to the artery involved and area of the brain it
supplies
 Assessment Findings: Signs and Symptoms
 Numbness; Weakness
 Mental confusion; Impaired ambulation
 Severe headache
 Hemiplegia; Aphasia; Hemianopia
 82
Right-brain damage Left-brain damage
(stroke on right side of the brain) (stroke on left side of the brain)
 Paralyzed left side: hemiplegia  Paralyzed right side: hemiplegia
 Left-sided neglect  Impaired speech/language
 Spatial-perceptual deficits aphasias
 Tends to deny or minimize  Impaired right/left
problems discrimination
 Rapid performance, short  Slow performance, cautious
attention span  Aware of deficits: depression,
 Impulsive, safety problems anxiety
 Impaired judgment  Impaired comprehension related
 Impaired time concepts
to language, math
 Motor Effects
83

 Motor deficits include impairment of:

(1) mobility, (2) respiratory function, (3) swallowing
and speech, (4) gag reflex, and (5) self-care abilities.

 The characteristic motor deficits include loss of

skilled voluntary movement:
 (akinesia), impairment of integration of movements,
alterations in muscle tone, and alterations in reflexes.
 The initial hyporeflexia (depressed reflexes) progresses to
hyperreflexia (hyperactive reflexes) for most patients.
 Communication
84

 Aphasia
 receptive aphasia (loss of comprehension),
 expressive aphasia (inability to produce language), or global
aphasia (total inability to communicate)

 Dysphasia
Impaired ability to communicate.

 Dysarthria
disturbance in the muscular control of speech. Impairment
may involve pronunciation, articulation, and phonation.
 Affect
85

 After a CVA/Stroke patients may have difficulty

controlling their emotions.
 Emotional responses may be exaggerated or
 unpredictable.
 Depression and feelings associated with changes in
body image and loss of function can make this worse.
 Patients may also be frustrated by mobility and
communication problems.
 Intellectual Function
86

 As a result of a Stroke both memory and judgment

may be impaired.
 These impairments can occur with strokes affecting
 either side of the brain.
 A left-brain stroke is more likely to result in memory
problems related to language. Patients with a left-
brain stroke often are cautious in making judgments.
 The patient with a right-brain stroke tends to be
impulsive and move quickly.
 Spatial-Perception
87

 Four categories:
 1st (damage of the parietal lobe) Incorrect perception of self
and illness.

 2nd erroneous perception of self in space -

patient neglects all input from the affected side.
 Made worsened by homonymous hemianopsia, in
which blindness occurs in the same half of the visual
fields of both eyes.
 Spatial-Perception
88

 Four categories:
 3rd agnosia, the inability to recognize an object by sight,
touch, or hearing.

 4th. The fourth deficit is apraxia, the inability to carry out

learned sequential movements on command.
 Elimination
89

 Problems are initially present with urinary and

Bowel elimination but are temporary.
 Initially urinary frequency, urgency, and
incontinence may be present
 Constipation is associated with immobility, weak
abdominal muscles, dehydration, and diminished
response to the defecation reflex.
 Cerebrovascular Accident (Stroke)
90

 Diagnostic Findings
 CT Scan; MRI; Transcranial Doppler ultrasonography

 Single photon emission CT; Lumbar puncture; Cerebral

angiography
 Cerebrovascular Accident (Stroke)
91

 Medical, Surgical Management

 Antiplatelet drugs (Prevention)
 Aspirin commonly at a dose of 81 to 325 mg/day. Other drugs:
ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine),
and combined dipyridamole and aspirin (Aggrenox).
 Drug Therapy (Hemorrhagic Stroke)
 Anticoagulants and platelet inhibitors are contraindicated.
 Manage hypertension. Oral and IV agents may be used to maintain BP
within a normal to high normal range (systolic BP less than 160 mm
Hg).
 Drug Therapy (Ischemic Stroke)
 Recombinant tissue plasminogen activator (tPA) is used to produce
localized fibrinolysis by binding to the fibrin in the thrombi
 Cerebrovascular Accident (Stroke)
92

 Medical, Surgical Management

 Emergency treatment according to cause
 Initial
 Ensure patent airway.
 Remove dentures.
 Perform pulse oximetry.
 Maintain adequate oxygenation (SaO2 >95%) with supplemental
O2, if necessary.
 Establish IV access with normal saline.
 Maintain BP according to guidelines.
 Obtain CT scan or MRI immediately.
 Perform baseline laboratory tests (including blood glucose)
immediately, and treat if hypoglycemic.
 Cerebrovascular Accident (Stroke)
93

 Medical, Surgical Management

 Emergency treatment according to cause

 Initial
 Position head in midline.
 Elevate head of bed 30 degrees if no symptoms of shock or injury.
 Institute seizure precautions.
 Anticipate thrombolytic therapy for ischemic stroke.
 Keep patient NPO until swallow reflex evaluated.

 Ongoing Monitoring
 Monitor vital signs and neurologic status, including level of
consciousness (NIH Stroke Scale), motor and sensory function,
pupil size and reactivity, SaO2, and cardiac rhythm.
 Reassure patient and family.
 Cerebrovascular Accident (Stroke)
94

 Medical, Surgical Management

 Prevention measures
 Reduce salt and sodium intake.
 Maintain a normal body weight.
 Maintain a normal blood pressure.
 Increase level of physical exercise.
 Avoid cigarette smoking or tobacco products.
 Limit consumption of alcohol to moderate levels.
 Follow a diet that is low in saturated fat, total fat, and
dietary cholesterol and high in fruits and vegetables.
 Cerebrovascular Accident (Stroke)
95

 Nursing Management
 Client education: Medication: Administration, side effects;
Eating, swallowing techniques
 Heimlich maneuver

 Follow-up care: Speech pathologist; Dietitian

 Community resources for special care devices

 Regular exercises; Maintain extremities in proper anatomic

position
 Cerebrovascular Accident (Stroke)
96

 Nursing Diagnosis
Risk for aspiration related to decreased level of
consciousness and decreased or absent gag and
swallowing reflexes

 Patient Goals
1. Patient will demonstrates an ability to swallow oral foods
without aspiration
2. Patient will maintains a clear airway
Aspiration Precautions
 Monitor level of consciousness, cough reflex, gag reflex, and swallowing
ability to determine patient’s ability to swallow foods without aspiration.
 Avoid liquids or use thickening agent to facilitate swallowing.
 Feed in small amounts until patient is no longer at risk for aspiration.
 Offer foods or liquids that can be formed into a bolus before swallowing.

Airway Management
 Auscultate breath sounds, noting areas of decreased or absent ventilation
and presence of adventitious sounds to identify airway obstruction and
accumulation of secretions.
 Remove secretions by encouraging coughing or by suctioning to clear
airway.
 Encourage slow, deep breathing; turning; and coughing to increase airway
clearance without increasing ICP.
 Assist with incentive spirometer to open collapsed alveoli, promote deep
breathing, and prevent atelectasis.
 Keep patient NPO until swallow evaluation completed to prevent
aspiration.
97
 98

 Nursing Diagnosis
Unilateral neglect related to visual field cut and loss on one
side of body (hemianopsia) and brain injury from
cerebrovascular problems as evidenced by consistent
inattention to stimuli on affected side

 Patient Goals
1. Patient will care for both sides of the body appropriately utilising
strategies to minimize unilateral neglect
Unilateral Neglect Management
 Monitor for abnormal responses to three types of stimuli: sensory, visual,
and auditory to determine the presence of and degree to which unilateral
neglect exists (e.g., inability to see objects on affected side, leaving food on
a plate that corresponds to affected side, lack of sensation on affected
side).
 Instruct patient to scan from left to right to visualize the entire
environment.
 Position bedside area so that individuals approach and care for patient on
unaffected side.
 Rearrange the environment to use the right or left visual field; position
personal items, or reading materials within view on unaffected side to
compensate for visual field deficits.
 Touch unaffected shoulder when initiating conversation to attract patient’s
attention.
 Gradually move personal items and activity to affected side as patient
demonstrates an ability to compensate for neglect.
 Include family members/care givers in rehabilitation process to support
the patient’s efforts and assist with care to promote reintegration with the
whole body.

99
 Cerebrovascular Accident (Stroke)
100

 Nursing Diagnosis
Impaired physical mobility related to neuromuscular and
cognitive impairment and decreased muscle strength and
control as evidenced by limited ability to perform gross
and fine motor skills, limited range of motion, and
difficulty turning

 PATIENT GOALS
1. Patient will demonstrates increased muscle strength and ability to
move
2. Patient will buses adaptive equipment to increase mobility
Exercise Therapy: Muscle Control
 Collaborate with physical, occupational, and recreational
therapists in developing and executing exercise program to
determine extent of problem and plan appropriate
interventions.
 Determine patient’s readiness to engage in activity or exercise
protocol to assess expected level of participation.
 Apply splints to achieve stability of proximal joints involved
with fine motor skills to prevent contractures.
 Encourage patient to practice exercises independently to
promote patient’s sense of control.
 Reinforce instructions provided to patient about the proper
way to perform exercises to minimize injury and maximize
effectiveness.
 Provide restful environment for patient after periods of
exercise to facilitate recuperation.

101
 102

 Nursing Diagnosis
Impaired verbal communication related to aphasia as
evidenced by refusal or inability to speak, difficulty
forming words and sentences to express thoughts, and
inappropriate verbalization

 Patient Goals
1. Patient will use effective oral and written communication
techniques
2. Patient will demonstrates congruency of verbal and nonverbal
communication
Communication Enhancement: Speech Deficit
 Listen attentively to convey the importance of patient’s
thoughts and to promote a positive environment for
learning.
 Provide positive reinforcement and praise to build self-
esteem and confidence.
 Use simple words and short sentences to avoid
overwhelming patient with verbal stimuli.
 Collaborate with other members of health care team
(speech pathologist) to provide continuity in patient’s
rehabilitative plan
 Perform prescriptive speech-language therapies during
informal interactions with patient to reinforce prescribed
therapies.
 Provide verbal prompts and reminders to help patient to
express self.
103
 104

 Nursing Diagnosis
Impaired urinary elimination related to impaired impulse
to void or inability to reach toilet or manage tasks of
voiding as evidenced by loss of urinary control and
involuntary loss of urine at unpredictable times
 Patient Goals
1. Perceives impulse to void, removes clothing for toileting, and uses
toilet
2. Demonstrates ability to urinate when the urge arises or with a timed
schedule
Urinary Habit Training
 Keep a continence specification record for 3 days to establish
voiding pattern and plan appropriate interventions.
 Establish interval of initial toileting schedule (based on
voiding pattern and usual routine) to initiate process of
improving bladder functioning and increased muscle tone.
 Assist patient to toilet and prompt to void at prescribed
intervals to assist patient in adapting to new toileting
schedule.
 Teach patient to consciously hold urine until the scheduled
toileting time to improve muscle tone.
 Discuss daily record of continence with staff to provide
reinforcement and encourage compliance with toileting
schedule.
 Give positive feedback or positive reinforcement to patient
when he or she voids at scheduled toileting times, and make
no comment when patient is incontinent, to reinforce desired
behaviour.
105
 106

 Nursing Diagnosis
Impaired swallowing related to weakness or
paralysis of affected muscles as evidenced by
drooling, difficulty in swallowing, choking

 Patient Goal
1. Demonstrates effective swallowing without choking, coughing, or
aspiration
Swallowing Therapy
 Collaborate with other members of health care team (e.g.,
occupational therapist, speech pathologist, dietitian) to provide
continuity in patient’s rehabilitative plan.
 Assist patient to sit in an erect position (as close to 90 degrees as
possible) for feeding/ exercise to provide optimal position for
chewing and swallowing without aspirating.
 Assist patient to position head in forward flexion in preparation for
swallowing (“chin tuck”).
 Assist patient to maintain sitting position for 30 min after
completing meal to prevent regurgitation of food.
 Instruct patient or caregiver on emergency measures for choking to
prevent complications in the home setting.
 Check mouth for pocketing of food after eating to prevent collection
and putrefaction of food and/or aspiration.
 Provide mouth care as needed to promote comfort and oral health.
 Monitor body weight to determine adequacy of nutritional intake.

107
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 Nursing Diagnosis
Situational low self-esteem related to actual or
perceived loss of function and altered body image
as evidenced by refusal to participate in self-care
and expressions of helplessness and uselessness

 Patient Goals
1. Expresses positive feelings of self-worth
2. Participates in self-care of affected body parts
Self-Esteem Enhancement
 Monitor patient’s statements of self-worth to determine
effect of stroke on self-esteem.
 Encourage patient to identify strengths to facilitate
patient’s recognition of intrinsic value.
 Assist in setting realistic goals to achieve higher self-
esteem.
 Reward or praise patient’s progress toward reaching
goals.
 Encourage increased responsibility for self to promote
sense of satisfaction, independence, and control, and to
reduce frustrations.
 Monitor levels of self-esteem over time to determine
stressors or situations that trigger low self-esteem and
to teach coping mechanisms.

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End of Presentation