2-42. CEREBRAL VASCULAR ACCIDENT)

a. Definition. Cerebral vascular accident (CVA) (stroke) is the disruption of the blood supply to the brain, resulting in neurological dysfunction.

b. Causes of Cerebral Vascular Accidents.

(1) Thrombosis–blood clot within a blood vessel in the brain or neck.

(2) Cerebral embolism.

(3) Stenosis of an artery supplying the brain.

(4) Cerebral hemorrhage–rupture of a cerebral blood vessel with bleeding/pressure into brain tissue.

c. Risk Factors Associated with Cerebral Vascular Accidents.

(1) Hypertension.

(2) Previous transient ischemic attacks.

(3) Cardiac disease (atherosclerosis, arrhythmias, valvular heart disease).

(4) Advanced age.

(5) Diabetes.

d. Signs and Symptoms.

(1) Highly dependent upon size and site of lesion.

(2) Motor loss–hemiplegia (paralysis on one side of the side) or hemiparesis (motor weakness on one side of the body).

(3) Communication loss.

(a) Receptive aphasia (inability to understand the spoken word).

(b) Expressive aphasia (inability to speak).

(4) Vision loss.

(5) Sensory loss.

(6) Bladder impairment.

(7) Impairment of mental activity.

(8) In most instances onset of symptoms is very sudden.

(a) Level of consciousness may vary from lethargy, to mental confusion, to deep coma.

(b) Blood pressure may be severely elevated due to increased intracranial pressure.

(c) Patient may experience sudden, severe, headache with nausea and vomiting.

(d) Patient may remain comatose for hours, days, or even weeks, and then recover.

(e) Generally, the longer the coma, the poorer the prognosis.

(9) Increased intracranial pressure is a frequent complication resulting from hemorrhage or ischemia and subsequent cerebral edema.

e. Medical and Nursing Management during the Acute Phase of Cerebral Vascular Accidents.

(1) Objectives of care during the acute phase:

(a) Keep the patient alive.

(b) Minimize cerebral damage by providing adequately oxygenated blood to the brain.

(2) Support airway, breathing, and circulation.

(3) Maintain neurological flow sheet with frequent observations of the following:

(a) Level of consciousness.

(b) Pupil size and reaction to light.

(c) Patient’s response to commands.

(d) Movement and strength.

(e) Patient’s vital signs–BP, pulse, respirations, and temperature.

(f) Be particularly aware of changes in any of the above. Deterioration could indicate progression of the CVA.

(4) Continually reorient patient to person, place, and time (day, month) even if patient remains in a coma. Confusion may be a result of simply regaining consciousness, or may be due to a neurological deficit.

(5) Maintain proper positioning/body alignment.

(a) Prevent complications of bed rest.

(b) Apply foot board, sand bags, trochanter rolls, and splints as necessary.

(c) Keep head of bed elevated 30º, or as ordered, to reduce increased intracranial pressure.

(d) Place air mattress or alternating pressure mattress on bed and turn patient every two hours to maintain skin integrity.

(6) Ensure adequate fluid and electrocyte balance.

(a) Fluids may be restricted in an attempt to reduce intracranial pressure (ICP).

(b) Intravenous fluids are maintained until patient’s condition stabilizes, then nasogastric tube feedings or oral feedings are begun depending upon patient’s abilities.

(7) Administer medications, as ordered.

(a) Antihypertensives.

(b) Antibiotics, if necessary.

(c) Seizure control medications.

(d) Anticoagulants.

(e) Sedatives and tranquilizers are not given because they depress the respiratory center and obscure neurological observations.

(8) Maintain adequate elimination.

(a) A Foley catheter is usually inserted during the acute phase; bladder retraining is begun during rehabilitation.

(b) Provide stool softeners to prevent constipation. Straining at stool will increase intracranial pressure.

(9) Include patient’s family and significant others in plan of care to the maximum extent possible.

(a) Allow them to assist with care when feasible.

(b) Keep them informed and help them to understand the patient’s condition.

f. Rehabilitation of the Patient after a Cerebral Vascular Accidents.

(1) Multidisciplinary team is most frequently utilized.

(2) Process of setting goals for rehabilitation must include the patient. This increases the likelihood of the goals being met.

(3) General rehabilitative tasks faced by the patient include:

(a) Learning to use strength and abilities that are intact to compensate for impaired functions.

(b) Learning to become independent in activities of daily living (bathing, dressing, eating).

(c) Developing behavior patterns that are likely to prevent the recurrence of symptoms.

1 Taking prescribed medications.

2 Stopping smoking.

3 Reducing day-to-day stress.

4 Modifying diet.

(4) Specific teaching, encouragement, and support are needed.

(5) Individualized exercise program involving both affected and unaffected extremities is required.

(6) Speech therapy, as indicated by patient’s condition, may be necessary.

(7) Continuous revaluation of goals and patient’s ability to meet the goals is required to maintain a realistic plan of care.

(8) Counseling and support to family is an integral part of the rehabilitation process.

(a) Both family and patient need direction and support in coping with intellectual and personality impairment.

(b) Instruct family to expect some emotional lability such as inappropriate crying, laughing, or outbursts of temper.

(c) Instruct family to be supportive and optimistic, but firm as well. They must avoid doing things for the patient that he can do for himself.

2-43. EPILEPSY

a. Definition. Epilepsy is an abnormal electrical disturbance in one or more areas of the brain. An estimated 2 to 4 million persons in the United States are afflicted with epilepsy and more that half of those are under 20 years of age.

(1) The basic problem is thought to be an electrical disturbance in the nerve cells in one section of the brain, causing them to give off abnormal, recurrent, uncontrolled electrical discharges that produce a seizure or convulsion.

(2) The underlying disorder may be structural, chemical, physiological, or a combination of all three.

(3) Factors that may predispose a patient to epilepsy/seizures.

(a) Trauma to the head/brain.

(b) Brain tumor.

(c) Circulatory disorder, stroke.

(d) Metabolic disorder (such as hypoglycemia, hypocalcemia, or cerebral anoxia).

(e) Drug/alcohol toxicity.

(f) Infection (meningitis/brain abscess).

b. Grand Mal Seizure. (Characterized by three phases.)

(1) Preictal phase.

(a) Consists of vague emotional changes (depression, anxiety, nervousness).

(b) Lasts for minutes to hours. Followed by an “aura.”

(c) Aura is usually a sensory “cue” (odor or sound) or sensation “cue” (weakness, numbness). It is related to the anatomical origin of the seizure, and warns the patient that a seizure is imminent.

(d) Preictal phase may or may not be present in all patients.

(2) Tonic-clonic phase.

(a) Loss of consciousness.

(b) Skin may become cyanotic, breathing is spasmodic, jaws are tightly clenched, and tongue and inner teeth may be bitten.

(c) Urinary and fecal incontinence usually occur.

(d) Phase may last one or more minutes.

(e) Tonic activity is characterized by rigid contraction of the muscles.

(f) Clonic activity is characterized by alternate contraction and relaxation of muscles, causing jerking movements of the arms and legs.

(3) Postictal phase.

(a) Phase will vary in symptoms.

(b) Many patients fall into a deep sleep which may last for several hours.

(c) Patient may experience headache, fatigue, confusion, and nausea.

c. Petit Mal Seizure.

(1) Characterized by brief loss of consciousness, or “blank spells.”

(2) Individual stares blankly, eyelids may flutter, and there is slight movement of head and extremities.

(3) More common in children.

(4) May occur dozens of times per day.

d. Psychomotor Seizure.

(1) Different forms of seizure activity often appearing as irrational or odd behavior, such as removing one’s clothing or purposeless behaviors such as smacking one’s lips.

(2) Last only a few moments and individual has no recall of behavior.

(3) Auditory, visual, or olfactory hallucinations may also occur.

e. Jacksonian Seizure. (Also called focal or marching seizures.)

(1) Seizures may start in one part of the body and move to another.

(2) Consciousness may not be lost.

(3) May be followed by a grand mal seizure.

f. Status Epilipticus.

(1) Series of grand mal seizures experienced by the patient without regaining consciousness.

(2) Extreme neurological emergency.

(3) May occur spontaneously or if anticonvulsant medications are suddenly stopped.

g. Medical and Nursing Management.

(1) Objectives of care:

(a) Determine and treat underlying cause of seizures if possible.

(b) Prevent recurrence of seizures and therefore allow patient to live a normal life.

(2) Institute and reinforce the importance of anticonvulsant drug therapy:

(a) Drug therapy is a means of controlling the condition; it is not a cure.

(b) Initially, dosage will have to be monitored and altered to provide maximum control with minimum side effects.

(3) Instruct patient to keep record of events surrounding his/her seizures (number, duration, time, sleep/eating patterns).

(4) Use of multidisciplinary approach to cope with social, emotional, and vocational pressures of the person with epilepsy.

(5) Place a padded tongue blade and oral airway at the patient’s bedside. Tape them to the headboard or wall above the bed. This provides easy emergency access.

(6) Take the seizure prone patient’s temperature with a rectal thermometer; prevents possibility of patient biting an oral thermometer if a seizure should occur.

(7) Set up suction equipment at the patient’s bedside.

(a) Check the equipment daily to be sure it is working properly.

(b) Use during or after a seizure to clear the patient’s airway.

(8) Essential steps necessary to protect the patient during a seizure.

(a) Turn patient on his side to provide for drainage of oral secretions.

(b) Do not forcibly restrain patient during seizure.

(c) Remove objects that may obstruct breathing or cause injury to patient.

(d) Protect patient’s head from injury with pillow, blanket, etc.

(9) Essential steps necessary to ensure safety of the patient following a seizure.

(a) Keep bed flat and patient turned on his side until he is alert.

(b) Room lighting should be dim and noise kept to a minimum.

(c) Loosen restrictive clothing (if not done during seizure).

(d) Check vital signs immediately following seizure and every 30 minutes (or as ordered) until patient is alert.

(e) Check lips, tongue, and inside of mouth for injuries.

(f) If patient is incontinent, change clothing and bedding with as little disturbance as possible.

h. Documentation.

(1) Document all precautions taken.

(2) Document all activity observed during a seizure, to include the time, location, circumstances, length of seizure activity, and vital signs.

(3) Document any injury sustained during a seizure.

2-44. BRAIN TUMOR

a. Definition. A brain tumor is a localized intracranial lesion which occupies space with the skull and tends to cause a rise in intracranial pressure.

b. Signs and Symptoms.

(1) A brain tumor is usually characterized by a progressive course of symptoms over a period of time.

(2) Symptoms depend primarily on the location of the mass within the cranium.

(3) Symptoms related to increased intracranial pressure will occur.

(a) Decrease in level of consciousness.

(b) Confusion.

(c) Headache.

(d) Lethargy.

(e) Vomiting.

(f) Papilledema–edema of optic nerve.

(4) Alterations in mentation.

(5) Aphasia.

(6) Hemiparesis.

(7) Visual field defects.

(8) Sensory defects (smell, hearing).

(9) Seizures.

c. Preoperative Medical and Nursing Management.

(1) Instruct patient and family about the necessity and importance of diagnostic tests to determine the exact location of the tumor.

(2) Monitor and record vital signs and neurological status accurately q2-4h, or as ordered. Report changes to professional nurse immediately.

(3) Institute measures to prevent inadvertent increases in intracranial pressure.

(a) Elevate head of bed 30º.

(b) Stool softeners to prevent straining at stool (which increases intracranial pressure).

(4) Institute seizure precautions at patient’s bedside. (Tongue blade airway.)

(5) Supportive nursing care is given depending upon the patient’s symptoms and ability to perform activities of daily living.

(6) Administer all doses of steroids and antiepileptic agents on time.

(a) Withholding steroids can result in adrenal crisis.

(b) Withholding of antiepileptic agents frequently precipitates seizure.

(7) Surgery (craniotomy) is performed to remove neoplasm and alleviate symptoms.

d. Post Operative Nursing Care Considerations.

(1) Meticulous nursing management and care aimed at prevention of postoperative complications are imperative for the patient’s survival.

(2) Accurately monitor and record all vital signs and neurological signs.

(a) Postoperative cerebral edema peaks between 48 and 60 hours following surgery.

(b) Patient may be lucid during first 24 hours, then experience a decrease in level of consciousness during this time.

(3) Administer artificial tears (eye drops) as ordered, to prevent corneal ulceration in the comatose patient.

(4) Maintain skin integrity.

(5) Bone flap may not have been replaced over surgical site; turning patient to the affected side, if the flap has been removed, can cause irreversible damage in the first 72 hours.

(6) Maintain head of bed at 30ºelevation.

(7) Perform passive range of motion exercises to all extremities every 2-4 hours.

(8) Maintain body temperature.

(a) Increases of body temperature in the neurosurgical patient may be due to cerebral edema around the hypothalamus.

(b) Monitor rectal temperature frequently.

(c) Place patient on hypothermia blanket, as ordered.

(9) Institute seizure precautions at patient’s bedside. (Tongue blade, airway.)

(10) Maintain accurate record of intake and output.

(11) Prevent pulmonary complications associated with bedrest.

(a) Cough and deep breath every 2 hours.

(b) Perform gentle chest percussion, with the patient in the lateral decubitus position, if tolerated.

(12) Continuously talk to the patient while providing care, reorienting him to person, place, and time.

2-45. CONCLUSION

a. This lesson has introduced the basic nursing care techniques and procedures involved in the nursing care related to the neurological system.

b. Review the lesson objectives once again. If you feel confident that you have achieved the lesson objectives, complete the exercises at the end of this lesson.

c. If you do not feel that you have met the lesson objectives, review the necessary material before you attempt the end of lesson exercises.