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1/3/2008
1
MedicalMedical--Surgical Surgical Nursing CareNursing Care
Second EditionSecond Edition
Karen Burke
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Chapter 38Chapter 38Caring for Clients withCaring for Clients withIntracranial DisordersIntracranial Disorders
Priscilla LeMoneElaine Mohn-Brown
Intracranial DisordersIntracranial Disorders
Increased intracranial pressureIncreased intracranial pressureHead injuriesHead injuriesBrain tumorsBrain tumorsCerebrovascular accidentsCerebrovascular accidents
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Cerebrovascular accidentsCerebrovascular accidentsSeizuresSeizuresIntracranial infectionsIntracranial infections
Increased Intracranial PressureIncreased Intracranial Pressure
Components of craniumComponents of craniumBrainBrainBlood in cerebral vesselsBlood in cerebral vesselsCerebrospinal fluidCerebrospinal fluid
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
1/3/2008
2
Increased ICPIncreased ICP
Common causesCommon causesTraumatic brain injuryTraumatic brain injuryCerebral edemaCerebral edemaBrain tumorBrain tumor
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Cerebral hematomaCerebral hematomaCerebrovascular accidentCerebrovascular accidentBrain infectionsBrain infections
Increased ICPIncreased ICP
ManifestationsManifestationsChange in LOCChange in LOC
Earliest signEarliest signCan progress to comaCan progress to coma
P ilP il
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
PupilsPupilsSluggish to fixed and dilatedSluggish to fixed and dilated
VisionVisionBlurryBlurryDiplopiaDiplopia
Increased ICPIncreased ICP
Manifestations Manifestations Motor functioningMotor functioning
HemiparesisHemiparesisHemiplegiaHemiplegiaP t iP t i
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
PosturingPosturingDecorticateDecorticateDecerebrateDecerebrate
Difficulty speakingDifficulty speaking
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Increased ICPIncreased ICP
Manifestations Manifestations Altered vital signsAltered vital signs
Cushing’s triad (Cushing’s response)Cushing’s triad (Cushing’s response)Widening pulse pressureWidening pulse pressureSlow bounding bradycardic pulseSlow bounding bradycardic pulse
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Slow bounding bradycardic pulseSlow bounding bradycardic pulseAlteration in respiratory patternAlteration in respiratory pattern
Change in body temperatureChange in body temperatureHeadacheHeadacheProjectile vomitingProjectile vomiting
Increased ICPIncreased ICP
Fatal Complications Fatal Complications Brain herniationBrain herniation
Shifting of brainShifting of brainCompression of brain/brainstemCompression of brain/brainstem
B i d hB i d h
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Brain deathBrain deathCessation of cerebral blood flow/vital functionsCessation of cerebral blood flow/vital functions
Increased ICPIncreased ICP
Assessing for IICPAssessing for IICPCerebral monitoringCerebral monitoring
Determining the causeDetermining the causeCT scan or MRICT scan or MRI
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Cerebral angiographyCerebral angiographyLumbar punctureLumbar punctureDiagnostics: Altered LOCDiagnostics: Altered LOC
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Increased ICP Increased ICP –– Lab TestsLab Tests
Blood glucoseBlood glucoseArterial blood gasesArterial blood gasesToxicology screeningToxicology screeningSerum creatinine/BUNSerum creatinine/BUN
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Serum creatinine/BUNSerum creatinine/BUNLiver functionLiver functionComplete blood countComplete blood count
Increased ICP Increased ICP -- MedicationsMedications
Osmotic diuretics/loop diureticsOsmotic diuretics/loop diureticsMonitor client for fluid and electrolyte imbalancesMonitor client for fluid and electrolyte imbalancesMonitor client for dehydrationMonitor client for dehydration
CorticosteroidsCorticosteroids
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Assess for GI irritation/ulcersAssess for GI irritation/ulcersAdminister H2 blockers and/or antacids concurrentlyAdminister H2 blockers and/or antacids concurrently
Increased ICP Increased ICP -- MedicationsMedications
AnticonvulsantsAnticonvulsantsMonitor for signs of seizure activityMonitor for signs of seizure activityDocument cessation of signs of seizure activityDocument cessation of signs of seizure activity
Barbiturate therapy for severe TBI, IICPBarbiturate therapy for severe TBI, IICP
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
py ,py ,Artificial coma requiring ICU monitoringArtificial coma requiring ICU monitoring
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Increased ICP Increased ICP –– Nursing CareNursing Care
AssessmentAssessmentLOC/vital signsLOC/vital signsAltered cognitive functioningAltered cognitive functioningHeadacheHeadache
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
VomitingVomiting
Increased ICP Increased ICP –– Nursing CareNursing Care
AssessmentAssessmentSensory alterations: vision/hearingSensory alterations: vision/hearingNumbness or tingling in extremitiesNumbness or tingling in extremitiesHistory; medication/alcohol useHistory; medication/alcohol use
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Reflexes; posturingReflexes; posturing
Increased ICP Increased ICP –– Nursing CareNursing Care
Nursing DiagnosesNursing DiagnosesIneffective Tissue PerfusionIneffective Tissue PerfusionIneffective Breathing PatternIneffective Breathing PatternRisk for Imbalanced NutritionRisk for Imbalanced Nutrition
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Risk for Impaired Skin IntegrityRisk for Impaired Skin IntegrityImpaired Physical MobilityImpaired Physical MobilityRisk for InfectionRisk for Infection
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Increased ICP Increased ICP –– Nursing CareNursing Care
EvaluationEvaluationLOCLOCGrips, gaitGrips, gaitAbsence of deficitsAbsence of deficits
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Increased ICPIncreased ICP
Interdisciplinary CareInterdisciplinary CarePharmacotherapyPharmacotherapyRespiratory supportRespiratory supportNutritional supportNutritional support
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
SurgerySurgeryDischarge planningDischarge planning
Skull FracturesSkull Fractures
LinearLinearSimple clean break in skullSimple clean break in skull
ComminutedComminutedSkull in fragmented piecesSkull in fragmented pieces
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
g pg p
DepressedDepressedSkull bone fragments pushed into brainSkull bone fragments pushed into brain
BasilarBasilarAt base of skull, may extend to temporal boneAt base of skull, may extend to temporal bone
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Skull FracturesSkull Fractures
Leakage of blood or CSF from nose/earsLeakage of blood or CSF from nose/earsBattle’s signBattle’s sign“Raccoon” eyes“Raccoon” eyes
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Open Head InjuryOpen Head Injury
Opening through skull and duraOpening through skull and duraSevere blunt traumaSevere blunt traumaPenetrating injuriesPenetrating injuries
Brain exposed to external environmentBrain exposed to external environment
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
ppRisk of meningitis; brain damageRisk of meningitis; brain damage
Closed Head InjuryClosed Head Injury
CoupCoup––contrecoup phenomenoncontrecoup phenomenonBruising of brain at two pointsBruising of brain at two pointsBrain damageBrain damage
Focal symptoms related to area of brain injuredFocal symptoms related to area of brain injured
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Focal symptoms related to area of brain injuredFocal symptoms related to area of brain injuredPossible increased ICPPossible increased ICP
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Closed Head InjuryClosed Head Injury
Concussion r/t shaking of brainConcussion r/t shaking of brainImmediate loss of consciousness < 5 minImmediate loss of consciousness < 5 minDrowsiness, confusionDrowsiness, confusionHeadache, blurred/double visionHeadache, blurred/double vision
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Closed Head InjuryClosed Head Injury
Contusion: bruising/swelling of brain tissueContusion: bruising/swelling of brain tissueInitial loss of consciousnessInitial loss of consciousnessMotionless, pale, clammyMotionless, pale, clammyHypotensive weak pulse shallow respirationsHypotensive weak pulse shallow respirations
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Hypotensive, weak pulse, shallow respirationsHypotensive, weak pulse, shallow respirationsAltered motor responseAltered motor response
Epidural HematomaEpidural Hematoma
Arterial bleed between skull and duraArterial bleed between skull and duraCan be caused by skull fracture/contusionCan be caused by skull fracture/contusionBrief loss of consciousness short period of alertness Brief loss of consciousness short period of alertness rapid progression to comarapid progression to coma
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
rapid progression to comarapid progression to comaPosturing, pupil changes, seizures; IICPPosturing, pupil changes, seizures; IICP
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Subdural HematomaSubdural Hematoma
Venous bleed between dura and subarachnoid layerVenous bleed between dura and subarachnoid layerAcuteAcute
Rapid progression to coma, pupil dilation, contralateral Rapid progression to coma, pupil dilation, contralateral hemiparesishemiparesis
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
SubacuteSubacuteSymptoms 48 hrs to 2 wks; alert period then slow Symptoms 48 hrs to 2 wks; alert period then slow progression to comaprogression to coma
Subdural HematomaSubdural Hematoma
ChronicChronicSymptoms weeks to months laterSymptoms weeks to months laterImpaired thinkingImpaired thinkingConfusionConfusion
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
DrowsinessDrowsinessPupil changesPupil changesMotor deficitsMotor deficits
Intracerebral HematomaIntracerebral Hematoma
Bleeding into brain tissueBleeding into brain tissueDecreasing LOCDecreasing LOCPupil changesPupil changesMotor deficitsMotor deficits
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Motor deficitsMotor deficits
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Head Injuries Head Injuries –– Diagnostic TestsDiagnostic Tests
Skull series: xSkull series: x--rayrayCT scanCT scan
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
IICP in Head InjuriesIICP in Head Injuries
IICP results from:IICP results from:Direct trauma to the brain tissueDirect trauma to the brain tissueCerebral edemaCerebral edemaHematomasHematomas
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Head Injuries Head Injuries –– Nursing CareNursing Care
Discharge teaching topicsDischarge teaching topicsSymptoms of IICPSymptoms of IICPFrequent monitoring at homeFrequent monitoring at homePostconcussion syndromePostconcussion syndrome
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Necessity for rehabilitationNecessity for rehabilitationNecessity for longNecessity for long--term careterm care
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Brain TumorsBrain Tumors
Abnormal growths within the craniumAbnormal growths within the craniumBenign or malignantBenign or malignantPrimaryPrimary
Arising from brain cells/structuresArising from brain cells/structures
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
SecondarySecondaryMetastasis from other primary site of cancerMetastasis from other primary site of cancer
Brain TumorBrain Tumor
GliomaGliomaAstrocytomaAstrocytomaGlioblastomaGlioblastoma
MeningiomaMeningioma
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
ggAcoustic neuromaAcoustic neuromaMetastatic brain tumorsMetastatic brain tumors
BOX 38BOX 38--55 Manifestations of Brain Tumors.Manifestations of Brain Tumors.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
1/3/2008
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Brain Tumors Brain Tumors –– Diagnostic TestsDiagnostic Tests
CT scan or MRICT scan or MRIEEGEEGCerebral angiogramCerebral angiogramStereotactic needle biopsyStereotactic needle biopsy
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Stereotactic needle biopsyStereotactic needle biopsy
Brain Tumors Brain Tumors -- MedicationsMedications
ChemotherapyChemotherapyOmmaya reservoirOmmaya reservoirWafers in tumor cavityWafers in tumor cavity
Assess for bone marrow suppressionAssess for bone marrow suppression
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Assess for bone marrow suppressionAssess for bone marrow suppression
Brain Tumor Brain Tumor –– Nursing CareNursing Care
AssessmentAssessmentCognitive changesCognitive changesPainPainSensory changes: vision, hearingSensory changes: vision, hearing
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
ParesthesiasParesthesiasVital signs, LOCVital signs, LOCStrength, movementStrength, movementGait, coordinationGait, coordination
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Brain Tumor Brain Tumor –– Nursing CareNursing Care
DiagnosesDiagnosesAnxietyAnxietyDisturbed Body ImageDisturbed Body Image
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Brain Tumor Brain Tumor –– Nursing CareNursing Care
EvaluationEvaluationEffectiveness of interventions: postop craniotomyEffectiveness of interventions: postop craniotomy
Absence of neurologic deficitsAbsence of neurologic deficitsNo signs of infectionNo signs of infection
K l d f llK l d f ll hh
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Knowledge re: followKnowledge re: follow--up care at homeup care at home
Cerebrovascular AccidentCerebrovascular Accident
Terms preferred by National Stroke Association:Terms preferred by National Stroke Association:Stroke or brain attackStroke or brain attack
Affects 700,000 people in the U.S. per yearAffects 700,000 people in the U.S. per yearThird leading cause of death in the U.S.Third leading cause of death in the U.S.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
ggMost frequent cause of chronic neurologic disabilityMost frequent cause of chronic neurologic disability
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Stroke/Brain AttackStroke/Brain Attack
Risk FactorsRisk FactorsRace: African AmericanRace: African AmericanHypertensionHypertensionObesityObesity
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Diabetes mellitusDiabetes mellitusAtrial fibrillationAtrial fibrillationAtherosclerosisAtherosclerosis
Stroke/Brain AttackStroke/Brain Attack
Other Risk Factors: Lifestyle ChoicesOther Risk Factors: Lifestyle ChoicesSmokingSmokingHigh cholesterolHigh cholesterolExcessive use of alcohol, cocaine, and heroinExcessive use of alcohol, cocaine, and heroin
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Oral contraceptive use by womenOral contraceptive use by women
Transient Ischemic Attack (TIA)Transient Ischemic Attack (TIA)
Temporary reduction in cerebral blood flowTemporary reduction in cerebral blood flowReversible neurologic deficitsReversible neurologic deficits
Several minutes to 24 hoursSeveral minutes to 24 hours
Warning sign of an impending or future strokeWarning sign of an impending or future stroke
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Warning sign of an impending or future strokeWarning sign of an impending or future strokeCarotid endarterectomyCarotid endarterectomy
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TIATIA
ManifestationsManifestationsDizzinessDizzinessLoss of vision in one eyeLoss of vision in one eyeNumbness, weaknessNumbness, weakness
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
One arm, hand, legOne arm, hand, legAphasiaAphasia
Stroke Stroke –– Diagnostic TestsDiagnostic Tests
CT scan/MRICT scan/MRICerebral arteriogramCerebral arteriogramDoppler ultrasoundDoppler ultrasoundPET scanPET scan
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
PET scanPET scanLumbar punctureLumbar puncture
Stroke/Brain AttackStroke/Brain Attack
Sudden loss of neurologic function due to decreased Sudden loss of neurologic function due to decreased blood supply to a local area of the brainblood supply to a local area of the brainIschemicIschemic
ThrombusThrombus
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
EmboliEmboli
HemorrhagicHemorrhagic
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Right Hemisphere ProblemsRight Hemisphere Problems
ManifestationsManifestationsLeft hemiplegia; visual field deficitsLeft hemiplegia; visual field deficitsSpatialSpatial--perceptual deficitsperceptual deficitsPoor judgment; easily distractedPoor judgment; easily distracted
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
ImpulsiveImpulsive
Left Hemisphere Problems Left Hemisphere Problems
ManifestationsManifestationsRight hemiplegia; visual field deficitsRight hemiplegia; visual field deficitsAphasiaAphasiaImpaired intellectImpaired intellect
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Slow/cautious; high frustrationSlow/cautious; high frustration
Stroke/Brain AttackStroke/Brain Attack
Motor DeficitsMotor DeficitsContralateralContralateralHemiparesisHemiparesisHemiplegiaHemiplegia
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Flaccidity moving to spacticityFlaccidity moving to spacticity
Problems associated with immobilityProblems associated with immobility
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Stroke/Brain AttackStroke/Brain Attack
Speech DeficitsSpeech DeficitsExpressive aphasiaExpressive aphasiaReceptive aphasiaReceptive aphasiaGlobal aphasiaGlobal aphasia
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
DysarthriaDysarthria
Stroke/Brain AttackStroke/Brain Attack
Visual DeficitsVisual DeficitsDue to parietal and/or temporal lobe damageDue to parietal and/or temporal lobe damageDiplopiaDiplopiaHomonymous hemianopiaHomonymous hemianopia
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Stroke/Brain AttackStroke/Brain Attack
SensorySensory--Perceptual DeficitsPerceptual DeficitsAgnosiaAgnosiaApraxiaApraxiaUnilateral neglectUnilateral neglect
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Alterations in perceptionAlterations in perceptionTemperature; vibration; pain; pressure; proprioceptionTemperature; vibration; pain; pressure; proprioception
Increased risk for injuryIncreased risk for injury
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Stroke/Brain AttackStroke/Brain Attack
Cognitive/Behavioral ChangesCognitive/Behavioral ChangesMemory loss; decreased attention spanMemory loss; decreased attention spanPoor judgment; inability to solve problemsPoor judgment; inability to solve problemsEmotionally labile/loss of selfEmotionally labile/loss of self--controlcontrol
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Depression; stress manifesting as angerDepression; stress manifesting as anger
Stroke/Brain AttackStroke/Brain Attack
Urinary/Gastrointestinal ProblemsUrinary/Gastrointestinal ProblemsUrinary frequency, urgency, incontinenceUrinary frequency, urgency, incontinenceConstipationConstipationDysphagiaDysphagia
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Choking, drooling, aspirationChoking, drooling, aspiration
Stroke/Brain Attack Stroke/Brain Attack --MedicationsMedications
Preventive post TIAPreventive post TIAAntiplateletsAntiplatelets
ThrombolyticsThrombolyticsOnly in ischemic strokeOnly in ischemic stroke
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
yyTime frame criticalTime frame critical
Major nursing responsibilityMajor nursing responsibilityAssess for bleedingAssess for bleeding
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Stroke/Brain Attack Stroke/Brain Attack --MedicationsMedications
Anticoagulants (thrombotic stroke)Anticoagulants (thrombotic stroke)Assess for bleedingAssess for bleeding
AntihypertensivesAntihypertensivesAssess BPAssess BP
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Osmotic diuretics for IICPOsmotic diuretics for IICPMonitor I&OMonitor I&O
AnticonvulsantsAnticonvulsantsWatch for seizure activityWatch for seizure activity
Stroke/Brain Attack Stroke/Brain Attack –– Nursing Nursing CareCare
AssessmentAssessmentCognitive changesCognitive changesSensory changesSensory changesChange in motor functionChange in motor function
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
HeadacheHeadache
Stroke/Brain Attack Stroke/Brain Attack –– Nursing Nursing CareCare
AssessmentAssessmentHistory of:History of:
HTN, TIA, diabetes, cardiac dysrhythmiasHTN, TIA, diabetes, cardiac dysrhythmiasAlcohol abuse, smokingAlcohol abuse, smokingU f ti l tU f ti l t
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Use of anticoagulantsUse of anticoagulants
Vital signsVital signsFocused neurologic examFocused neurologic exam
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Stroke/Brain Attack Stroke/Brain Attack –– Nursing Nursing CareCare
DiagnosesDiagnosesIneffective Tissue Perfusion: CerebralIneffective Tissue Perfusion: CerebralRisk for Ineffective Airway ClearanceRisk for Ineffective Airway ClearanceImpaired Physical MobilityImpaired Physical Mobility
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Impaired Verbal CommunicationImpaired Verbal Communication
Stroke/Brain Attack Stroke/Brain Attack –– Nursing Nursing CareCare
DiagnosesDiagnosesDisturbed Sensory PerceptionDisturbed Sensory PerceptionImpaired Urinary Elimination/ConstipationImpaired Urinary Elimination/ConstipationImpaired SwallowingImpaired Swallowing
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
SelfSelf--Care DeficitCare Deficit
Stroke/Brain Attack Stroke/Brain Attack –– Nursing Nursing CareCare
EvaluationEvaluationAirwayAirwaySelfSelf--carecareCommunicationCommunication
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
CopingCopingKnowledge of medicationsKnowledge of medications
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Seizure DisordersSeizure Disorders
Abnormal electrical activity in brain cellsAbnormal electrical activity in brain cellsInvolving all or part of brainInvolving all or part of brainCan be isolated eventCan be isolated eventChronic pattern epilepsyChronic pattern epilepsy
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Chronic pattern epilepsyChronic pattern epilepsy
Seizures Seizures
CausesCausesMost unknownMost unknownIn adults:In adults:
Brain infectionBrain infection
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
StrokeStrokeBrain tumorBrain tumorHypoglycemia, high fever, hypoxiaHypoglycemia, high fever, hypoxia
Seizures Seizures –– Diagnostic TestsDiagnostic Tests
RadiologicRadiologicSkull xSkull x--rays; CT; MRIrays; CT; MRI
EEGEEGCBC, electrolytes, BUN, glucoseCBC, electrolytes, BUN, glucose
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
CBC, electrolytes, BUN, glucoseCBC, electrolytes, BUN, glucoseTesting for syphilisTesting for syphilis
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SeizuresSeizures
SimpleSimpleJacksonian marchJacksonian marchFlashing lights; tingling sensation; hallucinationsFlashing lights; tingling sensation; hallucinations2020––30 secs; no loss of consciousness30 secs; no loss of consciousness
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
ComplexComplexAutomatismsAutomatismsAltered LOCAltered LOCAuraAura
SeizuresSeizures
AbsenceAbsenceBrief change in consciousnessBrief change in consciousnessMotor activity haltsMotor activity haltsTonicTonic--clonicclonic
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
AuraAuraTonic contractionsTonic contractions——rigidityrigidityClonic contractionsClonic contractions——muscle jerking; eyes roll; frothing at mouth; muscle jerking; eyes roll; frothing at mouth; incontinenceincontinencePostictal periodPostictal period
Status EpilepticusStatus Epilepticus
LifeLife--threatening emergencythreatening emergencyContinuous tonicContinuous tonic--clonic activity and loss of clonic activity and loss of consciousnessconsciousnessCan deprive brain of oxygen/glucoseCan deprive brain of oxygen/glucose
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Can deprive brain of oxygen/glucoseCan deprive brain of oxygen/glucoseCauses physical exhaustion/respiratory distressCauses physical exhaustion/respiratory distressCan cause permanent brain damageCan cause permanent brain damage
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Seizures Seizures -- MedicationsMedications
Halting status epilepticusHalting status epilepticusValiumValiumAtivanAtivanPhenobarbitalPhenobarbital
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
LongLong--term seizure controlterm seizure controlAnticonvulsantsAnticonvulsants
Assess for effectiveness: monitor drug levelsAssess for effectiveness: monitor drug levels
Seizures Seizures –– Nursing CareNursing Care
AssessmentAssessmentSeizure experienceSeizure experience
Onset, duration, aura, postictal periodOnset, duration, aura, postictal period
History of intracranial disordersHistory of intracranial disorders
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
ObservationObservationPhysical symptoms before, during, and after seizurePhysical symptoms before, during, and after seizure
Seizures Seizures –– Nursing CareNursing Care
DiagnosesDiagnosesRisk for Ineffective Airway ClearanceRisk for Ineffective Airway ClearanceRisk for InjuryRisk for InjuryAnxietyAnxiety
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
EvaluationEvaluationSeizure controlSeizure controlSafetySafetyKnowledge of medicationsKnowledge of medications
1/3/2008
24
MeningitisMeningitis
Inflammation of the meninges: brain and spinal cordInflammation of the meninges: brain and spinal cordBacterialBacterialViralViral
Less severeLess severe
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Shorter courseShorter course
MeningitisMeningitisPositive Brudzinski’s signPositive Brudzinski’s signPositive Kernig’s signPositive Kernig’s signHeadache, photophobiaHeadache, photophobiaHigh fever, nausea, vomitingHigh fever, nausea, vomiting
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
g gg gRestlessness, confusion, seizuresRestlessness, confusion, seizuresAltered LOCAltered LOCSigns of IICPSigns of IICPAltered vital signsAltered vital signs
EncephalitisEncephalitis
Acute inflammation of white and gray matter: brain Acute inflammation of white and gray matter: brain and spinal cordand spinal cordDamage of nerve cellsDamage of nerve cells
Cerebral edema, necrosis, localized hemorrhageCerebral edema, necrosis, localized hemorrhage
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
, , g, , g
Manifestations similar to meningitisManifestations similar to meningitis
1/3/2008
25
Brain AbscessBrain Abscess
Collection of purulent material within the brainCollection of purulent material within the brainCaused by/often follow:Caused by/often follow:
Middle ear/sinus infectionMiddle ear/sinus infectionHead injury/intracranial surgeryHead injury/intracranial surgery
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
j y g yj y g yBacterial infections in hear, bone, lungBacterial infections in hear, bone, lung
Manifestations similar to meningitisManifestations similar to meningitis
Brain Infections Brain Infections –– Diagnostic Diagnostic TestsTests
Lumbar punctureLumbar punctureCulture, sensitivity and Gram stain of CSFCulture, sensitivity and Gram stain of CSFBlood, urine, throat, and nasal culturesBlood, urine, throat, and nasal culturesCT MRI skull xCT MRI skull x raysrays
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
CT, MRI, skull xCT, MRI, skull x--raysrays
Brain Infections Brain Infections -- MedicationsMedications
Antibiotics: teaching related to completionAntibiotics: teaching related to completionAntivirals: teaching related to completionAntivirals: teaching related to completionAnticonvulsants: monitor for seizuresAnticonvulsants: monitor for seizuresAntipyretics/analgesics: monitor tempAntipyretics/analgesics: monitor temp
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Antipyretics/analgesics: monitor tempAntipyretics/analgesics: monitor tempOsmotic diuretics/corticosteroids: assess for signs of Osmotic diuretics/corticosteroids: assess for signs of IICPIICPAntiemetics: assess for nauseaAntiemetics: assess for nausea
1/3/2008
26
Brain Infections Brain Infections –– Nursing CareNursing Care
AssessmentAssessmentNausea, vomitingNausea, vomitingPhotophobia; stiff neckPhotophobia; stiff neckConfusion; headacheConfusion; headache
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
History of:History of:Head injury; brain surgery; infectionsHead injury; brain surgery; infections
Brain Infections Brain Infections –– Nursing CareNursing Care
AssessmentAssessmentVital signs/LOCVital signs/LOCChanges in vision/hearingChanges in vision/hearingBrudzinski’s and Kernig’s signsBrudzinski’s and Kernig’s signs
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
SeizuresSeizuresPetechial rashPetechial rash
Brain Infections Brain Infections –– Nursing CareNursing Care
DiagnosesDiagnosesRisk for Ineffective Tissue Perfusion: CerebralRisk for Ineffective Tissue Perfusion: CerebralHyperthermiaHyperthermiaAcute PainAcute Pain
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
EvaluationEvaluationAfebrileAfebrileAbsence of headache/signs of IICPAbsence of headache/signs of IICPKnowledge of antiKnowledge of anti--infective therapyinfective therapy
1/3/2008
27
Craniotomy Craniotomy
Surgical opening into the cranial cavitySurgical opening into the cranial cavityPurposes:Purposes:
Elevate a depressed skull fractureElevate a depressed skull fractureRemove foreign bodyRemove foreign body
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
g yg yEvacuate hematomaEvacuate hematomaDebulk/remove tumorDebulk/remove tumor
CraniotomyCraniotomy
Preoperative CarePreoperative CareRoutine preoperative care/teachingRoutine preoperative care/teachingAssess understanding of procedureAssess understanding of procedureAssess anxiety levelAssess anxiety level
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Postoperative appearancePostoperative appearance
CraniotomyCraniotomy
Postoperative CarePostoperative CareMonitoringMonitoring
Vital signs, respiratory status oxygenation statusVital signs, respiratory status oxygenation statusIICP; CSF leak; manifestations of meningitis; seizuresIICP; CSF leak; manifestations of meningitis; seizures
P i l ibi i hP i l ibi i h
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Pain control; antibiotic therapyPain control; antibiotic therapyPositioningPositioningCare of the wound/incisionCare of the wound/incision
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