bled ppt ch29
TRANSCRIPT
-
7/24/2019 Bled Ppt Ch29
1/62
Copyright 2006 Pearson 29-1
Chapter 29Neurology
-
7/24/2019 Bled Ppt Ch29
2/62
Copyright 2006 Pearson 29-2
Lecture Outline
Introduction
Pathophysiolgy
General assessment findings Management of nervous system
emergencies
-
7/24/2019 Bled Ppt Ch29
3/62
Copyright 2006 Pearson 29-3
Introduction
Nervous system disorders affect
thousands of Canadians each year
Strokes affect 50 000 Epilepsy affects 00 00
!00 000 people have "een diagnosed #ith
Parkinson$s disease
-
7/24/2019 Bled Ppt Ch29
4/62
Copyright 2006 Pearson 29-4
Pathophysiology
%lterations in cognitive systems &%S
Cere"ral corte' Peripheral nervous systems
disorders
Peripheral neuropathy
-
7/24/2019 Bled Ppt Ch29
5/62
Copyright 2006 Pearson 29-5
Central Nervous System
Disorders Structural lesions (umour
)egenerative
disease Intracranial
hemorrhage
Parasites
(rauma
(o'ic*meta"olic
states %no'ia
)ia"etic
ketoacidosis
+epatic failure
+ypoglycemia
&enal failure
(hiamine deficiency
(o'ic e'posure
-
7/24/2019 Bled Ppt Ch29
6/62
Copyright 2006 Pearson 29-6
Assessment
Scene and primary assessment %,P-
General appearance Speech
Skin and facial drooping
Mood. thought. perception. /udgment.
memory. and attention
-
7/24/2019 Bled Ppt Ch29
7/62
Copyright 2006 Pearson 29-7
History
hen did the incident occur1
2oss of consciousness1
Incontinence1 Chief complaint1
Changes1 Complicating factors1
-
7/24/2019 Bled Ppt Ch29
8/62
Copyright 2006 Pearson 29-8
Secondary
Assessment 3ace Smile. fro#n. facial drooping
Eyes Pupils
Nose4mouth
Potential compromise of the air#ay
-
7/24/2019 Bled Ppt Ch29
9/62
Copyright 2006 Pearson 29-9
espiratory Status
-
7/24/2019 Bled Ppt Ch29
10/62
Copyright 2006 Pearson 29-10
Cardiovascular System
Status +eart rate ECG
ruits 6,)
-
7/24/2019 Bled Ppt Ch29
11/62
Copyright 2006 Pearson 29-11
Nervous System
Status Sensorimotor evaluation %,P-
Incontinence
)istal properties Motor system status
Muscle tone
Strength
3le'ion4e'tension
Coordination
alance
-
7/24/2019 Bled Ppt Ch29
12/62
Copyright 2006 Pearson 29-12
Posturing
)ecorticate %rms fle'ed. legs e'tended
2esion at or a"ove the upper "rainstem
-
7/24/2019 Bled Ppt Ch29
13/62
Copyright 2006 Pearson 29-13
Posturing
)ecere"rate Sustained e'tension
2esion in the "rainstem
-
7/24/2019 Bled Ppt Ch29
14/62
Copyright 2006 Pearson 29-14
Nervous System
Status Cranial nervestatus
Glasgo# Coma
Scale 7GCS8 Eye opening
,er"al response
Motor response
-
7/24/2019 Bled Ppt Ch29
15/62
Copyright 2006 Pearson 29-15
-
7/24/2019 Bled Ppt Ch29
16/62
Copyright 2006 Pearson 29-16
Additional Assessment
!ools End tidal C9: Pulse o'imetry
lood glucose determination
-
7/24/2019 Bled Ppt Ch29
17/62
Copyright 2006 Pearson 29-17
"eriatric
Considerations More suscepti"le to systemicillness
Certain changes occur naturally#ith aging Pupil sluggishness
2oss of overall "ody strength Muscle atrophy
%ltered sensation
-
7/24/2019 Bled Ppt Ch29
18/62
Copyright 2006 Pearson 29-18
"eneral
#anagement %ir#ay and "reathing Circulatory support
Pharmacological intervention Psychological support
(ransport considerations Primary treatment is supportive
-
7/24/2019 Bled Ppt Ch29
19/62
Copyright 2006 Pearson 29-19
Altered #ental
Status% acidosisE epilepsy
I infection
9 overdose- uremia 7kidney failure8
( trauma. tumour. to'in
I insulin 7hypoglycemia. ketoacidosis8P psychosis. poison
S stroke. sei;ure
-
7/24/2019 Bled Ppt Ch29
20/62
Copyright 2006 Pearson 29-20
#anagement
%ir#ay and "reathing
Circulatory support
Esta"lish I, lood glucose
(reat reversi"le causes +ypoglycemia Narcotic overdose
-
7/24/2019 Bled Ppt Ch29
21/62
Copyright 2006 Pearson 29-21
Altered #ental
Status Chronic %lcoholism Significant percentage have a thiamine
deficiency
ernicke$s Syndrome
-
7/24/2019 Bled Ppt Ch29
22/62
Copyright 2006 Pearson 29-22
Stro$e
In/ury or death to "rain tissue -sually due to an interruption in cere"ral
"lood flo#
Physiology compares to an MI
Categories
9cclusive +emorrhagic
-
7/24/2019 Bled Ppt Ch29
23/62
Copyright 2006 Pearson 29-23
Occlusive Stro$e
Cere"ral artery "locked "y a clot or
foreign matter
Ischemia Infarction
(issue s#ells
+erniation
-
7/24/2019 Bled Ppt Ch29
24/62
Copyright 2006 Pearson 29-24
Occlusive Stro$e
Em"olic stroke Em"olus carried to cere"ral "lood vessel from a
remote site
-sually clots arising from diseased vessels %trial fi"rillation
(hrom"otic stroke lood clot gradually develops in and o"structs a
cere"ral "lood vessel
Signs develop gradually
9ccurs at night. patient #akes up #ith signs
-
7/24/2019 Bled Ppt Ch29
25/62
Copyright 2006 Pearson 29-25
-
7/24/2019 Bled Ppt Ch29
26/62
Copyright 2006 Pearson 29-26
Hemorrhagic Stro$e
Sudden onset characteri;ed "y
headache and decreased 29C
Intracranial ithin the "rain
Small "lood vessels
Effects depend on location of "lood vessels
Su"arachnoid )evelops from congenital "lood vessel
a"normalities
-
7/24/2019 Bled Ppt Ch29
27/62
Copyright 2006 Pearson 29-27
Hemorrhagic Stro$e
+emorrhage inside the "rain tears
and separates "lood vessels
Impaired drainage of CS3 +erniation of "rain tissue occurs
rapidly
-
7/24/2019 Bled Ppt Ch29
28/62
Copyright 2006 Pearson 29-28
-
7/24/2019 Bled Ppt Ch29
29/62
Copyright 2006 Pearson 29-29
Presentation
Signs 3acial )rooping
+eadache
%phasia4)ysphasia +emiparesis
+emiplegia
Paraesthesia
Gait )istur"ances
Incontinence
Symptoms Confusion
%gitation
)i;;iness ,ision Pro"lems
-
7/24/2019 Bled Ppt Ch29
30/62
Copyright 2006 Pearson 29-30
!ransient Ischemic
Attac$s Indicative of carotid artery disease= Symptoms of neurological deficit>
Symptoms resolve in less than :? hours=
No long*term effects=
Evaluate through history taking> +istory of +(N. prior stroke. or (I%=
Symptoms and their progression
+igh risk of throm"otic stroke
-
7/24/2019 Bled Ppt Ch29
31/62
Copyright 2006 Pearson 29-31
#anagement
Scene safety and SI Maintain the air#ay= Support "reathing=
9"tain a detailed history= Position the patient= )etermine the "lood glucose level=
Esta"lish I, access= Monitor the cardiac rhythm= Protect paraly;ed e'tremities=
-
7/24/2019 Bled Ppt Ch29
32/62
Copyright 2006 Pearson 29-32
Sei%ure
(emporary alteration in "ehaviour
die to massive electrical discharge
from one or more groups ofneurons in the "rain +ypo'ia
)ecreased "lood sugar Epilepsy
Idiopathic sei;ures
-
7/24/2019 Bled Ppt Ch29
33/62
Copyright 2006 Pearson 29-33
"enerali%ed
Sei%ures (onic*Clonic %lso called grand mal
%ura
2oss of consciousness
(onic phase
+ypertonic phase
Clonic phase Postsei;ure
Postictal
-
7/24/2019 Bled Ppt Ch29
34/62
Copyright 2006 Pearson 29-34
"enerali%ed
Sei%ures %"sence %lso called petit mal
Presents #ith "rief loss of consciousness
May not respond to normal treatment
Pseudosei;ure
-sually stem from a psychologicaldisorder
No post ictal phase
-
7/24/2019 Bled Ppt Ch29
35/62
Copyright 2006 Pearson 29-35
Partial Sei%ures
Simple partial sei;ures Involve one "ody area
Can progress to generali;ed sei;ure
Comple' partial sei;ure Characteri;ed "y an aura
(ypically :* minutes in length 2oss of contact #ith surroundings
-
7/24/2019 Bled Ppt Ch29
36/62
Copyright 2006 Pearson 29-36
-
7/24/2019 Bled Ppt Ch29
37/62
Copyright 2006 Pearson 29-37
Patient History
+istory of sei;ures
+istory of head trauma
%ny alcohol or drug a"use
&ecent history of fever. headache. or stiffneck
+istory of heart disease. dia"etes. or stroke
Current medications
Physical e'am Signs of head trauma or in/ury to tongue. alcohol or drug
a"use
-
7/24/2019 Bled Ppt Ch29
38/62
Copyright 2006 Pearson 29-38
#anagement
Scene safety and SI= Maintain the air#ay= %dminister high*flo# o'ygen=
Esta"lish I, access= (reat hypoglycemia if present= Protect the patient from the
environment= )o not restrain the patient= Maintain "ody temperature=
-
7/24/2019 Bled Ppt Ch29
39/62
Copyright 2006 Pearson 29-39
Protection o& a sei%uringpatient
-
7/24/2019 Bled Ppt Ch29
40/62
Copyright 2006 Pearson 29-40
#anagement
Position the patient=
Suction if re@uired=
Monitor cardiac rhythm= (reat prolonged sei;ures=
%nticonvulsant medication
Provide a @uiet atmosphere=
(ransport=
-
7/24/2019 Bled Ppt Ch29
41/62
Copyright 2006 Pearson 29-41
Place a sei%uring patient'ith no spinal in(ury on her
side
-
7/24/2019 Bled Ppt Ch29
42/62
Copyright 2006 Pearson 29-42
Status )pilepticus
(#o or more generali;ed sei;ures Sei;ures occur #ithout a return of
consciousness=
Management Management of air#ay and "reathing is critical=
Esta"lish I, access and cardiac monitoring=
%dminister :5g 50A de'trose if hypoglycemia is
present=
%dminister 5B!0mg dia;epam I,=
Monitor the air#ay closely=
-
7/24/2019 Bled Ppt Ch29
43/62
Copyright 2006 Pearson 29-43
Syncope
% sudden. temporary loss ofconsciousness
%ssessment Cardiovascular
)ysrhythmias or mechanical pro"lems
Noncardiovascular Meta"olic. neurological. or psychiatric condition
Idiopathic (he cause remains unkno#n even after careful
assessment
E'tended unconsciousness is not syncope
-
7/24/2019 Bled Ppt Ch29
44/62
Copyright 2006 Pearson 29-44
#anagement
Scene safety and SI= Maintain the air#ay= Support "reathing=
Check circulatory status= Monitor mental status= Esta"lish I, access=
)etermine "lood glucose level= Monitor the cardiac rhythm= &eassure the patient and transport=
-
7/24/2019 Bled Ppt Ch29
45/62
Copyright 2006 Pearson 29-45
Headache
,ascular
Migraines (hro""ing pain. photosensitivity. nausea.
vomiting. and s#eats more fre@uent in #omen May last for e'tended periods of time=
Cluster 9ne*sided #ith nasal congestion. drooping
eyelid. and irritated or #atery eye more fre@uentin men
(ypically lasts !B? hours=
-
7/24/2019 Bled Ppt Ch29
46/62
Copyright 2006 Pearson 29-46
Headache
(ension
9rganic
9ccurs due to tumours. infection. or otherdiseases of the "rain. eye. or other "ody
system=
+eadaches associated #ith fever.
confusion. nausea. vomiting. or rash can"e indicative of an infectious disease=
-
7/24/2019 Bled Ppt Ch29
47/62
Copyright 2006 Pearson 29-47
Assessment
hat #as the patient doing at the onsetof pain1
)oes anything provoke or relieve the
pain1 hat is the @uality of the pain1 )oes the pain radiate to the neck. arm.
"ack. or /a#1
hat is the severity of the pain1 +o# long has the headache "een
present1
-
7/24/2019 Bled Ppt Ch29
48/62
Copyright 2006 Pearson 29-48
#anagement
Scene safety and SI Maintain the air#ay= Position the patient=
Esta"lish I, access= )etermine "lood glucose level= Monitor the cardiac rhythm=
Consider medication= %ntiemetics or analgesics
&eassure the patient and transport=
-
7/24/2019 Bled Ppt Ch29
49/62
Copyright 2006 Pearson 29-49
*+ea$ and Di%%y,
%ssessment Symptomatic of many illnesses
3ocused assessment
Include a detailed neurological e'am=
Specific signs and symptoms>
Nystagmus
Nausea and vomiting )i;;iness
-
7/24/2019 Bled Ppt Ch29
50/62
Copyright 2006 Pearson 29-50
#anagement
Scene safety and SI=
Maintain air#ay and administer high*flo#o'ygen=
Position of comfort=
Esta"lish I, access D monitor cardiacrhythm=
)etermine "lood glucose level=
Consider medication= %ntiemetic
(ransport and reassure patient=
-
7/24/2019 Bled Ppt Ch29
51/62
Copyright 2006 Pearson 29-51
Neoplasms
&efers to the gro#th of a ne# tumour CNS neoplasms have a high mortality
enign %"normal gro#th
Pressure in confined spaces 7cranial vault8
Malignant
Infiltrates healthy tissue 2ikely to metastasi;e
-
7/24/2019 Bled Ppt Ch29
52/62
Copyright 2006 Pearson 29-52
Assessment
Signs and symptoms &ecurring or severe headaches Nausea and vomiting eakness or paralysis 2ack of coordination or unsteady gait )i;;iness. dou"le vision Sei;ures #ithout a prior history of sei;ures
+istory Surgery. chemotherapy. radiation therapy. or
holistic therapy E'perimental treatments
-
7/24/2019 Bled Ppt Ch29
53/62
Copyright 2006 Pearson 29-53
#anagement
Scene safety and SI= Maintain air#ay and administer high*
flo# o'ygen=
Position of comfort= Esta"lish I, access and monitor
cardiac rhythm= Consider medication administration=
%nalgesics. antisei;ure meds. anti*inflammatorymeds
(ransport and reassure patient=
-
7/24/2019 Bled Ppt Ch29
54/62
Copyright 2006 Pearson 29-54
-rain A.scess
%"scess Collection of Pus
%ssessment Signs and symptoms
2ethargy. hemiparesis. nuchal rigidity
+eadache. nausea. vomiting. sei;ures
Management Similar to neoplasm
-
7/24/2019 Bled Ppt Ch29
55/62
Copyright 2006 Pearson 29-55
Degenerative
Disorders %l;heimer$s disease Most fre@uent cause of dementia in the elderly &esults in atrophy of the "rain due to nerve cell
death in the cere"ral corte'
Muscular dystrophy Progressive muscle #eakness and degeneration
of muscle fi"res
Multiple sclerosis -npredicta"le disease resulting from
deterioration of the myelin sheath eakness and sensory loss
-
7/24/2019 Bled Ppt Ch29
56/62
Copyright 2006 Pearson 29-56
Degenerative
Disorders )ystonia Group of disorders
Muscle contractions that cause t#istingrepetitive movements
Parkinson$s disease Chronic progressive motor system disorder
(remor. rigidity. "radykinesia. postural insta"ility
Central pain syndrome &esult of CNS in/ury
Intense. steady "urning pain
-
7/24/2019 Bled Ppt Ch29
57/62
Copyright 2006 Pearson 29-57
Degenerative
Disorders ell$s palsy 9ne*sided facial paralysis
-nkno#n cause
%mytrophic lateral sclerosis )egeneration of motor tracts
eakness. loss of motor control
Myoclonus (emporary. involuntary t#itching of
muscles
-
7/24/2019 Bled Ppt Ch29
58/62
Copyright 2006 Pearson 29-58
Degenerative
Disorders Spina "ifida 9ne or more fetal verte"ra fail to close
Portion of the spine left unprotected
Poliomyelitis Inflammatory. viral disease of CNS tissue
Sometimes results in permanent paralysis
i
-
7/24/2019 Bled Ppt Ch29
59/62
Copyright 2006 Pearson 29-59
Degenerative
Disorders %ssessment 9"tain history=
E'acer"ation of chronic illness or ne#
pro"lem1
Management Special considerations
Mo"ility. communication. respiratory
compromise. and an'iety
- $ P i d
-
7/24/2019 Bled Ppt Ch29
60/62
Copyright 2006 Pearson 29-60
-ac$ Pain and
Nontraumatic SpinalDisorders 2o# ack Pain
Most common "ack pain complaint
%ccounts for greatest amount of lost #ork time
in Canada
Causes
)egeneration or rupture of discs )egeneration or fracture of the verte"ra
Cyst or tumour that impinges on the spine
A t d
-
7/24/2019 Bled Ppt Ch29
61/62
Copyright 2006 Pearson 29-61
Assessment and
#anagement %ssessment Evaluate history
Speed of onset=
&isk factors such as vi"ration or repeated lifting=
)etermine if pain is related to a life*threatening
pro"lem=
Management
Consider c*spine= Immo"ili;e if in dou"t=
Consider analgesics=
S
-
7/24/2019 Bled Ppt Ch29
62/62
Summary
Pathophysiology
General assessment findings Management of nervous system
emergencies