UNIT 5 Alteration in Neurological Function

Alteration in Neurological Function Neuro assessment Symptoms  Complaints o Pain o Seizure o Dizziness/ vertigo o Visual disturbance o Muscle weakness o Sensation changes  Physical findings o Alertness/ LOC o GCS- eye opening, verbal, motor (3-15) o Thought content o Language o Emotional control o Motor function o Sensory perception Neuro diagnostic assessment  VS & ECG  CT- computed tomography scan o CT-A- CT angiography  MRI- magnetic resonance imaging o MR-A- magnetic resonance angiography  Cerebral angiogram  Carotid ultrasound  Echocardiogram  Lumbar puncture  Blood work o Lipids, clotting factors  Antiphospholipid, Factor V, Antithrombin III Acute Disorders of the brain  Cerebrovascular disease & Stroke o Risk factors  Ischemic event  Anticoagulant use  DM  High cholersterol  Oral conttraceptives  Carotid artery disease  Physical inactivity  Obesity  Afib  Smoking  Stress  Hemorrhagic event  Hypertension  Anticoagulation therapy  Obesity  Excess alcohol intake/ drug use  Stress  Trauma o Stroke (CVA)/ TIA findings  Acute/ unilateral  Lethargic  Obtunded  Numbness  Weakness/ hemiparesis  Paralysis/ hemiplegia  Hemianopsia- loss of half of vision field  Agnosia- inability to recognize objects  Dysarthria- difficulty forming words  Apraxia- inability to perform familiar tasks  Ataxia- unsteady gait  Neglect  Aphasia  Expressive  Receptive  Global  Emotional change  Behavioral change  Cognitive change o TIA/RIND  Presents as stroke  Neurological deficits o Motor/sensory/visual  Neuro assessments  GCS/ symptoms  Symptoms resolve  1-2 hours  Ischemia, not infarct  Precursor to ischemic stroke  Diagnosis  Non-con CT  Carotid US, ECG, CT-A  Management  Assess (symptoms, full neuro, GCS)  Identify cause (BP, arteries, spasms)  Decrease risk o Manage HTN/ cholesterol/ CAD  Patient education Ischemia stroke vs. bleeding  Ischemic Stroke o Blockage o Thrombotic/ embolic o Assessment/ nursing  GCS  FAST  NIHSS o Diagnosis  Report any symptoms  LKW or LSN (last know well/ last seen normal)  Non-Con CT  30 minutes  Additional testing (MRI, MR-A, CT-A) o Management  Assess/ stabilize*  tPA*- tissue plasminogen activator  page 2015 chart 67-3  screening/ inclusion/ exclusion (next slide)  3-4.5 hours of symptom onset  Within 60 minutes of arrival in ED  Weight based/ 1 min/ 60 min  Manage complications  Airway/ O2  Cardiac/ ECG  (later) immobility o Bowel/ bladder  UTIs, incontinence, stool softeners (Dulcolax) o TPA V. No TPA management  TPA  BP control (lower)  Bleeding consideration  Expectations  Very frequent VS/ assessment  No tPA/ >24 hours post tPA  Consider alternative medication therapies o Antiplatelets (ASA, clopidogrel) o Anticoagulants (warfarin, heparin, enoxaparin) o Antihypertensives (MD choice) o Statins (rosuvastatin, atorvastatin) o Nursing interventions for ischemic stroke patient  NIHSS  Frequent neuro assessments, frequency depends on treatment  Swallow evaluation  TORBSST, Toronto bedside swallowing screening test  Monitor/ assess/ prevent complications  Exercise, turning, repositioning, mobility, self-care, bowel and bladder, sexual dysfunction  Maintain medication administration regimen  Consult- nutrition, PT/OT, neurology  Monitor cardiac rhythm & vitals (BP, O2)  PRN oxygen therapy, BP controlled based on treatments  Patient and family education  Max functional status  6 months o Nursing diagnosis  Impaired swallowing  Impaired speech  Ineffective health maintenance  Risk for impaired skin/ imbalanced nutrition: less than  Self-care deficit  Constipation  Impaired urinary elimination  Impaired comfort  Sexual dysfunction  Incontinence  Social- interrupted family process  Knowledge deficit  Risk for injury  Ineffective maintenance