This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Structures and Functions of Nervous System Left hemisphere of
cerebrum, lateral surface, showing major lobes and areas of the
brain.
Slide 3
Structures and Functions of Nervous System Structural features
of neurons: dendrites, cell body, and axons.
Slide 4
Structures and Functions of Nervous System Major divisions of
the central nervous system (CNS).
Slide 5
Structures and Functions of Nervous System The cranial nerves
are numbered according to the order in which they leave the
brain.
Slide 6
Structures and Functions of Nervous System Arteries of the head
and neck. Brachiocephalic artery, right common carotid artery,
right subclavian artery, and their branches. The major arteries to
the head are the common carotid and vertebral arteries.
Slide 7
Structures and Functions of Nervous System Arteries at the base
of the brain. The arteries that compose the circle of Willis are
the two anterior cerebral arteries joined to each other by the
anterior communicating cerebral artery and to the posterior
cerebral arteries by the posterior communicating arteries.
Slide 8
Structures and Functions of Nervous System The vertebral column
(three views).
Slide 9
Stroke Stroke occurs when ischemia or hemorrhage into the brain
results in death of brain cells. Also known as a brain attack
Functions are lost or impaired Such as movement, sensation, or
emotions that were controlled by the affected area of the brain
Severity of the loss of function varies according to the location
and extent of the brain involved.
Slide 10
Risk Factors Most effective way to decrease the burden of
stroke is prevention. Risk factors can be divided into non
modifiable and modifiable risks.
Slide 11
Risk Factors Modifiable Hypertension Metabolic syndrome Heart
disease Heavy alcohol consumption Poor diet Drug abuse Sleep apnea
Obesity Physical inactivity Smoking Non modifiable Age Gender Race
Heredity/family history
Slide 12
Types of Stroke Strokes are classified on the basis of
underlying pathophysiologic findings. Ischemic Thrombotic Embolic
Hemorrhagic
Slide 13
Major Types of Stroke
Slide 14
Ischemic Stroke Ischemic strokes result from Inadequate blood
flow to the brain from partial or complete occlusion of an artery
80% of all strokes are ischemic strokes. Ischemic strokes can be
Thrombotic Embolic
Slide 15
Ischemic Stroke Thrombotic stroke Thrombosis occurs in relation
to injury to a blood vessel wall and formation of a blood clot.
Result of thrombosis or narrowing of the blood vessel Most common
cause of stroke Lacunar strokes a stroke from occlusion of a small
penetrating artery with development of a cavity in the place of the
infarcted brain tissue. thrombotic strokes are associated with
hypertension or diabetes mellitus, both of which accelerate
atherosclerosis
Slide 16
Pathogenesis of Atherosclerosis A, Damaged endothelium. B,
Diagram of fatty streak and lipid core formation. C, Diagram of
fibrous plaque. Raised plaques are visible: some are yellow, others
are white. D, Diagram of complicated lesion: thrombus is red,
collagen is blue. Plaque is complicated by red thrombus
deposition.
Slide 17
Pathogenesis of Atherosclerosis Developmental stages: Fatty
streaks Earliest lesions Characterized by lipid-filled smooth
muscle cells Potentially reversible Fibrous plaque Beginning of
progressive changes in the arterial wall Lipoproteins transport
cholesterol and other lipids into the arterial intima. Fatty streak
is covered by collagen, forming a fibrous plaque that appears
grayish or whitish. Result = Narrowing of vessel lumen Complicated
lesion Continued inflammation can result in plaque instability,
ulceration, and rupture. Platelets accumulate and thrombus forms.
Increased narrowing or total occlusion of lumen
Slide 18
Ischemic Stroke Embolic stroke Occurs when an embolus lodges in
and occludes a cerebral artery Results in infarction and edema of
the area supplied by the involved vessel Second most common cause
of stroke Patient with an embolic stroke commonly has a rapid
occurrence of severe clinical symptoms. Onset of embolic stroke is
usually sudden and may or may not be related to activity. Patient
usually remains conscious, although he may have a headache.
Slide 19
Ischemic Stroke Transient ischemic attack Transient episode of
neurologic dysfunction caused by focal brain, spinal cord, or
retinal ischemia, without acute infarction of the brain Symptoms
last
Collaborative Care Acute Care Surgical interventions for stroke
Ischemic stroke MERCI (mechanical embolus removal in cerebral
ischemia) Hemorrhagic stroke Immediate evacuation of
aneurysm-induced hematomas Cerebellar hematomas >3 cm After
stroke has stabilized for 12 to 24 hours, collaborative care shifts
from preserving life to lessening disability and attaining optimal
functioning. Patient may be transferred to a rehabilitation unit,
outpatient therapy, or home carebased rehabilitation.
Slide 54
Merci Embolus Retriever in Cerebral Ischemic Stroke The MERCI
retriever removes blood clots in patients who are experiencing
ischemic strokes. The retriever is a long, thin wire that is
threaded through a catheter into the femoral artery. The wire is
pushed through the end of the catheter up to the carotid artery.
The wire reshapes itself into tiny loops that latch onto the clot
and the clot can then be pulled out. To prevent the clot from
breaking off, a balloon at the end of the catheter inflates to stop
blood flow through the artery.
Slide 55
Clipping and Wrapping of Aneurysms
Slide 56
GDC Coil: Gugleilmi detachable coils A, A coil is used to
occlude an aneurysm. Coils are made of soft, spring like platinum.
The softness of the platinum allows the coil to assume the shape of
irregularly shaped aneurysms while posing little threat of rupture
of the aneurysm. B, A catheter is inserted through an introducer
(small tube) in an artery in the leg. The catheter is threaded up
to the cerebral blood vessels. C, Platinum coils attached to a thin
wire are inserted into the catheter and then placed in the aneurysm
until the aneurysm is filled with coils. Packing the aneurysm with
coils prevents the blood from circulating through the aneurysm,
reducing the risk of rupture.
Slide 57
Nursing Management Nursing Assessment If the patient is stable,
obtain Description of the current illness with attention to initial
symptoms History of similar symptoms previously experienced Current
medications History of risk factors and other illnesses Family
history of stroke or cardiovascular disease
Slide 58
Nursing Management Nursing Assessment Comprehensive neuro
examination Level of consciousness Cognition Motor abilities
Cranial nerve function Sensation Deep tendon reflexes
Nursing Management Planning Goals are that the patient will
Maintain stable or improved level of consciousness Attain maximum
physical functioning Maximize self-care abilities and skills
Maintain stable body functions Maximize communication abilities.
Avoid complications of stroke. Maintain effective personal and
family coping.
Slide 61
Nursing Management Nursing Implementation Health promotion To
reduce the incidence of stroke, the nurse should focus teaching
toward stroke prevention. Particularly in persons with known risk
factors Education about hypertension control and adherence to
medication Teaching patients and families about Early symptoms
Stroke TIA When to seek health care for symptoms
Slide 62
Nursing Management Nursing Implementation Respiratory system
Management of the respiratory system is a nursing priority. Risk
for atelectasis Risk for aspiration pneumonia Risks for airway
obstruction May require tracheal intubation and mechanical
ventilation
Slide 63
Nursing Management Nursing Implementation Neurologic system
Monitor closely to detect changes suggesting Extension of the
stroke ICP Vasospasm Recovery from stroke symptoms Table 58-8, page
1472 the NIH Stroke Scale (NIHSS)national institutes of health
stroke scale.
Slide 64
Nursing Management: Nursing Implementation Cardiovascular
system Goals aimed at maintaining homeostasis Many patients with
stroke have decreased cardiac reserves from the secondary diagnoses
of cardiac disease. Monitoring vital signs frequently Monitoring
cardiac rhythms Calculating intake and output, noting imbalances
Regulating IV infusions Adjusting fluid intake to the individual
needs of the patient Monitoring lung sounds for crackles and
rhonchi (pulmonary congestion) Monitoring heart sounds for murmurs
After stroke, patient is at risk for deep vein thrombosis. Related
to immobility, loss of venous tone, and muscle pumping in leg Most
effective prevention is keeping the patient moving.
Slide 65
Nursing Management Nursing Implementation Musculoskeletal
system Goal is to maintain optimal function. prevention of joint
contractures and muscular atrophy range-of-motion exercises and
positioning are important. Paralyzed or weak side needs special
attention when positioned. Avoidance of pulling the patient by the
arm to avoid shoulder displacement Hand splints to reduce
spasticity
Slide 66
Nursing Management Nursing Implementation Integumentary system
Susceptible to breakdown related to Loss of sensation Decreased
circulation Immobility Compounded by patient age, poor nutrition,
dehydration, edema, and incontinence Pressure relief by position
changes, special mattresses, or wheelchair cushions Good skin
hygiene Early mobility Position patient on the weak or paralyzed
side for only 30 minutes.
Slide 67
Nursing Management Nursing Implementation Gastrointestinal
system Stress of illness. Constipation. Patients may be placed on
stool softeners. Physical activity promotes bowel function. Urinary
system promote normal bladder function. Avoid the use of indwelling
catheters.
Slide 68
Nursing Management Nursing Implementation Nutrition Nutritional
needs require quick assessment and treatment. May initially receive
IV infusions to maintain fluid and electrolyte balance May require
nutritional support First feeding should be approached carefully.
Test swallowing, chewing, gag reflex, and pocketing before
beginning oral feeding. Feedings must be followed by oral
hygiene.
Slide 69
Nursing Management Nursing Implementation Communication Nurses
role in meeting psychologic needs of the patient is primarily
supportive. Patient is assessed for both the ability to speak and
the ability to understand. Speak slowly and calmly, using simple
words or sentences. Gestures may be used to support verbal
cues.
Slide 70
Nursing Management Nursing Implementation Sensory-perceptual
alterations Blindness in same half of each visual field is a common
problem after stroke. Known as homonymous hemi anopsia A neglect
syndrome (decrease in safety, increase risk for injury) Other
visual problems may include Diplopia (double vision) Ptosis
(drooping eyelid)
Slide 71
Homonymous Hemianopsia (Food on left side is not seen) Spatial
and perceptual deficits in stroke. Perception of a patient with
homonymous hemi anopsia Shows that food on the left side is not
seen and thus is ignored.
Slide 72
Nursing Management Nursing Implementation Coping Affects family
Emotionally Socially Financially Changing roles and
responsibilities Explain What has happened Diagnosis Therapeutic
procedures Should be clear and understood by patient. social
services referral is often helpful.
Slide 73
Nursing Management: Nursing Implementation Ambulatory and home
care Patient is usually discharged to home, an intermediate or
long-term care facility, or a rehabilitation facility. discharge
planning with the patient and family starts early in the
hospitalization and promotes a smooth transition from one care
setting to another. prepare the patient and family for discharge
through Education Demonstration Practice Evaluation of self-care
skills Rehabilitation to promote optimal functioning. Physical,
mental, and social well-being
Slide 74
Loss of Postural Stability Loss of postural stability is common
after stroke. The patient is unable to sit upright and tends to
fall sideways. Appropriate support with pillows or cushions should
be provided.
Slide 75
Nursing Management Nursing Implementation Ambulatory and home
care (contd) Musculoskeletal interventions Balance training
Transferring from bed to chair Bobath method Therapists and nurses
use the Bobath approach to encourage normal muscle tone, normal
movement, and promotion of bilateral function of the body. An
example is to have the patient transfer into the wheelchair using
the weak or paralyzed side and the stronger side to facilitate more
bilateral functioning. CIMT is a more recent approach.
Constraint-induced movement therapy (CIMT) encourages the patient
to use the weakened extremity by restricting movement of the normal
extremity. This approach is challenging, and the ability of
patients to comply may limit its use.
Slide 76
Nursing Management Nursing Implementation Ambulatory and home
care (contd) After acute phase, a dietitian can assist in
determining appropriate daily caloric intake based on the patients
Size Weight Activity level Nurse and speech therapist must assess
ability of patient to swallow solids and fluids and must adjust the
diet appropriately. Inability to feed oneself can be frustrating
and may result in malnutrition and dehydration.
Slide 77
Assistive Devices for Eating A, The curved fork fits over the
hand. The rounded plate helps keep food on the plate. Special grips
are helpful for some persons. B, Knives with rounded blades are
rocked back and forth to cut food. The person does not need a fork
in one hand and a knife in the other. C, Plate guards help keep
food on the plate. D, Cup with special handle.
Slide 78
Nursing Management Nursing Implementation Implement a bowel
management program for problems with Bowel control Constipation
Incontinence High-fiber diet and adequate fluid intake
Slide 79
Nursing Management Nursing Implementation Patients with stroke
on right side of brain Difficulty in judging position, distance,
and movement Impulsive, impatient, and denying problems related to
stroke Respond best to directions given verbally Patients with
stroke on left side of brain Slower in organization and performance
of tasks Impaired spatial discrimination Have fearful, anxious
response to stroke Respond well to nonverbal cues
Slide 80
Nursing Management Nursing Implementation Interventions for
atypical emotional response Distract the patient. Explain that
emotional outbursts may occur. Maintain a calm environment. Avoid
shaming. Patients with a stroke may be coping with many losses
Often go through the process of grief Some patients experience
long-term depression Support communication between the patient and
family. Discuss lifestyle changes. Discuss changing roles within
the family. Be an active listener. Include family in goal planning
and patient care. Support family conferences.
Slide 81
Nursing Management Nursing Implementation Family members must
cope with Recognition of behavioral changes resulting from
neurologic deficits that are not changeable Responses to multiple
losses by both the patient and the family. Behaviors that may have
been reinforced during the early stages of stroke as continued
dependency Stroke support groups within rehab facilities and
community are helpful. Mutual sharing Education Coping
Understanding
Slide 82
Nursing Management Nursing Implementation Speech,
comprehension, and language deficits are the most difficult problem
for the patient and family. Speech therapists can assess and
formulate a plan to support communication. Nurses can be a role
model for patients with aphasia.
Slide 83
A patient with right-sided paresthesias and hemiparesis is
hospitalized and diagnosed with a thrombotic stroke. Over the next
72 hours, the nurse plans care with the knowledge that the patient:
1. Is ready for aggressive rehabilitation. 2. Will show gradual
improvement of the initial neurologic deficits. 3. May show signs
of deteriorating neurologic function as cerebral edema increases.
4. Should not be turned or exercised to prevent extension of the
thrombus and increased neurologic deficits. Question #1
Slide 84
While performing health screening at a health fair, the nurse
identifies which of the following individuals at greatest risk for
experiencing a stroke? 1. A 46-year-old white female with
hypertension and oral contraceptive use for 10 years. 2. A
58-year-old white male salesman who has a total cholesterol level
of 285 mg/dL. 3. A 42-year-old African American female with
diabetes mellitus who has smoked for 30 years. 4. A 62-year-old
African American male with hypertension who is 35 pounds
overweight. Question #2
Slide 85
Answer #2 Answer: 4 Rationale: Option 4: This individual has
five risk factors: age, African American, male, hypertension, and
overweight. Option 1: This individual has two risk factors:
hypertension and oral contraception use. Option 2: This individual
has two risk factors: male and increased cholesterol level. Option
3: This individual has three risk factors: African American,
diabetes mellitus, and smoking.
Slide 86
Answer #2 Nonmodifiable risk factors include age, gender,
ethnicity/race, and family history/heredity. Stroke risk increases
with age, doubling each decade after 55 years of age. Two thirds of
all strokes occur in individuals >65 years. Strokes are more
common in men, but more women die from stroke than men. Because
women tend to live longer than men, they have more opportunity to
suffer a stroke. African Americans have a higher incidence of
stroke, as well as a higher death rate from stroke than whites. A
family history of stroke, a prior transient ischemic attack, or a
prior stroke also increases the risk of stroke. Modifiable risk
factors are those that can potentially be altered through lifestyle
changes and medical treatment, thus reducing the risk of stroke.
Modifiable risk factors include hypertension, increased
cholesterol, elevated blood lipid levels, heart disease, smoking,
excessive alcohol consumption, obesity, sleep apnea, metabolic
syndrome, lack of physical exercise, poor diet, and drug abuse.
Early forms of birth control pills that contained high levels of
progestin and estrogen increased a womans chance of experiencing a
stroke, especially if she also smoked heavily. Newer, low- dose
oral contraceptives have lower risks for stroke except in those
individuals who are hypertensive and smoke. Other conditions that
may increase stroke risk include migraine headaches, inflammatory
conditions. Sickle cell disease is another known risk factor for
stroke.
Slide 87
A patient with a stroke has dysphagia. Before allowing the
patient to eat, which of the following actions should the nurse
take first? 1. Check the patients gag reflex. 2. Request a soft
diet with no liquids. 3. Place the patient in high-Fowlers
position. 4. Test the patients ability to swallow with a small
amount of water. Question #3
Slide 88
Answer #3 Answer: 1 Rationale: Before initiation of feeding,
assess the gag reflex by gently stimulating the back of the throat
with a tongue blade. If a gag reflex is present, the patient will
gag spontaneously. If it is absent, defer the feeding, and begin
exercises to stimulate swallowing. To assess swallowing ability,
elevate the head of the bed to an upright position (unless
contraindicated), and give the patient a small amount of crushed
ice or ice water to swallow.
Slide 89
Case Study 73-year-old man was admitted to the hospital with
right-sided paresis and expressive aphasia. He had been
experiencing periods of confusion, right-sided weakness, and
slurred speech for the past several weeks. These episodes were
brief and resolved completely within an hour. No treatments were
sought.
Slide 90
Case Study 1 History of COPD, MI 15 years prior, and atrial
fibrillation Over the first 24 hours of admission, his neurologic
deficits gradually progressed. By day 2 of admission, he had
right-sided flaccid paralysis and global aphasia.
Slide 91
Discussion Questions Case Study 1. What is probably the cause
of his stroke? 2. Could this stroke have been prevented?
Slide 92
Discussion Questions Case Study 3. What are the priority
nursing interventions for him? 4. What teaching will you need to do
for him and his family?