You are on page 1of 155

Medical-Surgical Nursing

A Review of Neurologic
Concepts

Nurse Licensure Examination
Review
Key to Success!
 Confidence
 Test taking strategies
 Ample test preparation and study
habits
 Review of frequent board
examination topics
 Focus on your goals
 Above all- PRAYERS
Outline of Our Review
 Brief review of Anatomy and Physiology
 Application of the Nursing process in the
approach of neurologic problems:
 ASSESSMENT – relevant techniques and lab
procedures
 DIAGNOSIS
 PLANNING
 IMPLEMENTATION
 EVALUATION
Outline of the review

 Trauma and related accidents
 Traumatic brain injury
 Spinal cord injury
 Cerebrovascular Accidents
Outline of the review
 Degenerative disorders-
demyelinating
 Multiple sclerosis
 Guillain-Barre’ syndrome
Degenerative disorders-
NON-demyelinating
 Alzheimer’s disease
 Parkinson’s disease
Outline of the review
 Motor dysfunction- CNS
 Epilepsy
 Motor dysfunction- cranial nerve
 Bell’s palsy
 Trigeminal neuralgia
 Motor dysfunction- peripheral
 Myasthenia gravis
Outline of the review
 Infectious Disease
 Meningitis
 Brain abscess
 Encephalitis
 Neoplastic disease
IMPLEMENTATION PHASE
 Increased Intracranial pressure
 Altered level of consciousness
 Seizures
 Autonomic
dysreflexia/hyperreflexia
 Spinal shock
 Cognitive impairment
 Bowel incontinence
IMPLEMENTATION PHASE
 Impaired physical mobility
 Impaired swallowing
 Disturbed sensory perception
Anatomy and Physiology
 Gross anatomy
 The nervous system is divided into
the central and peripheral nervous
system
 The Central nervous system consists
of the BRAIN and the Spinal Cord
 The peripheral nervous system
consists of the Spinal nerves and the
cranial nerves
Anatomy and Physiology
The brain is composed of lobes-
 Frontal lobe- personality, memory

and motor function
 Parietal lobe- sensory function

 Temporal lobe- hearing and

olfaction and emotion by the limbic
system
 Occipital lobe- vision
Anatomy and Physiology
 The cerebellum is involved in
coordination and equilibrium
 The diencephalon consists of the :
 Thalamus- the relay center of all
sensory input
 Hypothalamus- center for endocrine
regulation, sleep, temperature, thirst,
sexual arousal and emotional
response
Anatomy and Physiology
 The brainstem is composed of the:
 MIDBRAIN- for visual and auditory
reflexes
 Pons- respiratory apneustic center,
nucleus of cranial nerves- 5,6,7,8
 Medulla oblongata- respiratory and
cardiovascular centers, nucleus of
cranial nerves 9,10,11,12
ASSESSMENT OF THE
NEUROLOGIC SYSTEM
 HISTORY
 A confused client becomes an
unreliable source of history
ASSESSMENT OF THE
NEUROLOGIC SYSTEM
PHYSICAL EXAMINATION
 5 categories:
 1. Cerebral function- LOC, mental
status
 2. Cranial nerves
 3. Motor function
 4. Sensory function
 5. Reflexes
ASSESSMENT OF THE
NEUROLOGIC SYSTEM
Neuro Check
 Level of consciousness

 Pupillary size and response

 Verbal responsiveness

 Motor responsiveness

 Vital signs
CEREBRAL FUCTION
 Assess the degree of
wakefulness/alertness
 Note the intensity of stimulus to
cause a response
 Apply a painful stimulus over the
nailbeds with a blunt instrument
 Ask questions to assess orientation
to person, place and time
Cerebral function
 Utilize the Glasgow Coma Scale
 An easy method of describing
mental status and abnormality
detection
 Tests 3 areas- eye opening, verbal
response and motor response
 Scores are evaluated- range from
3-15
 No ZERO score
Glasgow Coma Scale

Glasgow Coma Score
 Eye Opening (E)

 Verbal Response (V)

 Motor Response (M)
Glasgow Coma Scale
Glasgow Coma Score
 Eye Opening (E)

4=Spontaneous
3=To voice
2=To pain
1=None (No response)
Glasgow Coma Scale
Glasgow Coma Score
 Verbal Response (V)

5=Normal/oriented
4=Disoriented/CONFUSED
3=Words, but incoherent/ inappropriate
2=Incomprehensible/mumbled words
1=None
Glasgow Coma Scale
Glasgow Coma Score
 Motor Response (M)

6=Normal- obeys command
5=Localizes pain
4=Withdraws to pain (Flexion)
3=Decorticate posture
2=Decerebrate posture
1=None (flaccid)
Cranial Nerve Function:
Cranial Nerve 1- Olfactory
 Check first for the patency of the
nose
 Instruct to close the eyes
 Occlude one nostrils at a time
 Hold familiar substance and asks
for the identification
 Repeat with the other nostrils
 PROBLEM- ANOSMIA- “loss of
Cranial Nerve Function:
Cranial Nerve 2- Optic
 Check the visual acuity with the
use of the Snellen chart
 Check for visual field by
confrontation test
 Check for pupillary reflex- direct
and consensual
 Fundoscopy to check for
papilledema
Snellen chart
Cranial Nerve Function:
Cranial Nerve 3, 4 and 6
 Assess simultaneously the
movement of the extra-ocular
muscles
Deviations:
 Opthalmoplegia- inability to move

the eye in a direction
 Diplopia- complaint of double

vision
Cranial Nerve Function:
Cranial Nerve 5 -trigeminal
 Sensory portion- assess for
sensation of the facial skin
 Motor portion- assess the muscles
of mastication
 Assess corneal reflex
Cranial Nerve Function:
Cranial Nerve 7 -facial
 Sensory portion- prepare salt,
sugar, vinegar and quinine. Place
each substance in the anterior two
thirds of the tongue, rinsing the
mouth with water
 Motor portion- ask the client to
make facial expressions, ask to
forcefully close the eyelids
Cranial Nerve Function:
Cranial Nerve 8- vestibulo-
auditory
 Test patient’s hearing acuity
 Observe for nystagmus and
disturbed balance
Cranial Nerve Function:
Cranial Nerve 9-
glossopharyngeal
 Together with Cranial nerve 10 –
vagus
 Assess for gag reflex
 Watch the soft palate rising after
instructing the client to say “AH”
 The posterior one-third of the
tongue is supplied by the
glossopharyngeal nerve
Cranial Nerve Function:
Cranial Nerve 11-
accessory
 Press down the patient’s shoulder
while he attempts to shrug against
resistance
Cranial Nerve Function:
Cranial Nerve 12-
hypoglossal
 Ask patient to protrude the tongue
and note for symmetry
ASSESS Motor function
 Assess muscle tone and strength
by asking patient to flex or extend
the extremities while the examiner
places resistance
 Grading of muscle strength
Assessing the motor
function of the cerebellum
 Test for balance- heel to toe
 Test for coordination- rapid
alternating movements and finger
to nose test

 ROMBERG’s is actually a test for
the posterior spinothalamic tract
Assessing the motor
function of the brainstem
Test for the Oculocephalic reflex-
doll’s eye
 Normal response- eyes appear to

move opposite to the movement of
the head
 Abnormal- eyes move in the same

direction
Assessing the motor
function of the brainstem
Test for the Oculovestibular reflex
 Slowly irrigate the ear with cold

water and warm water
 Normal response- cOld- OppOsite,

wArM- sAMe
Assessing the sensory
function
 Evaluate symmetric areas of the body
 Ask the patient to close the eyes while
testing
 Use of test tubes with cold and warm
water
 Use blunt and sharp objects
 Use wisp of cotton
 Ask to identify objects placed on the
hands
 Test for sense of position
Assessing the reflexes
 Deep tendon reflexes
 Biceps
 Triceps
 Brachioradialis
 Patellar
 Assessing the sensory function
Achilles
Assessing the reflexes
 Superficial reflexes
 Abdominal
 Cremasteric
 Anal
 Pathologic reflex
 Babinski- stroke the lateral aspect of
the soles doing an inverted “J”
 (+)- DORSIFLEXION of the Big toe
with fanning out of the little toes
Grading of reflexes
Deep tendon reflex
 0- absent

 + present but diminished

 ++ normal

 +++ increased

 ++++ hyperactive or clonic

Superficial reflex
 0 absent

 +present
DIAGNOSTIC TESTS
 EEG
 Withhold medications that may
interfere with the results-
anticonvulsants, sedatives and
stimulants
 Wash hair thoroughly before
procedure
DIAGNOSTIC TESTS
CT scan
 With radiation risk

 If contrast medium will be used-

ensure consent, assess for
allergies to dyes and iodine or
seafood, flushing and metallic
taste are expected as the dye is
injected
DIAGNOSTIC TESTS
MRI
 Uses magnetic waves

 Patients with pacemakers,

orthopedic metal prosthesis and
implanted metal devices cannot
undergo this procedure
DIAGNOSTIC TESTS
Cerebral arteriography
 Note allergies to dyes, iodine and

seafood
 Ensure consent

 Keep patient at rest after

procedure
 Maintain pressure dressing or

sandbag over punctured site
DIAGNOSTIC TESTS
Lumbar puncture
 Ensure consent, determine ability

to lie still
 Contraindicated in patients with

increased ICP
 Keep flat on bed after procedure

 Increase fluid intake after

procedure
Increased Intracranial
pressure
Intracranial pressure more than 15 mmHg
Brunner= Normal intracranial pressure 10-20
mmHg
Causes:
 Head injury

 Stroke

 Inflammatory lesions

 Brain tumor

 Surgical complications
Increased Intracranial
pressure
Pathophysiology
 The cranium only contains the brain

substance, the CSF and the blood/blood
vessels
 MONRO-KELLIE hypothesis- an increase

in any one of the components causes a
change in the volume of the other
 Any increase or alteration in these

structures will cause increased ICP
Increased Intracranial
pressure
Pathophysiology
 Compensatory mechanisms:

 1. Increased CSF absorption

 2. Blood shunting

 3. Decreased CSF production
Increased Intracranial
pressure
Pathophysiology
Decompensatory mechanisms:
 1. Decreased cerebral perfusion

 2. Decreased PO2 leading to brain

hypoxia
 3. Cerebral edema

 4. Brain herniation
Decreased cerebral blood
flow
 Vasomotor reflexes are stimulated
initially slow bounding pulses
 Increased concentration of carbon
dioxide will cause VASODILATION
 increased flow increased ICP
Cerebral Edema
 Abnormal accumulation of fluid in
the intracellular space,
extracellular space or both.
Herniation
 Results from an excessive increase
in ICP when the pressure builds up
and the brain tissue presses down
on the brain stem
Cerebral response to
increased ICP
1. Steady perfusion up to 40 mmHg
2. Cushing’s response
 Vasomotor center triggers rise in BP
to increase ICP
 Sympathetic response is increased
BP but the heart rate is SLOW
 Respiration becomes SLOW
Increased Intracranial
pressure
CLINICAL MANIFESTATIONS
Early manifestations:
 Changes in the LOC- usually

the earliest
 Pupillary changes- fixed, slowed

response
 Headache

 vomiting
Increased Intracranial
pressure
CLINICAL MANIFESTATIONS
late manifestations:
 Cushing reflex- systolic

hypertension, bradycardia and
wide pulse pressure
 bradypnea

 Hyperthermia

 Abnormal posturing
Increased Intracranial
pressure
Nursing interventions:
Maintain patent airway
 1. Elevate the head of the bed 15-

30 degrees- to promote venous
drainage
 2. assists in administering 100%

oxygen or controlled
hyperventilation- to reduce the CO2
blood levelsconstricts blood vessels
Increased Intracranial
pressure
Nursing interventions
 3. Administer prescribed

medications- usually
 Mannitol- to produce negative fluid
balance
 corticosteroid- to reduce edema
 anticonvulsants-p to prevent seizures
Increased Intracranial
pressure
Nursing interventions
 4. Reduce environmental stimuli

 5. Avoid activities that can

increase ICP like valsalva,
coughing, shivering, and vigorous
suctioning
Increased Intracranial
pressure
 Nursing interventions
 6. Keep head on a neutral position.
ACOID- extreme flexion, valsalva
 7. monitor for secondary
complications
 Diabetes insipidus- output of >200
mL/hr
 SIADH
Altered level of
consciousness
 It is a function and symptom of
multiple pathophysiologic
phenomena
 Causes: head injury, toxicity and
metabolic derangement
 Disruption in the neuronal
transmission results to improper
function
Altered level of
consciousness
Assessment
 Orientation to time, place and

person
 Motor function

 Decerebrate
 Decorticate
 Sensory function
Altered level of
consciousness
 Patient is not oriented
 Patient does not follow command
 Patient needs persistent stimuli to
be awake

 COMA= clinical state of
unconsciousness where patient is
NOT aware of self and environment
Altered level of
consciousness
 Etiologic Factors
2. Head injury
3. Stroke
4. Drug overdose
5. Alcoholic intoxication
6. Diabetic ketoacidosis
7. Hepatic failure
Altered level of
consciousness
 ASSESSMENT
2. Behavioral changes initially
3. Pupils are slowly reactive
4. Then , patient becomes
unresponsive and pupils become
fixed dilated
Glasgow Coma Scale is utilized
Altered level of
consciousness
Nursing Intervention
1. Maintain patent airway
 Elevate the head of the bed to 30

degrees
 Suctioning

2. Protect the patient
 Pad side rails

 Prevent injury from equipments,

restraints and etc.
Altered level of
consciousness
Nursing Intervention
3. Maintain fluid and nutritional
balance
 Input an output monitoring

 IVF therapy

 Feeding through NGT

4. Provide mouth care
 Cleansing and rinsing of mouth

 Petrolatum on the lips
Altered level of
consciousness
Nursing Intervention
5. Maintain skin integrity
 Regular turning every 2 hours

 30 degrees bed elevation

 Maintain correct body alignment by

using trochanter rolls, foot board
6. Preserve corneal integrity
 Use of artificial tears every 2 hours
Altered level of
consciousness
Nursing Intervention
7. Achieve thermoregulation
 Minimum amount of beddings

 Rectal or tympanic temperature

 Administer acetaminophen as

prescribed
8. Prevent urinary retention
 Use of intermittent catheterization
Altered level of
consciousness
Nursing Intervention
9. Promote bowel function
 High fiber diet

 Stool softeners and suppository

10. Provide sensory stimulation
 Touch and communication

 Frequent reorientation
SEIZURES
 Episodes of abnormal motor,
sensory, autonomic activity
resulting from sudden excessive
discharge from cerebral neurons
 A part or all of the brain may be
involved
SEIZURES
 PATHOPHYSIOLOGY
 An electrical disturbance in the
nerve cells in one brain section
EMITS ELECTRICAL IMPULSES
excessively
SEIZURES
 ETIOLOGIC FACTORS
2. Idiopathic
3. Fever
4. Head injury
5. CNS infection
6. Metabolic and toxic conditions
SEIZURES
Nursing Interventions
During seizure
 1. remove harmful objects from the

patient’s surrounding
 2. ease the client to the floor

 3. protect the head with pillows

 4. Observe and note for the duration,

parts of body affected, behaviors
before and after the seizure
SEIZURES
Nursing Interventions
During seizure
 5. loosen constrictive clothing

 6. DO NOT restrain, or attempt

to place tongue blade or insert
oral airway
SEIZURES
Nursing Interventions
POST seizure
 1. place patient to the side to drain

secretions and prevent aspiration
 2. help re-orient the patient if

confused
 3. provide care if patient became

incontinent during the seizure
attack
 4. stress importance of medication

regimen
headache
 Cephalgia
 Primary headache- no organic
cause
 Secondary headache- with organic
cause
 Migraine headache- periodic
attacks of headache due to
vascular disturbance
 Tension headache-the most
common type- due to muscle
headache
 Migraine
2. Prodrome stage
3. Aura phase
4. Headache
5. Recovery phase
headache
Nursing Interventions
 1. Avoid precipitating factors

 2. modify lifestyle

 3. relieve pain by pharmacologic

measures
 Beta-blockers
 Serotonin antagonists- “triptan"
Autonomic
Dysreflexia/hyperreflexia
 Seen commonly in spinal cord
injury above T6
 An exaggerated response by the
autonomic system resulting from
various stimuli most commonly
distended bladder, impacted feces,
pain, skin irritation
Autonomic
Dysreflexia/hyperreflexia
 Clinical MANIFESTATIONS
 1. Hypertension
 2. Bradycardia
 3. severe pounding headache
 4. diaphoresis
 5. nausea and nasal congestion
Autonomic
Dysreflexia/hyperreflexia
NURSING INTERVENTIONS
 1. Elevate the head of the bed

immediately
 2. Check for bladder distention and

empty bladder with urinary catheter
 3. Check for Fecal impaction and other

triggering factors like skin irritation,
pressure ulcer
 4. Administer antihypertensive

medications- usually hydralazine
Spinal Shock
Pathophysiology
 The sudden depression of reflex

activity in the spinal cord below
the level of injury
 The muscles below the lesion are

flaccid, the skin without sensation
and the reflexes are absent
including bowel and bladder
functions
Spinal Shock
 Nursing Interventions
 1. Assist in chest physical therapy
 2. Manage potential complication-
DVT
Cognitive Impairment
Nursing Interventions
2. Assist or encourage the patient to
use eyeglass, hearing aid or
assistive devices
3. Reorient the patient by calling his
name frequently
4. Provide background information
as to date, time, place,
environment
Cognitive Impairment
Nursing Interventions
4. Use large signs as visual cues
5. Post patient's photo on the door
6. Encourage family members to
bring personal articles and place
them in the same area
Bowel and Bladder
incontinence
 Establish a regular pattern for
bowel care
 Maintain a dietary intake. Avoid
foods that can cause excessive gas
production
CONGENITAL DISORDERS:
Hydrocephalus
 Excessive CSF accumulation in the
brain’s ventricular system
 In infants, head enlarges
 In children and adults- brain
compression
CONGENITAL DISORDERS:
Hydrocephalus
 Non-communicating hydrocephalus
results from CSF outflow
obstruction
 Communicating hydrocephalus
results from faulty absorption or
increased CSF production
CONGENITAL DISORDERS:
Hydrocephalus
 Assessment
 1. irritability
 2. change in LOC
 3. infants- enlargement of the head,
thin scalp skin
 4. sunset eyes
CONGENITAL DISORDERS:
Hydrocephalus
 DIAGNOSTIC TESTS
 1. Skull x-ray
 2. ventriculography
CONGENITAL DISORDERS:
Hydrocephalus
 Nursing Intervention
 1. monitor neurologic status
 2. teach parents to watch for signs
of shunt malfunction, and periodic
surgery to lengthen the shunt as
child grows
CONGENITAL DISORDER-
Spinal cord defects
 1. Spina bifida occulta- incomplete
closure of one or more vertebrae
without protrusion of the spinal cord or
meninges
 2. Spina bifida with meningocele- a sac
contains meninges and CSF
 3. Spina bifida with meningomyelocele-
a sac contains spinal cord substance,
meninges and CSF
CONGENITAL DISORDER:
Spinal cord defects
 Causes
 1. environmental factors
 2. radiation
 3. folic acid deficiency in a
pregnant woman
 4. possibly genetic
CONGENITAL DISORDER:
Spinal cord defects
 ASSESSMENT
 1. a dimple or tuft of hair in the
vertebral area
 2. external sac
 DIAGNOSIS
 1. Spinal x-ray
 2. myelography
CONGENITAL DISORDER:
Spinal cord defects
 NURSING INTERVENTION
 1. cover the defect with sterile
dressing moistened with sterile
saline
 2. position the patient on prone or
side to protect the fragile sac
 3. place a diaper under the infant
and change it often
CONGENITAL DISORDER:
Spinal cord defects
 NURSING INTERVENTION
 4. avoid the use of lotion
 5. avoid frequent handling
 6. Measure the child’s head
circumference daily
 7. check anal reflex
 8. support family members
 9. prepare the parents for the possible
outcome of eh defect
CONGENITAL DISORDER:
Spinal cord defects
 NURSING INTERVENTION
 10. Post-operative care
 Position on abdomen
 Check post-operative dressings
 Place infant’s hips in abduction and feet
in neutral position
 Monitor intake and output
 Check for urine retention
 Asess infant frequently as he recovers
from the surgery
Traumatic brain injury
1. CONCUSSION
 Involves jarring of head without

tissue injury
 Temporary loss of neurologic

function lasting fore a few minutes
to hours
Traumatic brain injury
2. CONTUSION
 Involves structural damage

 The patient becomes unconscious

for hours
Traumatic brain injury
3. Diffuse Axonal injury
 Involves widespread damage to

the neurons
 Patient has decerebrate and

decorticate posture
Traumatic brain injury
4. Intracranial hemorrhage
Epidural Hematoma- blood collects
in the epidural space between
skull and dura mater. Usually due
to laceration of the middle
meningeal artery
Symptoms develop rapidly
Traumatic brain injury
4. Intracranial hemorrhage
Subdural hematoma- a collection of
blood between the dura and the
arachnoid mater caused by
trauma. This is usually due to
tear of dural sinuses or dural
venous vessels
Symptoms usually develop slowly
Traumatic brain injury
4. Intracranial hemorrhage
Intracerebral Hemorrhage and hematoma-
bleeding into the substance of the
brain resulting from trauma,
hypertensive rupture of aneurysm,
coagulopahties, vascular abnormalities
Symptoms develop insidiously,
beginning with severe headache and
neurologic deficits
Traumatic brain injury
MANIFESTATIONS
 1. Altered LOC

 2. CSF otorrhea

 3. CSF rhinorrhea

 4. Racoon eyes and battle sign

 HALO SIGN- blood stain surrounded
by a yellowish stain
Traumatic brain injury
NURSING MANAGEMENT
1. Monitor for declining LOC- use
of Glasgow
2. Maintain patent airway
 Elevate bed, suction prn,

monitor ABG
Traumatic brain injury
NURSING MANAGEMENT
3. Monitor F and E balance
 Daily weights

 IVF therapy

 Monitor possible development

of DI and SIADH
Traumatic brain injury
4. Provide adequate nutrition
5. Prevent injury
 Use padded side rails

 Minimize environmental stimuli

 Assess bladder

 Consider the use of

intermittent catheter
Traumatic brain injury
6. Maintain skin integrity
 Prolonged immobility will likely

cause skin breakdown
 Turn patient every 2 hours

 Provide skin care every 4

hours
 Avoid friction and shear forces
Traumatic brain injury
7. Monitor potential
complications
 Increased ICP

 Post-traumatic seizures

 Impaired ventilation
Spinal cord injury
 The most frequent vertebrae – C5-
C7, T12 and L1
 Concussion
 Contusion
 Compression
 Transection
Spinal cord injury
Clinical manifestations
 1. Paraplegia

 2. quadriplegia

 3. spinal shock
Spinal cord injury
 DIAGNOSTIC TEST
 Spinal x-ray
 CT scan
 MRI
Spinal cord injury
 EMERGENCY MANAGEMENT
 A-B-C
 Immobilization
 Immediate transfer to tertiary
facility
Spinal cord injury
NURSING INTERVENTION
 1. Promote adequate breathing

and airway clearance
 2. Improve mobility and proper

body alignment
 3. Promote adaptation to sensory

and perceptual alterations
 4. Maintain skin integrity
Spinal cord injury
 5. Maintain urinary elimination
 6. Improve bowel function
 7. Provide Comfort measures
 8. Monitor and manage
complications
 Thromboplebhitis
 Orthostaic hypotension
 Spinal shock
 Autonomic dysreflexia
Spinal cord injury
 9. Assists with surgical reduction
and stabilization of cervical
vertebral column
CEREBROVASCULAR
ACCIDENTS
 An umbrella term that
refers to any functional
abnormality of the CNS
related to disrupted blood
supply
CEREBROVASCULAR
ACCIDENTS
 Can be divided into two major
categories
 1. Ischemic stroke- caused by
thrombus and embolus
 2. Hemorrhagic stroke- caused
commonly by hypertensive
bleeding
CEREBROVASCULAR
ACCIDENTS
The stroke continuum
 1. TIA- transient ischemic attack,

temporary neurologic loss less
than 24 hours duration
 2. Reversible Neurologic deficits

 3. Stroke in evolution

 4. Completed stroke
General manifestations
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
 There is disruption of the cerebral
blood flow due to obstruction by
embolus or thrombus
RISKS FACTORS
Non-modifiable Modifiable
 Advanced age  Hypertension

 Gender  Cardio disease

 race  Obesity

 Smoking

 Diabetes mellitus

 hypercholesterolemia
Pathophysiology of
ischemic stroke
 Disruption of blood supply
 Anaerobic metabolism ensues
 Decreased ATP production leads to
impaired membrane function
 Cellular injury and death can occur
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
 DIAGNOSTIC test
 1. CT scan
 2. MRI
 3. Angiography
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
CLINICAL MANIFESTATIONS
 1. Numbness or weakness
 2. confusion or change of LOC
 3. motor and speech
difficulties
 4. Visual disturbance
 5. Severe headache
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
Motor Loss
 Hemiplegia
 Hemiparesis
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
Communication loss
 Dysarthria= difficulty in speaking
 Aphasia= Loss of speech
 Apraxia= inability to perform a
previously learned action
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
Perceptual disturbances
 Hemianopsia

Sensory loss
 paresthesia
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
2. Improve Mobility and prevent
joint deformities
 Correctly position patient to
prevent contractures
 Place pillow under axilla
 Hand is placed in slight supination-
“C”
 Change position every 2 hours
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
2. Enhance self-care
 Carry out activities on the
unaffected side
 Prevent unilateral neglect
 Keep environment organized
 Use large mirror
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
3. Manage sensory-perceptual
difficulties
 Approach patient on the
Unaffected side
 Encourage to turn the head to the
affected side to compensate for
visual loss
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
4. Manage dysphagia
 Place food on the UNAFFECTED
side
 Provide smaller bolus of food
 Manage tube feedings if
prescribed
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
5. Help patient attain bowel and
bladder control
 Intermittent catheterization is
done in the acute stage
 Offer bedpan on a regular
schedule
 High fiber diet and prescribed
fluid intake
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
6. Improve thought processes
 Support patient and capitalize on
the remaining strengths
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
7. Improve communication
 Anticipate the needs of the patient
 Offer support
 Provide time to complete the sentence
 Provide a written copy of scheduled
activities
 Use of communication board
 Give one instruction at a time
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
8. Maintain skin integrity
 Use of specialty bed
 Regular turning and positioning
 Keep skin dry and massage NON-
reddened areas
 Provide adequate nutrition
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
9. Promote continuing care
 Referral to other health care
providers
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
10. Improve family coping
11. Help patient cope with sexual
dysfunction
CVA: Hemorrhagic Stroke
 Normal brain metabolism is
impaired by interruption of blood
supply, compression and increased
ICP
 Usually due to rupture of
intracranial aneurysm, AV
malformation, Subarachnoid
hemorrhage
CVA: Hemorrhagic Stroke
 Sudden and severe headache
 Same neurologic deficits as
ischemic stroke
 Loss of consciousness
 Meningeal irritation
 Visual disturbances
CVA: Hemorrhagic Stroke
 DIAGNOSTIC TESTS
 1. CT scan
 2. MRI
 3. Lumbar puncture (only if with no
increased ICP)
CVA: Hemorrhagic Stroke
 NURSING INTERVENTIONS
 1. Optimize cerebral tissue
perfusion
 2. relieve Sensory deprivation and
anxiety
 3. Monitor and manage potential
complications