CEREBROVASCULAR DISORDERS  Abnormality in embryonal development that leads to a tangle

of arteries and veins that lacks capillary bed leading to dilation

an rupture.
ISCHEMIC STROKE’  Common cause of hemorrhagic stroke in young people.
 ”brain attack”

 Sudden loss of function from disruption of blood supply to a Subarachnoid Hemorrhage

part of the brain.
 Result of AVM, aneurysm,trauma, or hypertension
 Types:

>Large artery thrombosis (artherosclerotic plaque in large vessels of

the brain) PATHOPHYSIOLOGY

>Small penetrating artery thrombosis (a.k.a Lacunar Stroke) Intracerebral Blood Vessel rupture

Cardiogenic embolic (cardioembolic) stroke - associated with cardiac

dysrhythmias “atrial fibrillation”
Increased Intracranial Disruption of metabolism due to brain
 Cryptogenic stroke (no known cause)
Pressure tissue exposure to blood
 Stroke from other causes

Compression of brain tissue Reduced perfusion

HEMORRHAGIC STROKE
And cranial nerves And pressure
BLEEDING

 Brain tissue
Signs and symptoms Secondary ischemia
 Ventricles
Depends on the area
 Subarachnoid space
Effected.
Causes:

 Intracerebral haemorrhage

 Cerebral aneurysm

 Arteriovenous malformation

 Subarachnoid hemorrhage

Intracerebral hemorrhage

 Hypertensive pateints

 Cerebral artherosclerosis
CLINICAL MANIFESTATIONS
 Brain tumor
 Similar with Ischemic stroke
 Medications (anticoagulant)
 Symptoms common in Hemorrhagic stroke

 Severe headache
Cerebral aneurysm
 Vomiting
 Dilatation of weakened arterial wall
 Sudden onset of change in LOC
 Usually form on the bifurcations of large arteries
 Seizures

 Nuchal rigidity (rigidity at the back of the neck)

Arteriovenous Malformations (AVMs)
DIAGNOSTIC FINDINGS  WOF changes in:

COMPUTED TOMOGRAPHY SCAN (CT SCAN)  Blood pressure

 Plain or with Contrast  Pulse

Cerebral angiography  LOC

Confirms the presence of aneurysm of AVMs  Pupillary response (Anisocoria)

 CT angiography  Motor function

 MRI  Respiratory function

 Lumbar puncture Aneurysm Precaution!

If no sign of increased ICP, CT is negative, to confirm subarachnoid Non-stimulating environment

hemorrhage.
Prevent increase in ICP

Avoid increase in:

COMPLICATIONS AND MNGT
 IINTRAABDOMINAL PRESSURE
Cerebral hypoxia and decreased blood flow
 INTRATHORACIC PRESSURE
 Oxygenation
 PRESSURE ON JUGULAR VEIN
 Adequate hydration (IV)

Vasospasm

Calcium channel blocker (nimodipine-Nimotop)

Hypertension

 Antihypertensives

 Stool softener- prevents straining

PREVENT DVT
Medical Management
Compression stockings
Antihypertensives

Analgesics
NURSING MANAGEMENT
Antiseizure
 VASOSPAMS
Antiembolic stockings
 SEIZURE
Prevents Deep Vein Thrombosis (DVT)
 HYDROCEPHALUS
Antipyretric
Dilated ventricles confirms the diagnosis
Fever increases brain’s metabolic demand
REBLEEDING
Hyperglycemia
 HPN- most serious factor
Insulin- lowers blood sugar
 Confirmed by CT scan
SURGICAL MANAGEMENT
 HYPONATREMIA
Craniotomy or Craniectomy
SIADH or cerebral salt-wasting syndrome
Evacuate the blood and decrease intacranial pressure

NURSING MANAGEMENT
SEIZURE DISORDERS
 NEUROLOGICAL monitoring

 Prevent increase in ICP

SEIZURE
 Prevent further vasospasm
Episodes of abnormal motor, sensory, autonomic, or psychic activity AURA
(or combination of these) that result from sudden excessive  Involves a peculiar SENSATION
discharge from cerebral NEURONS
 May be psychic or sensory

Two main types:

Partial Seizure (begin in one part of the brain)

TONIC PHASE
Generalized seizure (involve electrical discharges in the
whole brain)  Loss of consciousness

 Body rigid

OTHER CLASSIFICATION UNDER PARTIAL AND GENERALIZED  Eyes roll up

SEIZURE
Generalized Tonic-Clonic Seizure (Grand-Mal)
 Commonly mistaken with MI and stroke
 A convulsive seizure characterized by alternating muscle
rigidity and jerking temporarily, suspended breathing
and altered consciousness
HYPERTONIC PHASE
 Extreme muscle rigidity and HPN
 Signals the end of continuous contraction
CLONIC PHASE
 Alternate rigidity and relaxation

Absence (Petit-Mal) AUTONOMIC DISCHARGE

 Commonly mistaken as daydreaming, inattention, and  Hyperventilation

ignoring adults.
 Salivation and tachycardia
 Characterized by blank stare that lasts only a few
POST ICTAL PHASE
second
 All muscle relax
Simple Partial (Jacksonian) Seizure
 Patient becomes unresponsive
 Characterized by jerking in fingers and toes

 May spread to involve the entire arm or leg

NURSING MANAGEMEMNT
 Mistaken for acting out and bizarre behavior
DURING SEIZURE
Complex Partial (psychomotor) Seizure
 OBSERVE and RECORD the sequence of signs
 Starts with blank stare then progresses into chewing
and random activity  Predisposing factors
 May be mistaken for drunkness, MI, drug interaction  Occurrence of AURA
Myoclonic Seizure  The initial movements or action of patient
 Characterized by sudden, brief, massive muscle jerks  Type of movement
that involve part or all of the body
 Area of the body involved
 May be mistaken for clumsiness and poor coordination
 Pupil size
Atonic Seizure
 Eye movement during seizure
 Also called “drop attack” in which the legs of a child
suddenly collapse  Presence or absence of automatism

 Mistaken for clumsiness or lack of normal walking  Incontinence

STAGES OF GRAND MAL SEIZURE  Duration

 Unconsciousness SECONDARY (known cause)

AFTER SEIZURE

 Paralysis or weakness STATUS EPILEPTICUS

 Speaking ability  Acute, prolonged seizure activity

 Movements  Series of generalized seizures that occur without

recovery of consciousness
 Sleepiness
MANAGEMENT
 Cognitive status
ANTISEIZURE MEDICATIONS
 Place in side-lying position
 Carbamazepine (Tegretol)
 Suction
 Clonazepam
NURSING MANANGEMENT
 Gabapentin
DURING A SEIZURE
 Levetiracetam (Keppra)
 PRIVACY
 Phenobarbital (Luminal)
 SAFETY
 Phenytoin (Dilantin) *Gingival hyperplasia
Ease to the floor
 Valproate (Depakene) *hepatotoxic
Protect head
SURGICAL MANAGEMENT
No restrain
 Tumor, cyst, abcess, vascular anomalies
 AIRWAY

Place on side
HEAD INJURIES
AURA:
PRIMARY INJURY
Avoid forced mouth opening
 Damage to the brain from traumatic events
AFTER A SEIZURE
SECONDART INJURY
 AIRWAY
 Evolves after the initial injury and results from
Place on side
inadequate delivery of oxygen and nutrients to the cell
 REORIENT
SKULL FRACTURES
 AGITATION
 Break in the continuity of the skull caused by forceful
Persuasion and gentle restrain trauma

 SIMPLE LINEAR (break in the continuity)

 COMMINUTED (Splintered or multiple fracture line)

“crushed”

 DEPRESSED (skull displaced downward) “indented”

EPILEPSY
 BASILAR (fracture of the base of the skull)
Group of syndrome characterized by unprovoked, recurring
seizures
BRAIN INJURY

PRIMARY (idiopathic) TYPES

CONCUSSION

(temporary loss of neurologic function with no apparent SPINAL CORD INJURY

structural damage)
 Transient concussion, contusion, laceration,
CONTUSSION compression, complete transection (severing) of the
spinal cord that renders the patient paralyzed below the
(brain is bruised and damaged in a specific area)
level of injury
DIFFUSED AXONAL INJURY

(widespread shearing and rotational forces that produces

CLINICAL MANAGEMENT
damage throughout the brain)
CERVICAL SCI
INTRACRANIAL HEMORRHAGE
 Injury of C@ and C3 is usually fatal
 Epidural hematoma (extradural)
 Quadriplegia -”4 ext.”
 Subdural hematoma (between the dura and brain)
 Respiratory muscle paralysis
 Intracerebral hemorrhage and hematoma
 Bowel and bladder retention
NURSING MANAGEMENT
THORACIC SCI
MONITOR NEUROLOGIC FUNCTION
 Paraplegia -”lower”
 Check the LOC
 Poor control of upper trunk
 GCS monitoring
 Bowel/bladder retention

 *autonomic dysreflexia (overstimulation of sympathetic

NS, resulting to paroxysmal HPN, etc)
MAINTAIN AIRWAY
 Usually injury T6 and above
 HOB elevated 30 degrees
LOWER SCI
 Suctioning
 Paraplegia
 Positioning
 Bowel and bladder paralysis
MONITOR FLUID AND ELECTROLYTE BALANCE
SACRAL SCI
PROMOTE ADEQUATE NUTRITION
 Above S2: males allow erection but no ejaculation
PREVENT INJURY
 S2-S4: prevents erection and ejaculation
MAINTAIN BODY TEMP
 Bowel and bladder incontinence
 Acetaminophen and cooling measures
 Paraplegia
MAINTAIN SKIN INTEGRITY
COLLABORATIVE MANAGEMENT
 Turning every 2 hours
 Promotion of respiratory function especially in cervical
IMPROVE COGNITIVE FUNCTION SCI

PREVENT SLEPP PATTERN DISTURBANCE  Immobilization in flat,firm, surface

 Group nursing activities  Apply cervical collar

 Dim lighting  Transport client as a unit

 Decrease noise  Do not attempt to realign body parts

 Back rubs  Definitive Mngt:

 Traction Mngt:

Surgery  Range of Motion Exercises

Cast  Position changes

 Monitor and manage potential complications of SCI  Maintaining proper body alignment

 Promote skin integrity

COMPLICATIONS

SPINAL SHOCK (NEUROGENIC SHOCK) MENINGITIS

 Sudden depression of reflex activity in the spinal cord Inflammation of meninges (lining of the brain and spinal
cord)
 (areflexia) below the level of injury
SEPTIC MENINGITIS
 Loss of autonomic innervation below the level of injury
Cause by Bacteria (S.pneumoniae and N.meningitidis)
S/Sx:
ASEPTIC MENIGITIS
 Absence of sweating below the
Viral, secondary to lymphoma, leukemia, HIV
 Bowel and bladder retention
CLINICAL MANIFESTATIONS
 Hypotension and bradycardia
 Headache and Fever
DEEP VEIN THROMBOSIS (DVT)
 SIGNS of Meningeal Irritation
 Due to immobility
 Nuchal Rigidity (stiff and painful neck in any attempt to
 Patients who develop DVT is at risk for Pulmonary
flex)
Embolism
 Positive Kernig’s Sign (patient is lying with thigh flexed
Mngt:
on the abdomen, the leg cannot be completely
 Anti-embolic stocking (compression stockings) extended)

 Pneumatic compression device  Positive Brudzinski’s Sign (neck flexion produces flexion
of the knees and hips
 Permanent indwelling filters (placed in vena cava)
 Photophobia
 Low-dose anticoagulation therapy
 Change in LOC
AUTONOMIC DYSREFLEXIA (HYPERREFLEXIA)

 Acute emergency resulting from exaggerated autonomic

responses to stimuli that are harmless in normal people

 Occurs after spinal shock has resolved

S/Sx: DIAGNOSTICS FINDINGS

 Severe pounding headache  CT Scan

 Paroxysmal HPN  MRI

 Profuse diaphoresis (forehead)  Lumbar puncture

 Nausea, nasal congestion  GS/CS

DISUSE SYNDROME  LOW GLUCOSE

 Contractures and muscle atrophy as a result of  HIGH PROTEIN LEVELS

immobility
 HIGH WBC
MEDICAL MANAGEMENT

Antibiotic therapy

That crossess the blood-brain barrier

Dexamethasone

Corticosteroid

Fluid volume expanders

Dehydration and shock

Phenytion (Dilantin)

Seizure attacks

Increased ICP management

NURSING MANAGEMENT

 Neurologic status and vital signs assessment

 Maintenance of proper oxygenation

 Cooling measures for hyperthermia

 Replacement of fluid and prevention of shock

 Patient’s safety

 Monitoring DAILY WEIGHT

 Prevent complications from prolonged immobility

 Infection control

MULTIPLE SCLEROSIS

CLINICAL MANIFESTATIONS

 Relapsing-Remitting Course

 S/sx depends on the location of lesion (plaque)

PRIMARY symptoms:

 Fatigue

 Depression

 Weakness

 Numbness difficulty in coordination

 Ataxia (cerebellar and basal ganglia involvement)

 Pain (lesiion on sensory pathways)