2012+02+14+philippines daiwai

7/27/2019 2012+02+14+Philippines Daiwai

1/289

The Plan Neuroscience Nursing

Nursing Assessment in Acute Neurologic Injury Correlational Neuroanatomy

Neuroscience Nursing Research Evidence-based practice and neuroscience

application of nursing research to the practiceof neuroscience Examples of nursing research in Neuroscience


2/289


3/289

DaiWai M. Olson PhD RN CCRN

Assistant Professor of Medicine/Neurology


4/289

Disclosures

Aspect Medical Systems

Alsius Medical

Amer. Assoc. Crit. Care

American Heart Assoc.

Bristol-Meyers Squibb

Edwards Lifesciences

Hospira

LiDCO Corporation

Medicines Company

Medtronic Corp.

Nat. Inst. Health (NIH)

Neuro. Nursing Foundation

Sanofi Aventis

Abbott Laboratories

Aspect Medical Systems

Alsius Medical

Barbara Clark-Mims Assoc.

Hospira

Medivance Corp

USB Pharma

Zoll Medical

None

Research Grant Recipient

Speakers Bureau

Stock/Financial interest


5/289

A B C D E F G H I J K L M N O

Airway

Breathing

Circulation

Disability

Expose

Circulation

Airway

Breathing

Disability

Expose


6/289

Evidence

Circulation Airway - Breathing

Editorial Board

2010 AHA Guidelines for CPR andEmergency care Science

2010Circulation

Vol. 122

S640-S656


7/289


8/289


Fahrenheit (temperature)

Gadgets (your call)

History (1st assessment)

Head - to Toe (every time)

I.V. s (your call)


9/289


Jackson-Pratt (all drains)

Keep family informedLabs (due, done, & to treat)

Medications (due, done & followup)

New orders


10/289


Okay

Okay, move on

Overview

On top of it

Other patientsOther projects (chart)


11/289

The great divide

Upper motor neuron lesion

Lower motor neuron lesion

What is a

lesionanyway ?

Non-specific term refers toany abnormal tissue


12/289

Nurses differentiate UMN vs LMN

K. Clarke & T. Levine

Clinical Recognition and Management ofAmyotropic Lateral Sclerosis: The Nurses Role

2011

Journal of Neuroscience Nursing

Vol. 43 (4)

pp 205-214

Evidence


13/289

Upper or Lower ?

Lower motor neurons are:

From the SPINAL CORD to the MUSCLE


14/289

Upper or Lower ?

Upper motor neurons are:

From the BRAIN to the SPINAL CORD

NICE to KNOW

Efferent------

Afferent------
http://av.rds.yahoo.com/_ylt=A9ibyKw6jzdFHtYA9EOHBqMX;_ylu=X3oDMTBwanIybjRqBHBndANhdHdfaW1nX3Jlc3VsdARzZWMDc3I-/SIG=13cc8181r/EXP=1161355450/**http:/kidshealth.org/broadcast/article_images/article45354/1098284737268.brainTeam5.jpg


15/289

Upper or Lower Motor Neuron

Upper Motor Lower Motor

We Present Present

F No Yes

A No Yes

R Up Down

T Up Down

Weakness

Fasciculations

Atrophy

Reflexes

Tone


16/289

Primary lesson is Nursing assessment

The Case of J. P.

Highlighting

Nursing Assessment


17/289

for telling stories

M. Sandelowski

We are the stories we tell1994

Journal of Holistic Nursing

Vol. 12 (1)

pp 23-33

Evidence


18/289

What happened to J.P.?We need to understand 3 things

1. Cerebral artery circulation

2. Cranial nerves

3. Do your damn job

Please


19/289

J.P. 20 year old G.I. return from Iraq

Prior to formation c/o dizzy and thirsty

Went for gatorade tell everyone I went back Found unresponsive minutes later, minimal

respiratory effort, EMS called by C.O.

Transfer to Duke

Glasgow Coma Score = 3


20/289

Complete Basilar Artery Thrombosis


21/289

MERCI Merci retrieval

Returned to ICU


22/289


23/289

ICU

Day 1 32 C for 24 hours

Day 2 wean paralytics passive rewarm on

Day 3 he returned to baseline temp, wean pressors

Day 4 ventric inserted (ICP =36) = GCS 4 , extensorposturing, pupils sluggish, irreg shape, no dolls eyes, weakgag, good cough

Day 5 See video on next slide for NIHSS exam


24/289


25/289


26/289


27/289

ICU

Day 5 = GCS from 3 8

Day 6 = GCS from 8 -10


28/289


29/289


30/289

Appearance

GCS / NIH

CranialNerves

Motor

Aphasia

Midbrain

Pons

Medulla

Thalamus

H m m m ? ? ?


31/289

12 pairs

Of

Cranial

Nerves

In

The

Brain Stem

Teaching Tip Lets Play GOD

Cranial Nerves


32/289

Midbrain

Pons

Medulla

Cranial Nerves Playing GODWhat is this?


33/289

Appearance

GCS / NIH

CranialNerves

Motor

Aphasia

Midbrain

Pons

Medulla

Cranial Nerves Playing GODWhere will you put 12 nerves ?

12 nerves - - - 3 places ? ? ?

4

4

4

What would you call these 12 nerves?How about

1

2

3

4

5

6

7

8

9

10

11

12


34/289

Appearance

GCS / NIH

CranialNerves

Motor

Aphasia

Midbrain

Pons

Medulla

Cranial Nerves Playing GODBONUS Question for GOD

Where would you put #1, #2 . . . Etc?

I II III IV

V VI VII VIII

IX X XI XII

C i l N


35/289

Cranial Nerves

I Olfactory Smell

II Optic Vision

III Oculomotor Eye movement

IV Trochlear Eye movement

V Trigeminal Face/mouth

VI Abducens Eye movement

VII Facial expressions

VIII Auditory hearing/balance

IX Glossopharyngeal Taste

X Vagus HR / BP

XI Spinal Accessory swallowing

XII Hypoglossal tongue movement


36/289

On

OldOlympus

Towering

Top

A

Friendly

Viking

GrewVines

And

Hops

Some

SayMarry

Money

But

My

Brother

Says

BadBusiness

My

Man There

AreOthers ! ! !


37/289

for Cranial Nerve Assessment

T. Latha, R. Prakash, L.D. Josphine

Effectiveness of two Teaching Methodsfor Cranial Nerve Assessment

2011International Journal of Nursing Education

Vol. 3 (2)

pp 65-69

Evidence


38/289

CN I - OlfactoryCharacteristics: Sensory

Sense of smell

Clinical Correlate

Injury will result in a loss ofsmell


39/289

CN II - OpticCharacteristics: Sensory Clinical Correlate

Injury will result in a loss ofvision

Injury will cause a loss ofpupil constriction to light(direct)

Vision

Pupillary light reflex


40/289CN III


41/289

CN III - OculomotorCharacteristics: Motor

Motor of the oculo

Upward movement of theeyeball

Raising the eyelid

Pupillary constriction withaccomodation

Clinical Correlate

Patients with CN III injurylook down and out.

Injury causes diplopia

BLOWN PUPIL from CN IIIcompression secondary toelevated ICP

III


42/289

Pupil = little doll (latin pupilla)


43/289

Swinging Flashlight - Test

Normal Reaction


44/289

Swinging Flashlight - Test

Marcus Gunn


45/289

CN IV - TrochlearCharacteristics: Motor

Rotation and adduction ofthe eye

Clinical Correlate

Lazy downward gaze


46/289

CN V - TrigeminalCharacteristics: Both Sensation (touch) face, scalp,

cornea

Motor for chewing

Clinical Correlate

Injury results in loss of facialsensation, decreased direct

corneal reflex Partial facial paralysis

= three

Tri


47/289

CN VI - AbducensCharacteristics: Motor Lateral movement of the eye

Clinical Correlate

The patient can not look tothe side with the affected eye

(maintains peripheral vision)
http://photos1.blogger.com/hello/287/8689/640/DSCN1501.jpg


48/289

The six cardinal fields of gaze


49/289

The Visual Exam

Vision (CN II)

How many fingers do you see

Pupillary reflex (CN III)Direct response to light

EOMs (CN IV and CN VI)

Follow my fingers as I make the letter N

Swinging flashlight


50/289

CN VII - FacialCharacteristics: Both Sensory is taste on the front

2/3 of the tongue

Motor is for facial expression,eyelid closure and for boththe lacrimal & salivary glands

Clinical Correlate

Injury leads to crocodile tears

Decreased taste sensation

Poor closure of the eye

7


51/289

Characteristics: Sensory

Hearing

Equilibrium

Balance

Some feedback tocompensatory eye movement(dolls eyes)

Clinical Correlate

Wobbly

Vertigo

Loss of hearing

Patients flip upside down inbed

CN VIII - Vestibulocochlear


52/289

CN IX - Glossopharyngeal

Characteristics: Both

Sensory taste on posteriorportion of tongue

Motor parotid gland

Clinical Correlate

Injury will result in a loss oftaste

Loss of Gag reflex

G

= Gag


53/289

Clinical Correlate

Loss of gag & cough reflex

Bradycardia

CN X - VagalCharacteristics: Both Sensory sensation of the

pharynx & larynx & Carina

Motor swallowing, cardiac& GI


54/289


55/289

Clinical Correlate

Injury will result in aninability to turn heador droopy shoulders

SCM and Trapezius

Accessorize !

CN XI - AccessoryCharacteristics: Motor


56/289

CN XII - HypoglossalCharacteristics: Motor Clinical Correlate

Injury will result in tonguedeviation.

The tongue points to theweak side

This test may not be as clinically relevant as we want it to seem


57/289

I tt f t!


58/289

but trust me. . . Its gonna end up alright !

Im gonna go pretty fast!


59/289


60/289

Miss Delia

While at church c/o WHOL & DFO

Family rushed her to OSH

Transfer to Duke as probably an SAH GCS = 6 (E2, V1, M3[flexion])

DFO she got all swimmy headed and done fell out


61/289

Emergency Department Rapid assessment A B C D

Stroke Code

Imaging (?WHY? Is imaging important)


62/289

Imaging to rule out/in bleeding


63/289


64/289

Stroke Ischemic >24 hours = Acute ischemic Stroke (AIS)


65/289

Nursing Role in Emergence Stroke care

DM Olson, M Constable, G Britz, CB Lin, L Zimmer, LH Schwamm, GC

Fonarow, ED PetersonA Qualitative Assessment of Practices

Associated with Shorter Door-to-Needle Timeof Thrombolytic Therapy in Acute Ischemic

Stroke2011

Journal of Neuroscience NursingVol. 43 (6)

pp 329-336

Evidence


66/289

Cerebral Aneurysm Nearly 20 million Americans harbor an aneurysm

Annually 30,000 of these rupture resulting in

subarachnoid hemorrhage (SAH)

Women affected more than men

Typically present between 35-60 years of age


67/289

Aneurysms

A bubble in an artery caused by a

weakening of the vessel wall.


68/289

Delia CT shows diffuse blood

Suspicious for aneurysm

Transfer to NeuroCritical Care Unit (NCCU)

Develops continually falling level of consciousness

Progression in weakness of her left arm.

Prep for ANGIOGRAM


69/289

Delia Stabilize & prep for A-gram

Why A-gram and not O.R.


70/289


71/289

Wide Neck Aneurysms cant be

coiled - - -yet (sorta)


72/289

Hunt and Hess ScoreHunt & Hess

Grade Description

1 Asymptomatic, mild headache, slight nuchal rigidity

2 Moderate to severe headache, nuchal rigidity, no neurologic deficitother than cranial nerve palsy

3 Drowsiness or confusion, mild focal neurologic deficit

4 Stupor, moderate to severe hemiparesis

5 Coma, decerebrate posturing


73/289

Fisher ScalePresence of Subarachnoid Blood Fisher Grade

No blood on CT scan I

Diffuse blood, < 1 mm thick II

Localized clot or think layer, >1 mm thick III

Diffuse or none, with intracerebral orintraventricular blood IV


74/289

WFNS SAH Grading ScaleGrade G C S Motor Deficit

I 15 None

II 13 14 NoneIII 13 14 Present

IV 7 12 None / Present

V 3 - 6 None / Present

World Federation of Neurological Societies


75/289

DeliaA-gram shows large right MCA aneurysm Not amenable to coiling

Surgical ligation NOW


76/289

Surgery


77/289

Back from Surgery

NOW WHAT ? ? ? ?

What do we expect and why?

Case study - Delia

V l A


78/289

Vascular AnatomyThere are two very common representations of the cerebral

arteries. I find they are both confusing. Well look at thembriefly and then . . . . .


79/289

ACA

MCA

ACommA

PCA

Basilar


80/289

We are going to look at a series of slides

that I created to look at circulation.

Try to focus on the ONE artery that I

highlight in each slide


81/289

Vertebral Arteries


82/289

Basilar Artery


83/289

Internal Carotid Arteries


84/289


85/289

Posterior communicating


86/289

Anterior Cerebral Arteries


87/289


88/289

Posterior Cerebral Arteries


89/289

S.A.H. Secondary Brain Injury

ICP

Perfusion (PbtO2)

Neuro exam

Multi-modal monitoring

Respond to changes

Blood in subarachnoid spacecauses primary brain injury whichthrough a variety of

neurochemical changes causes arisk of secondary brain injury

T.B.I. Secondary Brain Injury

ICP

Perfusion (PbtO2)

Neuro exam

Multi-modal monitoring

Respond to changes

Direct trauma to the skull/braincauses primary brain injury whichthrough a variety of neurochemical

changes causes a risk of secondarybrain injury

* More alike then different

What are we concerned with?


90/289

Day 14 transfer to step down

Case study - Delia


91/289

Transition

The Case of Phineas Gage


92/289

* * * Classic Case * * *

The Case of Phineas Gage

Highlighting

Functional Neuroanatomy

Phi G


93/289

Phineas Gage (b. 1823 d.1860) Year 1848 (age 25)

The Foreman - Hard working, energetic, driven

Setting explosives in Vermont for Rutland andBurlington Railroad

Phineas Gage (b. 1823 d.1860)


94/289

g ( )

The tamping iron for the explosives reverseddirection (caused by a spark) and shot through hisskull and his frontal lobe.

Family prepared a coffin upon hearing of a fungalinfection following surgery.

Phineaswas fine as reported in 1949. But . . .

1848

Wyatt Earp born

Wisconsin becomesthe 30th state


95/289

Friends of gage, now state that . . .


96/289

Harlow, J.M. (1868) Bulletin of Mass. Med. Society

His contractors, who regarded him as the most efficient andcapable foreman in their employ previous to his injury,considered the change in his mind so marked that they couldnot give him his place again. He is fitful, irreverent, indulging

at times in the grossest profanity (which was not previously hiscustom), manifesting but little deference for his fellows,impatient of restraint of advice when it conflicts with hisdesires, at times pertinaciously obstinent, yet capricious and

vacillating, devising many plans of future operation, which areno sooner arranged than they are abandoned in turn for others

appearing more feasible.In this regard, his mind was radically changed, so decidedly that

his friends and acquaintances said he was no longer Gage.


97/289

The


98/289

Frontal

Lobe

Extends back to the central sulcus

executive functions

thought

Emotion

voluntary motor control

Contains the MOTOR STRIP


99/289

no too much yet


100/289

y

Frontal Lobe


101/289

Drawing class !


102/289

g

C

entral

S

ulcus

Drawing class !


103/289

Inferior Temporal Gyrus

C

entral

S

ulcus


104/289

Superior Frontal Gyrus Higher cognitive functions

We are able to deduce and infer and plan

Working memory (later)


105/289


106/289

Your middle frontal gyrustells you this is the letter . . .

.?

Middle Frontal GyrusWe are not sure yet

Maybe in decoding/encoding and arbitration


107/289

Inferior Frontal Gyrus The go / no-go area

Response inhibition

Why we stop walking when we hear a snake rattle

H l


108/289

Homunculus

Motor homunculus


109/289

Frontal Lobe motor strip


110/289

P t C t A t


111/289

Premotor Cortex - Anatomy

LocationWithin the frontal lobe

Anterior to the motor strip


112/289

Premotor cortex - Function

Lateral Premotor Cortex

Intentional movements (preparation)

Triggered by visual cues Baby claps when you clap

catch a ball


113/289

Premotor cortex - Function

Medial Premotor Cortex

Mediates movements

Triggered by internal cuesYour hand comes up to your mouth before you

cough


114/289

Executive Function Controls other functions. My intact executive function

will tell my motor cortex to lift my hand of the hotstove, or will see a wall in front of me and tell my legs

to stop moving.


115/289

The Case of Tan Tan


116/289


Highlighting

Functional Neuroanatomy

Who was Dr Paul Broca?


117/289

Who was Dr. Paul Broca?

Physician

(b. 1824 d.1880)

Asylum

Bicetre Hospital (Paris)

Most famous resident

speech pattern recognized in Tan Tan

the Marquis de Sade

19th Century BB
http://upload.wikimedia.org/wikipedia/commons/4/4b/The_Rake's_Progress_8.jpghttp://upload.wikimedia.org/wikipedia/commons/4/4b/The_Rake's_Progress_8.jpghttp://upload.wikimedia.org/wikipedia/commons/4/4b/The_Rake's_Progress_8.jpghttp://upload.wikimedia.org/wikipedia/commons/4/4b/The_Rake's_Progress_8.jpg


118/289

19th Century BB (before Broca)

The gyri of the brain were drawn resembling intestines

Thought the gyri kept the brain warm

Focus on ventricles brainstem internal capsule

Late 1700 some thought that back of skull = vision

1861 Paul Broca performed an autopsy on Tan Tan

1865 Broca published a paper that there are many patients whohave lost speech and have left frontal lesions

First called non-fluent aphasia


119/289


120/289

B A h i


121/289

Brocas Aphasia

Patient can not name items (anomia) Show objects fingernail wedding ring

There is no fluency to the speech pattern Do the words flow together?

You can understand the patient Often only 1 or 2 unrelatedwordstan

Unable to repeat phrases Five Purple Monkeys

Wernickes Aphasia
http://rds.yahoo.com/_ylt=A0WTb_xvBJpJUTsAI4qJzbkF;_ylu=X3oDMTBpaWhqZmNtBHBvcwMzBHNlYwNzcgR2dGlkAw--/SIG=1jfnv6j82/EXP=1234916847/**http:/images.search.yahoo.com/images/view?back=http://images.search.yahoo.com/search/images?p=paul+broca&fr=yfp-t-305&toggle=1&cop=mss&ei=UTF-8&w=95&h=116&imgurl=www.hominides.com/data/images/illus/Scientifiques/paul-broca-anthropologue.jpg&rurl=http://www.hominides.com/html/dossiers/devenir-anthropologue-etude.html&size=4.8kB&name=paul-broca-anthropologue.jpg&p=paul+broca&type=JPG&oid=ff243df592fd697a&no=3&tt=225&sigr=127ul8r0m&sigi=12e14p3th&sigb=1309amo64


122/289

Wernicke s Aphasia

Patient can not name items (anomia) Show objects fingernail wedding ring

There is a fluency to the speech

Although it does not make sense, thespeech the patient produces is fluent

You can not comprehend the speech May be some recognizable words, but

communication is not understood

Unable to repeat phrases Five Purple Monkeys


123/289


124/289


125/289

The scan


126/289


127/289


128/289


129/289

This leads us to think about a new

problem . . . Overlapping function


130/289

So What ? If one location deals with one function then other

locations may similarly deal with separate functions.

Hint: in the 21st century, we are reversing our thinking away from theone-to-one relationship

Transition ! ! !


131/289

Transition ! ! !

The Case of Yoel


132/289

Highlighting

Visual Cortex

Yoel


133/289

YoelDuring World War I, Yoel was a first lieutenant

in the British Army. As was common during

WWI, he was hit with very small bore lead

shot. The bullet penetrated the back of his

head. In the excitement of the battle he did

not at first realize he had been hit, but he didimmediately note that he had visual field

changes.

Yoel


134/289

Yoel

The Bullets used in WWIwere considerably smaller

than those used today, andalso had a lower spread(we had not learned how to be as deadly).

The brain injuries werehighly localized.

Drawing Class ! ! !

Drawing class !


135/289

Drawing Class ! ! !

?


136/289

Line from parieto-occipital sulcus to pre-occipital notch (like

that helps!) Important for Vision

Interpreting visual input

Visual reflex

The Occipital Lobe

Anatomy of the EYE


137/289

X Word


138/289


139/289

D i Cl h d


140/289

Drawing Class - - -use your handouts


141/289


142/289

Transition


143/289

transition


144/289

Thanks !

DaiWai Olson

[email protected]

The Case of H.M.


145/289

Highlighting

Memory


H. M.


146/289

27 y.o. male H.M.

intractable seizures

1953 = surgical resection (bitemporal lobectomy)

No more seizures !

BUT

No more memory Thibodaux LA & Mom is Irish

December 2nd2008 HM dies HenryMolaison

H.M.


147/289

Throughout his life, H.M. was extensively studied.

Probably in more studies than any other human.

His memory was reduced to less than 5 minutes.

No short term memory.

No long term memory.

Hippocampus

Surgical removal of the hippocampi.

Every day is alone by itself

The Limbic


148/289

SystemA.K.A. emotional system

Olfactory cortex

Smell Hippocampus

memory

Amygdala

Emotion Hypothalamus

Homeostasis:

the quaalude of the limbic system


149/289

Coronalslice of

the

Amygdala

In the next slide (animated) try to focus on structures around the amygdala


150/289

Hippocampus


151/289

Required for making new memories but not storing new memories.

Spatial relationship. H.M. could not develop newmemories

but he could develop new skills.One such example is where he coulddraw objects in the mirror.

Try it sometime !

Memory organization along temporal lobe


152/289

Subjects were asked questions & shown pictures that made them think about people,animals, and tools . . . . *considerable overlap*

think of your first pet could elicit, Dog Heidi leash pet store mother etc.

Long Term

Non

Short Term


153/289

153

Declarative

Events

SpecificPersonal

experiences

Facts

World, objectLanguageknowledge

Non-Declarative

Procedural

S k i l l s

Perceptual

Representation

Perceptualpriming

ClassicConditioning

ConditionedResponse

Non-associative

Learning

Sensory Working

Long Term Memory

Schema theory

ChunkingMemories from S.T.M.

Are moved to L.T.M.

And sorted into

Where they fit best and

Added to existing

Chunks of data

To become

SCHEMA

Short Term Memory

Humans can haveAbout 7 +/- 2

chunks

Of information

At any given

One point

In time

What is the basic difference between short term and long term memory?

Ch ki d


154/289

Chunking and memory

Key concepts in MEMORY


155/289

Key concepts in MEMORY

Perceptual priming prior recent exposure affects the next action.look at my new watch. I bought this watch at the watch store.

Fill in the blanks: W A T __ __

Conditioned response think Pavlovs Dog

Habituation the more you do somethingthe lesser the response

Sensitization each stimulus brings a greater response(shes touching me ! ! !)

Long Term

Non-

Short Term


156/289

156

Declarative

Events

SpecificPersonal

experiences

Facts


Non-Declarative

Procedural

S k i l l s

Perceptual

Representation

Perceptualpriming

ClassicConditioning

ConditionedResponse

Non-associative

Learning

Sensory Working

***Short term memory is your desktop***

Sensory= sensory information is registered briefly. We selectively attend to this(and shift to working) or ignore.

Example: you hear something, but dont attend to it until your spouseasks, what was that? then you suddenly remember it.

Working = command and controlExample: I say something that reminds you of your shopping list. You put

this idea in short-term working, get your list, add that item,remember to put the pen and paper back.

This is ONE model of short term memory . . . there are others

*

N


157/289

Nemo

Dory

No short-termmemory

No what area?

Short term memory


158/289

prefrontal Lobe

Is there photographic memory?


159/289

The Savant Syndrome (aka idiot savant)

Males > females

1 in 10 autistics have some savant syndrome

Most have very narrow skill set The skills almost always are linked to

phenomenal memory

We still dont have theory as to how this works.

The savant syndrome: an extraordinary condition. A synopsis: past, present, future Darold A. Treffert. Phil. Trans. R. Soc. B 2009. 364, 1351-1357

Blind Tom


160/289

Born May 25th, 1849 Thomas GreenBethune was born blind a slave in Georgia.

Spoke early, and in

perfect tone and pitch but inappropriately.

Mother taught him likeyou would a horse

Played severalinstruments havingheard a song only once.

Long Term

D l tiNon-

Short Term

S W ki


161/289

161

Declarative

Events

SpecificPersonal

experiences

Facts


Declarative

Procedural

S k i l l s

Perceptual

Representation

Perceptualpriming

ClassicConditioning

ConditionedResponse

Non-associative

Learning

Sensory Working

Lets put this allback together


162/289

Temporal lobe


163/289

Anatomy hint: thinkSylvian Fissure


164/289

Correlative Neuroanatomy


165/289

Correlative Neuroanatomy1. Left vs Right

A. Motor & Sensory

B. Logic vs. Emotion

2. Key locationsA. Occipital vision

B. Frontal motor & premotor

C. Motor STRIP

D. Speech & Language

3. Neuroanatomist have ZERO imagination


166/289


167/289


168/289

?

SystematicReview


169/289

Review

RandomizedClinical Trial

Non-experimentalresearch

Clinical Reports

Nursing Experience

Textbooks

The Religion of Science opinions &beliefs


170/289


171/289


172/289


173/289


174/289

Experience is really the foundation

Not a bad startbut

Is this EVIDENCE

?

SystematicReview


175/289

Review



Clinical Reports

Nursing Experience

Textbooks


Evidence Based Practice


176/289

A shift in the culture of healthcare provision awayfrom basing decisions on opinion, past practice andprecedent toward making more use of science,research and evidence to guide clinical decision

making(Appleby et al, 1995)


177/289


178/289

Evidence Based Health Care


179/289

an approach to health care that promotes the collection,interpretation and integration of valid, important andapplicable patient-reported, clinician-observed andresearch-derived evidence

(McKibbon et al, 1995)

Evidence Based Practice


180/289

the conscientious, explicit and judicious use ofcurrent best evidence about the care ofindividual patients

(Sackett et al, 1996)

Evidence-Based PracticeEvidence-Based Nursing


181/289

Process by which nurses make

clinical decisions using the best

available research evidence, their

clinical expertise and patient

preferences

?

SystematicReview


182/289

Review



Clinical Reports

Nursing Experience

Textbooks



183/289


184/289


185/289


186/289


187/289

ICP MAPN s.d. 95%CI s.d. 95%CI

Before CPT 46 25.6 8.4 2.49 91.82 12.26 3.48

During 48 23.0 9.57 2.77 91.73 10.48 3.04

After CPT 50 17.3 7.15 2.03 90.08 9.95 2.83

Steady decrease in ICP associated with a NURSING intervention.


188/289


189/289


190/289

Hypothesis Testing


191/289

We wish to draw a conclusion about somepopulation based on some sample.

Who will be likely to graduate on time?

We wish to make a decision about ahypothesis.

Does being married lead to longer lifespan?

Hypothesis TestingW h ll h h i (H ) i h l i


192/289

We test the null hypothesis (HO) against the alternative

hypothesis (HA)

We either reject HO or we fail to reject HO. We sort of end

up accepting HAbecause we dont have any

ALTERNATIVE.

Its all about evaluating the evidence

Hypothesis Testing


193/289

Criminal trial- Presumed innocent. Declared guiltywhen the evidence leading towards being guilty is

beyond a reasonable doubt

H0: Defendant is not guilty

versus

HA: Defendant is guilty

Hypothesis Testing


194/289

Criminal trial- Presumed similar. Declared differentwhen the evidence leading towards difference is

beyond a reasonable doubt

H0: Not enough evidence to declare a difference

versus

HA: The evidence is overwhelming and I am forced toreject the idea that there is no difference

Hypothesis Testing

Th D i i R l


195/289

The Decision Rule

Typically something like

we will reject the null hypothesis if the

observed Z score is so unusual that it justdoesnt make sense to keep believing that the

null hypothesis represents reality

A fancier way to express this is . . .

IfZobs > 1.96 reject Ho

Truth

Hypothesis Testing


196/289

H0 is true H0 is false

DecisionReject H0

Type I error

(sig. level)

Correct decision

(1 - ) = Power

Fail toreject H0

Correct decision(1-)

Type II error

A Type I error is like convicting an Innocent man

GuiltyNot Guilty

Go to Jail

Go Free

But, the juryhas the POWERto make the

right decision

?

SystematicReview


197/289



Clinical Reports

Nursing Experience

Textbooks


The Key factor here is that we are still doing RESEARCH

But it isNon-experimental research

We are generating NEW knowledge


198/289

DaiWai M. Olson PhD RN CCRN

Ananda R. Gurram MD

Brad Kolls MDJulie Eckstrand

Carmelo Graffagnino MD


199/289

Very Low Glucose is Bad in Critical Illness

NICE SUGAR St d 1 6 t i ICU d i d t


200/289

NICE-SUGAR Study1- 6104 pts in ICU randomized tointensive glucose control (81-108 mg/dL) vs. standardglucose control (180 mg/dL).

Mortality was worse in the intensive groupwas 27.5%

vs. 24.9% (OR for death, 1.14; 95 %CI, 1.02 to 1.28)

Severe hypoglycemia (40 mg/dL) in 6.8% of intensivegroup vs. 0.5% in conventional group (P


201/289

Study randomized 90 patients with V Fib arrest and

post anoxic coma to intensive insulin therapy(glucose 72-108 mg/dL) vs standard therapy (108-144 mg/dL)

No differences in mortality however, intensiveinsulin therapy was associated with hypoglycemia18% of the time compared to 2% for standard

therapy (P=.008)


202/289

Duke NICU Glucose Control Study

NICU is a 16 bed neurological, neurosurgical


203/289

NICU is a 16 bed neurological, neurosurgical

semi-closed ICU

All neurosurgical patients are co-cared by NICUteam and neurosurgical team

All other patients admitted to NICU service

NICU team made up of one of 6 attendings,ACNPs, house-staff, unit pharmacist.

Insulin therapy based on written protocols



204/289

Sept 2006 - glucose protocol changed to anintensive insulin therapy (iiT) protocol

target glucose of 80 120 mg/dL.

Spring of 2008 we conducted a QA project toevaluate our experience with iiT.

Retrospective before and after historical cohort study



205/289

Retrospective, before and after, historical cohort study

Data extracted from, electronic health record andexported into Microsoft AccessTM.

Results approved for publication by IRB

Compared 1885 patients admitted to our NICU between2/1/2005 and 8/30/2006 (SIT) to 1871 patients admitted

between 9/1/2006 and 3/30/2008 (IIT)

Standard iiT Group P value

Total Subjects 1885 1871


206/289

Female : N (%) 51% 50.5% 0.07Mean Age 53.66 54.68 0.06

Intracerebral Hemorrhage 147 192 0.007

SubarrachnoidHemorrhage

120 142 0.125

Ischemic Stroke 94 99 0.620

Traumatic Brain Injury 49 82 0.002

Other 1497 1378


207/289

Glucose Values

Intensive InsulinTherapy Group

Yaxis

=

Frequen

c

* Note similar distribution of values. Intensive Insulin therapy results in slightly tightergrouping of scores with lower mean glucose value compared to standard insulin group

StandardInsulin GroupN= 1885

IntensiveInsulin GroupN= 1871

StatisticP - value

OR (95%CI)

Mean glucose level145 136.7


208/289

Insulin Given 56.1% 82.5% 0.0001Insulin Infusion 9.7% 13.3% 0.0006

Moderate Hypoglycemia


209/289

Conclusions

Intensive insulin therapy = more hypoglycemia


210/289

Intensive insulin therapy more hypoglycemia

Hypoglycemia = increased mortality

the more severe the hypoglycemia, thehigher the likelihood of death

Given the above : iit = increased risk of death

?

SystematicReview


211/289



Clinical Reports

Nursing Experience

Textbooks


A different level of? Evidence ?


212/289


213/289

I opted to test C.t.M. outside the casino using the toss of a coin.

Evidence


214/289

I toss a coin (not actually randombut close enough for our example)

If C.t.M. guesses (the voices tell him) correctly - - -then the answer is yes

Chaz the MagnificentY N First Toss of the Coin

So,


215/289

Y N Y N

I decide to start by tossing the coin twice

If the voices in C.t.M.shead are just guessingthen there is an equalchance of one of four outcomes

2nd Toss of the Coin

Y YY YN N

NN

What can we say about C.t.M. after 2tosses of the coin?


216/289

Chaz the Magnificent

What would convince you?


217/289

How many times would C.t.M. have to tossthe coin for you to listen to use your money

and gamble at roulette based on input fromthe voices in his head?

Raise your hand

2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 50, 95


218/289


219/289

Why do we care about p ?

What is a SAMPLE ?


220/289

Lets conduct a simple experiment.For some odd reason, I want to know the average number of boxingmatches a nursing student watches during each month.

Our population is nursing students . . . So I will SAMPLE this class

We will assume that this class is representative of ALL the nursingclasses in ALL the nursing schools in ALL the world.

Further, this includes past present and future nursing students.

THINK ABOUT THIS - I take a sample of 30 students from this class.- - - How many samples of 30 are there?

What does a sample of 30 really

What is a SAMPLE ?


221/289

30 students = 1 sample

31 students = 30 samples

32 students = 90 samples

33 students = 270 samples100 students = some crazynumber

3070

p 3 y

represent?

( )


222/289

Bell Curve


223/289

The more you sample the better the curve

The standard normal distribution

68% of the area is between -1 and 1 SD



224/289



225/289

0.5 %

68%

95%

99%

Standard Normal Curve = 0, = 1


226/289

= 01.96-1.96 Z-Scores

95%

2.5%2.5%

?

SystematicReview


227/289



Clinical Reports

Nursing Experience

Textbooks


A different level of? Evidence ?

BISBISpectral Index

Using


228/289

microprocessortechnology it is

now possible to

continuously

analyze the EEG

signal and relay

that information

in a combinationof a digital and

analog output.


229/289

COST Study operationalized


230/289

Does: BIS + Ramsay = Sedation

Does: Physiologic

+ Observational = Sedation

a.k.a.

COST Study Methods


231/289

Enroll 67 patients in the Neuro ICU

Enroll EVERY nurse in the Neuro ICU

Randomly assign at patient to group

Standard of care (aka Ramsay)

Standard of care + BIS (aka Ramsay + BIS)Observer and record Sedative Use for 24 hours

Olson, Thoyre, Graffagnino (in press)Bispectral Index reduces drug use

HO: BIS = RamsayHypothesis


232/289

Dependent

Variable

BIS-Augmentation

Mean

Ramsay-

Alone

Mean

F p value r2

Propofol

Volume97.51 ml 175.36 ml 6.00 .0180 .11

Propofol Rate15.35

mcg/kg/min

30.19

mcg/kg/min8.63 .0050 .15

HA: BIS Ramsay

50% reduction


233/289

Does the % of time at goal predict the propofol infusion rate ?

50


234/289

InfusionRatemcg/kg/min

00 10 30 40

Percent of time at goal BIS (60 70)

20

Is it worth exploringintervention fidelity?


235/289

Do group assignment and intervention fidelity (takentogether) help to predict sedation use?

Sum of MeanSource DF Squares Square F Value Pr > FModel 2 2533.65683 1266.82842 5.52 0.0087Error 32 7341.81185 229.43162Corrected Total 34 9875.46869

Root MSE 15.14700 R-Square 0.2566Dependent Mean 22.87827 Adj R-Sq 0.2101Coeff Var 66.20694

Parameter EstimatesParameter Standard

Variable DF Estimate Error t Value Pr > |t| Type I SS Type II SSIntercept 1 38.85466 5.60518 6.93


236/289

Yir-YorontMissionaries noted that everyone used the axes, the stone axes

were inefficient, and there were not enough axes to go around. . .


237/289

And so . . They got new steel axes, which they gave freely to all themembers of the tribe.

Youngmales

Eldermales

MostFemales


238/289


239/289


240/289


241/289

Innovators

Diffusion of Innovations


242/289

I am venturesome. I am the first one to tryand to endorse a new innovation.

Diffusion of InnovationsEarly Adopters


243/289

Although I am not the first to adopt a new innovation,other people seek my opinion or follow my examplewhen it comes to new ideas and new innovations.

Early Majority



244/289

I am usually in the first half of people to adopt anew innovation.

Late Majority



245/289

I am skeptical about new ideas and new innovations.I am in the last half of people who adopt a new

innovation.


246/289

?

SystematicReview

R d i d


247/289



Clinical Reports

Nursing Experience

Textbooks



248/289


249/289

Del Zoppo GJ, Saver JL, Jauch EC, Adams HP, Jr. Expansion of

the time window for treatment of acute ischemic stroke withintravenous tissue plasminogen activator: A science advisoryfrom the american heart association/american strokeassociation. Stroke. 2009;40:2945-2948


250/289


251/289

clumping

H i l I i i d S


252/289

Hospital-Initiated Support

Patient and Family education

hospital-based home-based

Community-based Support

Chronic Disease management

Hospital-Initiated SupportIntervention Good measures Equal measures

E l 8 D th B th l I d RS NHP


253/289

Earlysupporteddischarge

8 DeathmRSNottingham HPLOSpt. satisfactionInstitutionalizaito

n I-ADL

10 Barthel Index, mRS, NHP,Death, BBS, Timed walk,EADL, GHQ, MADR, FAI,MMSE, AshSS, FIM, SF-36,Timed - up-n-go,Rehosp, MD-follow

Integrated carepathway

0 ----- 2 Barthel IndexDeathLOSEQ-5D

ESD forcaregivers

1 Caregivers strain 3 Caregiver StrainBurden Scale for FamilyCaregivers

Patient and Family education(hospital-based)

I i G d E l M


254/289

Intervention Good measures Equal Measures

Computer-tailorededucation

1 Pt. Satisfaction 1 Dartmouth CO-OPKnowledgeself-efficacy

HADS (Hospital Anxiety andDepression)


255/289


Intervention Good measures Equal measures


256/289

Post-dischargecaremanagement

2 SIPKnowledge

3 Barthel, CES-D, Death, Falls,NIHSS, LOS, Timed up-n-go,QOL, FAI, FQM, I-ADL

FamilySupport,Community-based stroketeam

3 SF-36 energySF-36 caregiverQOLPt. Satisfaction

3 Barthel, COOP-(patient),COOP(caregiver), FAI-caregiver,HADS, LHS, RMI, GHQ,Caregiver Strain, EQ-5D, LOS,SF-36 (MCS), SF-36 (PCS), Timedwalk

Page 1 of 3


Intervention Good measures Equal Measures


257/289

Telephonecounseling

1 CGI-I (only @ 3months)

2 CGI-I (6-months)Barthel IndexmRS, HADS, SASC, SF-36

Expert PatientProgramme

0 1 HADS (anxiety)HADS (depression)MIDASSF-36 (MCS)SF-36 (PCS)

Page 2 of 3


Intervention Goo

d

measures Equal measures


258/289

dSocial Worker,psychosocialinterventions

1 Self-carecomplianceGDSSF-36 (motor)

2 Barthel IndexSF-36 PCS

Home carecognitiveTherapy

0 1 CSSDeathI-ADLPhysical Exercise

Page 3 of 3

Chronic Disease managementIntervention Good measures Equal measures


259/289

Integrated care 3 Depression(PHQ-9),ActivitymRSQuality of Life

2 BarthelDepressionMMSE

Usual care

M t t di d l th i


260/289

Most studies used usual care as theircomparator, but few studies actually tell

us what usual care really is.

ConclusionEarly Supported Discharge may be

h l f l f t k


261/289

helpful for stroke

For stroke no other intervention had

sufficient evidence of benefit to berecommended.

We have a long way to go . . .

?

SystematicReview

RandomizedCli i l T i l


262/289



Clinical Reports

Nursing Experience

Textbooks


Should We

QuestionOur

PAST ?

S bj ti


263/289

Subjective

Sedation

Assessment

Sedation - Scales

G i


264/289

Guessing Patient movement

Increased heart rate

Increased blood pressure

too little


265/289

too much


266/289

? Just Right ?


267/289

1 anxious/agitated restless or both

Subjective Ramsay


268/289

1 anxious/agitated, restless or both

2 cooperative, oriented, and tranquil

3 responding to commands only

4 brisk response to light glabellar tap

5 slow response to light glabellar tap

6 no response to light glabellar tap

Richmond Agitation-Sedation Score

+ 4 Combative, violent, danger to staff

P ll b i

Subjective RAAS


269/289

+ 3 Pulls or removes tubes, aggressive

+ 2 Frequent non-purposeful movement, fights ventilator

+ 1 Anxious, apprehensive, but not aggressive

0 Alert and calm

- 1 Awakens to voice > 10 seconds

- 2 Light sedation, awakens to voice < 10 seconds

- 3 Movement or eye opening, no eye contact

- 4 No response to voice, eye opening to physical contact

- 5 No response to voice or physical stimulation

1 dangerous agitation

Subjective Sedation-Agitation Scale


270/289

1 dangerous agitation

2 very agitated

3 agitated4 calm and cooperative

5 sedated

6 very sedated

7 unarousable

Motor Activity Assessment Scale

0 unresponsive

Subjective MAAS


271/289

0 unresponsive

1 responds to noxious stimuli

2 responds to touch or name

3 calm and cooperative

4 restless and cooperative

5 agitated

6 dangerously agitated

Ramsay started this. But


272/289


273/289

* Ramsay MA, Aavege TM, Simpson BR, Goodwin R (1974) Controlled Sedation with alphaxalone alphadolone. Br Med J 2(920):656-9

A little background on this paper . . ..


274/289

. . Six levels of sedation were formulated; three with the patient awake

and three with the patient asleep.

Awake levels where: 1, patient anxious and agitated or restless or

both; 2, patient co operative, oriented and tranquil; 3, patient responds to

commands only. Asleep levels where dependent on the patients response


275/289

y p p p pto a light glabellar tap or loud auditory stimulus: Level 4, a brisk response;

5, a sluggish response; 6, no response.

The Original Ramsay Paper

fto

tal)

40ftotal)

4040 N = 30


276/289

Time spent at different sedation levels expressed aspercentages of total sedation time. (See text for definition ofsedation level)


Sedationtime(%of 40

30

20

10

Level ofSedation

Unsatisfactory Satisfactory Unsatisfactory4-6% 86-5% 8-9%

Sedationtime(%of

1 2 3 4 5 6

4030

20

10

Level ofSedation

Unsatisfactory Satisfactory Unsatisfactory4-6% 86-5% 89%

4030

20

10

Level ofSedation

Unsatisfactory Satisfactory Unsatisfactory4-6% 86-5% 9%


N 30

What Is Reliability

Inter-Rater Reliability Intra-Rater Reliability

We decided to test the reliability ofthe Ramsay Scale


277/289

Inter Rater Reliability Intra Rater Reliability

MethodsWhat did we do?


278/289

Phase 1 - - - Make the videos

Expert scoring

Phase 2 - - - Reliability assessment

Phase 1 - - - Making the videos

Consent the patient


279/289

Consent the patient

Set up equipment

Film for ~ 1 minuteHead to the BBL

Edit to a 30 second video clip

Present video-clips to experts

Present video-clips to experts

H


280/289

Harry

Hagrid

Dumbledore

ChoFawkes

Ron

Hermoine

Cho

Harry

Snape

McGonagal

Phase2

Yes

No

Phase 2 - - - Recruit & Randomize


281/289

Phase 2 - - - Scoring the video


282/289

241 RNs enrolled

Days (48%) - Nights (28%) - Both(24%)


283/289

Female (81%) - Male (19%)

2200

44 RNs

3200

28 RNs

PACU

11 RNs

4200

60 RNs

720039 RNs

Cath Lab12 RNs

820045 RNs

ISRP2 RNs

( 7 critical care areasrepresented )

Red Yellow Orange Green Blue Totals

Red 7 0 1 0 0 8

Yellow 1 24 0 0 0 25

exp

exp

1P

PPK

obs

Data Analysis - what does Kappa measure ?


284/289

Orange 1 1 17 2 2 23

Green 0 0 3 25 1 29

Blue 0 0 0 1 14 15

Total9 25 21 28 17 100

)100100(

)1517()2928()2321()2525()89(exp

P2247.exp P

100

142517247

obsP87.

obsP

2247.1

2247.87.

K

8323.K

Reliability of

Ramsay

Data Analysis


285/289

Ramsay

Kappa = .277

Ramsay Scores by Nurse Subjects

Score 1 2 3 4 5 6

Total

1 12 4 9 6 8 39

2 11 14 11 4 40

3 3 2 27 9 41

4 1 2 3 33 39

5 1 29 9 39

Ramsay

Scores

By

Experts6 3 36 39

Total 13 15 28 23 104 54 237

ConclusionWhat does this mean?


286/289

Why does this matter?

M iWeaning

Weaning


287/289

TheRamsay Scale

Much of whatwe know and think of as the

SCIENCEof sedation assessment and managementSedation

AgitationScale

RASS(Richmond)

ManagingPropofol

NursingWorkload

gFrom

VentilatorCAM - ICU

MAAS Documentation

StandardsWhatDrugs

Work ?

Cost

Studies

BISSedation

AgitationScale

RASS(Richmond)

ManagingPropofol

NursingWorkload

WeaningFrom

VentilatorCAM - ICU

MAAS Documentation

StandardsWhatDrugsWork ?

Cost

Studies

BISCost

StudiesMAAS

MAAS

WeaningFrom

Ventilator

DONE


288/289

Now, its Your Turn


289/289

2012+02+14+philippines daiwai

Documents