neurological
Terms
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- Describe what happens in the brain during a CVA "brain attack"
- Disruption in the nml blood supply to the brain
- What is Cerebral Autoregulation? How is it characterized?
-
1000ml/min blood flow
Dilation/constriction prn
Lack of perfusion - Name the 2 types of strokes and their subsets.
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Ischemic (occlusive)
Thrombolic stroke
Embolic stroke
Hemorragic - Describe the etiology of an embolic stroke.
-
Embolus/emboli travel to cerebral arteries via carotid artery
Sources of emboli are cardiac
Can be TIA's, RIND's or permanent
Accounts for 1/3d of all strokes - Describe the etiology of a Thrombolic Stroke. Acounts for 1/2 of all strokes
-
Associated with atherosclerosis, plaques build up and occlude vessels
slow onset of s/s
occurs at bifurcations of the common carotid and vertebral arteries at juncture with basilar artery - What types of medications will be given for the eschimic stroke?
- Heparin initially until INR's are therapeutic then concurrent Coumadin for a few days before d/cing Heparin.
- Aphasia
-
inablility to use/ comprehend
expressive/ receptive - Alexia
- reading difficulty
- agraphia
- writing difficulty
- hemiplegia
- paralysis, one sided
- hemeparesis
- weakness, one sided
- flaccidity (hypotonia)
- nurse notes a fall to one side
- what is the etiology of an Hemorragic stroke?
-
weakened vessel walls cause a rupture and brain bleed
Saccular or Berry aneurysm -
What is a TIA
What is a RIND
how are they the same and how are they different.
what type of stoke are they associated with? -
TIA = few minutes, <24 hours
Blurred/double/blindness/tunneling
–Weakness/gait disturbance
–Numbness (transient)
–Vertigo
–Aphasia/dysarthria (slurred speech)
RIND = > 24 hours <week - what are some physical assessments of an eschimic stroke
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Cognitive changes:
LOC may vary
Hemiparesis
Denial
Spatial/ proprioceptive dysfx
memory impairment
Prolem solving/decision-malking issues - What types of manifestations are seen with the Left sided brain injury/stroke?
- Aphasia, alexia, agraphia. This is the speech/language center
- What clinical manifestations are associated with Right sided brain injury/stroke?
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Neglect syndrome
visual field deficitsamaurosis fugax/brief blindness
may be impulsive
emotional lability if frotal lobe is involved. - Causes of Hemorrhagic Stroke?
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HTN--stretches and thins vessel wall
genetic/traumatic weakening of the vessel walls
Rupture usually occurs with activity - Risk Factors for hemoragic stroke
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HTN, diabetis mellitus
heart disease
nonvalvular a-fib
smoking/substance abuse
sedentary lifestyle
WOMEN--high Hgb (>14) - what kind of Hx is gathered for stroke pts.
-
• Accurate history
• Important to affected area
• s/sx?
• When did it start? (ischemic = sleep; hemorrhagic = activity…usually)
• How the s/sx progressed?
• Onset important (embolic/hemo = abrupt; thrombolytic = gradual…usually)
• S/Sx come and go? (TIA, RIND)
• Observe LOC during interview
• Monitor speech pattern/body posture, etc
• Medical hx?
• Family hx?
• Diet? - interventions for stroke pts
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•Stabilize patient, reduce further injury
•Determined by type/extent of injury
•Nonsurgical management
Patient may be at risk for increased ICP
Glasgow Coma Scale (GCS) - What are key features of increased ICP
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Decreases LOC sensorimotor ^
Behavioral^s pupillary^
HA cranial nerve involve
N/V ataxia
Speech ? sz
Aphasia Cushings' Triad
Slurred speech Posturing - What is Cushings Triad/ cuushings reflex?
- Bradycardia, hypertension, widening pulse pressure
- Nursing interventions for ICP increase
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•Frequent nursing assessments
First 72 hours critical
•Elevate HOB
•Maintain head position ¨ drainage
•Avoid extreme flexion (ª ITP)
•Avoid clustering of activities - Drug Therapy for increased ICP
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Thrombolytic therapy - dissolves occlusion
•Rt-PA (recomb tissue plasminogen act)
Anticoagulants - What labs for drug therapy
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PT
PTT
INR - wHAT TYPES OF SURGICAL MGT IS USED FOR STROKES
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• Endarterectomy
• Extracranial-intracranial bypass
• AVM management
• Craniotomy
Remove clots - Nursing interventions FOR SURGERY of stroke pts
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• Self-Care Deficit
Facilitate increased muscle strength/function
Positioning important
•Splinting Avoid contractures
DVTs are a risk to develop
• Antiembolism stockings
• Compression boots
• Frequent position changes
• Mobilization of the client - Disturbed Sensory Perception interventions (r-sided)
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visual/perceptual or spatial impairments depth erception/discrimination (up/down) thus ADLs
•Provide frequent cues
•Break down tasks into simple steps
•Approach from UNAFFECTED side
•UNAFFECTED side: should FACE the door
•Teach patient to scan environment
•Diplopia: use patch
•Remove clutter - interventions for L sided repercussions?
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Memory deficits, simple tasks difficult
Reorient to month, day, year
Establish routine schedule
Structured environment
Familiar objects
Step by step teaching -
Unilateral Neglect
•Goal: compensate for affected side
•Most common with R-sided stroke
•increased risk for injury -
Teach patient to touch/use both sides
Affected side first
Turn head for full vision fields
"scanning" technique -
Impaired Verbal Communication l-sided
•Goal: effective communication
• -
Language/speech (dominant hemisphere)
•Aphasia:
Expressive (Broca's; motor) frontal
Receptive (Wernicke's; sensory) Temporal/Parietal area: may talk but language is meaningless
Global (mixed) - Describe Broca's
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Expressive
1. Motor speech problem
2. Understands but unable to communicate
3. Difficulty with writing
4. Frustration and anger - describe Wernicke's
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Receptive /sensory
1. Unable to understand spoken and written word
2. Neologisms
3. Global or mixed aphasia
4. Reading and writing equally affected - Waht are foods that facilitate salivary production and aid is swollowing. What interventions for cliet iwth difficulty swallowing?
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Beef broth, sweek, sour, salty
Place food on the unaffected side
reduce distratctions
observe for s/s of fatigue - Health Teaching for stroke pt and their families
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Medication schedule (s/s bleeding, electric razor, avoid Vit.K etc.)
•Mobility
•Communication (patience, shortcommands)
•Safety
•Dietary (fat reduction diet with thrombotic stoke)
•Activity/self-care skills
•Psychosocial intervention (lability) (depression precautions)
•Families encouraged to permit individual to do as much as possible
•Families - take and plan for extra time to do things
•Care givers may need respite/time to relax
•Counseling - what age grou[ is most affected by TBIs
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18-34•year olds
MVA, most common cause
•Summer, spring, pm, noc, weekends
•3X more in males - TBI: Glascow Coma Scale
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Mild :13-15 gait altered
Mod: decreasing LOC GCS 9-12¨ 24 h observation
Severe: GCS <9 ¨ critical care - What is the problem with increased ICP
- increased ICP = decresed cerebral blood flow = tissue hypoxia = ¯decreased serum pH and increased CO2 = cerebral vasodilation = edema = increased ICP = brain hernation = irreversible brain damage = death (uncal herniation)
- when there is an increase in ICP, what happens to the cerebral blood flow
- decreases
- what happens with increase ICP and decreased cerebral blood flow?
-
tissue hypoxia, decrease in pH
increase in CO2 (causing cerebral vasodilation, edema, further increaseing iCP
brain my herniate into brainstem (uncal) -
Cytotoxic, cellular edema
From hypoxia
etiology -
Disturbance in cellular metabolism
Sodium pump Active ion transport
Brain depleted of O2, CHO, glycogen
Na+ pump fails, Na+ enters the cells and pulls H2O
Simultaneous decrease Na+ serum (<120 mEq/L) -
Interstitial edema:
Acute brain swelling - Assoc with HTN,increased ICP
- Three types of cerebral hemorrhage
-
Epidural Hematoma
Subdural Hematoma (SDH)
Intracrebral Hemorrhage -
Epidural Hematoma
Arterial bleeding -
Space: skull and dura mater
Frequent site: temporal lobe injury
"lucid" interval leading to unconsciousness
May proceed to coma and death -
Subdural Hematoma (SDH)
venous -
Space: dura mater and arachnoid
Common: laceration of brain tissue
Bleed is slower
•Acute - preseents with 48 hourse after impact
•Subacute - between 48 hours and 2 weeks
•Chronic - form 2 weeks to several months following the injury - Intracrebral Hemorrhage
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Intracrebral Hemorrhage
Accumulation of blood within tissue - Hydrocephalus
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Abnormal increase CSF volume
Caused dilation of ventricles
May lead to increased ICP -
Herniation
Uncal: life threatening -
Shift of one/both temporal lobes (uncus)
Pressure on 3rd cranial nerve
S/Sx: dilated/fixed pupils
Ptosis
Rapid? in conciousness - CENTRAL HERNIATION
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Downward shift of brainstem
Diencephalon
S/Sx: Cheyne-Stokes respirations
Pinpoint, fixed, nonreactive pupils -
Traumatic Brain Injury-Interventions
ﬠ -
Prevention of increased ICPï€
•Fluid and electrolyte balance
•Positioning/hyperventilation
•Induction of barbiturate coma/drug therapy (mannitol)
•Strategies for sensory/perceptual alterations
•Pulmonary management/behavioral management
•Strategies for preventing complications of immobility
•Nutrition management - Surgical management for TBI's
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Intracranial pressure monitoring
Craniotomy - Brain Tumors-Complications
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Cerebral (vasogenic) edema/ „^ ICP
Herniation of brain tissue/ischemia of affected area
Rupture/hemorrhage into brain tissue
Seizure activity/hydrocephalus
Pituitary dysfunction/SIADH/diabetes insipidusFluid and electrolyte imbalances -
Brain Tumors-Classification
„PƒnMalignant or benign -
Gliomas (malignant)
Meningiomas (benign)
Pituitary gland (benign)
Acoustic neuromas - Brain Tumors-Symptoms
-
Headache (severe on awakening in the AM)
Nausea and vomiting
Visual symptoms
Seizures
Changes in mentation or personality
Papilledema (swelling of the optic disk) -
Brain Tumors-Interventions
Nonsurgical management -
Radiation/chemotherapy
ƒnBlood brain barrier disruption
Recombinant DN
Monoclonal antibodies„PƒnAntineoplastic drugs
Immunotherapy/hyperthermia -
Interventions
Surgical management -
nBiopsy
Craniotomy - Brain Tumors-Postoperative Complications
-
Increased ICP
Hematomas
Hydrocephalus accumulation of the fluid
Respiratory problems
Neurogenic pulmonary edema
Would infection
Meningitis
Fluid/electrolyte imbalance