Adult Health Chapter 45 Neuro Flashcards
What are some non-modifiable risk factors for ischemic stroke?
Age
2/3 over 65
Gender-M=F
Female>fatality
Race-Higher incidence AA, NA, Hispanic than caucasian
Heredity-Family history, Previous TIA/CVA
What are some modifiable risk factors for ischemic stroke?
"***Hypertension **** Diabetes mellitus Heart disease A-fib Asymptomatic carotid stenosis Hyperlipidemia Obesity Oral contraceptive use Heavy alcohol use Physical inactivity Smoking Substance abuse
Describe a hemorrhagic stroke.
Rupture of vessel Sudden Active Fatal HTN Trauma Varied manifestations
What is the patho behind a hemorrhagic stroke.
Pathophysiology review
Blood will enter brain tissue, cerebral ventricles, &/or subarachnoid space
Tissue compression, blood vessel spasm, and edema occur
Blood is irritant to tissues, causing inflammatory reaction and affecting CSF circulation/absorption
What are the 2 kinds of hemorrhagic stroke?
Intracerebral
Hemorrhage
Subarachnoid
Hemorrhage
Describe a SAH- Subarachnoid hemorrhage.
SAH: much more common and results from bleeding into subarachnoid space
Usually caused by ruptured aneurysm, AVM or trauma
Describe ICH- intracerebral hemorrhage
ICH: Intracerebral hemorrhage is bleeding into brain tissue
Usually caused by severe or sustained HTN
HTN damages arterial wall and will weaken over time
What is the subarachnoid space?
space between the pia mater and the arachnoid layers of the meninges
Describe the etiology of a hemorrhagic stroke.
Chronic HTN Anticoagulation AVM Ruptured aneurysm (usually subarachnoid) Tumor Drugs ex. Cocaine Trauma Transformation of ischemic stroke Physical exertion, Pregnancy Post-operative
What are the 5 most common symptoms of stroke?
Sudden difficulty speaking
Sudden numbness/weakness in arm, leg, face
Sudden trouble seeing in one or both eyes
Sudden dizziness, trouble walking or loss of balance or coordination
Sudden severe headache ‘worst headache of my life’ associated with SAH
Describe a neuro assessment and prioritization..
Transport patient to stroke center; ABC’s is the priority
Focused history- is the pt. on any anticoagulants?
When did the stroke begin? What were they doing? Hemorrhagic tends to be more abrupt; thrombotic more gradual
What are some specific assessments for neuro?
Cognitive changes: LOC, (r/o hypoglycemia, and hypoxia)
Motor changes
Sensory changes- LOC, speech,
Cranial nerve assessment - shrug shoulders, blow cheeks, smile, tongue symetrical
CV assessment
Do NIH stroke scale upon arrival to ED
What is the NIH stroke scale score?
Current NIH Stroke Score guidelines for measuring stroke severity:
Points are given for each impairment.
0= no stroke
1-4= minor stroke
5-15= moderate stroke
15-20= moderate/severe stroke
21-42= severe stroke
A maximal score of 42 represents the most severe and devastating stroke
What does the NIH stroke scale score mean?
It is a standardized method which measures the degree of stroke r/t impairment and change in a patient over time.
Measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language not measured by Glasgow coma scale.
Describe the NIH stroke scale table and what it includes.
Assesses 11 areas including: LOC Gaze Visual deficits Facial palsy Motor; arms and legs Limb atxia (gait disturbance) Sensory deficit Language Dysarthria Neglect (ex. does not recognize one’s own hand)
What does a low scale on the Glasgow coma scale mean?
Close to a coma or inability to respond
What diagnostic test is most important for confirming the dx of a stroke?
Head CT without contrast- negative result =ischemic stroke
MRI shows an ischemic stroke sooner
What are some labs to indicate a stroke?
check for infection, coagulation, pt, ptt, INR, 12 lead EKG, and enzymes rule out any cardiac problems
What is the treatment for stroke?
IV or IA thrombolytic therapy Alteplase/Activase t-PA (for ischemic)
Eligibility criteria: time of onset of stroke 3 hours, up to 4.5 hrs. Longer for IA (6 hours)
Describe nursing care with t-PA .
ABC’s, VS, Two IV lines with non-dextrose solution, monitor for increasing ICP, screening criteria for thrombolytic therapy (anticoagulants, recent surgery, elevated INR, past 4 hours and 30 minute time frame, age, hypertension, any recent GI bleeding, any hx of hemorrhagic stroke/just stroke, trauma patient), No antiplatelet or anticoagulant therapy should be administered for 24 hours following tPA, and first do f/u CT
Keep SBP
What is a embolectomy?
retrieval of clot with special instrument and suction
What is a carotid endarterectomy?
preventive > 100,000/year
removal of atheromatous lesions, stent placement
What is the treatment of AV malformations?
craniotomy to remove, bypass AVM, and radiosurgery (gamma knife) to thicken the AVM vessel walls to keep from enlarging
What are the different ways to fix an aneurysm?
clipping, wrapping, coiling
Describe some drug therapy.
Anticoagulants including anti-platelet drugs like aspirin (325mg given within first 24-48 hours within onset of stroke)
Clopidogrel (Plavix), also has been used, especially in patients who are intolerant orto aspirin. Aspirin is sometimes combined with a second anti-platelet agent, dipyridamole (Persantine, Aggrenox), to prevent strokes.
Anti-coagulants: heparin, warfarin are used in presence of atrial fibrillation
Describe traumatic Brain injury
Blow or jolt to head causing damage to brain
May be open or closed injury, direct or indirect
ex. Direct blow to head vs. indirect injury from brain moving within cranial vault from force of injury.
Can cause laceration within brain, contusion, bleeding, tearing/rotation of brain from brainstem
Describe an acceleration injury
external force contacting the head suddenly
Describe a deceleration injury
when that force suddenly stops or hits a stationary object
Describe open vs. closed brain injury
Open vs. closed head injuries
Open- skull fracture present, integrity of brain and dura is open to contaminants
Closed: contusion at site of impact (coup) and opposite site (counter-coup), tearing of vessels can lead to secondary hemorrhage
Describe the primary brain injury classification.
Mild, moderate(few minutes to hours), severe (LOC for 6 hours to a few days or longer)classification: starts with initial GCS upon injury, length of loss of consciousness, loss of memory, neurological deficits (aka concussion)
Describe coup and coutrecoup injury
Coup (site of impact) injury to frontal area of brain, and contrecoup injury to frontal and temporal areas of the brain
Where is the acceleration-deceleration injury seen?
typically seen during MVCs- motor vehicle crashes
Describe the hematomas.
Epidural hematoma (outside the dura mater of the brain), subdural hematoma (under the dura mater), and intracerebral hemorrhage (within the brain tissue).
Describe subdural hematoma.
Subdural-Venous bleeding into space beneath dura and above arachnoid
Most commonly from tearing of bridging veins within cerebral hemispheres or from laceration of brain tissue
Bleeding occurs more slowly, sometimes sx not recognized
Can be acute or chronic
Describe an epidural hematoma
Arterial bleeding into space between dura and inner skull
May be from skull fracture of temporal bone housing middle meningeal artery
Period of lucidity after unconsciousness, followed by unconsciousness
What is hydrocephalus?
buildup of CSF inside the skull, which leads to brain swelling and increased ICP
What is a brain herniation?
in the presence of increased ICP, brain tissue, cerebrospinal fluid, and blood vessels are moved or pressed away from their usual position inside the skull; moved to one side uncal or downward to brainstem
What are some late findings with a brain herniation?
pupillary changes, rapid deterioration in LOC, changes in VS: life threatening
What are some complications of hematomas?
hydrocephalus, brain hernication
Describe Increased Intracranial Pressure
Leading cause of death from head trauma in patients who reach hospital alive
Brain cannot accommodate increased volume
As ICP increases, cerebral perfusion pressure decreases leading to ischemia and edema
If edema remains untreated, brain can herniate downward to brainstem or to one side leading to irreversible damage
What is the Cerbral Perfusion Pressure?
CPP= MAP – ICP
Goal is to keep CPP greater than 70 and ICP less than 20
What is the first sign of neuro deterioration?
diminished LOC
What is Cushing’s triad?
classic but late sign of increasing ICP
HTN, widened pulse pressure, and bradycardia
Describe the brain tumors.
Primary tumors originate within central nervous system (CNS)
Secondary tumors from metastasis in other parts of body (ex. Lung, breast, kidney, GI tract)
Describe the classification of brain tumors.
benign- meningioma, pituitary adenoma, acoustic neuroma
malignant- glioblastoma, astrocytoma, glioma
What are some other classifications of brain tumors?
: supratentorial (within cerebral hemisphere) and infratentorial (within brainstem and cerebellum)
What are some clinical presentation of brain tumors?
Headaches
Nausea/vomiting
Visual changes
New onset of seizures
Numbness/paralysis on one side of body or face
Difficulty speaking, change in personality or mentation
Papilledema (swelling of optic disc) increased ICP
Describe the management of brain tumors.
Radiation therapy
Chemotherapy: IV or intrathecally (Ommaya reservoir)
Analgesics
Dexamethasone
Anti-epileptics: ex. Phenytoin
Stereotactic radiosurgery: gamma knife or cyber knife
Describe a craniotomy.
Incision into cranium to remove tumor, repair vessel, debulk tumor
Post op care: maintain airway, neuro checks
Prevent complications table 45-7
Monitor for signs of I ICP
Respiratory complications
Wound infection
Fluid/electrolyte imbalances (could develop DI/SIADH)
Monitor for seizure activity/prevent
What does contralateral mean?
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What does arteriovenous malfomation?
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What does aphasia mean?
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What does dyslexia mean?
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What does agraphia mean?
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What does ataxia mean?
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What does homonymous hemianopsia mean?
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what does dysphagia mean?
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What does agnosia mean?
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What does apraxia mean?
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What does nystagmus mean?
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What does dipliopia mean?
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What does decerebrate mean?
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What does decorticate mean?
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What does craiotomy/crainioectomy mean?
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The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine.
What is the priority nursing intervention for this patient at this time?
A. Provide perineal care.
B. Assess for gag reflex.
C. Elevate the head of the bed.
D. Perform a linen and gown change.
Answer: C
The airway must be protected. Elevating the head of the bed prevents swallowing concerns and allows for an open airway. The patient should then be assessed for a gag reflex, perineal care should be provided, and linens changed
An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which manifestations would the nurse expect? (Select all that apply.)
A. Constant smiling
B. Intellectual impairment
C. Deficits in the right visual field
D. Disorientation to time, place, and person
E. Inability to discriminate words and letters
Answer: B, C, E
Patients experiencing a left hemisphere stroke display an inability to discriminate words and letters, intellectual impairment, and deficits in the right visual field. Disorientation, constant smiling, and neglect of left visual field are manifestation of a right hemisphere stroke
The patient is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV thrombolytic therapy. What is the nurse’s best response?
Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is the nurse’s best response?
- Patients must meet strict eligibility criteria for thrombolytic therapy with rtPA (recombinant tissue plasminogen activator), including giving the drug within 3 hours after the first stroke symptoms.
- Before the patient is given any liquids, food, or medications, he must be screened for the ability to swallow. Also his gag and cough reflexes must be checked. After he has his swallowing screen and it is determined that he can tolerate liquids or food without aspirating, fluids and food will be provided.
The patient’s wife must leave her husband’s bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to patient safety while she is gone?
A. Apply restraints.
B. Maintain the bed in a low position.
C. Sit with the patient until his wife returns.
D. Place the call light in the patient’s right hand.
Answer: B
Restraints should not be applied until all alternate methods have been attempted. Sitting with a patient for 2 hours is impractical for the nurse. Placing a call light in the patient’s right hand would not be effective because he has deficits in his right visual field and may have right field neglect.
The patient needs assistance with feeding, but can swallow well. To whom should the nurse delegate this responsibility?
A. Hospital volunteer
B. Licensed practical nurse
C. Certified nursing assistant
D. Student nurse doing first patient care experience
Answer: C
Feeding patients falls within the scope of practice for a CNA.
The nurse understands that the greatest risk for a patient with dysfunction of cranial nerves IX and X is which of the following?
A. Weight loss
B. Dehydration
C. Constipation
D. Aspiration pneumonia
Answer: D
Rationale: Cranial nerves IX (glossopharyngeal) and X (vagal) assist with the patient’s ability to swallow. Aspiration pneumonia is a serious risk associated with dysfunction of these cranial nerves. Other concerns include dehydration, constipation, and inadequate nutrition.
The nurse understands which symptom is the earliest indicator of increased intracranial pressure when caring for a patient with a head injury?
A. Increased pupil size
B. Nausea and vomiting
C. Agitation and confusion
D. Elevated blood pressure
Answer: C
Rationale: The first sign of increased intracranial pressure (ICP) is a declining or changing level of consciousness (LOC). Patients may be agitated and slightly confused before progressing to difficult to arouse as an early assessment variable of increased ICP. Changes in vital signs, nausea and vomiting, and pupillary response occur as ICP increases.
The nurse understands that what percent of strokes occur in patients less than 65 years of age?
A. 10%
B. 15%
C. 25%
D. 35%
Answer: C
Rationale: Most strokes (~75%) occur in people over the age of 65. The risk of having a stroke more than doubles each decade after the age of 55. Strokes can – and do – occur at any age. Nearly one quarter of strokes occur in people under the age of 65.
