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Nursing 2016 > Adult Health Chapter 45 Neuro > Flashcards

Adult Health Chapter 45 Neuro Flashcards

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1
Q

What are some non-modifiable risk factors for ischemic stroke?

A

Age
2/3 over 65
Gender-M=F
Female>fatality
Race-Higher incidence AA, NA, Hispanic than caucasian
Heredity-Family history, Previous TIA/CVA

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2
Q

What are some modifiable risk factors for ischemic stroke?

A 
"***Hypertension ****
Diabetes mellitus
Heart disease
A-fib
Asymptomatic carotid stenosis
Hyperlipidemia
Obesity
Oral contraceptive use
Heavy alcohol use
Physical inactivity
Smoking
Substance abuse
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3
Q

Describe a hemorrhagic stroke.

A 
Rupture of vessel
Sudden
Active
Fatal
HTN
Trauma
Varied manifestations
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4
Q

What is the patho behind a hemorrhagic stroke.

A

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

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5
Q

What are the 2 kinds of hemorrhagic stroke?

A

Intracerebral
Hemorrhage
Subarachnoid
Hemorrhage

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6
Q

Describe a SAH- Subarachnoid hemorrhage.

A

SAH: much more common and results from bleeding into subarachnoid space
Usually caused by ruptured aneurysm, AVM or trauma

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7
Q

Describe ICH- intracerebral hemorrhage

A

ICH: Intracerebral hemorrhage is bleeding into brain tissue
Usually caused by severe or sustained HTN
HTN damages arterial wall and will weaken over time

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8
Q

What is the subarachnoid space?

A

space between the pia mater and the arachnoid layers of the meninges

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9
Q

Describe the etiology of a hemorrhagic stroke.

A 
Chronic HTN
Anticoagulation
AVM
Ruptured aneurysm (usually subarachnoid)
Tumor
Drugs ex. Cocaine
Trauma 
Transformation of ischemic stroke
Physical exertion, Pregnancy
Post-operative
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10
Q

What are the 5 most common symptoms of stroke?

A

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

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11
Q

Describe a neuro assessment and prioritization..

A

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

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12
Q

What are some specific assessments for neuro?

A

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

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13
Q

What is the NIH stroke scale score?

A

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

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14
Q

What does the NIH stroke scale score mean?

A

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.

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15
Q

Describe the NIH stroke scale table and what it includes.

A 
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)
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16
Q

What does a low scale on the Glasgow coma scale mean?

A

Close to a coma or inability to respond

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17
Q

What diagnostic test is most important for confirming the dx of a stroke?

A

Head CT without contrast- negative result =ischemic stroke

MRI shows an ischemic stroke sooner

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18
Q

What are some labs to indicate a stroke?

A

check for infection, coagulation, pt, ptt, INR, 12 lead EKG, and enzymes rule out any cardiac problems

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19
Q

What is the treatment for stroke?

A

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)

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20
Q

Describe nursing care with t-PA .

A

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

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21
Q

What is a embolectomy?

A

retrieval of clot with special instrument and suction

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22
Q

What is a carotid endarterectomy?

A

preventive > 100,000/year

removal of atheromatous lesions, stent placement

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23
Q

What is the treatment of AV malformations?

A

craniotomy to remove, bypass AVM, and radiosurgery (gamma knife) to thicken the AVM vessel walls to keep from enlarging

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24
Q

What are the different ways to fix an aneurysm?

A

clipping, wrapping, coiling

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25
Q

Describe some drug therapy.

A

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

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26
Q

Describe traumatic Brain injury

A

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

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27
Q

Describe an acceleration injury

A

external force contacting the head suddenly

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28
Q

Describe a deceleration injury

A

when that force suddenly stops or hits a stationary object

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29
Q

Describe open vs. closed brain injury

A

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

30
Q

Describe the primary brain injury classification.

A

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)

31
Q

Describe coup and coutrecoup injury

A

Coup (site of impact) injury to frontal area of brain, and contrecoup injury to frontal and temporal areas of the brain

32
Q

Where is the acceleration-deceleration injury seen?

A

typically seen during MVCs- motor vehicle crashes

33
Q

Describe the hematomas.

A

Epidural hematoma (outside the dura mater of the brain), subdural hematoma (under the dura mater), and intracerebral hemorrhage (within the brain tissue).

34
Q

Describe subdural hematoma.

A

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

35
Q

Describe an epidural hematoma

A

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

36
Q

What is hydrocephalus?

A

buildup of CSF inside the skull, which leads to brain swelling and increased ICP

37
Q

What is a brain herniation?

A

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

38
Q

What are some late findings with a brain herniation?

A

pupillary changes, rapid deterioration in LOC, changes in VS: life threatening

39
Q

What are some complications of hematomas?

A

hydrocephalus, brain hernication

40
Q

Describe Increased Intracranial Pressure

A

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

41
Q

What is the Cerbral Perfusion Pressure?

A

CPP= MAP – ICP

Goal is to keep CPP greater than 70 and ICP less than 20

42
Q

What is the first sign of neuro deterioration?

A

diminished LOC

43
Q

What is Cushing’s triad?

A

classic but late sign of increasing ICP

HTN, widened pulse pressure, and bradycardia

44
Q

Describe the brain tumors.

A

Primary tumors originate within central nervous system (CNS)

Secondary tumors from metastasis in other parts of body (ex. Lung, breast, kidney, GI tract)

45
Q

Describe the classification of brain tumors.

A

benign- meningioma, pituitary adenoma, acoustic neuroma

malignant- glioblastoma, astrocytoma, glioma

46
Q

What are some other classifications of brain tumors?

A

: supratentorial (within cerebral hemisphere) and infratentorial (within brainstem and cerebellum)

47
Q

What are some clinical presentation of brain tumors?

A

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

48
Q

Describe the management of brain tumors.

A

Radiation therapy
Chemotherapy: IV or intrathecally (Ommaya reservoir)
Analgesics
Dexamethasone
Anti-epileptics: ex. Phenytoin
Stereotactic radiosurgery: gamma knife or cyber knife

49
Q

Describe a craniotomy.

A

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

50
Q

What does contralateral mean?

A

.

51
Q

What does arteriovenous malfomation?

A

.

52
Q

What does aphasia mean?

A

.

53
Q

What does dyslexia mean?

A

.

54
Q

What does agraphia mean?

A

.

55
Q

What does ataxia mean?

A

.

56
Q

What does homonymous hemianopsia mean?

A

.

57
Q

what does dysphagia mean?

A

.

58
Q

What does agnosia mean?

A

.

59
Q

What does apraxia mean?

A

.

60
Q

What does nystagmus mean?

A

.

61
Q

What does dipliopia mean?

A

.

62
Q

What does decerebrate mean?

A

.

63
Q

What does decorticate mean?

A

.

64
Q

What does craiotomy/crainioectomy mean?

A

.

65
Q

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.

A

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

66
Q

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

A

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

67
Q

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?

A
  1. 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.
  2. 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.
68
Q

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.

A

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.

69
Q

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

A

Answer: C

Feeding patients falls within the scope of practice for a CNA.

70
Q

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

A

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.

71
Q

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

A

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.

72
Q

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%

A

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.

Nursing 2016 (20 decks)

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