critical neurological disorders Flashcards
transient ischemic attack (TIA)
temporary dysfunction resulting from a brief interruption in cerebral blood flow
- symptoms resolve in 30-60 minutes
TIA s/sx
1) visual deficits: blurred vision, diplopia, blindness in one eye, tunnel vision
2) motor deficits: weakness, facial droop, arm or leg drift, hand grasp, ataxia, gait disturbance
3) sensory perception deficits: numbness to face, hand, arm or leg, vertigo
4) speech deficits: aphasia, dysarthria
TIA treatment
focuses on preventing another TIA or stroke
- BP control: ACE, ARBs, beta, calcium channel, diuretics
- antiplatelet medication: plavix, heparin, warfarin, aspirin
- blood sugar control
- cholesterol control
- promoting lifestyle changes : obesity, smoking cessation, nutrition/dieting as needed
stroke
caused by an interruption of perfusion to any part of the brain, resulting in cerebral tissue infarction in minutes
- types of stroke: ischemic (thrombotic/embolic), hemorrhagic (aneurysm, HTN, ateriovenous malformation)
ischemic stroke
caused by the occlusion (blockage) of a cerebral atery
- types: thrombotic, embolic
thrombotic stroke
caused by a thrombus from the development of atherosclerosis
- tends to have a slow onset, evolving over minutes to hours
embolic stroke
caused by dislodged clot that travels to the cerebral arteries
- sudden development and rapid occurrence of neurological deficits
TIP: embolic EXITS original site
hemorrhagic stroke
vessel integrity is interrupted and bleeding occurs into the brain tissue or into the subarachnoid space
- types of bleed: intracerebral, subarachnoid - aneurysm, ateriovenous malformation
intracerebral hemorrhage (ICH)
- bleeding into the brain tissue generally resulting from severe or sustained HTN
subarachnoid hemorrhage (SAH)
- bleeding into the subarachnoid space generally resulting typically from a ruptured aneurysm or arteriovenous malformation
aneurysm (SAH subtype)
abnormal ballooning or blister along a normal artery, which usually develops in a weak spot on the arterial wall
arteriovenous malformation (AVM) - SAH subtype
abnormality that occurs during embryonic development that causes tangled malformed thin-walled, dilated vessels without a capillary network
stroke s/sx
- sudden confusion or trouble speaking or understanding others
- sudden numbness or weakness of the face, arm, or leg (especially on one side of the body)
- sudden trouble seeing in one or both eyes
- sudden dizziness, trouble walking, or loss of balance or coordination
- sudden severe headache with no known cause
tip: BE FAST (balance, eyes, face, arms, speech, time)
left stroke
affects the right side
- paralysis or weakness on right side
- right visual field deficit
- aphasia (expressive, receptive, global)
- altered intellectual ability
- slow, cautious behavior
right stroke
affects the left side
- paralysis or weakness on left side
- left visual field deficits
- spatial perceptual deficits
- increased distractibility
- impulsive behavior and poor judgement, lack of awareness of benefits
stroke assessment
- gather an accurate history from patient or family
- physical assessment: ABC, neuro (LOC, CN assess, PERRLA, motor, sensation BL)
- glasgow coma scale
- NIH stroke scale
stroke assessment of cognitive problems
the patient may have a variety of cognitive problems in addition to changes in LOC
- LOC varies depending on extent of increased ICP caused by stroke and location
assess of:
- denial of illness
- spatial and proprioceptive (awareness of body position in space) dysfunction
- impair memory, judgement, or problem solving and decision making abilities
- decreased ability to concentrate and attend to tasks
- dysfunction in one or more of these areas may be severe depending on the hemisphere involved
stroke assessment of motor problems
physical assessment:
- R cerebral hemisphere deficits include: hemiplegia or hemiparesis on L side body
- L cerebral hemisphere deficits include: hemiplegia or hemiparesis on R side body
- musculoskeletal assess: grade muscle strength, assess hypertonia (high muscle tone), hypotonia (low muscle tone), flaccid paralysis, bowel or bladder dysfunction
stroke assessment of sensory problems (physical assessment (2), evaluate for? (4))
physical assessment:
- assess patient response to touch and painful stimuli
- assess CN
evaluate for:
- unilateral body neglect syndrome
- pupillary dilation or constriction (CN2)
- visual field deficits (hemianopsia - loss half visual field, homonymous hemianopsia - loss visual fields in both eyes - full risk precautions)
stroke assessment of other problems
physical assessment:
- cardiovascular: assess heart murmurs, dysrhythmias, HTN, allow for permissive HTN around 150/100 to maintain cerebral perfusion
- psychosocial: assess for patient’s reaction to illness, body image, self concept, ability to perform ADLs, coping and personality changes
stroke diagnostic labs
- glucose
- CBC
- BMP
- INR/PTT
- toxicology
stroke diagnostic imaging
- CT without contrast: STANDARD FOR INITAL DIAGNOSIS (asap)
- MRI: can detect ischemic changes earlier than CT
- ultrasonography (carotid artereis -> perfusion, BF, clots) & echocardiography help determine cardiovascular risk (function, structure, EF -> increased turbulence -> clot formation)
- 12 lead ECG to help determine cause
- Lumbar Puncture is no ICP and CT negative, subarachnoid hemorrhage must be confirmed
ischemic stroke nursing interventions (6)
1) 2 major treatment modalities for patients with acute ischemic stroke
- systemic fibrinolytic therapy: tPA (tissue plasminogen activator)
- endovascular interventions: balloon angioplasty, stenting
2) assess ABC
3) start 2 IV lines w/ non-dextrose isotonic saline
4) consider placing patient in SUPINE position
5) CT scan within 25 minutes
6) continually monitor for neuro changes or complications
ischemic stroke: treatment with fibrinolytic therapy (what, pharm, success, risk)
- systemic fibrinolytic therapy: standard of practice to improve blood flow to or through the brain for ischemic strokes
- alteplase (activase): only drug approved at this point for the treatment of acute ischemic stroke. it ACTIVATES plasminogen to degrade thrombus
- success of fibrinolytic therapy for stroke depends on interval between the time symptoms begin and available treatment
- delays make the patient ineligible for therapies, because revascularization of necrotic tissue (which develops after 3 hours) increases risk of cerebral edema and hemorrhage
ischemic stroke decision making criteria for alteplase (tPA) (inclusion (2), exclusion (4))
inclusion criteria
- diagnosis of ischemic stroke causing measurable neurological deficits
- treatment within 3-4.5 hours
exclusion criteria
- current intracranial hemorrhage, subarachnoid hemorrhage, active internal bleeding
- recent (within 3 months) intracranial or intra spinal surgery or serious head trauma, presence of intracranial conditions that may increase risk of bleeding (eg. some neoplasms, AV malformations, or aneurysms)
- current severe uncontrolled HTN (SBP >185 or DBP >110)
- bleeding diathesis (platelets <100,000 or elevated aPTT or INR >1.7)
ischemic stroke nursing interventions and after IV administration of alteplase
- perform double check of dose (programmable pump to deliver the initial dose of 0.9mg/kg (max dose 90mg) over 60 minutes with 10% of dose given over 1 minute (DO NOT IVP)
- admit patient to critical care or specialized stroke unit
- perform neuro assessments, including VS, Q10-15 minutes during infusion and Q30 minutes after that for atleast 6H, monitor QH after for 24H
- if SBP >180mmhg or DBP >105, give antihypertensives as prescribed
- to prevent bleeding, do NOT place invasive tubes (NG, foley) until patient stable
- discontinue infusion if patient reports severe headache or severe HTN, bleeding, n/v, and NOTIFY PROVIDER IMMEDIATELY
- obtain follow up CT scan post treatment before starting antiplatelet or anticoag drugs
ischemic stroke treatment endovascular interventions
- endovascular procedures: intra-arterail thrombolysis using drug therapy, mechanical embolectomy (clot removal), carotid stent placement
intra-arterail thrombolysis
delivers fibrinolytic agent directly into thrombus within 6 hours of stroke onset
mechnical embolectomy
removing clot through suction or other method within 8 hours of stroke onset
carotid stent placement
to prevent and in some cases help manage acute ischemic stroke
hemorrhagic stroke nursing interventions
- assess ABV
- start 2 IV lines with non-dextrose isotonic saline
- get CT scan within 25 minutes
- continually monitor for neuro changes or complications such as vasopsms or ICP
- careful management of cerebral hemodynamics to maintain cerebral perfusion
- neurosurgeon may perform decompressive craniectomy to manage refractory intracranial HTN in patient with massive stroke
stroke pharmacological therapy
(depends on type of stroke and resulting neuro dysfunction)
1) ischemic stroke
- aspirin or other antiplatelet drug
- calcium channel blockers
- stool softeners: valsalva maneuver (decrease ICP)
- analgesics/antianxiety
2) ischemic stroke with afib
- heparin
- warfarin
managing ongoing complications from stroke
- impaired swallowing
- impaired mobility & self care
- ineffective communication
- incontinence
- changes in sensory perception
- unilateral body neglect
managing impaired swallowing
patient must be observed for paroxysms of coughing, food dribbling out or pooling in one side of mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids
- swallowing difficulties place the patient at risk for aspiration, pneumonia, dehydration, and malnutrition
- apiration is a frequent complication for patients with dysphagia. many of these aspirations are “silent” and are NOT recognized until pulmonary complications occur
improving mobility and promoting self care
- begin rehab ASAP to regain function and prevent complications of immobility (pneumonia, atelectasis, DVT, PE, pressure ulcers)
- rehab therapists evaluate patient’s ability to perform mobility skills, basic ADLs, and household tasks that will be performed at home (collaborate with them to develop a plan of care to promote patient independence)
- correct positioning is important to prevent contractures, measures are used to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies
- as soon as patient can sit up, he or she is encouraged to participate in personal hygiene activities
promoting effective communication
- patients with stroke should be able to receive, interpret, and express spoken, written, and nonverbal messages if possible
- 2 types aphasia: expressive, receptive
- develop strategies for alternative methods of communication (written, gestures, visual communication boards, sign language)
- involvement with SLP as early as possible in hospitalization greatly increases the patient’s changes for optimal recovery
promoting continence
- patient may be incontinent of urine/stool d/t altered LOC, impaired innervation to the bladder and rectum, and/or the inability to communicate the need to urinate or defecate
- begin a “bladder training program” -> bedpan, BSC, offer urinal Q2H
- encourage total fluid intake to maintain dilute urine and a balanced intake and output
- check for residual urine with bedside bladder US
- encourage patient to drink 2-3L/day of water (apple or prune juice can also help) and to consume high fiber foods to help promote bowel elimination
managing changes in sensory perception
- after stroke, patient may have problems with cognitive, behavioral, and emotional deficits related to brain damage
- patients with right hemisphere brain damage typically have difficulty with visual perceptual or spatial perceptual tasks: use frequent verbal/tactile cues by breaking down tasks into discrete steps, approach patient from unaffected side, place objects within patient’s field of vision_
- patients with a left hemisphere lesion generally have memory deficits and may show significant changes in the ability to carry out simple tasks: reorient patient, establish routine or schedule that is structured/repetitious, provide information in simple, concise manner
managing unilateral body neglect
- most commonly in patients with right cerebral stroke or hemianopsia
- teach pt. to touch and use both sides of body
- when dressing, remind patient to dress affected side first
- teach patient to turn his or her head from side to side to expand visual field
discharge teaching
- teach patient to take prescribed drugs to prevent another stroke and control HTN
- teach patient how to transfer from bed to chair, get in/out of car, climb stairs safely, use aids properly for mobility
- teach family about depression that may occur within 3 months post stroke
head injury
broad classification that encompasses any damage to the head as a result of trauma
- does not necessarily mean a brain injury is present
- isolated scalp trauma
- skull fracture
isolate scalp trauma
- minor injury
- d/t its many blood vessels constrict poorly, scalp bleeds profusely when injured
- scalp wounds are potential portals of entry for organisms that cause intracranial infections
skull fracture (what, may occur w or without what, classified by, types (3), location(3))
- break in the continuity of the skill caused by forceful trauma
- may occur with or without damage to the brain
- classfied by: type and location
- types: linear, commiuted, depressed skull fractures (forcefully displaced downward)
- location: frontal, temporal, basal skull fractures
basilar fracture (head injury)
fracture occurring in bones that constitute base of the skull
s/sx:
- battle sign (bruising mastoid)
- raccoon eyes (bruising eyes)
- CSF otorrhea (ear)
- CSF rhinorrhea (nose)
- LOC changes (AMS)
traumatic brain injury
what: damage to the brain from an external mechanical force and not caused by neurodegenerative and congenital factors
- can lead to temporary and permanent impairment of cognitive, physical, and psychosocial functions
- direct injury: force produced by blow to head
- indirect injury: force applied to another body part with a rebound effect to the brain (MVA)
even seemingly minor injury can cause significant brain damage s/d obstructed BF and decreased tissue perfusion
- brain cannot restore oxygen or glucose to any significant degree
- the cerebral cells need an uninterrupted blood supple to obtain these nutrients, irreversible brain damage and cell death occur if blood supply is interrupted for even a few minutes
TIP: time is BRAIN
TBI: injuries to the brain can be ____ and _____?
focal or diffuse
focal injures (2)
1) contusions: brain is bruised and damaged in a specific area because of severe acceleration-deceleration force or blunt trauma
2) hematomas: collections of blood in the brain that may be epidural (above the dura), subdural (below the dura), or intracerebral (within the brain)
diffuse injuries (2)
1) concussion: temporary loss of neurologic functions with no apparent structural damage to the brain
2) diffuse axonal injury (DAI): when the brain responds to mechanical movement by rotating on the brainstem causing widespread shearing injuries
TBI: hematoma
aka hemorrhage
- causes brain hematoma (collection of blood) or clot from vascular injury
- all hematomas are potentially life threatening because they act as space occupying lesions and are surrounded by edema (surrounding swelling)
major types:
- epidural
- subdural
- intracerebral
- subarachnoid
TBI: epidural hematoma
- results from arterial bleeding into the space between the dura and inner skull
- pt. with epidural hematomas have a momentary loss of consciousness and then “lucid intervals” that last for minutes during which time the patient is awake and talking
TBI: subdural hematoma
- results from venous bleeding into the space beneath the dura and above the arachnoid
- bleeding from this injury occurs more slowly than from an epidural hematoma
SDHs are subdivided:
- acute
- subacute
- chronic
TBI: intracerebral hemorrhage
accumulation of blood within the brain tissue caused by the tearing of small arteries and veins in the subcortical white matter
- may produce significant brain edema and ICP elevations
- sx: headache, weakness, confusion, paralysis (particularly on one side of the body)
TBI: subarachnoid hemorrhage
- extraversion of blood into the subarachnoid space between the pia and arachnoid membranes
s/sx:
- sudden onset of severe headache
- n/v
- meningeal irritation
- photophobia
- visual changes
- focal neurological deficits
- sudden LOC
- seizures
