M3 D3 Flashcards
Stroke (CVA) and TIA
what is it, what kinds
Stroke:
- occurs when ischemia or hemorrhage into the brain results in the death of brain cells.
Classification
- Ischemic (85%)
- Hemorrhagic (15%)
Transient Ischemic Attack (TIA)
- Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction of the brain
- Symptoms last <1 hour.
ishcemic
Ischemic
- Occurs when an embolus lodges in and occludes a cerebral artery
- Results in infarction and edema of the area supplied by the involved vessel
- Symptoms sudden onset
Hemorrhagic
Rupture of a blood vessel
Result from:
- Hypertension is the primary cause
- Intracerebral bleeding
- Occurs during periods of activity
- Sudden onset of symptoms
Causes of CVA
Causes of CVA
- Sudden vascular compromise causing disruption of blood flow to the brain
- Thrombosis
- Trauma
- Aneurysm
- Embolism
- Hemorrhage
stroke manifestations
right sided brain damage
Stroke on the right side of the brain
- Paralysis left side: hemiplegia
- Left-sided neglect
- Spatial-perceptual deficit
- Tends to deny or minimize problems
- Compulsive; safety problems
- Impaired judgement
- Impaired time concepts
stroke manifestations
Left sided brain damage
Stroke on the left side of the brain
- Paralyzed right side: hemiplegia
- Impaired speech-language (aphasia)
- Impaired right-left discrimination
- Slow performance, cautious
- Aware of deficits
- Impaired comprehension for language, math
diagnostic stroke studies
why? Types?
Why?
- Confirm that it is a stroke
- Identify the likely cause of the stroke
- CT is the primary diagnostic test used after a stroke.
- MRI, MRA – extent of brain injury
- Cerebral angiography – blood flow
- Digital subtraction angiography – less contrast
- Transcranial Doppler
- ultrasonography
- Lumbar puncture
initial stroke managment
- Obtain CT scan immediately.
- Perform baseline laboratory tests (CBC, PT/INR to espablish risk for hemorrhagic)
- Position head midline.
- Elevate the head of the bed 30
degrees if no symptoms of shock or
injury occur. - Ensure patent airway and adequate oxygenation
- Call stroke code or stroke team.
- neuro examination
- Remove dentures.
- Perform pulse oximetry.
- Obtain IV access with normal saline.
- Maintain BP according to guidelines.
- Institute seizure precautions.
- Anticipate thrombolytic therapy for ischemic stroke.
Post stroke interventions
hypertension, F/E balance, TPA asprin use
Hypertension
- is common immediately after stroke.
- Drugs to lower BP are used only if BP is markedly increased.
- Goal SBP 140; MAP >75
Fluid and electrolyte balance
- must be controlled carefully.
- Adequate hydration promotes perfusion and decreases further brain injury.
Recombinant tissue plasminogen activator (tPA)
- Used to reestablish blood flow through a blocked artery to prevent cell death
- Must be administered within 3 to 4.5 hours of onset of clinical signs of ischemic stroke
Aspirin is used within 24 to 48 hours of stroke.
Platelet inhibitors and anticoagulants may be used in thrombus and embolus stroke patients after stabilization.
- Contraindicated for patients with hemorrhagic stroke
interventions for ischemic stroke vs hemorrhagic stroke
Ischemic stroke
- MERCI (mechanical removal of clot in brain)
Hemorrhagic stroke
- Immediate evacuation of aneurysm-induced hematomas
- Cerebellar hematomas >3 cm
Nsg interventions post stroke
resp and cardio system
Respiratory system
Management of the respiratory system is a nursing priority.
- Risk for atelectasis
- Risk for aspiration pneumonia
- Risks for airway obstruction
- May require endotracheal intubation and mechanical ventilation
Cardiovascular system
- Cardiac efficiency may be compromised
- Risk for DVT
- Monitor vital signs and cardiac rhythm frequently
- Intake and output - note imbalances
- Regulate IV infusions
Nsg interventions post stroke
MSK and INTEG
Musculoskeletal system
- Trochanter roll at hip - prevent external rotation
- Hand cones - prevent hand contractures
- Arm supports with slings and lap boards - prevent shoulder displacement
- Foot boards - prevent foot drop
- Passive ROM
Integumentary system (Cont.)
- Pressure relief by position changes, special mattresses, or wheelchair cushions
- Position patient on the weak or paralyzed side for only 30 minutes.
Nsg interventions post stroke
nutrition and sensory alterations
Nutrition
- May initially receive IV infusions to maintain fluid and electrolyte balance
- Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding.
Sensory–perceptual alterations
- Blindness in the same half of each visual field is common after stroke (Known as homonymous hemianopsia)
- Diplopia (double vision)
- Loss of the corneal reflex
- Ptosis (drooping eyelid)
seizures
causes and phases, what is epiplepsy
Seizure
- Transient uncontrolled neuronal activity in the brain, interrupting normal function
Cause
- Trauma (head injury) or tumour
- Infection or underlying illness (metabolic disturbance)
- Genetic factors
Phases of Seizures
1. Prodrome phase
2. Aural phase
3. Ictal phase
4. Postictal phase
Epilepsy
- At least two spontaneous seizures >24 hours apart, caused by underlying chronic pathology
Clinical Manifestations of Tonic-Clonic Seizure (Grand-mal)
Loss of consciousness and falling
The body stiffens (tonic) with subsequent jerking of extremities (clonic).
Cyanosis, excessive salivation, tongue or cheek biting, and incontinence
Postictal phase characterized by muscle soreness, fatigue; patient may sleep for hours
Nursing Intervention - Seizures
O2 and medications
Oxygenation
- Maintain patent airway, support head, turn patient to their side, oxygen mask 6L)
- Don’t restrain the patient.
- Don’t put anything into the patient’s mouth.
- May require repositioning, suctioning, or oxygen after seizure
- Assessment of level of understanding
Medication therapy aimed at prevention
- Stabilize nerve cell membranes and prevent spread of epileptic discharge
- 70% of patients controlled with medication
- Monitor medication serum levels.
MS
what is it, types of symptoms and symptom relief
Multiple Sclerosis
- Chronic, progressive, degenerative autoimmune disorder of the central nervous system (CNS)
- More common in women
Vague symptoms:
- occur intermittently over months and years.
- Rapid, progressive deterioration in some individuals
- Remissions and exacerbations in others
symptom relief
- Corticosteroids
- Immunomodulators
- Antispasmodics
- CNS stimulants
- Anticholinergics
- Antidepressants
- Physiotherapy
- Nutritional therapy
Parkinsons
Disease of basal ganglia characterized by
- Slowing down in the initiation and execution of movement
- ↑ Muscle tone
- Tremor at rest
- Impaired gait changes
Manifestations of parkinsons
- Onset is gradual and insidious (“TRAP”)
- Tremor
- Rigidity
- Akinesia
- Postural instability
medications
- Levodopa with carbidopa (Sinemet) is often the first medication used.
- Antiviral – unknown why
- Anticholinergics
- Antihistamines
Myasthenia Gravis
A chronic neuromuscular autoimmune disease
Caused by loss of ACH receptors necessary for muscles to contract
Causes weakness and abnormal fatigue of voluntary muscles
- Occular muscle weakness
- Bulbar muscle weakness
- Skeletal muscle weakness
Pharmacological Interventions
- tensilon
- Anticholinesterase agents
- Common medications: pyridostigmine bromide, neostigmine bromide
- Corticosteroid: Prednisone
- Immunosuppressive agents: azathioprine, cyclophosphamide
Mya G nsg interventoins
Coughing and deep breathing
exercises
- Suction at bedside
- Sit upright when eating and 1 hour
after
- Keep chin down when swallowing
- Plan activities and rest periods
