Neuro/Stroke Flashcards
0
Q
The brain constitutes ____ of body weight
A
2%
1
Q
Def Monroe Kellie hypothesis
A
The Monro-Kellie hypothesis states that the cranial compartment is incompressible, and the volume inside the cranium is a fixed volume. The cranium and its constituents (blood, CSF, and brain tissue) create a state of volume equilibrium, such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another.[5]
2
Q
The brain uses _____ of resting CO
A
20%
3
Q
Lower fx of the brain
A
Hr
Resp
Digestion
4
Q
Higher fx of the brain
A
Thought
Reason
Abstraction
5
Q
What controls our primal instincts and most basic fxs
A
Hindbrain and midbrain
6
Q
The hindbrain consists of …
A
SC
Medulla oblongata
Pons
Cerebellum
7
Q
The SC consists of _____ and ______ pathways
A
Ascending
Descending
8
Q
What does the medulla oblongata control
A
Autonomic fxs:
- Resp
- digestion
- hr
9
Q
What does the Pons control
A
- consciousness
- sleep
- level of arousal
- autonomic body fxs
10
Q
What does the cerebellum control
A
- regulates and coordinates body mvmt
- posture
- balance
- learning mvmt
11
Q
What does the limbic system control
A
Emotions
Unconscious value judgements
12
Q
What does the limbic system consist of
A
- amygdala
-hippocampus
Hypothalamus
Thalamus
13
Q
What is the amygdala responsible for
A
Processing of memory
Emotional reactions
14
Q
What does the hippocampus do
A
Long term memory
Spatial navigation
15
Q
What does the hypothalamus control
A
Regulated metab processes/ANS
- body temp
- hunger
- thirst
- circadian rhythm
16
Q
What does the thalamus control
A
States of sleep and wakefulness
Arousal
Level of awareness
Consciousness
17
Q
The cerebral cortex is divided into ____ ____ and ____ ______
A
Left hemisphere
Right hemisphere
18
Q
Ridges on the cerebral cortex is aka
A
Gyri
19
Q
Grooves on the cerebral cortex is aka
A
Sulci
20
Q
Deeper grooves on the cerebrum is aka
A
Fissures
21
Q
The cerebral cortex is made of
A
Frontal lobe Parietal lobe Temporal lobe Occipital lobe Corpus colossum
22
Q
What is the frontal lobe responsible for
A
Reasoning Prob solving Judgement Impulse control Higher emotions- empathy, altruism Speech- Broca's area
23
Q
What does Broca’s area responsible for
A
Speech
24
Where is Broca's area located
Frontal lobe
25
What is the parietal lobe responsible for
```
Pain
Touch sensation
Cognition- calcs and speed of objects
Mvmt
Orientation
Recognition
Speech
```
26
What is the temporal lobe responsible for
Hearing
Sound sensation
Auditory cortex
Wernickes area- language recognition
27
Where is wernickes area located
Temporal lobe
28
What is the wernickes area responsible for
Language recognition
29
What is the corpus colossum
Neural bridge that connects the 2 hemispheres
| In the center of the brain
30
What do you monitor in elderly patients pits op heart surgery and why
Monitor carotid a with duplex bc they easily stroke
31
CSF FYI
- brain and SC
- contained by the dura lining
- 125-150 mL
- clear, colorless, odorless
- delicate balance must be maintained to regulate ICP
32
Purpose of the dura lining
Cushion the CSF
33
What is the blood brain barrier (bbb)
Structure that acts to protect the brain from harmful chemicals
34
What size particles can cross the bbb
< 500 Dalton's
35
What are the most important parts of the Neuro exam and why are they significant
LOC
Mentation
Change in either can Be the first clue to Neuro deterioration
36
Name the different levels of consciousness
```
Full consciousness
Lethargy
Obtunded
Stupor
Coma
```
37
Describe lethargy
Drowsy but easily woken
38
Describe obtruded
Patient difficult to arous and needs constant stimulation to follow a command
39
Describe stupor
Patient arouses with constant and vigorous stimulation- usually pain
Will withdraw from pain but will not follow commands
40
Describe coma
Patient is not aroused with constant or painful stimulation
| Only mvmt may be reflexive
41
Describe the GCS
- a numerical rating of eye,verbal, and Motor responses
- baseline can be used for comparison
- 9-15: mild- moderate injury
- 3-8: severe injury
42
Change in LOC can be indicative of...
- hypoxia
- hypercarbia: Carbon monoxide
- hypotension
Drug related
Hypothermia
Prostictal state- post seizure
Hypoglycemia
43
Pupillary response
- fixed: brisk, sluggish, non reactive
| - ETOH/drugs may mask response (Pinpt pupils)
44
What do fixed and dilated pupils indicate
Herniation syndrome
45
How do you assess motor strength bilaterally
Squeeze hands
Lift limb
Push against resistance
46
How do you check for arm pronation/drift
Arms outward
Palms up
Eyes closed
Observe for arm drifting
47
How do you assess motor response in an unconscious pt
Central stimulation
| Peripheral stimulation
48
How do you test central stimulation
Sternal rub
49
How do you test peripheral stimulation
Nail bed pressure
50
Is testing central or peripheral stimulation better and why
Central stimulation creates an overall body response and is more reliable.
51
Abnormal motor response
Posturing
- flexion
- extension
52
What is flexion
Decorticate posturing
53
What is extension
Decerebrate posturing
54
Why is posturing significant
Poor prognostic sign
| At risk for constant vegetative state
55
List the types of muscle tones
Flaccid
Rigid
Spastic
56
Def flaccid
Rag doll appearance
57
If a pts muscle tone is flaccid, they are at risk for what?
Foot drop
58
What can you do for a pt with foot drop
- give them a boot
| - ask family to bring in sneakers for support
59
Describe rigid muscle tone
Increasing resistance to PROM
60
Pts with rigid muscle tone are at an increased risk for what?
Contractures
61
Describe spastic muscle tone
Rigidity, contracture, spasm
62
Testing sensation allows the HCp observe the pts ability to distinguish bx ....
Sensation and lack of sensation
| Sharp and dull
63
When assessing gait, what should you observe for
```
Even and steady?
One limb drag
Shuffling
One or both arms not swing
Posture
Balance
Coordination
```
64
Name the DTRs
```
Tricep
Bicep
Brachioradialis
Patellar
Achilles
```
65
The plantar reflex is a _______ reflex
Superficial
66
Which reflex is commonly assessed
Plantar reflex
67
Describe babinsky sign
- babies: extension of the big toe is normal
- > 2 yo: curling of the ties
Extension of the big toes or fanning is abnormal
68
Describe the gag reflex
- protective reflex
| - yankaur / tongue blade to back of throt should produce gag reflex.
69
Vital signs and Neuro status
- injury to CN X will demonstrate vital sign changes
| - abnormal vital signs are not a reliable indicator of Neuro deterioration
70
What is cushings triad
ICP produces a specific set of changes
71
When will a cushings triad be seen
Late indicators of Herniation syndromes
72
List the cushings triad components
- incr syst BP w/ widening pulse pressure
- bradycardia
- bradypnea
73
What is the normal ICP range
1-15 mm hg
74
Def Herniation syndrome
- occurs when cerebral pressure is not exerted evenly
| - one portion of the brain herniates into another
75
What can cause Herniation
Cerebral edema
| Mass
76
Clinical manif of Herniation
Fixed and dilated pupils
77
T/f - brain Herniation is fatal
True
78
Def dementia
An organic mental disorder char by a cluster of cognitive impairments that are generally gradual onset
Usually irreversible
79
Clinical manif of dementia
```
Decr attention span
Disorientation
Inappropriate behavior
Labile affect
Restlessness
Agitation
```
80
Care of a dementia pt requires
```
Constant reorientation
Simple communications and interactions
Cautions with meds
More assistance with ADLs
CM & SW involvement
```
81
Stroke risk factors
Smoking doubles risk
Afib - 5 fold
HTN- most significant
82
What actions give the stroke pts the best chance for survival
Administration of TPA within 3 hrs
83
Def stroke
An acute neurological impairment that occurs following an interruption of blood supply to a specific region of the brain
84
How are strokes classified
Ischemic
| Hemorrhagic
85
How are ischemic strokes classified
Anterior circulation
| Posterior circulation
86
Describe anterior circulation
Stroke that follows an occlusion of the carotid artery
| Usually involve the cerebral hemispheres
87
Describe the posterior circulation
Stroke that follows an occlusion of the vertibrobasilar artery
Usually involved the brain stem or cerebellum
88
Def ischemic stroke
A result of an occlusion within the blood vessel
89
What are the most common type of stroke
Ischemic stroke
90
Ischemic strokes further classified as
Thrombotic
Embolic
Flow disturbance- hypo perfusion
91
Describe thrombotic stroke
- Thrombus forming process in the affected artery
| - thrombus gradually narrows vessel and impedes blood flow to distal tissues
92
The s&s of thrombotic ischemic stroke are gradual or acute
Usually gradual
93
Risk factors for thrombotic stroke
```
Atherosclerosis
HTN
Cad
Vasoconstriction
Dissection of the artery
```
94
Def embolic stroke
Stroke caused by a traveling particle in the arterial bloodstream originating from somewhere else in the body
95
Embolisms can be made of ....
Blood clot
Plaque
Air
Bacterial emboli
96
Risk factors for embolic stroke
```
Afib, PAf , sustained flutter
DVT, PE
Rheumatic mitral or aortic valve disorders
Prosthetic or mechanical heart valves
Symptomatic CHF with ef < 30
Dilated cardiomyopathy
Infective endocarditis
CABG
Pt foremen ovale
```
97
Def flow disturbance hypoperfusion
- Inadequate cerebral flood flow due to decr BP or due to hematologic hyperviscosity
- reduction in blood flow is global and may affect all parts of the brain
- blood flow to these areas may not necessarily stop but may lessen to the point of damage
98
Risk factors for flow disturbance hypoperfusion
- CO, pump failure
- AMI
- unstable arrhythmias
- polycythemia Vera
Sickle cell
99
Def penumbra
- area surrounding the center of infarction
| - this area of damage so potentially reversible
100
Def transient ischemic attacks
- Neuro deficits thT resolve in 24 h
- 80% resolve within 60 minutes
- precede 30% of ischemic strokes
101
What can happen if TIA's are not treated
- can lead to ischemic stroke
20% within the first month
50% within the first year
102
Def carotid endardectomy
- gold standard for preventing a stroke from carotid stenosis
- surgeon removes lacquer from arterial media
- area is then irrigated and the debris is removed
- sometimes a patch is placed
103
Candidate criteria for endardectomy
Asymptomatic carotid artery disease
TIA, Stroke
Recurrent Carotid Artery disease
104
Can a pt who had a recent stroke secondary to thrombus have CEA and why?
No, must wait a few weeks
| Increased risk for stroke extension
105
CEA complications
```
BP deviation-can cause a carotid bleed out
Hyperperfusion syndrome- h/ a's common
Cranial nerve injuries
Re op for bleeding
Restenosis
```
106
Carotid stents
- for the tx of high risk on surgical patients with high grades of symptomatic carotid artery stenosis
107
What is used in conjunction with carotid stents
Angioplasty- prevents the loose of debris and flatten the plaque against the wall of the vessel
108
Nursing protocols after stent/ angio
```
Hydration to counteract the dye
D/c 48 hrs post op
Restart on ASA and plavix
Heparin drip for first 24 hrs
Check pt/ ptt / inr q 6 h
Keep leg straight for 6 hrs
Check Neuro q 2 h
```
109
Potential complications of stents
```
Femoral site bleeding
Hematoma
Aneurysm
TIA
Stroke
Restenosis
```
110
Def hemorrhagic stroke
Occurs when a bv in the brain ruptures or bleeds
111
Effects of hemorrhagic stroke
- incr ICP: decreases blood flow to brain tissue
112
Which stroke is more fatal: ischemic or hemorrhagic
Hemorrhagic
113
List types of hemorrhagic strokes
- ICH - intracranial hemorrhage
| - SAH- subarachnoid hemorrhage
114
Def intracranial hemorrhage
Bleeding directly into the brain tissue, forming a gradually enlarged hematoma
- mortality 44% after 30 days
115
Most common causes of intracranial hemorrhage
```
HTN
Trauma
Bleeding disorders
Illicit drug use
Vascular malformations
```
116
Def subarachnoid hemorrhage - SAH
Bleeding into the CSF of the subarachnoid space surrounding the brain ( not the brain itself)
- bleeding lasts a few seconds but rebleeding is common
- 40% mortality within 30 days
117
Common causes of SAH
- Rupture of aneurysms from the base of the brain
| - bleeding form vascular formations
118
Dx ing of a stroke
- based on clinical assessment
- imaging- helps determine the type of stroke
CT- mandatory and emergent
- will tell if hemorrhagic or embolic
- if hemorrhagic, cannot give TPA
MRI
- carotid u/s
- echo
- TEE
- EKG
119
How do lab studies help in dx ing a stroke
They don't diagnose but rather help find the underlying cause
120
Physical exam for a stroke
- time of onset
- meds
- med hx
- Neuro exam
- Glasgow is LOC
121
What is NIHSS
- national institute of health stroke scale
- rapid and reproducible tool for quantifying Neuro deficits
- 11 item ordinal scale ( score 0- 42)
122
What is of paramount importance when considering a stroke pt for thrombolytic therapy
Time of onset
123
What is the avg time frame that a stroke pt presents in the ED
4- 24 hrs
124
Reasons for delay in seeking care post stroke
- wake up stroke
- recognition of s&s - go unrecognized
- may leave pt too incapacitated to call for help
125
S&s of a stroke
Sudden onset of : hemiparesis, monoparesis, quadriparises
Facial assymmetry
Monocular/binocular vision loss, visual field deficits, diplopia
Dysarthria(diff w/ speech)
Ataxia- unsteady gait
Vertigo
Aphasia- diff comprehending/prod language
Decr in LOC
sever h/a- usually assoc with bleed
126
Left hemisphere stroke s&s
```
Dominant
Aphasia
Right hemiparesis
Right sided sensory loss
Right visual field defect
Dysarthria
Poor right conjugate gaze
Diffic reading, writing, calc
```
127
Right hemisphere stroke
```
Non- dominant
Neglect of left visual space
Left hemiparesis,
Left sensory loss
Left visual field def
Dysarthria
Spatial disorientation
Extinction of left sided stimuli
```
128
Acute Neuro complications of a stroke
Cerebral edema
Incr ICP
seizures
Hemorrhagic conversions
129
Def cerebral edema
Accum of fluid in ECF and ICF, causing increase in brain volume
- death post stroke is commonly caused by cerebral edema / incr ICP
130
When does cerebral edema usually occur
3-5 days post stroke
131
What solutions cannot be used for stroke pts and why
Solutions with glucose
- LR, NS, hypotonic
- increases ICP
132
What medication is used to decr ICP
Mannitol
| - rapid and temporary
133
What is usually the first sign of cerebral edema
Change LOC
134
When do post stroke seizures occur (if they occur)
Usually within 24 hrs
135
What kind of stroke usually occurs post stroke
Partial seizures
136
What is the initial tx for seizure post stroke
Dilantin 20 mg/ kg IVPB - up to 50/ min
137
What can you give status epilepticus
Lorazepam 1-2 mg
| Diazepam
138
Def hemorrhagic conversion
Conversion of ischemia stroke to hemorrhagic state
139
What increases the chances of hemorrhagic stroke conversion
Anticoagulants and thrombolytics
140
NYSDOH & TJC guidelines for stroke protocol
- triage to er md eval - 10 mins
- door to ct scan- 25 mins
- triage to meds- 60 mins
141
Standardized stroke protocol set
- DVT proph, dc anticoag ther
- anti thrombotic therapy by day 2
- dc statin meds
- dysphagia screening
- stroke edu
- smoking cessation
- assess for rehab
142
What labs should you run for a stroke
CBC
Bmp
Coags
T&s
143
FAST(stroke)
F- face- drooping face, loss sudden loss of vision
A- arm- weak/ drooping arm
S-speech- inability to understand/ be understood
T- time- time of onset of symptoms, witnessed, call RRT
144
What is the most important priority for stroke pts
Maintain airway
- loss of protective reflexes or oral-pharyngeal reflexes
- hob > 30
- suction prn
- o2 sat assessment
145
S&s of dysphagia(inability to swallow)
```
Weak/absent gag reflex
Drooling, excessive chewing
Difficulty pushing food to back of mouth
Dysarthria- dif speaking
Voice- gurgle,wet,hoarse, strident
Parasthesia of face, lips, tongue
```
146
What is Modified Massey Bedside Swallow Test
- indicated for all stroke/ Tia pts
- within 24 hrs of admission
- documenting +\- alone is not acceptable
- must be done by RNA
- when in doubt, keep NPO
147
What is a very serious complication of CVA
Pneumonia
148
Dx of post cva PNA
```
Fever
Incr WBC above 10,000
Rales
+ sputum C&S
Productive cough
PaO2 < 70 mm hg
Cxr
```
149
Oral care for cva pts
- am/pm
- q 2 hrs for incubated/ trach pts
- assessment of mucosa
- peridex
- ETOH free mouthwash
- toothpaste
150
Medications administered for reflux
Proton pump inhibitors
Antacids
Histamine blockers
151
Diet for dysphagia I
Puréed food
| Little to no chewing
152
Diet for dysphagia II
- mechanically altered
- semi solids
- ground meats
Require some chewing
153
What is the time window for admin anti thrombotics
3 hrs
154
What do you assess after admin TPA
Monitor for bleeding
Maintain BP
Monitor Neuro status for change in LOC
155
What can you not use and/ or admin within 24 hrs of a anti thrombotics
Scds,
BP cuff
Heparin
156
What is anti thrombotics are indicated for non qualified TPA pts
ASA- 150-325 mg
157
What anti thrombotics are indicated for non e
| Eligible TPA pts who are immobilized
LMWH- prophylactic low dose SQ
Ipc- intermittent pneumatic compression
Coumadin
158
What condition may be protective during or after stroke
Hypothermia
159
Anti thrombotics that are indicated for day 2 post cva/Tia
```
ASA
agrenox
Coumadin
Plavix
Ticlid
IV heparin
LMWH- full dose
```
160
Long term anti thrombotic therapies
- coumadin ( 2-3)
| - ASA 75-325 mg/ day
161
What is the modified rankin scale
- scale for measuring the degree of disability or dependance in ADL"s
- used to eval stroke outcomes and trials
- added in 2012 for dc of stroke pts
162
Def hemiparesis
Weakness of face, arm, and leg on one side
163
Hemiplegia
Paralysis of face, arm, leg on one side
164
What is CN I and what does it control
Olfactory
| - sense of smell
165
How do you test olfactory nerve
Place strong scented tie,s under nares bilaterally and ask pt to identify it
166
What is CN II and what does it control
Optic
| - visual acuity
167
How do you test the optic nerve
Smelled chart @ 14"
168
What is CN III and what does it control
Oculomotor
| - rxn to light
169
How do you test the oculomotor CN
- pen light
- side to inward: pupil accommodation
- far to near: pupils constrict
170
What is CN IV and what does it control
- trochlear
| - downward and inward mvmt of eyes
171
How do you test the trochlear nerve?
- have pt follow pen light up, down, sideways, diagonal w/o moving head
172
What is CN V and what does it control
Trigeminal
| Sensation of the face, scalp, cornea
173
How do you test the trigeminal nerve
- touch lateral sclera and observe for blinking
- cotton ball to forehead, maxillary (cheeks), and chin: should be able to sense cotton ball and distinguish sharp from dull sensations
- ask pt to clench teeth
174
What is CN VI and what does it control
Abductees
| Lateral eye mvmt
175
How do you test the abducens nerve
Ask pt to move eyeball laterally
176
What is CN VIII and what does it control
Facial
- taste on anterior 2/3 of tongue- sweet, salty, bitter
- facial mvmt
177
How do you test the facial nerve
- have pt test sweet, salt, and bitter
Sugar, salt, coffee
- have pt smile, frown, raise eyebrows, and puff cheeks
178
What is CN IX and what does it control
Glossopharyngeal
- posterior 1/3 of the tongue
- sensation of eardrum to canal
- gag response
179
How do you test the glossopharyngeal nerve
- gag reflex
- "Ka" and " go"
- tongue side-side, and up-down
- swallow
180
What is CN X and what does it control
Vagus nerve
| Sensation of the pharynx, viscera, carotid body, carotid sinus
181
How do you test the vagus nerve
Swallow
182
What is CN XI and what does it control
Accessory nerve
| - trapezius + sternomastoid muscle mvmt
183
How do you test the accessory nerve
- shrug shoulder side to side against resistance
| - turn head from side to side against resistance
184
What is CN XII and what does it control
Hypoglossal
| Tongue mvmt for speech, sound articulation, and swallowing
185
How do you test the hypoglossal nerve
Have pt stick out tongue and move side to side
| Look for atrophy and assymmetry
