NRSG 126 - Week 10 Flashcards
Layers of the brain
- Meninges – secures and absorbs shock
- Epidural – small vessels and fat
- Dura – thick and strong
- Subdural space – not really a space
- Arachnoid - connecting
- Subarachnoid – CSF and major blood vessels
- Pia – thin and hugs brain and spine
4 lobes of the cerebral cortex and what does frontal damage do?
o Frontal: motor function, motivation aggression, smell, and mood
o Parietal: reception and evaluation of sensory info.
o Temporal: smell, hearing, memory and abstract thought
o Occipital: visual processing
- Frontal Damage can impact/cause- speech/language, hemiplegia, ataxia, problem solving, judgement, behavior, dysarthria, apraxia of speech
what do the Hypothalamus and Medulla Oblongata
both help to support ANS responses!
- Hypothalamus: command center for ANS activation. It is also our thirst center.
- Pons and Medulla are resp centers for automatic breathing in the pons and medulla is activated by local CO2 and peripheral chemoreceptors (carotid and aortic arch) sense O2 and tell the medulla what’s up! and the medulla is also activated by baroreceptors in our aortic arch and carotid sinus detecting changes in BP.
o Remember our HR is controlled by the SA node or pacemaker but it can be impacted by the ANS and the PNS and SNS in response to changes. SNS: Norepinephrine and Adrenaline (adrenals)= fight/flight; PNS: ACH or acetylcholine= rest/digest
- We can control our breathing with the cerebellum.
what is intracranial pressure and why is it important
- Pressure inside the cranial vault
- Depend on 3 volumes: Brain 10%, CSF (cerebrospinal fluid) 10%, Blood (in vessels) 80%
- If any of the pressures in the brain changes, it caused pressure on the brain
what can change the brain compnent?
o Tumor: takes up space
o Surgery: cut neurons?
o Atrophy: change with ageing or health conditions
what can change the blood component
o Stroke: clot or bled
o Deformity: AVM, aneurysm
o Injury: SDH, SAH epidural hemorrhage
o Always consider health conditions that increase these risks
what can change the CSF and where is it
subarachnoid space and ventricles
o Injury
o surgery (cause) can cause leak complication of epidural break through dura – “dural tear”
o Surgery (fix) – VP shut to fix (hydrocephalus), EBP 9epidural blood patch for dural tear
o It is a clear colour
o Leak = headache
nerves: where is the phrenic nerve and what does it innervate. Where is the most common site of injury?
o C3-5 phrenic nerve diaphragm
o L1 – 5 most common site of injury
what is radiculopathy
o Associated with nerve pinching causing neuropathic pain
PNS (Peripheral Nervous System)
- Sensory neurons – afferent
o Somatic and visceral sensory ganglia
o Cranial nerve ganglia
o Autonomic:
PNS (far from spine)
SNS (close to spine) - Motor neurons – effect
o Conus medullairis
o Cauda equina - The PNS consists of Ganglion and nerves.
- Ganglion: nerve clusters coming out from spinal cord.
- Nerves: extending to skin and all other organs, muscles, bones etc
what is afferent, efferent, grey matter, white matter?
- Afferent - Sensory goes to CNS (sense pain)
- Efferent – motor goes away from CNS (run!!!)
- grey matter – neuron
- White matter – axon
summary of CNS
o Brain and spinal cord
o Protected by skull, vertebrae, and meninges
o Meninges: dura, arachnoid, pia
o Spaces: epidural, subdural, subarachnoid (CSF here*)
Summary of PNS
o Ganglia and nerves
o Neurons: dendrite – cell body – axon (myelin) – synapse
o Sensory: afferent bring information to the CNS
o Motor: afferent bring information away from the CNS
Dermatomes
In both CNS and PNS
- Dermatomes from C-spine, thoracic, lumbar, and sacral connect the CNS to the PNS
Summary of sensory experience
o Reception (afferent), perception (as discussed in pain week- quality and nature of stimuli, previous experiences and LOC), reaction (efferent).
macular degernation
o Leading cause of vision loss, affects >50yrs
o Incurable
o Loss of central vision
cataracts
o Everyone will develop it with age, gradually and without pain
o Blurs all vision
diabetic retinopathy
o Leading cause of vision loss <50yrs
o Uncontrolled diabetes
o Severe vision loss/blindness
glaucoma
o Second most common cause of vision loss >65
o Visual field loss, decreased acuity, halo, or blindness
Refractive Errors
o Myopia – nearsighted
o Hyperopia – farsighted
o Presbyopia - difficulty reading small print
Senses – Hearing (ears: hearing and balance)
- The inner ear helps with balance- there is fluid and small hair-like sensors.
- There are many changes that can happen or diseases that can impact hearing. We will go more in-depth with each of these.
Conductive hearing loss (conduction from one end to another)
o Inefficient sound waves outer to inner ear
o Ear canal blockage- cold, allergy, infection
Central auditory processing disorder
o Auditory center damage (pathway to medulla)
o Central cortex pathway damage
o TBI, tumor, heredity
Otitis media (itis = infection, common in children and infants)
o Eardrum and middle ear damage
o Infection
o Can lead to permanent hearing loss
otosclerosis
o Hereditary
o Ossicle hardening
o Causes tinnitus
Sensorineural hearing loss
o Cochlea or nerve damage
o Causes- excess noise, meds, virus
cerumen accumulation
o Wax build-up that can harden
o Common in elderly
presbycusis
o Low-pitched sounds are heard better
o Muffles hearing
o Age related hearing loss
Meniere’s disease
o Inner ear disease
o Fluid in the ears
o Can cause tinnitus, hearing loss, vertigo
Taste deficit
Taste deficit: any impairment to the ability to taste
o Xerostomia – dry mouth – decreases saliva & thicker mucus.
o Causes: medications, cancer and ageing.
o Risks: food aversions decreasing calorie intake.
Senses - Smell
- Olfaction- decreases with age due to reduces sensory neurons and bulb cells.
- Affects sensitivity to odours and taste discrimination.
Sensation - Older Persons
o decreased blood flow: decreased cardiac output, decreased peripheral blood flow.
o changes to nervous system: decrease in nerve cells, myelin sheath degeneration, decreased neurotransmitters and conduction rate.
sensation - neurological deficit (causes)
o neuropathy – damage or disease affecting the nervous
o sensory processing disorders
Define and understand changes with ageing: Peripheral neuropathy, brain atrophy, hardened disks and vertrae overgrowth
o Peripheral neuropathy – affects the peripheral (outside CNS nerves)
o Brain atrophy – loss of neurons in the brain and connections between them resulting in decrease of brain size and mass
o Hardened disks and vertebrae overgrowth – can cause pain, numbness, and weakness
what is sensory processing
o It is the process of how the brain receives, organizes, and uses sensory information from the body and the environment to function and perform interactions
Pain
o Nociception (the process of detecting a painful stimuli) – somatic and visceral
o Neuropathic - nerve
o Older persons – altered sensitivity to pain
Pain Patho
transduction where the pain starts, transmission is how the pain reaches our brain, perception is how our bodies define the pain and modulation where we have our signals and response
Senses - other senses
- Kinesthetic: movement awareness
- Proprioception: position awareness
- Stereognosis: recognition of object texture and size
cognition - neuro tests
- Remember the 3Ds!
- Consider culture, education, values, beliefs, and previous experience of client.
o GCS – Glasgow coma scale tests LOC
o MOCA – Montreal cognitive assessment; checks focused on the assessment of mild cognitive impairment
o AEIOUTIFPS – recall the possible causes for altered LOC/mental status
o Neuro – vital signs??
o MMSE – mini mental state examination is a tool to screen for cognitive impairment, assessing orientation, memory, attention, and language skills
o CAM/Prisme – delirium CAM+ means they have delirium, Prisme is a guide to find the causes of delirium
o NIHSS – assess stroke in hospital setting
Can you tell me what brought you to the hospital?
testing knowledge/memory
Don’t count your chickens before they hatch!
abstract thinking
what do you think of when i ask about heart health
association
How are you going to manage with your broken foot at home?
judgement
How can we help to keep our clients safe?
- Appropriate stimuli
- Family support
- Environment
o Good lighting, carpets, making sure they can leave their house in the event of a fire - Medication review
o Reducing polypharmacy - Use of assistive devices
Hearing Safety Risks - Older Adult
(Hearing: Older persons hear low pitch better but have trouble hearing over background noise.)
o Presbycusis: difficulty discriminating some constants and hearing high-frequency sounds.
o Reduced: hearing acuity, speech intelligibility, pitch discrimination and hearing threshold.
Sigh Safety Risks - Older Adult
o Presbyopia: difficulty reading due to lens stiffening.
o Reduced: visual field, night vision, accommodation, depth perception, colour discrimination.
o Increased glare
what is a CVA and types
- Cerebral vascular accident – CVA AKA stroke
o TIA – transient ischemic attack
o Ischemic stroke
o Hemorrhagic stroke
CVA risk factors
- Loss of neurological function due to vascular injury
- The usual suspects:
o Hypertension
o Atherosclerosis
o Smoking
o Age > 65yrs
o Diabetes
o Obesity
o Atrial fibrillation
what is a TIA
Transient Ischemia Attack (TIA)
- “Mini stroke” (Ischemic), that lasts several minutes with no permanent damage.
o 1 in 3 people who have TIA’s will have a stroke
o S/S and risk factors same as the ischemic stroke – resolve without intervention
Hemorrhagic vs Ischemic, which is more common?
ischemic
Ischemic stroke types and what does ischemia mean
thrombotic and embolic
Ischemic Stroke: Embolic
- Moves to the blood vessels in the brain
- Atherosclerosis, smoking/ETOH, obesity, high LDL, HTN, arterial fibrillation
- Less commonly can be caused by air, vegetation, amniotic:
o Air – air bubbles getting into vascular system
o Vegetation – ie – oral infection from flossing, gets into cardiac valve, flicks off into brain.
o Amniotic – pregnancy – gets amniotic fluid into bloodstream
Ischemic Stroke: Thrombotic
- Blood vessels in the brain
- Risk factors same as all arterial disease
o Atherosclerotic plaque
o Clot formation - The brain does not get enough O2
Treatment Specific for Ischemic Stroke
- Open up the blood vessels
- Increase the odds of recovery
- Don’t let it happen again!
- Break up the clot:
o t-PA= recombinant tissue plasminogen activator (thrombolytic).
o TPA: Intended to open occluded arteries in order to improve perfusion (timeframes- resource says 3 hours, can be up to 6) but goal- ASAP!
o Alteplase- for NCLEX is 3.5 hours. - Remove the clot:
o EVT (endovascular treatment)- thrombectomy.
o EVT: typically if within 6 –hours.
o Increases risk for intracerebral bleed
Ischemic Prevent Further Damage
- Prevent clots – do not thin the blood (easier to bleed is thinner)
o Antiplatelets
Platelets will not sick as easily
Meds: ASA, Plavix (Clopidogrel)
o Anticoagulants
Interfere with the coagulation cascade
Meds: Heparin, Warfarin, Rivaroxaban, Apixaban
Hemorrhagic Stroke Types
- Intracerebral & Subarachnoid
- Remember we talked about the layers. Major vessels are in this space, they go through the other spaces to perfuse the bone.
Hemorrhage: Intracerebral
- Bleeding into the brain tissue
- Signs and symptoms: headache, nausea/vomiting, changes to LOC, seizure (ICP)
- Blood in the cranial vault = increased intracranial pressure (ICP)
Hemorrhage: Subarachnoid Hemorrhage (SAH)
- Bleeding into the subarachnoid space
- Signs and symptoms:
o Worst headache EVER! (thunderclap), nuchal rigidity (stiff neck), photophobia, nausea/vomiting - Causes:
o AVM, aneurysm, trauma, bleeding disorder, medication
Recognizing Increased ICP Early
- Assessment!!
- Neurovascular assessment:
o 1st sign of increased ICP is an altered level of consciousness (LOC)
o Common symptom of increased ICP is headache - Brain herniation: nowhere else to go ☹
Treatment specific for hemorrhage
- Both under general anesthetic
- Coiling: prevents clots from forming- prevents entry of blood into weak space. Via artery
- Clipping: to clip off broken area. Via craniotomy.
CVA Diagnostics
- Both under general anesthetic
- Coiling: prevents clots from forming- prevents entry of blood into weak space. Via artery
- Clipping: to clip off broken area. Via craniotomy.
Neuro Assessment – Nursing Process
- NIHSS – stroke severity, monitor for changes
- TOR-BSST – stroke swallowing assessment
- Level of Consciousness (LOC) and Glasgow Coma Scale (GCS)
o Causes AEIOUTIPS – to be covered in 101
o Range from coma to hyperactive.
Examples: confusion, personality changes, coma, alert and orientated, obtunded, stupor, lucid
what is the reticular activating system
The reticular activating system is found in the midbrain, pons, medulla and part of the thalamus. It controls levels of wakefulness, enables people to pay attention to their environments and is involved in sleep patterns
AEIOU TIPS - LOC
: Alcohol/Acid Base Disorders/Ammonia/Arrhythmias;
o E: Epilepsy/Electrolyte Disorders;
o I: Insulin;
o O: Overdose;
o U: Underdose/Uremia;
o T: Trauma/Tumor/Thermal Insult (Hypothermia);
o I: Infection;
o P: Psychiatric/Poisoning;
o S: Stroke/Shock
understimulation
an lead to depression and decreased LOC changes receptiveness
obtudation
a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states
stupor
a state of near-unconsciousness or insensibility
lucid
expressed clearly; easy to understand
Right Brain (Left sided hemiplegia)
- Emotional highs/lows
- Concentration/attention span
- Judgement/Impulsiveness
- Confusion/memory loss
o Agnosia - objects, faces, places, etc.
o Anomia – names of everyday objects - Vision
- Neglect left side
Left Brain (Right Sided hemiplegia)
- Cautious/Compulsive behaviours
- Apraxia (movement)
- Aphasia (more on next slide)
o Expressive aka Broca’s aphasia
o Receptive aka Wernicke’s aphasia - Dysarthria (slurring)
- Comprehension
- Neglect right side
Aphasia - Broca’s area
Expressive (non-fluent) from frontal lobe stroke- in the left hemisphere- may still be able to sing! Comes from the opposite side of the body. May be able to understand but not respond. Difficulty in forming complete sentences or trouble in understanding sentences, or may experience both
Aphasia - Wernice’s
Receptive (fluent) from temporal stroke- central processing disorder. Characterized by the client using wrong or meaningless words that do not make sense.
how to improve aphasia
Can do SLP to improve. Can also suffer from isolation
Stroke Complications - Immediate
o Airway
o Increased Intracranial Pressure (ICP)
o Seizure
o Death (ex: brain stem stroke)
o Infection: UTI/Urosepsis, Pneumonia
o In completing our assessment we want to identify any of these potential complications to guide priorities, nursing diagnosis and planning.
Stroke Complications - Ongoing
o Nutrition
o Communication
o Motor Function
o Behaviour
o Memory
o Communicate with appropriate HCPs: OT, PT, SLP etc. Dietician
o Initially may need specialized equipment, intravenous fluids. What if they get too dehydrated? What organ is really impacted by blood flow?
nursing process - diagnosis
- Diagnosis focus
o Analyze
identify good and bad
formulate nursing diagnosis - the purpose is to identify client needs
nursing process - planning
- Planning focus
o Prioritize
o Formulate goals and expected outcomes
o Select nursing interventions
o Write care plan - Education – positive image, recognize strengths
Examples of diagnoses
Impaired swallowing
o Risk for falls
o Risk for pressure ulcer
o Impaired verbal communication
o Disturbed body image
o Impaired social interaction
Examples of safe feeding practices
o Sit up
o Sit after
o No straws
o Dysphagia if needed
Examples of Plans
o Support safe Nutrition
o Feeding practices
o Nutritional preferences
o oral hygiene
nursing process - implement
- implementation focus
o Begin interventions
o Supervise, delegate, communicate with team
o Determine nursing assistance needed
o Reassessing….always - Do all stroke clients need dysphagic diet? No
Nursing Process – Evaluation
- Evaluation focus
o Collect data and compare
o Connect nursing interventions
o Draw conclusions
o Continue, modify or terminate. - Nutritional
- Oxygenation
