Rehab Test #1 - CVA, Neuro

Question 1

stroke

Answer 1

also known as cerebrovascular accident or brain attack, is a nontraumatic brain injury caused by disruption in blood flow to part of the brain. When blood flow is interrupted, the brain is deprived of nutrients and oxygen, resulting in cell death.

Question 2

Name 2 common types of stroke

Answer 2

Ischemic stroke
Transient ischemic attack (warning!)
Can be either Thrombotic or Embolic
Blood clot breaking off and moving to the brain

Hemorrhagic stroke
Hypertension
Aneurysms- weaker area in walls of blood
Arteriovenous (AV) malformation

Question 3

Ischemic stroke

Answer 3

Transient ischemic attack (warning!)
Can be either Thrombotic or Embolic
Blood clot breaking off and moving to the brain

occur as a result of an obstruction within a blood vessel supplying blood to the brain. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis.

Question 4

Hemorrhagic stroke

Answer 4

Hypertension
Aneurysms- weaker area in walls of blood
Arteriovenous (AV) malformation

a burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak

Question 5

Identify modifiable and non-modifiable risk factors for stroke

Answer 5

Modifiable
Hypertension
Coronary artery disease
Diabetes
Obesity
Smoking
Atrial fibrillation - blood stay in the same place, causing clots of the blood
Substance abuse
Oral contraceptives - increase for younger females

Nonmodifiable
Age
Gender
Race
Family history

Question 6

What is BE FAST used for and what does it stand for?

Answer 6

Stroke assessment:
Balance lost
Eye blur
Face drooping
Arm Weakness
Speech Difficulty
Time

Question 7

Differentiate the clinical manifestations of ischemic stroke versus TIA

Answer 7

Ischemic stroke - Ischemic strokes occur as a result of an obstruction within a blood vessel supplying blood to the brain. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis.

Transient ischemic attack (TIA) - A brief stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke.
A transient ischemic attack (TIA) is a stroke lasts only a few minutes. It happens when the blood supply to part of the brain is briefly blocked

Question 8

Right Brain Damage

Answer 8

paralyzed left side- hemiplegia
left sided neglect
spatial perceptual deficits
tends to deny or minimize problems
rapid performance, short attention span, impulsive safety problems
impaired judgement
impaired time concepts

Question 9

Left Brain Damage

Answer 9

paralyzed right side- hemiplegia
impaired speech/language aphasias
impaired right/left discrimination
slow performance, cautious
aware of deficits: depression, anxiety
impaired comprehension related to language, math

Question 10

Identify diagnostic studies performed for patients with strokes

Answer 10

Non-contrast Computed Tomography (CT) Scan

If you give CT scan with contrast it wouldn’t be able to differentiate between the two types of stroke

Question 11

Agnosia-

Answer 11

inability to interpret sensations and hence to recognize things, typically as a result of brain damage.

Question 12

Apraxia-

Answer 12

People who have it find it difficult or impossible to make certain motor movements, even though their muscles are normal

Question 13

Aphasia-

Answer 13

loss of ability to understand or express speech, caused by brain damage.
Broca’s- unable to produce the appropriate language
Wernicke’s - unable to comprehend language
Global - both

Question 14

Ataxia-

Answer 14

the loss of full control of bodily movements.

Question 15

Dysphagia-

Answer 15

difficulty or discomfort in swallowing, as a symptom of disease.

Question 16

Dysarthria-

Answer 16

often is characterized by slurred or slow speech that can be difficult to understand. Common causes of dysarthria include nervous system (neurological) disorders such as stroke, brain injury, brain tumors, and conditions that cause facial paralysis or tongue or throat muscle weakness.

Question 17

emotional labile-

Answer 17

a disorder characterized by involuntary emotional displays of mood that are overly frequent and excessive, often the result of various neuropathologies.

Question 18

Hemiparesis-

Answer 18

unilateral paresis, that is, weakness of the entire left or right side of the body (hemi- means “half”).

Question 19

Hemiplegia-

Answer 19

in its most severe form, complete paralysis of half of the body.

Question 20

homonymous hemianopsia-

Answer 20

a visual field loss on the left or right side of the vertical midline

Question 21

Asomatognosia -

Answer 21

is a neurological disorder characterized as loss of recognition or awareness of part of the body.

Question 22

unilateral neglect -

Answer 22

is a neuropsychological condition in which, after damage to one hemisphere of the brain is sustained, a deficit in attention to and awareness of one side of the field of vision is observed.

Question 23

Prevention of CVA

Answer 23

Therapeutic lifestyle changes (TLC)
Anti-platelet drugs
   ASA 81 to 325mg PO daily
   Clopidogrel (Plavix) PO
Anticoagulant (atrial fibrillation)
    Warfarin (Coumadin) PO
Surgical (reperfusion) therapy
Carotid endarterectomy
Brain stent
Extra cranial artery to intracranial artery (EC-IC)

Question 24

Acute Care of CVA

Answer 24

Anti-thrombolic therapy
***Tissue plasminogen activator (tPA)
Must be given within 3 hours of onset
Surgical therapy
Mechanical embolus removal in cerebral ischemia (MERCI)

Question 25

Differentiate among the drug therapy, and surgical therapy for patients with ischemic strokes and hemorrhagic strokes

Answer 25

Drug therapy for ischemic strokes include: Fibrinolytic therapy, recombinant tissue plasminogen activator (tPA) can only be used w/in 3 to 4 and 1/2 hours of stroke. Aspirin 325 mg, platelet inhibitors (Plavix), statins. Surgical therapy for ischemic strokes include: Stent retrievers (Solitaire FR, Trevo) are used to open blocked arteries in the brain it starts in the femoral. Another surgical approach uses the mechanical embolus removal in cerebral ischemia (MERCI) retriever, this tehcnique allows the surgeon to go inside the blocked artery of a patient experiencing ischemic strokes.

Drug and surgical therapy for hemorrhagic strokes
Management of oral hypertension with oral and IV meds. Anticoagulants and antiplatelets are contraindicated. Seizure prophylaxis can be used in certain situations. Surgical therapy include: Evacuation of aneurysm-induced hematomas or cerebellar hematomas > 3cm. Individuals w/ an arteriovenous malformation (AVM) can experience a hemorrhagic stroke if the AVM ruptures; treatment for this is surgical resection and/or radiosurgery (i.e. gamma knife).

Question 26

Collaberative care: ischemic and hemorrhagic

Answer 26

Collaberative care: ischemic
The goals for collaborative care during the acute phase are preserving life, preventing further brain damage, and reducing disability.
Acute care begins with managing the airway, breathing, and circulation. Elevated BP is common immediately after a stroke and may be a protective response to maintain cerebral perfusion.
Baseline neurologic assessment is carried out, and patients are monitored closely for signs of increasing neurologic deficit and increased ICP.
Fluid and electrolyte balance must be controlled carefully. The goal generally is to keep the patient adequately hydrated to promote perfusion and decrease further brain injury.
During initial evaluation, the single most important point in the patient’s history is the time of onset. Recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke. It is used to reestablish blood flow through a blocked artery to prevent cell death.
After the patient has stabilized and to prevent further clot formation, patients with strokes caused by thrombi and emboli may be treated with platelet inhibitors and anticoagulants.

Collaberative care: hemorrhagic
Goals for managing airway, breathing, circulation, and intracranial pressure are the same as for the patient with ischemic stroke.
A number of surgical interventions are used to treat hemorrhagic strokes, including resection, clipping of an aneurysm, and evacuation of hematomas. The procedure chosen depends on the cause of the stroke.
Seizure prophylaxis is recommended. Additional drug therapy is used to manage hypertension and reduce the incidence of cerebral vasospasms.

Question 27

Define and articulate the rationale for the different type of diets that may be ordered for a patient with a swallowing impairment.

Answer 27

Dysphagia- choking and aspiration pneumonia, pt aren’t allowed to drink thin liquid, so would add thickness to it

Question 28

Describe the acute nursing management of a patient with a stroke

Answer 28

During the acute phase following a stroke, management of the respiratory system is a nursing priority. Stroke patients are particularly vulnerable to respiratory problems, including atelectasis, airway obstruction, and aspiration pneumonia.
The patient's neurologic status must be monitored closely to detect changes suggesting extension of the stroke, increased ICP, vasospasm, or recovery from stroke symptoms.
Nursing goals for the cardiovascular system are aimed at maintaining homeostasis; the nurse must perform a thorough cardiac assessment, manage infusions, and monitor fluid balance. Measures to prevent deep venous thrombosis (DVT) are often implemented.
To maintain optimal function of the musculoskeletal system, measures are used to prevent joint contractures and muscular atrophy.
The skin of the patient with stroke is particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility.
The most common bowel problem for the patient who has experienced a stroke is constipation. Patients may be prophylactically placed on stool softeners and/or fiber.
The primary urinary problem is poor bladder control, resulting in incontinence. Efforts should be made to promote normal bladder function and to avoid the use of indwelling catheters.
The patient may initially receive IV infusions to maintain fluid and electrolyte balance, as well as for administration of drugs. Patients with severe impairment may require enteral or parenteral nutrition support. Swallowing ability will need to be assessed.
Assess the patient both for the ability to speak and the ability to understand and support the patient accordingly.
Homonymous hemianopsia (blindness in the same half of each visual field) is a common problem after a stroke. Persistent disregard of objects in part of the visual field should alert you to this possibility.
A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. Use nursing interventions designed to facilitate coping by providing information and emotional support.

Question 29

Describe the rehabilitative nursing management of a patient with a stroke

Answer 29

The patient is usually discharged from the acute care setting to home, an intermediate or long-term care facility, or a rehabilitation facility.
Regardless of the care setting, ongoing rehabilitation is essential to maximize the patient’s abilities. Rehabilitation requires a team approach so the patient and family can benefit from the combined, expert care of a stroke team.
The goals for rehabilitation of the patient with stroke are mutually set by the patient, family, nurse, and other members of the rehabilitation team.
Initially you emphasize the musculoskeletal functions of eating, toileting, and walking for the rehabilitation of the patient. Interventions advance in a manner of progressive activity.
After the acute phase, a dietitian can assist in determining the appropriate daily caloric intake based on the patient’s size, weight, and activity level. The diet must also be adjusted for the ability of the patient to swallow solids and fluids.
A bowel management program is implemented for problems with bowel control, constipation, or incontinence. Nursing measures are also focused on promoting urinary continence.
Patients who have had a stroke frequently have perceptual deficits. For example, patients with a stroke on the right side of the brain usually have difficulty in judging position, distance, and rate of movement.
The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. As a nurse, you should help patients and families cope with these losses.
Speech, comprehension, and language deficits are the most difficult problems for the patient and family. Speech therapists can assess and formulate a plan of care to support communication.

Question 30

Explain the psychosocial impact of a stroke on the patient, caregiver, and family

Answer 30

Patients who have had strokes often exhibit emotional responses that are not appopriate or typical for the situation. Sometimes those w/ a stroke on the left side of the brain (right hemiplegia) have exaggerated mood swings that they cannot control. Nursing interventions include: distracting the patient on outbursts, explain to pt and family that the outbursts are due the stroke, maintain a calm environment and avoid shaming or scolding the patient during the outbursts. Patient may deal with maladjusted dependence when inadequate coping occurs when the patient cannot function like before; the patient and the family may resent each other. In order to deal with the situation: recognition of behavioral changes resulting from neurologic deficits that are not changeable, responses to multiple losses by both the patient and the family, and behaviors that may have been reinforced during the early stages of stroke as continued dependency.

Question 31

difference between peripheral vs. central nervous system

Answer 31

CNS is brain and spinal cord. PNS are the sensory and motor neurons. The PNS breaks down further into the autonomic and the sensory-somatic nervous system. The autonomic breaks down further into the sympathetic and parasympathetic nervous systems. It is very complex but to answer your question when you touch a hot stove sensory neurons (PNS) send a message to the brain (CNS) and the brain process that the hand is being injured and reacts by sending motor neurons (PNS) to tell the hand to pull away.

Question 32

Axons-

Answer 32

a long, slender projection of a nerve cell, or neuron, that typically conducts electrical impulses away from the neuron’s cell body

Question 33

Myelin-

Answer 33

a mixture of proteins and phospholipids forming a whitish insulating sheath around many nerve fibers, increasing the speed at which impulses are conducted.

Question 34

upper vs lower motor neurons

Answer 34

Upper- brain to spine
Degeneration- lose the ability to regulate it, because of that muscle becomes spasm and atrophy. More muscle contraction, reflexes, disuse of the muscle, and toes point up
Disuse atrophy
Lower- spine and brain branch to the muscles
Degeneration- losing the innovation of the muscle

Question 35

Differentiate between autoimmune and degenerative

Answer 35

autoimmune: inappropriate activation of immune system; autoimmune antibodies destroy receptors or peripheral myelin and include guillain-barre syndrome, multiple sclerosis, and myasthenia gravis
degenerative: breakdown in the body; impairment or loss of motor functions; amyotrophic lateral sclerosis and Parkinson’s disease

Question 36

Guillain-Barre Syndrome:

Answer 36

developing numbness starting from lower extremities and moving up; vital signs; respiratory status; maintain patient airway and manage secretions; neuro checks; ability to swallow; control pain; prevent muscle atrophy; prevent other complications related to immobility, turn them, prevent DVT

Definition
Autoimmune disease of unknown origin that involves degeneration of the myelin sheath of peripheral nerves
Incidence
2,700 annually
1 in every 100,000
Ages 15-35 and 50-75 years

Pathophysiology
2/3 of cases proceeded by viral or bacterial infection (esp. Camphylobacter jejuni)
Exposure of infectious agents triggers development of antibodies
Antibodies attack peptides within peripheral myelin sheath
Neither hereditary nor contagious
Acute
Ascending paresthesia, paresis, and paralysis
Absent DTR
Autonomic dysfunction
Respiratory failure  
Plateau
Symptoms remain but do not worsen 
Recovery
Begin to improve in descending pattern
Approximately 80% of patients recover completely within 1 year, severe cases take 2 years for maximal recovery
Diagnosis
No specific tests
Lumbar puncture (↑ protein)
Electromyography (EMG)
Nerve conduction test
Treatment
Medical emergency
Plasmapheresis
Intravenous immunoglobulin (IVIG)
Nursing management
Vital signs
Respiratory status
Maintain patent airway & manage secretions
Neuro checks
Ability to swallow
Control pain
Prevent muscle atrophy
Prevent other complications related to immobility

Question 37

Multiple sclerosis:

Answer 37

patient can experience relapses (p. 347). administer corticosteroids for exacerbations, administer immune suppressive agents such as interferon-

Definition
Chronic immune-mediated demyelination and scarring of neurons in central nervous system
Incidence
400,000 people in the U.S.  
Onset 20 - 50 years (women > men)
Higher incidence in Caucasians 
More prevalent in colder climates

Pathophysiology
Destruction of myelin sheath surrounding neurons primarily in the central nervous system (peripheral nerves are spared)
Believed to be immune mediated triggered by a virus (e.g. Epstein-Barr) in genetically predisposed
Plaques form along myelin sheath, eventually causing scarring and destruction 
Irreversible axonal damage 
Clinical Manifestation
Impaired visual acuity
Blurred vision
Diplopia
Weakness
Numbness
Paresthesia
Extreme fatigue
Ataxia
Gait imbalance
Spasticity (late)
Bladder/ bowel difficulties
Pain
Depression, labile mood, memory and cognitive impairment
Diplopia on Lateral Gaze (33%)	
Chronic and unpredictable course with disease exacerbations and remissions
Relapsing-remitting (RRMS) – 85%!
Primary progressive
Secondary progressive
Progressive-relapsing
Diagnosis
History (episodes of neuro dysfunction)
MRI of brain and spinal cord (MS plaques)
Treatment
Relapses & exacerbations
Corticosteriods (methylprednisolone, prednisone)
Immune suppressive agents such as Interferon-B SQ injection QOD

Question 38

Myasthenia gravis:

Answer 38

assess: ptosis; diplopia; dysphagia; dysarthria; mysathenic snarl; muscle weakness that worsens with exercise and improves with rest; respiratory insufficiency and failure
management: anticholinesterase drugs; corticosteroids; immune suppressants; plasmaphersis; intravenous immune globulin (IVIG)

Definition
Autoimmune neuromuscular disorder
Incidence
60,000 people in U.S.
Early onset, age 20-30 (women)
Late onset, after age 50 (men)
Pathophysiology
Autoantibodies block the skeletal muscle receptor sites, preventing acetylcholine from attaching to them
Because not enough acetylcholine is attached to the receptor sites, muscle contraction does not occur
Autoantibodies Block ACh Receptors
Clinical manifestations
Ptosis (50-90%) - dropping of the eyelid
Diplopia- double vision
Dysphagia- difficulty to swollow
Dysarthria - slow in speech
Mysathenic snarl
Muscle weakness that worsens with exercise and improves with rest
Respiratory insufficiency & failure
Diagnosis
Serum acetylcholine receptor antibodies
Tensilon test
http://www.youtube.com/watch?v=k7YX9kuWrxA
Electromyography (EMG)
Treatment
Anticholinesterase drugs (neostigmine)
Corticosteroids
Immune suppressants
Plasmaphersis
Intravenous immune globulin (IVIG)
Surgery - Thymectomy

Question 39

ALS:

Answer 39

assess: initial, unexplained weakness and fasciculating (twitching) muscles in a limb; muscle atrophy with increased tone and hyperreflexia; eventually the muscles that control speech, swallowing, and breathing are affected (death); positive Babinski reflex
management: maintain sensory and cognitive functions

Definition
Rare progressive neuromuscular disorder characterized by loss of upper and lower motor neurons leading to eventual wasting and atrophy of all voluntary muscles, including respiratory muscles. Also, known as Lou Gehrig’s disease
Amyotrophy - Process of muscle atrophy
Lateral - Loss of nerves on each side of the spinal cord
Sclerosis -Hardened scar tissue when nerve cells die
Incidence
5000 people in U.S. affected annually
Onset age 40-60 years, men > women
Fatal, death within 3 to 5 years
Clinical manifestations
Initial, unexplained weakness and fasciculating (twitching) muscles in a limb
Muscle atrophy with increased tone and hyperreflexia
Eventually the muscles that control speech, swallowing, and breathing are affected (death)
Positive Babinski reflex

Note: Maintain sensory and cognitive functions

Question 40

Parkinson’s disease:

Answer 40

assess gait, rest tremor, mask-like face, drooling, delayed swallowing
management: levodopa/carbidopa (Sinamet), surgery- deep brain stimulation (for refractory PD only)
monitor for dysphagia

Definition
Chronic progressive degenerative neurologic disorder that results from loss of dopamine in the brain structures that control movement
Incidence
1 million people in U.S.
60,000 new cases each year
65 years and older at greatest risk
Pathophysiology
Dopamine (DA) is produced in substantia nigra, which delivers it to the basal ganglia, a section of the brain that coordinates movement
Degeneration of the substantia nigra leads to decrease in levels of dopamine (DA)
Acetylcholine (ACh) is uninhibited, resulting in muscle tremor and rigidity
Accumulation of abnormal proteins within neurons (Lewy Bodies)
Clinical Manifestation
Rest tremor 
Rigidity
“Cogwheel”
Flexed posture
Bradykinesia
Difficulty initiating movement 
“Freezing”
Shuffling gait
Decreased or absent arm swing
Mask-like face
Infrequent blinking
Delayed swallowing
Drooling
Mumbled speech
Small, cramped handwriting (micrographia)

Diagnosis
No definitive tests
Drug challenge
Treatment
Levodopa/ carbidopa (Sinamet)
Surgery
Deep brain stimulation (for refractory PD only)
Nursing management
Monitor for dysphagia
Education
Importance of taking meds on time
Constipation (↑fluids & fiber)
Handle coins in pockets
Fall precautions (wear sturdy shoes; remove throw rugs, electrical cords, and clutter; consciously pick up your feet to take steps; install grab bars; rock back and forth to get started)

Question 41

CHOLINERGIC TOXICITY

Answer 41

Cholinergic poisoning
S salivation
L lacrimation
U urinary incontinence
D diarrhea
G GI cramps
E emesis
Cholinergic crisis
Bronchospasm & bradycardia 
Leads to respiratory & cardiac arrest 
Antidote: Atropine
Nursing management
Monitor for dyspnea, ineffective cough, and swallowing difficulties
Plan activities to include rest periods
Educate about adverse effects both of anticholinesterase drugs and steroids

Question 42

Outline the major goals of treatment for the patient with a chronic, progressive
neurologic disease

Answer 42

The goal is to prevent seizures with minimum toxic side effects from drug therapy (since it cannot be cured).The patient should wear helmelts in situations involving head injury; improved perinatal, labor, and delivery care to reduce fetal trauma and hypoxia (to avoid brain damage). The patient should practice good health habits (including stress management)

Question 43

Paresthesia -

Answer 43

burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body. The sensation, which happens without warning, is usually painless and described as tingling or numbness, skin crawling, or itching.

Question 44

Ptosis

Answer 44

-the upper eyelid droops over the eye.

Question 45

autonomic dysfunction-

Answer 45

can affect a small part of the ANS or the entire ANS. Some symptoms that may indicate the presence of an autonomic nerve disorder include: dizziness and fainting upon standing up, or orthostatic hypotension. an inability to alter heart rate with exercise, or exercise intolerance

Question 46

Diplopia -

Answer 46

the subjective complaint of seeing 2 images instead of one and is often referred to as double-vision in lay parlance

Question 47

Dysphagia -

Answer 47

the medical term for the symptom of difficulty in swallowing.

Question 48

Dysarthria

Answer 48

• often is characterized by slurred or slow speech that can be difficult to understand

Question 49

Bradykinesia -

Answer 49

slowness of movement and is one of the cardinal manifestations of Parkinson’s disease.

Question 50

cog wheel-

Answer 50

muscular rigidity in which passive movement of the limbs (as during a physical examination) elicits ratchet-like start-and stop movements through the range of motion of a joint (as of the elbow) and that occurs especially in individuals affected with Parkinson’s disease
The third major sign, rigidity (sometimes called “cogwheel” rigidity), is peculiar to Parkinson’s disease.

Question 51

Spasticity-

Answer 51

a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles and can interfere with normal movement, speech and gait

Question 52

Rigidity-

Answer 52

inability to be to bent or be forced out of shape.

Question 53

intention -

Answer 53

healing

Question 54

rest tremors-

Answer 54

Parkinsonian tremor is a common symptom of Parkinson’s disease, although not all people with Parkinson’s disease have tremor. Generally, symptoms include shaking in one or both hands at rest.

Question 55

Describe the rehabilitative nursing management of patients with these disorders.

Answer 55

maintaining patient airway, control process of immune activation; corticosteroids

Question 56

Explain the impact of a chronic neurologic disease on the physical and psychosocial well-being of the patient and family

Answer 56

The patient is unable to breathe properly during seizure activity, the patient is at risk for injury (loss of consciousness during seizure activity, and postictal physical weakness), the patient may not manage medications and modify lifestyles appropriately, the patient may feel socially isolated.
Depression and hopelessness