Stroke/ ICP/ aneurysms NIHSS exam 2 Flashcards
What are general considerations of the neurological assessment
Systematic approach
Do it the same way every time
What is the most sensitive indicator of change in a patient
LOC
What is the order of LOC
AWAKE/ ALERT CONFUSED LETHARGIC OBTUNDED STUPOR COMA
−
What is lethargic
Severe drowsiness
The pt. cam be aroused by moderate stimuli and then drift back to sleep.
What is OBTUNDED
Patient has a lessened interest in the environment
Slowed response to stimulation
Tends to sleep more than normal with drowsiness in between sleep states
What is stupor
ONLY VIGOROUS AMD REPEATED STIMULI WILL AROUSE THE PERSON
WHEN LEFT UNDISTURBED, THE PT. WILL IMMEDIATELY LAPSE BACK INTO THE UNRESPONSIVE STATE
What is coma
State of unarousable, unresponsiveness
What is the left hemisphere responsible for
It is the primary language center
What is the right hemisphere responsible for
Visual- spatial perception
Music
Processing of information
Recognition of faces
For a neurological assessment, what 3 cranial nerves are tested together and what are they responsible for
Cranial nerves 3,4,6 They are MOTOR NEURONS responsible for 1. Eye movement 2. Eye lid opening 3. Pupil reaction
What is important to remember regarding documentation of pupil size
Do not document unequal pupils if you are not sure what the baseline pupils looked like…..
Some pupils may be uneven doe to past eye surgeries.
What does mental status entail?
- LOC
- Orientation
- Appearance and behavior
- Speech pattern
- Thought and perceptions
- Cognitive functions
What does a motor examination entail?
Strength
Tone
Symmetry
Coordination
If a person has loss of balance, what type of stroke would the nurse immediately assume
Cerebellum stroke
What is the cerebellar assessment
A assessment where balance and coordination are assessed.
How do you test balance and coordination
Pronate- supinate hand
Tap index finger to thumb
What is the Romberg test
A test that assesses balance
It is indicative of cerebellar damage on the side to which the patient leans
What is the Glasgow coma scale?
It is developed for assessment of patients in a coma
What are the 3 categories of the Glasgow coma scale
- Eye opening
- Best verbal
- Best motor
What is the score range for the Glasgow coma scale
3-15
The lower the score, the worse the patient and prognosis
What are considerations of the elderly to consider during a neurological assessment
Isles to consider include
- Decreased hearing
- Decreased mobility
- Change in cognitive ability
- Decreased vision
What is a stroke
A syndrome that is characterized as a sudden, non convulsive ( without seizures), onset of neurological deficits related directly or indirectly to a deficiency of the cerebral blood supply
What is the nations 5th leading cause of death
Stroke
What are stroke risk factors
Smoking
Uncontrolled HTN
Hex of stoke in family
Chronic A fib
Strokes can be caused by what
Clot formation ( ischemic strokes) Hemmorhage ( hemmorhagic strokes)
For hemmorhagic strokes what medication would the nurse seek clarification from the MD
Anticoagulants
What percentage of strokes are classified as ischemic
87%
Most strokes are ischemic
What percentage of strokes are considered ICH
10%
What is ICH
Intracranial hemmorhage
What percentage of strokes SAH
3%
What sex is more prone to strokes
Woman what are the 2 types of ischemic stroke
What are the 2 types of ischemic strokes
- Embolic
2. Lacunar
What is a embolic stroke
A type of ischemic stroke that develops from emboli such as in A fib when a emboli breaks loose and enters the brain
What is a lacunar stroke
A type of ischemic stroke that is more minor than emboli strokes. It is found in the lacuna of the brain
Can be seen on MRI’s
Who do lacunar strokes more commonly occur in
The elderly… They are generally asymptomatic
What are the classifications of a hemmorhagic stroke
Non traumatic SAH
RUPTURED CEREBRAL ANEURYSM
SPONTANEOUS ICH ( intracranial hemmorhage)
What can non traumatic SAH’s be caused by
They can be due to cerebral aneurysms
What is the most dangerous type of hemmorhagic stroke
Spontaneous ICH because there are no wearing signs… They are sudden
What is a transient ischemic attack ( TIA)
They are not strokes, there is a temporary disruption of blood flow result no in temporary deficits that are gone within minutes…. TIA’s can be a precursor to stroke
For a ruptured cerebral aneurysm, what will the patient complain of
Severe headache
What is AIS
Acute ischemic stroke
What is the clinical profile of AIS
Pt awakens with neurological deficits
They are usually sedentary when symptoms occur ( during sleep, at rest)
How does AIS progress
In a systemic manner
Hypo perfusion, then decreased cerebral perfusion, then ischemia and infarct.
Peaks in 1-3 days then stabilizes
What is the clinical profile of embolic stroke
Sudden onset
Occurs when the patent is awake and active
Very rapid onset
Maximum deficit within minutes… The deficit won’t get worse
What can embolic stroke occur from
Cardiogenic embolism A fib Valvular disease Ventricular thrombi Plagues of proximal aorta Left middle cerebral artery (MCA) most often affected
What is a lacunar stroke
A small penetrating stoke
Predominately basal, ganglia, thalamus, pons
What are risk factors of a hemmorhagic stroke
HTN, HTN, HTN, HTN,HTN, HTN,HTN, AVM ( arterio venous malformation) coagulopathy ( liver disease, warfarin) Trauma Drugs ( cocaine) Tumor Endocarditis
What is the clinical profile of ICH in the older person
Poorly controlled HTN
person is active with no warning signs
Occurs rapidly in minutes to hours
What is the clinical profile of the younger person with ICH
Drugs
Patent foramen ovale
Trauma
What is initial management of ICH
- Airway, breathing, circulation
- Determine Glasgow coma scale and NIHS, check brain stem reflexes If comatose
- BP control ( keep BP under 140)
- If low platelets ( transfuse)
- If on warfarin and INR is greater than 1.4, give FFP, PCC FACTOR VII
What does fresh frozen plasma and PCC do
It is reversal to decreased INR
What does factor VII do
Lowers risk of ICH enlargement
Increased risk of MI, ischemic stroke, DVT/PE
it does not improve mortality or functional outcome
Appro px 15% of all strokes are preceded by what
TIA’s
Why is it important to keep BP under 140 and not 120 during ICH management
Keep them under 140 to keep them perfused, If BP is lowered too quickly, repercussion rebound will occur, the patient will recieve no perfusion at all
MCA
Middle cerebral artery
ACA
Anterior communicating artery
What does the internal carotid supply
2/3 of the brain
Frontal, temporal, and parietal
What are symptoms of a anterior stroke
One side of the body
Both motor and sensory
Left side of brain causes aphasia
Usually not conscience
What are basilar arteries
Main blood supply to the brain.
Brain stem, thalamus, occipital, inferior temporal lobes
What are the 4 D’s of a posterior stroke
Diplopia
Dysarthria ( speech)
Dysphasia ( swallowing)
Dizziness ( vertigo)
How is a stroke diagnosed?
Symptomatology CT scan MRI/ MRA CBC, PLATELET COUNT, PT, PTT serum electrolytes and glucose Neck and heart auscultation EKG,electrocardiogram, TEE carotid and cranial ultrasound
What is a bad value for serum lactate
Above 4
Why are neuro patients one insulin drip
Blood glucose increases in brain tissue damage/ hypoxia
If a patient hits their head what can be expected of the MD to order
A CT scan which is quicker, cheaper, takes less time… The CT will show head trauma.
What is used as a definitive diagnosis of a stroke
A MRI/ MRA
A MRA looks at all the blood vessels
If a patient is on anticoagulation therapy what diagnostic will be ordered first
A MRI
What is medical treatment for a stroke
Anti platelet & anti thrombolic therapy
Treat hypertension
Neuroprotectives such as Calcium channel blockers ( nimodipine)
What are surgical interventions for a stroke
CEA
THROMBECTOMY
LOBECTOMIES ( almost never done)
What is CEA
Carotid endorectomy
It is done prophylactically so the patient won’t have a stroke.
A stethoscope is held on carotid and if a bruit is heard a ultrasound will be ordered
What is interventional radiology of a stroke
TPA
STENT PLACEMENT
THROMBOLYSIS
What is tPa
A enzyme found on blood vessel walls that defends against excessive clotting in normal vessels.
It dissolves thrombin clots
What is criteria for tPa
Symptom onset within 3 hours
No ICB, NO SAH
What are contraindications to tPa
Rapidly improving symptoms Serious brain trauma or intracranial surgery within last 3 months Seizure at onset of stroke Active internal bleeding Intracranial neoplasm, AVM, aneurysm Uncontrolled HTN ( above 185/110) Glucose less than 50 or greater than 400 LP within last 7 days Major surgery within 14 days Acute MI coagulopathies
What does sequelae mean
After effects
What is the sequelae of a stroke
Motor/ sensory deficits
Perceptual difficulties
Seizures
Hydrocephalus
What risk factors can be modified for stroke prevention
Control HTN, arrthymias, DM
exercise
Diet ( cholesterol)
At what age does SAH peak
55-60
What is the chief complaint of SAH
97% complain of the worst headache of their life
What are signs and symptoms of SAH
30-60% sentinel hemmorhage or wearing headaches prior Transient loss of consciousness N/V, blurred vision Photophobia Seizures
What is photophobia
Light sensitivity
What are risk factors for SAH
HTN,
SMOKING
ORAL CONTRACEPTIVES
COCAINE
What is the outcome of SAH
15% dies before reaching medical care
What is the mortality rate for SAH
19% in first 2 weeks
50-60% in first month
66% never return to the same quality of life they end up with. Neurological deficits for life.
What are risk factors for aneurysm rupture
Female population peaking in the 50’s and 60’s
Genetic disorders such as polycystic kidney disease, ehlers- Danlos syndrome
Smoking
Diabetes
Familial history especially in woman.
What are the shapes of a aneurysm
Berry
Fusiform
What is the pathophysiology of aneurysms
Blood under high pressure bleeds out of the dome of the aneurysm.
Accumulation is within the subarachnoid space at the base of the brain.
Blood may also collect in the parenchyma, ventricles, or subdural spaces, forming a hematoma.
What is physical examination of a aneurysm
Nuchal rigidity ( pain when flexing neck)
Restlessness
Diminished LOC
focal neurological signs related to the vascular territory involved in the hemmorhage
Cranial nerves 3,4,6
What is initial management of the brain aneurysm patient
Admit to ICU ABC's Possible central/ swan- gantz/ arterial line Possible EVD strict BP management Nimodipine Stool softeners Ulcer, seizure/ DVT prophylaxis
What is analgesia for aneurysm
Morphine for headaches
What is surgical treatment for brain aneurysms
CEA
surgery to correct bleeding of brain
Craniotomy
What is a coil
Used for fusiform aneurysms, keeps blood from going to the aneurysm. If the blood flow doesn’t go there it will die.
What is a coil used for
Fusiform aneurysms
What is surgical clips used for
A berry aneurysm, it cuts off blood flow,to,the aneurysm
What are complications of endovascular amd surgical treatment for aneurysms
Aneurysm rupture
Compromise ( including perforation) of parent vessels and/ or their branches
Thromboembolism death
What is nursing care and after intervention of surgical treatment for a aneurysm
VS/ neuro checks
Pain control ( morphine)
Fluid management ( critical)
IV line maintenance, including ensuring integrity of the line
Observation ( after coiling) for bleeding at site, loss of pulse to extremity, back pain, decreased urinary output, vomiting, tachycardia, or hypotension, watch urinary output for kidney failure.
What are complications of aneurysm SAH
- Cerebrovascular vasospasm
- Fluid and electrolyte disturbances
- Hydrocephalus
- Increased ICP
What is cerebral vasospasm
Narrowing of the cerebral vessels near or distant to the SAH causing cerebral ischemia
When does cerebral vasospasm occur
4-14 days post SAH
What are signs and symptoms of cerebral vasospasm
Focal speech/ motor deficit
Altered LOC
diagnostic imaging showing vasospasm
What is treatment of a cerebral vasospasm
Cerebral angiogram with intra arterial papaverine or balloon angioplasty
What diagnostic will show vasospasms
MRI/ MRA
What is triple H therapy for cerebral vasospasm
Hypertensive
Hypervolemic
Hemodiutional therapy
What is treatment for the first H in cerebral vasospasm
HYPERTENSION
Elevate SBP per MD
order with fluids or vasopressors ( dopamine, neosyphrine)
What is treatment for the second H in cerebral vasospasm treatment
HYPERVOLEMIA
keep PCWP 10-16 and CVP 8-12 using N/S, albumin, crystalloids, colloids, or PRBC
What is the third H in treatment of cerebral vasospasm treatment
HEMODILUTION
maintain HCT less than 40% using N/S and albumin
What medication treats cerebral vasospasm
Nimodipine ( Nimotop)
What are complications from triple H therapy
Pulmonary edema
MI ( by stress is on the heart, PAWP is increased diving the heart more workload, due to the extra fluids given)
cerebral edema
What is a potential complication of brain aneurysms
Hydrocephalus
Arachnoid villi are unable to reabsorption CSF sufficiently; often laden with byproducts of blood breakdown from SAH
This results from the hemmorhage itself.
What is treatment of hydrocephalus
Acutely, an EVD may be inserted
Overtime EVD level may be raised to allow patients to reabsorption their own CSF, then EVD is discontinued
What Happens if a patient is unable to reabsorb CSF
A ventriculoperitoneal shunt (VP SHUNT) may be performed
What is EVD
External ventricular drain. It is common after brain surgery
It can be inserted at the bedside or at time of surgery.
Can nurses regulate and adjust EVD’s
YES
What are common causes of increased ICP
Hydrocephalus Space occupying lesions Cerebral edema Head trauma Intracranial hemmorhage
What is important to note with increased intracranial hemmorhage
It is very dangerous
The more pressure =less perfusion
What is CCP
The amount of pressure to adequately perfuse the brain
How do you calculate CCP
( MAP-ICP)
How can CCP pressure be released
By draining pressure in the brain
Increased ICP diminishes what
Circulation to the brain
What are signs and symptoms of increased ICP
Decreased LOC HTN ( increased systolic, diastolic stays the same, widened pulse pressure) Bradycardia Respiratory pattern changes Pupil dysfunction ( cranial nerve 3)
What are SAH considerations/ interventions
Nurse must monitor for rebleeding, cerebral vasospasm, hydrocephalus, fluid and electrolyte disturbances
How much time laspses before complete oxygen deprivation causes IRREVERSIBLE neuronal damage
2-5 minutes
What are the categories of the NIHSS scale
- LOC, LOC questions, LOC commands
- Best gaze ( horizontal eye movements tested)
- Visual fields
- Facial palsy
- Motor arm
- Motor leg
- Limb ataxia
- Sensory
- Best language
- Dysarthria
- Extinction and inattention
