Week 10: NEUROCOGNITION II

Question 1

Stroke

Answer 1

• 3rd leading cause of death in Canada
• Acute: Disruption of perfusion of O2 and nutrients to cerebral tissues

Types:
- Ischemic – blocked vessel 80%

• Hemorrhagic – bleed 20%
• Transient Ischemic Attack (TIA) – neurological dysfunction that resolves
  without imaging evidence of infarction

Question 2

Pathophysiology: Stroke

Answer 2

Decreased blood flow to the brain due to thrombus/clot (occlusion) or blood vessel rupture (hemorrhage)

Decreased perfusion causes brain cells to be starved of O2, leading to neurological deficits

If not resolved, cell death from prolonged ischemia leads to severe deficits or death

Entire cascade can also lead to cerebral edema

Question 3

Risk factors: Stoke

Answer 3

Age 55+ (doubles every 10 years after)

Men at risk for stroke, women at higher risk for mortality

Family members

Prior stroke/TIA

HTN, A fib, diabetes, sleep apnea, dyslipidemia

Substance use (vasoconstriction, increased HR)

Obesity

Physical activity

Smoking, alcohol use

Diet

Stress/depression

Oral contraceptives

Question 4

Ischemic Stroke

Answer 4

Disrupted blood flow to the brain due to thrombus/clot (occlusion)

• Classifications:
  Large artery (BAD) – atherosclerotic plaque formation leads to occlusion, brain perfusion is interrupted

Small artery – emboli, high BP, vasospasm

Cardiogenic embolic – clot from heart goes to brain (Afib)

Cryptogenic – idiopathic (no known cause)

Question 5

Nursing assessment: Ischemic Stroke

Answer 5

Health history:
Experience of stroke symptoms, VS, LOC
- FAST – face, arms, speech, time

Physical assessment:
 ABCs and LOC
Neuro:
 Motor deficits
 Sensory deficits
 Cognitive and verbal deficits
 Seizure activity?

Question 6

Labs and Investigations: Ischemic stroke

Answer 6

Imaging – immediate non-contrast CT or MRI

4.5 hours eligible for thrombolysis

6 hours eligible for endovascular thrombectomy

Can differentiate between ischemic versus hemorrhagic

Question 7

Medical interventions: Ischemic Stroke

Answer 7

Thrombolysis:
- Fibrinolytic therapy: tissue Plasminogen Activator (tPA) – must be given within 3 hours to dissolve clot
- Anticoagulants – prevent further clots

Endovascular thrombectomy
- Removal of a thrombus under image guidance

Question 8

Left versus Right Sided Stroke

Answer 8

Left: (speech and language)
Right sided paralysis
Speech issues
Language issues
Memory loss
Slow and cautious
Right sided neglect

Right: (safety risk)
Left sided paralysis
Vision issues
Memory loss
Fast and risky
Left sided neglect

Question 9

Hemorrhagic Stroke (bleed)

Answer 9

Intracranial:
- Bleeding into brain tissue due to ruptured vessel (tumour, atherosclerosis, etc.)

Subarachnoid:
- Bleeding into subarachnoid space (aneurysm, arterial wall weakness, AVM)

• Results in:
  Blood compressing brain tissue increases ICP and causes cerebral edema

Question 10

Nursing assessment: Hemorrhagic Stroke

Answer 10

Health history:
Rapid onset
Severe headache (splitting)
Nausea/vomiting
Confusion, altered LOC
One-sided weakness
Impaired speech
Fixed pupils

Physical assessment:
Abnormal neuro findings
Weakness – declining motor function
Lethargy, LOC, seizure, coma
Pupil changes and no blinking
Hemodynamic instability (increased BP, decreased HR)
Respiratory distress
Vomiting (w or w/o nausea)

Question 11

Labs and investigations: Hemorrhagic Stroke (bleed)

Answer 11

Immediate non-contrast CT or MRI

Question 12

Medical interventions: Hemorrhagic Stroke

Answer 12

Endovascular procedure – use a catheter to repair vessel wall from the inside

Surgical procedure – done outside of the vessel

Question 13

Nursing Management of Stroke

Answer 13

• Manage ABCs
  o Monitor swallowing – aspiration risk, usually NPO
  o HOB at 30 degrees – reduces aspiration risk
  o Oxygenation
  o Blood pressure
  o Fluids for perfusion
• Manage increased ICP
  o Cerebral edema/blood in cranial cavity
  o Osmolar diuretics – mannitol
  o Increase osmolality of blood – draws fluid from brain
  o Increase fluid volume in intravascular space, then use diuretics to excrete
  o Caution – electrolyte imbalance and seizures
  o Elevate HOB – flat/high fowlers may increase ICP
  o Low stimulation environment
• Manage interventions
  o Reperfusion
  o Surgery – remove clots or repair hemorrhage o Medications

Question 14

Stroke Rehabilitation

Answer 14

Residual deficits:
o Motor
o Dysphagia
o Incontinence
o Aphasia
o Cognitive changes

Question 15

Nursing Management: Post-Acute Stroke

Answer 15

• Cerebral vascular risk factor modification:
  o Healthy balanced diet (reduced cholesterol, high fiber, low sodium)
  o Physical activity
  o Weight management
  o Smokingcessation
  o Alcohol use
• New medications
  o Antihypertensives
  o Lipid management (statin)
  o Diabetes management
  o Antiplatelets
  Anticoagulant therapy

Question 16

Seizure pathology

Answer 16

• Healthy brain – balance of excitatory neurons releasing glutamate, inhibitory release GABA
• Brain during seizure – increased excitatory neurons releasing glutamate, less inhibitory releasing GABA

Question 17

Seizure Disorders

Answer 17

Seizures are excessive and acute-onset electrical activity of cerebral neurons causing
abnormal motor, sensory, autonomic, and/or psychiatric activity

• Epilepsy – two unprovoked seizures occurring 24 hours apart
• Numerous causes

Question 18

Underlying Causes of Seizures

Answer 18

• Electrolyte & metabolic imbalances (blood glucose, acidosis, fluid deficit)
• Drug toxicity
• Brain tumours
• CNS infections

Question 19

Seizure Triggers

Answer 19

• Stress
• Trauma
• Overexertion
• Period/pregnancy
• Sleep loss
• Visual disturbances, sounds, smells
• Recreational drugs
• Alcohol use
• Undermedicated w anticonvulsants

Question 20

Prodromal seizure

Answer 20

Before seizure activity
- May follow exposure to a trigger

Most common symptoms: confusion, anxiety, irritability, headache, tremor,
anger, mood disturbances

Question 21

Aura seizure

Answer 21

Warning felt before seizure

Focal aware seizure that precedes a generalized seizure

Most common symptoms: visual disturbances, cognitive disturbances (eg.
feelings of déjà vu)

Question 22

Ictus seizure

Answer 22

Seizure activity

Important to measure duration

Question 23

Post ictus

Answer 23

From end of seizure to return of client to baseline

Altered LOC, state of inhibition
- Poverty of speech, motor impairment, memory, lethargy/drowsiness, confusion, delirium, psychosis
- S&S depend on location and type of seizure

3⁄4 of clients with epilepsy experience postictal symptoms

Hours to days to resolve deficits

Question 24

Focal Onset Seizures

Answer 24

Aware (simple)
Referred to as aura

Motor: jerky movements

Non-motor:
- Sensory
- Autonomic: bp, bowel/bladder control
- Psychiatric: cognition disturbances, anxiety, fear

Impaired Awareness (complex)

Motor: Jerky movements

Non-motor:
- Sensory
- Autonomic: bp, bowel/bladder control
- Psychiatric: cognition disturbances, anxiety, fear

Question 25

Status Epilepticus

Answer 25

Seizure that lasts longer than 5 minutes OR a seizure within 5 minutes after returning to
baseline – emergency (possible brain damage)

• Causes:
• Uncontrolled epilepsy
• Stroke
• CNS infections
• Fever
• Electrolyte imbalances o BG imbalances
• Alcohol withdrawal
• Treatment:
• Treat cause, give antiseizure meds

Pharmacological Interventions
- Anticonvulsant medications
- Daily – routine blood work monitoring, take same time every day, do not stop abruptly, can interact with one another
- Emergency medications

Question 26

Surgical Treatment of Seizure Disorders

Answer 26

Focal resection – part of brain is removed

Hemispherotomy – hemispheres of the brain are disconnected

Corpus callosotomy – corpus collosum is disconnected between the right and left
hemispheres of the brain

Vagal nerve stimulator – implantable device stimulates the vagus nerve to prevent
seizures

Question 27

Nursing Management: Seizures

Answer 27

• Seizure precautions if known epilepsy or risk factors
• Suction and O2 at bedside
• IV access
• Padded bedrails
• Pillows
• Bed in lowest position
• Remove objects likely to cause injury
• Call for help – ABCs
• Administer meds (know orders)
• Clear area of hazards
• Time the phases of seizure, monitor symptoms
• If safe, turn client on side (aspiration prevention)
• Do not restrain client

Postictal:
- Maintain side-lying related to LOC
- Suction secretions
- Reorient to environment
- Low stimulation environment
- Frequent neuro assessments