week 3 (neuro, sensorineural) Flashcards
Nursing management MG
Meals coinside with the peak anticholinesterase meds
suction available
impaired vision (tape/patch eye closed)
avoid stress factors (stress, infections, high temp., vigorous exercise).
Rest throughout day
Food considerations (soft, small, etc.)
Myasthenic Crisis
Temporary exacerbation of symptoms triggered by infection. As a nurse, you should monitor for respiratory weakness, dysphagia, and avoid any sedative medications.
Cholinergic crisis (MG)
We treat MG with anticholinergic medications. However, the patient can become overmedication and go into cholinergic crisis. You will see respiratory impairment, muscle weakness, and excessive pulmonary secretions. To treat this, stop the medications.
What are we concerned about with Guillain-Barre Syndrome?
respiratory function
What is Amyotropic Lateral Sclerosis?
ALS - degenerative disease that results in the loss of both upper and lower motor neurons.
ALS - s/s
Variable depending on where you are at in the progression of the disease.
a. Spasticity - no loss of bladder/bowel control/ respiratory function
b. ultimately, respiratory function is impaired.
ALS treatment
Nothing specific - manage symptoms.
What medications can be given to ALS patients who have trouble with spasticity?
Baclofen, dantrolene sodium, diazepam
ALS nursing management
guide them on end-of-life care
Supportive therapy
Ischemic stroke: cause
Large artery thrombosis Small, penetrating artery thrombosis Cardiogenic emboli Cryptogeni other
Hemorrhagic stroke: cause
Intracerebral hemorrhage
Subarachnoid hemorrhage
Cerebral aneurysm
Arteriovenous malformation
Ischemic stroke s/s
Numbness or weakness of the face, arm, leg especially on one side of the body. You may also see slurred speech or difficulty with word finding or comprehension
Hemorrhagic stroke s/s
"Exploding headache" Decrease LOC N/V Visual changes Seizures
What is the BE FAST acronym for strokes?
Balance loss Eye blur Face droop Arm weakness Speech difficulty Time to call 911
Risk factors for ischemic stroke
HTN Smoking Diabetes A-fib Obstructive sleep apnea Family Race/ethnicity
The list goes on and on
Hemiplegia
paralysis on one side of the body or part of it
Hemiparesis
weakness to one side of the body or part of it
Aphasia
Inability to express oneself or to understand language
Dysarthria
difficulty in speaking
Dysphasia
impaired speech
Aphasia: expressive, receptive, global
expressive aphasia(inability to express oneself)
receptive aphasia(inability to understand language)
global (mixed) aphasia (combo of the 2)
Apraxia
inability to perform a previously learned action
Homonymoushemianopsia
blindness in half of the visual field in one or both eyes - temporary or permanent
The affected side of vision corresponds to the paralyzed side of the body.
agnosia
loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile
What might you see if someone is having a left hemisphere stroke
Paralysis or weakness on right side of body Right visual field deficit Aphasia Altered intellectual ability Slow, cautious behavior
What might you see if someone is having a stroke in their right hemisphere
Paralysis/weak on left side of body Left visual field deficit Spatial-perceptual deficits Increased distractibility Impulsive/poor judgement Lack of awareness of deficits
Stroke prevention
Decrease risk factors and know medical conditions that increase the chance of a stroke (HLD, a-fib, diabetes, HTN).
What do we do when someone is discharged of a stroke?
We have to follow through with core measures such as medications (medications such as Plavix, -statins, BP medications, Aspirin).
HOWEVER, if someone had a hemorrhagic stroke, we want to be careful with aspirin or plavix because it can cause more bleeding. Depends on what the Dr. wants.
Why would someone get a CT and MRI scan when they come in for a stroke
CT - to see if hemorrhagic or ischemic
MRI - tells exactly where stroke has occurred
How do we assess someone who has a stroke
NIH scale (0-42)
The higher the score, the worse the client is
If you assess and their score goes up, call provider
Reperfusion therapies: tPA - when is it given
within 3 hours of last seen normal
may be up to 4.5 with no history of DM, or previous stroke, not on anticoagulants, and NIH less than 25
tPA dosing
weight based dose 0.9 mg/kg with a maximum dose of 90 mg
How much tPA is given at a time?
10% given over 1 minute
Remaining is given over 1 hour
What are things to considered once tPA is given
Assess for bleeding
Once given, no anticoagulants for 24 hours
Must go to ICU for 24 hours
No inserting any tubes for 24 hours (unless emergent)
What do we want in regard to reperfusion for an ischemic stroke
for the first 24 hours we want that patient to have permissive hypertension (HIGH BP) because the more blood flow we can force to brain better chance of perfusion. After 24 hours, immediately bring BP down
Reperfusion therapies: Thrombectomy with or without intra arterial alteplase
Give within 6 hours LSN
Reperfusion therapies: Endovascular therapy
Now recommended that patients with acute ischemic stroke
Endovascular therapy: criteria that needs to be met
Prestroke status of no deficits
Acute ischemic stroke receiving IV t-PA within 4.5 hours of onset according to guidelines from professional medical societies
Causative occlusion of the internal carotid artery or proximal middle cerebral artery
Age ≥18 years
NIHSS score of ≥6
ASPECT (a radiologic assessment of the CT scan) score of ≥6, and treatment can be initiated (groin puncture) within 6 hours of symptom onset
Patients eligible for t-PA should receive IV t-PA even if endovascular treatments are being considered (Powers et al., 2015). Thrombolytic therapy should not be delayed.
Reperfusion therapies: Carotid Endarterectomy (CEA)
surgery to treat carotid artery diseases (i think a stent is inserted)
CEA complications - incision hematoma: intervention
Monitor neck discomfort and wound expansion. Report swelling, subjective feelings of pressure in the neck, difficulty breathing.
CEA complications - hypertension: intervention
Keep in mind that risk is highest in the first 48 hours after surgery. Check blood pressure frequently, and report deviations from baseline. Administer medications, as prescribed, to reduce hypertension. Observe for and report new onset of neurologic deficits.
CEA complication - postoperative hypotension: intervention
monitor blood pressure and observe for s/s of hypotension
CEA complication - hyperperfusion syndrome: intervention
Observe for severe unilateral headache improved by sitting upright or standing.
CEA complication - intracerebral hemorrhage: intervention
monitor neurological status, and report any changes in mental status or neurological functioning immidiately
Ischemic stroke intervention:
Mobility and preventing joing deformities
- prevent should adduction
- position the hands and fingers
- changing positions
- exercise program
- preparing for ambulation
Preventing shoulder pain Self-care Bladder and bowel control (training) Nutrition (dysphagia) Improve thought process and communication Skin integrity
Ischemic stroke: preventing should adduction
To prevent adduction of the affected shoulder while the patient is in bed, a pillow is placed in the axilla when there is limited external rotation; this keeps the arm away from the chest. A pillow is placed under the arm, and the arm is placed in a neutral (slightly flexed) position, with distal joints positioned higher than the more proximal joints (i.e., the elbow is positioned higher than the shoulder and the wrist higher than the elbow). This helps to prevent edema and the resultant joint fibrosis that will limit range of motion if the patient regains control of the arm
Ischemic stroke: changing positions
The patient’s position should be changed every 2 hours. To place a patient in a lateral (side-lying) position, a pillow is placed between the legs before the patient is turned. To promote venous return and prevent edema, the upper thigh should not be acutely flexed. The patient may be turned from side to side, but if sensation is impaired, the amount of time spent on the affected side should be limited.
If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures. The prone position also helps drain bronchial secretions and prevents contractural deformities of the shoulders and knees. During positioning, it is important to reduce pressure and change position frequently to prevent pressure ulcers
Ischemic stroke: establishing exercise program
The affected extremities are exercised passively and put through a full range of motion four or five times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Exercise is helpful in preventing venous stasis, which may predispose the patient to venous thromboembolism (VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolus (PE).
Ischemic stroke: preparing for ambulation
As soon as possible, the patient is assisted out of bed and an active rehabilitation program is started. The patient is first educated to maintain balance while sitting and then to learn to balance while standing. If the patient has difficulty in achieving standing balance, a tilt table, which slowly brings the patient to an upright position, can be used. Tilt tables are especially helpful for patients who have been on bed rest for prolonged periods and have orthostatic blood pressure changes.
If the patient needs a wheelchair, the folding type with hand brakes is the most practical because it allows the patient to manipulate the chair. The chair should be low enough to allow the patient to propel it with the uninvolved foot and narrow enough to permit it to be used at home. When the patient is transferred from the wheelchair, the brakes must be applied and locked on both sides of the chair.
The patient is usually ready to walk as soon as standing balance is achieved. Parallel bars are useful in these first efforts. A chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy.
The training periods for ambulation should be short and frequent. As the patient gains strength and confidence, an adjustable cane can be used for support. In general, a three- or four-pronged cane provides a stable support in the early phases of rehabilitation
Ischemic stroke: positioning the hands and fingers
The fingers are positioned so that they are barely flexed. The hand is placed in slight supination (palm faces upward), which is its most functional position. If the upper extremity is flaccid, a splint can be used to support the wrist and hand in a functional position. If the upper extremity is spastic, a hand roll is not used, becauseit stimulates the grasp reflex. In this instance, a dorsal wrist splint is useful in allowing the palm to be free of pressure. Every effort is made to prevent hand edema.
Hemorrhagic stroke nursing intervention: optimizing tissue perfusion
The patient is closely monitored for neurologic deterioration resulting from recurrent bleeding, increasing ICP, or vasospasm. A neurologic flow record is maintained. The blood pressure, pulse, level of consciousness (an indicator of cerebral perfusion), pupillary responses, and motor function are checked hourly. Respiratory status is monitored, because a reduction in oxygen in areas of the brain with impaired autoregulation increases the chances of a cerebral infarction. Any changes are reported immediately.
Implementing Aneurysm Precautions.Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is placed on bed rest in a quiet, nonstressful environment, because activity, pain, and anxiety are thought to elevate the blood pressure, which may increase the risk for bleeding. Visitors may be restricted (American Association of Neuroscience Nurses [AANN], 2009;Hickey, 2014).
The head of the bed is elevated 30 degrees to promote venous drainage and decrease ICP. Any activity that suddenly increases the blood pressure or obstructs venous return is avoided. This includes the Valsalva maneuver, straining, forceful sneezing, pushing oneself up in bed and acute flexion or rotation of the head and neck (which compromises the jugular veins). Stool softeners and mild laxatives are prescribed. Both prevent constipation, which can cause an increase in ICP. Dim lighting is helpful, because photophobia (visual intolerance of light) is common. The purpose of aneurysm precautions should be thoroughly explained to both the patient (if possible) and family. Intermittent pneumatic compression devices are prescribed to decrease the incidence of DVT resulting from immobility. The legs are observed for signs and symptoms of DVT (tenderness, redness, swelling, warmth, and edema), and abnormal findings are reported.
Hemorrhagic stroke nursing interventions: relieving anxiety
Sensory stimulation is kept to a minimum for patients on aneurysm precautions. For patients who are awake, alert, and oriented, an explanation of the restrictions helps reduce the patient’s sense of isolation. Reality orientation is provided to help maintain orientation.
Keeping the patient well informed of the plan of care provides reassurance and helps minimize anxiety. Appropriate reassurance also helps relieve the patient’s fears and anxiety. The family also requires information and support.
Hemorrhagic stroke nursing interventions: monitoring and managing potential complications - vasospasm
The patient is assessed for signs of possible vasospasm: intensified headaches, a decrease in level of responsiveness (confusion, disorientation, lethargy), or evidence of aphasia or partial paralysis. These signs may develop several days after surgery or on the initiation of treatment and must be reported immediately. The calcium channel blocker nimodipine should be given for prevention of vasospasm, and fluid volume expanders in the form of triple-H therapy may be prescribed as well
Hemorrhagic stroke nursing interventions: monitoring and managing potential complications - Seizures
Seizure precautions are maintained for every patient who may be at risk for seizure activity. Should a seizure occur, maintaining the airway and preventing injury are the primary goals. Medication therapy is initiated at this time
Hemorrhagic stroke nursing interventions: monitoring and managing potential complications - hydrocephalus
Blood in the subarachnoid space or ventricles impedes the circulation of CSF, resulting in hydrocephalus. A CT scan that indicates dilated ventricles confirms the diagnosis. Hydrocephalus can occur within the first 24 hours (acute) after subarachnoid hemorrhage or several days (subacute) to several weeks (delayed) later. Symptoms vary according to the time of onset and may be nonspecific. Acute hydrocephalus is characterized by sudden onset of stupor or coma and is managed with a ventriculostomy drain to decrease ICP. Symptoms of subacute and delayed hydrocephalus include gradual onset of drowsiness, behavioral changes, and ataxic gait. A ventriculoperitoneal shunt is surgically placed to treat chronic hydrocephalus. Changes in patient responsiveness are reported immediately.
Hemorrhagic stroke nursing interventions: monitoring and managing potential complications - rebleeding
The rate of recurrent hemorrhage is approximately 1% to 5% per patient per year after intracerebral hemorrhage (Hemphill et al., 2015). Hypertension is the most serious and modifiable risk factor, which shows the importance of appropriate antihypertensive treatment.
Aneurysm rebleeding is the highest during the first 2 to 12 hours after the initial hemorrhage (Connolly et al., 2012) and is considered a major complication. Symptoms of rebleeding include sudden severe headache, nausea, vomiting, decreased level of consciousness, and neurologic deficit. Rebleeding is confirmed by CT scan. Blood pressure is carefully maintained with medications. The most effective preventive treatment is to secure the aneurysm if the patient is a candidate for surgery or endovascular treatment.
Hemorrhagic stroke nursing interventions: monitoring and managing potential complications - hyponatremia
After subarachnoid hemorrhage, hyponatremia is found in 10% to 30% of patients. Hyponatremia has been found to be associated with the onset of vasospasm (Connolly et al., 2012). Laboratory data must be checked frequently, and hyponatremia (defined as a serum sodium concentration less than 135 mEq/L) must be identified as early as possible. The patient’s primary provider needs to be notified of a low serum sodium level that has persisted for 24 hours or longer. The patient is then evaluated for syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. SIADH is described inChapter 13. Cerebral salt-wasting syndrome occurs when the kidneys are unable to conserve sodium and volume depletion results. The treatment most often is the use of IV hypertonic 3% saline.
Described the anatomy of the eyes in relation to the cranial nerves
The four rectus muscles and two oblique muscles are innervated by cranial nerves (CN) III, IV, and VI.
Normally, the movements of the two eyes are coordinated, and the brain perceives a single image.
Tears: role
protect the cornea and sclera with lubrication, nutritional support, moisture, and protection from microbes
The external eye contain immunoglobulins that do what?
contribute to the increase in tearing during allergic responses
What should the nurse do in the absence of the patient’s corneal reflex?
protect the patient’s affectedeye from injury by lubricating it with artificial tears to prevent drying.
Conjunctiva
provides a barrier to the external environment and nourishes the eye.
What do the goblet cells of the conjunctiva do
secrete lubricating mucus
What does the bulbar conjunctiva do and what does the palpebral conjunctiva do
Bulbar conjunctiva: covers sclera
Palpebra conjunctiva: lines the inner surface of the upper and lower eyelids
The junction of the 2 of known as the fornix
Describe the sclera
dense, fibrous structure that helps maintain the shape of the eyeball and protects the intraocular contents from trauma
Describe the sclera across age groups
children can have slightly blue
adults can have dull white
elderly can have slightly yellow
African Americans can have muddy brown
Describe the cornea
a transparent, avascular, domelike structure that covers the iris, pupil, and anterior chamber. It is the most anterior portion of the eyeball and is the main refracting surface of the eye.
What is the uvea
consists of the iris, the ciliary body, and the choroid. The iris, or colored part of the eye, is a highly vascularized, pigmented collection of fibers surrounding the pupil
What is the pupil
The pupil is a space that dilates and constricts in response to light.
Describe the lens of the eye
Directly behind the pupil and iris
A colorless and almost completely transparent biconvex structure
Avascular, no nerve or pain fibers
What does the lens enable the eye to do
Enables focusing on near vision and refocusing for distance vision (ACCOMODATION)
