X Neuro: Mrs Si (Burke) Flashcards
Assessing Mental Status
- Orientation (person, place, time, event)
- Mood/Behavior
- General knowledge
- ST/LT memory
- attention span/ability to focus
Assessment: Orientation
-person, place, time, event/purpose
A+Ox3 w understanding of event, or document pt doesn’t know whey they are here if they are A+O all three except event.
Adequate cerebral functioning is determined by ..
assessing mental status
Ability to show orientation depends on
memory and attention
Orientation Questions
- Person: What is your name?
- Place: Can you tell me the name of this facility? What town? (DON’T ask pt Do you know where you are? Insults them)
- Time: What year is it? What month? Who is president? (understand time frame)
- Purpose/Event: What brought you here?
Mood/Behavior: Mood
-How does pt feel? person has their own perception of how they feel. Opinion. They may look happy but not be.
Mood/Behavior: Behaviour
Cooperative? Agitated? Pleasant?
-be objective not subjective. i.e. if you document it, make sure you have proof to back it up.
General Knowledge Assessment Question
- Who’s the president of USA?
- What major holiday is in Nov?
- What was last big storm?
- What wars are we involved in recently?
Test for short term memory
- list 3 objects
- ask pt to repeat them
- check recall in 5 min
Test for Long Term memory
- job history
- where born/raised
- family hx, brothers, sisters?
Do demented pts have short term mem?
no
-talk about past to make them comfortable
Attn Span and Ability to Focus
ability to focus or concentrate over time on 1 task or activity.
-if inattentive, pt has hard time providing their med hx
LOC (Level of Consciousness)
- indicator of brain fx
- earliest sign of changes in MS
What are the 2 components of LOC
- Arousal (wakefulness)
- Awareness
LOC’s
ACLOSC
- alert
- confused
- lethargic
- obtunded (alertness w slow psycho motor response)
- stuporous (sleep like state, not coma, little or no spontaneous activity. only responds to vigorous stimulate)
- comatose (unable to respond to any stimuli verbal/physical)
When documenting LOC, Orientation
AA+Ox3 (awake, alert, oriented x3)
i.e. lethargic, easily arousable, oriented x3
Awareness
- ability to interact w and interpret your environment.
- higher fx controlled by brain stem
Components of Awareness
- orientation
- memory
- calculation (planning, time mgmt.)
- Fund of knowledge (the historically accumulated and culturally developed bodies of knowledge and skills essential for household or individual functioning and well-being”)
Glasgow Coma Scale
- assess of pt’s level of responsiveness
- use for pts who have suffered head injuries
- indicates severity of coma
- predicts possible pt outcomes
Glasgow Coma Scale evaluates…
- motor
- verbal
- eye opening responses
- scale of 3-15
- 3 = coma, 15 = normal
- not to replace a neuro assessment
Glasgow Coma Scale scores
Eye Opening 4 - Spontaneous 3 - to loud voice 2 - to pain 1 - none
Verbal Response 5 - oriented 4 - confused, disoriented 3 - inappropriate words 2 - incomprehensible sounds 1 - none
Best Motor Response 6 - obeys 5 - localizes 4 - withdraws (flexion) 3 - abnormal flexion (posturing) 2 - extension posturing 1 - none
2 Types of Posturing
Decorticate: pt turning inward
Deceribrate: turning outward
Stroke (CVA, Brain Attack)
Cerebrovascular accident: sudden death of brain cells due to lack of oxygen when blood flow to brain is impaired by blockage or rupture of an artery to the brain. Symptoms of a stroke depend on the area of the brain affected.
- # 1 cause of adult disability
- 5th leading cause of death in US
- Affects all ages
- # 3 for women
- # 5 for men
- # 1 preventable cause of disability
Stroke Stats
- In US, stroke every 40sec
- 795,000 have stroke every year
- 6.8mil Americans 20yrs UP have had a stroke
- once you have a stroke, poss of 2nd very real
Stroke Prevention
- diet
- exercise
- HTN controll
Stroke Risk Factors
- HTN
- Obesity
- DM
- AFIB (atria doesn’t pump well, while hesitating, blood stagnant and starts to clot, pump can send clot through body, candidates for AntiCoag meds, but if they are risk for fall bc can bleed out)
- Cocaine: vaso constrictor
- ETOH
- Male
- Oral Contraceptives
- Race (AfAm, Hispanic, Caucasion)
- Age 65 UP
- Family Hx
- Sleep Apnea
- Smoking
Stroke: Major Players
- HTN
- Cholesterol
- Smoking
- 40% of Americans have had at least 1 stroke
Stroke: Def
sudden loss of brain fx d/t blockage of rupture of blood vessel in or to the brain
Types of Strokes
- Ischemic (blockage)
- Hemorrhagic (ruptured BV)
Ischemic Stroke
- most common, 80%
- interruption of blood flow to brain causing hypoperfusion, hypoxia, cell death
Types of Ischemic Stroke
- Thrombotic
- Embolic
Thrombotic Stroke (Cerebral Thrombosis): Def
-clot forms in cerebral artery (supply blood to brain)
Thrombotic Stroke (Cerebral Thrombosis): Causes
- Atherosclerosis *** (most common)
- HTN
- DM (w accelerate Atherosclerosis)
What is Atherosclerosis?
- Accumulation of lipids, cholesterol on intimal layer of artery.
- causes narrowing
Atherosclerosis risks
if piece breaks off, the body sends inflammatory response and the artery clogs up. The cells and platelets obstruct entire vessel –> Ischemic Stroke
Thrombotic Stroke
- plaque narrows the artery
- The plaque ruptures
- clot forms
- clot blocks blood flow
- Ischemia occurs
Embolic Stroke
- blood clot forms in vessel, not in brain
- travels thru blood, lodges in small brain artery
- r/t afib
Embolic Clot
travelling clot
Other types of embolism
- Air Embolism (30ml air)
- Fat embolism (orthopedic sx, GU sx)
- Amniotic fluid (following child birth)
Hemorrhagic Stroke
Rupture of blood vessel in brain
Hemorrhagic Stroke: cause
- uncontrolled HTN
- aneurism
- arteriovenous malformations (AVMS)
Types of Hemorrhagic Stroke
- intracerebral (in brain)(d/t HTN)
- subarachnoid hemorrhage (in space btwn skull and brain)
Arterial Aneurysm
- dilation, ballooning of portion of artery
- forms at weak point
- rupture –> hemorrhage and death (arteries under high pressure)
- cause :trauma, congenital defect, infection
arteriovenous malformations (AVMS)
- congenital disorder
- direct connection btwn veins and arteries . cluster of blood vessels lacking capillaries
- risk for hemorrhage
- mostly asymtomatic, usually revealed in autopsy
Blood Vessels: hi pressure to Lo
Artery–arterioles–capillaries–venues–veins
See pic is AVM
arteriovenous malformations (AVMS)
Is hemorrhage d/t head injury considered a stroke?
NO
TIA (Mini Stroke)
- Transient Ischemic Attack
- decrease in blood to area of brain
- results in brief neuro dysfx lasting
TIA S/S
- temp vision loss
- apasia (A language disorder that affects a person’s ability to communicate.)
- contralateral hemiparesis (opposite side weakness, face, arms, hands, legs)
- paresthesia (numbness/tingling)
- vertigo
- ataxia (impaired coor)
- loss of consciousness (uncommon)
TIA is warning sign for what?
- CVA
- 33% w TIA will have CVA in 2-5yrs
- need to dx underlying cause (afib?)
- anti platelet aggregation/anticoag meds
- factor Xa inhibitor med
MED: Anti-Platelet Aggregation
- ASA
- Clopidogrel (Plavix)
- Aggrenox
- Ticlopidine (Ticlid)
MED: Anti Coag
Cumadin
MED: Factor Xa Inhibitor
Eliquis
MED: Aspirin (ASA)
- Class: salicylate
- decreases platelet aggregation
- Use: LO risk of thrombotic CVA
- Dose: 50mg - 325mg/day
- SE: bleeding, tinnitus
- Monitor: Liver, renal Fx
- Teach: swallow enteric whole
- Warning: use w caution for asthma, can worsen
MED: Aggrenox
- combo of ASA (25mg) and Dipyridamole (200mg)
- Class: platelet aggregate inhibitor
- Use: LOwer risk of thrombotic CVA
- Dose: 1cap BID
- SE: weakness, faint, hypotension, bleed, HA
- Monitor: liver/renal fx
- Teach: SS bleeding, no preg, no ETOH (cause stomach bleeding)
- Class D: w cause damage to fetus, goes into breast milk
MED: Plavix
- Class: platelet aggregation inhibitor
- Use: LO risk of thrombotic CVA
- Dose: 75mg po qd
- SE: pruritis, purpuria (large petechia), hemorrhage
- Monitor: CBC, Liver fx
- Teach: bleeding precautions
MED: Ticlid
- Class: platelet aggregation inhibitor
- Use: LO risk of thrombotic CVA
- Dose: 250mg BID w food
- SE: bloody dyscrasias, hepatitis (non viral), GI upset
- Monitor: CBC, Liver fx
- Teach: bleeding precautions
MED: Coumadin
- Class: anti coag aka Warfarin
- Action: interferes w blood clotting
- Use: PE, DVT, MI, CVA, Atrial Dysrhythmias, post valve replacement
- Dose: /
- SE: bleeding, hepatitis
- Monitor: PT/INR (doses based on INR)
- Teach: bleeding precautions (can bleed anywhere, nose, cut, gut…)
- Reversal Tx for OD: Shot of Vit K
MED: Coumadin: more teaching
- if already eat leafy greens, base dose on that, but don’t all of a sudden eat greens if it’s not your normal diet.
- drug works when INR is 2-3. (doc needs to determine what dose w keep you at 2-3)
- less than 2, risk for clotting
- over 3, risk for bleeding
- no vit k (dk leafy greens)
- do not double dose if missed
- reg blood checks
- same time every day
- don’t miss dose
- Reversal Tx for OD: Shot of Vit K
MED: Eliquis
- Class: factor Xa inhibitor
- Use: LO risk of CVA and clots in pt w afib
- Dose: 5mg bid
- SE: easy bruising, bleeding
- Teach: doesn’t need as much blood work as Coumadin
- Neg: no reversal agent to combat OD. Must give Fresh Frozen Plasma (blood product)
Surgical Interventions for TIA
- carotid endarterectomy
- transluminal angioplasty
Carotid Endarterectomy
- correct carotid stenosis, limit blood flow to brain
- remove inner lining of carotid artery
- risk: dislodging plaque –> emboli –>CVA, will travel to brain
- done when 70-99% occluded
- done when pt is symptomatic
- pt awake to ensure no stroke
Transluminal Angioplasty
balloon squished plaque against wall of artery
Stroke: S/S
- visual field deficit
- motor deficit
- sensory-perceptual deficit
- verbal deficit
- cognitive deficit
- emotional deficit
Visual Field Deficits
- Homonymous Hemianopsia
- Loss of peripheral vision
- Diplopia (double vision)
Homonymous Hemianopsia
loss of half field of vision on same side in both eyes
Diplopia (double vision)
simultaneous perception of 2 images of 1 object
Motor Deficits: Hemiparesis
- weakness on a hemisphere
- Rt sided CVA = L sided damage
- face, arms, legs
Motor Deficits: Hemiplegia
- paralysis
- Lt sided CVA = Rt sided paralysis
- face, arms, legs
More Motor Deficits
- Ataxia (staggering, unsteady gait)
- Dysarthria (diff forming words/articulation)
- Dysphagia (diff swallowing)
Sensory Deficit
- Paresthesia (numbness/tingling)
- Rt brain CVA w have L paresthesia
Sensory-Perceptual Deficits
- Agnosia: diff recognizing and identifying objects or person
- Apraxia: diff performing tasks or mvmts when asked
- Neglect Syndrome: deficit in attention to and awareness of 1 side of space/body
Verbal Deficits - Aphasia
DEF: loss of ability to produce and comprehend language
CAUSE: Injury to areas of brain responsible for language production and interpretation.
Broca - Production
Wernicke - Language, Understanding
What are these areas responsible for?
BROCA and WERNICKE
Broca - comprehension and production
Wernicke - language, understanding
Sensory Aphasia (Receptive)
inability to comprehend spoken or written word
Motor Aphasia (Expressive)
inability to use symbols of speech. They understand but can’t verbalize
Global Aphasia
inability to understand the spoken word or to speak
Dysphasia
difficulty speaking
Dysphagia
difficulty swallowing
Dysarthria
difficulty i speaking due to problems with muscles of speech
difficult or unclear articulation of speech that is otherwise linguistically normal.
Agnosia
not able to recognize and identify objects or person
Apraxia
unable to preform tasks or mvmts when asked
Neglect Syndrome
deficit in attention to and awareness of 1 side of space
Ataxia
unsteady gait
Paresteshia
numbness/tingling
Cognitive Deficits d/t stroke
- ST/LT mem loss
- DEC attention span
- impaired ability to concentrate
- poor abstract reasoning
- altered judgement
Emotional Deficits d/t stroke
- loss of self control
- DEC tolerance to stressful situations
- depression/withdrawal
- fear, hostility, anger, feelings of isolation
Comparison of L v R hemispheric stroke
LEFT
- paralysis on R side
- R visual field deficit
- Aphasia (expressive, receptive, global)
- Altered intellectual ability
- Slow cautious behavior
RIGHT
- paralysis on L side
- L visual field deficit
- Spatial/Perceptual deficits
- Increased distraction
- impulsive behavior, poor judgement
- lack of awareness of deficits
Stoke MM
- treat rapidly
- IV access
- CT scan or MRI (thrombotic or hemorrhagic? Tx diff for each)
Single most important factor dealing w stroke?
TIME (tPA works better when given immediately)
Ischemic CVA: MM
- clot busting drugs (tPA, can kill if out of the window of effectiveness)
- admin w/in 4.5 hrs of onset of SS (when did ss start?)
tPA (Tissue Plasminogen Activator)
- Route: IV (VERY POTENT!!)
- strict criteria: acute Ischemic CVAs ONLY
- Clot busting
- use up to 4.5 hr after onset
- SE: Hemorrhage
- **-after tPA: NO ASA for 24hr, NO invasive procedures (foley, IBG, ABG) because you could bleed to death
Fx of Coumadin and Heparin
DON’T BUST CLOTS
prevent clots from enlarging and new ones from forming
tPA EXCLUSION criteria
- later than 4.5 hrs onset
- UP BP over 185/over 110
- sig head trauma or cva within 3 mos
- SS sub arachnoid of hemorrhage
- Hx of previous brain hem.
- prior aneurysms, AVMS, neoplasm
- heparin within 48hrs
- pt on Anti Coag
- arterial puncture in last 7 days
- BG
SS Sub arachnoid Hemmorahge (SAH)
main symptom is sudden, severe headache, (THUNDERCLAP HA) which is more intense at the base of the skull. Some people may even feel a popping sensation in their head before the hemorrhage begins.
also: neck pain numbness throughout your body shoulder pain seizures confusion irritability sensitivity to light decreased vision nausea vomiting rapid loss of alertness
Hemorrhagic CVA: MM
- Sx (maybe)
- Calcium Chann Blockers (prevent vasospasms)
Hemorrhagic CVA: Sx types
- *** Aneurysm Clipping (standard)
- Aneurysm Embolization (coiling, putting wire into aneurysm to impair blood flow, as it slows, it clots.
- Surgical AVM removal
Aneurysm Rupture compications
1) rebleeding
2) vasospasm, contracts and stops blood flow
Hemorrhagic CVA: NI (Acute phase)
- assess VS
- neuro checks
- HOB 30* (to lower ICP)
- NPO
- IV fluid
- Foley
- safety precautions
When do you treat BP during stroke?
only UP 220/UP 120
-hi pressure is delivering Ox to brain. If you treat it within limits, you impair blood flow to brain.
NI: Communication
- talk
- tone/pace
- avoid distractions (radio/tv)
- adequate time, do not rush
- communications boards (if aphasia)
NI: Swallowing
- dysphagia screen (90ml H2O in cup, drink in one gulp, if cough, NPO, swallow study, speech pathologist)
- HOB 90* meals - 30 min after
- oral care ac/pc
- suction at bedside
- thicken liquids
NI: Sensory Perception
- approach pt from unaffected side (acute phase. affected once chronic)
- place items on unaffected side
- teach pt to turn head to affected side
- ***call bell always on unaffected side
NI: Neglect syndrome
- approach pt from neglected side
- place nightstand on neglected side
- place necessities on neglected side
- ***Call bell on unaffected side
NI: Elimination
-toileting q2-4 hrs
-encourage fluid 2000ml/day, limit at night
-skin care
Retrain pt to use bathroom
NI: Mobility
- T/P q2hr
- proper body alignment, protect joints
- active/passive ROM (keep joints mobile)
NI
- involve speech therapist, OT, PT
- MEDS (dose, SE, when to take)
- refer to support groups
- safety precautions
- teach prevention (control HTN, lo cholesterol, control DM, healthy weight, exercise, manage stress, ETOH moderation
Trigeminal Neuralgia (tic douloureux): SS
- causes severe pain in Trigeminal nerve (V)
- shooting pain on 1 side of face
Trigeminal Nerve responsible for
- senses touch, pain, pressure, temp
- makes saliva/tears
- scalp, teeth sensation
- chewing movements
Trigeminal Neuralgia (tic douloureux): Pathos
- compression of Trigeminal nerve
- compresses on area near pons, superior cerebellar artery
- compression w damage cells myelin sheath, can lead to eratic and hyperactive fx of nerve
- severe pain at slightest stimulation
Trigeminal Neuralgia (tic douloureux): Cause
- Idiopathic (if not structural cause)
- annuerism?
- tumor
- arachnoid cyst?
- traumatic event (car acc, tongue piercing)
- 2-4% (young pt d/t MS)
Postherpetic neuralgia (PHN)
nerve pain (neuralgia) that persists after shingles rash has cleared. If pain goes, but then returns at a later date, this too is called PHN.
Shingles is an infection of a nerve, and causes a typical rash. It is caused by the varicella-zoster virus.
- UP 60yrs
- MS possible factor
- more WOMEN
- r/t some Sx dental procedures (damage to nerve)
- attacks, remissions
Postherpetic neuralgia (PHN): SS
- excruciating, knife like, electrical shock pain to 1 side of face, unilateral.
- can affect lips, gums, cheeks, side of nose
Postherpetic neuralgia (PHN): Triggers
- touching face
- chewing
- shaving
- speaking
- brushing teeth
- drinking hot/cold
- trigger point areas along nerve
- pain lasts sec - minutes
Cranial nerves CN 0 – Terminal CN I – Olfactory CN II – Optic CN III – Oculomotor CN IV – Trochlear CN V (1,2,3) – Trigeminal CN VI – Abducens CN VII – Facial CN VIII – Vestibulocochlear CN IX – Glossopharyngeal CN X – Vagus CN XI – Accessory CN XII – Hypoglossal
Cranial nerves CN 0 – Terminal CN I – Olfactory CN II – Optic CN III – Oculomotor CN IV – Trochlear CN V (1,2,3) – Trigeminal CN VI – Abducens CN VII – Facial CN VIII – Vestibulocochlear CN IX – Glossopharyngeal CN X – Vagus CN XI – Accessory CN XII – Hypoglossal
Trigeminal Nerve Innervation (see pic of head w dermatomes)
1 - Ophthalmic Branch
2 - Maxillary
3 - Mandibular
Trigeminal Neuralgia (tic douloureux): Dx
- no specific test
- neuro asst
- pain Hx
- MRI (to rule out MS or tumor)
Trigeminal Neuralgia (tic douloureux): Sx
-Micro-vascular Decompression (removing or relocating BV in contact w trigem nerve)
-Gamma Knife Radiosurgery: .surgeon directs focused dose of radiation to root of trigem nerve .using radiation to damage nerve .relief is gradual, may take several wks .works in majority of pt .can be repeated .considered Safe
Trigeminal Neuralgia (tic douloureux): MM
- microvascular decompression
- anticonvulsants
- antispasmodics
- Rhizotomy (alchohol or glycerol inj)
Trigem Neur: Rhizotomy
-neurosurgical procedure that selectively destroys problematic nerve roots in the spinal cord
GLYCEROL INJ:
-needle through face to base of skull
-needle guided through
Post PO: numbness/tinging
ALCOHOL INJ:
-may need repeated injs
BALLOON COMPRESSION:
- needle through face
- baloon at end of catheter
- inflate at right spot to supply pressure to trig nerve to damage it and block pn signals
SEVER NERVE COMPLETELY:
incision behind ear
Risk, perm numbness in face. instead of cutting, surgeon may decide to traumatize nerve instead (rubbing)
Trigem Neur: Radiofrequency Thermal Lesioning
- destroy nerve fibers asociated w pain
- while dedated, insert hollow needle thru face to base of skull to trig nerve
- when needle in position, awaken pt.
- dr sends electrode thru needle and send current through
- pt lets dr know when and where they feel tingling
Trigem Neur: AntiConvulsants
- **most common
- also used to treat behavioral probs
- MED: Tegretol, Carbatrol (Carbamazepine)
- MED: Dilantin, Phenytek (Phenytoin)
- MED: Lamictal (Lamotrigine)
- MED: Neurontin (Gabapentin)
Trigem Neur: Antispaciticity
helps w pain, muscle relaxant
-MED: Baclofen (alone or w Tegritol and/or Dilantin)
SE: drowsiness, N, confussion
Trigem Neur: Comfort Measures
- avoid touching face
- no shaving/washing area
- avoid extreme hot/cold fluid
- puree food, straw (eliminate chewing)
- IV fluids
- Monitor I/O
- soft foods, hi caolorie/protein
- poor oral hygiene becasue brushing may cause pain
- permanent numbness d/t Sx possible
- RSK: won’t feel cavities, tooth pain, biting skin, burns from hot food etc
Bells Palsy
- damage to CN VII.
- nerve goes through tunnel of bone on face, if inflamed, could be compression
- usually temporary
- weakness/paralysis
- sudden onset, 24-48hrs (peak 48hrs)
- rare in children
- men/women equal
- 50/60s
- DM more prone
- last trimester of preg
- unilateral, rarely bilateral
- sudden onset
- some recover quickly (few wks)
- 35% take longer to fully recover
Bells Palsy: Cause
Inflammation d/t
- Herpes Simplex
- Herpes Zoster (chix pox)
- Epstein Barr (mono)
- Cytomegalovirus (herpes fam)
- Lyme Disease
Bells Palsy: SS
-***facial paralysis
-muscle weakness/paralysis
-temporary
-facial drooping
-drooling
-dry eye/mouth
-loss of blink reflex (dry eye)
-excessive tearing
-distortion of face
-pain in ear (early)
-loss of taste
-changes ear/saliva production
-sound louder on affected side
-
Bells Palsy: Dx
- no specific test, rule out others
- ct scan to rule out tumor
- med hx of virus
- blood titres (antibodies)
Bells Palsy: MM
- MED: Corticosteroids (Prednisone, Man Tx for inflammation)
- MED: Acyclovir (antiviral, herpes types)
- Physical therapy (massage facial muscles)
- Analgesics (pain)
- Sx: not recommended, surgically open bony passage and decompress
Bells Palsy: Prognosis
- 85 fully recover in wks - 1 yr
- recover taste w’in 1st week = sign of recovery
- 15% have continued asymmetric facial muscle mvmts.
Meningitis
.use handout
and
http://www.cdc.gov/meningitis/index.html
Difference btwn CVA and TIA
CVA: sudden death of brain cells due to lack of O2.
TIA: decrease in blood supply to area of brain resulting in brief neuro disfunction
Patient w Dysphasia is at risk for?
Aspiration, Malnutrition
2 radiology tests used to Dx CVA
CT Scan, MRI, Carotid US, Cerebral Angiogram
Common SS of Subarachnoid Hemorrhagic Stroke
-sudden sever HA (Thunderclap HA)
Causes of Subarachnoid Hemorrhagic Stroke
- Aneurysm
- AVM
- Cocaine
- HTN
Should a pt w Dysphagia use a straw?
NO
A pt who has suffered brain injury becomes ?? very quickly
fatigued
