Neurosensory: Stroke and Brain Tumors

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Neurosensory Stroke and Brain Tumors

• Part 1 Stroke (Brain attack/CVA)

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A. Pathophysiology/etiology Normal brain
physiology and stroke

• Ranks 3rd as cause death
• Blood supply to one hemisphere is typically
  blocked, hence terms right left stroke
• Functioning brain depends on continuous blood
  supply for oxygen and glucose remove end
  products metabolism

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Risk factors for stroke

• Hypertension
• Heart disease
• Atherosclerosis
• Diabetes mellitus
• Medications birth control pills, substance
  abuse- cocaine, heroin
• Sedentary life style

• Obesity
• High cholesterol diet
• Smoking
• Stress
• Age gt 65 yrs
• Sickle cell disease

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Brain dysfunction length of
time without blood supply

• Brain function depends on collateral circulation
  and amount of cerebral edema
• TIA- neuro deficits last lt 24 hrs
• RIND- neuro deficits last gt 24 hrs but reverse
  not greater than 21 days
• CVA- irreversible brain damage with residual
  neuro deficits
• Stroke-in-evolution- progressive neuro deficits
  developing over hours or days. Usual cause
  thrombosis

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Disease process

• Ischemic stroke
• Occlusion of artery
• Generally do not lose consciousness
• Better prognosis than hemorrhagic
• May have TIAs before
• Thrombosis or embolism

• Hemorrhagic stroke
• Bleed occurs with activity
• Usually rapid onset
• Generally loss of consciousness
• Poorer prognosis
• Intracranial or subarachnoid

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Ischemic stroke Thrombosis

• Most common cause of a stroke
• Cause- narrowing of artery from atherosclerotic
  plaques
• Blood is blocked to part of brain that the artery
  supplies
• Often occurs in older individuals who are at
  rest/sleeping
• Tend to form in large arteries that bifurcate,
  internal carotid artery common site
• Can begin as TIAs, present as stroke-in-evolution
  , or have completed stroke outright

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Ischemic stroke Embolism

• Caused by clotted blood from other arteries in
  the body (heart during atrial fibrillation) fat,
  bacteria (endocarditis) or air
• Emboli circulate until reach an artery in brain
  that is too narrow to pass through
• Usually awake with rapid onset
• Extent damage is less severe and recovery faster
  than other strokes

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Hemorrhagic stroke
Intracranial hemorrhage (ICH)

• Caused by ruptured artery in the brain
• Bleeding varies in size from petechial to
  massive, edema occurs around the bleed
• Blood may form hematoma or be diffuse within the
  brain
• Usually occurs rapidly with the deep arteries
• Hypertension is main cause
• Most common cause of death due to a stroke
• Have more extensive residual deficits and slower
  recovery than other causes of stroke

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Hemorrhagic Subarchnoid hemorrhage
(SAH)

• Caused by bleeding into subarchnoid space from
• Extension of a intracranial hemorrhage
• Aneurysm
• AV malformation

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B. Common manifestations/complications-
by body systems
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By artery affected by occlusion or hemorrhage
Internal carotid
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Middle cerebral artery
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Middle cerebral artery

• Contralateral motor loss in the arm and the lower
  part of the face (central facial palsy)
• Contralateral sensory loss in face and arm
• Homonymous hemianopsia
• Left middle-communication deficits
• Right- spatial/perceptual

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Vertebral artery

• Pain or numbness of involved side
• Vertigo
• Contralateral ataxia
• Dysphagia, dysarthria
• Cranial nerve dysfunctions

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Motor deficits

• Motor nerve pathways cross in the medulla
  (brainstem) Prefix hem- used to describe
• Amount of motor involvement varies from weakness
  (-paresis) to paralysis (-plegia).
• End paralysis can be flaccid or spastic depending
  on amount of damage to the motor strip
• Initially flaccid and if progress spastic in 6-8
  weeks.

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Motor deficits

• Characteristic body posture

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Motor deficits

• Facial palsy- (central/UMN) where lower part face
  affected
• Bells palsy (LMN- 7th CN) where the whole side of
  face affected

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Elimination Deficits

• Partial loss of sensation (hemi) can affect
  perception of need to eliminate bowel/bladder
• Cognitive problems may affect the social aspect
  of elimination
• Level of consciousness, immobility, dehydration,
  diet changes

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Sensory-perceptual deficits
Lack of sensation/propriocetion

• Lack of sensation (hemi)- inability to
  perceive/interpret pain, touch, pressure( post
  central gyrus)
• Lack of/decrease in proprioception or the
  inability to know where body part is without
  having to look at it bodys position sense

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Sensory-perceptual deficits
Visual field deficits

• Disruption anywhere along the pathway
• Homonymous hemianopsia- most common. Loss of half
  of visual field in each eye. Cant see toward the
  same side as the paralysis

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Sensory-perceptual deficits
Agnosia Apraxia

• Inability of the senses to perceive stimuli that
  were previously familiar.
• May be any of the senses and varying degrees

• Inability to carry out purposeful task in the
  absence of paralysis
• or the individual carries out task
  inappropriately

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Sensory-perceptual deficits Neglect
syndrome (unilateral neglect)

• Attention disorder in which individual ignores
  affected part of the body,
• Cannot integrate or use perceptions from affected
  side
• More common in right CVAs

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Communication Deficits

• Motor, speech, language, memory, reasoning,
  emotions can be affected
• Dominant hemisphere for the brain centers is left
  in most individuals
• Global (mixed) aphasia- both expressive and
  receptive aphasia
• Dysarthria- difficulty with articulation or
  muscular control for speech. Sound like have
  mashed potatoes in their mouth

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Communication Deficits Brocas
and Wernickes aphasia

• Brocas, expressive or nonfluent aphasia where
  unable to express- understands
• Wernickes, receptive, fluent aphasia where
  unable to understand

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Broca speech area Wernicke speech area
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Communication Deficits
Normal process recovery

• Begin with one word speech- swearing, ouch
• Progress to sayings days of week, social
  speech, singing
• Volitional- normal speech
• Recovery may stop at any point

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Cognitive and behavioral deficits

• Change level consciousness- confusion to coma
• Emotional liability
• Loss of self control, decrease tolerance for
  stress
• Intellectual changes resulting in memory loss,
  decreased attention span, poor judgment,
  inability to think abstractly

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C. Therapeutic interventions
Diagnostic tests

• CT/MRI- bleeding, edema, tissue necrosis,
  shifting intracranial contents
• Arteriogram- abnormal structures vasospasm,
  stemosis
• PET- cerebral blood flow and metabolic activity
• Transcranial ultrasound doppler velocity of blood
  flow, degree of occlusion
• Lumbar puncture- obtain CSF, bleeding

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Therapeutic interventions
Rehabilitation

• Outpatient or in-house
• Physical therapy
• Occupational therapy
• Speech therapy
• Cognitive therapy

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Therapeutic interventions
Thrombolitic stroke

• Medication
• Thrombolitic agents to dissolve clot- 3 hrs!!!
• Anticoagulants to prevent further extension
• Antithrombolitic inhibit platelet phase of clot
  formation
• Anticonvulsants
• Surgical
• Endarterectomy
• Angioplasty, carotid artery stenting
• Bypass superficial temporal to middle cerebral

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Therapeutic interventions
Embolic/intracranial stroke

• Embolic stroke
• Medications If blood clot- anticoagulants,
  thrombolitic agents, antiarrhythmics If
  bacterial- antibiotics
• Intracranial hemorrhage (ICH) stroke
• Bedrest
• Medication- antihypertensives to normal BP
• Surgery- remove hematoma if possible

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D. Nursing assessment specific to stroke
Health history physical exam

• Health history-
• Risk factors when symptoms began describe
  symptoms current medications (legal/illegal)
  other health problems
• Physical exam-
• Vital signs neuro vital signs (LOC, pupils,
  motor, sensory) continued next slides

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Nsg assess- neuro deficits common in stroke
Motor

• Movement, strength (with without resistance),
  symmetry of all extremities
• Pronator drift- detects weakness of upper
  extremity. Hold arms, palms up in front with eyes
  closed- should be able to hold for 30 seconds.
  Weakness pronates and drifts downward
• Use similar techniques used to assess motor SCI-
  motor pathways affected begin motor strip brain
• Test facial movement- smile/frown test for Bells
  (7th CN) and central facial (motor strip)

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Nursing assess- neuro deficits common stroke
Motor

• EOMs- head still, follow your finger in all
  quadrants. Eyes should move together (conjugate
  gauze) Abnormal dysconjugate gauze nystagmus
  3rd nerve palsy (occulomotor) 6th nerve palsy
  (abducens)

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Nursing assess neuro deficits Motor
3rd nerve palsy 6th nerve palsy
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Nursing assess- neuro deficits common stroke
Motor

• Assess ability to void and move bowels
• Assess communication ability
• Assess cognitive and behavioral aspects

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Nursing assess-neuro deficits common stroke
Sensory deficits

• Superficial sensation
• With paperclip and eyes closed alternate sharp
  and dull ends
• Reference is the sensory strip on the parietal
  side

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Nursing assess- neuro deficits common
strokeSensory- visual field loss
common- homonymous hemianopia

• Patients head in still position cover one eye-
  test one at time
• Move your wiggling finger into the patients field
  of vision- in all 6 quadrants
• State when 1st sees

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Nursing assess- neuro deficits common stroke
Sensory

• Proprioception-
• position sense
• With eyes closed and hoding the toe on the sides,
  move toe up down (not touching the other toes),
  stop- then ask is toe up or down

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Nursing assess- neuro deficits common stroke
Sensory-perceptual

• Visual agnosia individual becomes lost on unit
  cannot read sign/symbols difficulty estimating
  distance (spills food) cannot find objects does
  not recognize faces on photo or own image
• Auditory agnosia ind appears bewildered by
  sounds and does not respond approp- phone
  ringing cant identify sound as running water
• Tactile agnosia- with eyes closed cant recognize
  familiar objects- comb, pencil unaware location
  diff positioning self- slouches to one side

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Nsg assess- neuro deficits common stroke
Sensory-perceptual

• Apraxia- stares at food tray unaware of how to
  get food to mouth combs hair with toothbrush
  puts shirt on legs
• Unilateral neglect ignores paralyzed arm or leg
  may claim it is not theirs bumps into wall as
  going down hall unaware of objects place on
  paralyzed side

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Nursing assessment specific to stroke National
institute health (NIH) stroke scale

• An assessment scale to reflect the degree of
  neurologic dysfunction specifically for stroke
• A high score correlates with a large stroke
• Based on level of consciousness, gaze, visual,
  facial palsy, motor, ataxia, sensory, language,
  dysarthria, and extinction and inattention
  (neglect)
• http//www.ninds.nih.gov/doctors/NIH_Stroke_Scale.
  pdf

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E. Nursing problems/interventions 1.
Ineffective tissue perfusion (cerebral)

• Monitor resp status provide O2 suction needed
• Monitor neuro, specifically increasing neuro
  deficits, seizures, and ICP HOB 30 degrees
• Monitor cardiac status, esp dysrhythmias
• If individual unconscious- coma care

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Nursing problems/interventions 2. Impaired
physical mobility

• Encourage active (when possible) passive ROM
• Change position every 2 hrs, esp if comatose
• Monitor/prevent thrombophlebitis
• Work with Rehab team
• Arm sling- used to prevent subluxation of the
  shoulder from a paralyzed arm when OOB
• Splints- hand/foot to prevent contractures set
  up schedule- on 2 hrs off 2 hrs- use ROM

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Nursing problems/interventions3. Self-care
deficit

• Eourage use of paralyzed extremity
• Teach dsg tech- affected arm in clothing first
• Work with rehab team regarding ADLs, use of
  assistive devices, plans for progress, home care
• Allow time and encouragement ADLs
• Assess both physical cognitive ability ADL
• With agnosia encourage pt use other senses

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• With apraxia- break complex tasks down into
  simple steps have a single item out at one time
  use colored labels on clothes or velcro on one
  sleeve allow time encourage independence
• Perseveration- may have to tell person to stop
  action that they are perseverating about or may
  have to physically stop them

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Nursing problems/interventions4. Impaired verbal
communication

• Assess speaking, writing, gestures, understanding
• Support speech therapist plan
• Support guidelines as LeMone p. 1317
• Swearing may be first sign of return of speech,
  not directed at you or family

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Nursing problems/interventions5.Impaired urinary
elimination/riskcontipation

• Set up schedule to void
• Support guidelines LeMone 1317

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Nursing problems/interventions6. Impaired
swallowing

• Dysphagia- difficulty swallowing LeMone 1317
• Provide safety when eating
• Occupation therapy and /or speech therapy can
  evaluate the individuals ability to get food to
  mouth and to swallow
• Swallow studies

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Nursing problems/interventions7. Home care

• May return home, go to a rehabilitation center
  (in-house or outpatient) or may be placed in a
  nursing home
• Home evaluation by rehabilitation team
• Encourage self-care as much as possible with
  family involvement
• Community resources should e evaluated for each
  ind with stroke, including family support

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Subarachnoid hemorrhage A. Pathophysiology/eti
ology

• Subarachnoid hemorrhage- aneurysm or A-V
  malformation
• Usually occur in younger adults 30-60 than other
  strokes

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SAH- Pathophysiology/etiology
Aneurysm

• Occur at bifurcations, braches of carotids
  vertebrobascular arteries
• 85 base brain in anterior circulation
• Caused by trauma, congential, arteriosclerosis

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SAH Pathophysiology/etiology
A-V malformation

• Congential abnormal joining of arteries to veins
  in the brain.
• As pressures changes occur becomes tangled
  collection of dilated vessels.

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B. SAH- Common manifestation/complication
Aneurysm

• Aneurysms are graded 0-V on the Hunt/Hess scale
  higher the number, poorer chance survival.
• Based on LOC quality of cerebral function
• Aneurysm are usually asymptomatic until rupture
• Ruptured- sudden explosive headache loss of
  consciousness N V nuchal rigidity (stiff
  neck) and photophobia from meningeal irritation
  cranial nerve deficits

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SAH- Common manifestation/complications
A-V malformation

• Ischemia symptoms-seizures and interference with
  normal function of those brain cells
• As pressures changes occur the malformation
  ruptures and get bleed symptoms (SAH)

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SAH- Common manifestation/complications
Major complications

• Rebleed due to reabsorption of the clot that is
  stopping the bleed
• Vasospasms due to irritation of the blood vessels
• Hydrocephalus from blockage of normal absorption
  of CSF

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C. Therapeutic interventions SAH
Diagnostic tests

• CT/MRI
• Angiogram- outline the blood vessels
• Lumbar puncture- blood in CSF
• Risk of bleeding
• Herniation with LP

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Therapeutic interventions SAH
Treatments

• Aneurysm precautions- decrease external/internal
  stimuli
• Medications
• Aide with aneurysm precautions- stool softners,
  antinausea,etc
• To prevent rebleed/lysis of clot- Ammicar
• To prevent vasospasms- Nimodipine
• Before OR- Ca channel blocker- Nimodipine
• After OR-triple H- vasodilators (Isuprel)
  induced arterial hypertension (Dopamine)
  hypervolemic hemodilution (Albumin)
• Prophylactic antiepileptic- Cerebex/Dilantin

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Therapeutic interventions SAH
Treatments

• Surgical intervention
• Aneurysm-clip aneurysm, wrap with muslin or
  muscle, insert endovascular coils. If unstable
  may delay OR
• A-V mal- embolization ligation of feeders, laser
  surgery to remove malformation

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Therapeutic intervention SAH
Treatments

• Gamma Knife- radiation to reduce size of A-V
  malformationgt over
• Cyberknife below

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LeMone Blackboard site Care Plan Elizabeth
with a Subarachnoid Hemorrhage

• http//wps.prenhall.com/chet_lemone_medicalsurg_3
  /0,7859,757263-,00.html

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Nursing Care Plan A Client with a Stroke
LeMone p. 1319

• http//wps.prenhall.com/wps/media/objects/737/755
  395/stroke.pdf

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Added Critical thinking questions Nursing Care
Plan A Client with a Stroke p. 1319

• 1.What could be the possible cause of Orvilles
  spells the week before his stroke?
• 2. Are Orvilles symptoms consistent with right
  middle cerebral artery thrombolitic stroke?
  Describe.
• 3. Had Orville gotten to the ER in 3 hrs, what
  could they have done that may have completely
  reversed the stroke?
• 4. Is the fact that Orville is left handed
  significant?
• 5. Which side will Orville not be able to see
  toward due to his homonymous hemianopia? How do
  you test?
• 6. Does he have neglect syndrome?
• 7. What type of aphasia does Orville have?