Neurology

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Neurology

• Cerebrovascular Accident
• Brunners Ch. 62 pg 1887

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Breaking down in tears

• Im a nursing student whos never seen a person
  die. When the time comes, Im afraid Ill lose
  it and upset the patient or family. How do you
  do this work all the time and not break down in
  tears?

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Cerebrovascular accident

• AKA
• CVA
• Stroke
• Brain attack

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CVA Pathophysiology

• Disruption of blood flow to part of the brain ?
• Ischemia ?
• Tissue Anoxia ?
• i PaO2 h PaCO2 ?
• Acidosis ?
• Infarction ?
• Edema ?
• h ICP

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CVA Etiology

• Ischemic
• Thrombosis
• __?__ ? thrombosis
• Arteriosclerosis
• Common site
• Carotid artery
• Embolism
• Atrial fib or HTN ?
• Plaque breaking off and becoming an emboli
• d/t Long standing cardio-vascular disease

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CVA Etiology

• Hemorrhage
• Rupture of the cerebral blood vessel
• Commonly caused by poor control of HTN

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CVA Etiology

• Hemorrhage
• This type of CVA results in
• Slow recovery
• h probability of neurological deficits
• No meds to reverse the effects

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CVA Etiology

• Other causes
• Syphilis
• Trauma
• Hypertension
• Hypoxia
• Anything the i blood flow

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CVA Risk Factors

• Changeable
• Smoking
• Obesity
• HTN
• Sedentary life
• Stress
• h fat diet
• h Na diet
• Substance abuse
• Oral contraceptives
• Diabetes mellitus

• Non-changeable
• Age
• Gender
• Family history
• Race

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CVA Risk Factors

• Which is the most important risk factor for a
  stroke?
• Smoking
• Weight
• Diet
• HTN
• Stress
• Substance Abuse

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CVA Risk Factors

• What is the number one cause of CVA in a younger
  patient?
• Smoking
• Weight
• Diet
• HTN
• Stress
• Substance Abuse

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CVA Pathophysiology substance abuse

• Substance (PCP, crack) ?
• h Blood pressure ?
• h ICP ?
• Subarachnoid intracerebral hemorrhage ?
• Interrupt blood flow ?
• i O2 i glucose ?
• Depressed neurons ?

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CVA Pathophysiology

• Vessels involved determine the area of the
  brain involved
• Area affected determines the SS

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CVA Clinical manifestations

• SS depend on
• Location
• Size
• Amount

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CVA Clinical ManifestationsCommon clinical
manifestations

• Syncope
• Alt. LOC
• Paresthesia
• H/A
• Aphasia
• Seizures
• Vision disturb
• Difficulty walking
• Labile emotion
• Hemiparesis/hemiplegia

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Left vs. Right Hemispheric CVA
Left CVA Right CVA
Aphasia Language Intact
Dysarthria Speech Dysarthria
Right Homonyous hemianopsia Sensation Left Homonyous hemianopsia
Normal awareness Perception Unilateral neglect
Right side paresis Movement Left side paresis
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Left vs. Right Hemispheric CVA
Judgment intact Depression Slow cautious Behavior Judgment impaired Denial Impulsive behavior
Impaired analytical Cognition
Deficit new language info Memory Deficit new spatial info
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CVA diagnostic findings

• LP
• h pressure
• Blood
• CT / MRI
• Bleeding
• Infarction
• Shift
• Angiography
• Occlusion

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CVA Medical Management

• Focus on Cause Control
• 1 cause
• Hypertension
• Medications

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CVA Rx - HTN

• Beta-blockers
• Action
• Block sympathetic response
• Example
• Propranolol hydrochloride

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CVA Rx - HTN

• Central acting Anti-hypertensive
• Action
• i Cardiac output
• i Heart rate
• Example
• Catapres

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CVA Rx - HTN

• Vasodilators
• Action
• Relax smooth muscles
• Example
• Apresoline
• Emergency
• Hyperstat
• Nipride

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CVA Medical Management

• Diet
• Sodium
• i
• Fat
• i
• Potassium
• h
• Stimulants
• i
• Fluids
• i

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CVA Medical Management

• Prevent clot formation
• Meds / anticoagulants
• Coumadin
• Antidote?
• Vit K
• Heparin
• ASA

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CVA Medical Management

• Prevent clot formation
• Non-Rx
• Ted hose
• ROM
• Isometric exercise

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CVA Medical Management

• Surgery
• Endarterectomy
• Carotid stenosis
• Craniotomy
• Evacuate clot

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CVA Medical Management

• Thrombolytic agents
• Action
• Break down thrombi
• S/E
• Hemorrhage
• Streptokinase
• Urokinase
• Tissue-type prasminogen activator (tPA)

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CVA Medical Management

• Thrombolytic agents
• Tissue-type prasminogen activator (tPA)
• Take in 3 hrs of CVA

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CVA Medical Management

• Airway
• Patent
• P reflex
• O2
• Suction
• Mech vent

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CVA Medical Management

• Prevent Seizures
• Precaution
• Meds
• i stimuli

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CVA Medical Management

• i ICP
• O2
• Mech vent
• Position
• HOB h
• Activity
• Rest
• Meds
• Diuretics
• Glucocorticoids
• Monitor
• BP
• Systolic lt 180
• Diastolic lt 100

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CVA Medical Management

• Nutrition
• NGT

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CVA Medical Management

• Monitor for trouble
• VS
• Rectal temp
• NO
• IO
• Labs
• Na
• K
• Glucose
• ABGs
• PT/PTT
• Pulse oximetry

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CVA Medical Management

• Prevent complications
• ROM
• PT/SLP
• Isometric exercise
• Antacids
• Maalox
• Tums
• Histamine antagonist
• Tagamet
• Zantac
• Pain
• Codeine

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CVA NRS management

• Alt. tissue perfusion
• r/t h ICP
• Monitor ICP
• Avoid act that h ICP

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CVA NRS management

• Risk for injury
• r/t seizures
• r/t repeat CVA
• r/t unilateral neglect
• r/t falls
• Padded side rails
• Call light
• Assist w. amb.
• Suction
• BR assist
• Items w/in reach
• Clear path
• H2O temps
• Turn position

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CVA NRS management

• Alt. nutrition
• r/t impaired swallowing
• Motor deficits
• Impaired judgment
• SLP
• Swallow eval
• HOB high fowlers
• Straws no
• Thick liquids
• Swallow twice
• P pocketing food

• Talk eat NO
• Easy chew
• Head position
• Unaffected side of tongue
• P gag
• P choking
• Small meals
• High texture food

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CVA NRS management

• Alt. Mobility
• r/t neuro deficits
• Begin on admit
• Turn q2hr
• Pillows
• P skin
• ROM

• Splints
• Hand fingers
• Arm
• Legs
• Footboards
• Built-up utensils
• Raised toilet
• W/in reach
• Pt. to do exercises

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CVA NRS management

• Impaired Communication
• r/t aphasia
• SLP
• Time
• Anticipate
• Call bell
• Slow clear
• Face patient
• Eye contact

• Yes/No ?
• ID methods
• Gestures
• Visual aids

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CVA NRS management

• Knowledge Deficit
• r/t new diagnosis
• Orient
• Explain
• K.I.S.S.
• Written, verbal picture
• Little at a time
• Meds
• Safety

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CVA NRS management

• Self-Care Deficit
• Eating
• Non-skid mats
• Stabilizer plates
• Plate guards
• Wide grip utensils

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CVA NRS management

• Self-Care Deficit
• Bathing Grooming
• Long handle sponge
• Grab bars
• Non-skid mats
• Hand held showers
• Electric razor
• Shower seat

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CVA NRS management

• Self-Care Deficit
• Toileting
• Raised seat
• Grab bars

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CVA NRS management

• Self-Care Deficit
• Dressing
• Velcro
• Elastic shoelaces
• Long-handle shoehorn

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CVA NRS management

• Self-Care Deficit
• Mobility
• Canes
• Walkers
• Wheelchair
• Transfer devices

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CVA NRS management

• Risk of care-giver role strain
• Support systems

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CVA NRS management

• Unilateral neglect
• Unaffected side
• Personal items
• Approach
• Door face
• Cue
• Scan environment
• Sling

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CVA NRS management

• Impaired thought processes
• Family
• KISS
• SSTTP
• i distractions
• Repeat
• Visual reminders

• Time
• Simple ? complex
• Positive feedback
• Non-judgmental

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Hemorrhagic Stroke

• Usually more severe with a longer recovery period
  than ischemic stroke
• Caused by bleeding into
• Brain
• Ventricles
• Subarachnoid space

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Hemorrhagic Stroke

• Cerebral aneurysm
• Dilitation, bulging or ballooning out of part of
  the wall of a vein or artery in the brain
• When they enlarge and press upon cranial nerves
  or tissue ?
• Symptoms

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Hemorrhagic Stroke

• Etiology
• HTN
• Arteriosclerosis
• Meds

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Hemorrhagic Stroke

• Clinical Manifestations
• Similar to ischemic
• Unique SS
• H/A
• LOC
• Nuchal rigidity

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TIA Transient Ischemic Attack

• Short reversible ischemic event
• Duration
• lt 24 hrs
• No permanent neuro deficit
• Warning!