neurological system (includes stroke)
TRANSCRIPT
Neurological System
Brain Anatomy
Cerebrum Reasoning Judgment Concentration, Motor, sensory, speech
Cerebellum Coordination
Brainstem Cranial nerves Respiratory center Cardiovascular center
Brain Anatomy Cont.
Cerebral Blood Flow 20% of CO
Cerebral tissues – Have no oxygen or glucose reserves
Blood flows through Carotid Arteries to Circle of Willis
Intracranial Pressure (ICP)
Composition 80% brain tissue and water 10% blood 10% cerebrospinal fluid (CSF)
Increased ICP caused by: Severe head injury/ Subdural
hematoma Hydrocephalus Brain tumor Meningitis/Encephalitis Aneurysm Status epilepticus/Stroke
A medical emergency that can lead to:
Brain hypoxia, herniation, death
Clinical Manifestations Vomiting Headache Blurred vision Seizure Changes in behavior Loss of consciousness Lethargy Neurological symptoms
Neurological Assessment
Rapid Neurological Assessment Emergent situations Sudden changes in neurologic status
1. LOC: first indicator of a decline in neurological function and increase in ICP (intracranial pressure); use the GCS
2. Pupils
3. PUPILS
Pupils equal and react normally
Pupils react to light (slowly or blriskly)
Dilated pupil (compressed cranial nerve III)
Bilateral dilated, fixed (ominous sign)
Pinpoint pupils (pons damage or drugs)
Neuro-Diagnostic Tests Routine labs Radiology Tests
CT scan, MRI Carotid ultrasound Cerebral angiogram/
MRA
CT SCAN
MRA
Carotid US
Neuro-Diagnostic Tests: Lumbar Puncture Spinal needle inserted
into SA L3/L4 or L-4 /L-5 using
strict asepsis Obtain CSF specimens and
pressure readings To remove bloody or
purulent CSF Administer spinal
anesthesia
Case Study: Introduction
Nancy is a 66 year old female, came in to the ER with her daughter Gail. Gail states that her mother woke up in the middle of the night to go to the bathroom and fell to the ground because she was not able to control her right leg.
Case StudySubjective data
R arm and leg weak and numb Feeling depressed and fearful Requires help with ADLs Says she has not taken her meds for high
cholesterol History of brief episode of right sided
weakness and tingling of the face, arm, and hand 3 months earlier, which totally resolved and for which she did not seek treatment
Case StudyObjective Data Alert and oriented, and able to answer questions
appropriately with mild slowness in responding BP 180/110 Global aphasia, facial drooping, dysphagia Right sided paralysis Decreased sensation to right side, particularly the
hand Right homonymous hemianopsia Overweight Incontinent of urine
Stroke: Brain Attack
Cerebrovascular Accident (CVA) - loss of brain functions that occur when the blood supply to any part of the brain is interrupted.
Sudden onset of neurological deficits
Serious Medical Emergency- reduction in cerebral blood flow & tissue death Brain dependent on constant supply of oxygen and
glucose
Types of Stroke
Ischemic- results from an occlusion of a cerebral artery by a thrombus or embolus Thrombotic Stroke Embolic Stroke
Hemorrhagic – bleeding into brain tissue
Ischemic: Thrombotic Stroke
Atherosclerosis -most common cause
Thrombosis-clot forms at rough or narrowed artery
Complete blockage Accounts for half of all
strokes
Ischemic: Embolic StrokeAccounts for 1/3 of all strokesEmbolism-emboli breaks off and travels to
cerebral or carotid arteries (blood clot or fatty plaque released into circulation)
Often a fragment from a thrombosis or fatty plaque
TIA: Transient Ischemic Attack or “Silent stroke:/ mini stroke Warning sign: Temporary onset of neurological
symptoms often lasting 15 min but no longer than 24 hours
Needs prompt work-up: carotid U/S, brain and heart Key features:
Blurred vision, double vision, blindness one eye; Transient weakness, ataxia; Speech deficits
Treatment Cont: Surgical Therapy Carotid
Endarterectomy- for pts who have had TIAs or significant narrowing of carotid arteries
Hemorrhagic Stroke
Rupture of weak vessel wall or cerebral aneurysm
Intracerebral or subarachnoid hemorrhage
Arteriovenous malformation
Bleeding into brain or meninges
Risk Factors for StrokeModifiable Hypertension Heart disease (MI, A Fib) DM, Hyperlipidemia Sedentary Lifestyle Smoking/Alcohol Obesity Hyperlipidemia Illicit Drug Use;
cocaineNonmodiafiable Age - People over 55 are at high risk family history African american, hispanic,
asian descent
Clinical Manifestations Depend on the extent of injury
May be transient, mild or result in major neuro deficits
Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
Sudden complete or partial loss of vision on one or both sides
Sudden confusion or trouble speaking or understanding
Sudden loss of balance, unsteadiness or an unexplained fall
Sudden vertigo, dizziness, swallowing difficulties or memory disturbances
Sudden, severe headache with no known cause
Hemorrhagic Worst HA ever for bleeds
R Hemiplegia/paresis
Impaired speech(Aphasias)
Impaired discrimination(R/L)
Slow performance,Cautious
Aware of deficitsDepression, Anxiety
Impaired comprehension & Memory R/T language and mathLeft -Sided CVA:
LEFT BRAIN DAMAGE R Hemianopsia
Right-sided CVA:RIGHT BRAIN DAMAGE Impaired judgment
Impulsive/Safetyproblems
Denies/Minimizesproblems
L hemiplegia/paresis
Left-sided neglect
Spatial-perceptual deficits
Rapid performanceShort attention
span
L Hemianopsia
Impaired Swallowing
Cognitive Changes
Motor Deficits
Sensory Changes
Impaired Communication
Altered Elimination
Nancy
Psychosocial
Impaired Swallowing Stroke →dysphagia Risk for airway obstruction/ aspiration Nursing Interventions: Maintain patent airway
NPO until swallow eval (by ST) Assess swallow, cough, gag reflex Safe Feedings: High Fowler’s position with head
flexed forward Thickened liquids if impaired swallowing Instruct to
position food on unaffected side in back of throat Avoid distractions to reduce aspiration risks Soft, semi-soft foods, pureed, baby food, dental diet Suction as needed
Cognitive Changes
Change in LOC Impaired judgment,
memory, problem solving
Denial of illness Inability to
concentrate
Nursing Interventions: Frequent reorientation Frequent safety
instructions Repeat directions on
tasks by steps Give time to process
and respond
Motor Deficits Loss of voluntary movement on
contralateral (opposite) side of stroke Weakness & paralysis
Hemiplegia and/or Hemiparesis Gait changes
Motor Deficit Cont.Nursing Interventions: Maintain optimal functioning and assist as
necessary Prevent contractures & atrophy PT and OT eval/tx to promote independence
Positioning- intermittent prone positions; elevate affected extremity
ROM exercises (passive: begin 1st day of hosp; no ambulation with hemorrhagic stroke- limit mvmt to extremities only )
Assist with ADLs (Self Care Deficit) Use assistive devices (wide grip utensils, plate guards) Rehab and use of ambulation devices
Motor Deficit Cont.Splints, hand rolls, trochanter rolls
Assessment and Management Sensory Changes
Contralateral sensory deficits Decreased sensation to touch
Spatial dysfunction (kinesthesia/proprioception altered) ↓ Awareness of position
Neglect Syndrome – Ignore affected side due to
altered perception and vision Visual Deficits
(Hemianopsia)
Nursing Interventions: Teach client to touch and
use both sides Remind client to dress and
bathe both sides Place objects within
patients field of vision Approach patient from
unaffected side
Sensory Changes Cont. - Visual Deficits: Hemianopsia
Blindness in one side of visual field Homonymous hemianopsia
Blindness in in the same side of each visual field
Visual Deficits: Hemianopsia Cont. Nursing Interventions:
Place objects in client’s visual fieldRemove clutterTeach patient to attend to the neglected
side Teach scanning technique during ADLs
Assess the neglected side (paralyzed or weak side) for trauma, adequacy of dressing and hygiene
Impaired Communication Aphasia-loss of use
and comprehension
Receptive aphasia- Wernicke’s area (sensory)
Expressive aphasia – Broca’s area (motor)
Global aphasia- mixed
Nursing Interventions:
Assess ability to speak and understand
Provide + reinforcement Picture board Repeat names of
objects routinely Allow plenty of time for
client to answer
Picture Communication Board
Altered Elimination
Temporary or permanent loss of bladder/bowel function
Constipation common Weakness Dehydration Immobility
Nursing Interventions: Increase fiber and fluids Stool softeners Digital
stimulation/suppositories bladder retraining Straight cath to check
residual
Assessment and Management Problems R/T Immobility
Risk for atelectasis and pneumonia Risk for impaired skin integrity and DVT
Nursing Interventions:
Assessment and Management: Psychosocial Emotional Support
Depression a major problem
Discharge planning
Care of the caregiver
Treatment of Stroke:Thrombotic Stroke Thrombolytic Therapy : rtPA (recombinant tissue Plasminogen Activator-
Retavase) A clot-buster delivered intravenously; breaks up the
clot allowing blood flow to return to the deprived area of the brain
Must be administered within 3 hours of the onset of clinical signs of ischemic stroke
Quick CT scan to see if stroke from clot or bleed
Treatment Cont:
Acute phase:
Anticoagulant - Heparin continuous infusion
Osmotic Diuretics – to reduce brain swelling
Anticoagulants contraindicated in Hemorrhagic Strokes
Long Term Drug TherapyTo Prevent Stroke: Antiplatlet Drugs
ASA, Ticlid, Persantine, Plavix
Anticoagulants Coumadin Lovenox
Antiepileptics
Treatment Cont: Surgical Treatment For Bleeds (Interventional Radiology)
Angiograms to see arteries and detect bleeding sites
Aneurysm clips and coils
Surgical Removal:Hematoma