Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/82

Click to flip

82 Cards in this Set

  • Front
  • Back
* Southern states: “stroke belt”
- High fat diet
- Smoking
- More elderly individuals
Stroke (CVA)
* Disruption in the normal blood supply to the brain
* Cerebral vascular accident (CVA) "brain attack"
* Medical emergency that strikes suddenly
* Should be treated immediately
* Third most common cause of death in U.S.
* Primary cause of adult disability
Stroke, “Brain Attack”
* National Stroke Association
* Medical emergency
* Requires prompt/immediate intervention
Pathophysiology of Stroke
* Brain unable to store O2, glucose
* Unable to remove toxins, byproducts
* Damage within few minutes
* Cerebral autoregulation
* 1000ml/min blood flow
* Dilation/constriction prn
* Lack of perfusion
* Involved area/contralateral hemisphere involvement with stroke
* Small strokes “lacunar infarcts”
Types of Strokes
* Ischemic (occlusive)
* Caused by occlusion of cerebral artery by thrombus or embolus
* Thrombolic stroke
Thrombolic stroke
1. Accounts for more than one half of all strokes
2. Associated with atherosclerosis
3. Lacunar stroke
Embolic stroke
1. Accounts for 1/3 of all strokes
2. Embolus/emboli travel to cerebral arteries via carotid artery
3. Sources of emboli are cardiac
Transient ischemic attack (TIA)
Reversible ischemic neurologic deficit (RIND)
*
Ischemic Brain Attacks
Etiology: occlusion (thrombus/embolus)
* Thrombolytic – more than half
* Associated with plaques
* May affect any blood vessel
* Deposits continue to build up
* May occur over many years
* Collateral circulation develops
* Transient ischemia to affected area
* Complete ischemia and infarction
* Total occusion = 72 hours severe s/sx such as necrosis, edema, cavity devel
* Most common sites: bifurcation of the common carotid artery, vertebral arteries at juncture with basilar artery
* SLOW onset, TIAs often precede these
Embolic stroke (~1/3 of all)
* Embolism/emboli travel to cerebral arteries via carotids
* Usually…CARDIAC origination
* A fib
* Ischemic heart disease
* RHD
* Mural thrombi p MI
* Prosthetic valve/other structures
* Plaque that breaks free from other vessels
Embolic stroke
* Middle cerebral artery (MCA) most commonly involved
* Emboli occlude the vessel, ischemia develops
* Occlusion often temporary, ª fragments
* Become lodged in smaller bifurcations or where lumen narrows
Transient Ischemic Attack TIA
* gSilenth stroke
* precedes other strokes
Reversible Ischemic Neurologic Deficit (RIND)
* Transient focal dysfunction d/t brief interruption of blood flow, e.g., spasms
TIA and RIND differ in
duration
TIA duration?
= few minutes, <24 hours
TIA -
* Blurred/double/blindness/tunneling
* Weakness/gait disturbance
* Numbness (transient)
* Vertigo
* Aphasia/dysarthria (slurred speech)
* RIND = > 24 hours <week
* Brain tissue is damaged in both types
Hemorrhagic Stroke
* Interruption of vessel integrity
* Bleeding occurs into tissue/spaces
* Ventricular, subdural, subarachnoid
* Hemorrhage from rupture of
* saccular (berry) aneurysm
* Arteriovenous malformation
* Cerebral aneurysm
* Hypertension
* Speculation: elevated systolic/diastolic pressure rupture vessel walls
* Cerebral aneurysm = abnormal distension (may be congenital, traumatic)
* Weakening of the vessel wall
* Continued pressure stretches/thins
* Rupture usually during ACTIVITY
* Aneurysm rupture
* Intracerebral hematoma
* Ventricular bleeding
* Subarachnoid bleeding
* Vasospasms (sudden, transient constriction) may occur p hemorrhage
* Distal blood flow « leading to ischemia
Arteriovenous Malformation (AVM)
* Embryonic development
* Entangled mass
* Thin-walled, dilated vessels
* Abnormal communication with arterial and venous systems
* Ruptures may cause bleeding
Risk Factors - stroke
* HTN
* Diabetes mellitus
* Heart disease
* Nonvalvular atrial fibrillation
* Smoking/substance abuse
* Sedentary lifestyle
* Women: ªHgb (>14 g) « bone density, migraines
Stroke-Clinical Manifestations
* Cognitive changes
* Motor changes
* Sensory changes
* Cranial nerve intactness
* Cardiovascular assessment
* Psychosocial assessment
History
* Accurate history
* Important to affected area
* s/sx?
* When did it start? (ischemic = sleep; hemorrhagic = activity…usually)
* How the s/sx progressed?
* Onset important (embolic/hemo = abrupt; thrombolytic = gradual…usually)
* S/Sx come and go? (TIA, RIND)
Hx
* Observe LOC during interview
* Monitor speech pattern/body posture, etc
* Medical hx?
* Family hx?
* Diet?
* Other risk factors?
* Medications?
Physical Assessment - neuro
* Cognitive Changes
* LOC may vary
* Denial
* Hemiparesis
* Spatial/proprioceptive dysfunction
* Memory impairment
* Problem-solving/decision-making
Left v Right Sided Hemispheres
(Table 45-4)
Terms
* Aphasia = inability to use/comprehend
* Alexia = reading difficulty
* Agraphia = writing difficulty
* Hemiplegia = paralysis, one side
* Hemiparesis = weakness, one side
Aphasia =
inability to use/comprehend
Alexia =
reading difficulty
Agraphia =
writing difficulty
Hemiplegia =
paralysis, one side
Hemiparesis =
weakness, one side
Motor ∆s
* Provides info about which hemisphere
* Nurse must assess for hypotonia (flaccidity) = tends to fall to one side
* Extremities may feel heavy
* Inadequate balance, equilibrium
* Hypertonia (spastic paralysis) → fixed
* contractures
Sensory ∆s
* Assess response to stimuli, touch
* May be unable to write, comprehend, use an object correctly, or be purposful
* Neglect syndrome (esp RIGHT sided)
* e.g. resident/patient in wheelchair leaning
* Perceives he/she is upright
* May wash/dress only one side of body
Visual changes:
* Ptosis (eyelid drooping)
* Visual field deficits
* Pallor/petechiae of conjunctiva
* Amaurosis fugax = brief blindness
* Hemianopsis = blindness, half field (damage to optic tract/occipital lobe); most often bilat
Cardiovascular Assessment
* Embolic strokes– murmur, dysrhythmia, HTN
* Psychosocial
* Finances, ADLs, care at home
* Emotional lability (esp with frontal lobe)
* Labs, radiographs (CT), MRI
Interventions - stroke
* Stabilize patient, reduce further injury
* Determined by type/extent of injury
* Nonsurgical management
* Patient may be at risk for ª ICP
* Neurological Nursing Assessment
* Glasgow Coma Scale (GCS)
ICP monitoring
* Key Features:
* «LOC sensorimotor ∆
* Behavioral ∆s pupillary ∆
* HA cranial nerve involve
* N/V ataxia
* Speech ∆ sz
* Aphasia Cushingsf Triad
* Slurred speech Posturing
Nursing Interventions - ICP
* Frequent nursing assessments
* First 72 hours critical
* Elevate HOB
* Maintain head position ¨ drainage
* Avoid extreme flexion (ª ITP)
* Avoid clustering of activities
Drug therapy - stroke
* Thrombolytic therapy – dissolves occlusion
* Rt-PA (recomb tissue plasminogen act)
* Anticoagulants
* PT
* PTT
* INR (International Normalized Ratio)
* Target 2-3; 3-4.5 (cardiac-related strokes)
* Other medications, e.g., anti-seizures
Surgical Management stroke
* Endarterectomy
* Extracranial-intracranial bypass
* AVM management
* Craniotomy
* Remove clots
Nursing interventions stroke
* Self-Care Deficit
* Facilitate increased muscle strength/function
* Positioning important
* Splinting Avoid contractures
* DVTs are a risk to develop
* Antiembolism stockings
* Compression boots
* Frequent position changes
* Mobilization of the client
Disturbed Sensory Perception
* Assist patient to adapt to ∆s
* Interventions:
* R ¨ visual/perceptual or spatial impairments depth perception/discrimination (up/down) thus ADLs
* Provide frequent cues
* Break down tasks into simple steps
* Approach from UNAFFECTED side
* UNAFFECTED side: should FACE the door
* Teach patient to turn head/scan environment
* Diplopia: use patch
* Remove cluter
L sided repercussions:
* Memory deficits, simple tasks difficult
* Reorient to month, day, year
* Establish routine schedule
* Structured environment
* Familiar objects
* Step by step teaching
Unilateral Neglect
* Goal: compensate for affected side
* Most common with R-sided stroke
* ª risk for injury (« proprioception)
* Teach patient to touch/use both sides
* Affected side first
* Turn head for full vision fields
* gscanningh technique
Impaired Verbal Communication
* Goal: effective communication
* Language/speech (dominant hemisphere)
Aphasia:
* Expressive (Broca’s; motor) frontal
* Receptive (Wernicke’s; sensory) T-P area may talk but language is meaningless
* Global (mixed)
Stroke-Impaired Verbal Communication
* Occurs in dominant hemisphere/majority in left hemisphere
* Dysarthria due to loss of motor function
* Aphasia caused by cerebral hemisphere damage
* Expressive (Broca's or motor) aphasia
Expressive (Broca's or motor) aphasia
1. Motor speech problem
2. Understands but unable to communicate
3. Difficulty with writing
4. Frustration and anger
Receptive (Wernicke's or sensory) aphasia
1. Unable to understand spoken and written word
2. Neologisms
3. Global or mixed aphasia
4. Reading and writing equally affected
Impaired swallowing
* Goal: ingestion without aspiration
* Interventions:
* Assess swallowing ac
* Facial drooping, drooling, weak/hoarse voice
* Gag/cough reflex
* Positioning
* Monitor weight/diet
* Avoid foods that ª salivary production
- Beef broth
- Sweet, sour, salty
- Place food in back of mouth, UNAFFECTED side
* Distractions may cause aspiration
* Reduce sensory stimulation
* Observe for s/sx fatique
Incontinence
Goal: regain continence
* From ∆LOC, innervation, « communication
* Etiology must be established
* Patients may re-learn
* Bladder training program
* Place on bedpan/commode q 2 hr
* Encourage fluid intake 2000 cc/d
* Check residual urines
Bowel retraining program
* Establish normal BM for patient
* Identify any routines
* Place patient on bedpan/commode during this time
* High fiber/bulk diet
* Fluids
* Suppositories
* Digital stimulation may assist
Health Teaching
* Medication schedule
* Mobility
* Communication
* Safety
* Dietary
* Activity/self-care skills
* Psychosocial intervention
* Families encouraged to permit individual to do as much as possible
* Families – take and plan for extra time to do things
* Care givers may need respite/time to relax
* Counseling
* Social worker
Traumatic Brain Injury (TBI)
* 18-34 years – #1 cause of death
Traumatic Brain Injury (TBI)Pathophysiology
consciousness ∆
* Direct/Indirect
* Reversible/irreversible
* Temporary ¨ permanent
* Primary Brain Injury
TBI Incidence/Prevalence
* MVA, most common cause
* 7 million Americans/year
* 500,000 hospitalized
* 100,000 with permanent damage
* 2000 vegetative state
* Summer, spring, pm, noc, weekends
* 3X ª in males
Pathophysiology TBI
* TBI: Mild with GCS 13-15 gait altered
* Mod: « LOC GCS 9-12¨ 24 h observation
* Severe: GCS <9 ¨ critical care
* Open: unique fracture, CSF leakage
* Most: gunshot, knife
* Risk for infection
* Closed: blunt trauma
* Concussions, contusions, lacerations
Concussion =
brief loss of consciousness
* Damage is functional, not structural (thus, not “permanent”)
Contusion =
bruising of brain at coup or contracoup site
* laceration
Traumatic Brain Injury-Types of Forces
* Acceleration injury
* Deceleration injury
* Shearing
* Straining
* Distortion of brain tissue
* Destruction of adjacent brain tissue
Types of Forces
* Acceleration injury – velocity
* Deceleration injury – e.g., whiplash
2˚ injuries
* Increase mortality/morbidity
* Most common: ª ICP
* Edema
* Hemorrhage
* Impaired cerebral autoregulation
* Hydrocephalus
* Hypoxemia
* Hypercapnia
* Systemic hypotension
Increased Intracranial Pressure
* Monro-Kellie hypothesis
* Normal ICP 10 to 15 mm Hg
* Leading cause of death from head trauma
Increased Intracranial Pressure
Monro-Kellie hypothesis
* Normal ICP 10 to 15 mm Hg
* Leading cause of death from head trauma
* ICP = cerebral blood flow = tissue hypoxia = serum pH and CO2 = cerebral vasodilation = edema = ICP = brain hernation = irreversible brain damage = death (uncal herniation)
* Edema
* Vasogenic
* Cytotoxic
* Interstitial
*
ICP
Monro-Kelli hypothesis
* ª in volume « volume elsewhere
* CSF shunted/displaced from cranial compartment ¨ subarachnoid space
* OR, rate of CSF reabsorption ªª
* Compensation protects structures
* LEADING CAUSE OF DEATH
* ª ICP = cerebral blood flow decreases
* Tissue hypoxia
* Decrease in pH
* Increase in CO2 levels
* causes cerebral vasodilation, edema, ª ICP
* Cycle continues
* Brain may herniate into brainstem
* Irreversible damage
* UNCAL HERNIATION
ICP
Two types edema cause ª ICP
* Vasogenic
* Cytoxic
* One type edema exacerbates:
interstitial
Vasogenic: adults
* Abnormal permeability of cerebral vessels
* Protein-rich plasma leaks
* Fluid collection: white matter
ICP
Cytotoxic, cellular edema
* From hypoxia
* Disturbance in cellular metabolism
* Sodium pump
* Active ion transport
* Brain depleted of O2, CHO, glycogen
* Na+ pump fails
* Na+ enters the cells and pulls H2O
* Simultaneous « Na+ serum (<120 mEq/L)
ICP
Abnormal accumulation of cellular fluids
* Decrease in ECF space
* Cytotoxic edema ensues
* Interstitial edema:
* Acute brain swelling
* Assoc with HTN, ª ICP
Cerebral Hemorrhage
Life-threatening
Three primary types:
* Epidural
* Subdural
* Intracerebral
Epidural
* Arterial bleeding
* Space: skull and dura mater
Hemorrhage
* Frequent site: temporal lobe injury
* glucidh interval ¨ unconsciousness
* May proceed to coma and death
Subdural Hematoma (SDH)
* venous
* Space: dura mater and arachnoid
* Common: laceration of brain tissue
* Bleed is slower
* Acute, subacute, chronic
Hemorrhage
* Intracerebral Hemorrhage
* Accumulation of blood within tissue
* Loss of Autoregulation
* Usually, remains constant
* Loss of regulation ¨ ∆ in blood flow
* Systemic HTN ¨ ª ICP
TBI
* Hydrocephalus
* Abnormal ª CSF volume
* Caused dilation of ventricles
* May lead to ª ICP
* Herniation
* Uncal: life threatening
* Shift of one/both temporal lobes (uncus)
* Pressure on 3rd cranial nerve
* S/Sx: dilated/fixed pupils
* Ptosis
* Rapid ∆ in conciousness
* CENTRAL HERNIATION
* Downward shift of brainstem
* Diencephalon
* S/Sx: Cheyne-Stokes respirations
* Pinpoint, fixed, nonreactive pupils
Traumatic Brain Injury-Interventions
* Nonsurgical management
* Prevention of ICP
* Fluid and electrolyte balance
* Positioning/hyperventilation
* Induction of barbiturate coma/drug therapy
Strategies for sensory/perceptual alterations
* Pulmonary management/behavioral management
Strategies for preventing complications of immobility
* Nutrition management
* Surgical management
* Intracranial pressure monitoring
* Craniotomy
Brain Tumors
* Primary tumors
* Secondary tumors
s/s brain tumors
* Increased ICP
* Focal neurologic deficits
* Obstruction of flow of cerebrospinal fluid (CSF
Brain Tumors-Complications
* Cerebral (vasogenic) edema/ ICP
* Herniation of brain tissue/ischemia of affected area
* Rupture/hemorrhage into brain tissue
* Seizure activity/hydrocephalus
* Pituitary dysfunction/SIADH/diabetes insipidus
* Fluid and electrolyte imbalances
Brain Tumors-Classification
* Malignant/benign
* Location:
* Gliomas
* Meningiomas
* Pituitary gland
* Acoustic neuromas
Brain Tumors-Symptoms
* Headache (severe on awakening in the AM)
* Nausea and vomiting
* Visual symptoms
* Seizures
* Changes in mentation or personality
* Papilledema (swelling of the optic disk)
Brain Tumors-Interventions
* Nonsurgical management
* Radiation/chemotherapy
* Blood brain barrier disruption
* Recombinant DNA
* Monoclonal antibodies
* Antineoplastic drugs
* Immunotherapy/hyperthermia
* Surgical management
* Biopsy
* Craniotomy
Brain Tumors-Postoperative Complications
* Increased ICP
* Hematomas
* Hydrocephalus
* Respiratory problems
* Neurogenic pulmonary edema
* Wound infection
* Meningitis
* Fluid/electrolyte imbalance