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38 Cards in this Set
- Front
- Back
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Peripheral Nerve Trauma
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Seen commonly as a result of an injury/combat injuries
Clinical manifestations-will depend on where the nerve is located Treatment-will depend on the nerve that is damaged |
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Trigeminal Neuralgia
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Also called tic douloureux
Extreme pain of the 5th cranial nerve followed by no pain |
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Stroke – main focus for exam
Cerebrovascular accident(CVA) – old terminology Brain attack – new terminology |
Considered a medical emergency
FAST Face – face droop, weakness Arms – one weaker than the other Speech – slurred speech Time – call 911 immediately, need to know how long symptoms have been there |
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Stroke
Pathophysiology |
Blood flow in-Carries oxygen and glucose
Blood flow out-Carries metabolic wastes, carbon dioxide, lactic acid Disruption in either leads to cerebral tissue death Brain has the ability to autoregulate so that this blood flow is maintained, vessles can dilate to allow more blood flow |
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Types of strokes
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Hemorrhagic strokes
Ischemic strokes – Thrombotic – Embolic |
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Ischemic strokes (occlusive stroke)
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Accounts for 80% of all strokes
Includes- thrombotic and embolic |
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Thrombotic stroke
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Occurs due to rupture of plaque and resulting clot formation due to atherosclerosis to the walls of the cerebral vessels
The clot occludes the vessel resulting in decreased or absent blood flow to an area and ischemia Usually has a slow onset |
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Embolic Stroke
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Occurs due to movement of a clot from some other area causing blockage in a cerebral artery
The clot occludes the vessel resulting in decreased or absent blood flow to an area and ischemia Usually occurs suddenly and rapidly |
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Hemorrhagic Stroke
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Cerebral tissue damage due to bleeding
– Ruptured aneurysm – Ruptured AV malformation – Severe hypertension is common |
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Aneurysm
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A weakened area on a cerebral vessel
Often congenital Often ruptures during activity Cerebral Aneurysm called a Berry Aneurysm happens at vessels that bifurcate |
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Arteriovenous malformation (AVM)
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A spaghetti like tangle of blood vessels with abnormal blood flow between arteries and veins
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Hypertension
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Increased BP for periods of time change the arterial wall until it ruptures, seen more commonly now from cocaine use
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Transient Ischemic Attacks (TIAs)
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Often precede ischemic strokes
Cause a transient episode of neurological dysfunction TIA-last from a few minutes to less than 24 hours |
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Reversible Ischemic Neurological Deficit (RIND)
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Same as TIA but lasts from 24 hours to less than one week
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Risk factors for strokes
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Hypertension
DM Heart disease Hypercholestermia Hypercoagulable state Illegal drug use (esp. cocaine) Obesity Atrial fibrillation |
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Stroke
Medical Emergency |
Must make a diagnosis quickly to preserve brain tissue, medication must be administered within 3 hours of symptoms
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Stroke Alerts/Brain attacks
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History- last time normal is very important
When did it happen? – Ischemic-sleep – Hemorrhagic-activity Progression of symptoms Embolic or hemorrhagic-rapid onset Thrombolitic-gradual Severity of symptoms – Hemorrhagic-gets worse – Embolic-gets better TIA/RIND-symptoms come and go |
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Stroke assessment
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LOC/GCS
Assess for posturing Pupillary assessment Difficulty speaking Balance instability Muscle strength different on one side Past medical history Illegal drug use |
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Glascow Coma Scale (GCS)
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Allows for a rapid neurological assessment
Standardized assessment Scored on three areas-eye opening, motor response, and verbal response. The higher the score the better (15 is the best, 3 is the worst) |
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Stroke Assessment
LOC |
Must be very exact with documentation
Subtle changes can be a big deal Changes can be-headache, restlessness, irritability or very quiet, slurred speech, changes in level of orientation |
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Stroke Assessment
Posturing |
Late sign of neurological deterioration
Notify the physician immediately Decorticate position-arms, wrists, and fingers flex with internal rotation. Feet flex in Decerebrate position-rigid extension of arms and legs, pronation of the arms and plantar flexion of the feet. Dysfunction of the brainstem |
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Stroke Assessment
Pupillary reaction |
PERRLA-pupils equal in size, round and regular in shape, and react to light and accommodation
Dilated or non reactive pupils sign of neurological deterioration and the physician should be notified immediately, usually already too late, only about 15 minutes to intervene. |
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Stroke
Problems with speech |
Aphasia-inability to use or comprehend language
Alexia-reading problems Agraphia-difficulty with writing Left cerebral hemisphere is dominate in most of the population-area of language skills, math skills, analytical thinking |
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Stroke
Motor Problems |
hemiplegia-paralysis on one side of the body
Hemiparesis-weakness on one side of the body Remember that motor nerve fibers cross the midline before going to the spinal cord. Right hemisphere problems mean left sided paralysis Flaccid paralysis-extremities just all to the side-patient does not have the ability to hold them up Spastic paralysis-contractures (lack of movement) in a joint |
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Stroke
Sensory Problems |
Agnosia-inability to use an object correctly
Apraxia-inability to carry out purposeful motor activity Neglect Syndrome-unaware of one side of the body Ptosis-drooping eyelid Anaurosis fugaz-brief period of blindness in one eye Hemianopsia-blindness in half the visual field |
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Stroke
Diagnostic Tests |
No lab tests that can confirm a stroke diagnosis
CT scan or CT angiography-give a baseline, identifies cerebral hemorrhage, R/O other problems MRI/MRA-show problems earlier than CT scan is most important Goal is to have the CT scan done and read within 45 minutes, can tell if it’s a hemorrhagic or ischemic stroke, don’t treat a hemorrhagic stroke because medication would make it worse and cause more bleeding |
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Carotid Artery Angioplasty
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Done to visualize the cerebral circulation
Helps to identify aneurysms, injuries, strictures/occlusions, tumors, AV malformations Patient preparation for carotid artery angioplasty Check allergies Obtain consent NPO Baseline neurological assessment Explain procedure – Will need to be still/lay on hard table – May or may not receive sedation – Will feel pressure in the groin area when catheter is inserted Post procedure care – Assess VS – Neuro assessment – Neurovascular checks-check pulses/color/sensation – Bed rest with leg straight/immobilzed – Assess insertion site – Encourage fluids |
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Stroke
Interventions |
Depends on the type of stroke (3 hour window for thrombolytics)
ABCs-priority Monitor for signs of IICP (increased intracranial pressure) such as change in LOC, changes in behavior, changes in vital signs |
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Stroke
Non surgical interventions |
Monitor/assess for changes in ICP/neurological changes and report
HOB controversy should it be up or down Head should be in straight alignment Avoid anything that increases ICP (coughing, crying, straining, sneezing, etc) so no turn/cough/deep breath after surgery |
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Stroke
Medications |
Thrombolytic therapy
Anticoagulants/antiplatelets Calcium channel blockers-smooth muscle relaxers that decrease cerebral spasms Other meds if needed-seizure med, anti anxiety meds, stool softeners, pain meds |
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Stroke
Thrombolytic therapy |
Used for ischemic strokes only
Dissolves clots-reestablishes blood flow Example: – Recombinant tissue plasminogen activator (Retavase) –given systemically – Urokinase (abbokinase) or t-PA- (Alteplase )-given at site and IV |
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Anticoagulants/antiplatelet
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Controversial
Can not be used with hemorrhagic strokes Used more to prevent recurrent strokes Some antiplatelet examples-aspirin, ticlopidine hydrochloride (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine)-should monitor anyone taking these for bleeding. |
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Other medications for strokes
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Seizure meds-if needed
Calcium channel blockers Stool softeners Analgesics Antianxiety drugs |
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Strokes
Complications |
Hydrocephalus-increased CSF within brain that causes ICP
Vasospasms-narrowing of cerebral artery causing decreased blood flow Rebleed-common with aneurysms/AVM |
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Strokes
Surgical Interventions |
Endarterectomy-prevents strokes in patients with carotid stenosis by opening up the carotid artery to increase blood flow, but increases chance of embolytic ischemic stroke
Extracranial-intracranial by pass-blood flow is rerouted around the blockage AVM/Aneurysms-seal or clip the weakened area-Gamma Knife used to make the walls of the vessel more fibrous |
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Nursing Care of stroke patients
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Depends on the deficit
– PT/OT/ROM/assistance – ADLs – Safe environment – Reorient – Remind patients with neglect syndrome of their other side |
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Stroke
Speech Deficits |
Dysarthia-slurred speech due to decreased muscle control of tongue-may also have swallowing problems
Expressive aphasia-understands speech but can not answer Receptive aphasia-can talk but words don’t’ make sense. No understanding of spoken or written word Get speech therapy involved Look for other ways to communicate |
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Stroke
Swallowing Deficits |
Assess ability to swallow early on and on going
Position upright to eat and drink Soft/semisoft foods usually tolerated better than liquids May need “thick it” Work with dietitian and speech therapist |
