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82 Cards in this Set
- Front
- Back
* Southern states: stroke belt
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- High fat diet
- Smoking - More elderly individuals |
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Stroke (CVA)
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* 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 |
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Stroke, Brain Attack
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* National Stroke Association
* Medical emergency * Requires prompt/immediate intervention |
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Pathophysiology of Stroke
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* 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 |
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Types of Strokes
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* Ischemic (occlusive)
* Caused by occlusion of cerebral artery by thrombus or embolus * Thrombolic stroke |
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Thrombolic stroke
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1. Accounts for more than one half of all strokes
2. Associated with atherosclerosis 3. Lacunar stroke |
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Embolic stroke
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1. Accounts for 1/3 of all strokes
2. Embolus/emboli travel to cerebral arteries via carotid artery 3. Sources of emboli are cardiac |
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Transient ischemic attack (TIA)
Reversible ischemic neurologic deficit (RIND) |
*
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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 |
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Embolic stroke
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* 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 * gSilenth stroke * precedes other strokes |
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Reversible Ischemic Neurologic Deficit (RIND)
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* Transient focal dysfunction d/t brief interruption of blood flow, e.g., spasms
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TIA and RIND differ in
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duration
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TIA duration?
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= few minutes, <24 hours
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TIA -
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* 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 |
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Hemorrhagic Stroke
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* 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 |
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Arteriovenous Malformation (AVM)
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* Embryonic development
* Entangled mass * Thin-walled, dilated vessels * Abnormal communication with arterial and venous systems * Ruptures may cause bleeding |
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Risk Factors - stroke
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* HTN
* Diabetes mellitus * Heart disease * Nonvalvular atrial fibrillation * Smoking/substance abuse * Sedentary lifestyle * Women: ªHgb (>14 g) « bone density, migraines |
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Stroke-Clinical Manifestations
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* Cognitive changes
* Motor changes * Sensory changes * Cranial nerve intactness * Cardiovascular assessment * Psychosocial assessment |
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History
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* 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) |
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Hx
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* Observe LOC during interview
* Monitor speech pattern/body posture, etc * Medical hx? * Family hx? * Diet? * Other risk factors? * Medications? |
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Physical Assessment - neuro
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* Cognitive Changes
* LOC may vary * Denial * Hemiparesis * Spatial/proprioceptive dysfunction * Memory impairment * Problem-solving/decision-making |
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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 |
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Aphasia =
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inability to use/comprehend
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Alexia =
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reading difficulty
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Agraphia =
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writing difficulty
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Hemiplegia =
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paralysis, one side
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Hemiparesis =
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weakness, one side
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Motor ∆s
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* 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 |
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Sensory ∆s
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* 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 |
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Visual changes:
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* 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 |
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Cardiovascular Assessment
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* Embolic strokes murmur, dysrhythmia, HTN
* Psychosocial * Finances, ADLs, care at home * Emotional lability (esp with frontal lobe) * Labs, radiographs (CT), MRI |
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Interventions - stroke
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* 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) |
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ICP monitoring
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* Key Features:
* «LOC sensorimotor ∆ * Behavioral ∆s pupillary ∆ * HA cranial nerve involve * N/V ataxia * Speech ∆ sz * Aphasia Cushingsf Triad * Slurred speech Posturing |
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Nursing Interventions - ICP
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* Frequent nursing assessments
* First 72 hours critical * Elevate HOB * Maintain head position ¨ drainage * Avoid extreme flexion (ª ITP) * Avoid clustering of activities |
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Drug therapy - stroke
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* 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 |
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Surgical Management stroke
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* Endarterectomy
* Extracranial-intracranial bypass * AVM management * Craniotomy * Remove clots |
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Nursing interventions stroke
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* 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 |
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L sided repercussions:
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* Memory deficits, simple tasks difficult
* Reorient to month, day, year * Establish routine schedule * Structured environment * Familiar objects * Step by step teaching |
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Unilateral Neglect
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* 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 * gscanningh technique |
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Impaired Verbal Communication
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* Goal: effective communication
* Language/speech (dominant hemisphere) |
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Aphasia:
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* Expressive (Brocas; motor) frontal
* Receptive (Wernickes; sensory) T-P area may talk but language is meaningless * Global (mixed) |
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Stroke-Impaired Verbal Communication
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* 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 |
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Expressive (Broca's or motor) aphasia
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1. Motor speech problem
2. Understands but unable to communicate 3. Difficulty with writing 4. Frustration and anger |
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Receptive (Wernicke's or sensory) aphasia
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1. Unable to understand spoken and written word
2. Neologisms 3. Global or mixed aphasia 4. Reading and writing equally affected |
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Impaired swallowing
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* 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 |
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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 |
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Bowel retraining program
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* 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 |
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Health Teaching
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* 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 |
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Traumatic Brain Injury (TBI)
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* 18-34 years #1 cause of death
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Traumatic Brain Injury (TBI)Pathophysiology
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consciousness ∆
* Direct/Indirect * Reversible/irreversible * Temporary ¨ permanent * Primary Brain Injury |
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TBI Incidence/Prevalence
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* 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 |
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Pathophysiology TBI
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* 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 |
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Concussion =
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brief loss of consciousness
* Damage is functional, not structural (thus, not permanent) |
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Contusion =
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bruising of brain at coup or contracoup site
* laceration |
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Traumatic Brain Injury-Types of Forces
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* Acceleration injury
* Deceleration injury * Shearing * Straining * Distortion of brain tissue * Destruction of adjacent brain tissue |
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Types of Forces
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* Acceleration injury velocity
* Deceleration injury e.g., whiplash |
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2˚ injuries
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* Increase mortality/morbidity
* Most common: ª ICP * Edema * Hemorrhage * Impaired cerebral autoregulation * Hydrocephalus * Hypoxemia * Hypercapnia * Systemic hypotension |
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Increased Intracranial Pressure
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* Monro-Kellie hypothesis
* Normal ICP 10 to 15 mm Hg * Leading cause of death from head trauma |
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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) |
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* Edema
* Vasogenic * Cytotoxic * Interstitial |
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ICP
Monro-Kelli hypothesis |
* ª in volume « volume elsewhere
* CSF shunted/displaced from cranial compartment ¨ subarachnoid space * OR, rate of CSF reabsorption ªª * 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 |
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ICP
Two types edema cause ª ICP |
* Vasogenic
* Cytoxic |
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* One type edema exacerbates:
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interstitial
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Vasogenic: adults
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* Abnormal permeability of cerebral vessels
* Protein-rich plasma leaks * Fluid collection: white matter |
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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) |
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ICP
Abnormal accumulation of cellular fluids |
* Decrease in ECF space
* Cytotoxic edema ensues * Interstitial edema: * Acute brain swelling * Assoc with HTN, ª ICP |
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Cerebral Hemorrhage
Life-threatening Three primary types: |
* Epidural
* Subdural * Intracerebral |
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Epidural
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* Arterial bleeding
* Space: skull and dura mater |
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Hemorrhage
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* Frequent site: temporal lobe injury
* glucidh interval ¨ unconsciousness * May proceed to coma and death |
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Subdural Hematoma (SDH)
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* venous
* Space: dura mater and arachnoid * Common: laceration of brain tissue * Bleed is slower * Acute, subacute, chronic |
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Hemorrhage
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* Intracerebral Hemorrhage
* Accumulation of blood within tissue * Loss of Autoregulation * Usually, remains constant * Loss of regulation ¨ ∆ in blood flow * Systemic HTN ¨ ª ICP |
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TBI
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* 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 |
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Traumatic Brain Injury-Interventions
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* Nonsurgical management
* Prevention of ICP * Fluid and electrolyte balance * Positioning/hyperventilation * Induction of barbiturate coma/drug therapy |
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Strategies for sensory/perceptual alterations
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* Pulmonary management/behavioral management
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Strategies for preventing complications of immobility
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* Nutrition management
* Surgical management * Intracranial pressure monitoring * Craniotomy |
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Brain Tumors
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* Primary tumors
* Secondary tumors |
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s/s brain tumors
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* Increased ICP
* Focal neurologic deficits * Obstruction of flow of cerebrospinal fluid (CSF |
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Brain Tumors-Complications
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* 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 |
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Brain Tumors-Classification
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* Malignant/benign
* Location: * Gliomas * Meningiomas * Pituitary gland * Acoustic neuromas |
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Brain Tumors-Symptoms
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* Headache (severe on awakening in the AM)
* Nausea and vomiting * Visual symptoms * Seizures * Changes in mentation or personality * Papilledema (swelling of the optic disk) |
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Brain Tumors-Interventions
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* Nonsurgical management
* Radiation/chemotherapy * Blood brain barrier disruption * Recombinant DNA * Monoclonal antibodies * Antineoplastic drugs * Immunotherapy/hyperthermia * Surgical management * Biopsy * Craniotomy |
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Brain Tumors-Postoperative Complications
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* Increased ICP
* Hematomas * Hydrocephalus * Respiratory problems * Neurogenic pulmonary edema * Wound infection * Meningitis * Fluid/electrolyte imbalance |