neurology
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Neurology. Cerebrovascular Accident Brunner’s Ch. 62 pg 1887. Breaking down in tears. I’m a nursing student who’s never seen a person die. When the time comes, I’m afraid I’ll lose it and upset the patient or family. How do you do this work all the time and not break down in tears?. - PowerPoint PPT PresentationTRANSCRIPT
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Neurology
Cerebrovascular AccidentBrunner’s Ch. 62 pg 1887
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Breaking down in tears
• I’m a nursing student who’s never seen a person die. When the time comes, I’m afraid I’ll 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
• PaO2 & PaCO2 • Acidosis • Infarction • Edema • 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• probability of
neurological deficits• No meds to reverse the
effects
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CVA: Etiology
• Other causes– Syphilis– Trauma– Hypertension– Hypoxia– ***Anything the blood
flow
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CVA: Risk FactorsChangeable• Smoking• Obesity• HTN• Sedentary life• Stress• fat diet• 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?A. SmokingB. WeightC. DietD. HTNE. StressF. Substance Abuse
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CVA: Risk Factors
What is the number one cause of CVA in a younger patient?
A. SmokingB. WeightC. DietD. HTNE. StressF. Substance Abuse
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CVA: Pathophysiology substance abuse
• Substance (PCP, crack) • Blood pressure • ICP • Subarachnoid &
intracerebral hemorrhage
• Interrupt blood flow • O2 & glucose • Depressed neurons
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CVA: Pathophysiology
• ** Vessels involved determine the area of the brain involved
• ***Area affected determines the S&S
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CVA: Clinical manifestations
S&S depend on:1. Location2. Size3. 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 CVALeft 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– 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
• Cardiac output• 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
• – Fat
• – Potassium
• – Stimulants
• – Fluids
•
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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– reflex– O2– Suction– Mech vent
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CVA: Medical Management
• Prevent Seizures– Precaution– Meds– stimuli
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CVA: Medical Management• ICP
– O2• Mech vent
– Position• HOB
– Activity• Rest
– Meds• Diuretics• Glucocorticoids
– Monitor• BP• Systolic < 180• Diastolic < 100
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CVA: Medical Management
• Nutrition– NGT
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CVA: Medical Management
• Monitor for trouble– VS
• Rectal temp– NO
– I&O – Labs
• Na• K• Glucose• ABG’s • 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 ICP
– Monitor ICP– Avoid act that ICP
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CVA: NRS managementRisk 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– pocketing food
– Talk & eat – NO– Easy chew– Head position– Unaffected side of tongue– gag– 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• SS&TTP• 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 S&S
– H/A– LOC– Nuchal rigidity
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TIA: Transient Ischemic Attack
• Short reversible ischemic event
• Duration– < 24 hrs
• No permanent neuro deficit
• Warning!