Week 5: Alterations in Cerebral Function

Question 1

Agnosia

Answer 1

can’t recognize familiar objects

Question 2

Agnosognosia

Answer 2

fail to recognize themself. May not recognize half the body, or that they’ve even had a stroke.

Question 3

Aphasia

Answer 3

inability to understand and speak

Question 4

apraxia

Answer 4

the inability to move purposefully

Question 5

ataxia

Answer 5

impaired gait

Question 6

dysphagia

Answer 6

impaired swallowing

Question 7

hemianopsia

Answer 7

ex: right sided stroke, can’t see on left vision field

Question 8

hemiplegia

Answer 8

half of body has paralysis or weakness

Question 9

pneumbra

Answer 9

around where the ischemia is. It’s the area we hope we can salvage

Question 10

subluxation

Answer 10

partial dislocation of the shoulder on the opposite side of the stroke

Question 11

non-modifiable risk factors of stroke

Answer 11

• AGE: 55 and older – incidence doubles every decade
• GENDER: Men
• RACE: African Americans 2X more likely than Caucasians

Question 12

modifiable cva risk factors

Answer 12

• Hypertension – major risk factor
• A-Fib
• Hyperlipidemia
• Diabetes
• Smoking
• Carotid Stenosis, valvular heart disease
• Obesity
• ETOH – excessive consumption
• Periodontal Disease

Question 13

• Sudden loss of function resulting from disruption of the blood supply to the brain
• Accounts for 80% of Brain Attacks
• Needs to be treated early to have fewer stroke symptoms, less loss of function, less permanent loss, etc.
• Causes – 1. atherosclerotic plaques in the large blood vessels of the brain result in thrombus formation and occlusion at site, and result in ischemia and infarction

Type of CVA?

Answer 13

ischemic brain attack

Question 14

ISCHEMIC BRAIN ATTACK – CAUSES

Answer 14

• several small vessels affected, but they are ones that penetrate deeper into the brain (small penetrating artery thrombotic attack)
• heart can throw clots (a-fib, etc.)
• other causes: some are just unknown, illicit drug use, coagulopathies, spontaneous dissection of the carotid artery

Question 15

• Disruption of cerebral blood flow because of an obstruction of a blood vessel
• This starts a series of events known as the Ischemic Cascade

Type of cerebral attack?

Answer 15

Thrombus related cerebral attack

Question 16

THE ISCHEMIC CASCADE, describe?

Answer 16

• Blood flow decreases to a point where neurons are no longer able to maintain aerobic respiration
• So the mitochondria in the cells switch to anaerobic respirations (less efficient)
• Anaerobic respirations causes a large amount of lactic acid to be produced
• The large amount of lactic acid causes a change in the pH level (acidosis)
• Anaerobic respirations cause less ATP to be produced (because it is less efficient system), and depolarization of the cells is inhibited
• Ultimately the process leads to cellular death

Question 17

Penumbra

Answer 17

• an area of low cerebral blood flow around the site of the infarction
• It is an area of ischemic brain tissue that can be saved with timely intervention

Question 18

If ischemic cascade continues?

Answer 18

• it threatens the area of the penumbra also, causing cell death in that area and enlarging the infarction
• If this happens , it is called “extending the stroke”

Question 19

Clinical manifestations of stroke

Answer 19

• Symptoms depend upon the location and size of the affected area
• Numbness or weakness of face, arm, or leg, especially on one side - Hemiplegia, Hemiparesis
• Aphagia, Drooping of 1 side of mouth
• Confusion or change in mental status
• Trouble speaking or understanding speech – Dysarthria, Aphasia (expressive vs. receptive)
• Difficulty in walking, dizziness, or loss of balance or coordination, Apraxia
• Sudden, severe headache (more hemmorrhagic)
• Perceptual disturbances – Hemianopsia, Agnosia

Question 20

Spot a stroke saying?

Answer 20

FAST

• facial drooping
• arm weakness
• speech difficulty
• time to call 911

Question 21

• Temporary neurological deficit resulting from a temporary impairment of blood flow
• “Warning of an impending stroke”
• Diagnostic work-up is required to treat and prevent irreversible deficit

Type of stroke?

Answer 21

TIA: transient ischemic attack

Question 22

Medical managment of stroke

Answer 22

• ABC’s, stabilizing the pt., and preventing complications
• Mainly focusing on preventing extending the attack, and secondary prevention
• t-PA Tx
• Carotid Stents
• Carotid Endarterectomy
• Medications
• Innovations in Treatment: Clot removal catheter, Laser Treatments to the prenumbra

Question 23

TPA what it does, time frame, contraindications

Answer 23

• Dissolves the clot - Works by binding fibrin, and converts plasminogen to plasmin, which stimulates fibrinolysis of the clot
• Must be given within 3 hrs of the onset of the attack
• Revascularization of necrotic tissue (>3 hrs) increases the risk for cerebral edema and hemorrhage
• Leads to a decrease in the size of the attack and an overall improvement in outcome

Question 24

TPA dosage, side effects, and nursing indications

Answer 24

Dosage

• is based on weight –
• 10% is given as a bolus
• other 90% over 1 hr

Side effect :

• Bleeding is the most common
• 6.4% have intracranial bleeding

Nursing:

• watch IV site for bleeding
• no NG tubes, suction, foleys
• frequent neuro checks (Q 15 minutes)

Question 25

CONTRAINDICATIONS TO T-PA

Answer 25

* SBP \> 185 or DBP \> 110 mm Hg, or aggressive treatment (IV medication) necessary to achieve these limits * CT findings suggesting ICH, SAH, or established major acute stroke * Suspicion of subarachnoid hemorrhage (even if head CT is negative for hemorrhage) * Seizure at onset (If rapid diagnosis of vascular occlusion can be made, treatment may begiven.) * Recent intracranial or spinal surgery, head trauma, or stroke (less than 3 months) * History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor * Major surgery or trauma within 3 months * Recent active internal bleeding (less than 22 days) (including arterial puncture at a non-compressible site) * Platelets \< 100,000; heparin use within 48 hours with PTT \> 40 (or exceeding upper limitsof normal range); INR \> 1.7 * Known bleeding diathesis or other major disorder associated with increased bleeding risk

Question 26

Carotid endarterectomy nursing care

Answer 26

\*Watch for complications: brain attack, cranial nerve injuries, infection, hematoma \*Maintain adequate blood pressure - Hypotension- cerebral ischemia and thrombosis - Hypertension – cerebral hemorrhage, edema, and hemorrhage at the surgical site \*Neuro flow sheets \*Edema in neck is normal, but watch for airway obstruction -should have emergency airway supplies at bedside

Question 27

Nursing management for acute phase of ischemic attack

Answer 27

* Ongoing/frequent monitoring of all systems including vital signs, neurologic assessment: LOC, motor, speech, and eye symptoms * Monitor for potential complications including: swallowing difficulties, respiratory problems, signs and symptoms of increased ICP

Question 28

* 15-20% of attacks * Mortality rate up to 43% * Usually have more severe deficits, and a longer recovery time * Caused by bleeding into brain tissue, ventricles, or subarachnoid space Type of CVA?

Answer 28

HEMORRHAGIC BRAIN ATTACK

Question 29

amyloid angiopathy

Answer 29

* Cause unknown, sometimes passed down through families * Persons with this condition have deposits of amyloid protein in the walls of the brain arteries. The protein is usually not deposited anywhere else in the body. * The major risk factor is increasing age. It is more often seen in those older than 60.

Question 30

Hemmorrhagic brain attack causes

Answer 30

_Spontaneous rupture of small vessels primarily related to_: - hypertension - subarachnoid hemorrhage due to a ruptured aneurysm _Intracerebral hemorrhage related to_: - amyloid angiopathy - arterial venous malformations (AVMs) - intracranial aneurysms - medications such as anticoagulants

Question 31

Pathophysiology of Hemorrhagic brain attack

Answer 31

* Brain metabolism is disrupted by exposure to blood * ICP increases due to blood in the subarachnoid space * Compression or secondary ischemia from reduced perfusion * vasoconstriction injures to brain tissue and cranial nerves * when blood vessels lyse, releases proteints, cause irritant to tissue around it gets inflammed, vessels around it get damaged leading to further hemmorrhagic strokes

Question 32

* Similar to other kinds of strokes * _Severe headache_ * Early and sudden changes in LOC * Vomiting Manifestations of what type of stroke?

Answer 32

hemorrhagic stroke

Question 33

Medical management of hemmorrhagic stroke

Answer 33

_\*Goal – allow the brain to recover_ - prevent rebleeding - prevent Tx complications _\*Usually not treated surgically unless hematoma is at least 3 cm_ - Surgical evacuation of hematoma - isolate the aneurysm _\*Bed rest with sedation_

Question 34

Acute phase complications of hemmorrhagic stroke

Answer 34

\*I_CP = Increased Intracranial Pressure_ - Causes a decrease in cerebral perfusion, stimulates further swelling, and can cause death by shifting brain tissue through openings in dura, - or by causing so much loss in cerebral blood flow * Can occur with ischemic attack, but almost always with a hemorrhagic attack * Occurs during acute phase, but may also develop in the recovery phase * Also occurs tumors, head injuries, etc.

Question 35

Nursing management of complications with hemmorrhagic stroke

Answer 35

**_Complications_** _Vasospasms: _occur 4-14 days after the event _Narrowing of the blood vessels_ * leads to vascular resistance- * Impedes blood flow * ischemia * infarction **_Nursing Management_** * Monitor ICP * Watch for and manage Hypertension, Seizures, Rebleeding, Hyponatremia – IV Tx, Hydrocephalus (CSF cannot drain) - shunt

Question 36

Long Term Medications for Strokes

Answer 36

* _Warfarin (Coumadin)_ – esp. useful for afib or cardioembolitic attacks – the target INR= 2.5 * _If warfarin is contradicted_ –ASA (don’t give within 24 hours of thrombolytic agents) * Clopidogrel (Plavix) * Ticlopidine (Ticlid) * Statins – Zocor, Crestor, Lipitor * Antihypertensives

Question 37

What is a seizure?

Answer 37

* SpontaneousaAbnormal neuronal activity * A sudden biochemical imbalance at the cell membrane * Repeated abnormal electrical discharges * Seen clinically as changes in motor control, sensory perception and/or autonomic function

Question 38

Clinical presentations of seizure

Answer 38

* Feeling nauseous * Feeling odd or peculiar * Losing control of bowel or bladder * Feeling numbness, tingling * Experiencing odd smells or sounds

Question 39

Precipitators of seizures?

Answer 39

* Dehydration * Fatigue * Flashing lights * Hypoxia * Stress * Monthly hormonal fluctuations * Head injury * Electrolyte imbalances

Question 40

Absence seizure

Answer 40

* Brief alteration in consciousness 5–30 seconds * • Staring * • Mild increase or decrease in muscular tone * • Automatisms—chewing, rapid eye-blinking, lip-smacking * • No postictal phase

Question 41

Tonic-clonic seizures

Answer 41

* May have aura or vocalize a sudden cry from forced expiration 3–5 minutes * • Loss of consciousness, stertorous respirations * • 30–60 second tonic phase * • Apnea and cyanosis may occur until end of tonic phase * • Clonic phase of rhythmic, synchronous, jerky movements * Dilated pupils, hypertension, tachycardia * • Bilateral Babinski * • May bite tongue, become incontinent * • Postictal fatigue, memory loss, headache, confusion (minutes to hours)

Question 42

myoclonic seizure

Answer 42

Quick symmetrical muscular, jerky movement of body, face, trunk extremity or entire body; may be bilateral or unilateral

Question 43

seconds seizure

Answer 43

* Violent (may fall and hit objects) * • Impaired consciousness Seconds

Question 44

Atonic (drop attack) seizure

Answer 44

* Abrupt loss of muscle tone (may fall and injure self) * • Unconsciousness during episode * • Short postictal phase—can resume activity

Question 45

Simple Partial seizure

Answer 45

* Conscious, but without control Seconds to minutes * • Twitching, jerky, unilateral movements of an extremity, eyes or face * • Todd paralysis of involved area may occur

Question 46

Generalized seizures, vs. complex and simple

Answer 46

_Generalized_ * Involves BOTH hemispheres of the brain * Always involves loss of consciousness * Types: Tonic or clonic movements or combination (grand mal), Absence (petit mal), Myoclonic, Atonic (e.g., drop attacks), Infantile spasms _Complex_ * May have aura * Involves motor\* or autonomic# symptoms with altered level of consciousness * May generalize _Simple_ * No impaired consciousness * Can involve motor,\* autonomic# or somatosensory+ symptoms * May generalize

Question 47

motor symptoms of seizure

Answer 47

head/eye deviation, jerking, stiffening

Question 48

autonomic symptoms of seizure

Answer 48

pupils dilatation, drooling, pallor, change in heart rate or respiratory rate

Question 49

Somatosensory symptoms of seizure

Answer 49

smells, alteration of perception (déjà vu)

Question 50

Complex partial

Answer 50

* Loss of consciousness, unresponsive Minutes * • Impaired awareness (confused, unfocused), blank stare * • May have aura * • Unusual sensations—memory flashbacks, depersonalization of surroundings, “out of body” * experience, visual or auditory distortions, rage, terror, elation, sadness * • Automatisms—lip-smacking, chewing, picking up objects, aimless walking, removing clothing, * repeating phrases * • Unaware of danger such as traffic, fire, heights * • Postictal confusion and amnesia of event * Secondarily generalized • Any partial seizure that becomes generalized with loss of consciousnes

Question 51

Seizure phases

Answer 51

_Aura_ * actually a small partial seizure that is often followed by a larger event. * Alterations in senses. _Ictus._ * The seizure event. _Postictal state._ * After the ictus phase. * Drowsiness and confusion are commonly experienced during this phase. * The postictal state is the period in which the brain recovers from the insult it has experienced.

Question 52

diagnostic tests for seizures

Answer 52

* Laboratory tests for electrolyte balance, blood glucose, and anticonvulsant levels * CT scan * EEG

Question 53

Collaborative care for seizures

Answer 53

_Anticonvulsants_ - Phenytoin (Dilantin) - 10-20 mg/kg loading dose - Mix with NS _not_ dextrose - 25-50 mg/min IVP - Monitor MP and Heart Rate x 30 min: May use Fosphenytoin children (SIVP or IM)\* -Benzodiazepine: Given emergent with Dilantin _Keatogenic Diet_: High fat, low carb, low protein _Vagus Nerve Stimullator_: implanatble device that stimulates the vagus nerve. Done after trying 3 or more meds

Question 54

nursing care for seizure pts

Answer 54

* _Make certain that the patient has the following equipment_: Nasal cannula and tubing, Oxygen flow meter; , Suction gauge, Suction canister, Suction tubing to connect to canister * Assign patient to room in close proximity to the nurses station * Maintain continuous observation via video monitor or sitter * Pad side rails of bed * Keep bed in low position with all side rails up at all times * Keep unnecessary equipment out of patients room * Instruct patient not to get out of bed without assistance * Assure that call bell is always within patients reach. Make sure that the family knows where it is and how to use it * Avoid use of restraints * Check vital signs every fifteen minutes and maintain airway patency during the post ichtal phase (period of time immediately following the seizure, during which the patient remains comatose or stuperous).

Question 55

pt. education on what to do if a seizure occurs

Answer 55

* DO NOT restrain. * DO NOT place anything between the person's teeth during a seizure. * DO NOT move the person unless they are in danger or near something hazardous. * DO NOT try to make the person stop convulsing. * DO NOT give the person anything by mouth until the convulsions have stopped and the person is fully awake and alert. * DO NOT start CPR unless the seizure has clearly stopped and the person is not breathing or has no pulse.

Question 56

STATUS EPILEPTICUS

Answer 56

\*A sustained seizure lasting 5 minutes \*150, 000 each year experience SE \*40,000 die as a result -Surge of catecholamines -HTN -Tachycardia -Cardiac arrhythmias -Hyperthermia \*Results in increase neuronal metabolic needs and ultimate neuronal death

Question 57

Management of seizure pt.

Answer 57

\*Stay with Patient! \*Secure Airway/Oxygenation \*Establish IV access with NS or D5 (if hypoglycemic) \*_Drug of choice_: - Benzodiazepine (Lorazepam) 2-4 mg IVP over 1 minute - Phenytoin IV drip

Question 58

Febrile seizures risk/cause, types, meds

Answer 58

* Most common neurological condition in childhood * 2-5% of all children experience between 6-60 months * Cause unknown: Associated with viral infections, Family hx, Premature birth * 1% Long Term risk for developing epilepsy _Types_ * _Simple_: No hx of previous seizure, High fever, Tonic-clonic, Less than 15 minutes * _Complex_: Previous hx of seizures Greater than 15 minutes _Treatment_ * safety till resolved * Acetaminophen for fever * Diazepam IV or rectal if seizure continues