Med Surg Neuro 2

Created by gingerthurston 

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217 terms

a temporary blockage of blood to the brain that causes transient neuro impairment

TIA

Are the risk factors for a TIA the same as for a full blown stroke?

yes

about ____ of patients that have a TIA will have a stroke in the future.

1/3

When is it determined that a TIA was actually a stroke?

if it causes permanent damage to the brain

What is the focus of treatment for a TIA?

preventing a full stroke

Stroke is our nation's number ___ killer.

3

What 2 things are essential for the survival of the brain?

o2 and glucose (it cannot store it so it needs a constant supply)

healthy tissue that surrounds an infarct in the brain in which the brain tissue is stunned and can be revived if perfused

penumbra

strokes are classified as _______ or _______.

ischemic
hemmorhagic

what kind of stroke is most common?

ischemic

What are the 2 kinds of ischemic strokes?

embolic
thrombotic

this kind of stroke occurs when the blood supply to the brain is blocked or significantly slowed

ischemic

this stroke occurs when an occlusion builds up in an artery until it significantly decreases or stops blood to the brain

thrombotic

where do a lot of thrombotic strokes occur?

carotid arteries

this stroke is typcially caused by a blood clot that is created somewhere in the body and travel through the arteries until it becomes trapped in a smaller vessel. Usually in a cerebral artery.

embolic

this kind of stroke is caused by the rupture of a cerebral blood vessel that allows blood to escape into brain tissue and not travel beyond the point of rupture

hemorrhagic stroke

What are the 2 kinds of hemorrhagic strokes?

subarachnoid
intracerebral

this type of stroke occurs on the surface of the brain and is most often the result of a ruptured cerebral aneruysm. These are very serious, require surgery, often fatal.

subarachnoid hemorrhage

THIS TYPE OF STROKE OCCURS IN THE DEEPER TISSUES OF THE BRAIN AND USUALLY IS CAUSED FROM UNCONTROLLED HYPERTENSION.

INTRACEREBRAL HEMORRHAGE

A patient can have multiple undetected instances of this, with minimal deficits noted. However, damage will eventually accumlate and major defecits will develop.

intracerebral hemorhhage

What is the goal for pts who have had an intracerebral hemorrhage?

maintain bp below 120/80

Risk factors for ischemic strokes are classified as _______ and _________

modifiable
non-modifiable

every ___ points of systolic bp over 120 doubles the risk of a stroke.

15

what are the 5 s/sx of stroke?

(all sudden onset)
1. numbness or weakness of face, arm or leg on one side
2. confusion or trouble speaking
3. trouble seeing in one or both eyes
4. trouble walking or with coordination
5. severe headache with no known cause

Keeping blood sugar steady is a _______ risk factor for stroke.

modifiable

Why is atrial fibrillation a risk factor for stroke?

the afibrillation can create blood clots

asymptomatic carotid stenosis is caused by?

cholesterol >200

What is the best route of action to follow if you observe a stroke victim?

call EMS for an ambulance. They are treated faster (within 2 hours of symptom onset)

What does the acronym FAST (used to recognize stroke) mean?

Facial droop (ask person to smile)
Arm drift (close eyes with arm out in front and one drifts downward)
Speech (is their speech affected?)
Time (time is of the essence!)

What is the window for treatment from the onset of stroke symptoms?

3 hours

when both expressive AND receptive aphasia is present, it is called

global aphasia

slurred or indistinct speech because of a motor problem is referred to as

dysarthria

motor disturbances of stroke are:

paralysis
weakness
numbness

What is often the first evidence of paralysis or weakness after stroke?

feeling of clumsiness or heaviness in limb

motor disturbances are felt on the _______ side of the body from the damaged area of brain.

opposite

deficits of stroke may appear in both sides of the body if the stroke was a _______stroke

brainstem or vertebrobasilar

______ is caused by damage to the cerebellum during stroke.

ataxia (unsteady gait)

What should you do before you give a stroke victim ANYTHING by mouth?

pt should pass a swallow test to prevent possible aspiration

When assessing stroke damage in relation to swallowing ability, what should you look for?

weakness or asymmetry of facial features

If a stroke victim does not show facial weakness or asymmetry, how much water do you give to see if they can tolerate it?

30 mL

what side of the body do visual distrubances occur after a stroke?

the SAME side as the brain damage.

how do pts describe vision loss from stroke?

curtain dropping
fog
gray out or black out vision

What is the first test performed in the ER if stroke is suspected?

CT scan

What is the purpose of the initial CT scan in the ER to check for stroke?

to see if the stroke was hemorrrhagic. Ischemic strokes will not be visible till several days after the event.

After a CT in the ER for suspected stroke, the pt may have and ECG to check for:

atrial fibrillation or heart disease that may increase the risk of thrombus formation

Tests that may be done is stroke is suspected

CBC
blood glucose
BMP
blood typing
PT
INR
serum pregnancy (if applicable)
stools and emesis checked for blood
cardiac monitor and pulse oximeter

a stroke scale to determine the patients neurologic defeicit level. 11 point scale that determines severity of stroke.

national institues of health stroke scale

How is stenosis of the carotid arteries detected?

carotid doppler testing

Initial emergent care of a stroke is _____ while test results are pending. ABC's are monitored.

supportive

When is 02 administered to a potential stroke pt?

<92%

a temp > than _____ is treated in suspected stroke cases.

99.6 f

What kind of fluids are NOT given to potential stroke patients?

solutions with glucose that could cause hyperglycemia

if stroke is suspected, the dr. will make a decision regarding thrombolytic therapy within ____ hour of arriving.

one

When must thrombolytic therapy be given to prevent permanent brain damage?

within 3 hours of symptom onset

thrombolytic agents lyse a thrombus by causing conversion of plasminogen to ______.

plasmin

thrombolytics are associated with a significant risk of __________, so all risk of bleeding must be ruled out before these drugs will be considered.

hemorrhage

What is the body's natural response to lack of perfusion to areeas of the brain due to stroke?

to increase the systolic bp in order to perfuse the brain

If the pt is to receive TPA, the bp must be maintained below______ to reduce the risk of bleeding.

185/110 (through use of labetalol or nicardipine)

allowing the bp to remain high for a period of time to help salvage brain tissue from stroke is called

permissive hypertension

When permissive hypertension is allowed to help perfuse infarcted brain tissue, when are antihypertensives given?

220/120

What are the common antiplatelet drugs?

aspirin
plavix
aggrenox

drugs that prolong the time to form clots are

anticoagulants

what are the common anticoagulants used for stroke?

warfarin (monitor INR)
heparin (bleeding times)

what are some common statin drugs used with stroke?

zocor
pravachol
lipitor
mevacor

what is a common side affect of statin drugs?

muscle weakness

what is a common side affect of antiplatelet and anticoagulant drugs?

bruising, change in LOC

according to the ASA, pts who have had a TIA should receive antiplatelet therapy how soon after symptom onset?

24 hours

What drug does a stroke patient receive who is in atrial fibrillation?

coumadin (to prevent clots)

statins are ordered for the stroke patient who has a cholesterol level > _____

100 mg/dl

statins may have a ________ effect.

neuroprotective

Why are stroke pts at risk for respiratory complications?

r/t an IICP
prone to aspiration

procedure done in patients with significant carotid artery occlusion to remove the carotid occlusion

endarterectomy

If a pt is no a good candidate for a carotid endarterectomy, a carotid _____ may be placed during a carotid angiogram.

stent

paresthesia and paralysis are common long term effects of strokes that were not treated with a ________ agent.

thrombolytic

the side of the body opposite the cerebral infarct is affected because:

nerve fibers cross over as they pass from the brain to the spinal cord

impaired motor function due to stroke puts people at high risk for _____

contractures

If a stroke affects the _____- lobe, the speech center will likely be affected.

temporal

stroke damage also causes emotional ______.

lability (emotional instability)

all pts who have had a stroke, in particular those with ____-_____ brain lesions present a high safety risk. Pts may have poor understanding of their limitations.

right sided

If the frontal lobes are involved in stroke, learned _____ behaviors may be lost.

social (may have personality changes)

the phenomenon of unilateral neglect is seen predominantly in pts who have _____ hemishphere infarcts.

right (so pts need to be taught to be more aware of where their left limbs are located)

a weakness in the wall of a cerebral artery that may be congenital, traumatic or the result of disease.

cerebral aneurysm

where in the brain do most aneurysms occur?

circle of willis (at a bifurcation of an artery)

It is believed that irritation from blood breakdwon after a cerebral aneurysm is the major cause of __________.

vasospasm (a common complication of subarachnoid hemmorrhage caused by anuerysm)

when a cerebral aneurysm ruptures, it causes a

subarachnoid hemmorrhage

some pts experience a small hemorrhage before diagnosis of a subarachnoid hemorrhage. This leakage of blood may cause the following 3 symptoms

mild headache
vomitting
disorientation

the most common presentation of rupture of an aneurysm is

sudden, severe headache (and sensitivity to light)

When someone has a cerebral aneurysm, what is it that causes a decreased LOC?

IICP and impairment of blood flow

other s/sx of cerebral aneurysm are:

seizures
nuchal rigidity
cranial nerves 3 and 6 affected
enlarged pupils, abnormal gaze

What tests are done to diagnose cerebral aneurysm?

CT is done first, then a cerebral angiogram

why is monitoring bp so important after a cerebral aneurysm?

high bp=possibility of re-rupture
low bp=ischmia of brain tissue

There is no cure for subarachnoid hemmorhage. Treatment consists of treating the cause of the hemmorhage by performing a _______.

crainiotomy

what kind of aneurysm has a neck that can be clamped off?

berry aneurysm

why would you wrap steril plastic or muslin around an aneurysm?

to provide stability to keep it from rupturing

pts who have had a cerebral aneurysm are at risk of rebleed until it is _______.

repaired

blood in the ventricular system caused by a cerebral aneurysm interferes with the absorption of CSF and _______ may develop.

hydrocephalus (treated by inserting an external ventricular drain or ventriculoperitoneal shunt)

_______ is responsible for most long term complications of subarachnoid hemorrage due to cerebral aneurysm.

vasospasm

signs/sx of decreased cerebral perfusion:

decreased LOC
irritability or restlessnes
dizziness
syncope
blurred or dimmed vision
diplopia
unequal pupil, sluggish or absent reactions to lt
parestheisa
motor weakness
paralysis
seizures

after a cerebral incident, assess vitals every ______ until stable, then every 4 hours.

30 minutes

elevated glucose is associated with worsening of infarct and hemorrhage, so blood glucose > than _____ should be reported.

140

you should monitor for signs of hemorrhage for ___ to ___ hours following thrombolytic therapy.

24-36

following a stroke, a limb or muscle group can be retaught to function using a technique called ______ therapy.

constraint

when feeding a pt who has had a stroke, you should:

stay with pt during meals
ensure pt is fully alert before feeding
place in high fowlers
avoid use of straws
thicken liquids
place food on unaffected side
teach to swallow twice after each bite
check for pocketing of food
have suction equipment available
avoid foods with multiple textures
give only a 1/2 teaspoon at a time

priority nursing diagnosis for stroke:

ineffective cerebral tissue perfusion
ineffective airway clearance
risk for injury

this group of neurologic conditions is crhonic a nd degenerative in nature.

neuromuscular disorders

neuromusculare disorders involve a disruption of the tranmission of impulses between neurons and the ______they stimulate. This breakdown causes muscle ______.

muscles
weakness

What are the 4 neuromuscular disorders

MS
MG
ALS
GBS

a choronic progresssive degenerative disease that affects the myelin sheath of the neurons in the CNS.

MS

what is responsible for the smooth transmisison of nerve impulses?

myelin

with MS, the myelin sheath begins to break down as a result of activation of the body's ______ system.

autoimmune

With MS, the degeneration of the myelin sheath causes the nerve to become inflamed and causes impulses to the muscles to ____ down.

slow

as MS progresses, the degeneration and slowing of impulses causes _____ or scar tissue that damages the nerves permanentlyl.

sclerosis

eventually in MS, the scar tissue and sclerosis causes nerve impulses to become completely ______.

blocked

MS is thought to be from an autoimmune process, but may also be related to heredity and ______ infection.

viral

the environmental triggers that seem to exacerbate MS are:

extreme hot or cold
fatigue
infection
physical or emotional stress
hormonal changes after pregnancy

the patient with MS presents with

muscle weakness
numbness
tingling sensations
visual disturbances/eye pain

the cause of death from MS is generally due to

respiratory infection

what diagnostic tests are used to detect MS?

CSF analysis for oligoclonal immununoglobulin
MRI
bood test (gms DX) to identify antibodies associated with MS

Early treatment can sometimes delay the progression of MS. _______ therpy may redue exacerbations and delay disability.

interferon

steroids such as adrenocorticotropic hormone and prednisone are given to decrease ______ of the neurons, which may relieve some symptoms of MS.

inflammation

Drug therapies used for MS:

interferon therapy (betaseron, avonex)
adrenocoticotropic hormone (ACTH-decrease inflammation)
prednisone (decrease inflammation)
immunosuppressants (Cytoxan, Imuran)
Dilantin and Tegretol (anticonvulsants help relieve neuropathic pain)

For MS, _______ must be injected daily to help prevent the immune system's attack on the myelin.

Glatiramer

With MS, Natalizumab is adminsitered IV once every ____ weeks to prevent immune cells from moving to the brain and spinal cord.

4

this is done to exchange plasma and remove antibodies from the plasma that may be attacking the myelin in MS.

plasmapharesis

What is the average length of a plasmapharesis procedure?

2-3 hours

When doing plasmapharesis, you should observe the pt for signs of ________.

hypovolemia

studies have shown that ______ can hep preserve muscle strength and exercise tolerance, maintain mobility and improve mood in pts with MS.

exercise

What kind of infection is most dangerous for someone with MS?

respiratory infection

disorder that means "grave muscle weakness"

MG

MG affects the _______ muscles of the body.

skeletal (voluntary)

MS affects the ______ muscles of the body

smooth

MG is a disease of the ___________ junction. (where the neuron releases acetylcholine)

nueromuscular

In MG, the bodies immune system is activated, producing antibodies that attack and destroy _________ receptors at the neuromuscular junction. Hence, there is a loss of voluntary muscle strength.

acetylcholine

MG is a chronic _______ process. No specific cause has been found, although current thought is that a virus may initiate the disease.

autoimmune

disorders of the ____ gland are often associated with MG.

thymus

MG results in extreme muscle weakness. The hallmark of MG is increased muscle weakness during _____ and improvement during _____ periods.

activity
rest

activities affected by MG include

eye and eyelid movements
chewing
swallowing
speaking
breathing

pts with MG often present with ______ and facial expressions are ______ like. After long conversations, the person with MG's voice may fade.

ptosis
mask

pts with MG experience periods of _____ and ______, just like pts with MS.

exacerbation
remission

MG exacerbations can be caused by:

stress
pregnancy
menses
illness
extremes in temperature changes
electrolyte imbalance
surgery
drugs that block action at neuromuscular junct.

major complications associated with MG result from weakness of muscles that assist with _________ and ________.

swallowing
breathing

What are the leading causes of death from MG?

aspiration, resp infections and resp failure

sudden onset of muscle weakness in pts with MG resulting from not enough medication is called a:

myasthenic crisis

overmedications with _________ drugs cause a cholinergic crisis in pts with MG.

anticholinesterase

Symptoms of cholinergic crisis (overmedication) can be identified with the acronym SLUDGE

Salivation
Lacrimation
Urination
Diarrhea
Gastrointestinal cramping
Emesis

a simple test for MG is to have the pt look up for 2-3 minutes. Increased ______ of eyelids occurs is MG is present.

droop (ptosis)

s/sx of myasthenic crisis (too LITTLE medication)

ptosis
dysphagia
dysphasia
dyspnea
weakness

s/sx of cholinergic crisis (too MUCH medication)

increasing muscle weakness
dyspnea
salivation
lacrimation
urination
diarrhea
emesis
increased bronchial secretions
miosis (constriction of pupils)

In addition to the ptosis test for MG, the Tensilon test can be done by injecting Tensilon. If the pt's muscle strength ______ dramatically after injection, MG is diagnosed.

improves

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