Professional Nursing II Ch. 35, 36, 37
Terms in this set (71)
A stroke occurs when part of the brain is damaged due to lack of blood flow.
2 main types of strokes:
Ischemic: a clogged artery results in impaired blood flow. [blood clot or embolism]
Hemorrhagic: a vessel bursts leaking blood into brain tissue and surrounding spaces. [account for only 10% of strokes] *trauma/aneurysms
CVA risk factors
Modifiable risk factors: HTN, high cholesterol, obesity, smoking, alcohol, atheroscelrosis, A. Fib, and other diseases; DM, sickle cell anemia.
Non-modifiable risk factors: Family history, past history of strokes, Age > 65, Men at higher risk [more stoke deaths in women].
Risk factors, current meds (blood thinners)
Symptoms of CVA
-Severe headache, rapid onset [hemorrhagic]
-Weakness or paralysis on one side, dizziness, double vision, loss of balance, facial droop, slurred speech, memory issues, incontinence, fatigue, headaches. [ischemic]
-Aphasia [expressive, receptive, global], dysphagia
-Expressive (Broca's): Pt. knows what they want to say but cannot get words to form. what pt. says does not make sense to us
-Receptive (Wernicke's): unable to understand. Pt. hears gibberish
-Global: both expresive & receptive
-CT scan for quick results
-MRI for better picture, takes 45m-2h to read [BEST! vessels & more]
-Carotid ultrasound can determines blood flow to the brain
-PTT, INR, Hgb, plt, crt, BUN
Return function and independence
Prevention of CVA
Educate the public on risk factors, sign/symptoms
Therapy for CVA
-Can be from stroke, congenital malformation, convulsive disorder, or encephalopathy.
-TBI is a common cause in children where diffuse brain damage as a result of external forces.
-Language problems can be evident even after a small incident
-abnormal growth of brain tissue and meninges
-Intracranial mass; may be malignant or benign; dangerous because occupies space
Spinal Cord Injury causes
Most SCIs are cause by MVA, falls, violence and sports injuries
Prevention education is the key for Spinal Cord Injury
-Sports safety equipment (helmet)
-Alcohol/drug related injuries
-Wearing seat belts, and how to prevent falls
Damage of spinal cord can lead to dysfunction with
Parasympathetic and sympathetic nervous systems, pain, temperature, touch, position sense, motor function, and all body systems.
Upper motor neurons [Spastic paralysis]
-originate in the brain;Suppress the firing of the lower motor neurons.
-Without this suppression, the lower neurons will fire spontaneously, resulting in spasticity.
-Spastic paralyses results due to hyperactive responses to stimuli
Lower motor neurons [Flaccid Paralysis]
-originate in spinal cord; Send impulses to peripheral areas of the body [back to brain].
-Flaccid paralysis occurs from damage to the lower motor neurons.
Spinal Cord: Mechanisms of Injury
-From fracture, or dislocation of vertebrae resulting in compression
-transection or deformity of spinal cord.
Transection of spinal cord
-full flaccid paralysis
-loss of sensation below level of injury
What's the difference between paraplegia and quadriplegia?
-Para: (2)able move two extremities; arms only.
-Quad: (4) unable to move any extremity
Spinal Cord Injuries: What's the difference?
-Complete: Everything below transection will not work.
-Incomplete: Some things will and some won't work.
Level of Injury
Refers to where the injury is; the lowest level of normal functioning.
Cervical Level Injury
-C6 most common
-Loss of function in arms/legs
-Injuries at and above
loss of respiratory function.
Thoracic Level of Injury
-Loss of function in legs
Other Levels of Injury less common
What are the most common areas of spinal injury?
-T11, T12 due to increased movement capabilities in those areas.
Acute Management of injury
-Immobilization of neck/spine
-Questions to ask:
any neck/spinal pain?
stiffness or tenderness?
any alcohol or drug use?
Does the patient have any LOC changes?
Any paralysis or sensory changes? [touch toe].
Complications of Spinal Injury
*Spinal Shock: immediate reaction, a physiological response.
-Results in complete loss of motor and sensory function: movement, bowel/bladder function, reflexes
-Occurs within 1st week of injury up to 6 weeks after, or longer
-Resolves when reflexes return, hyperreflexia happens, or bladder emptying returns.
Spinal Shock: Cervical
- most life threatening,
-Autonomic Nervous System interrupted.
[C4 and above CANNOT breath]
Spinal Shock:Injury above T6
-sympathetic will be lost, parasympathetic will continue.
-What effects will this have? Decreased in: HR, BP, RR as well as Pupils and bronchioles constrict.
Thoracic and lumbar (No spinal shock)
not affected due to low level of injury
Spinal Shock: What to assess?
-Deep Tendon Reflexes (DTRs) are tested to look for complete vs incomplete injury, as well as resolving spinal shock.
-Pay close attention to the patient's fluid level. Why? Because of decrease HR & BP because
vasodilated all the time
-IV fluids [unable to empty bladder]
-TED hose [edema, risk for clots]
-Fluid overload happens fast.
Autonomic Dysreflexia [Patient goes full on "Flight or Flight"]
Happens because the healthy signal to the stimuli cannot transcend the spinal cord, so the sympathetic system is triggered.
Autonomic Dysreflexia can be Life threatening
-Massive discharge of sympathetic responses.
-Triggered by noxious stimuli below level of injury.
-Increased Heart Rate, Increased BP: Red/Diaphorectic above level of injury
Types of Triggers for Autonomic Dysreflexia
-Distended bladder or bowel
-Tight clothing or bedding
Signs/Symptoms of Autonomic Dysreflexia
-Body does the
to get message heard
-Skin above injury level has red blotches
-Sweating above injury level
Treatment is remove trigger
Guillian Barre Syndrome
Acute neuropathy involving motor and sensory nerves in the peripheral system.
-Begins in the legs and spreads to the arms and face.
-Rapid developing and ascending weakness.
-Affects motor function= weakness, and sensory= parasthesia
-Caused by a demylenating process
-Extreme, intense pain affecting Cranial Nerve V
-Pain is unilateral, described as sharp/stabbing/burning.
-A facial spasm (tic) can sometimes accompany the pain.
-No motor or sensory deficits
-Triggers:Eating, talking, draft of air, touch, extreme temps.
Unilateral facial paresis (weakness) that worsens over the first few days, accompanied by pain.
Signs & Symptoms of Bell's Palsy
-inability to blink or close eye
-hypersensitivity to sound.
60-80% fully resolve within weeks to months
An entrapment neuropathy of the median nerve.
Signs & Symptoms of Carpal Tunnel
-Wrist pain [especially at night]
-Weakness of hand/thumb muscles
-Sensory loss [numbing]; primarily in first 3 fingers
-Tinel's sign [tap on median nerve], and Phalen's sign [flex wrist 90 degrees].
Primary: no cause identified;Tension, cluster, migraine.
-Most common type, approx 90% of all headaches.
-Most difficult to treat.
Signs & Symptoms of Tesion Headaches
-pressure/tightness that worsens with activity,
-possibility of sensitivity to light/sound.
-May last weeks, to months, to years.
Vascular in nature
-Assessment: Pain-steady ache to violent throbbing, Pain on one side of the head, worsens with activity
Migraines are preceded by an aura
Signs of Aura
-Educate to avoid triggers
-Uncommon, also vascular in nature.
-Assessment: Rapid onset of pain that
pt from sleep
-Pt is unable to sit still due to pain, usually paces while holding head
-Pain is one sided, usually behind the eye
**Each attack lasts from 15min-2hours. One or more attack a day for 4-12 weeks. Then a pain free period for months to years.
Sudden, uncontrolled discharge of electricity in the brain.
-Usually result of underlying pathology.
-Correct the cause and the seizures resolve.
abnormal motor response, or jerking movements that occurs with seizures
spontaneous, recurring seizures caused by chronic pathology.
Phases of Seizures
Prodromal phase: Signs or activity before a seizure [headache/depression].
-Aural phase: Sensation or warning that a seizure is imminent [Taste, odor, flashing lights, etc.]
-Ictal phase: seizure occurs
-Postictal phase: Immediately following the seizure [Pt is confused, disoriented, may sleep deeply for hours].
Types of seizures
-Generalized: Clonic, Tonic-clonic
-Status Epilepticus:A continuous seizure lasting more than 5 minutes. [[Medical emergency: due to respiratory distress, hypoxia, or anoxia]].
-1st lorazepam/Ativan, [Lorazepam IV push (diluted ! Very thick) push over 2-3 min]
-Chronic inflammatory disease of the CNS, having periods of remission and exacerbation.
-Affects Caucasian females more, ages 20-40
-Inflammatory cells cross the blood/brain barrier and destroy the myelin sheath.
Signs & Symptoms of MS
-Immunosupression drugs to slow disease process
-anticholinergics, etc to treat symptoms
-Take meds every day
Education on exacerbation symptoms and when to notify MD.
Slowly progressing, degenerative neurological disorder.
-Caused by loss of nerve cell function in the basal ganglia, resulting in low dopamine production.
neurotransmitter, responsible for motor function, supporting posture, and voluntary movements.
-Tremor: rhythmic, purposeless, fine trembling/quivering.
-Most commonly seen in fingers and hands, but can also affect entire arm, extremities, and/or facial muscles.
-Difficulty swallowing, speaking
-Malnutrition is a common problem: monitor weight, albumin levels, dysphagia
-Exercise regimen- PT can help maintain muscle strength
-Depression- educate pt and family on the incidence of depression and how the neurotransmitter Serotonin can also be affected.
administration, side effects [Do not miss a dose]
Most common cause of dementia, progressive.
3 stages of Alzheimer's
-Early: deficits may not be recognized, family/friends may notice subtle changes in memory
-Middle: changes in memory, speech, orientation and ability to perform ADLs
-Late: Pt is completely dependent for cares.
-lifestyle changes, as well as mental, emotional and physical needs/changes.
-Teach about meds, side effects, and importance of daily administration.
-Risk for malnutrition- monitor weight, supplements, etc.
-Therapies: PT- exercise can help to reduce weakness and atrophy, SPEECH- help with dysphagia/communication issues, OT- ADL training.
Chronic, autoimmune, progressive, neuromuscular disease.
-Symptoms include abnormal weakness and fatigue of skeletal muscles
-Symptoms worsen with exertion, extreme temps, infection, and menses.
Assessment of Myasthemia Gravis
-double vision (one or both)
-Inability to perform the 6 positions of gaze (vision)
-Weakness of facial muscles: loss of expression, choking, regurgitation of fluid, slurred speech, jaw drop.
-Fine motor movement issues: handwriting, combing hair, climbing stairs, walking, running.
Testing for Myasthenia Gravis
-EMG: assess response of muscles
-CT or MRI: assess the thymus gland
-Tensilon Test: Pt receives IV Tensilon, in pts with M.G there is a rapid improvement in symptoms in 15-30 seconds, and lasts around 5 minutes.
[Montior closely for Heart issues. Monitor heart rate, have Atropine ready to administer if needed].
Treatment for Myasthenia Gravis
-Medications: Anticholinesterase inhibitors [Mestinon, Prostigmin]
MUST be administered on time, or pt may become too weak to swallow pill.
-Surgery: Removal of thymus gland, for 85% of patients this corrects symptoms.