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LP3: Neurologic Disorders/ Stroke
Terms in this set (119)
What is a seizure?
Abnormal episode of motor, sensory, autonomic, or psychic activity (or combo of these) resulting from a sudden electrical discharge from cerebral neurons
What are the three classifications of seizures?
Focal, Generalized & Unknown.
What happens with a focal seizure?
There is an issue with one hemisphere of the brain
What happens with a generalized seizure?
Both hemispheres of the brain are affected.
-Motor aka "grand mal"
What does motor or "Grand mal" mean?
Pt loses control of body
What do they mean by "absence" with seizures?
Typically with children, you'll see them spacing out and staring at a wall or into a corner of a wall.
What is a provoke seizure?
You know what is causing the seizure. It is acute and irreversible.
What are the causes of a provoked seizure?
b. metabolic disorders
c. increased fever
e. all the above
e. all the above
What is the pathophysiology of seizures?
-Hypoxemia (b/c of vascular insufficiency)
-Fever-childhood (above 104 F)
-Head injury (ICP)
-Metabolic&toxic conditions (hyponatremia/hypoglycemia and exposure to pesticides)
-Brain tumor (ICP)
S/S that can indicate a seizure
tongue is chewed
What does tonic-clonic mean?
Possible intense rigidity followed by relaxation
What does epileptic cry indicate?
An unusual cry to the breathing caused by contraction of the diaphragm and chest muscles.
True or False: It is okay to try to grab the tongue from the back of a seizing pt's mouth so that they don't choke and die.
False- The person who is seizing may bite down so hard that they can bite through whatever you stick in their mouth including a finger.
What is a postical state?
It means "after seizure" where the pt is confused and hard to arouse.
What diagnostic assessments can be preformed for seizures?
a. CT scan
Why would we use an MRI?
This is to rule out any brain abnormalities (potential tumors) or structural issues of the brain.
What does an EEG measure/show and how is it done?
An EEG measures brain waves.
You put probes on the brain to test how the brain is firing.
What is the NUMBER 1 thing to do with a pt who had a seizure?
a. Allow them to sleep
b. Observe and time the pt/seizure
c. Rearrange the room so they do not get injured
d. None of the above
B. OBSERVE AND TIME THE PT/SEIZURE
After the pt has had a seizure, what are some things you want to do to manage their seizures in the future?
Observe and document:
-Circumstances before (flashing light/fatigue)
-Aura (pt can sometimes tell when it is coming)
-1st thing pt does in seizure (movement, eye motion)
-Types of movement (be specific)
-Area of body involved (to see what part of brain affected)
-Size of pupils&whether eyes are open
-Involuntary motor activity (smacking lips/repeat swallowing)
-incontinence (urine or stool)
-Unconscious and duration
-Paralysis/weakness post seizure
-Inability to speak post seizure
-Movements post seizure
-Does pt sleep after seizure
-Cognitive status; confused/not confused
What is the BIGGEST thing you want to prevent with a person having a seizure?
After the seizure what are some things you as a nurse should do?
-Document events of seizure (before and after)
-AIRWAY MANAGEMENT IS KEY!!
-Place pt on side
-Suction if necessary
-Bed at lowest position and want padding on side rails
What is the pt at risk for after having a seizure?
a. hypoxia, vomiting & aspirations
b. hypoxia & aspirations ONLY
c. vomiting &aspirations ONLY
a. hypoxia, vomiting & aspirations
What is epilepsy?
Atleast two unprovoked seizures occurring more than 24 hours apart.
What is primary epilepsy?
It is ideopathic, meaning we don't know what causes it.
What is secondary epilepsy?
The cause is known. (ex: Brain tumor)
True or False: Men are more prominent than women to have epilepsy.
False- Women are more prominent to have epilepsy.
What are some gerontologic considerations?
What pharmacologic therapy is there for epilepsy?
Dilantin (phenytion) or tegretol
True or False: It is only important to take this medication prn for seizure activity.
False- Pts should take this medication CONSISTENTLY to PREVENT seizures from occuring.
Inflammation of the meninges that surround the brain and spinal cord.
What are the three major causes of meningitis?
Which of the three major causes of meningitis is the most deadly?
d. They're all just as equally deadly.
Which of the three major causes of meningitis is a person most susceptible during summer&fall?
Which of the three major causes of meningitis is higher in people who use tobacco and have upper respiratory infections, as well as during winter/early spring?
What is the pathophysiology of meningitis?
Through the blood stream into cerebrospinal fluid.
Direct spread. (ex: invasive procedure that can have cross contamination into brain area)
What are some ways you can tell a person has meningitis?
-Neck immobility (nuchal rigidity)
-Positive Kernig (ex: when pt lift leg up & it causes pain)
-Positive Brudzinski (ex: flex head up, the knees come up like wise and causes pain)
-Photophobia (= to severe migraine headache)
With a positive Brudzinski, what is the reason the knees flex when the neck flexes?
The knees flex when the head flexes because the spinal cord is inflamed.
What are some assessment/diagnostic findings for meningitis?
-CT scan (looking for shift of brain contents b/c of inflammation)
-Lumbar puncture (to check cerebrospinal fluid)
When preforming a lumbar puncture, what should the cerebrospinal fluid look like if the person has meningitis?
The fluid will be cloudy if the person has meningitis. (usually CSF is clear)
What type of precautions are the nurses on for pt with meningitis?
What are some nursing managements for a pt with meningitis?
-Infection control for 24 hours after ATB
-Assist with pain
-Rest; quiet darkened room (for migraine)
-Treat elevated temp (tylenol)
-Frequent neuro monitoring
-Protect from seizure due to ICP
What type of ATB would we give to a pt with meningitis?
Usually penicillin-G, cephalosporins, and sometimes use dexamthasone (anti-inflam. steroidal)
What is the MOA of penicillin-G?
Binds to bacterial cell wall, resulting in cell death.
What is Parkinson's disease?
A progressive neurological movement disorder.
True or False: The average age for Parkinson's disease is 50's and is more common in men than in women?
Parkinson's disease is an imbalance between what two neurotransmitters?
Acetylcholine and Dopamine
True or False: With Parkinson's disease, there is an increase in dopamine and a decrease in acetylcholine.
False- There is a decrease in dopamine and acetylcholine takes over. So, we need to get more dopamine back into the body to SLOW things down.
True or False: Parkinson's disease is ideopathic, meaning we do not know the cause of it.
What are the four cardinal signs of Parkinson's disease?
1. Tremor (unilateral when resting. Do not have a tremor with purposeful movement/sleeping)
3. Bradykinesia (slow moving)
4. Postural Instability (slouched over)
What are some other signs of Parkinson's disease that were not discussed?
- Propulsive gait (hard to get going)
- Pill rolling motion with fingers
- Supine and Prone flipping with hands.
What is the biggest problem with Parkinson's disease?
Symptoms don't start to show until about 60% of neurons are lost & dopamine is decreased by 80%.
What are some assessments/diagnostic findings of Parkinson's disease?
Diagnosed through history
Presentation of atleast two of the four clinical manifestations.
What medication is given to help with Parkinson's disease?
What is the pharmacologic class of Carbidopa-levodopa?
What is Carbidopa-levodopa's MOA?
Levodopa- converted to dopamine in the CNS, where it serves as a neurotransmitter
Carbidopa- a decarboxylase inhibitor, prevents peripheral destruction of levodopa
What is the issue with long term use of Carbidopa-levodopa?
It becomes less effective. (sometimes pt do what is called a "drug holiday")
What is a drug holiday?
Start and stop drug to avoid long term use issues and help the drug be more effective.
What S/E should you think about with Carbidopa-levodopa?
If levodopa is what turns into dopamine then why is carbidopa added to levodopa?
So that the levodopa is not metabolized before it reaches the brain.
What are some nursing interventions for people with Parkinson's disease?
-Improve bowel elimination (prone to constipation)
-Improve nutrition (slow with eating)
-Encourage assistive devices (larger cups, heated bowl)
-Improve communication (have long pauses in convos)
-Supporting coping abilities
True or False: Parkinson's is a degenerative disease
What does degenerative disease mean?
Worsens over time.
What is the reason for having bigger cups and heated bowls/plates for meals for a pt with Parkinson's disease?
-Bigger cups so the pt has less issues with spilling.
-Heated bowls/plates because a pt with Parkinson's is slower at eating and we want the food to stay warm during the duration of their meal.
A cerebrovascular disorder is when...
blood supply to the brain is disrupted.
What is the primary cerebrovascular disorder and 5th leading cause of death in the U.S.?
What is a stroke?
"Brain attack" Sudden loss of function resulting from a disruption of the blood supply to a part of the brain.
What are the two types of strokes?
Ischemic and Hemorrhagic
True or False: Ischemic is the most deadly type of stroke.
False: Hemorrhagic stroke is the most deadly type of stroke because there isn't much time to fix it once bleeding starts.
a type of stroke that occurs when the flow of blood to the brain is blocked.
occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed.
Which type of stroke is most common?
c. They're both equal
With an Ischemic stroke, what is the window of time you have to treat it?
a. 30 minutes
b. 2 hours
c. 3 hours
d. none of the above
c. 3 hours; can be up to 4.5 hours
What is the issue with someone having a stroke after sleeping?
Can't figure out the last known "normal behavior" for a person to figure out their window of time.
An ischemic stroke is usually caused by...
thrombus or embolism
What is a thrombus?
What is an embolus?
a blood clot that has broken loose and is floating freely in the blood stream.
What are some types of Ischemic strokes?
-Large artery thrombosis (plaque build up)
-Small penetrating artery thrombosis (small lacunar strokes; small area of brain affected)
-Cardiogenic embolism (starts in heart and travels through the blood stream)
-Cryptogenic (no known cause)
What are some examples of cardiogenic embolisms?
-Afib (heart not pumping effectively and prone to clot formation)
Manifestations of Ischemic strokes....
-Numbness/weakness of face, arm, or leg. (especially on 1 side)
-Confusion/change in mental status.
-Trouble speaking/understanding speech.
-Difficulty walking, dizziness, or loss of balance/coordination.
-Sudden, severe headaches. (worry about hemorrhagic)
-Perceptual disturbances. (glass looks further away than it is)
Name the three non-modifiable risk factors of an ischemic strokes.
Age (older than 55 years), male gender, and African Americans.
Name the modifiable risk factors of an ischemic stroke.
-Elevated cholesterol or elevated hematocrit
-Oral contraceptive use
-Smoking, drugs, and alcohol abuse
weakness on one side of the body
difficulty forming words
What are the two types of aphasia?
expressive and receptive
expressive aphasia (Broca's aphasia)
Partial loss of ability to produce language (spoken, manual, written)
Difficulty understanding spoken/written language.
Blindness in half the visual field.
Inability to recognize familiar objects.
A mixture of both expressive and receptive aphasia is called...
What happens if the frontal lobe is affected during a stroke?
Memory and comprehension is affected. Also, may not recognize people you know.
Transient Ischemic Attach (TIA)
Temporary neurologic deficit resulting from a temporary impairment of blood flow. (WARNING SIGN OF AN IMPENDING STROKE)
What are some things you will see in a pt with a TIA?
Facial droop or numbness in arm for 1-2 hours.
What are some diagnostics we will do with a pt who had a TIA?
-ECG (to rule out afib)
-CT scan (if CT scan is negative and ICP isn't elevated to confirm subarachnoid hemorrhage, then will preform a lumbar puncture)
-Carotid ultra sound
True or False: The care we give to a pt with a stroke is primarily supportive care; bed rest with sedation and oxygen.
True or False: Ischemic stroke is primarily dealing with a bleed.
False- It is dealing with emboli.
What is important with knowing about HTN when it comes to an ischemic stroke?
-Need to know how high BP is. Sometimes it is okay for a bit higher BP b/c if there is a clot, higher BP will help that blood sneak past that clot. If you slow the BP, then it might make it harder for that blood to get past. (HEMORRHAGIC STROKE IS A DIFF. STORY)
Prevention/Secondary Prevention with strokes..
- Health maintenance measures (healthy lifestyle, not smoking, exercise, healthy diet/weight)
-Carotid endarterectomy (for carotid stenosis)
-Anticoagulant therapy (for afib)
-Antiplatelet therapy (ex: Clopidogrel, Plavix)
-"Statins" (for high cholesterol)
What is a carotid endarterectomy?
Open carotid and clean out plaque.
What is some medical management for an ACUTE PHASE of stroke?
-Prompt diagnosis and treatment
-Assess stroke (NIHSS assessment tool)
-Thrombolytic therapy (to break up clot)
-Elevate head of bed unless contraindicated
-Maintain airway and ventilation
-Cont'd. hemodynamic monitoring and neurologic assessment.
What are two scales to use for neurologic assessment of strokes?
Stroke scale and Glasgow coma scale.
What is a hemorrhagic stroke?
Caused by bleeding into brain tissue, the ventricles, or subarachnoid space.
True or False: Hemorrhagic strokes are the most deadly type of stroke and have a 50% mortality rate.
What are some causes for a hemorrhagic stroke to occur?
-Spontaneous rupture of small vessels (primarily r/t HTN)
-Subarachnoid hemorrhage (ruptured aneurysm)
-Intracerebral hemmorhage (amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants b/c blood is too thin.
What are some manifestations in hemorrhagic stroke pts?
-Similar to ischemic stroke
-Early and sudden changes in level of consciousness (LOC)
What is the difference between Ischemic and Hemorrhagic stroke?
Ischemic occurs when a blood vessel supplying blood to the brain is obstructed.
Hemorrhagic occurs when a weakened blood vessel ruptures.
What kind of assessments are done with a pt who is recovering from an Ischemic stroke; acute phase?
-Ongoing, frequent monitoring all systems including vitals and neurologic exam
-Motor symptoms (bilateral)
What are some cares done for Ischemic stroke; post acute phase?
-Swallowing ability (may get permanent feed tube)
-Bowel&Bladder function (may need rectal stim.)
Pt recovering from an Ischemic stroke may have the following DX...
-Impaired physical mobility
-Impaired comfort r/t disturbed sensory perception
-Impaired verbal communication
-Risk for impaired skin integrity
-Interrupted family processes
What are some complications associated with strokes?
-Decreased cerebral blood flow
-Inadequate O2 delivery to brain
-Pneumonia (can be aspiration pneumonia)
How might someone who had a stroke get pneumonia?
Lost cough reflex or being immobile
What are some major goals for the pt that is recovering from a stroke?
-Avoidance of shoulder pain
-Achievement of self-care
-Relief of sensory/perceptual deprivation
-Prevention of aspiration
-Continence of bowel and bladder
-Improved thought processes
-Achieving a form of communication
-Maintaining skin integrity
-Restored family functioning
-Improved sexual function
-Absence of complications
What are some interventions you would focus on for a pt who had a stroke?
-FOCUS ON WHOLE PERSON
-provide interventions to prevent complications and promote rehabilitation
-provide support and encouragement
-listen to the patient
What are some ways to improve mobility and prevent joint deformities for pts who had a stroke?
-Turn and position in correct allignment q2h
-Passive/Active ROM qid or 5 times daily
-Positioning of hands and fingers
-Prevention of flexion contractures
-Prevention of shoulder abduction
-DO NOT lift by flaccid shoulder
-Measures to prevent and treat shoulder problems
-Encourage pt to exercise unaffected side
-Est. reg. exercise routine
-Quad setting and gluteal exercises
-Assist pt out of bed asap; assess&help pt achieve balance; move slowly
Interventions for hemorrhagic stroke...
-Strategies to enhance communication
-Encourage pts to turn head, look to side w/ visual field loss
How might you enhance self care for a pt?
*Set realistic goals with pt
*Encourage personal hygiene
*Ensure pt doesn't neglect the affected side
*Use of assistive devices and modify clothing
When focusing on nutrition for a pt with a stroke, what might you do for that?
*Consult w/ speech therapy/nutritional services
*Have pt sit up, preferably out of bed, to eat
*Chin tuck or swallow method
*Use of thickened liquids or pureed diet
For bowel and bladder control, what might you do to help the pt who had a stroke?
*Assessment of voiding and scheduled voiding
*Measures to prevent constipation; fiber, fluid,
*Bowel and bladder retraining
What are some things you could educate the pt who had a stroke on?
-Prevention of subsequent strokes, health promotion, and follow-up care
-Prevention of and S/S of complications
-Safety measures (High fall risk)
-Adaptive strategies and use of assistive devices for ADL's
-Nutrition (diet, swallowing techniques, tube feeding administration)
-Elimination (bowel/bladder program)
-Exercise and activities, recreation and diversion
-Socialization, support groups, and community resources
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