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Med Surg Neuro 2

STUDY
PLAY
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
one tx for MG is to remove the ____ gland, which can decrease production of acetylcholine receptor antibodies and decrease symptoms in some pts.
thymus
Meds used to treat MG are:
anticholinesterase drugs (destroy the actylcholinesterase that breaks down aCh)
drug names: Prostigmin, Mestinon
(PREDNISONE, IMMUNOSUPPRESANTS AND PLASMAPHARESIS ARE ALSO USED)
You should schedule anticholinesterase drugs so that peak action occurs at times when increased _____ _______ is needed.
muscle strength
With MG, teach the pt to rest in between activities so muscle _____ has time to be restored.
strength
Many medications can _____ muscle weakness due to MG, therefore, have all meds checked by an MD before taking.
exacerbate
medications that can exacerbate MG:
antibiotics
interferon
neuromuscular blocking agents used in anesthesia
prednisone
beta and calcium channel blockers
anticholinergic drugs
ALS is also called
Lou Gherig's disease
a progressive, degenerative condition that affects motor neurons responsible for the control of voluntary muscles.
ALS
In ALS, the neurons degenerate in the brain and spinal cord and form scar tissue or die, ______ transmission of nerve impulses.
blocking
In ALS, muscles don't get stimulated due to lack of receiving impulses and they begin to _____.
atrophy
The heart and gastrointestinal tract are not affected by ALS, as well as the ability to ______ and reason.
think
ALS generally appears in _______, although a specific cause is unknown. It's thought to be a genetic predisposition.
adulthood
life expectancy after diagnosis of ALS is ___ to ____ years.
2-5 (although in SOME pts, the disease slows or stops progressing completely)
what are the primary, vague symptoms noted with ALS
progressive muscle weakness
decreased coordination
the twitching of muscles that is seen with ALS is called
fasciculations
what causes the pain r/t ALS?
muscle spasms
bladder and bowel functions remain intact with ALS. True or false?
true
Late in the disease of ALS _______ is necessary if wanted by the pt.
mechanical ventilation
ALS eventually leads to death from _______ complications such as atelectasis, resp failure and pneumonia.
respiratory
tests done to detect ALS:
CSF analysis
EEG
nerve biopsy
nerve conduction velocity
EMG
blood enzymes may increase due to muscle atrophy
goals of tx for ALS include improving function as long as possible and ________ supporting the pt and family through the illness.
emotionally
What 2 drugs are given to relieve muscle spasms in pts with ALS
baclofen
valium
What is the drug name used for ALS that may prolong life by slowing the progression of the disease?
Rilutek
GBS is also called:
acute inflammatory polyneuropathy
this disorder is characterized by abrupt onset of symmetrical weakness that progresses to paralysis. Myelin is destroyed by inflammation caused by infiltrations of lymphocytes in the nerves.
GBS
In GBS, segmental ______ causes atrophy of the axons resulting in slowed or blocked nerve conduction. This typically starts in the most distal nerves and ascends symmetrically.
demyelination
this occurs in a descending pattern and is accompanied by the resolution of symptoms of GBS.
remyelination
Four variants of GBS are:
ascending GBS (most common)
descending GBS
Miller Fisher syndrome
pure motor GBS
with acending GBS, there are no deep tendon _______ presnet.
present
Where does descending GBS originate?
brainstem (resp compromise is rapid)
In Miller Fisher syndrom, a variant of GBS, there is no _____ compromise or sensory loss. Symptoms are usually ataxia, absence of reflexes and paralysis of extraocular muscles.
respiratory
pure motor GBS is considered to be a milder form of _____ GBS except there is no numbness or muscle weakness.
ascending
GBS is thought to be caused by an ______ response to some type of viral infection (resp or gastrointestinal 2 weeks prior to symptom onset) or to certain vaccines.
autoimmune
What are the 3 stages of GBS?
1. onset of symptoms-progression of symptoms stop
2. abrupt and rapid onset of muscle weakness and paralysis.
3. recovery phase (remyelination occurs)
Which types of GBS probably would require resp support?
ascending and descending
how is need for resp support assessed in pts with GBS
monitoring ABG's
The _______ nervous system is often affected by GBS, causing labile vital signs, dysrhythmias, urine retention and paralytic ileus.
autonomic
the recovery phase of GBS can last anywhere from ___ to ____ months
6-24
pts with GBS are prone to _____ and ______.
uti's
pneumonia
What tests are done to confirm GBS?
lumbar puncture with CSF that shows elevated protein levels
EMG
nerve conduction velocity tests
pulmonary function tests
plasmapharesis is one treatment for GBS but must be started within ______ days of symptom onset.
7-14
______ are not considered to helpful and may even be harmful in the tx of GBS.
steroids
postpolio syndrome involves a further weakening of the muscles that were affected with the first involvement with the poliovirus. T or F?
true
cranial nerves are the ______ nerves of the brain.
peripheral
(problems with the crainial nerves are called peripheral neuropathies)
What are 2 common crainial nerve problems?
trigeminal neuralgia (tic doulourex)
bell's palsy
What nerve does trigeminal neuralgia affect?
the 5th cranial nerve
What portion of the nerve is affected in TN?
the sensory portion
with TN, irritation or chronic _______ of the nerve is suspected to initiate symptoms.
compression
intense episodes of ____characterize TN.
pain
Pain from TN is felt in the skin on one side of the face. Triggers for the pain include:
touch, cold breeze, talking, chewing
areas affected by TN include:
lips, gums, cheeks, forehead, side of nose, frequent blinking or tearin of eye on affected side
What provides relief from the pain associated with TN?
sleep
CT scans and MRI are used to rule out other causes of pain from TN. T or F?
true
What drugs are used to reduce transmission of painful nerve impulses r/t TN?
Dilantin, Neurotin, Tegretol (anticonvulsants)
Baclofen (muscle relaxant)
injections of alcohol in painful areas
nerve block with local anisthetic
a nerve block for TN usually lasts how long?
8-16 months
What are 2 surgeries that can be performed to relieve TN?
radio frequency ablation
gamma knife radio surgery
after a nerve block or ablation for TN, the pt should be taught to _____ the anethsetized areas of the face.
protect
Bells palsy affects the ____ cranial nerve causing inflammation and nerve interruption. Thought to caused by nerve trauma due to a _____ infection such as herpes simplex or herpes zoster.
7th
viral
bells palsy generally affects both sides of the face. T or F
false. Bells Palsy affects only one side of the face.
If recovery from Bell's Palsy is slow, facial muscle _______ may occur.
contracture
Bell's Palsy is more common in:
women in 3rd trimester
ppl with autoimmune disease like AIDS
ppl with diabetes
What are some of the vague intial symptoms of Bell's Palsy?
pain behind the ear
dry eye
tingling around lips
With BP, the mouth is pulled toward the ______ side.
unaffected
sense of taste is lost over _____ of the tongue in BP.
2/3rds
What must be ruled out before a diagnosis of BP can be made?
stroke
What is the goal of tx for bell's palsy?
prevention of complications
(prednisone and analgesics given)
moist heat and gentle massage are helpful
the complications of TN and BP are the same. They are:
corneal damage
poor nutrition
depression
nursing diagnosis for TN and BP are:
acute pain
imbalanced nutrition: less than body req.
risk for injury to eye