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
this kind of stroke occurs when the blood supply to the brain is blocked or significantly slowed
this stroke occurs when an occlusion builds up in an artery until it significantly decreases or stops blood to the brain
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.
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
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.
THIS TYPE OF STROKE OCCURS IN THE DEEPER TISSUES OF THE BRAIN AND USUALLY IS CAUSED FROM UNCONTROLLED HYPERTENSION.
A patient can have multiple undetected instances of this, with minimal deficits noted. However, damage will eventually accumlate and major defecits will develop.
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
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 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.
deficits of stroke may appear in both sides of the body if the stroke was a _______stroke
brainstem or vertebrobasilar
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?
what side of the body do visual distrubances occur after a stroke?
the SAME side as the brain damage.
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
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
Initial emergent care of a stroke is _____ while test results are pending. ABC's are monitored.
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.
When must thrombolytic therapy be given to prevent permanent brain damage?
within 3 hours of symptom onset
thrombolytics are associated with a significant risk of __________, so all risk of bleeding must be ruled out before these drugs will be considered.
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
When permissive hypertension is allowed to help perfuse infarcted brain tissue, when are antihypertensives given?
according to the ASA, pts who have had a TIA should receive antiplatelet therapy how soon after symptom onset?
procedure done in patients with significant carotid artery occlusion to remove the carotid occlusion
If a pt is no a good candidate for a carotid endarterectomy, a carotid _____ may be placed during a carotid angiogram.
paresthesia and paralysis are common long term effects of strokes that were not treated with a ________ agent.
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
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.
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.
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)
some pts experience a small hemorrhage before diagnosis of a subarachnoid hemorrhage. This leakage of blood may cause the following 3 symptoms
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:
cranial nerves 3 and 6 affected
enlarged pupils, abnormal gaze
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 _______.
why would you wrap steril plastic or muslin around an aneurysm?
to provide stability to keep it from rupturing
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.
signs/sx of decreased cerebral perfusion:
irritability or restlessnes
blurred or dimmed vision
unequal pupil, sluggish or absent reactions to lt
elevated glucose is associated with worsening of infarct and hemorrhage, so blood glucose > than _____ should be reported.
you should monitor for signs of hemorrhage for ___ to ___ hours following thrombolytic therapy.
following a stroke, a limb or muscle group can be retaught to function using a technique called ______ therapy.
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
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
neuromusculare disorders involve a disruption of the tranmission of impulses between neurons and the ______they stimulate. This breakdown causes muscle ______.
a choronic progresssive degenerative disease that affects the myelin sheath of the neurons in the CNS.
with MS, the myelin sheath begins to break down as a result of activation of the body's ______ system.
With MS, the degeneration of the myelin sheath causes the nerve to become inflamed and causes impulses to the muscles to ____ down.
as MS progresses, the degeneration and slowing of impulses causes _____ or scar tissue that damages the nerves permanentlyl.
eventually in MS, the scar tissue and sclerosis causes nerve impulses to become completely ______.
MS is thought to be from an autoimmune process, but may also be related to heredity and ______ infection.
the environmental triggers that seem to exacerbate MS are:
extreme hot or cold
physical or emotional stress
hormonal changes after pregnancy
the patient with MS presents with
visual disturbances/eye pain
what diagnostic tests are used to detect MS?
CSF analysis for oligoclonal immununoglobulin
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.
steroids such as adrenocorticotropic hormone and prednisone are given to decrease ______ of the neurons, which may relieve some symptoms of MS.
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.
With MS, Natalizumab is adminsitered IV once every ____ weeks to prevent immune cells from moving to the brain and spinal cord.
this is done to exchange plasma and remove antibodies from the plasma that may be attacking the myelin in MS.
studies have shown that ______ can hep preserve muscle strength and exercise tolerance, maintain mobility and improve mood in pts with MS.
MG is a disease of the ___________ junction. (where the neuron releases acetylcholine)
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.
MG is a chronic _______ process. No specific cause has been found, although current thought is that a virus may initiate the disease.
MG results in extreme muscle weakness. The hallmark of MG is increased muscle weakness during _____ and improvement during _____ periods.
pts with MG often present with ______ and facial expressions are ______ like. After long conversations, the person with MG's voice may fade.
MG exacerbations can be caused by:
extremes in temperature changes
drugs that block action at neuromuscular junct.
major complications associated with MG result from weakness of muscles that assist with _________ and ________.
sudden onset of muscle weakness in pts with MG resulting from not enough medication is called a:
Symptoms of cholinergic crisis (overmedication) can be identified with the acronym SLUDGE
a simple test for MG is to have the pt look up for 2-3 minutes. Increased ______ of eyelids occurs is MG is present.
s/sx of cholinergic crisis (too MUCH medication)
increasing muscle weakness
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.
one tx for MG is to remove the ____ gland, which can decrease production of acetylcholine receptor antibodies and decrease symptoms in some pts.
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.
With MG, teach the pt to rest in between activities so muscle _____ has time to be restored.
Many medications can _____ muscle weakness due to MG, therefore, have all meds checked by an MD before taking.
medications that can exacerbate MG:
neuromuscular blocking agents used in anesthesia
beta and calcium channel blockers
a progressive, degenerative condition that affects motor neurons responsible for the control of voluntary muscles.
In ALS, the neurons degenerate in the brain and spinal cord and form scar tissue or die, ______ transmission of nerve impulses.
In ALS, muscles don't get stimulated due to lack of receiving impulses and they begin to _____.
The heart and gastrointestinal tract are not affected by ALS, as well as the ability to ______ and reason.
ALS generally appears in _______, although a specific cause is unknown. It's thought to be a genetic predisposition.
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
ALS eventually leads to death from _______ complications such as atelectasis, resp failure and pneumonia.
tests done to detect ALS:
nerve conduction velocity
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.
What is the drug name used for ALS that may prolong life by slowing the progression of the disease?
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.
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.
this occurs in a descending pattern and is accompanied by the resolution of symptoms of GBS.
Four variants of GBS are:
ascending GBS (most common)
Miller Fisher syndrome
pure motor GBS
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.
pure motor GBS is considered to be a milder form of _____ GBS except there is no numbness or muscle weakness.
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.
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)
The _______ nervous system is often affected by GBS, causing labile vital signs, dysrhythmias, urine retention and paralytic ileus.
What tests are done to confirm GBS?
lumbar puncture with CSF that shows elevated protein levels
nerve conduction velocity tests
pulmonary function tests
plasmapharesis is one treatment for GBS but must be started within ______ days of symptom onset.
postpolio syndrome involves a further weakening of the muscles that were affected with the first involvement with the poliovirus. T or F?
cranial nerves are the ______ nerves of the brain.
(problems with the crainial nerves are called peripheral neuropathies)
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 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
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.
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.
bells palsy generally affects both sides of the face. T or F
false. Bells Palsy affects only one side of the face.
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
tingling around lips
What is the goal of tx for bell's palsy?
prevention of complications
(prednisone and analgesics given)
moist heat and gentle massage are helpful