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Neurosensory: Stroke and Brain Tumors. Part #1 Stroke (Brain attack/CVA). A. Pathophysiology/etiology Normal brain physiology and stroke. Ranks 3 rd as cause death Blood supply to one hemisphere is typically blocked, hence terms right & left stroke

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Neurosensory stroke and brain tumors

Neurosensory: Stroke and Brain Tumors

Part #1 Stroke (Brain attack/CVA)


A pathophysiology etiology normal brain physiology and stroke
A. Pathophysiology/etiology Normal brain physiology and stroke

  • Ranks 3rd as cause death

  • Blood supply to one hemisphere is typically blocked, hence terms right & left stroke

  • Functioning brain depends on continuous blood supply for oxygen and glucose & remove end products metabolism


Risk factors for stroke

Hypertension

Heart disease

Atherosclerosis

Diabetes mellitus

Medications: birth control pills, substance abuse- cocaine, heroin

Sedentary life style

Obesity

High cholesterol diet

Smoking

Stress

Age > 65 yrs

Sickle cell disease

Risk factors for stroke


Brain dysfunction length of time without blood supply
Brain dysfunction & length of time without blood supply

  • Brain function depends on collateral circulation and amount of cerebral edema

  • TIA- neuro deficits last < 24 hrs

  • RIND- neuro deficits last > 24 hrs but reverse not greater than 21 days

  • CVA- irreversible brain damage with residual neuro deficits

  • Stroke-in-evolution- progressive neuro deficits developing over hours or days. Usual cause thrombosis


Disease process

Ischemic stroke

Occlusion of artery

Generally do not lose consciousness

Better prognosis than hemorrhagic

May have TIA’s before

Thrombosis or embolism

Hemorrhagic stroke

Bleed occurs with activity

Usually rapid onset

Generally loss of consciousness

Poorer prognosis

Intracranial or subarachnoid

Disease process


Ischemic stroke thrombosis
Ischemic stroke Thrombosis

  • Most common cause of a stroke

  • Cause- narrowing of artery from atherosclerotic plaques

  • Blood is blocked to part of brain that the artery supplies

  • Often occurs in older individuals who are at rest/sleeping

  • Tend to form in large arteries that bifurcate, internal carotid artery common site

  • Can begin as TIA’s, present as stroke-in-evolution, or have completed stroke outright


Ischemic stroke embolism
Ischemic stroke Embolism

  • Caused by: clotted blood from other arteries in the body (heart during atrial fibrillation) fat, bacteria (endocarditis) or air

  • Emboli circulate until reach an artery in brain that is too narrow to pass through

  • Usually awake with rapid onset

  • Extent damage is less severe and recovery faster than other strokes


Hemorrhagic stroke intracranial hemorrhage ich
Hemorrhagic stroke Intracranial hemorrhage (ICH)

  • Caused by ruptured artery in the brain

  • Bleeding varies in size from petechial to massive, edema occurs around the bleed

  • Blood may form hematoma or be diffuse within the brain

  • Usually occurs rapidly with the deep arteries

  • Hypertension is main cause

  • Most common cause of death due to a stroke

  • Have more extensive residual deficits and slower recovery than other causes of stroke


Hemorrhagic subarchnoid hemorrhage sah
Hemorrhagic Subarchnoid hemorrhage (SAH)

  • Caused by bleeding into subarchnoid space from

    • Extension of a intracranial hemorrhage

    • Aneurysm

    • AV malformation





Middle cerebral artery1
Middle cerebral artery

  • Contralateral motor loss in the arm and the lower part of the face (central facial palsy)

  • Contralateral sensory loss in face and arm

  • Homonymous hemianopsia

  • Left middle-communication deficits

  • Right- spatial/perceptual


Vertebral artery
Vertebral artery

  • Pain or numbness of involved side

  • Vertigo

  • Contralateral ataxia

  • Dysphagia, dysarthria

  • Cranial nerve dysfunctions


Motor deficits
Motor deficits

  • Motor nerve pathways cross in the medulla (brainstem) Prefix hem- used to describe

  • Amount of motor involvement varies from weakness (-paresis) to paralysis (-plegia).

  • End paralysis can be flaccid or spastic depending on amount of damage to the motor strip

  • Initially flaccid and if progress spastic in 6-8 weeks.


Motor deficits1
Motor deficits

  • Characteristic body posture


Motor deficits2
Motor deficits

  • Facial palsy- (central/UMN) where lower part face affected

  • Bells palsy (LMN- 7th CN) where the whole side of face affected


Elimination deficits
Elimination Deficits

  • Partial loss of sensation (hemi) can affect perception of need to eliminate bowel/bladder

  • Cognitive problems may affect the social aspect of elimination

  • Level of consciousness, immobility, dehydration, diet changes


Sensory perceptual deficits lack of sensation propriocetion
Sensory-perceptual deficits Lack of sensation/propriocetion

  • Lack of sensation (hemi)- inability to perceive/interpret pain, touch, pressure( post central gyrus)

  • Lack of/decrease in proprioception or the inability to know where body part is without having to look at it; body’s ‘position sense’


Sensory perceptual deficits visual field deficits
Sensory-perceptual deficits Visual field deficits

  • Disruption anywhere along the pathway

  • Homonymous hemianopsia- most common. Loss of half of visual field in each eye. Can’t see toward the same side as the paralysis


Sensory perceptual deficits agnosia apraxia

Inability of the senses to perceive stimuli that were previously familiar.

May be any of the senses and varying degrees

Inability to carry out purposeful task in the absence of paralysis

or the individual carries out task inappropriately

Sensory-perceptual deficits: Agnosia Apraxia


Sensory perceptual deficits neglect syndrome unilateral neglect
Sensory-perceptual deficits previously familiar. Neglect syndrome (unilateral neglect)

  • Attention disorder in which individual ignores affected part of the body,

  • Cannot integrate or use perceptions from affected side

  • More common in right CVA’s


Communication deficits
Communication Deficits previously familiar.

  • Motor, speech, language, memory, reasoning, emotions can be affected

  • Dominant hemisphere for the brain centers is left in most individuals

  • Global (mixed) aphasia- both expressive and receptive aphasia

  • Dysarthria- difficulty with articulation or muscular control for speech. Sound like have mashed potatoes in their mouth


Communication deficits broca s and wernicke s aphasia
Communication Deficits previously familiar. Broca’s and Wernicke’s aphasia

  • Broca’s, expressive or nonfluent aphasia where unable to express- understands

  • Wernicke’s, receptive, fluent aphasia where unable to understand



Communication deficits normal process recovery
Communication Deficits previously familiar. Normal process recovery

  • Begin with one word speech- swearing, ‘ouch’

  • Progress to sayings – days of week, social speech, singing

  • Volitional- normal speech

  • Recovery may stop at any point


Cognitive and behavioral deficits
Cognitive and behavioral deficits previously familiar.

  • Change level consciousness- confusion to coma

  • Emotional liability

  • Loss of self control, decrease tolerance for stress

  • Intellectual changes resulting in memory loss, decreased attention span, poor judgment, inability to think abstractly


C therapeutic interventions diagnostic tests
C. Therapeutic interventions previously familiar. Diagnostic tests

  • CT/MRI- bleeding, edema, tissue necrosis, shifting intracranial contents

  • Arteriogram- abnormal structures; vasospasm, stemosis

  • PET- cerebral blood flow and metabolic activity

  • Transcranial ultrasound doppler velocity of blood flow, degree of occlusion

  • Lumbar puncture- obtain CSF, bleeding


Therapeutic interventions rehabilitation
Therapeutic interventions previously familiar. Rehabilitation

  • Outpatient or in-house

  • Physical therapy

  • Occupational therapy

  • Speech therapy

  • Cognitive therapy


Therapeutic interventions thrombolitic stroke
Therapeutic interventions previously familiar. Thrombolitic stroke

  • Medication

    • Thrombolitic agents to dissolve clot- 3 hrs!!!

    • Anticoagulants to prevent further extension

    • Antithrombolitic inhibit platelet phase of clot formation

    • Anticonvulsants

  • Surgical

    • Endarterectomy

    • Angioplasty, carotid artery stenting

    • Bypass superficial temporal to middle cerebral


Therapeutic interventions embolic intracranial stroke
Therapeutic interventions previously familiar. Embolic/intracranial stroke

  • Embolic stroke

    • Medications: If blood clot- anticoagulants, thrombolitic agents, antiarrhythmics; If bacterial- antibiotics

  • Intracranial hemorrhage (ICH) stroke

    • Bedrest

    • Medication- antihypertensives to normal BP

    • Surgery- remove hematoma if possible


D nursing assessment specific to stroke health history physical exam
D. Nursing assessment specific to stroke previously familiar. Health history & physical exam

  • Health history-

    • Risk factors; when symptoms began; describe symptoms; current medications (legal/illegal); other health problems

  • Physical exam-

    • Vital signs; neuro vital signs (LOC, pupils, motor, sensory); continued next slides


Nsg assess neuro deficits common in stroke motor
Nsg assess- neuro deficits common in stroke previously familiar. Motor

  • Movement, strength (with & without resistance), symmetry of all extremities

  • Pronator drift- detects weakness of upper extremity. Hold arms, palms up in front with eyes closed- should be able to hold for 30 seconds. Weakness pronates and drifts downward

  • Use similar techniques used to assess motor SCI- motor pathways affected begin motor strip brain

  • Test facial movement- smile/frown test for Bell’s (7th CN) and central facial (motor strip)


Nursing assess neuro deficits common stroke motor
Nursing assess- neuro deficits common stroke previously familiar. Motor

  • EOM’s- head still, follow your finger in all quadrants. Eyes should move together (conjugate gauze) Abnormal: dysconjugate gauze; nystagmus; 3rd nerve palsy (occulomotor); 6th nerve palsy (abducens)


Nursing assess neuro deficits motor 3 rd nerve palsy 6 th nerve palsy
Nursing assess neuro deficits: Motor previously familiar. 3rd nerve palsy 6th nerve palsy


Nursing assess neuro deficits common stroke motor1
Nursing assess- neuro deficits common stroke previously familiar. Motor

  • Assess ability to void and move bowels

  • Assess communication ability

  • Assess cognitive and behavioral aspects


Nursing assess neuro deficits common stroke sensory deficits
Nursing assess-neuro deficits common stroke previously familiar. Sensory deficits

  • Superficial sensation

  • With paperclip and eyes closed alternate sharp and dull ends

  • Reference is the sensory strip on the parietal side


Nursing assess neuro deficits common stroke sensory visual field loss common homonymous hemianopia
Nursing assess- neuro deficits common stroke previously familiar.Sensory- visual field loss common- homonymous hemianopia

  • Patients’ head in still position & cover one eye- test one at time

  • Move your wiggling finger into the patients field of vision- in all 6 quadrants

  • State when 1st sees


Nursing assess neuro deficits common stroke sensory
Nursing assess- neuro deficits common stroke previously familiar. Sensory

  • Proprioception-

    position sense

  • With eyes closed and hoding the toe on the sides, move toe up & down (not touching the other toes), stop- then ask is toe up or down


Nursing assess neuro deficits common stroke sensory perceptual
Nursing assess- neuro deficits common stroke previously familiar. Sensory-perceptual

  • Visual agnosia: individual becomes lost on unit; cannot read sign/symbols; difficulty estimating distance (spills food); cannot find objects; does not recognize faces on photo or own image

  • Auditory agnosia: ind appears bewildered by sounds; and does not respond approp- phone ringing; can’t identify sound as running water

  • Tactile agnosia- with eyes closed can’t recognize familiar objects- comb, pencil; unaware location; diff positioning self- slouches to one side


Nsg assess neuro deficits common stroke sensory perceptual
Nsg assess- neuro deficits common stroke previously familiar. Sensory-perceptual

  • Apraxia- stares at food tray unaware of how to get food to mouth; combs hair with toothbrush; puts shirt on legs

  • Unilateral neglect; ignores paralyzed arm or leg; may claim it is not theirs; bumps into wall as going down hall; unaware of objects place on paralyzed side


Nursing assessment specific to stroke national institute health nih stroke scale
Nursing assessment specific to stroke previously familiar. National institute health (NIH) stroke scale

  • An assessment scale to reflect the degree of neurologic dysfunction specifically for stroke

  • A high score correlates with a large stroke

  • Based on level of consciousness, gaze, visual, facial palsy, motor, ataxia, sensory, language, dysarthria, and extinction and inattention (neglect)

  • http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf


E nursing problems interventions 1 ineffective tissue perfusion cerebral
E. Nursing problems/interventions previously familiar. 1. Ineffective tissue perfusion (cerebral)

  • Monitor resp status; provide O2; suction needed

  • Monitor neuro, specifically increasing neuro deficits, seizures, and ICP; HOB 30 degrees

  • Monitor cardiac status, esp dysrhythmias

  • If individual unconscious- coma care


Nursing problems interventions 2 impaired physical mobility
Nursing problems/interventions previously familiar. 2. Impaired physical mobility

  • Encourage active (when possible)& passive ROM

  • Change position every 2 hrs, esp if comatose

  • Monitor/prevent thrombophlebitis

  • Work with Rehab team

  • Arm sling- used to prevent subluxation of the shoulder from a paralyzed arm when OOB

  • Splints- hand/foot to prevent contractures; set up schedule- on 2 hrs off 2 hrs- use ROM


Nursing problems interventions 3 self care deficit
Nursing problems/interventions previously familiar.3. Self-care deficit

  • Eourage use of paralyzed extremity

  • Teach dsg tech- affected arm in clothing first

  • Work with rehab team regarding ADL’s, use of assistive devices, plans for progress, home care

  • Allow time and encouragement ADL’s

  • Assess both physical cognitive ability ADL

  • With agnosia encourage pt use other senses


  • With apraxia- break complex tasks down into simple steps; have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence

  • Perseveration- may have to tell person to stop action that they are perseverating about or may have to physically stop them


Nursing problems interventions 4 impaired verbal communication
Nursing problems/interventions have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence4. Impaired verbal communication

  • Assess speaking, writing, gestures, understanding

  • Support speech therapist plan

  • Support guidelines as LeMone p. 1317

  • Swearing may be first sign of return of speech, not directed at you or family


Nursing problems interventions 5 impaired urinary elimination riskcontipation
Nursing problems/interventions have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence5.Impaired urinary elimination/riskcontipation

  • Set up schedule to void

  • Support guidelines LeMone 1317


Nursing problems interventions 6 impaired swallowing
Nursing problems/interventions have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence6. Impaired swallowing

  • Dysphagia- difficulty swallowing LeMone 1317

  • Provide safety when eating

  • Occupation therapy and /or speech therapy can evaluate the individuals ability to get food to mouth and to swallow

  • Swallow studies


Nursing problems interventions 7 home care
Nursing problems/interventions have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence7. Home care

  • May return home, go to a rehabilitation center (in-house or outpatient) or may be placed in a nursing home

  • Home evaluation by rehabilitation team

  • Encourage self-care as much as possible with family involvement

  • Community resources should e evaluated for each ind with stroke, including family support


Subarachnoid hemorrhage a pathophysiology etiology
Subarachnoid hemorrhage have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence A. Pathophysiology/etiology

  • Subarachnoid hemorrhage- aneurysm or A-V malformation

  • Usually occur in younger adults 30-60 than other strokes


Sah pathophysiology etiology aneurysm
SAH- Pathophysiology/etiology have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Aneurysm

  • Occur at bifurcations, braches of carotids & vertebrobascular arteries

  • 85% base brain in anterior circulation

  • Caused by trauma, congential, arteriosclerosis


Sah pathophysiology etiology a v malformation
SAH Pathophysiology/etiology have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence A-V malformation

  • Congential abnormal joining of arteries to veins in the brain.

  • As pressures changes occur becomes tangled collection of dilated vessels.


B sah common manifestation complication aneurysm
B. SAH- Common manifestation/complication have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Aneurysm

  • Aneurysms are graded 0-V on the Hunt/Hess scale; higher the number, poorer chance survival.

  • Based on LOC & quality of cerebral function

  • Aneurysm are usually asymptomatic until rupture

  • Ruptured- sudden explosive headache; loss of consciousness; N & V; nuchal rigidity (stiff neck) and photophobia from meningeal irritation; cranial nerve deficits


Sah common manifestation complications a v malformation
SAH- Common manifestation/complications have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence A-V malformation

  • Ischemia symptoms-seizures and interference with normal function of those brain cells

  • As pressures changes occur the malformation ruptures and get bleed symptoms (SAH)


Sah common manifestation complications major complications
SAH- Common manifestation/complications have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Major complications

  • Rebleed due to reabsorption of the clot that is stopping the bleed

  • Vasospasms due to irritation of the blood vessels

  • Hydrocephalus from blockage of normal absorption of CSF


C therapeutic interventions sah diagnostic tests
C. Therapeutic interventions SAH have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Diagnostic tests

  • CT/MRI

  • Angiogram- outline the blood vessels

  • Lumbar puncture- blood in CSF

    • Risk of bleeding

    • Herniation with LP


Therapeutic interventions sah treatments
Therapeutic interventions SAH have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Treatments

  • Aneurysm precautions- decrease external/internal stimuli

  • Medications

    • Aide with aneurysm precautions- stool softners, antinausea,etc

    • To prevent rebleed/lysis of clot- Ammicar

    • To prevent vasospasms- Nimodipine

      • Before OR- Ca channel blocker- Nimodipine

      • After OR-triple H- vasodilators (Isuprel); induced arterial hypertension (Dopamine); hypervolemic hemodilution (Albumin)

    • Prophylactic antiepileptic- Cerebex/Dilantin


Therapeutic interventions sah treatments1
Therapeutic interventions SAH have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Treatments

  • Surgical intervention

    • Aneurysm-clip aneurysm, wrap with muslin or muscle, insert endovascular coils. If unstable may delay OR

    • A-V mal- embolization; ligation of feeders, laser surgery to remove malformation


Therapeutic intervention sah treatments
Therapeutic intervention SAH have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Treatments

  • Gamma Knife- radiation to reduce size of A-V malformation> over

  • Cyberknife below


Lemone blackboard site care plan elizabeth with a subarachnoid hemorrhage
LeMone Blackboard site Care Plan: have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence Elizabeth with a Subarachnoid Hemorrhage

http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html


Nursing care plan a client with a stroke lemone p 1319
Nursing Care Plan: A Client with a Stroke have a single item out at one time; use colored labels on clothes or velcro on one sleeve; allow time; encourage independence LeMone p. 1319

http://wps.prenhall.com/wps/media/objects/737/755395/stroke.pdf


Added critical thinking questions nursing care plan a client with a stroke p 1319
Added Critical thinking questions: Nursing Care Plan: A Client with a Stroke p. 1319

  • 1.What could be the possible cause of Orville’s ‘spells’ the week before his stroke?

  • 2. Are Orville’s symptoms consistent with right middle cerebral artery thrombolitic stroke? Describe.

  • 3. Had Orville gotten to the ER in 3 hrs, what could they have done that may have completely reversed the stroke?

  • 4. Is the fact that Orville is left handed significant?

  • 5. Which side will Orville not be able to see toward due to his homonymous hemianopia? How do you test?

  • 6. Does he have neglect syndrome?

  • 7. What type of aphasia does Orville have?


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