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Neurology

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  • 1. Neurology Cerebrovascular Accident Brunner’s Ch. 62 pg 1887
  • 2. Breaking down in tears
    • I’m a nursing student who’s never seen a person die. When the time comes, I’m afraid I’ll lose it and upset the patient or family. How do you do this work all the time and not break down in tears?
  • 3. Cerebrovascular accident
    • AKA
    • CVA
    • Stroke
    • Brain attack
  • 4. CVA: Pathophysiology
    • Disruption of blood flow to part of the brain 
    • Ischemia 
    • Tissue Anoxia 
    •  PaO2 &  PaCO2 
    • Acidosis 
    • Infarction 
    • Edema 
    •  ICP
  • 5. CVA: Etiology
    • Ischemic
      • Thrombosis
        • __?__  thrombosis
        • Arteriosclerosis
        • Common site
          • Carotid artery
      • Embolism
        • Atrial fib or HTN 
        • Plaque breaking off and becoming an emboli
      • d/t Long standing cardio-vascular disease
  • 6. CVA: Etiology
    • Hemorrhage
      • Rupture of the cerebral blood vessel
      • Commonly caused by poor control of HTN
  • 7. CVA: Etiology
    • Hemorrhage
      • This type of CVA results in:
        • Slow recovery
        •  probability of neurological deficits
        • No meds to reverse the effects
  • 8. CVA: Etiology
    • Other causes
      • Syphilis
      • Trauma
      • Hypertension
      • Hypoxia
      • *** Anything the  blood flow
  • 9. CVA: Risk Factors
    • Changeable
    • Smoking
    • Obesity
    • HTN
    • Sedentary life
    • Stress
    •  fat diet
    •  Na diet
    • Substance abuse
    • Oral contraceptives
    • Diabetes mellitus
    • Non-changeable
    • Age
    • Gender
    • Family history
    • Race
  • 10. CVA: Risk Factors
    • Which is the most important risk factor for a stroke?
      • Smoking
      • Weight
      • Diet
      • HTN
      • Stress
      • Substance Abuse
  • 11. CVA: Risk Factors
    • What is the number one cause of CVA in a younger patient?
      • Smoking
      • Weight
      • Diet
      • HTN
      • Stress
      • Substance Abuse
  • 12. CVA: Pathophysiology substance abuse
    • Substance ( PCP, crack ) 
    •  Blood pressure 
    •  ICP 
    • Subarachnoid & intracerebral hemorrhage 
    • Interrupt blood flow 
    •  O2 &  glucose 
    • Depressed neurons 
  • 13. CVA: Pathophysiology
    • ** Vessels involved determine the area of the brain involved
    • ***Area affected determines the S&S
  • 14. CVA: Clinical manifestations
    • S&S depend on:
    • Location
    • Size
    • Amount
  • 15. CVA: Clinical Manifestations Common clinical manifestations
    • Syncope
    • Alt. LOC
    • Paresthesia
    • H/A
    • Aphasia
    • Seizures
    • Vision disturb
    • Difficulty walking
    • Labile emotion
    • Hemiparesis/hemiplegia
  • 16. Left vs. Right Hemispheric CVA Movement Perception Sensation Speech Language Aphasia Right CVA Left CVA
  • 17. Left vs. Right Hemispheric CVA Movement Perception Sensation Speech Dysarthria Language Aphasia Right CVA Left CVA
  • 18. Left vs. Right Hemispheric CVA Movement Perception Sensation Right Homonyous hemianopsia Speech Dysarthria Language Aphasia Right CVA Left CVA
  • 19. Left vs. Right Hemispheric CVA Movement Perception Normal awareness Sensation Right Homonyous hemianopsia Speech Dysarthria Language Aphasia Right CVA Left CVA
  • 20. Left vs. Right Hemispheric CVA Movement Right side paresis Perception Normal awareness Sensation Right Homonyous hemianopsia Speech Dysarthria Language Aphasia Right CVA Left CVA
  • 21. Left vs. Right Hemispheric CVA Memory Cognition Behavior Judgment intact Depression Slow & cautious
  • 22. Left vs. Right Hemispheric CVA Memory Cognition Impaired analytical Behavior Judgment intact Depression Slow & cautious
  • 23. Left vs. Right Hemispheric CVA Memory Deficit new language info Cognition Impaired analytical Behavior Judgment intact Depression Slow & cautious
  • 24. Left vs. Right Hemispheric CVA Movement Right side paresis Perception Normal awareness Sensation Right Homonyous hemianopsia Speech Dysarthria Intact Language Aphasia Right CVA Left CVA
  • 25. Left vs. Right Hemispheric CVA Movement Right side paresis Perception Normal awareness Sensation Right Homonyous hemianopsia Dysarthria Speech Dysarthria Intact Language Aphasia Right CVA Left CVA
  • 26. Left vs. Right Hemispheric CVA Movement Right side paresis Perception Normal awareness Left Homonyous hemianopsia Sensation Right Homonyous hemianopsia Dysarthria Speech Dysarthria Intact Language Aphasia Right CVA Left CVA
  • 27. Left vs. Right Hemispheric CVA Movement Right side paresis Unilateral neglect Perception Normal awareness Left Homonyous hemianopsia Sensation Right Homonyous hemianopsia Dysarthria Speech Dysarthria Intact Language Aphasia Right CVA Left CVA
  • 28. Left vs. Right Hemispheric CVA Left side paresis Movement Right side paresis Unilateral neglect Perception Normal awareness Left Homonyous hemianopsia Sensation Right Homonyous hemianopsia Dysarthria Speech Dysarthria Intact Language Aphasia Right CVA Left CVA
  • 29. Left vs. Right Hemispheric CVA Memory Deficit new language info Cognition Impaired analytical Judgment impaired Denial Impulsive behavior Behavior Judgment intact Depression Slow & cautious
  • 30. Left vs. Right Hemispheric CVA Deficit new spatial info Memory Deficit new language info Cognition Impaired analytical Judgment impaired Denial Impulsive behavior Behavior Judgment intact Depression Slow & cautious
  • 31. My Mother:
    • What side stroke did she have?
      • Right sided
    • How do you know?
      • Denial
      • Poor judgment
      • No aphasia
  • 32. My step Father
    • What side stroke did she have?
      • Left sided
    • How do you know?
      • Depression
      • Emotional labile
      • Normal awareness
      • Aphasia
  • 33. CVA: diagnostic findings
    • LP
      •  pressure
      • Blood
    • CT / MRI
      • Bleeding
      • Infarction
      • Shift
    • Angiography
      • Occlusion
  • 34. CVA: Medical Management
    • Focus on Cause & Control
    • #1 cause =
      • Hypertension
      • Medications
  • 35. CVA: Rx - HTN
    • Beta-blockers
      • Action
        • Block sympathetic response
      • Example
        • Propranolol hydrochloride
  • 36. CVA: Rx - HTN
    • Central acting Anti-hypertensive
      • Action
        •  Cardiac output
        •  Heart rate
      • Example
        • Catapres
  • 37. CVA: Rx - HTN
    • Vasodilators
      • Action
        • Relax smooth muscles
      • Example
        • Apresoline
      • Emergency
        • Hyperstat
        • Nipride
  • 38. CVA: Medical Management
    • Diet
      • Sodium
      • Fat
      • Potassium
      • Stimulants
      • Fluids
        • 
  • 39. CVA: Medical Management
    • Prevent clot formation
      • Meds / anticoagulants
        • Coumadin
          • Antidote?
            • Vit K
        • Heparin
        • ASA
  • 40. CVA: Medical Management
    • Prevent clot formation
      • Non-Rx
        • Ted hose
        • ROM
        • Isometric exercise
  • 41. CVA: Medical Management
    • Surgery
      • Endarterectomy
        • Carotid stenosis
      • Craniotomy
        • Evacuate clot
  • 42. CVA: Medical Management
    • Thrombolytic agents
      • Action
        • Break down thrombi
      • S/E
        • Hemorrhage
      • Streptokinase
      • Urokinase
      • Tissue-type prasminogen activator (tPA)
  • 43. CVA: Medical Management
    • Thrombolytic agents
      • Tissue-type prasminogen activator (tPA)
        • Take in 3 hrs of CVA
  • 44. CVA: Medical Management
    • Airway
      • Patent
      •  reflex
      • O2
      • Suction
      • Mech vent
  • 45. CVA: Medical Management
    • Prevent Seizures
      • Precaution
      • Meds
      •  stimuli
  • 46. CVA: Medical Management
    •  ICP
      • O2
        • Mech vent
      • Position
        • HOB 
      • Activity
        • Rest
      • Meds
        • Diuretics
        • Glucocorticoids
      • Monitor
        • BP
        • Systolic < 180
        • Diastolic < 100
  • 47. CVA: Medical Management
    • Nutrition
      • NGT
  • 48. CVA: Medical Management
    • Monitor for trouble
      • VS
        • Rectal temp
          • NO
      • I&O
      • Labs
        • Na
        • K
        • Glucose
        • ABG’s
        • PT/PTT
      • Pulse oximetry
  • 49. CVA: Medical Management
    • Prevent complications
    • ROM
    • PT/SLP
    • Isometric exercise
    • Antacids
      • Maalox
      • Tums
    • Histamine antagonist
      • Tagamet
      • Zantac
    • Pain
      • Codeine
  • 50. CVA: NRS management
    • Alt. tissue perfusion
    • r/t  ICP
      • Monitor ICP
      • Avoid act that  ICP
  • 51. CVA: NRS management
    • Risk for injury
    • r/t seizures
    • r/t repeat CVA
    • r/t unilateral neglect
    • r/t falls
      • Padded side rails
      • Call light
      • Assist w. amb.
      • Suction
      • BR assist
      • Items w/in reach
      • Clear path
      • H2O temps
      • Turn & position
  • 52. CVA: NRS management
    • Alt. nutrition
    • r/t impaired swallowing
    • Motor deficits
    • Impaired judgment
      • SLP
      • Swallow eval
      • HOB high fowlers
      • Straws – no
      • Thick liquids
      • Swallow twice
      •  pocketing food
      • Talk & eat – NO
      • Easy chew
      • Head position
      • Unaffected side of tongue
      •  gag
      •  choking
      • Small meals
      • High texture food
  • 53. CVA: NRS management
    • Alt. Mobility
    • r/t neuro deficits
      • Begin on admit
      • Turn q2hr
      • Pillows
      • P skin
      • ROM
      • Splints
        • Hand & fingers
        • Arm
        • Legs
      • Footboards
      • Built-up utensils
      • Raised toilet
      • W/in reach
      • Pt. to do exercises
  • 54. CVA: NRS management
    • Impaired Communication
    • r/t aphasia
      • SLP
      • Time
      • Anticipate
      • Call bell
      • Slow & clear
      • Face patient
      • Eye contact
      • Yes/No ?
      • ID methods
      • Gestures
      • Visual aids
  • 55. CVA: NRS management
    • Knowledge Deficit
    • r/t new diagnosis
      • Orient
      • Explain
      • K.I.S.S.
      • Written, verbal & picture
      • Little at a time
      • Meds
      • Safety
  • 56. CVA: NRS management
    • Self-Care Deficit
    • Eating
      • Non-skid mats
      • Stabilizer plates
      • Plate guards
      • Wide grip utensils
  • 57. CVA: NRS management
    • Self-Care Deficit
    • Bathing & Grooming
      • Long handle sponge
      • Grab bars
      • Non-skid mats
      • Hand held showers
      • Electric razor
      • Shower seat
  • 58. CVA: NRS management
    • Self-Care Deficit
    • Toileting
      • Raised seat
      • Grab bars
  • 59. CVA: NRS management
    • Self-Care Deficit
    • Dressing
      • Velcro
      • Elastic shoelaces
      • Long-handle shoehorn
  • 60. CVA: NRS management
    • Self-Care Deficit
    • Mobility
      • Canes
      • Walkers
      • Wheelchair
      • Transfer devices
  • 61. CVA: NRS management
    • Risk of care-giver role strain
      • Support systems
  • 62. CVA: NRS management
    • Unilateral neglect
    • Unaffected side
      • Personal items
      • Approach
      • Door face
    • Cue
    • Scan environment
    • Sling
  • 63. CVA: NRS management
    • Impaired thought processes
    • Family
    • KISS
    • SS&TTP
    •  distractions
    • Repeat
    • Visual reminders
    • Time
    • Simple  complex
    • Positive feedback
    • Non-judgmental
  • 64. Hemorrhagic Stroke
    • Usually more severe with a longer recovery period than ischemic stroke
    • Caused by bleeding into:
      • Brain
      • Ventricles
      • Subarachnoid space
  • 65. Hemorrhagic Stroke
    • Cerebral aneurysm
      • Dilitation, bulging or ballooning out of part of the wall of a vein or artery in the brain
      • When they enlarge and press upon cranial nerves or tissue 
        • Symptoms
  • 66. Hemorrhagic Stroke
    • Etiology
      • HTN
      • Arteriosclerosis
      • Meds
  • 67. Hemorrhagic Stroke
    • Clinical Manifestations
    • Similar to ischemic
    • Unique S&S
      • H/A
      • LOC
      • Nuchal rigidity
  • 68. TIA: Transient Ischemic Attack
    • Short reversible ischemic event
    • Duration
      • < 24 hrs
    • No permanent neuro deficit
    • Warning!