Neurological System (includes Stroke)

Neurological System

Brain Anatomy

Cerebrum Reasoning Judgment Concentration, Motor, sensory, speech

Cerebellum Coordination

Brainstem Cranial nerves Respiratory center Cardiovascular center

Brain Anatomy Cont.

Cerebral Blood Flow 20% of CO

Cerebral tissues – Have no oxygen or glucose reserves

Blood flows through Carotid Arteries to Circle of Willis

Intracranial Pressure (ICP)

Composition 80% brain tissue and water 10% blood 10% cerebrospinal fluid (CSF)

Increased ICP caused by: Severe head injury/ Subdural

hematoma Hydrocephalus Brain tumor Meningitis/Encephalitis Aneurysm Status epilepticus/Stroke

A medical emergency that can lead to:

Brain hypoxia, herniation, death

Clinical Manifestations Vomiting Headache Blurred vision Seizure Changes in behavior Loss of consciousness Lethargy Neurological symptoms

Neurological Assessment

Rapid Neurological Assessment Emergent situations Sudden changes in neurologic status

1. LOC: first indicator of a decline in neurological function and increase in ICP (intracranial pressure); use the GCS

2. Pupils

3. PUPILS

Pupils equal and react normally

Pupils react to light (slowly or blriskly)

Dilated pupil (compressed cranial nerve III)

Bilateral dilated, fixed (ominous sign)

Pinpoint pupils (pons damage or drugs)

Neuro-Diagnostic Tests Routine labs Radiology Tests

CT scan, MRI Carotid ultrasound Cerebral angiogram/

MRA

CT SCAN

MRA

Carotid US

Neuro-Diagnostic Tests: Lumbar Puncture Spinal needle inserted

into SA L3/L4 or L-4 /L-5 using

strict asepsis Obtain CSF specimens and

pressure readings To remove bloody or

purulent CSF Administer spinal

anesthesia

Case Study: Introduction

Nancy is a 66 year old female, came in to the ER with her daughter Gail. Gail states that her mother woke up in the middle of the night to go to the bathroom and fell to the ground because she was not able to control her right leg.

Case StudySubjective data

R arm and leg weak and numb Feeling depressed and fearful Requires help with ADLs Says she has not taken her meds for high

cholesterol History of brief episode of right sided

weakness and tingling of the face, arm, and hand 3 months earlier, which totally resolved and for which she did not seek treatment

Case StudyObjective Data Alert and oriented, and able to answer questions

appropriately with mild slowness in responding BP 180/110 Global aphasia, facial drooping, dysphagia Right sided paralysis Decreased sensation to right side, particularly the

hand Right homonymous hemianopsia Overweight Incontinent of urine

Stroke: Brain Attack

Cerebrovascular Accident (CVA) - loss of brain functions that occur when the blood supply to any part of the brain is interrupted.

Sudden onset of neurological deficits

Serious Medical Emergency- reduction in cerebral blood flow & tissue death Brain dependent on constant supply of oxygen and

glucose

Types of Stroke

Ischemic- results from an occlusion of a cerebral artery by a thrombus or embolus Thrombotic Stroke Embolic Stroke

Hemorrhagic – bleeding into brain tissue

Ischemic: Thrombotic Stroke

Atherosclerosis -most common cause

Thrombosis-clot forms at rough or narrowed artery

Complete blockage Accounts for half of all

strokes

Ischemic: Embolic StrokeAccounts for 1/3 of all strokesEmbolism-emboli breaks off and travels to

cerebral or carotid arteries (blood clot or fatty plaque released into circulation)

Often a fragment from a thrombosis or fatty plaque

TIA: Transient Ischemic Attack or “Silent stroke:/ mini stroke Warning sign: Temporary onset of neurological

symptoms often lasting 15 min but no longer than 24 hours

Needs prompt work-up: carotid U/S, brain and heart Key features:

Blurred vision, double vision, blindness one eye; Transient weakness, ataxia; Speech deficits

Treatment Cont: Surgical Therapy Carotid

Endarterectomy- for pts who have had TIAs or significant narrowing of carotid arteries

Hemorrhagic Stroke

Rupture of weak vessel wall or cerebral aneurysm

Intracerebral or subarachnoid hemorrhage

Arteriovenous malformation

Bleeding into brain or meninges

Risk Factors for StrokeModifiable Hypertension Heart disease (MI, A Fib) DM, Hyperlipidemia Sedentary Lifestyle Smoking/Alcohol Obesity Hyperlipidemia Illicit Drug Use;

cocaineNonmodiafiable Age - People over 55 are at high risk family history African american, hispanic,

asian descent

Clinical Manifestations Depend on the extent of injury

May be transient, mild or result in major neuro deficits

Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body

Sudden complete or partial loss of vision on one or both sides

Sudden confusion or trouble speaking or understanding

Sudden loss of balance, unsteadiness or an unexplained fall

Sudden vertigo, dizziness, swallowing difficulties or memory disturbances

Sudden, severe headache with no known cause

Hemorrhagic Worst HA ever for bleeds

R Hemiplegia/paresis

Impaired speech(Aphasias)

Impaired discrimination(R/L)

Slow performance,Cautious

Aware of deficitsDepression, Anxiety

Impaired comprehension & Memory R/T language and mathLeft -Sided CVA:

LEFT BRAIN DAMAGE R Hemianopsia

Right-sided CVA:RIGHT BRAIN DAMAGE Impaired judgment

Impulsive/Safetyproblems

Denies/Minimizesproblems

L hemiplegia/paresis

Left-sided neglect

Spatial-perceptual deficits

Rapid performanceShort attention

span

L Hemianopsia

Impaired Swallowing

Cognitive Changes

Motor Deficits

Sensory Changes

Impaired Communication

Altered Elimination

Nancy

Psychosocial

Impaired Swallowing Stroke →dysphagia Risk for airway obstruction/ aspiration Nursing Interventions: Maintain patent airway

NPO until swallow eval (by ST) Assess swallow, cough, gag reflex Safe Feedings: High Fowler’s position with head

flexed forward Thickened liquids if impaired swallowing Instruct to

position food on unaffected side in back of throat Avoid distractions to reduce aspiration risks Soft, semi-soft foods, pureed, baby food, dental diet Suction as needed

Cognitive Changes

Change in LOC Impaired judgment,

memory, problem solving

Denial of illness Inability to

concentrate

Nursing Interventions: Frequent reorientation Frequent safety

instructions Repeat directions on

tasks by steps Give time to process

and respond

Motor Deficits Loss of voluntary movement on

contralateral (opposite) side of stroke Weakness & paralysis

Hemiplegia and/or Hemiparesis Gait changes

Motor Deficit Cont.Nursing Interventions: Maintain optimal functioning and assist as

necessary Prevent contractures & atrophy PT and OT eval/tx to promote independence

Positioning- intermittent prone positions; elevate affected extremity

ROM exercises (passive: begin 1st day of hosp; no ambulation with hemorrhagic stroke- limit mvmt to extremities only )

Assist with ADLs (Self Care Deficit) Use assistive devices (wide grip utensils, plate guards) Rehab and use of ambulation devices

Motor Deficit Cont.Splints, hand rolls, trochanter rolls

Assessment and Management Sensory Changes

Contralateral sensory deficits Decreased sensation to touch

Spatial dysfunction (kinesthesia/proprioception altered) ↓ Awareness of position

Neglect Syndrome – Ignore affected side due to

altered perception and vision Visual Deficits

(Hemianopsia)

Nursing Interventions: Teach client to touch and

use both sides Remind client to dress and

bathe both sides Place objects within

patients field of vision Approach patient from

unaffected side

Sensory Changes Cont. - Visual Deficits: Hemianopsia

Blindness in one side of visual field Homonymous hemianopsia

Blindness in in the same side of each visual field

Visual Deficits: Hemianopsia Cont. Nursing Interventions:

Place objects in client’s visual fieldRemove clutterTeach patient to attend to the neglected

side Teach scanning technique during ADLs

Assess the neglected side (paralyzed or weak side) for trauma, adequacy of dressing and hygiene

Impaired Communication Aphasia-loss of use

and comprehension

Receptive aphasia- Wernicke’s area (sensory)

Expressive aphasia – Broca’s area (motor)

Global aphasia- mixed

Nursing Interventions:

Assess ability to speak and understand

Provide + reinforcement Picture board Repeat names of

objects routinely Allow plenty of time for

client to answer

Picture Communication Board

Altered Elimination

Temporary or permanent loss of bladder/bowel function

Constipation common Weakness Dehydration Immobility

Nursing Interventions: Increase fiber and fluids Stool softeners Digital

stimulation/suppositories bladder retraining Straight cath to check

residual

Assessment and Management Problems R/T Immobility

Risk for atelectasis and pneumonia Risk for impaired skin integrity and DVT

Nursing Interventions:

Assessment and Management: Psychosocial Emotional Support

Depression a major problem

Discharge planning

Care of the caregiver

Treatment of Stroke:Thrombotic Stroke Thrombolytic Therapy : rtPA (recombinant tissue Plasminogen Activator-

Retavase) A clot-buster delivered intravenously; breaks up the

clot allowing blood flow to return to the deprived area of the brain

Must be administered within 3 hours of the onset of clinical signs of ischemic stroke

Quick CT scan to see if stroke from clot or bleed

Treatment Cont:

Acute phase:

Anticoagulant - Heparin continuous infusion

Osmotic Diuretics – to reduce brain swelling

Anticoagulants contraindicated in Hemorrhagic Strokes

Long Term Drug TherapyTo Prevent Stroke: Antiplatlet Drugs

ASA, Ticlid, Persantine, Plavix

Anticoagulants Coumadin Lovenox

Antiepileptics

Treatment Cont: Surgical Treatment For Bleeds (Interventional Radiology)

Angiograms to see arteries and detect bleeding sites

Aneurysm clips and coils

Surgical Removal:Hematoma