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Neurosensory: Stroke and Brain Tumors

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Neurosensory: Stroke and Brain Tumors Part #1 Stroke (Brain attack/CVA) A. Pathophysiology/etiology Normal brain physiology and stroke Ranks 3rd as cause death Blood ... – PowerPoint PPT presentation

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Title: Neurosensory: Stroke and Brain Tumors


1
Neurosensory Stroke and Brain Tumors
  • Part 1 Stroke (Brain attack/CVA)

2
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

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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 gt 65 yrs
  • Sickle cell disease

5
Brain dysfunction length of
time without blood supply
  • Brain function depends on collateral circulation
    and amount of cerebral edema
  • TIA- neuro deficits last lt 24 hrs
  • RIND- neuro deficits last gt 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

6
Disease process
  • Ischemic stroke
  • Occlusion of artery
  • Generally do not lose consciousness
  • Better prognosis than hemorrhagic
  • May have TIAs before
  • Thrombosis or embolism
  • Hemorrhagic stroke
  • Bleed occurs with activity
  • Usually rapid onset
  • Generally loss of consciousness
  • Poorer prognosis
  • Intracranial or subarachnoid

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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 TIAs, present as stroke-in-evolution
    , or have completed stroke outright

9
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

10
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

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Hemorrhagic Subarchnoid hemorrhage
(SAH)
  • Caused by bleeding into subarchnoid space from
  • Extension of a intracranial hemorrhage
  • Aneurysm
  • AV malformation

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B. Common manifestations/complications-
by body systems
15
By artery affected by occlusion or hemorrhage
Internal carotid
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Middle cerebral artery
20
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

21
Vertebral artery
  • Pain or numbness of involved side
  • Vertigo
  • Contralateral ataxia
  • Dysphagia, dysarthria
  • Cranial nerve dysfunctions

22
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.

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25
Motor deficits
  • Characteristic body posture

26
Motor deficits
  • Facial palsy- (central/UMN) where lower part face
    affected
  • Bells palsy (LMN- 7th CN) where the whole side of
    face affected

27
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

28
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 bodys position sense

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Sensory-perceptual deficits
Visual field deficits
  • Disruption anywhere along the pathway
  • Homonymous hemianopsia- most common. Loss of half
    of visual field in each eye. Cant see toward the
    same side as the paralysis

31
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

32
Sensory-perceptual deficits 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 CVAs

33
Communication Deficits
  • 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

34
Communication Deficits Brocas
and Wernickes aphasia
  • Brocas, expressive or nonfluent aphasia where
    unable to express- understands
  • Wernickes, receptive, fluent aphasia where
    unable to understand

35
Broca speech area Wernicke speech area
36
Communication Deficits
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

37
Cognitive and behavioral deficits
  • 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

38
C. Therapeutic interventions
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

39
Therapeutic interventions
Rehabilitation
  • Outpatient or in-house
  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Cognitive therapy

40
Therapeutic interventions
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

41
Therapeutic interventions
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

42
D. Nursing assessment specific to stroke
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

43
Nsg assess- neuro deficits common in stroke
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 Bells
    (7th CN) and central facial (motor strip)

44
Nursing assess- neuro deficits common stroke
Motor
  • EOMs- 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)

45
Nursing assess neuro deficits Motor
3rd nerve palsy 6th nerve palsy
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Nursing assess- neuro deficits common stroke
Motor
  • Assess ability to void and move bowels
  • Assess communication ability
  • Assess cognitive and behavioral aspects

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Nursing assess-neuro deficits common stroke
Sensory deficits
  • Superficial sensation
  • With paperclip and eyes closed alternate sharp
    and dull ends
  • Reference is the sensory strip on the parietal
    side

50
Nursing assess- neuro deficits common
strokeSensory- 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

51
Nursing assess- neuro deficits common stroke
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

52
Nursing assess- neuro deficits common stroke
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 cant identify sound as running water
  • Tactile agnosia- with eyes closed cant recognize
    familiar objects- comb, pencil unaware location
    diff positioning self- slouches to one side

53
Nsg assess- neuro deficits common stroke
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

54
Nursing assessment specific to stroke 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

55
E. Nursing problems/interventions 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

56
Nursing problems/interventions 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

57
Nursing problems/interventions3. Self-care
deficit
  • Eourage use of paralyzed extremity
  • Teach dsg tech- affected arm in clothing first
  • Work with rehab team regarding ADLs, use of
    assistive devices, plans for progress, home care
  • Allow time and encouragement ADLs
  • Assess both physical cognitive ability ADL
  • With agnosia encourage pt use other senses

58
  • 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

59
Nursing problems/interventions4. 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

60
Nursing problems/interventions5.Impaired urinary
elimination/riskcontipation
  • Set up schedule to void
  • Support guidelines LeMone 1317

61
Nursing problems/interventions6. 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

62
Nursing problems/interventions7. 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

63
Subarachnoid hemorrhage A. Pathophysiology/eti
ology
  • Subarachnoid hemorrhage- aneurysm or A-V
    malformation
  • Usually occur in younger adults 30-60 than other
    strokes

64
SAH- Pathophysiology/etiology
Aneurysm
  • Occur at bifurcations, braches of carotids
    vertebrobascular arteries
  • 85 base brain in anterior circulation
  • Caused by trauma, congential, arteriosclerosis

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SAH Pathophysiology/etiology
A-V malformation
  • Congential abnormal joining of arteries to veins
    in the brain.
  • As pressures changes occur becomes tangled
    collection of dilated vessels.

67
B. SAH- Common manifestation/complication
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

68
SAH- Common manifestation/complications
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)

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SAH- Common manifestation/complications
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

71
C. Therapeutic interventions SAH
Diagnostic tests
  • CT/MRI
  • Angiogram- outline the blood vessels
  • Lumbar puncture- blood in CSF
  • Risk of bleeding
  • Herniation with LP

72
Therapeutic interventions SAH
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

73
Therapeutic interventions SAH
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

74
Therapeutic intervention SAH
Treatments
  • Gamma Knife- radiation to reduce size of A-V
    malformationgt over
  • Cyberknife below

75
LeMone Blackboard site Care Plan Elizabeth
with a Subarachnoid Hemorrhage
  • http//wps.prenhall.com/chet_lemone_medicalsurg_3
    /0,7859,757263-,00.html

76
Nursing Care Plan A Client with a Stroke
LeMone p. 1319
  • http//wps.prenhall.com/wps/media/objects/737/755
    395/stroke.pdf

77
Added Critical thinking questions Nursing Care
Plan A Client with a Stroke p. 1319
  • 1.What could be the possible cause of Orvilles
    spells the week before his stroke?
  • 2. Are Orvilles 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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