MedSurg 1 Exam 3

Neuro, MSK, Endocrine, Liver, Gallbladder, Immuno, Hemato

Neuro Diagnostics

Cerebral Angiography: cerebral blood vessels

—give meds

-steroid/antihistamine before

Common = metallic taste & warmth with dye injection

…..

Cerebral CT Scan: tumors, infarction, other abnormalities

-assess for shellfish & iodine allergy

-don’t wear any metal, including dentures

-radiation exposure

……

Electroencephalography EEG: electrical activity

—seizures, sleep disorders, behavioral changes

-avoid stimulants & sedatives before

…….

Lumbar Puncture, Spinal Tap: spinal fluid CSF

—diseases, infection, malignancies

—reduce CSF pressure, give meds

-no jewelry, void before, fetal position, remain lying for several hr after

Complication: headache due to CSF leakage, increased infection risk

—epidural blood patch if headache persists

………

MRI Scan: differentiate soft tissue from tumor/bone

-magnets, not radiation

—can’t scan if artificial devices = pacemakers, surgical clips, IV access port

-no metal objects, transdermal patches

……….

PET & SPECT Scans: 3D images, depicting activity

—tumor activity/treatment response, dementia

-glucose-based tracer in PET scan = metabolic activity

—radioisotope in SPECT

-radiation risks, caution with diabetes

……….

X-Ray: fractures, erosion, dislocation, tissue calcification

-no jewelry

Glasgow Coma Scale

EVM: Eyes, Verbal, Motor

—15 = fully conscious, 8 = coma

………

Eyes

4 = spontaneous

3 = sound

2 = pain

1 = don’t

…

Verbal

5 = coherent & oriented

4 = incoherent

3 = inappropriate words

2 = sounds not words

1 = nothing

…

6 = follow commands

5 = local reaction to pain

4 = general withdrawal from pain

3 = decorticate = adduct arms, flex elbows/wrists

2 = decerebrate = abduct arms, extend elbows/wrists

1 = nothing

Stroke Classifications

Hemorrhagic = ruptured artery aka aneurysm

—also called a intracerebral hemorrhage ICH

-ischemia + increased ICP = poor prognosis

—half die within 2days

-sudden symptoms

-HYPERTENSION

…………………….

Ischemic = most common, blockage of circulation

-reversed by tPA/alteplase if given within 3-5hr

….

Cardioembolic

—clot from faulty heart valve or atrial fibrillation

Embolic = embolus travels into cerebral artery

-neurologic deficits/LOC occur instantly

Thrombotic

—arterial plaque due to atherosclerosis

—manifestations evolve over hrs-days

Lacunar

—small vessel disease, thickened lumen, restricted blood flow

—associated with hypertension

Cryptogenic

—No cause

Other

—Coagulopathies

—Vasculitis

—Drug abuse

—Infections

Stroke Health Promotion & Prevention

BE FAST

-BALANCE unsteady

-EYES blurry

-unilateral FACIAL drooping

-ARM downward drift

-SPEECH impairment/difficulty

-TIME to call 911

……….

Sudden Signs:

—First sign = change in LOC

-severe headache, confusion, trouble articulating

-vertigo, dizziness, gait issues, vision issues

-unilateral numbness/paresthesia

…………………………………

Risk Factors

-Ethnicity = everyone but Asians & Caucasians

—higher incidence in black

-Older than 65

-More common in men, higher mortality in women

-cerebral aneurysm, AV malformation

-T2D, obesity, hypertension, sedentary lifestyle

-sleep apnea

-atherosclerosis, hyperlipidemia, heart disease

-hypercoagulability, sickle cell anemia

-smoking, alcohol, substance use, oral contraceptives

Transient Ischemic Attack, TIA

Caused by focal brain, spinal cord, retinal ischemia WITHOUT acute infarction

—aka BRIEF interruption of cerebral blood flow

….

Manifestations resolve within 1-24hr

—visual disturbances, slurred speech, dizziness, weak extremity

—warning of impending stroke

….

May have 1 or more TIAs before a complette stroke

-Nearly 40% go on to have complete stroke

Ischemic Stroke Causes

Atherosclerosis = in carotid & cerebral arteries

—vessel narrowing, clot formation

…………

Carotid Stenosis

-atherosclerotic plaques in carotid narrow lumen

—restrict blood flow causing cerebrovascular insufficiency

-can result in TIA or stroke if untreated

-occluded carotid can cause collateral blood flow

—alternate blood vessels form: angiogenesis

—can avoid neurologic compromise

Ischemic Cascade

Ischemic Core is surrounded by Penumbra

—necrotic core of dead tissue

……

Penumbra = nonfunctional bran area

-not infarcted, can be restored with timely perfusion

—infarcted = deprived of oxygen for certain length of time

-low blood flow, oxygen, & metabolites

—local autoregulation is impaired because of it

—decreased ATP production

—cells become more permeable, intake more sodium & potassium, causes intracellular swelling

—ischemic area increases, area of infarction increases

Brain Anatomy & Stroke

Left Hemisphere = language, math, analytical thinking

Right Hemisphere = visual & spatial awareness, proprioception

…….

Stroke in Left, Damage in Right Side

Stroke in Right, Damage in Left Side

…………..

Dominant Hemisphere

—left if right handed

—right if left handed

—if stroke occurs hear, aphasia is most common

Left CVA Manifestations

Right-sided Weakness or Paralysis

-Hemiparesis, hemiplegia, facial droop

…

Language & Communication Deficits

-Aphasia: Expressive & Receptive

-Dysarthria = slurred/slowed speech

…

Motor Deficits: Apraxia

Right Visual Field Deficits

…

Slow, cautious behavior

Cognitive & behavioral changes

-anxious, frustrated, depressed

-very aware of deficits

…

Difficulty with math, reading comprehension, problem-solving

Right CVA Manifestations

Left-sided Weakness or Paralysis

-hemiparesis, hemiplegia, facial droop

…

Spatial-Perceptual Deficits

-left-sided unilateral neglect

-Poor awareness of deficits = anosognosia

…

Visual-Spatial Changes

-left visual field deficits

-difficulty judging distances or navigating space

…

Cognitive, Behavioral, Emotional Changes

-impulsivity, poor judgement & safety awareness

-disinhibition = socially inappropriate behavior

-short attention span

-labile emotions, rapid mood changes

-may be euphoric or indifferent

-less aware of deficits

Stroke Terminology

Expressive Aphasia = inability to speak/write

—Broca’s area of brain

Receptive Aphasia = inability to understand language

—Wernicke’s area of brain

………………………………….

Agnosia = inability to recognize familiar objects

Alexia = reading difficulty

Agraphia = writing difficulty

Apraxia = inability to perform simple commands, skilled acts

Ataxia = decreased coordination, loss of balance

………….

Hemiplegia = one-sided paralysis

Hemiparesis = one-sided weakness

Hemianopsia = loss of visual field in one or both eyes

Additional Stroke Assessment Findings

Slow, cautious behavior

Depression, anger, quick to frustrate

Altered perception of deficits, overestimation of abilities

Loss of depth perception

Poor impulse control & judgement

…

Unilateral neglect

-can’t see/feel/move affected side, unaware of its existence

—more common with right-hemisphere strokes

Hemorrhagic Specific Manifestations

ICH volume is large

-Increased ICP

—headache, nausea

-Herniation

—altered consciousness, hypertension

Stroke Diagnosis & Care

IMMEDIATELY check blood glucose

Non-contrast CT Scan = FIRST LINE

—differentiates ischemic vs hemorrhagic

12 lead ECG

Telemetry

CBC, Coagulation, Troponin, Lipid, HbA1c, toxicology

……………………….

CT Angiography CTA

—determines eligibility for mechanical thrombectomy

MRI with DWI

—identify infarct location & size

..

CT Perfusion CTP

—when outside traditional window

—help determine if reperfusion therapy will work

..

Magnetic Resonance Angiography MRA

—evaluate cerebral blood vessels

..

Carotid Duplex Ultrasound

—carotid artery stenosis

..

Transcranial Doppler ultrasound TCD

—monitor for hemorrhage

..

Echocardiogram TTE, TEE

—if cardiac source is suspected for emboli

………………………..

Dysphagia screening

NIHSS

Glasgow Coma Scale

……………………………………………………………………

Vital signs every 15min-2hr

—fever can increase ICP

—BP over 185/110mmHg can indicate ischemic stroke

Head of Bed at 30deg

—reduce ICP, promote venous damage

….

Institute seizure precautions

Initiate fall precautions

—ABSOLUTE bed rest, not on paralyzed side for more than 20min, ROM every 4hr/3X a day

….

Assess communication skills

….

Keep NPO until swallowing is assessed

Safe Feeding = upright, sips, no straw, suction on standby, no distractions, check mouth for food

Incontinence is never justification for catheterization

Stroke Medications

Thrombolytics = t-PA alteplase

-within 45min of arrival, within 3-5hr of initial symptoms

-NO active bleeding

—don’t give antiplatelets or anticoagulants within 24hr

-Adverse effects: hypotension, intracranial hemorrhage, bleeding, ecchymoses

……………………………..……………….

Anticoagulants

-Warfarin

—Indicated: atrial fibrillation, cardioembolic stroke

—Not used in hemorrhagic stroke

Direct Oral Anticoagulants

-Dabigatran, Apixaban, Rivaroxaban

—alternatives for warfarin

…………………………………………….

Antiplatelets

-Aspirin, dipyridamole, clopidogrel

—Low dose aspirin given within 24-48hr following ischemic stroke to prevent further clot formation

—Platelet inhibitors given for thrombotic or embolic strokes

…………………………………………….

Antiepileptics

-phenytoin, gabapentin

—only if client develops post-seizures

—Gabapentin = for paresthetic pain in affected extremity

……………………………………………

Antihypertensives

-ACE inhibitors, diuretics, calcium channel blockers aka nimodipine

—nimodipine = decrease vasospasms due to hemorrhage

…………………………………………

Cholesterol Lowering Agents, Statins

-atorvastatin, simvastatin

—manage hyperlipidemia, prevent plaque formation

…………………………………………

Others

-stool softeners, prevent constipation & straining

—straining increases ICP

-analgesics

-antianxiety

Stroke Therapeutic Procedures

Within 6hr of manifestations, NOT for hemorrhagic strokes

…………………………………………………………………..

Thrombectomy = mechanical, endovascular, intra-arterial

….

Carotid Artery Angioplasty with stenting CAS

—less invasive, decreased blood loss

-catheter into femoral artery

-catch clot debris, stent to open blockage

-Postop: assess for increased headache, neck swelling, hoarse voice

—emergency airway equipment available

….

Extracranial-intracranial bypass

-craniotomy, restore blood flow to affected areas

…..

Carotid Endarterectomy

-open artery, remove plaque

-Postop: assess for increased headache, neck swelling, hoarse voice

—emergency airway equipment available

Post-Carotid Endarterectomy Management

Respiratory Distress, Difficulty swallowing

—postoperative hemorrhage

-Actions: measure neck circumference post-op & hourly for 24hr, monitor incision, observe tracheal deviation

……..

Decline in Neuro Function

—stroke or hemorrhage

-Actions: perform hourly neuro checks

Ischemic Stroke Treatment & Therapies

Risk Factor Management

-healthy diet, exercise, smoking cessation

………………………

Anticoagulants:

Most commonly used = aspirin

-alternative anticoagulants for patients with Afib

…

Antiplatelets: aspirin, clopidogrel

……………………….

Emergency Thrombolytic Therapy

-Thrombolytics: t-PA, prourokinase, streptokinase

—clot-busting: dissolve clot, restore blood flow, minimize neuro damage

-HIGH RISK of bleeding

-administer IV within 3-5hr of symptom onset

—not if active bleeding, head trauma, major surgery, MI, heparin/anticoagulant, low platelet, high BP, glucose imbalance, pregnancy, changing neuro status

…………………………

Mechanical Thrombectomy = FIRST LINE

-within 6-24hr of initial symptom onset

..

Carotid Revascularization Procedures

-Carotid Endarterectomy CEA

—prevents recurrent ischemic stroke, removes plaque from carotid

-Carotid Artery Angioplasty with Stent

—balloon dilation, stent to maintain patency, alternative for high risk patients

Post-Thrombolytic Therapy Management

Bleeding from catheter site

—possible hemorrhage

-Actions: monitor catheter insertion site

…..

Decline in Neuro assessment

—possible hemorrhage

-Actions: monitor neuro, monitor for increased ICP

Hemorrhagic Stroke Treatment & Therapies

Prevention

-modify hypertension, obesity, & diabetes

……………………..

FIRST LINE

-aneurysm clipping, endovascular coiling

..

Aneurysm Wrapping

Surgical Evacuation of Hematoma

CSF Drainage

………………………..

NO THROMBOLYTICS

Ischemic Stroke Complications

Dysphagia/Aspiration

-keep NPO until evaluated

-keep suction equipment available

-safe eating practices

—90deg, thickened liquids, eat on unaffected side, small bites/sips

….

Unilateral Neglect = greater injury risk/self-care deficit

-assess skin, properly position limb

-dress & care for affected side first

-keep affected limb midline instead of at side to avoid injury

…………….

Hemorrhagic Transformation

—becomes hemorrhagic stroke

Cytotoxic Edema

—ischemic cascade causes cerebral edema & increased ICP

Reperfusion injury

—oxygen free radicals damage cells

—cerebral edema & increased ICP

…

Contractures

Falls/Injuries

Depression

Hemorrhagic Stroke Complications

Delayed Cerebral Ischemia

-vasospasm

—occurs within 3-14 days

—new or worsening neurologic deficits

—leading cause of disability

…..

Hyponatremia

—syndrome of inappropriate antidiuretic hormone SIADH

..

Brain Herniation = MED EMERGENCY

—respiratory arrest, cardiac arrest, death

..

Seizures

—occurs within 24-48hr

..

Acute Respiratory Distress Syndrome

—severe inflammatory response causes impaired gas exchange

—may require mechanical ventilation

…..

MI

Increased ICP

Hematoma Expansion/Rebleeding

Stroke Management & Assessment

Assessment

-vital signs, cardiac monitoring

-neuro exam, LOC

-blood glucose, I&O, electrolytes

-gag reflex

..

Respiratory

-ABGs, continuous spO2, protection

Cardiovascular

-control BP: titrate meds to maintain

-hemodynamic monitoring

-ECG for arrhythmias

—cardiac stunning

………………

Management

-record Last known well LKW

-order STAT head CT & CTA

-start 2 IVs

—NS at 100 mL/hr

—1 line for nicardipine

-blood draw before CT

-VS & neuro checks q15miin

—maintain oxygen over 95%

Visual Scanning

Moving head & eyes side to side to view entire visual field

—compensation for hemianopsia

..

Brain doesn’t register missing side

—patient often unaware

……….

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