lec. 4 - Neuro 1: Strokes and dementia

Strokes - acute on chronic

acute stroke

• BEFAST call 911

  • balance, eyes, face, Arms, Speech, Time to call 911

• code neuro

• stroke team

• door to CT - within 25 mins of onset

• door to needle - within 60 min

• tpa monitoring

• Blood sugar - hypoglycemia can mimic stroke

Left hemispher stroke

• aphasia expressive or receptive

• impaired analytical skills

• cautious/slow behavior

Right hemispheric stroke

• spatial - perceptual defecits - neglect, poor depth perception

• impulsivity/ poor judgement

• difficulty with attention, recognition

Strokes - Neuro assesment

NIH stroke scale (0-42) Q2-4hrs

• LOC

• Best gaze

• visual fields

• facial palsy

• motor arm

• motor leg

• limb ataxia

• sensory

• best languag e

• dysarthria

• extinction and inattention

ongoing neuro - baseline compared to present

stroke - interventions

risk reduction

• identify stroke cause - ECG, Echocardiogram , carotid, US

• blood pressure

• cholesterol

• glucose

• CO

• arrhythmia

assess

• swallow, nutrition, repositioning, depression

after Stroke - education

• pt. education, fam/support sys education

• communication - comm. board or other strats

• positioning - limb mobility, strengthening, unilaterla neglect, acnhoring, scanning, mirroring (use affected side)

• reduce aspiration risk

Stroke Rehab - speech therapy

• swallowing safety

• speech improvement

  • communication strategies

stroke rehab - PT, OT

• strengthening

• energy conservation

• gross/fine motor skills retraining

stroke rehab - Rehab eligibility

• have to tolerate 3+ hrs rehab/day

• physical tolerance and willing to participate

Dementia - alzheimers dementia patho

characterized by memory changes, difficulty learning, communication challenges

• d/t degeneration of neurons in the brian

• retrogenesis

alzheimers disease patho - structural changes

• beta amyloid plaques - amyloid protein incorrectly broken down, remains insolble and clumps - interuppting neuron to neuron signaling, and disrupts memory

• neurofibrillary (tau) tangles

  • inside the cell - cytoskeletal structural malfxn

  • imapried neural cell fxning, impaired signaling between neurons causing neuro death

Alzheimers dementia - symptoms

• short term memory

• loss of motor skills, language

• long term memory

• disorientation and safet concerns

• eventually bedridden - most common cause of pneumonia

• diagnosis made by ruling out other causes of death - brain autopsy only definative way to diagnose

Alzheimers disease stages - early

maintanes independence

• symptoms

  • word finding difficulty, forgetting names, misplace obj., difficulty planning/organizing, ideal time to do life planning for later on

alzheimers disease stages - Mid stage

longest stage

• inc. assistance for daily tasks

• worse memory loss

• confusion r/t time and place

• behavioral changes - suspicious, wandering, delusional \

• bladder and bowel issues may begin

alzheimers disease stages - late stage

significant decline in cognitive and physiclal fxn

• loss of abiltiy to respond to environment/converse meaninfully

• walking, sitting up, eating, swallowing can be difficult

• 24/7 care required

• susceptible to infxn

• comfort and dignity become central

Alzheimers - acute on chronic disease progression - Mental

agitation, confusion, delirium

• new setting, acute illness, sundowning

Alzheimers - acute on chronic disease progression - infxns

• respiratory, urinary

Alzheimers - acute on chronic disease progression - aspiration and dysphagia

aspiration more commonly effects later stages when dysphagia affects patient

Alzheimers - acute on chronic disease progression - falls

• physical impairment related to gait

• impaired, judgement, confusion, wandering

Alzheimers - acute on chronic disease progression - dehydration/malnutrion

• forgetting to eat, drink

• swallowing difficulty

• more common in later stages

Alzheimers dementia - Assessment

• orientation - dont correct orientation/question response - will make them more sus or anxious

• agitaiton - troubleshooting, pain, frusturation, temperature, anzxiety, toileting, fear, hallucination

• caregiver - caregiver strain,

  • respite care - in home, adult day centers, long term care

Alzheimers - Interventions/desired outcomes - nursing strats

promote cognitive fxn

promote physical safety

promote independence/self care

promote nutrition

reduce anxiety

improve comm.

social engagement/intimacy

balanced activity and rest

Alzheimers - med management - Cholinesterase inhibitors

donazepil(Aricept), rivastigmine (Exelon)

moa - prevent breakdown of acetylcholine by inhibiting cholinesterase

AE - HA, NVD, anorexia, inc. BM

Alzheimers medication managment - NMDA antagonist/glutamate regulators

meds - mematine - namenda

MOA - regulate activity of glutamate to improve memory, attention, reasoning, language

AE - HA, constipation, confusion, dizziness

Cholinergic toxicity - Early

SLUDGEM

• salivation, lacrimation(tears), urinary incontinence, diarrhea, GI, cramps, emesis, miosis

DUMBELLS

• diaphoresis/diarrhea, urinary frequency, miosis, bronchospasms, emesis, lacrimation, lethargy, salivation

cholinergic toxicity - Late stage

• circulatory collapse

• muscle spasms/weakness

• bloody diarrhea

• cardiac and resp, arrest

cholnergic crisis - interventions

• ABC - priority

• vascular access, cirulatory support, ventilatory support

• pharmacologic managment to reverse effects of acetylcholine and systemic effects