T2 neuro disorders, stroke & dementia/delirium

ch 62 - 64

lumbar puncture

insertion of spinal needle through L3 - L4 space into lumbar subarachnoid space to

• obtain CSF

• measure CSF fluid or pressure

• instill air, dye or medication

contraindicated w/ increased ICP - rapid lowering of CSF → brainstem herniation

lumbar punction position & considerations

lateral recumbent w/ knees drawn up or sitting at edge of bed/table hunched over

empty bladder b4

strict asepsis

assess VS, neuro & for leaking CSF

lumbar puncture risks

CSF leakage

spinal h/a

hematoma

infection

meningitis

herniation of brain

EEG

graphic recording of electrical activity of superficial layers of the cerebral cortex

noninvasive → no danger of shock

withhold any meds (stimulants, tranqs, anti-seizure) for 24 - 48 hrs if ordered

cerebral angiography pre intervention

check allergies & kidney funct

NPO 4 - 6 hr b4

neuro assessment

premedicated if ordered

cerebral angiography post

monitor neuro stat & VS

neurovascular checks

maintain position as prescribed

• bedrest for 6 hrs

• keep bed flat if femoral artery was used

• limb immobilization

• pressure dressing to site

tension h/a

‘stress h/a’

bilateral frontal

constant full pressure or band like h/a

possible photo & phonophobia

most common

migraine

unilateral steady throbbing pain

w/ & w/o aura

visual disturbances

photo & phonophobia

n/v

cluster h/a

repeated h/a generally @ same time of day / night

severe, intense, sharp, stabbing pain

pain & swelling around eye, tearing, nasal congestion, pupil constriction

h/a prevention

coping mechanisms

relaxation

identify triggers

regular exercise

reduce stress

types of seizures

tonic clonic / grand - mal

absent

myoclonic

atonic

simple partial

complex partial

tonic clonic / grand - mal

tonic phase

• stiffening / rigidity of extremities for 10 - 20 sec

• loss of consciousness

clonic phase

• hyperventilation & jerking

absent / absence

brief lapse of awareness & activity for short periods

look as if staring into space

myoclonic

brief generalized jerking / stiffening of muscle or group of muscles

fall risk

atonic

sudden loss of muscle tone

fall risk

simple partial

conscious & alert but have unusual feelings

complex partial

altered behaviour w/o awareness

short loss of consciousness

eyes open → dreamlike stare

automatisms → repetitive seemingly purposeful motions

kinda like going through the motions

status elepticus

rapid succession of seizure w/o return to consciousness

> 5 min

fatal resp insufficiency, hypoxemia, dysrhythmias, hyperthermia

systemic acidosis may occur

seizure interventions and precautions

note duration & character of seizure

if pt is sitting / standing → place on floor, protect head

maintain / support airway → oxygen, turn to side

loose clothing

siderails up & padded

parkinsons sympt

TRAP

• Tremors

• Rigidity

• Akinesia

• Postural

blank facial expression

slow, slurred, mono speech

short shuffle gait

forward tilt to posture

tremor

pill rolling

parkinsons worsening sympt

loss of postural reflexes → ↑ fall risk

pneumonia, UTI, skin breakdown

ortho hypoTN, supine HTN

dementia

depression

hallucination

psychosis

parkinsons meds

levedopa - carbidopa

• primary for 5 - 10 yrs

acetylcholine antagonists

apomorphine & antiemetic for akinesia

parkinsons interventions

encourage activities & exercise

pt speak slowly & pause @ intervals

assess swallowing ability

avoid constipation → ↑ fluids

proper posture w/ firm mattress & positioning when prone w/o a pillow

modifiable stroke risk factors

HTN, diabetes, smoking

obesity, serum cholesterol, heart disease

previous TIA, sleep apnea, metabolic syndrome

lack of phys exercise, poor diet, drug use

> 2 alcoholic drinks / day

CVD → atherosclerosis, valve disease, dysrhythmias (esp. aflutter, afib)

ischemic stroke types

thrombotic

embolic

thombotic stroke

injury to vessel wall → clot forms

embolic stroke

most originate in endocardial layer of heart

• afib, MI, infective endocarditis, rheumatic heart disease, valve, problems, heart prothesis

hemorrhagic stroke types

intracerebral hemorrhage

subarachnoid hemorrhage

intracerebral hemorrhage

bleeding w/in brain

HTN most common cause

subarachnoid hemorrhage

in skull outside brain tissue

epidural → skull & dura membrane

• usually d/t head trauma

subdural → between dura & subarachnoid membrane

• usually d/t trauma

subarachnoid → arachnoid space

• often cerebral artery aneurism, “sudden h/a”, irritated meninges

stroke diagnostic studies

MRI or non - contrast CT scan

• show size & location of lesion

• distinguish between ischemic & hemorrhagic stroke

stroke risk factors

age → risk doubles each decade after 55

gender → common in men, women die

ethnicity → ↑ risk in african americans

fam hx

obesity

smoking

stroke sympt

BE FAST

• Balance → loss of balance, h/a or dizziness

• Eyes → blurred vision

• Face → one side of face is drooping

• Arms / appendages → arm or leg weakness

• Speech → speech difficulty

• Time → time to call 911

ischemic stroke treatment

ABC

onset time critical → give tPA w/in 3 - 4.5 hrs of onset

keep BP ↑

• only treat if SBP > 220 or DBP > 120

improve venous damage

• HOB up no more than 30°

• neck + shoulder aligned

• avoid hip flexion

drugs to prevent seizures, pain, fever & constipation

platelet aggregation inhibitors

hemorrhagic stroke treatment

ABC

prevent HTN → SBP between 160 & 90

improve venous drainage

• HOB up no more than 30°

• neck + shoulder aligned

• avoid hip flexion

drugs to prevent seizures, pain, fever & constipation

NO anticoags or platelet aggregation inhibitors

may need surgery (evacuation, restriction, slipping, coiling)

• hyperdynamic therapy after to ↑ perfusion

right sided stroke

affect left side

impulsive → dont know why they do smth, safety problems

disorientated

cant recognize faces

unaware of deficits

poor judgement

visual deficits → neglects left visual field

denies or minimized problems / deficits

left sided stroke

affects right side

loss of language → aphasia, agraphia

no memory deficit

slow, cautious, anxiety w/ new tasks

frustrated, quick anger, depression, worthlessness

impaired reading, math & language comprehension

right visual field deficits, no hearing deficit

aware of problems / deficits

hemiplegia

1 side paralyzed

paraplegia

lower body paralyed

quadriplegia

whole body paralyzed

monoplegia

1 limb paralyzed

wernicke’s aphasia

loss of language comprehension → speech is meaning less, non - sensical

‘what?’ → dosent understand others speech

word salad

broca’s / expressive aphasia

loss of use of language, slow speech → req lots of effort

broken words

frustrated

stroke communication interventions

speak slowly & calmly → simple words or sentences

use gestures for support

use normal tone & vol

ask yes or no questions

may not be able to read words → use picture boards

give plenty of time to respond

hemianopsia

blindness over field of vision

right CVA → left hemiplegia / anopsia

left CVA → right hemiplegia / anopsia

dysphagia

impaired speech & verbal comprehension

stroke nutrition

keep upright

encourage self feeding, put food on unaffected side

chin tuck & double swallow → watch for pocketing

good oral hygieve

may need nutritional support (PEG tube)

keep NPO until ST performs swallow test

coping and rehab for family

explain what happened

• diagnosis, therapeutic procedures → be clear

pt fam → give careful & detailed explanation of what happened

social services referral often helpful

dementia

gradual and permanent

decline from previous lvl of function in 1 or more cognitive domains

cognitive decline interferes w/ ability to function & perform daily activities

problems w/ judgement, memory, abstract thinking & social behaviour

delerium

acute & reversible

state of confusion that lasts from hours to days

memory deficits, orientation, language, visuospatial ability & perception

↓ ability to focus, direct, sustain & shift attention & awareness

dementia & delirium interventions

safe consistent treatment & caregiver → change increases anxiety & confusion

maintain health, nutrition, safety, hygiene & rest

assist w/ ADLs → dementia as disease progresses the need for assistance & skin protection increases

support for pt & fam

routine activities

mark bathroom clearly, safety

reorient, simple direct statements

5 A’s to alzheimers

Anomia

• inability to remember names of things

Apraxia

• misuse of objects d/t failure to identify them

Agnosia

• inability to recognize familiar objects, tastes, sounds & other sensations

Amnesia

• memory loss

Aphasia

• inability to express self through speech

dementia / alzheimers sympt

personal hygiene ↓

↓ in concentration & attention

unpredictable behaviour

unintentional & uncontrollable agitation or aggression

delusion & hallucinations

alzheimers further progression sympt

unable to communicate

cannot perform ADLs

wandering

alzheimers late stage sympt

pt becomes unresponsive & incontinent

total care is required

dementia / alzheimers management

simplify tasks

be flexible, patient, calm & understanding

DONT correct, rush pt, rationalize, talk about pt as if not there

Alzheimer caregiver mild stage

stop driving

provide cues in home

advance directives

alzheimer caregiver moderate stage

door locks for safety

protective wear for incontinence

remove rugs in home → good lighting

identify & reduce triggers

develop distraction for behaviour problems

provide memory triggers → pic of fam & friends

alzheimer caregiver severe stage

regular elimination schedule

provide needs → oral & skin care

monitor diet & fluid intake

continue communication

consider placement in long term facility

delirium causes

infection

drug reaction

substance intoxication or withdrawal

electrolyte imbalance

heat trauma

sleep deprivation

treatment is correction of cause