Exam 4 - Seizures, Strokes, Brain Tumors

cerebral angiography - what is it?

a procedure where a catheter is inserted through the groin or neck, and guided all the way up to the brain, where contrast dye is infused to confirm any abnormalities in the cerebral vasculature (THINK PCI OF THE BRAIN)

cerebral angiography - what can be diagnosed with them?

• aneurysms

• hemorrhages

• blood clots (find and remove)

• administration of chemo

cerebral angiography - pre/post op considerations (are they the same for regular PCI? what’s different?)

• OVERALL, the same as a regular PCI, but this cerebral angiographies require neuro checks/vascular checks

lumbar puncture - what does this procedure involve?

• CSF is withdrawn from the spinal cord

  • patient lies on side in fetal position or hunched over bedside table

lumbar puncture - used to diagnose what?

• MS

• syphilis

• meningitis/OTHER INFECTIONS

• cancer/malignancy

• increased ICP

lumbar puncture - do you sedate the patient?

NOT typically; only if the patient is fidgety

lumbar puncture - what medications are contraindicated for this procedure? why?

• ANTICOAGULANTS (until they have been reversed)

  • if not, they will bleed into spinal cord, causing increased ICP and worsening neuro functioning (decreased LOC, SEVERE headache)

lumbar puncture - RISKS

• SEVERE headache/increased ICP

• bleeding that compresses spinal cord

• infection (if not following sterile technique)

Glasgow coma scale - less than 8 = ?

INTUBATE!! (if they vomit, they cannot protect their own airway)

Glasgow coma scale - decorticate vs. decerebrate

• decorticate = movement TOWARDS the core

• decerebrate = movement AWAY from the core

electroencephalography (EEG) - what is it?

a procedure that measures brain waves (THINK EKG of brain), and is used to diagnose seizures / brain death

electroencephalography (EEG) - what does brain death look like?

ASYSTOLE !!!

seizure - definition

• abnormal episodes of motor, sensory, autonomic, or psychic activity resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons

epilepsy vs. seizures

• epilepsy = SEIZURE DISORDER

• seizure = the main manifestation of epilepsy

seizures - risk factors

• genetic predisposition (children more likely to experience absence seizures)

• acute febrile state (infants and children under 2)

• head trauma

• cerebral edema (especially if acute)

• abrupt cessation of antiepileptic drugs (REBOUND ACTIVITY)

• infection (if intracranial, a result of increased ICP; if systemic, due to persistent febrile state)

• metabolic disorder

• exposure to toxins

• stroke

• heart disease

• brain tumor

• hypoxia

• acute substance withdrawal

• F/E imbalances

3 types of GENERALIZED seizures

• tonic-clonic (phases can also be experienced separately)

• myoclonic seizure

• atonic

2 types of FOCAL seizures

• complex partial seizure

• simple partial seizure

seizures - nursing considerations DURING seizure

• know the patient’s aura (a sign specific to a patient that indicates a seizure) - THIS IS GOOD, as the patient can get ready/prepare

• SEIZURE PRECAUTIONS (padded side rails, suction equipment at bedside, LIMIT environmental stimuli, move anything out of way, loosen restrictive clothing)

• DOCUMENT (know when it starts/ends)

• put patient on side if they vomit

• keep head up and away from the ground to prevent hitting it on ground

• MEDICATIONS (IV diazepam (Valium) or lorazepam (Ativan) to TREAT ONGOING SEIZURES, do NOT prevent them)

what is the number one way to get a seizure?

• stop taking seizure medications

if a patient has a seizure and it stops, do you still give them Valium or Ativan?

NOPE!!

diazepam (Valium) and lorazepam (Ativan) - side effect to keep in mind?

SEDATION (may take patient post-seizure to wake up)

post-ictal phase - what type of seizure is this seen after? nursing considerations?

• seen ONLY after tonic-clonic (grand mal) seizures

• nursing considerations

  • POSITIONING for airway protection (at least 30 degrees up)

  • vitals

  • O2 monitoring

  • reorientation (they are confused); if they know they have a disorder, they are more likely to get oriented quicker

4 medications to PREVENT seizures? 2 methods of administration?

• phenytoin (Dilantin)

• Carbamazepine (Tegretol)

• Valproic acid (Depakote)

• Levetiracetam (Keppra)

  • ADMINISTERED oral or IV

seizure prevention medications - how often do you take these? what must you check with these medications?

• TAKE THESE EVERYDAY

• CHECK THE LEVELS OF MEDICATION!!

  • too low? = seizure

  • too high? = toxicity (LIVER)

stroke - heart or brain disease?

HEART disease, that affected the brain

cerebrovascular disorders - what are they?

ACUTE disruption of blood flow in the CNS/brain, either due to clots, atherosclerosis (carotid artery), or hemorrhage

cerebrovascular disorders - modifiable risk factors

• MANAGEMENT/CONTROL of HTN, obesity, DM, HLD, renal dysfunction, and A-Fib

• smoking (stop)

• sedentary lifestyle

• unhealthy diet

• substance abuse (cocaine)

hemorrhagic stroke - #1 cause

HYPERTENSION!!

what is the 3rd leading cause of death in US and #1 cause of serious long-term disability?

STROKES!!

stroke (brain attack) - what is it?

sudden loss of function resulting from a disruption of the blood supply to a part of the brain

2 types of stroke? how common are each (PERCENTAGE)?

1. ischemic (80-85%)

2. hemorrhagic (15-20%)

strokes - BEFAST (what does it stand for?)

• balance

• eyes (loss of vision)

• face (drooping on one side)

• arm (weakness on one side)

• speech (slurred speech/trouble speaking)

• TIME (the longer without blood flow, the worse the disability)

TIA - what is it?

• a warning sign of an impending stroke (blood flow is temporarily restricted but symptoms resolve)

  • think UNSTABLE ANGINA OF THE BRAIN

TIA - diagnostics?

• ECG (a-fib!!)

• echo

• carotid ultrasound (STENOSIS)!!

  • listen for bruits!!

which test differentiates between TIA and stroke? how?

CT scan!!

• TIA - NORMAL

• stroke - ischemia/hemorrhage

TIA - why do we do a CT scan instead of an MRI?

CT scan is MUCH quicker!! (TIME IS BRAIN!)

TIA vs. stroke - symptoms?

• TIA - symptoms completely resolve ON THEIR OWN (can take up to 24 hours)

• stroke - symptoms do NOT resolve without interventions and patient may have a new baseline in terms of functioning

stroke prevention - what does it depend on ?

DIAGNOSTIC TESTS!!!

• carotid stenosis?

• a-fib?

• HTN?

THINK CAD preventions: HTN meds, ASA, clopidogrel (Plavix), statins

ischemic stroke - what is it?

• disruption of the blood supply caused by an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue

ischemic stroke - how does the size of the vessel affect symptoms/prognosis?

• the SMALLER the vessel, the LESS symptoms and the BETTER the prognosis

ischemic stroke - where do they most commonly occur? can you remove the clot?

• occur most commonly where vessels BIFURCATE, such as the circle of willis

  • if the clot is in a BIG vessel, it can be removed with cerebral angiography, but if too small, you cannot

strokes - what is “last known well”? how is it determined?

• this is the last time the patient was SEEN normal!!

  • for example: if you see the symptoms occur spontaneously, the last known well is AT THAT MOMENT

ischemic stroke - when would clot busters be CONSIDERED as an option?

• if it has been LONGER than 4.5 hours after LKW, they will NOT use the clot buster (it will do more harm than good)

ischemic stroke - what type of medications are used if LKW is still very recent?

TPA (IV infusion over 2 hours) or TNK (IV push), CLOT BUSTERS!!

if somebody has a LEFT sided stroke, they will have ________? what is the only exception?

RIGHT sided symptoms!!

• exception: GAZE deviation (patient will look TOWARDS their stroke)

National Institute of Health Stroke Scale (NIHSS) - what is it?

a scale that indicates the resulting disabilities that come from a stroke

LEFT hemispheric strokes - resulting disabilities

• RIGHT sided paralysis/weakness; visual field deficit

• aphasia (expressive, receptive, or global)

• altered intellectual ability, slow cautious behavior

RIGHT hemispheric strokes - resulting disabilities

• LEFT sided paralysis/weakness; visual field deficit

• spatial-perceptual deficits

• increased distractibility

• impulsive behavior and poor judgement (at risk of being taken advantage of)

• lack of awareness of deficits

cerebellar stroke - resulting deficit?

ATAXIA (discoordination of movements) - think drunk walking

2 types of aphasia

1. broca’s aphasia

2. wernicke’s aphasia

Broca’s aphasia - what is it?

• aphasia that affects the MOTOR part of speech (helps in movements required to produce speech)

  • patient KNOWS what to say, but cannot use the muscles to say it; can write it out usually

Wernicke’s aphasia - what is it?

• aphasia that affects the SENSORY part of speech (helps understand speech and use correct words to express thoughts)

  • patient is speaking WORD SALAD (replaces words with other words, as they cannot express thoughts correctly)

ISCHEMIC stroke - acute phase management

• NIHSS scale

• CT of head (see if ischemic or hemorrhagic)

• SAVE PENUMBRA!! (TIME IS BRAIN)

• thrombolytic therapy (TPA or TNK)

  • take note of last known well (best within 3 hours, but can go up to 4.5 hours max)

• elevated HOB (unless contraindicated) to decrease ICP with gravity

• airway/ventilation maintenance

• continuous hemodynamic monitoring and neurologic assessment (Q15 min if TPA, Q1 hour if NO TPA)

• monitor for potential complications (musculoskeletal problems, dysphagia, respiratory problems, seizures, and s/s of increased ICP / meningeal irritation)

TPA and TNK - these medications are _______based

WEIGHT BASED

TPA/TNK - side effects?

• angioedema

• headache (ischemic → hemorrhagic)

• BLEEDING (VERY HIGH RISK)

while on thrombolytics, the placement of what 2 things are delayed for 24 hours? why?

• Catheters or NG tubes

  • VERY HIGH RISK OF BLEEDING

TPA/TNK - which vital sign must you monitor? what should it be? why?

• MUST monitor BP!!

  • should be less than 180/105, as a hemorrhagic stroke can result from giving these meds at this high of pressures

what percentage of people with strokes have seizures? is this normal?

• 15-20% of people end up having seizures (more with hemorrhagic strokes)

  • NOT a normal finding, and must be taken care of immediately

stroke recovery phase - what is the main focus?

• patient function (self-care ability, coping, education regarding rehabilitation needs)

  • LEARN THE PATIENT’S NEW BASELINE (getting them back to high of functioning as possible)

stroke recovery phase - GOALS

• improved mobility

• achievement of self-care

• relief of sensory/perceptual deprivation

• prevention of aspiration

• continence of bowel and bladder

• achieving a FORM OF COMMUNICATION

• maintaining skin integrity

• restored family functioning

• learn the patients NEW NORMAL

stroke recovery phase - where is the education directed towards? what must you do with these people as well?

• CAREGIVERS/family members, as most patients are able to be educated due to resulting disabilities

  • AS WELL, set realistic expectations!! (do NOT say they will get better if you know that they aren’t)

hemorrhagic stroke (ICH) - causes

• SPONTANEOUS (usual, due to uncontrolled HTN)

• ischemic stroke CONVERSION (improper monitoring of BP post TPA/TNK)

• anticoagulants!!

• ruptured aneurysm

• AVM (arterial venous malformation)

hemorrhagic stroke (ICH) - s/s that differentiate from ischemic stroke

• SEVERE headache/loss of consciousness

• early/sudden changes in LOC

• vomiting

• one blown/nonreactive pupil ON the side of the bleed

• other signs of ICP (seizures)

hemorrhagic stroke - what should the BP be at during it?

LESS THAN 140 SBP

2 BP meds of choice during acute phase of stroke?

• IVP labetalol (BETTER at controlling BP than HR)

• IVP hydralazine

what is the only medication approved for HTN in pregnancy?

IVP labetalol

are patients who had an ischemic stroke still at risk for converting/bleeding after discharge?

YES!! (educate patients on what signs to look for; take BP medications and continue to be on blood thinners)

subarachnoid hemorrhage (SAH) - what is it? what usually causes it?

• serious, life threatening type of stroke caused by bleeding into the SPACE SURROUNDING THE BRAIN (very similar symptoms/presentation)

• usually caused by a ruptured aneurysm

subarachnoid hemorrhage (SAH) - what medication are these patients usually put on? why?

• MANNTIOL

  • will lower the increased ICP caused by the hemorrhage by pulling fluid OUT OF THE BRAIN and back into the vascular system

Mannitol - in what setting is this medication given? what type of medication/solution is it?

ICU!!

• osmotic diuretic (cerebral dehydrant); HYPERTONIC solution

dysphagia screening - who is it done on? why?

• done on all patients who have had a stroke, or are a concern for having a stroke PRIOR to administering oral meds/food/fluid, in order to prevention aspiration

dysphagia screening - if patient fails/aspiration is suspected, what should the nurse do?

• make the patient NPO/place on aspiration precautions

• notify physician and order and speech therapy consult for formal swallow eval (BARIUM SWALLOW, to see if it goes into lungs)

dysphagia screening - STEPS (1-4)

1. FORMAL swallow eval if patient fails YOUR swallow eval (NPO until aspiration is ruled out)

   1. PROGRESS once aspiration is ruled out

2. test with thickened liquids

3. test with regular water

4. test with crackers

stroke symptoms can be mimicked by what other health concern?

HYPOGLYCEMIA!! (check blood sugar to rule this out before calling stroke alert)

if patient has kidney failure and needs contrast dye and is having a stroke, do you still give it?

YES!! (brain is WAYYY more important than kidneys)

brain tumors vs. stroke - how are the symptoms related/differentiated?

• just like with stroke, tumors on brain will cause OPPOSITE sided symptoms

  • differentiated by the ONSET of symptoms (brain tumors are VERY slow growing, and symptoms come very slowly), whereas strokes are INSTANTANEOUS

    • brain tumor patients also have positive romberg test and babinski test

brain tumors - what are romberg test/babinski test?

• romberg test - patient loses balance with eyes closed (sways)

• babinski test - toes FAN OUT when you rub the bottom of foot on AFFECTED SIDE

babinski test - when is a positive test considered normal?

INFANCY!!

craniotomy - what is it?

• a procedure where a piece of the skull is taken out to allow room for brain swelling (piece of skull will be placed somewhere else in body to preserve its life, usually under the skin in the thigh)

brain tumors - management techniques

• SYMPTOM management

• surgery, chemo, radiation

• craniotomy

brain tumors - what shows up on MRI?

midline suture is NO LONGER MIDLINE (deviates)

You’re assessing your patient load for the patients who are at MOST risk for seizures. Select all the patients below that are at risk:

• A. 32 yo with blood glucose of 20

• B. 63 yo whose CT scan shows ischemic stroke

• C. 72 yo who is post op day 5 from open heart surgery

• D. 16 yo with bacterial meningitis

• E. 58 yo experiencing ETOH withdrawal

• A. 32 yo with blood glucose of 20

• B. 63 yo whose CT scan shows ischemic stroke

• D. 16 yo with bacterial meningitis

• E. 58 yo experiencing ETOH withdrawal

A patient is admitted with uncontrolled A-fib. The patient’s medication history includes vitamin D supplements with calcium. What type of stroke is the patient at MOST risk for?

• A. ischemic thrombosis

• B. ischemic embolism

• C. hemorrhagic

• D. ischemic stenosis

• B. ischemic embolism (a-fib causes clots, and it can be carried up to the brain)