M3 Neurological Disorders

two types of stroke

ischemic → ~87%, vascular occlusion, significant hypoperfusion (subtypes: large artery thrombosis, small penetrating artery thrombosis, cardiogenic embolic, cryptogenic)
hemorrhagic → ~13%, blood escapes into brain tissue or subarachnoid space

what happens to tissue during a stroke

occlusion interrupts blood flow to a region of the brain, cells switch to anaerobic respiration and stop fxning

ischemic cascade

chain of cellular events that begins when cerebral blood flow falls far enough that neurons cannot sustain aerobic respiration

transient ischemic attack (TIA)

temporary ischemia w/ no death of neuronal tissue, neurologic deficit that resolves completely w/in 24 hrs (most <1hr)

stroke risk factors

nonmodifiable → age, gender, family h/x, race
modifiable → HTN, Afib, diabetes, dyslipidemia, smoking, excessive alcohol, asymptomatic carotid stenosis, hypercoagulable states, obesity, sedentary lifestyle, sleep apnea

acronym for recognizing stroke

F.A.S.T. → face drooping, arm weakness, speech difficulty, time to call 911

types of aphasias

Broca’s aphasia → aka expressive, inability to produce language
Wernicke’s aphasia → aka receptive, speech is fluent but unable to comprehend language
global aphasia → combination of expressive/receptive

deficits from L-sided hemispheric stroke

paralysis/weakness on RIGHT side, right visual field deficit, aphasias, altered intellectual ability, slow/cautious behavior

deficits from R-sided hemispheric stroke

paralysis/weakness on LEFT side, left visual field deficit, spatial/perceptual deficits, increased distractibility, impulsive behavior and poor judgment, lack of awareness of deficits

NIHSS

National Institutes of Health Stroke Scale, standardized bedside tool scoring 11 items (LOC, cranial nerve fxn, motor/sensory fxn, language/attention)

alteplase

a tissue plasminogen activator (tPA) used to treat acute ischemic stroke only, has to be given w/in 3-4.5hrs

alteplase management

BLEEDING is most common side effect, no anticoagulants/platelet-inhibiting meds for first 24 hrs, v/s q15min for 2hrs then q30 for 6hrs then q1h to 24 hrs, BP goal is no less then 180/105mmHg in first 24 hrs, treat fever

hemorrhagic stroke possible causes

• ruptured cerebral aneurysm causing subarachnoid hemorrhages

• arteriovenous malformation → tangle of arteries/veins lacking a capillary bed (more common cause in people <40y/o)

hemorrhagic signs/symptoms

worst headache of life, decreased LOC, seizure, nuchal rigidity

hemorrhagic stroke complications

rebleeding → bleeding recurs or the hematoma enlarges
cerebral vasospasm → intensified headache, confusion, lethargy, new aphasia/partial paralysis
acute hydrocephalus → blood obstructs CSF reabsorption, sudden onset of stupor/coma
seizures

hemorrhagic stroke management

maintain cerebral perfusion and prevent hypoxia, control BP, avoid anyt that raises BP or obstructs venous return, pneumatic compression devices, seizure precautions in place

possible causes of seizures

stroke, TBI, brain tumor, CNS infection, alcohol withdrawal, hypoxemia, kidney injury, hyponatremia, hypocalcemia

seizure

a single event of abnormal motor, sensory, autonomic, or psychic activity

epilepsy

more than one unprovoked seizure

seizure aura

a warning sensation that may be visual, auditory, or olfactory, and is part of a seizure

different presentations of seizures

focal, aware → conscious, able to respond, odd sensation, twitching, taste, remembers event afterward
focal, impaired → eyes open but cannot interact, staring, lip smacking/picking, no memory of the event
generalized → both hemispheres from start, LOC usual, tonic-clonic or absence staring

seizure precautions

bed in lowest positions w/ 2-3 side rails up, side rails padded and floor padded if possible, pillows removed when pt is in bed, functioning suction equipment w/ catheter at bedside, pt shielded from onlookers

nrsg care during a seizure

STAY WITH PT, time seizure from onset, ease to the floor or side-lying, protect head, loosen clothing at neck, clear hard objects away, have suction available to clear secretions if needed, DO NOT RESTRAIN, DO NOT PUT ANYTHING IN MOUTH

status epilepticus

continuous/repeated seizure activity w/o recovery between events, neurologic emergency w/ risk of hypoxia and permanent injury

A. assess the pt’s airway and check for injury

The nurse observes a patient ambulating in the hallway whose arms and legs suddenly jerk and who falls to the floor. What action should the nurse take first?

A. assess the patient’s airway and check for injury
B. give the scheduled dose of divalproex
C. note the timing and description of the seizure
D. notify the healthcare provider about the seizure

3 primary types of headaches

migraine → severe, incapacitating, photophobia, phonophobia, nausea, most occur w/o aura
tension-type → steady/constant P, bandlike (forehead to back of neck), described as weight on the head
cluster → excruciating pain at one eye w/ tearing/nasal congestion, 1-8 daily, 15min-3hrs, aborted w/ 100% O2

migraine triggers

tyramine-containing foods, long gaps between meals, hormone fluctuation, alcohol, disrupted sleep

4 phases of migraine

premonitory (hrs-days before), aura, headache, recovery

migraine symptoms

during headache → photophobia, phonophobia, N/V
postdrome → tiredness, weakness, cognitive difficulty, mood ∆ for hrs-days

C. cluster headache

A patient has severe pain around one eye several times a day, each lasting about an hour, with tearing and nasal congestion. Which headache type is this?

A. migraine w/ aura
B. tension-type headache
C. cluster headache
D. medication overuse headache

multiple sclerosis

progressive demyelinating disease of the CNS w/ loss of myelin, inflammatory immune-mediated disorder involving autoreactive lymphocytes

types of MS

relapsing-remitting, secondary progressive, primary progressive

demyelination

loss of the myelin sheath that covers nerves, providing insulation and speeding impulse conduction

MS signs/symptoms

fatigue (most common, often most disabling), blurry vision, diplopia, scotoma, muscle weakness, spasticity, ataxia, impaired gait/balance, numbness, paresthesias, pain, loss of proprioception, bladder problems, constipation, sexual dysfxn, memory loss, reduced concentration, emotional lability

treatment for acute MS exacerbation

short-term high-dose corticosteroids

nrsg care for MS

exercise to point just short of fatigue, frequent short rest periods, stretching/ROM, fall prevention, nutrition education, preventing UTI/constipation/pressure injury/contractures/pneumonia

B. loss of cognitive fxn

A nurse is caring for a client who has MS. Which of the following findings should the nurse expect?

A. fluctuations in BP
B. loss of cognitive fxn
C. ineffective cough
D. drooping eyelids

bradykinesia

overall slowing of active movement/speech w/ difficulty initiating movement

parkinson’s cardinal signs

tremor → slow, unilateral, present at rest, gone w/ purposeful movement and sleep
rigidity → resistance to passive movement, lead-pipe/cogwheel quality
akinesia/bradykinesia → slowing of active movement/speech
postural instability → stooped posture, leaning forward, shuffling gait, difficulty pivoting

Parkinson’s pathophysiology

degeneration of dopamine storage cells in the substantia nigra in the basal ganglia region

examples of lost automatic movements in PD

face becomes masklike/expressionless, blinking frequency decreases, reduced arm swing, shuffling gait, drooling/dysphagia, dysphonia, micrographia

PD complications

from disease → respiratory infections, UTI, skin breakdown, injury from falls
from meds → dyskinesia, orthostatic HOTN

PD diagnosis

often confirmed by positive response to levodopa trial

levodopa

a medication for PD that gets converted to dopamine in the basal ganglia providing symptom relief **very time-critical*

2 major nrsg safety concerns in PD pts

aspiration pneumonia (leading cause of death in PD), falls

eating precautions in PD pts

sit upright during mealtimes, semisolid diet, thick liquids, use stabilized plate, non-spill cup, built-up utensils, allow for prolonged eating time and rest periods

amyotrophic lateral sclerosis

aka ALS, disease characterized by loss of motor neurons in anterior horns of spinal cord and motor nuclei of the lower brainstem

ALS chief symptoms

fatigue, progressive muscle weakness (especially soft palate and upper esophageal leading to dysphagia/aspiration), cramps, fasciculations, lack of coordination

neurologic disease consideration in older adults

stroke incidence more than doubles w/ each decade after age 55