Neurological

NEUROLOGIC DISORDERS & PATIENT CARE

STROKE/CEREBRAL VASCULAR ACCIDENT

  • Types of Stroke

    • Ischemic Stroke

    • A clot blocks blood flow to an area of the brain.

    • Hemorrhagic Stroke

    • Bleeding occurs inside or around brain tissue.

STROKE DEFINITION

  • Definition: Syndrome characterized by the onset of one or more focal neurological deficits caused by a reduced cerebral blood flow that leads to brain cell death and functional disability.

  • Factors Influencing Neuro Deficits:

    • Area of brain involved

    • Size of area affected

    • Length of time blood flow has been interrupted

  • Statistics:

    • Stroke is the fifth leading cause of death in the U.S.

    • Nearly 800,000 people in the U.S. have a stroke every year.

    • Leading cause of long-term disability and leading preventable cause of disability.

RISK FACTORS FOR STROKE

Non-Modifiable Risk Factors

  • Age

  • Family History

  • Previous stroke/TIA

  • Race:

    • African Americans - twice the incidence of any other ethnic group.

    • Hispanics, Asians, Native Americans - higher incidence than whites.

  • Gender:

    • Men - more common.

    • Women - increased incidence of death.

Modifiable Risk Factors

  • Hypertension

  • Heart disease

  • Atrial fibrillation

  • Diabetes

  • Smoking

  • Obesity

  • Sleep apnea

  • Sedentary lifestyle

  • Hyperlipidemia

  • Drug & alcohol use

TYPES OF STROKES

  • Ischemic Stroke:

    • Caused by blood clot.

    • Most common type (approximately 87% of cases).

    • Classified as Thrombotic or Embolic:

    • Thrombotic Stroke: occurs from injury to a blood vessel and formation of a blood clot.

    • Embolic Stroke: forms at another location of the body and travels to the brain.

  • Hemorrhagic Stroke:

    • Blood vessel bursts and stops blood flow to brain.

  • Transient Ischemic Attack (TIA):

    • Also known as “mini stroke.”

    • Caused by a temporary clot.

ISCHEMIC STROKE DETAILS

  • Definition: Inadequate blood flow to the brain from partial or complete occlusion of an artery.

  • Thrombotic Stroke:

    • Develops readily where atherosclerotic plaques have narrowed blood vessels.

    • More common in older adults, commonly occurs while asleep.

    • No deficit in LOC in the first 24 hours.

  • Embolic Stroke:

    • Embolus occludes a cerebral artery resulting in infarction and edema of the area.

    • Second most common cause of stroke.

    • Can affect any age group; sudden onset of severe symptoms; decreased LOC at onset.

    • Most emboli originate from the heart.

HEMORRHAGIC STROKE DETAILS

  • Definition: Bleeding into the brain tissue occurs when a weakened vessel ruptures and bleeds into surrounding tissue.

  • Most Fatal Form of Stroke:

    • Includes Intracerebral hemorrhage and Subarachnoid hemorrhage.

Intracerebral Hemorrhage

  • A ruptured blood vessel bleeds into the brain tissue.

  • Commonly caused by hypertension.

  • Manifestations:

    • Headache

    • Nausea

    • Vomiting

    • Decreased LOC

    • Hemiplegia

Subarachnoid Hemorrhage

  • Blood vessel ruptures near the surface of the brain & leaks into the subarachnoid space.

  • Most cases caused by the rupture of a cerebral aneurysm due to head trauma.

  • Risk factors vary by age: younger individuals - MVA; older adults - falls.

Intracranial Aneurysms

  • Most common location: Circle of Willis.

  • Ruptured aneurysm is the most common cause of hemorrhagic stroke.

  • High Mortality Rate; significant complications.

  • Manifestations:

    • Sudden & explosive headache

    • Neck pain/stiffness

    • Nausea & vomiting

    • Photophobia

    • Cranial nerve deficits

TRANSIENT ISCHEMIC ATTACK (TIA)

  • Definition: Temporary episode of neuro dysfunction resulting from focal cerebral ischemia.

  • Typically lasts less than 1 hour and shows no evidence of infarct on follow-up brain scans.

  • Neuro signs & symptoms depend on the area of the brain and size of the vessel involved.

  • Emergency Treatment: Can lead to ischemic stroke.

SPOT A STROKE - WARNING SIGNS (BE FAST)

  • B: Loss of Balance, Headache, or Dizziness

  • E: Slurred Vision

  • F: One Side of the Face is Drooping

  • A: Arm or Leg Weakness

  • S: Speech Difficulty

  • T: Time to Call for Ambulance - Immediately Call 911

MANIFESTATIONS OF BRAIN DAMAGE

Right-Sided Brain Damage

  • Paralysis or weakness on left side of body (hemiplegia)

  • Left visual field deficit

  • Spatial perceptual deficits

  • Increased distractibility, short attention span

  • Impulsive behavior

  • Poor judgment

  • Lack of awareness

Left-Sided Brain Damage

  • Paralysis or weakness on right side of body (hemiplegia)

  • Right visual field deficit

  • Aphasia (communication loss, impaired comprehension related to language)

  • Slow cautious behavior

  • More awareness of deficits.

Communication Issues in Left-Sided Damage

  • Aphasia Types:

    • Expressive: Difficulty producing speech (Broca’s area)

    • Receptive: Difficulty understanding speech (Wernicke’s area)

    • Global: Total inability to communicate

    • Dysarthria: Slurred speech, loss of muscular control

CLINICAL MANIFESTATIONS - ADDITIONAL

  • Affect & emotions

  • Cognitive Impairment

  • Spatial-Perceptual Issues

  • Hemianopsia (loss of half of the field of vision)

  • Loss of perception of self and illness (agnosia)

  • Apraxia (difficulty with motor planning)

  • Dysphagia (swallowing complications)

  • Neglect Syndrome

  • Elimination issues (urinary retention, constipation)

DIAGNOSIS OF STROKE

  • History & Physical (H&P), including time of onset

  • Neuro assessment - NIH Stroke Scale

  • LOC, vision, facial paralysis, motor abilities, blood glucose

  • Imaging/diagnostic testing (e.g., head CT scan, MRI, angiography)

DIAGNOSTIC TESTS

  • Head CT Scan: Non-contrast, determines if the stroke is ischemic or hemorrhagic.

  • MRI: For more details, including the extent of damage.

  • Angiography: Can look at carotid arteries.

  • Cardiac Assessments.

TREATMENT STAGES

  • Goals of Stroke Care:

    • Stroke prevention

    • Acute care

    • Diagnosis type & cause

    • Supporting cerebral circulation

    • Controlling/preventing further deficits

    • Rehabilitation

ISCHEMIC STROKE TREATMENT

  • “Time is Brain”: Critical to act quickly.

  • Thrombolytic Therapy: tPA (Tissue Plasminogen Activator) - clot buster that binds fibrin and converts plasminogen to plasmin.

    • Considered the gold standard. MUST BE GIVEN WITHIN 3 HOURS AFTER SYMPTOM ONSET.

  • Risks: Must monitor closely for bleeding and other complications.

  • Surgical Intervention: Thrombectomy for surgically retrieving the clot (must be done within 6 hours of symptom onset).

  • Anticoagulant/Antiplatelet Therapies:

    • Warfarin (Coumadin)

    • Xarelto (Rivaroxaban)

    • Pradaxa (Dabigatran)

    • Heparin

    • Aspirin; Plavix (Clopidogrel)

HEMORRHAGIC STROKE TREATMENT

  • ABCs: Airway, Breathing, Circulation - stabilize first.

  • Antiplatelets and anticoagulants contraindicated.

  • Surgical evacuation may be indicated for cerebellar hemorrhage.

  • Surgical interventions for cerebral aneurysms to prevent hemorrhage, using endovascular procedures to occlude the aneurysm.

REHABILITATION AFTER STROKE

  • Collaborative approach involving patients, families, and the interdisciplinary team.

  • Goals: prevent deformity and maintain/improve function.

  • Options include in-patient rehabilitation (e.g., Dodd Hall), out-patient rehabilitation, skilled nursing facilities (e.g., Select Specialty Hospital).

REHABILITATION FOCUS AREAS

  • Physical Therapy: Prevent contractures, build muscle strength, improve coordination and mobility.

  • Occupational Therapy: Regain skills impacting Activities of Daily Living (ADLs).

  • Speech Therapy: Address language, communication, and swallowing issues.

NURSING MANAGEMENT

  • Frequent neuro assessments: NIHSS, Glasgow Coma Scale, mental status, pupils, vital signs monitoring.

  • Monitor motor skills: bilateral hand grasps, dorsiflexion, and plantar flexion.

  • Assess for swallowing impairment.

GLASGLOW COMA SCALE

  • Best Eye Response (E):

    • 4: Spontaneous

    • 3: Opens to verbal command

    • 2: Opens to pain

    • 1: None

  • Best Verbal Response (V):

    • 5: Oriented

    • 4: Confused conversation

    • 3: Inappropriate responses

    • 2: Incomprehensible sounds

    • 1: None

  • Best Motor Response (M):

    • 6: Obeys commands

    • 5: Purposeful movement

    • 4: Withdraws from pain

    • 3: Abnormal flexion

    • 2: Extensor response

    • 1: None

SEIZURE DISORDERS

  • Definition: Temporary episodes of abnormal motor, sensory, autonomic, or psychic activity resulting from sudden excessive electrical discharge from cortical neurons.

  • Epilepsy: A group of syndromes characterized by unprovoked, recurring seizures.

  • Status Epilepticus: A series of generalized seizures occurring without full recovery of consciousness between attacks.

REQUIREMENTS FOR SEIZURES

  1. Excitable neurons.

  2. Increase in excitatory glutaminergic activity.

  3. Reduction in activity of normal inhibitory neurotransmitters (GABA).

  • Imbalance between excitation and inhibition in CNS.

SEIZURE TRIGGERS

  • Common triggers include:

    • Odors

    • Flashing lights

    • Sounds

    • Fatigue/sleep deprivation

    • Hypoglycemia

    • Emotional stress

    • Electrical shock

    • Fever

    • Alcohol consumption

    • Drug use

    • Excessive water consumption

    • Constipation

    • Hyperventilation

TYPES OF SEIZURES

  • Partial Seizures: Seizure activity starts in one area of the brain.

    • Simple Partial: Minimal movement, remains conscious.

    • Complex Partial: Variable movement, loses consciousness.

  • Generalized Seizures: Activity involves both hemispheres of the brain.

    • Tonic-Clonic: Affects entire brain; begins with tonic rigidity followed by clonic jerking.

    • Tonic: Muscle stiffening and altered respiratory patterns.

    • Clonic: Jerking movements of both extremities.

    • Absence Seizures: Short episodes of staring and loss of awareness.

    • Myoclonic Seizures: Jerking movements of one muscle or muscle group with no loss of consciousness.

    • Atonic Seizures: Sudden loss of muscle tone.

MANAGEMENT OF SEIZURES

  • Goals: Stop seizures quickly to ensure adequate oxygenation to the brain and maintain patient safety.

  • During a seizure, the major responsibility is to observe and record the sequence of signs and symptoms.

  • Nursing Priorities: Prevention of injury, control of seizures, psychosocial adjustment, education, and absence of complications.

DIAGNOSTICS & TREATMENT

  • Imaging studies: EEG, MRI, PET.

  • Medications:

    • Acute events: Lorazepam (Ativan), Diazepam (Valium), Midazolam (Versed).

    • Drugs for later: Phenytoin (Dilantin) - must be given slowly via IV, Levetiracetam (Keppra), Phenobarbital (Luminal).

  • Surgery: Lobectomy or Vagal Nerve Stimulators.

NURSING INTERVENTIONS FOR SEIZURES

  • Maintain airway (ABCs).

  • Protect the patient from injury.

  • Accurate and descriptive documentation.

  • Administer medication as directed.

  • Monitor vital signs before, during, and after the seizure episode.

MENINGITIS

  • Definition: Inflammation of the protective membranes covering the brain and spinal cord, typically caused by infection (bacterial or viral).

  • Epidemiology: High fatality rate and long-term complications.

  • Common Causes:

    • Bacterial: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus agalactiae (group B strep).

RISK FACTORS FOR MENINGITIS

  • Affects all ages with young children being most at risk.

  • Newborns are at risk for Group B strep.

  • Young children are at higher risk for meningococcal, pneumococcal, and Haemophilus influenzae infections.

  • Adolescents and young adults are at higher risk for meningococcal disease.

  • Older adults are at higher risk for pneumococcal disease.

  • Risk increases with close proximity living, mass gatherings (refugee camps, overcrowding, student/military housing), immunodeficiencies, and smoking.

SIGNS AND SYMPTOMS OF MENINGITIS

  • Symptoms may include:

    • Headache

    • Fever

    • Nuchal rigidity

    • Positive Kernig or Brudzinski sign

    • Photophobia

MANAGEMENT OF MENINGITIS

  • Prevention: Vaccines for meningococcus, pneumococcus, Hib; preventative antibiotics for high-risk individuals.

  • Treatment: Antibiotics that cross the blood-brain barrier, supportive care including bed rest, managing fever, and nutritional support.

ENCEPHALITIS

  • Definition: Acute inflammatory process of the brain tissue, often secondary to infections by viruses (often HSV), bacteria, fungi, parasites, or autoimmune responses.

  • Symptoms may include headache, stiff neck, sensitivity to light, confusion, seizures, fever, movement disorders, and LOC changes.

DIAGNOSIS AND TREATMENT OF ENCEPHALITIS

  • Diagnostics: Neuroimaging, lumbar puncture, EEG.

  • Treatment is based on the underlying cause:

    • Acyclovir for HSV

    • Antibiotics for bacterial infections

    • Immunotherapy for autoimmune conditions.

NEUROLOGICAL MOVEMENT DISORDERS

BELL'S PALSY

  • Definition: Facial paralysis caused by unilateral inflammation of the 7th CN (facial nerve).

  • Causes: Cause is unknown but associated with vascular ischemia, viral diseases, Lyme disease, autoimmune disease.

  • Manifestations:

    • Tearing

    • Painful sensations

    • Ear pain

    • Speech difficulties

    • Trouble chewing

    • Asymmetry, absence of wrinkling.

  • Treatment:

    • Corticosteroids, antivirals (Acyclovir), analgesics, electrical stimulation, and eye protection.

AMYOTROPHIC LATERAL SCLEROSIS (ALS)

  • Also Known As: Lou Gehrig's Disease; progressive neurodegenerative disease associated with loss of both upper and lower motor neurons.

  • Risk Factors: Affected between ages 40-70, more common in men, familial and environmental associations (military veterans 2x likelihood).

  • Symptoms: Include difficulty walking, tripping and falling, spasticity, muscle weakness, slurred speech, difficulty swallowing, and respiratory complications.

  • Diagnosis: Based on symptoms; no specific clinical/laboratory test but EMG and MRI can aid.

  • Treatment: No cure; medications to manage symptoms and supportive measures for respiratory function.

PARKINSON’S DISEASE

  • Description: Slowly progressing neurologic movement disorder leading to disability, second most common neurodegenerative disease.

  • Mechanism: Decreased levels of dopamine lead to an imbalance between excitatory and inhibitory neurotransmitters.

  • Cardinal Signs: Tremor, Rigidity, Akinesia/Bradykinesia, Postural instability (T-R-A-P).

  • Medical Management: Controlled by therapy with Levodopa (Larodopa) with Carbidopa (Sinemet) - risk of developing dyskinesia.

DEMENTIA, DELIRIUM, AND ALZHEIMER'S DISEASE

DELIRIUM

  • Definition: An acute state of confusion; short-term and reversible.

  • Risk Factors: Advanced age, concurrent illnesses, falls, male sex, dehydration, sleep deprivation, hypoxia.

  • Manifestations include inability to concentrate, disorganized thinking, irritability, and confusion.

DIAGNOSTICS FOR DELIRIUM

  • Involves history, physical examination, medication reconciliation, and lab tests (e.g., CBC, electrolytes).

TREATMENT FOR DELIRIUM

  • Pharmacologic Treatments: Sedatives, low-dose atypical antipsychotics, short-acting benzodiazepines for withdrawal.

  • Non-Pharmacologic Treatments: Safe environment, reassurance, pain management, promoting physical activity.

DEMENTIA

  • Definition: Chronic cognitive decline affecting memory, language, and learning.

  • Risk Factors: Advancing age, family history, biological sex, smoking, atherosclerosis, hypertension, diabetes, social determinants of health (SDOH).

  • Manifestations: Cognitive deficits including abstract thinking, judgment, and personality changes.

  • Diagnosis: Neuroimaging and decline from a previous level of function.

  • Treatment Goals: Maintain functional ability and reduce injury risks.

DEMENTIA VS DELIRIUM

Aspect

Dementia

Delirium

Description

Chronic, progressive cognitive decline

Acute confusional state

Onset

Slow, insidious

Abrupt

Duration

Months to years

Hours to < 1 month

Cause

Unknown; possibly familial

Multiple, medications, infections

Reversibility

No

Usually

Management

Treat symptoms

Remove/treat underlying cause

TOOLS FOR COGNITIVE ASSESSMENT

  • Mini-Cog and Mini-Mental State Exam: Recall, orientation tasks, and attention assessment.

ADDITIONAL RESOURCES

  • American Stroke Association, Johns Hopkins Medicine, WHO on meningitis, ALS Association, Parkinson's Foundation, Hopkins Medicine on Bell's Palsy, etc.