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Neurological 3

  1. Two types of stroke by cause
    1. ischemic (also known as occlusive) stroke (clot) - slower onset
      1. results from inadequate blood flow leading to a cerebral infarction
      2. caused by cerebral thrombosis or embolism within the cerebral blood vessels
      3. most common cause: atherosclerosis
    2. hemorrhagic stroke (bleeding) - abrupt onset
      1. intracerebral hemorrhagic stroke
        • blood vessels rupture with a bleed into the brain
        • occurs most often in hypertensive older adults
        • may also result during anticoagulant or thrombolytic therapy
      2. subarachnoid hemorrhage (SAH)
        • most often caused by rupture of saccular intracranial aneurysms
        • more than 90% are congenital aneurysms
      3. epidural bleeds
        • arterial is involved
        • often loss of consciousness for a short period or called transient
        • recall clue: associate that "e" in epidural and "a" in artery are together at the top of the alphabet
      4. subdural bleeds
        • vein is involved
        • may not be evident until months after the initial trauma
        • recall clue: associate that "s" in subdural and "v" in vein are together at the bottom of the alphabet

    1. Findings (depends on location of lesion)

Types of CVA 

    1. Diagnostics
      1. History and physical exam
      2. Computerized tomogram (CT) scan (illustration)
      3. Magnetic resenance imaging (MRI) (illustration)
      4. Doppler echocardiography flow analysis
      5. Carotid artery duplex doppler ultrasonography
      6. EEG (illustration) - shows electrical activity
      7. Lumbar puncture (illustration) - shows if blood found in cerebral spinal fluid
      8. Cerebral angiography - shows blood flow
        1. may be done with or without contrast
    2. Management - to prevent or minimize the damaging effects of stroke; dependent on the type of CVA
      1. Expected outcomes:
        1. prevent or minimize the damaging effects of stoke
        2. is dependent on type of type of CVA
      2. Occlusive stroke
        1. pharmacologic
          1. thrombolytics
          2. anticoagulant therapy: heparin, coumadin
          3. antiplatelet therapy: aspirin, dipyridamole
            • platelet aggregation inhibitor: clopidogrel (plavix), ticlopidine HCL (ticlid)
          4. steroids: dexamethasone
        2. surgery - bypass
      3. Hemorrhagic stroke
        1. pharmacologic
          1. antihypertensive agents
          2. systemic steroids: dexamethasone (decadron)
          3. osmotic diuretics: mannitol
          4. antifibrinolytic agents: aminocaproic acid (amicar)
          5. vasodilators
          6. alpha-blockers and beta-blockers
          7. anticonvulsants
        2. surgical excision of aneurysm
      4. Common to both types of stroke
        1. care based on findings
        2. therapies:
          1. occupational
          2. speech
          3. nutritional support
    3. Nursing interventions
      1. In acute stage of stroke
        1. maintain airway patency; if grand mal seizure activity note time, length, behaviors
        2. monitor neuro vital signs
        3. maintain adequate fluids
        4. provide activity as ordered
        5. perform passive and/or active range of motion exercises
        6. position with head of bed elevated 15 to 30 degrees with client turned or tilted to unaffected side
        7. maintain proper body alignment
        8. administer medications as ordered
        9. care for post op client as indicated
        10. provide care for client with increased intracranial pressure 
      2. Long-term care of client with stroke
        1. monitor elimination patterns
        2. teach/evaluate the use of supportive devices
        3. maintain a safe environment
        4. prevent the effects of immobility
        5. maintain adequate nutrition in light of feeding and swallowing problems
        6. assist with eating and ADL as indicated
        7. provide emotional support
        8. provide methods of communication for client with aphasia
  1. Infectious, Inflammatory Disorders
    1. Meningitis (illustration 1  illustration 2)
      1. Definition/course
        1. acute or chronic inflammation of the meninges
        2. average length of illness is four months
      2. Types
        1. bacterial: most commonly meningococcus, haemophilus influenzae, pneumococcus
        2. viral
        3. fungal
        4. parasitic
      3. Findings
        1. severe headache
        2. fever
        3. nuchal rigidity(stiff neck)
        4. altered LOC
      4. Diagnostics
        1. history and physical exam
        2. positive Kernig's sign: 90-degree flexion of hip and knee with extension of knee causes pain
        3. positive Brudzinski's sign: flexion of neck causes flexion of hip and knee
        4. lumbar puncture (illustration) for characteristics of cerebral spinal fluid
      1. Management
        1. expected outcome: to cure the infection and prevent complications
        2. pharmacologic
          1. antibiotic therapy depends on type and pathogen
          2. preventive therapy for people exposed to those with meningococcal and H flu meningitis: rifampin (rifadin)
          3. H flu vaccine
        3. actions to minimize fever
        4. prevention of increased intracranial pressure or seizures
      2. Nursing interventions
        1. care of client with increased ICP 
        2. seizure precautions 
        3. administer drugs as ordered
        4. provide comfort measures for pain
        5. reduce external stimuli
    2. Parameningeal infections
      1. Definition
        1. localized collection of exudate in brain or spinal cord
        2. usually caused by bacteria
      2. Findings
        1. similar to meningitis
        2. headache, fever, stiff neck, altered consciousness
      3. Diagnostics
        1. NO lumbar puncture; may cause herniation
        2. computerized tomogram (CT) scan
      4. Management
        1. surgical decompression of abscess
        2. symptomatic and preventive treatment as with meningitis
        3. drugs: antibiotics
      5. Nursing interventions: same as meningitis