Chapter 17, 18, 19: Acute Stroke Injury, Traumatic Brain Injury, Acute Spinal Injury Flashcards
What are medical, modifiable, and non-modifiable risk factors of stroke?
Medical: High cholesterol, high blood pressure, heart disease, atrial fibrillation, carotid artery disease, diabetes, coagulopathies.
Modifiable: smoking, obesity, excessive ETOH intake, drug abuse, sedentary lifestyles, poor diet habits.
Non-modifiable: age, gender, race, family history, prior stroke or TIA.
What is the pathophysiology behind stroke?
Atherosclerosis can lead to thrombus or embolus which cut off circulation. Global ischemia is complete lack of blood flow and irreversible damage. Focal ischemia some blood flow, some neurons survive, fix it quick. SAVE THE PENUMBRA. TPA.
What are the signs and symptoms of stroke?
Sudden: severe headache, trouble walking, dizziness, loss of balance, lack of coordination, confusion, trouble seeing (in one or both eyes), trouble speaking or understanding speech, numbness, weakness especially on one side of the body.
What medications can you give to someone who is having a stroke? What is the management of the medications?
TPA: infused over one hour. Give 10% IV push over 1 min. Total dose 0.9 mg/kg or max of 90 mg. Can give within 3 hrs but NOT recommended after 4 1/2 hrs. Perform frequent neurological assessments during and after the infusion including BP. If pt develops N/V, severe headache, or acute HTN stop infusion and notify physician immediately (these are adverse drug effects that can be life threatening). Pt w/ acute ischemic stroke d/t occlusion of proximal cerebral artery can administer TPA within 6 hrs.
Describe the nursing management of stroke in terms of initial priorities.
Initial priorities: Assess ABCs. Hemiplegia, dysphagia, a weak cough reflex, and immobility have a high risk for hypoxemia, pneumonia, and aspiration. Continuously monitor breath sounds, breathing patterns, oxygen saturation, skin color, arterial blood gases (ABGs, ability to handle secretions). Pt who is comatose and has evidence of increased ICP then intubate and mechanical ventilate. Prevent hypercapnia by monitoring rate and rhythm of breathing, ABGs, and LOC. HR and BP monitoring. Assess heart rhythm for dysrhythmias by continuous telemetry. Palpate peripheral and carotid pulses.
What factors lead up to traumatic brain injury?
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What is the pathophysiology behind traumatic brain injury?
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What are the signs and symptoms of traumatic brain injury?
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What medications can you give to someone who has a traumatic brain injury?
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Describe the nursing management of traumatic brain injury.
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What are the signs and symptoms of a UMN injury?
Weakness or paralysis, spasticity, increased tendon reflexes, + Babinski, loss of abdominal reflexes, little to NO muscle atrophy.
What are the signs and symptoms of a LMN injury?
Motor weakness, flaccidity, muscle wasting, loss of tendon reflexes if those neurons are involved, normal abdominal and plantar reflexes if neuron is preserved.
What are the signs and symptoms of spinal shock?
There is absence of all reflexes so pt is very flaccid and loses sensation below lvl of injury. Tachycardia, cold and moist, no deep tendon reflexes, no bladder tone, paralytic ileus, anhidrosis, loss of piloerection, no sweating, loss of vasomotor tone, prone to dependent edema.
How do you treat spinal shock?
Symptomatic tx. Self limiting, usually lasts 24 hours but can last up to 7-20 days.
How do you spinal shock patient is getting better?
Pt is getting better when DTRs return, is spastic, and increased muscle tone.
What causes spinal shock?
Due to acute cervical and upper thoracic spinal cord transections
What causes neurogenic shock?
Injuries above T6 which leads to loss of sympathetic vascular tone from hypothalamus
What are the signs and symptoms of neurogenic shock?
Massive vasodilation leading to systemic hypotension and pooling of blood in the lower extremities. Loss of SNS control. Loss of venous return to heart. Pt very hypotensive, bradycardic, decreased CO, inability to sweat below lvl of lesion, warm.
How do you treat neurogenic shock?
Fluid resuscitation
Vasopressor medications
What causes autonomic dysreflexia?
Distended bladder, fecal impaction, skin lesions: pressure ulcer, ingrown toenail, blisters. UTI, pain.
What are the signs and symptoms of autonomic dysreflexia?
Severe HTN (240/140), tachycardia, severe pounding bilateral HA, redness of the face, neck and trunk. Sweating, anxiety, blurred vision, SOB.
What are complications of autonomic dysreflexia?
If left untreated it can lead to retinal hemorrhage, hemorrhagic stroke, SAH, seizures, pulmonary edema, MI.
Describe nursing interventions of autonomic dysreflexia.
Find the cause and fix it to lower the BP. Nitro S/L to decrease BP. Palpate bladder to see if distended, if blocked irrigate through cath. Check tubing to see if it’s messed up. Do a bladder scan. Check for bowel impaction. Palpate and auscultate the abdomen. Loosen any constrictive clothing. Inspect skin. Educate regarding prevention.
Define stroke.
Occurs when the brain is not getting enough blood which injures brain tissue.
What is ischemic stroke? What three components make up ischemic stroke? Explain.
Ischemic stroke occurs when blood supply to a part of the brain is topped. There are three different types: Thrombotic and Embolic, and TIA. Thrombotic strokes are caused by a blood clot that blocks flow to a part of the brain due to narrowing of the artery. Happens when person is asleep. Emoblic strokes are caused by a blood clot that travels and gets stuck in an artery which blocks off blood flow to the brain. Happens when person is awake. Transient ischemic attack is like stroke but doesn’t leave damage and goes awak
What is hemorrhagic stroke? What two components make up hemorrhagic stroke?
Hemorrhagic stroke occurs when a blood vessel in the brain ruptures. There are one of two places the bleed can occur. Either in the brain (interacerebral hemorrhage) or the subarachnoid space (subarachnoid hemorrhage).
How does intracerebral hemorrhage occur, what happens as a result, and where is the most common place it happens.
Occurs suddenly without warning causing blood to accumulate in the brain (most common site is basal ganglia).
What causes intracerebral hemorrhage?
HTN (is the most common cause), anticoagulant therapy, AV malformations, aneurysms, trauma, and erosion of blood vessels by tumors.
How do you treat intracerebral hemorrhage?
Control BP, close observation, anticoagulation reversal of agent.
What causes subarahnoid hemorrhage?
HTN is the number one cause, weakening and dilatation of blood vessel walls, artherosclerosis
Where does subarachnoid hemorrhage occur?
The circle of willis
How do you diagnose subarachnoid hemorrhage?
CT scan (THE CHICKEN). Hunt and hess grading scale for SAH.
What are the signs and symptoms of subarachnoid hemorrhage?
Sudden severe HA on side of bleed described as “the worse HA of my life”, nuchal rigidity, photophobia, N/V, syncope, lethargy, 3rd and 4th CN palsy, hemiparesis, hemiplagia, aphasia, low back pain.
What is the treatment of subarachnoid hemorrhage?
Clipping or coiling
What is transient ischemic attack?
Brief episodes of focal neuro deficit that resolves in a few minutes or within 24 hours.
Does not cause permanent brain injury but is a warning sign of an impending stroke.
What causes transient ischemic attack?
Emboli from heart (atrial fibrillation)
or emboli from unstable plaque in a vessel.
What are signs and symptoms of transient ischemic attack?
Sudden: severe headache, trouble walking, dizziness, loss of balance, lack of coordination, confusion, trouble seeing (in one or both eyes), trouble speaking or understanding speech, numbness, weakness especially on one side of the body.
What is the treatment of transient ischemic attack?
Diagnostic workup to find root cause
Describe the nursing management of stroke in terms of nutrition.
Dietary consult. Evaluate ability to swallow. Nutrition provided through enteral route until pt is safe to swallow or percutaneous endoscopic gastrostomy is placed for long-term tube feedings.
Describe the nursing management of stroke in terms of preventing infections.
In pts with acute ischemic stroke or TIA give aspirin therapy at dose of 160-325 mg. In pts with acute ischemic stroke and restricted mobility give anticoagulant meds, LMWH or heparin between days 2 and 4 following administration of thrombolytic agents. Increased risk of bleeding; contraindicated in first 24 hrs after tPA treatment. If stroke was caused by embolism give chronic anticoagulation with warfarin (to maintain an INR of 2–3) or aspirin (325 mg/day) is indicated to decrease the risk for recurrent stroke. Don’t give these drugs together b/c increases risk of intracranial hemorrhage. Non-cardiac related embolic strokes give long-term antiplatelet regimen with aspirin (81–325/per day) within 48 hours of stroke onset. Young pts w/o discernable risk factors for stroke hypercoagulation work up is warranted. Manage seizures with benzos and anticonvulsant meds. Cerebral edema can occur which leads to neurologic deterioration & respiratory failure.
Define focal brain injuries.
Occur in a defined area of brain.
What are the different types of focal brain injuries?
Contusions and hematomas.
Describe contusions in terms of definition, level of injury, uncs, prognosis, and signs and symptoms.
A bruising of soft tissue. Level of injury is moderate to severe and detected on MRI. Longer periods of uncs. Guarded prognosis (watching for deterioration). Signs and symptoms include macroscopic tissue and vessel damage, focal deficits become more diffuse over time.
What are hematomas?
An accumulation of blood.
Describe epidural hematoma in terms of definition, what happens as a result, signs and symptoms, and treatment.
Arterial bleed
that happens between the middle meningeal artery that results in bleeding between dura mater and skull. As a result there is rapid bleeding with decreased o2 to tissues. Signs and symptoms include rapid neurologic deterioration (brief loss of consciousness immediately following the injury from the initial traumatic impact, followed by an episode of being alert and oriented, and then a loss of consciousness again as the growing hematoma exerts excessive pressure on the brain). Treatment is neurosurgery.
Describe subdural hematoma in terms of definition, what happens as a result, subtypes, signs and symptoms, and treatment.
Slow venous bleeding under the skull but outside the brain in the subdural space. As a result blood accumulates and increases ICP.
Acute (within 48 hrs), subacute (48hrs-2 wks), chronic (>2 wks).
Signs and symptoms include large hematoma, pupillary dilation on side of hematoma, altered LOC, seizures, vision field alterations, hemiparesis. Treatment ranges from watchful waiting to brain surgery for evacuation.
Describe intracerebral hematoma in terms of definition, causes, signs and symptoms, and treatment.
The accumulation of blood in the parenchyma of the brain rather than between the meningeal layers. Results from uncontrolled HTN, ruptured aneurysm, trauma. Signs and symptoms include HA w/ decreased LOC, dilation of one pupil, hemiplegia.
What are different types of diffuse brain injuries?
Concussions, diffuse axonal injuries, subarachnoid hemorrhage.
Describe concussion in terms of definition, level of injury, uncs, and signs and symptoms.
Blunt trauma to the lead (injury is microscopic). Mild traumatic injury not detectable on imaging. Transient period of uncs (
Describe coup and countracroup in terms of definition, causes, and symptoms.
Coup: the direct impact that caused the brain to hit the skull. Contracroup: the skull bouncing off the other side of the skull. Causes for both are the same: car accidents, assault, shake baby syndrome, falls, sports and athletic injuries. Symptoms are the same: impaired concentration,
impaired memory, difficulty swallowing, problems with balance and coordination, muscle weakness or paralysis, sensory changes.
What’s the difference between a secondary and primary injury?
Primary: the reason for the injury. Secondary: complications resulting from the primary injury.
What are the different types of skull fractures?
Linear, depressed, open, and basilar.
Describe linear skull fracture.
Straight line fracture in skull, no fragmentation. These are typically minor and not obvious. Usually discovered through CT. Not life threatening and heal on their own.
Describe depressed skull fracture.
There is fragmentation of bone. These occur with higher forces of impact. May be visible and papable, open or closed. Surgery to fix and drainage of hematoma if indicated.
