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Altered Cognitive Fx
Care of the Client - K. Wolz - podcast notes
| Question | Answer |
|---|---|
| What is a characteristic of an Open Head Injury? | There is communication between the outside world and the inside of the brain. |
| What are examples of closed head injuries? | CVA, Concussion, Subarachnoid hemorrhage, Trauma, Post Concussion Syndrome, Aneurysm/Bleeds, Degenerative Diseases |
| What is unique about the symptomatology of Altered Cognitive Functioning regardless of the etiology/underlying disease processes? | Allot of the symptoms stay the same, though the treatments may be different. |
| Define TIA. | Transient Ischemic Attack is a neurological symptom that lasts less than 1 hr. |
| What is RIND? | Reversible Neurological Deficit. This was also an ischemic attack, but it lasted longer like 3-5 days. They have since determined that this no longer exists. |
| What is the characteristics of a stroke? | If a patient has symptoms of a CVA, and it lasts longer than 1 hr, even if it is not identifiable on MRI or CT scan. |
| If a TIA persists longer than an hour, what is it called? | CVA - Cerebrovascular Accident |
| What special diagnostic test can identify TIA or RIND as strokes? | DWI MRI |
| What do CT scans and MRI identify? | Location of vessels, geographic locations, but NOT PHYSIOLOGY. |
| What does a PET scan identify? | Physiology based on uptake of glucose, which identifies active cells. |
| CT scans can be with or without contrast, so what are considerations? | Allergies, protecting kidney function, due to dye. |
| Which test is useful in an emergent situation? | CT scan with or without contrast |
| What is a potential cause of a TIA or CVA? | Blocked carotid artery. |
| Where does blood flow from the carotid arteries and what do symptoms of a block resemble? | Carotid artery come off the neck and feeds the front part of the brain. So the symptomatology is like a classic stroke. |
| Symptoms of stroke include: | Weakness, facial drooping, paralysis on one side of the body, facial numbness, blurred vision, decreased LOC, severe headache |
| How is a blocked carotid artery diagnosed? | Ultrasound or Duplex Scan |
| What is a treatment for blocked carotid artery? | Carotid endartectomy if blockage is >70%. |
| Post-carotid endartectomy patients go to ICU. Why? | Vascular suture line is vulnerable to increase in blood pressure. This is a main artery, so risk for hemorrhage is high with a poor outcome likely. Surgical site in the neck could swell and has the potential to occlude the airway. |
| If a high-risk patient cannot tolerate a carotid endartectomy, what is the treatment approach? | Carotid stent. This is high risk due to proximity to barorecptors causing high fluctuations in BP, HR, possibly arrythmias. |
| Post carotid stent, patients go to ICU and are closely monitored for what? | Bleeding, stroke. |
| Why are older patients more likely to survive a vascular accident? | Development of collateral circulation with age. Every decade of life increases collateral circulation. |
| What are synonymous terms for stroke? | Brain attack or CVA |
| What is the most common disease of the nervous system? | CVA/Brain attack |
| What is the third highest cause of death in the US? | CVA/Brain attack |
| Why does it matter what the etiology of the CVA was even though we are not diagnosticians? | Because it determines the course of treatment. |
| What do we ask the family to help determine the cause of the CVA? | What was happening when the symptoms occurred? |
| What are possible activities that would elicit an embolic stroke? | Running on a treadmill, dancing, physical activity |
| What is a possible activity that would elicit a hemorrhagic stroke? | Cocaine use |
| What is an indicator of a thrombotic stroke? | Patient was at rest, difficult to arouse with facial drooping. |
| What are signs and symptoms dependent on? | The area of brain involvement. |
| Nursing care of the CVA patient relate to what? | ABCs and ADLs. |
| Define CVA. | Sudden interruption in adequate supply of blood, oxygen, and nutrients to the brain causing death to brain cells. |
| What do vertebral arteries feed? | The back of the brain. Cerebellum, which is responsible for motion and movement. |
| What do carotid arteries feed? | The front of the brain, so facial drooping is seen. |
| What are symptoms of a vertebral artery stroke? | Lack of Coordination and balance, vertigo, nausea and vomiting, diaphoresis, dizziness...very exaggerated. |
| What types of questions would you ask a neuro patient? | Do you have trouble bringing a spoon to your mouth? Can you touch your nose with your finger? Can you stand up and walk? Are you having trouble with emotions (labile)? |
| How is a vertebral artery stroke treated? | Not with surgery, because the arteries are too small and inaccessible. They are given platelet aggregation medication, frequently Aggrenox. This is persantine and aspirin. |
| What are non-modifiable risk factors for CVA? | Age over 55, Males, Blacks or Hispanics, Family History |
| What are modifiable risk factors for CVA? | Smoking, obesity, HTN, alcohol or cocaine use. |
| Why does the black population have an increased risk for CVA? | Noncompliance with HTN medications. Could be due to side effects like impotence. Should be placed on a different medication to ensure compliance. Black patients do not experience a drop in BP overnight as other populations do, so dosage should be bid. |
| Why shouldn't a man be on a beta blocker (-olol)? | Side effect: impotence. |
| Why does the hispanic population have an increased risk for CVA? | Diet |
| What is the immediate effect of cocaine? | Raise BP SKY HIGH!! (Hemorrhagic stroke) |
| What happens to BP in most people overnight? | It drops. |
| What does the phrase "Time is Brain" mean? | If the patient can recognize the symptoms, call 911, and get to the ER and get diagnosed, within 3 hours of start of symptoms, they can reverse the clot. |
| What is tPA? | Tissue Plasminogen Activator. It is a clot busting drug. |
| What do we do if a patient is NOT a candidate for tPA? | Airway and ventilatory support to prevent secondary injuries, prevent hyperglycemia, monitor and manage BP, Mag sulfate, Heparin, ASA, Plavix. |
| Why is preventing hyperglycemia so important? | Because it doesn't take a very elevated blood sugar to damage a vessel. |
| Why is there a risk for hyperglycemia in the CVA patient? | Because the body is stressed and it is going to go through glyconeogenesis and is going to burn glycogen stores which will pump a large amount of sugar into the blood. |
| Why is preventing hypotension so important? | BP under 90 is an acute episode that can damage the kidneys, and other organs quickly. |
| What is the easiest way to treat low blood pressure? | Fluid bolus of about 500 mLs of Normal Saline. |
| How can you tell if a patient can tolerate a rapid infusion of a 500 mLs fluid bolus ? | Can you chug a can of Coke? Then you can handle the bolus. |
| What is more damaging hypertension or hypotension? Why? | HYPOtension, because the body can learn to tolerate HTN. |
| How do we MANAGE blood pressure? | With vasopressors or vasodilators. Vasopressors will be Dopamine as your first choice, but it will raise the HR. If you have a pt who is tachycardic, dopamine may not be a good choice. |
| If you can't use Dopamine, what will you use? | Levophed, which is norepinephrine, raises the BP with no effect on the HR. |
| What do we use Magnesium Sulfate for? | It prevents vessels from spasm. It prevents spasm in the circulation collateral to the stroke site. Low magnesium will cause a spasm, which creates a secondary hypoxia injury. |
| KNOW HEPARIN DOSING!!! | . |
| What changes has evidence based practice made in ASA dosing? | We are no longer seeing the Baby aspirin dosing. We are seeing one adult dose now, 300mg vs 162 mg. |
| What type of anti-platelet medication is best for carotid disease? | Aggrenox. |
| What are 3 anti-aggregation meds? | Plavix, Ticlid, Aggrenox. |
| What are ways to PREVENT stroke? | Physical exercise, control stress, control HTN, good nutrition, maintain healthy weight, NO SMOKING, ALCOHOL OR DRUG ABUSE! |
| What are ways lay people can recognize a stroke? | (STAR)S: Ask the person to SMILE; T: Ask the person to TALK; R: Ask the person to RAISE both arms; Have the person stick out their tongue. (FAST) Face/Arms/Smile/Time. Trouble with any ONE of these is a sign of stroke. |
| Brain tumor symptoms are dependent on what? | Focal symptoms: What part of the brain is being compressed, ie an Occipital tumor could see eye changes. Frontal tumor could see personality/judgment changes. |
| What is the onset of symptoms for a brain tumor? | Gradual onset, because the tumor is growing slowly. |
| When does a brain tumor hurt and why? | Not until there is pressure on the meninges, because there are no pain receptors in the brain. |
| What are surgical options for brain tumors? | Craniotomy to remove the tumor; Stereotaxis and Radiation are where you use a gama knife to take the brain and map it and you destroy part of the tissue; Chemotherapy |
| What is a complaint of treatment for brain tumors? Why does that happen? | The patient has a personality change and is never the same. This happens because the brain is made up mostly of water, as are the cells, and healthy cells surrounding the tumor will uptake the radiation and die along with the tumor cells. |
| What is a challenge with Chemotherapy of a brain tumor? | The blood-brain barrier, so there are very few Chemotherapeutic agents that can be used. |
| What is the life expectancy of a patient with a malignant brain tumor? | About 2 years. |
| What are symptoms of brain tumor? | Dizziness, vertigo, balance, forgetfulness. This will seem clear retrospectively but not necessarily while it is occurring. |
| What are 2 types of Closed Head Injuries? | Concussion and Cerebral Contusion |
| Define Concussion | A Concussion is a transient state of partial or complete paralysis of cerebral functioning with loss of function and no residual damage. |
| Define Cerebral Contusion. | A Cerebral Contusion is a partial or complete dysfunction of CNS functioning that persists longer than 12 hours with organic damage to the brain. |
| What are s/s of concussion and diagnostics? | You may fall, vomit afterward, but there are no geaographic changes on CT scan. |
| How do you fix a Cerebral Contusion? | This is a bruise in the brain tissue. You can't fix a bruise. You have to wait and let it reabsorb. You can't take it out or put ice on it. As it swells, it will put pressure on structures and cause damage. |
| What are s/s of Post Concussion Syndrome? | Different personality: Headache and persistent irritability, emotional lability, easily fatigued, poor concentration, can impair job performance. (ie naked guy, swearing, slapping). |
| How long does Post Concussion Syndrome last? | Several days to 1 year. After 1 year, it becomes permanant. |
| Does the patient recognize the effects of Post Concussion Syndrome? | No. The patient is not aware that their personality has changed and is not aware of the new symptoms. |
| What characterizes a Linear Skull Fracture? | There is no displacement of the bone. |
| What characterizes a Depressed Skull Fracture? | It is a pressing down on the brain. They may need to go in and remove bone fragments. |
| Why is a Basal Skull Fracture a cause for concern? | Because the brain is dark, moist, full of sugar and CLEAN, while the nose and mouth are dirty, so a communication between the two is a risk for meningitis. |
| What do you look for in a Basal Skull Fracture? | CSF leaking through the nose or the ears. |
| How do you test for CSF? | You test for the presence of glucose. Halo or glucose-stick. |
| What are s/s of Basal Skull Fracture? | Owl's/Raccoon's eyes, or Battle signs - bleeding over the mastoid with bruising. |
| Define Hematomas. | A hematoma forms when a head injury forms a mass lesion that leads to increased intracranial pressure (ICP). |
| What is the most important of the 3 types of hematoma? | Epidural hematoma. |
| Why is it the most important? | Because it is usually an arterial bleed, which bleeds quickly, so sudden onset. |
| Define Epidural hematoma. | An Epidural Hematoma is a collection of blood between the inner table of the skill and the outermost layer of the dura. Frequently associated with skull fractures & middle meningeal artery laceration. |
| Epidural Hematoma has CLASSIC clinical presentation. What are they? | Brief loss of consciousness, followed by a period of lucidity (up to 12 hrs) and then a rapid, progressive deterioration in LOC; Dilation of pupil on that side (ipsilateral); Decorticate/Decerebrate posturing. |
| What famous actress just dies of an Epidural Hematoma? | Natasha Richardson |
| What is the treatment for an Epidural Hematoma? | Surgery to evacuate the clot and cauterize the bleeding vessels. |
| How is Epidural Hematoma diagnosed? | Symptoms and CT scan |
| What is the prognosis after surgical intervention if an Epidural Hematoma is caught early? | Excellent prognosis. |
| Define a Subdural Hematoma. | A Subdural Hematoma is an accumulation of blood between the dura and the underlying arachnoid membrane. It is usually venous with an insidious onset. Often associated w/cerebral contusions and intracerebral hemorrhage. |
| Define the classification of Acute SDH and s/s. | Occurs within 48 hours; headache, drowsiness, agitation, confusion, decreased LOC, pupil dilation, and hemiparesis. (Like MVA) |
| Define the classification of Subacute SDH and s/s. | Occurs in 2 days to 2 weeks; headache, drowsiness, agitation, confusion, decreased LOC, pupil dilation, and hemiparesis, but s/s appear slowly. (Like a developing bruise) |
| Define the classification of Chronic SDH and s/s. | Occurs in 2 wks to months; progressive lethargy, absent mindedness, headache, vomiting, seizures, ipsilateral pupil dilation, or contralateral hemiparesis. |
| What causes a shrink in the size of the brain? | Aging, Alcoholism, Dementia, Alzheimer's, Diabetes, COPD, drug addiction, bleeding and clotting disorders, chemo |
| What is the significance of the shrinking of the brain as it relates to an SDH? | The more excess space their is in the cranial cavity, the longer a bleed can bleed without pressing on the brain. |
| Why are Alcoholics prone to SDH? | Falls, bleeding coagulopathies, liver issues. |
| What medication causes an increased risk of SDH? | Coumadin, anticoagulants, |
| What is the treatment for SDH? | It depends on the size. Small SDH, depending on the patients condition and the underlying condition, will be allowed to reabsorb on its own. Large SDH will require a surgical intervention where they will go in and remove the clot. |
| Define Intracerebral Hematoma. | An Intracerebral Hematoma results when there is bleeding within the cerebral tissue. |
| What is the treatment for Intracerebral Hematoma? | May be surgical or non surgical and involves the management of ICH. |
Created by:
Kitty Groebli
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