Transcript C S I

Neurologic Disorders:
The case of Mr. Smith
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 Mr. Don Smith, is a 63 year-old retired
retail store owner and lives in a small
town. He and his wife Joyce have three
grown children: Mark (38), Darin (35),
Stefanie (24).
 Don is reading the
paper one spring
morning (a daily ritual
in the Smith home) and
he tells his wife that he
feels a bit ‘funny’ but
can’t really put his finger on it.
 He confesses the following:
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 “I have a black spot in the middle of
my vision sometimes”
 “I have these spells that make me
feel far away”
 “I have moments of not
being with everyone”
 “I find it hard to get my
words out and can’t find
the right words”
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 Joyce was anxious about these statements
and decided to take her husband Don to the
local hospital.
 She called their son
Darin before they
left to let him know
what was happening.
 It was a 20 minute drive to the hospital and
by the time they got there, the symptoms
were gone.
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 Don was checked at the hospital by
the local on call family physician.
 The doctor told Don and Joyce that he
felt Don had a ‘mini-stroke’ and to go
home for the time being.
 The doctor prescribes Aspirin which
Mr. Smith takes.
 If any of the symptoms returned, Don
was to get driven to the hospital
immediately.
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Transient Ischemic Attack
 Temporary episode of impairment of blood flow
to a specific region of the brain due to
atherosclerosis, obstruction of cerebral
microcirculation by a small embolus, a
decrease in cerebral perfusion pressure (CPP)
or cardiac dysrhythmias.
 Manifested by a temporary neurological
dysfunction - sudden loss of motor, sensory, or
visual function. It may last a few seconds or
minutes but not longer than 24 hours.
 Complete recovery usually occurs between
attacks.
 A TIA is a sign of an impending stroke, with
greatest incidence within one month post TIA.
Medication for TIA
Medication
Action
Dose
Aspirin
Inhibits platelet
aggregation
650mg bid
 Joyce tells her children, Mark and Darin,
what the doctor said but can’t tell their
youngest child, who is a nurse, about the
incident as she is out of country on her
honeymoon.
 Don has two more of these episodes that
day and goes to the hospital with every
one of them.
 They are told that there is virtually
nothing that can be done at this point and
they return home each time.
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 Don’s 4th episode is much different…
 Later that night, suddenly Don,
 Can’t walk and collapses to the floor
 Can’t move his right arm
 Has slurred speech that is
incomprehensible
 Loses control of his bladder
 Doesn’t respond to Joyce’s cries
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 Joyce calls an ambulance and Don is
rushed to the emergency department.
 There he undergoes several tests…
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You receive Mr. Smith in ER
 What do you suspect?
 What tests do you anticipate?
 What do you want to do for him right
now?
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Initial Nursing Assessment
 Glasgow Coma Scale: Total
8/15
- Eye Opening: to speech (3)
- Verbal Response: confused (4)
- Motor Response: none (1)
 Vital Signs: T 36.5, P 42, R 24
and shallow, BP 80/40
 CMS: Patient’s skin is warm to
the touch but he is diaphoretic
only on his upper torso. Patient
complains that he cannot feel
his legs. A sensory test using a
tongue blade reveals that the
patient cannot feel anything
from the navel down
http://archive.student.bmj.com/issues/00/05/education/im
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Glascow Coma Scale
 An international method for grading
neurological responses in patients
who have a low level of consciousness
or potential for rapid deterioration in
level of consciousness.
 Assesses three parameters of
consciousness: eye opening, verbal
response, and motor response.
Initial Nursing Assessment in ER
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Mr. Smith’s findings
 Vital Signs: T 36.6, P 92, R 18, BP 160/84
 Glasgow Coma Scale: Total 10/15
- Eye Opening: to pain (2)
- Verbal Response: inappropriate (3)
- Motor Response: localizes pain (5)
 Assess Neurologic Signs:
- PERRLA: unilaterally dilated and poor response
- Aphasia
- Unable to recall events
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National Institute of Health
Stroke Scale
 15 item neurologic examination stroke
scale used to evaluate the effect of
acute cerebral infarction on the levels
of consciousness, language, neglect,
visual-field loss, extraocular
movement, motor strength, ataxia,
dysarthria, and sensory loss.
 Rates the patient’s ability to answer
questions and perform activities, scored
with 3 to 5 grades with 0 as normal.
 The evaluation of stroke severity depends
upon the ability of the observer to
accurately and consistently assess the
patient.
 Mean for left hemisphere death 17.6,
right hemisphere 23.2
 Can find summarized version Med-Surg
text p. 1894.
ER Physician Orders
 X-ray
 CT scan (Computed Tomographic)
 Lab: Cardiac Profile, CBC, Glucose,
Liver and Abdominal Panel, Group
and Screen for Blood
 Foley Catheter
 ECG
 1L Bolus of Normal Saline, then
reduce 100ml/hr
After initial assessment…
 Mr. Smith is ordered a STAT CT scan
of his brain
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CT Scan
CT Scan of the Brain
 When a CVA is suspected, a CT is used
to determine between ischemic and
hemorrhagic
 A hemorrhagic stroke will show a soon
after event, however it takes 6-12 hours
for an infarct to show in CT
 Contrast medium is used to produce a
clearer image of the brain tissue,
however it takes longer to perform so is
not usually used for urgent scans
 Scan investigates legions in the brain
(ex. defects, inflammation/edema,
masses, hemorrhage, infarct,
hematoma).
Categories of CVAs
 Transient Ischemic Attacks (TIAs): They
represent thrombotic particles causing an
intermittent blockage of circulation or
spasm. All neurologic deficits must be
completely clear within 24 hours, leaving
no residual dysfunction.
 A stroke-in-evolution: Intermittent
progression of a neurologic deficit over
hours to days. Abrupt onset but has a slow
progression over minutes to hours.
 Completed stroke: A CVA that has reached
its maximum destructiveness in producing
neurologic deficits. Cerebral edema may
not have yet reached its maximum .
 It is determined that Mr. Smith has
suffered a complete ischemic stroke.
 It is hard to tell at this point but the
neurologist has predicted that a blood
clot has lodged somewhere near Mr.
Smith’s midbrain in the internal
carotid artery near the circle of willis.
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Major Anatomical Division Of
the Nervous System
 Central Nervous System (CNS)
 consists of the brain and the spinal cord
 Integrates, processes, and coordinates
sensory data and motor demands
 Peripheral Nervous System (PNS)
 Delivers sensory information to CNS
(afferent division) and carries motor
commands to peripheral tissues and
systems (efferent division)
Functions of the Brain
Functions of the Brain
 The brain is the control center for the
body. It manages functions such as
breathing, moving and seeing.
 Thus, an injury to the brain can affect
almost any function of the body.
 Just as important, the brain also
controls thinking, emotions and
behavior.
 As a result, a brain injury can sometimes
change aspects of a person’s personality.
The Brain Stem
 The brain stem
regulates basic,
primitive body
functions
 Breathing
 Blood pressure
 Swallowing
Cerebellum
 The cerebellum
controls balance
and co-ordination
 Important note, is
that a right sided
injury to the
cerebellum causes
effects on the
right side of the
body
 The major portion of
the brain
 Divided into 2 major
parts:
 Right cerebral
hemisphere
 Left cerebral
hemisphere
 The left hemisphere
controls the right side
of the body and viceversa. Thus, an injury
to the right side of the
brain can cause
weakness or paralysis
on the left side of the
body.
Cerebrum
Occipital Lobe
 Interprets visual
information
 Colours
 Shapes
Temporal Lobe
 Visual and verbal
memory
 Including
interpretation of
emotions and
reactions
Parietal Lobe
 Receives signals
related to vision,
hearing, motor,
sensory, and
memory
Frontal Lobe
 Functions of this
lobe include
motor skills such
as voluntary
movement,
speech,
intellectual and
behavioral
functions
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 Ischemic Stroke
 80%
Hardening of the arteries
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 Ischemic Stroke
 Thrombotic
 Embolic
 TIA
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Ischemic CVAs
 Thrombolytic:
 Arterial occlusions caused by thrombi formed in the
arteries supplying the brain.
 Attributed mostly to atherosclerosis and inflammatory
disease processes that damage arterial walls; also
increased coagulation can lead to thrombus formation.
 Embolic:
 Involves fragments that break away from a thrombus
formed outside the brain, usually in the heart, aorta,
common carotid or thorax.
 The embolus usually travels into small vessels and
obstructs at a bifurcation or other point of narrowing,
thus causing ischemia. An embolus may plug the
arterial lumen entirely and remain in place or fragment
and move up into the vessel.
 Hemorrhagic stroke
 20%
 2 types
 Subarachnoid –
uncontrolled bleeding
on surface of brain
(between brain &
skull)
 Intracerebral – an
artery deep in brain
ruptures, usually due
to HBP
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Clinical Manifestations
 Cerebral edema reaches its maximum
in approx. 72 hours and takes
approx. 2 weeks to subside.
 Most individuals survive unless
massive edema results. Clinical
manifestations vary depending on the
artery obstructed and different sites
create different occlusion syndromes.
Hemorrhagic CVA
 Pathology:
 Hypertension involves primarily smaller
arteries and arterioles, resulting in a
thickening of the vessel walls and increased
cellularity of the vessels.
 Necrosis may be present and microaneurysms
precipitates the bleeding. A mass of blood is
formed as bleeding continues into the brain.
Brain tissue is displaced producing ischemia
and subsequent edema, increasing ICP.
Rupture or seepage occurs. It resolves during
reabsorbption, macrophages and astrocytes
appear to clear away the blood.
Hemorrhagic CVA cont’
 In hemorrhagic strokes (red stroke) bleeding
occurs into the infarcted area as a result of
restoration of blood flow. Reperfusion occurs
when the embolus fragments or lysis or
compressive forces lessen allowing blood to be
reestablished into the infarcted area.
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Clinical Manifestations
 Onset of excruciating generalized
headache with an immediate lapse into
unresponsiveness.
 If confined to subarachnoid space no
local signs. If bleeding spreads into
brain tissue, variations of paralysis
occur.
 Once a deep unresponsive state
occurs, person rarely survives.
 Immediate prognosis is grave.
 Hypertensive strokes are related to a
significant increase in systolic and
diastolic pressure over several years
occurring within the brain tissue. A mass
of blood is formed and its volume
increases and adjacent brain tissue is
compressed and displaced.
 Common causes:
 hypertension, ruptured aneurysms, vascular
malformations, bleeding into a tumor,
hemorrhage associated with bleeding
disorders or anticoagulation, head trauma
and illicit drug use.
 Risk factors:
 hypertension, previous cerebral infarct,
coronary artery disease and diabetes mellitus.
Other tests for Mr. Smith
 Blood work
 Foley catheter
 IV (get in soon
why?)
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Blood work to be done
 BUN, creatinine
 Lytes
 CBC
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 Blood tests
 Complete blood count (as well
as imaging procedures) help
determine the type of stroke
and rule out other conditions
such as infection and brain
tumor.
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Laboratory Results
 CBC- anemia, infection,
inflammation




Hematocrit - 0.410
Hemoglobin – 139g/L
RBC - 4.4 x 1012/L
Platelets 100 000 cells
(100x109/L)
 Glucose – 3.5
 Electrolytes
 Sodium – 144 mmol/L
 Potassium – 4.0 mmol/L
 Chloride 103 mmol/L
 BUN – 8.0 mmol/L
Other bloodwork tests…
 pTT, INR – student presentation
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Other Treatment Options
 Anticoagulants (ex. Aspirin, Coumadin
Heparin, Persantine, Plavix, Ticlid)
 Temperature control (acetaminophen,
ibuprophen, ice, cold cloths)
 Oxygen therapy
 Blood pressure management (Beta
blockers, Calcium channel blockers,
diuretics)
 IV hydration
 Other symptomatic treatment
ER Medications
Heparin (Blood formers, coagulators, and
anticoagulants)
 Does not break up existing thrombi, but
may prevent them from getting worse;
also prevents new thrombi
 Do not give if actively bleeding
 Monitor for signs of bleeding after
administration (fever,  BP, HR,
bleeding gums)
 Monitor pTT levels
Dexamethosone (Hormone and synthetic substitute
– adrenal corticosteroid, glucocorticoid, steroid)
 Long-acting drug with a large anti-inflammatory
effect as well as an immunosuppressive effect
 Monitor of S&S of Cushing’s syndrome (fatty
swellings in the interscapular area and face,
abdominal distension, ecchymosis, hypertension,
weakness, loss of muscle mass, psychosis)
Labetalol (ANS agent – alpha and beta adrenergic
antagonist)
 Produces vasodilation,  peripheral resistance
 Causes orthostatic hypotension, bradycardia,
delay of AV conduction, and depression of
cardiac contractility
 Monitor BP q5min x 30min after IV
administration, then q30 min x 2h, then qh x 6h
Nitroprusside (CV agent – Antihypertensive)
 Used for rapid short-term decreases in BP
 Lowers arterial BP, slightly increases HR and
decreases cardiac output, moderately lowers
peripheral resistance
 Results should occur within 2 minutes of
administration
 Monitor BP and I&O closely
Versed (midazolam HCl) (CNS agent – sedativehypnotic, benzodiazepine anxiolytic)
 It is a CNS depressant that relaxes skeletal
muscles –used as conscious and unconscious
sedation
 Results seen in 1-5min after IV administration
 Monitor vital signs for hypotension
 TIME IS BRAIN:
Treatment of
stroke
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tPA
tPA = tissue plasminogen activator
 Binds to fibrin and converts
plasminogen to plasmin which
stimulates fibrinolysis of the
atherosclerotic lesion. Must give with
in 3 hours decreases in the size of the
stroke and overall improvement in
function after 3 months.
Do we give Mr. Smith tPA?
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Eligibility criteria:
 Age: 18+
 Score under 22
 Onset less than 3 hrs and no seizure
 BP les than 185/110
 Not a minor or rapidly resolving stroke
 Not taking warfarin
 INR less than 1.7
 Has not received heparin during the past 48 hours
with elevated partial thromboplastin time
 Platelet count greater than 100,000
 Glucose between 3 and 22 mmol/L
 No MI
 No prior intracranial hemorrhage
 No major surgery within 14 days
 No stroke or head injury within 3 months
 No GI or urinary bleed within 21 days
 Not lactating or within 30 days postpartum
 Contraindications: symptom onset greater
than three hours prior to admission,
anticoagulated client, recent MI or intracranial
pathology. NIH score greater than 22.
 Must be assessed using the NIH Stroke Scale
 No anticoagulants to be administered in the
following 24 hours
 Dosage and admin: client is weighed and min
dose is 0.9mg/kg max dose is 90mg.
 Loading dose is 10% of calculated dose and is
administered over 1 min.
 Remaning dose admin over 1 hour via infusion
pump
 Line is flushed with 20 ml NS to ensure all is
administered
Patient History
Related dx
 TIA –several episodes that day
 Hypertension x 10 years
 Hyperlipidemia at least 10 years
(does not know how long)
 Atherosclerosis at least 10 years
(does not know how long)
Repeat CT
Repeat CT
May 4th: CT of head is acquired with
vascular enhancement and is
compared to a previous exam of
2 days ago. There is now a site
of hemorrhage contained within
the lentiform nucleus on the left
extending superiorly and medially
to involve the corpus callosum
and caudate nucleus. The site of
hematoma measures approx.
3cms in max diameter and is
associated with significant
surrounding edema and mass
effect.
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CCU Medications
Mannitol (Electrolytic and water balance
agent – Osmotic diuretic)
 Increases electrolyte excretion by the
kidney by raising osmotic pressure
 Used especially for elevated intraocular
and cerebrospinal pressure
 Monitor serum electrolyte and kidney
function, I&O, and vitals for changes in
BP and signs of CHF
 Rebound increase in ICP sometimes
occurs 12h post administration
 Mr. Smith makes continued progress
and is eventually transferred to 4W.
 He is in hospital for 3 months and
then transferred to a stroke rehab
hospital in Ottawa.
 There he gets the support he needs
to start his long recovery.
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Other tests Mr. Smith has
 Other tests
(Imaging)
 Carotid Doppler
 ECHO
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Mr. Smith has carotid dopplers
 Ultrasound
 Uses high frequency
waves to produce
images of blood flow
through the arteries
in the neck that
supply blood to the
brain (i.e. carotid
arteries) an may be
used to detect
blockage.
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 Mr. Smith requires extensive
rehabilitation. All interventions are aimed
at promoting independence and
supporting self-care abilities.
 He requires:
-speech therapy
-physiotherapy
-swallowing function test
-meeting with a dietitian
-modified medication regime
 Don Smith lives 1.5 years in the
rehab centre and is then discharged
home.
 Before he arrives at home, much hard
work and preparation is done
 Support poles and handrails in home
 No floor rugs/mats to avoid tripping
 Special modifications to the family
vehicle so Don can get in and out
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 Caregivers
“When someone close to
you suffers a stroke, the
emotional impact can be
tremendous, but as anyone
caring for a loved one after
a stroke knows, the
psychological challenges
are only half the story”.
Dr. Richard D. Zorowitz: Caring for a Stroke Victim
(2002)
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 One day, after supper, Mr. Smith goes
to his favourite chair after eating dinner.
 Joyce hears a loud bang in the living
room and rushed in from doing the
dishes.
 She found her husband
on the floor. She was
alone in the house.
 He had ‘chipmunked’ a
piece of meat from
dinner.
 Joyce began CPR and
called 911.
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 The ambulance came 30
minutes later and took Mr.
Smith to the hospital.
 Upon arrival, the nurse and doctor
stabilized Don. He was intubated and
put on life support but they knew that
the prognosis was grim.
 The physician ordered an EEG.
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Mr. Smith has an EEG
(Electroencephalogram)
 The results of the EEG were very
poor.
 Due to lack of oxygen to the brain,
Mr. Smith was
pronounced brain
dead.
 The family needed to
make a decision.
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 After being intubated on life support for 4 days,
there was no hope and Mrs. Smith signed the papers
for the machines to be turned off.
 Mark, Darin, and Stefanie supported their mother as
they all surrounded their father and watched him
slowly die. He slipped away peacefully.
 He was buried four days later.
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Family considerations
 Upon the patients death the nurse should
make arrangements for a priest, another
nurse, or physician to stay with the family
while the primary nurse performs after death
care; cleansing the patient, laying him flat,
preparing him and his room for viewing by his
family.
 Religious aspect: He and his family are
protestant; with the family’s consent it would
be appropriate to allow a priest to come in for
prayers with the family, and blessing of the
body.
 Speak with the family, offer condolences
and allow the family time to grieve, let
them know it’s alright to touch the body
and talk to their deceist loved one. If
they wish the nurse may stay with them
while they say goodbye to their family
member.
 Grief is an individual process that will
continue on long after the family has left
the hospital. Do not expect to be able to
console family members, just be there for
them if they need someone to talk to and
to help them deal with the situation.
Questions?
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You check your patient’s GCS
and find that he opens eyes to
your voice, he is confused but
obeys your commands. His GCS
result is a number of:





a) 10
b) 11
c) 12
d) 13
e) 14
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Answer
 d) 13
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Your patient has sustained a
large left sided brain infarct.
You suspect that the following
will be impacted…





a) speech deficits
b) swallowing concerns
c) vision loss
d) a and c only
e) a and b only
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Answer
e) a and b only (speech and swallowing)
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