Cerebrovascular Accident (Stroke)

• Cerebrovascular Accident (CVA), commonly known as a stroke, involves the interruption of blood supply to the brain, leading to cell death and neurological deficits.

Types of Stroke

• Ischemic Stroke: Caused by a blockage in a blood vessel supplying the brain, such as thrombosis or embolism.
• Hemorrhagic Stroke: Caused by bleeding into or around the brain due to a ruptured blood vessel, the most fatal form of stroke, with hypertension as a main cause.

Signs and Symptoms of Stroke

• Sudden numbness or weakness in the face, arm, or leg, especially on one side.
• Confusion, trouble speaking, or understanding speech.
• Difficulty seeing in one or both eyes.
• Trouble walking, dizziness, or loss of balance and coordination.

Management of Stroke

• Thrombolytics for ischemic strokes and surgical intervention for hemorrhagic strokes.
• More common in males and individuals over 65.
• Risk Factors: Hypertension, diabetes mellitus, sickle cell disease, substance abuse, and atherosclerosis.
• Cells and cerebral blood vessels swell, decreasing blood flow; vasospasm and increased blood viscosity further impede blood flow.
• Penumbra: The central core of dead or dying cells surrounded by minimally perfused cells, which may survive if adequate circulation is re-established through early thrombolytic agents.

Types of Ischemic Stroke

• Transient Ischemic Attack (TIA): A brief period of localized cerebral ischemia causing neurologic deficits lasting less than 24 hours, usually 1-2 hours and serves as a warning signal for ischemic thrombotic stroke.
• Etiology: Inflammatory artery disorders, sickle cell anemia, and atherosclerotic changes in cerebral vessels, thrombosis, and emboli.

Thrombotic CVA

• Occlusion of a large cerebral vessel by thrombus, often in older persons resting or sleeping when blood pressure is lower.
• Thrombi tend to form in large arteries that bifurcate, with narrowed lumens due to atherosclerotic plaque.
• Common locations of thrombi: Internal carotid artery, vertebral arteries, and the junction of vertebral and basilar arteries.
• Lacunar strokes: Thrombotic strokes affecting smaller cerebral vessels, leaving small cavities or "lakes".
• Develops rapidly and progresses slowly, beginning as TIA and worsening over 1-2 days, known as stroke-in-evolution, with the maximum neurologic deficit reached in 3 days, called completed stroke, and the damaged area is edematous and necrotic.

Embolic CVA

• Occurs when a blood clot or clump of matter traveling through cerebral blood vessels lodges in a vessel.
• Most frequent site of cerebral emboli is at the bifurcation of vessels, specifically the carotid and middle cerebral arteries.
• Clients are usually younger and active, with most embolic strokes originating from thrombus in the left chambers of the heart during atrial fibrillation: cardiac embolic CVAs.
• Other sources of emboli: Carotid artery atherosclerotic plaque, bacterial endocarditis, and recent myocardial infarction.

Hemorrhagic Stroke

• Occurs most often in persons with a sustained increase in systolic-diastolic pressure.
• Other factors: Ruptured intracranial aneurysms, trauma, erosion of blood vessels by tumors, arteriovenous malformations, anticoagulant therapy, and blood disorders.
• Blood vessel ruptures causing blood to enter blood tissue, cerebral ventricles, or the subarachnoid space, compressing adjacent tissues leading to blood vessel spasm and cerebral edema.
• Manifestations: Sudden onset, focal, usually one-sided, with weakness of the face as the most common symptom.
• Other symptoms: Numbness on one side, loss of vision in one eye, speech difficulties, and balance issues.
• Complications: Motor deficits.

Glasgow Coma Scale (GCS)

• A neurological scale used to assess a patient's level of consciousness after a brain injury, including mental status and abnormality detection.
• Components:
  • Eye Opening (1-4): Ranging from no eye opening to spontaneous eye-opening.
  • Verbal Response (1-5): Ranging from no verbal response to oriented.
  • Motor Response (1-6): Ranging from no motor response to obeying commands.
• Scoring: A score of 7 or below indicates a coma.

Cranial Nerves Functions and Examination

• Olfactory (I): Smell
• Optic (II): Vision
• Oculomotor (III): Eye movement, pupil constriction
• Trochlear (IV): Eye movement downward and inward
• Trigeminal (V): Sensation of the face, mastication
• Abducens (VI): Eye movement laterally
• Facial (VII): Facial expressions, taste (anterior 2/3 of tongue)
• Vestibulocochlear (VIII): Hearing and balance
• Glossopharyngeal (IX): Taste (posterior 1/3 of tongue), swallowing
• Vagus (X): Autonomic functions, swallowing, speech
• Accessory (XI): Shoulder and neck movement
• Hypoglossal (XII): Tongue movement

Homonymous Hemianopsia

• Visual field loss on the same side of both eyes, typically resulting from damage to the optic tract or visual cortex.
• Causes: Strokes, tumors, or traumatic brain injuries
• Assessment: Difficulty seeing objects on one side; Visual field testing confirms the diagnosis.
• Management: Rehabilitation strategies, including visual field training and compensatory techniques.

Types of Aphasia

• Inability to use or understand language.

Types of Aphasia

• Expressive/Broca's Aphasia (Non-fluent): Motor speech problem, can understand and respond in short phrases.
• Receptive/Wernicke's Aphasia (Fluent): Sensory speech problem, cannot understand verbally and written, fluent but inappropriate.
• Mixed/Global Aphasia: Language dysfunction in both understanding and expression.
• Dysarthria Aphasia: Disturbance in muscular control of speech.

Multiple Sclerosis (MS)

• A chronic autoimmune disease affecting the central nervous system (CNS), leading to demyelination of nerve fibers.
• High incidence in young adults (20-40), more females, and common in temperate climates (Caucasians).

Signs and Symptoms of MS

• Fatigue
• Numbness or tingling
• Muscle weakness
• Difficulty with coordination and balance
• Vision problems, such as blurred or double vision
• Cognitive changes

Management of MS

• Medications: ACTH, Glucocorticosteroids, Immunosuppressants, antispasmodics, anticholinergics, and cyclophosphamide.
• Focus on health education and prevention of respiratory and urinary tract infections.

Parkinson's Disease

• A progressive neurodegenerative disorder with the tremors at rest, muscle rigidity, and akinesia (poor movement); cause unknown.
• Older adults (60s), males.
• Possibly occurs with some medications, encephalitis, or toxins (reversible).

Signs and Symptoms of Parkinson's Disease

• Tremors at rest
• Bradykinesia (slowness of movement)
• Rigidity (muscle stiffness)
• Postural instability
• Akinesia

Medications for Parkinson's Disease

• Levodopa/Carbidopa (Sinemet): The most effective treatment for motor symptoms.
• Selegiline (Carbex), amantadine (Symmetrel), and anticholinergics.
• Bromocriptine (Parlodel) and pergolide (Permax): Inhibit dopamine breakdown.
• Complications: Dyskinesias, cognitive decline, and increased risk of falls.
• Pallidotomy: Destruction of involved tissue.
• Stereotaxic thalamotomy: Destroys specific tissue involved in tremor.

Seizures/Convulsions

• Sudden, uncontrolled electrical disturbances in the brain that cause changes in behavior, movements, feelings, and consciousness.

Signs and Symptoms of Seizures

• Aura (warning signs)
• Loss of consciousness
• Convulsions (uncontrolled jerking movements)
• Postictal state (confusion, fatigue after a seizure)

Management of Seizures

• Immediate Care: Ensure safety, protect the patient from injury, and do not restrain movements.
• Medications: Antiepileptic drugs (e.g., levetiracetam, phenytoin) to control seizures.
• Laboratory Tests: EEG to assess electrical activity in the brain.

Nursing Interventions for Seizures

• Monitor vital signs and neurological status.
• Document seizure activity (duration, type, and postictal state).
• Educate patients about medication adherence and seizure triggers.

Meningitis

• Inflammation of the protective membranes covering the brain and spinal cord, often caused by infection.

Signs of Increased Intracranial Pressure (ICP)

• Headache
• Nausea and vomiting
• Altered level of consciousness
• Papilledema (swelling of the optic disc)

Clinical Tests for Meningitis

• Brudzinski's Sign: Involuntary lifting of the legs when the neck is flexed.
• Kernig's Sign: Inability to straighten the leg when the hip is flexed at 90 degrees.
• Lumbar Tap: A procedure to collect cerebrospinal fluid (CSF) for analysis to help diagnose the cause of meningitis (bacterial vs. viral).

Alzheimer's Disease

• Progressive neurodegenerative disorder characterized by memory loss, cognitive decline, and behavioral changes.
• Risk factors: Older age, female, and family history.
• Average life expectancy is 7 years from diagnosis to death (pneumonia or aspiration).
• Types: Familial (inheritance pattern) and sporadic, early onset (<65), and older onset (>65).

Signs and Symptoms of Alzheimer's Disease

• Memory loss, especially recent events
• Difficulty with problem-solving and planning
• Confusion with time or place
• Changes in mood and personality
• Problems with language and abstract thinking

Management of Alzheimer's Disease

• Medications: Cholinesterase inhibitors (e.g., donepezil) to improve symptoms.
• Treatments: Cognitive therapies, environmental modifications, and caregiver support; promotion of functional abilities and safety.

Guillain-Barré Syndrome (GBS)

• An autoimmune disorder where the body's immune system attacks the peripheral nervous system, leading to muscle weakness and paralysis (acute inflammation).

Signs and Symptoms of GBS

• Rapid onset of weakness, often starting in the legs and ascending.
• Tingling or numbness.
• Difficulty with eye movement, facial expressions, and swallowing.

Management of GBS

• Medications: Antibiotics, morphine (pain control), anticoagulants (thromboembolic complications), and vasopressors.
• Plasmapheresis or IVIG to reduce the immune response.
• Supportive Care: Physical therapy and rehabilitation to regain strength.

Myasthenia Gravis

• An autoimmune neuromuscular disorder characterized by weakness and rapid fatigue of voluntary muscles.

Signs and Symptoms of Myasthenia Gravis

• Muscle weakness that worsens with activity and improves with rest
• Ptosis (drooping eyelids)
• Difficulty swallowing and speaking

Management of Myasthenia Gravis

• Medications: Anticholinesterase agents (e.g., pyridostigmine) to improve neuromuscular transmission.
• Immunosuppressants: Corticosteroids (glucocorticoids) or other immunosuppressive drugs to reduce the immune response.
• Cyclosporizine and azathioprine (Imuran).
• Thymectomy: Surgical removal of the thymus gland may improve symptoms in some patients.

Sensory Disorders

Cataract

• A clouding of the lens in the eye leading to decreased vision.

Signs of Cataract

• Blurred or cloudy vision
• Difficulty with night vision
• Sensitivity to light and glare

Surgical Management of Cataract

• Cataract Surgery: The cloudy lens is removed and replaced with an artificial lens (intraocular lens).

Nursing Interventions After Cataract Surgery

• Monitor for signs of infection (redness, discharge)
• Educate the patient on eye care and the importance of follow-up appointments
• Advise on activity restrictions (e.g., avoid heavy lifting, bending over)
• Patients may need to wait several weeks for their vision to stabilize before getting new glasses.

Ménière's Disease

• Disorder of the inner ear that can lead to vertigo, hearing loss and tinnitus.

Triad of Signs of Ménière's Disease

• Recurrent episodes of vertigo
• Fluctuating hearing loss
• Tinnitus (ringing in the ears)

Causes of Ménière's Disease

• The exact cause is unknown, but it is thought to be related to fluid buildup in the inner ear.

Dietary Management of Ménière's Disease

• Low-Sodium Diet: Reducing salt intake can help decrease fluid retention
• Avoidance of Caffeine and Alcohol: These substances can exacerbate symptoms