ADVANCED MEDICAL-SURGICAL NURSING I CASE SCENARIO THE CLIENT WITH NEUROLOGIC ALTERATIONS Prepared by: John Henry O. Valencia, RN, RM Master of Arts in Nursing tudent 55y/o male office worker has a history of HTN which had been treated with hydrochlorothiazide, when he suffered a stroke during an altercation with a neighbor. He is also a known diabetic, Type 1 and is on NH insulin co!erage e!ery morning. "n admission to the #$ of a nearby hospital, he was comatose. %ollowing a brain scan, which showed a large hemisphere lesion, and a spinal puncture, which re!ealed increased intracranial pressure and bloody spinal fluid, the client was diagnosed as ha!ing suffered an intracerebral hemorrhage. %ollowing administration of &'( ml )annitol solution *+, he slowly regained consciousness and was found to ha!e right hemiplegia and e,pressi!e aphasia. INSTRUCTIONS 1. *dentify the !earnin" iss#es -at least ./ related to pathophysiology -%ocus on Neuro/ that you can draw out from this case. '. repare to discuss these learning issues with the class on Tuesday, 0eptember 1(, '(1& after the 2+ case scenario discussion. 1. %rom your 3ournal readings, what can you draw out as an identified pathophysiologic contro!ersial issue related to neurological care4 ro!ide a short discussion based on your 3ournal resources. &. 5our written answer to 6 1 7 1 will be submitted ne,t Tuesday8s class. Typed in 9& size, arial narrow, font 11. DIA$ETES MELLITUS T%&E ' :eta 2ell ;estruction <ack of *nsulin release $educe Tissue uptake of =lucose age ( of ) *ntracellular Hypoglycemia #,tracellular Hyperglycemia *ncrease =lucogenesis and =luconeogenesis :reakdown of %ats ;ecrease rotein 0ynthesis 2ache,ia, <ethargy and olyphagia ;ecrease > globulins *mpaired wound healing Hyperosmotic lasma ;ehydration of cells ;ecrease arterial fle,ibility *ncreased 9rterial 0tiffiness :lood =lucose ? $enal threshold =lycosuria *ncreased @rine 0pecific =ra!ity "smotic ;iuresis $990 9cti!ation *ncreased :lood +olume H%&ERTENSION *ncreased =lycoprotein cell wall deposits 9ccelerated 9therosclerosis %ormation of laAue deposits Thrombosis "cclusion of )a3or :lood +essel *% )9N9=#;B ossibleB D* cranial 2T scan, ;oppler, #T scan, )$*, cerebral angiography, lumbar puncture, ##=/#2=, skull ,Cray, carotid ultrasonography T* aspirin, thrombolytics, carotid stenting, hypothermia, anticoagulants, surgical decompression -hemicraniectomy/, carotid endartectomy =@9$;#; $"=N"0*0 *% N"T )9N9=#;B <ysed or )o!ed Thrombus from the !essel +ascular wall becomes weakened and fragile <eaking of blood from the fragile !essel INTRACERE$RAL HEMORRHAGE age + of ) *% )9N9=#;B Dx: !" scan, MR#, cerebral angiography, arteriography, lu$bar puncture, s%ull &'ray Tx: chronic hypertensi(es, surgical deco$pression, e(acuation and aspiration, ad$inistration of fresh fro)en plas$a *ith fibrinogen or cryoprecipitate Hematoma e!acuation %ormation of ca!ity surrounded by dense gliosis D 1( ml hemorrhage 1(CE( ml hemorrhage ? E( ml hemorrhage oor prognosis *ntermediate prognosis =ood prognosis Decreased ICP *% N"T )9N9=#;B 0,B, headache, unconsciousness, nausea+(o$iting, (isual disturbances )ass of blood forms and grows :lood seeps into the !entricles "bstruction of 20% passageway 9ccumulation of 20% in the !entricles +entricles dilate behind the point of obstruction INCREASED IC& *% )9N9=#;B Ventriculosto$y, VP shunt, #!P Monitoring 9lternati!e route for return of 20% in the circulation 2ompression of brain tissues will not occur =uarded rognosis *% N"T )9N9=#; @nrelie!ed obstruction %ormation of small and large hematomas <odges onto other cerebral arteries +asospasms of tissue and arteries CERE$RAL H%&O&ER,USION *mpaired distribution of o,ygen and glucose Tissue hypo,ia and cellular star!ation 2erebral *schemia *nitiation of ischemic cascade )ismatch of cerebral bloodflow and metabolic demands -"' F =lucose/ #lectric %ailure *onic pump failure otassium efflu, -from neurons/ 0odium *nflu, -into neurons/ 2alcium influ, 9naerobic metabolism by mitochondria =enerates large amounts of lactic acid <actic 9cidosis %ailure production of adenosine triphosphatase %ailure of energy dependent process -ion pumping/ age - of ) hospholipase 9' 9cti!ation 9rachidonic 9cid 9cti!ation -and other free fatty acids/ 2ycloCo,ygenase <ipoCo,ygenase Hydropero,ides <eukotrienes rostagladin #ndopero,ides Thrombo,ane 9' -potent !asoconstrictor and platelet aggreagnt/ roduction of o,ygen free radicals and other reacti!e o,ygen species $elease of e,citatory neurotransmitter glutamate *nflu, of calcium 9cti!ates enzymes that digest cell proteins, lipids and nuclear material %ailure of mitochondria TRANSIENT ISCHEMIC ATTAC. %urther energy depletion ;amage to the blood !essel endothelium *% )9N9=#;B Ct'PA ,uro%inase, strepto%inase- 'calciu$ channel bloc%ers *% N"T )9N9=#;B =uarded rognosis :rain sustains an irre!ersible cerebral damage 9lters cerebral metabolism ;ecreased 2erebral perfusion ;amage of hemisphere of brain 2ascade of biochemical processes 2ompression of tissue *schemic cascade threaten cell )embrane depolarization of cell wall *nflu, of sodium age / of ) edema +ascular 2ongestion *ncreased intracranial pressure *mpaired cerebral perfusion and function )iddle 2erebral 9rtery 9nterior cerebral artery osterior 2erebra* 9rtery *nternal 2arotid 9rtery +ertebrobasilar 0ystem 9nteroinferior 2erebellar osteroinferior cerebellr <ateral hemisphere, frontal, parietal and temporal lobes, basal ganglia .rontal /obe Occipital lobe0 anterior and $edial portion of te$poral lobe 1ranches into ophthal$ic, P!A, anterior choroidal, A!A, M!A !erebellu$ and brain ste$ !erebellu$ !erebellu$ S* 2ontralateral hemiparesis or hemiplegia, unilateral neglect, altered consciousness, homonymous hemianopsia, inability to turn eyes toward affected side, !ision changes, dysle,ia, dysgraphia, aphasia, agnosia, memory deficits, !omiting S* 2ontralateral hemiparesis, foot and leg deficits greater than the arm, foot drop, gait disturbances, contralateral hemisensory alterations, de!iation of eyes toward affected side, e,pressi!e aphasia, confusion, amnesia, flat affect, apathy, shortened attention span, loss of mental acuity, apra,ia, incontinence S* )ild contralateral hemiparesis, intention tremor, diffuse sensory loss, pupillary dysfunction, loss of con3ugate gaze, nystagmus, loss of depth perception, cortical blindness, homonymous hemianopsia, perse!eration, dysle,ia, memory deficits, !isual hallucinations S* contralateral hemiparesis with facial asymmetry, contralateral sensory alterations, homonymous hemianopsia, ipsilateral periods of blindness, aphasia if dominant hemisphere is in!ol!ed, )ild Horner8s syndrome, carotid bruits S* 9lternating motor weaknesses, ata,ic gait, dysmetria, contralateral hemisensory impairments, double !ision, homonymous hemianopsia, nystagmus, con3ugate gaze, paralysis, dysarthria, memory loss, disorientation, drop attacks, tinnitus, hearing loss, !ertigo, dysphagia, coma S* *psilateral ata,ia, facial paralysis, ipsilateral loss of sensation in face, sensation changes on trunk and limbs, nystagmus, Horner8s syndrome, tinnitus, hearing loss 0,B 9ta,ia, paralysis of the laryn, and soft palate, ipsilateral loss of sensation in face, contralateral on body, nystagmus, dysarthria, Horner8s syndrome, hiccups and coughing, !ertigo, nausea and !omiting age 0 of ) *% )9N9=#;B alliati!e careC %reAuent !ital sign and neuro!ital signs, intubation, mechanical !entilation, !asodilators, osmotic diuretics, !entriculostomy, *2 monitoring *% N"T )9N9=#;B 2ontinued insufficiency of blood flow %urther compression of tissues 2omatose 2erebral ;eath <oss of neural feedback mechanisms 2essation of physiologic functions =ood cerebral perfusion =ood impro!ement =ood rognosis 2ardio!ascular 0ystem "ther systems <oss of cardiac muscle function 0ystemic %ailure DEATH $ela,ation of !enous !al!es 0,B bradycardia 0,B hypotension ;ecreased cardiac output ulmonary 0ystem %ailure of accessory muscles for breathing <oss of lung mo!ement 0,B apnea 2ardiopulmonary arrest =astrointestinal Tract $ela,ation of intestines and sphincters <oss of bowel control =enito@rinary 0ystem Neurogenic bladder <oss of sphincter control 0,B restlessness, abnor$al ther$oregulation, $ental confusion, increased secretions, decreased urinary output. "ther 0ystems LEARNING ISSUES A1 ISCHEMIC CASCADE as a res#!t of !a23 of $!oo4 S#55!y to t6e 7rain 4#e to 6aemorr6a"e #MPOR"AN" "2P O. "H2 #!HA2M#! !A!A32: '1 Githout adeAuate blood supply and thus lack of o,ygen, brain cells lose their ability to produce energy C particularly adenosine triphosphate -9T/. (1 2ells in the affected area switch to anaerobic metabolism, which leads to a lesser production of 9T but releases a byCproduct called lactic acid. +1 <actic acid is an irritant, which has the potential to destroy cells by disruption of the normal acidCbase balance in the brain. -1 9TCreliant ion transport pumps fail, causing the cell membrane to become depolarizedH leading to a large influ, of ions, including calcium -2aII/, and an efflu, of potassium. /1 *ntracellular calcium le!els become too high and trigger the release of the e,citatory amino acid neurotransmitter glutamate. 01 =lutamate stimulates 9)9 receptors and 2aIICpermeable N);9 receptors, which leads to e!en more calcium influ, into cells. 81 #,cess calcium entry o!ere,cites cells and acti!ates proteases -enzymes which digest cell proteins/, lipases -enzymes which digest cell membranes/ and free radicals formed as a result of the ischaemic cascade in a process called e,citoto,icity. age 8 of ) )1 9s the cellJs membrane is broken down by phospholipases, it becomes more permeable, and more ions and harmful chemicals enter the cell. 91 )itochondria break down, releasing to,ins and apoptotic factors into the cell. ':1 2ells e,perience apoptosis. ''1 *f the cell dies through necrosis, it releases glutamate and to,ic chemicals into the en!ironment around it. To,ins poison nearby neurons, and glutamate can o!ere,cite them. '(1 The loss of !ascular structural integrity results in a breakdown of the protecti!e blood brain barrier and contributes to cerebral oedema, which can cause secondary progression of the brain in3ury. :. age ) of )