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RECOGNIZING THE SIGNS OF A NEURO EMERGENCY
Noorin Darvesh BScN, RN, CNN (C)
Clinical Nurse Educator, Unit 58
South Health Campus
Department of Clinical Neurosciences
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DISCLOSURES
• None
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WHO AM I?
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WHO ARE YOU?
Source: Retrived from URL. https://www.google.ca/search?q=who+are+you%3F&rlz=1C5CHFA_enCA768CA768&source=lnms&tbm=isch&sa=X&ved=0ahUKEwizy72kvbTeAhUjhOAKHTbnDqAQ_AUIDigB&biw=1440&bih=721#imgrc=1aRj08uriEj0lM:
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OUTLINE
• Case
• Objectives
• Discussion
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CASE STUDY
On January 26th, 2018, a 76-year-old male patient was admitted to the inpatientneurology ward with a diagnosis of an ischemic posterior inferior cerebellar artery(PICA) stroke. His primary deficit was ataxia, but could still ambulate with stand-byassistance to the bathroom.
Source: Retrived from URL. https://www.researchgate.net/figure/A-B-Cerebellar-infarct-in-the-distribution-of-the-posterior-inferior-cerebellar-artery_fig18_288579276
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• On the night of January 27th at approximately 0200, the patient’s daughterrang the patient’s call bell, as her father verbalized that he needed to go tothe bathroom.
• As the primary nurse was ambulating the patient, she noticed an increase inhis gait disturbance, and he required the assistance of 2 nurses to go to thebathroom. The patient reported unspecific visual disturbances, a low-gradeheadache, and appeared more confused in conversation.
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a) Let the patient sleep. He’s probably just tired.
b) Nothing. It is normal to have worsening of symptoms after an acute stroke due to cerebral edema.
c) Phone the on-call physician. Something is not right.
As the primary nurse, what would be your intervention for this patient?
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OBJECTIVES
• Analyze the anatomy and pathophysiology of the signs and symptoms present
• Identify the signs and symptoms of increased intracranial pressure (ICP) following a PICA stroke
• Outline the most anticipated nursing interventions utilized
• Hopefully influence your decision to choose C in the future
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ANATOMY
Posterior Circulation Diagram. Retrieved from URL:https://www.google.ca/search?q=posterior+circulation+stroke&rlz=1C5CHFA_enCA768CA768&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi44oqB_bDeAhVzKH0KHXBkDwwQ_AUIDigB&biw=1440&bih=721#imgrc=hlewarlgb-nhtM:
https://www.google.ca/search?q=posterior+circulation+stroke&rlz=1C5CHFA_enCA768CA768&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi44oqB_bDeAhVzKH0KHXBkDwwQ_AUIDigB&biw=1440&bih=721#imgrc=hlewarlgb-nhtM
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COMMON SYMPTOMS
• Headache
• Nausea/Vomiting
• Dysphagia/Dysarthria
• Horizontal Nystagmus
• Ataxia
• Vertigo
(Nouh, A., Remke, J., Ruland, S. (2014).
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WHY ARE WE WORRIED?
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MONROE-KELLIE HYPOTHESIS
Source:Retrieved from URL:https://canadiem.org/tiny-tips-ich-for-ich-brain-herniation/Source:Retrieved from URL: http://www.trauma.org/archive/neuro/icp.html
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HEADACHE
Source:(2016). Retrieved from URL: http://freeofpain.org/occipital-neuralgic-headaches/
When the full PICA cerebellar territory is involved, headache is usually present in the occiput or high neck on the ipsilateral side. (Caplan, L.R. (2018).
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PUPILLARY & OCULAR ABNORMALITIES
Source:Retrieved from URL:https://www.researchgate.net/figure/Clinical-manifestations-of-medial-pontine-syndrome-A-Body-representation-of-the_fig8_308065354
• CN III – originates from the midbrain
• CN IV – originates from the pons
• CN V1 – originates from the pons
• Cerebellum
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EMESIS
Source: (2011). Retrieved from URL: http://benbbrave.blogspot.com/2011/10/vomiting-centre.html
• Fourth ventricle located in the medulla
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DETERIORATION IN LOC
Source: Retrieved from URL:http://health-and-medicine.wikia.com/wiki/Brain
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POSTURING
Source: Retrieved from URL: http://betterpicf.pw/Decorticate-vs-Decerebrate-Posturing-posturing-Easy-read.html
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NURSING INTERVENTIONS
Notify MRHP:
Patient may require transfer to a hyper-acute neurological unit for further monitoring or surgical intervention
Source: Retrieved from URL: https://allnurses.com/first-year-after/50-things-new-982436.html
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OUTCOME
Source: Retrived from URL. https://journals.lww.com/neurotodayonline/blog/breakingnews/Pages/post.aspx?PostID=363
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QUESTIONS?
Source:Retrieved from URL:https://www.shutterstock.com/search/hands+up
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REFERENCES
• Caplan, L.R. (2018). Posterior circulation cerebrovascular syndromes. UpToDate, Inc.
• Hickey, J.V. (2014). The clinical practice of neurological and neurosurgical nursing. Philadelphia, PA:Lippincott Williams & Wilkins.
• Majid, A., Kassab, M. (2018). Pathophysiology of ischemic stroke. UpToDate, Inc.
• Nouh, A., Remke, J., Ruland, S. (2014). Ischemic posterior circulation stroke: a review of anatomy, clinicalpresentations, diagnosis, and current management. Frontiers in Neurology, 5(30). 1-16.
• Sharifi, M., Cisczek, B. (2013). Bilaterally absent posterior inferior cerebellar artery: case report. Surgicaland Radiologic Anatomy (2013). 35 (7). 623-625.
Recognizing the signs of a neuro emergency DisclosuresWho am i?Who are you?OutlineCase StudySlide Number 7Slide Number 8ObjectivesAnatomy Common SymptomsWhy are we worried?Monroe-Kellie Hypothesis HeadachePupillary & Ocular abnormalitiesEmesisDeterioration in LOCPosturingNursing interventionsoutcomeQuestions?References