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95 Cards in this Set
- Front
- Back
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High blood pressure in an ischemic stroke patient puts them at risk for:
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Secondary hemorrhage (hemorrhagic conversion)
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Early sign of aspiration:
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Fever spike
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Where do we want BP in an ischemic stroke pt?
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A bit high to keep perfusion good in the brain
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How long do ischemic stroke patients need telemetry monitoring?
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24 hours
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Why do ischemic stroke pts need telemetry monitoring?
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Clot caused stroke = risk for MI
A-fib may be source of stroke |
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Where are brain vessels in relation to the dura?
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Subarachnoid
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Window of opportunity for TPA use:
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4.5 hours from symptom onset
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How does a-fib lead to stroke?
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Blood sits static in atrium and forms clots
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How do we determine if there are clots in the heart from a-fib?
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Echocardiogram
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Prophylactic tx for a-fib patients:
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Coumadin
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What sort of blood thinner do stroke patients need to be put on?
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Depends on source of clots
Heart, from a-fib? Anticoags Thrombotic? Anti-platelets |
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Symptoms of thrombotic vs. embolic stroke:
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Thrombotic has slower onset of symptoms, often TIAs too
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What vision deficit can a stroke lesion to the optic nerve cause?
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Bilateral (not bitemporal) hemianopia
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In stroke-induced bilateral hemianopia, which side of the visual field will be lost?
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The opposite side from the lesion
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Warning signs of stroke:
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Sudden numbness, especially on one side
Sudden confusion or trouble speaking/understanding Sudden vision deficits Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache |
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Define the zone of penumbra:
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Ischemic but savable cells
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Immediate stroke interventions:
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ABC
Cardiac monitoring O2 - keep SpO2 > 92% Assess for hypoglycemia!! Keep NPO CT scan |
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Define focal deficit:
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Symptom that points to a specific part of the brain
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What is the purpose of an immediate CT for suspected stroke?
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Rule out hemorrhage to decide on TPA
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Medical treatment for ischemic stroke:
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TPA
Aspirin |
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Time frame for TPA:
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Intravenous within 4.5 hours of symptom onset
Intraarterial within 6 hours of symptom onset |
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Nursing issues with stroke:
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Mobility
Swallowing Communication Vision Urinary/bowel |
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Dietary orders for new stroke patients:
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NPO until swallow study is done
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How do we check gag reflex?
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Tongue blade to the back of the throat
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Assessing swallow status:
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Assess gag reflex
Assess palatal elevation Drooling Feel throat and have pt swallow Start with some water |
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Assessing palatal elevation:
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Have pt say "aahhh" and check the roof of the mouth
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Aspiration precautions during meals:
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HOB at 90 degrees for eating
Tuck chin for swallowing Put food on unaffected side of mouth |
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What's the cause of gaze preference?
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Oculomotor dysfunction
Tend to gaze towards the injured side |
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Treatment for a hemorrhagic stroke:
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Supportive of symptoms, no curative treatment
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Presence of pre-op symptoms after surgery:
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Likely will still be there, but should recover. Should not get worse.
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Frontal lobe injuries can cause:
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Judgement issues
Lack of inhibition, impulsivity |
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Nursing concerns with frontal lobe injuries:
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Falls risk
Pulling out IVs, etc (impulsivity) Saying offensive things |
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Post-craniotomy primary concern:
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ICP (especially after tumor surgery) and cerebral edema
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When is cerebral edema the highest concern post-op?
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About 3 days later
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Sx of increasing ICP:
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Decreased LOC
Worsening headache Dilated pupils (late) Unequal pupils |
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Concerns post-craniotomy for tumor resection:
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ICP/cerebral edema
Seizures Hyperglycemia r/t steroids |
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Purpose of pronator drift test:
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For subtle motor deficits
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Performing pronator drift test:
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Hold arms out supinated
Check to see if arm drifts down and pronates |
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How much drainage do we expect from a craniotomy incision?
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Not much; call surgeon for excess drainage
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The Glasgow Coma Scale only tells us:
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Arousability level
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Glasgow Coma Score scale:
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3-15; 15 is most arousable
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Assessing cognition:
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Serial 7s
A&O (check all 4) Naming common objects |
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Components of a neuro check (major categories):
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Arousability
Cognition Motor Cranial nerves |
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Primary problem with increased ICP:
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Perfusion reduced
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Formula for cerebral perfusion pressure:
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CPP = MAP - ICP
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Where do we want CPP to be?
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60-70
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What causes increased ICP post-craniotomy?
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Inflammation in the brain cells leads to cellular edema and pressure rises in the cranium
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What happens to the brain's ventricles when ICP rises?
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They collapse
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What drug is used to treat increased ICP?
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Mannitol
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Administration of mannitol:
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IV
Use a filter Give it as fast as possible |
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Assessing for efficacy of mannitol tx:
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Serum sodium/osmolarity
Urine output Neuro check's |
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At what osmolarity do we stop mannitol treatment?
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310
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Early sx of increasing ICP:
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Headache
N/V Change in LOC Rapid, deep respiration Unilateral pupil dilation |
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Late sx of increasing ICP:
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Bilateral pupil dilation
Cushing's triad:* - irregular breathing pattern - widened pulse pressure - bradycardia |
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Anticipated orders from MD for sx of increasing ICP:
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Mannitol
CT scan |
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Nursing actions for increased ICP:
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Raise the HOB
Keep neck straight to promote venous outflow |
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Medical treatment to reduce intracranial volume:
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Diuretics
Ventricular drain |
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Medical treatment to increase MAP:
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Permissive hypertension
Vasopressors |
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Two broad categories of medical treatment for high ICP:
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Reduce intracranial volume
Increase MAP |
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Tonic phase of tonic-clonic seizure:
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Stiffen, arch back, stop breathing
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Clonic phase of a tonic-clonic seizure:
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Convulsions
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Dealing with a generalized motor seizure:
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Get pt on to side
Call MD Administer benzos if an order is present Time the seizure Make sure O2 and suction are working |
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How long should a seizure last, max?
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3 minutes
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Medical treatment of seizures:
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Immediate: benzo IV
Followed by: dilantin IV or keppra IV |
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Administering dilantin IV:
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Only with NS
50 mg/min max Can be very painful, so must be diluted a lot Extravasation will cause necrosis |
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Typical loading dose of dilantin:
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Up to 1gm
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Nursing actions post-seizure:
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Turn to side
Suction the mouth Nasal/oral airway if needed Monitor O2 Vital signs Neuro assessment |
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Characteristics of post-ictal phase:
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New hemiparesis or other focal deficit
Confusion Decreased arousability Progressive improvement |
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Characteristics of status epilepticus:
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Seizure lasting > 5min
Back to back seizures without full recovery May be non convulsive |
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What causes ischemic events in a pt s/p subarachnoid hemorrhage?
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Vasospasm
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How long should a subarachnoid hemorrhage pt be on vasospasm watch?
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14 days or so
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What is endovascular treatment with platinum coils?
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Aneurysm is filled with platinum via angiography
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Scale of Hunt-Hess grading scale:
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1-5, with 5 being the worst
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What produces CSF?
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Choroid plexus
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What reabsorbs CSF?
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Arachnoid villa
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What causes hydrocephalus after a subarachnoid hemorrhage?
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Extravasated blood clots, clogs arachnoid villa and blocks reabsorption of CSF
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Treatment of hydrocephalus:
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Ventricular drain
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Three big complications of subarachnoid hemorrhage:
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Hyponatremia
Hydrocephalus Vasospasm |
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What causes hyponatremia after a subarachnoid hemorrhage?
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Imbalance of brain naturitic peptide
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How does blood in the cranium affect body temperature?
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Can cause a fever
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How do we prevent consequences of vasospasm post-subarachnoid hemorrhage?
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nimodipine, a calcium channel blocker
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Why does nimodipine improve outcomes with post-hemorrhage vasospasm?
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Theory: having the CCB on board keeps the cell from being flooded with calcium in its ischemic state
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Direct treatment of vasospasm post-hemorrhage:
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Neuro angiography - balloon dilation, vasodilating drugs to site
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When does vasospasm occur in relation to a subarachnoid hemorrhage?
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4-14 days
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Why does hyperventilation affect ICP?
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Raises pH, causes vasoconstriction and rise in MAP and perfusion to the brain
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Confirmatory tests for brain death:
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Cold calorics
Apnea |
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Types of brain trauma:
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Subdural hematoma
Epidural hematoma Concussion Diffuse axonal injury (mild, moderate, severe) |
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Define diffuse axonal injury:
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Tearing/injury of axon tracts in brain stem/spinal cord due to deceleration movement of brain
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Very bad responses to pain stimulus:
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Flexion (bad)
Extension (very bad) |
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What does doll's-eye testing test?
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CN 3, 6, 8
Oculocephalic reflex Eyes should move opposite head movement; if they stay stable as if painted on, widespread brain stem injury |
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What does the cold caloric test?
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Oculocephalic reflex
When iced saline is injected into the ear, eyes should move, dizziness, n/v should occur If no eye movement at all, brain is not doing well. |
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Define decorticate posturing:
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Abnormal flexion of the arms
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Define decerebrate posturing:
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Abnormal extension of the arms, arching of back
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Decorticate/decerebrate posturing rule out:
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Brain death
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Describe apnea testing:
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Hyperoxygenate the pt
Take pt off the ventilator Draw blood gasses every x minutes Watch for any effort to breathe despite a rise in CO2 to 60 |
