Chapter #45

A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate? A. Loss of vision B. Brain stem herniation C. Intense headache D. Projectile vomiting

B. Brain stem herniation

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? A. Approaches the client on the affected side B. Covers the affected eye C. Encourages turning the head from side to side D. Places objects in the client's field of vision

B. Covers the affected eye

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? A. Dexamethasone (Decadron) B. Hydrochlorothiazide (HydroDIURIL) C. Mannitol (Osmitrol) D. Phenytoin (Dilantin)

C. Mannitol (Osmitrol)

Primary TBI

can be mild, moderate, or several with open v. closed head injuries

Causes of a Hemorrhagic Stroke

caused from vessel damage from a Thrombotic/Embolic Stroke, ischemia, or severe/sustained HTN

Secondary TBI

characterized as any process that occurs after the initial injury which worsens patient outcome; these processes can include hypotension, hypoxia, increased ICP, hemorrhage, hydrocephalus, brain herniation, and temperature dysregulation

Severe TBI

characterized by a 3-6 GCS, loss of consciousness greater than six hours, focal/diffuse brain damage (along with cerebrovascular vessels + ventricles), open or closed injuries, tissue damage is seen early on scans, managed in CCU, hemodynamic monitoring, neurologic status, ICP monitoring, and are high risk of secondary injury (ex. cerebral edema, hemorrhage, reduced perfusion, bimolecular cascade)

Modifiable Risk Factors for Stroke Development

includes smoking, substance use (especially cocaine), obesity, sedentary lifestyle, oral contraceptives, heavy alcohol use, and the use of PPA which is found within antihistamines

Stroke Signs & Symptoms

includes sudden confusion, trouble speaking or understanding others, sudden numbness/weakness (face/arm/leg), sudden trouble seeing, dizziness, trouble walking, loss of balance/coordination, and a sudden + severe headache

Poor TBI Prognostic Sign = "blown pupils"

"blown" pupils which are characterized by wide, non-reactive pupils

Arteriovenous Malformation

(aneurysm) dilated and entangled blood vessels caused by a congenital absence of capillary network that forms from an abnormal communication between the Arterial & Venous Systems, rupture, and then a Hemorrhagic Stroke

TBI Interventions

1. ABCs 2. SCI w/ Spinal Precautions 3. ABGs & Capnography 4. Vital Signs 5. Monitor for Abnormal Posturing + Flaccidity 6. Basilar Skull Fracture (clear fluid out of ears/nose or raccoon eyes)

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? A. "I should spend all my time with my husband in case I'm needed." B. "My husband may get depressed." C. "My husband must take his medicine every day to prevent another stroke." D. "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

A. "I should spend all my time with my husband in case I'm needed."

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? A. Achieving the highest level of functioning B. Increasing cerebral perfusion C. Preventing further injury D. Preventing skin breakdown

A. Achieving the highest level of functioning

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? A. Assesses airway, breathing, and circulation B. Calls the provider C. Performs a neurologic check D. Assists the client to a sitting position

A. Assesses airway, breathing, and circulation

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? A. Changes in breathing pattern B. Dizziness C. Increasing level of consciousness D. Reactive pupils

A. Changes in breathing pattern

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. A. Giving tepid sponge baths B. Applying a hypothermia blanket C. Covering the client with blankets D. Administering acetaminophen per protocol E. Placing ice packs over the client's abdomen and in the axilla and groin

A. Giving tepid sponge baths B. Applying a hypothermia blanket D. Administering acetaminophen per protocol standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the patient ice packs could cause shivering which increases cellular oxygen demands and has the potential to increase ICP

Which are risk factors for stroke? Select all that apply. A. High blood pressure B. Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives E. Female gender

A. High blood pressure B. Previous stroke or transient ischemic attack (TIA) C. Smoking D. Use of oral contraceptives

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. A. The client is aphasic. B. The client has weakness on the right side of the body. C. The client has complete bilateral paralysis of the arms and legs. D. The client has weakness on the right side of the face and tongue. E. The client has lost the ability to move the right arm but is able to walk independently. F. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

A. The client is aphasic. B. The client has weakness on the right side of the body. D. The client has weakness on the right side of the face and tongue. hemiparesis is weakness of one side of the body that may occur after a stroke involving weakness of the face and tongue, arm, and leg on one side which requires assistance with feeding, bathing, & ambulating complete bilateral paralysis does not occur in hemiparesis

Interventions for Sensory Perception Impairment

ALWAYS approach the patient on the unaffected side

A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? A. A-V-P-U B. F-A-S-T C. K-I-N-D D. O-P-Q-R-S-T

B. F-A-S-T

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? A. Aphasia and cautiousness B. Impulsiveness and smiling C. Inability to discriminate words D. Quick to anger and frustration

B. Impulsiveness and smiling

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? A. Calling the Stroke Team B. Establishing an IV C. Positioning the client to prevent aspiration D. Preparing for thrombolytic administration

C. Positioning the client to prevent aspiration

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about? A Amnesia B. Asymmetric pupils C. Headache D. Head laceration

B. Asymmetric pupils

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which manifestations would the nurse expect? Select all that apply. A. Constant smiling B. Intellectual impairment C. Deficits in the right visual field D. Disorientation to time, place, and person E. Inability to discriminate words and letters

B. Intellectual impairment C. Deficits in the right visual field E. Inability to discriminate words and letters patients experiencing a left hemisphere stroke display an inability to discriminate words and letters, intellectual impairment, and deficits in the right visual field. disorientation, constant smiling, and neglect of left visual field are manifestations of a right hemisphere stroke

The patient's wife must leave her husband's bedside for 2 hours to run errands. Which nursing action is appropriate to contribute to patient safety while she is gone? A. Apply restraints. B. Maintain the bed in a low position. C. Sit with the patient until his wife returns. D. Place the call light in the patient's right hand.

B. Maintain the bed in a low position.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? A. Assessing for Grey Turner's sign B. Maintaining neutral head position C. Placing the client in the Trendelenburg position D. Suctioning the client frequently

B. Maintaining neutral head position

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? A. "A combination of treatments might be necessary." B. "In a craniotomy, holes are cut in the skull to access the tumor." C. "I can go home the day of my craniotomy." D. "The goal is to decrease tumor size and improve survival time."

C. "I can go home the day of my craniotomy."

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? A. "Call hospice." B. "Check the Internet." C. "The National Stroke Association has resources available." D. "The charge nurse at the desk has all of the information."

C. "The National Stroke Association has resources available."

The nurse understands which symptom is the earliest indicator of increased intracranial pressure when caring for a patient with a head injury? A. Increased pupil size B. Nausea and vomiting C. Agitation and confusion D. Elevated blood pressure

C. Agitation and confusion

The patient needs assistance with feeding, but can swallow well. To whom should the nurse delegate this responsibility? A. Hospital volunteer B. Licensed practical nurse C. Certified nursing assistant D. Student nurse doing first patient care experience

C. Certified nursing assistant

CASE STUDY: The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine. What is the priority nursing intervention for this patient at this time? A. Provide perineal care. B. Assess for gag reflex. C. Elevate the head of the bed. D. Perform a linen and gown change.

C. Elevate the head of the bed.

A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? A. Embolic stroke B. Hemorrhagic stroke C. Thrombotic stroke D. Transient ischemic attack

C. Thrombotic stroke

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? A. "Next time you eat, try lifting your chin when you swallow." B. "Let's advance your diet to solid food." C. "Let's see if the dietitian can help." D. "Let's see if the speech-language pathologist can help."

D. "Let's see if the speech-language pathologist can help."

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? A. "Frequent stimulation will help with the rehabilitation process." B. "My spouse will no longer need to take blood pressure medication." C. "Rehabilitation and physical therapy are the same thing." D. "The rehabilitation therapist will help identify changes needed at home."

D. "The rehabilitation therapist will help identify changes needed at home."

A client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates a correct understanding of the nurse's discharge teaching? A. "I will have to quit my job to care for my spouse." B. "Life will be back to normal soon." C. "The case manager will provide home care." D. "We can find a support group through the local American Cancer Society."

D. "We can find a support group through the local American Cancer Society."

The nurse is monitoring a client after supratentorial surgery. Which sign/symptom does the nurse report immediately to the provider? A. Periorbital edema B. Bilateral ecchymoses of both eyes C. Moderate amount of serosanguineous drainage on the head dressing D. Decorticate positioning

D. Decorticate positioning

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? A. Glasgow Coma Score (GCS) B. Intracranial pressure monitor C. Mini-Mental State Examination (MMSE; mini-mental status examination) D. National Institutes of Health Stroke Scale (NIHSS)

D. National Institutes of Health Stroke Scale (NIHSS)

Brain Tumor Drug Therapy

Dexamethasone can be administered to decrease edema, Phenytoin to prevent seizures, Ranitidine for stress ulcer preventions (or PPIs), Stereotactic Radiosurgery, and focused radiation to the intracranial lesion

Secondary TBI- Hypotension

MAP < 70 mmHg or hypoxia < 80% low blood flow + hypoxemia contribute to cerebral edema, creating a cycle of deteriorating perfusion with hypoxic damage (delivery of oxygen & glucose to the brain is interrupted)

What is the antidote to Coumadin?

Vitamin K

Transient Ischemic Attack (TIA)

a "warning sign" of transient focal neurologic dysfunction with a brief interruption in cerebral blood flow, usually resolves within 30-60 minutes, reoccurrence can cause brain damage, requires a complete neurologic assessment (rapid from RN), and placement on anticoagulants

Other Stroke Nursing Interventions- Secondary Brain Injury

a secondary injury may result from dysthymia, blood sugar issues, or temperature fluctuations

TBI Respiratory Monitoring

all TBI patients should be monitored for respiratory problems, diaphragmatic breathing, and diminished or absent reflexes in the airway as the Upper Cervical Neves innervate the diaphragm to control breathing; hypoxia & hypercapnia are best detected through PaO2, SpO2, and EtCO2 so be sure to observe chest wall movements and listens o breath sounds + report any sign of respiratory problems immediately

Post-Op Craniotomy

assess neurologic status + vital signs every 15-30 minutes for the first 4-6 hours (then every hour); report as well as document new neurologic deficits, such as a decreased LOC, motor weakness, paralysis, aphasia, decreased sensation, sluggish pupil reaction to light, and personality changes (ex. agitation, aggression, passivity) ALSO monitor patient dressing for excessive amounts of drainage, reporting > 50 mL/8 hr or a saturated dressing

CRITICAL RESCUE of a Stroke Assessment

assess the stroke patient within 10 minutes of arrival including ABCs and alert of stroke teams/center for management

Carotid Stent Placement Patient Education

before discharge, teach the patient to report the following to their provider of a severe headache, change in LOC or cognition (ex. drowsiness or new-onset confusion), muscle weakness, motor dysfunction, severe neck pain, swelling at the neck incisional site, hoarseness, or difficulty swallowing due to nerve damage = prevent or manage an Acute Ischemic Stroke with moderate sedation (Femoral Artery insertion)

Epidural Hematoma

bleeding which occurs into the space between the Dura Mater and inner skull, requiring neuro checks to be performed every 5-10 minutes if suspected (may lead to loss of consciousness & neurosurgery)

Older Adults & TBI

brain injury is the 5th leading cause of death in older adults commonly caused by falls or MVCs and 65-75 year olds have the 2nd highest incidence; factors which can contribute to high mortality are when falls cause a Subdural Hematoma (especially when chronic), closed head injuries, poorly tolerated systemic stress that's increased by a high-stimuli environment, medical complications (ex. hypotension, HTN, cardiac), decreased protective mechanisms causing the patient to be susceptible to infection (ex. Pneumonia), and decreased immunity

Secondary TBI- Herniation

brain swelling pushes down toward the brainstem and signs/symptoms include Cheyne-Stokes Respirations (fast/deeper followed by a gradual decrease + stop in breathing of apnea), pin-point ^ non-reactive pupils, and hemodynamic instability

Mild TBI

characterized by a blow to the head, transient confusion or daze/disorientation, loss of consciousness for 30 minutes (does NOT have to occur for diagnosis), loss of memory of events immediately before or after the accident, or focal neurologic deficits which may be permanent; there is NO evidence of brain damage on scans and symptoms include headache, dizziness, and changes in behavior but usually resolve within 72 hours (persistence is defined as Post-Concussion Syndrome)

Moderate TBI

characterized by a period of loss of consciousness for 30 minutes-6 hours, GCS of 9-12, focal/diffuse brain injury seen on scans, post-traumatic amnesia for 24 hours, closed or open, requires a short act or CCU stay for close monitoring, and secondary injury may occur (ex. brain edema, intracranial bleeding, inadequate cerebral perfusion)

National Institutes of Health Stroke Scale

commonly used assessment tool that nurses complete ASAP to determine IV Fibrinolytic eligibility with categories such as LOC, questions/commands, best gaze, visual, family palsy, and motor (arm + leg), limb ataxia, sensory, best language, dysarthria, and neglect (extinction/inattention)

Complications of Vessel Malformation Repair

complications include hydrocephalus, vasopasms, or re-bleeding/rupture

Patient History for Thrombolytic Therapy

consider when the stroke began, symptom progression, medical history, current medications (especially anticoagulants), OTCs, and age

Core Measures of Stroke

core measures include VTE prophylaxis, antithrombotic therapy upon discharge (thrombolytic if indicated), drug therapy re-evaluated by the end of the hospital stay day #2, discharge with a "-statin," documented stroke education, and rehabilitation assessment

Traumatic Brain Injury

damage to the brain from an external mechanical force such as a blow or jolt the head or head penetration by a foreign object, primary v. secondary

Stroke (Hemorrhagic Attack)/Cerebral Vascular Accident (CVA)

defined as an interruption in normal blood supply to the brain which is a medical emergency and should be treated immediately to reduce or prevent permanent disability + death; edema and cerebral chances can lead to increased ICP or a secondary brain injury

Secondary TBI- Increased ICP

detrimental to the brain when high and sustained, resulting in neuronal death which is the LEADING cause of death for head trauma patients who arrive to the hospital alive; cerebral perfusion decreases which can be caused by hemorrhage or hematoma = ISCHEMIA

Early Post-Op Craniotomy Complications

early signs of post-op Craniotomy complications include an increased ICP, Subdural or Epidural Hematoma, Subarachnoid Hemorrhage, hypovolemic shock, hydrocephalus, and any respiratory complication (ex. atelectasis, hypoxia, pneumonia, neurogenic pulmonary edema)

Stroke Diagnostics: CBC

elevated H & H associated with major strokes as the body attempts to compensate for a lack of oxygen to the brain

Secondary TBI- Hydrocephalus

fluid in the brain causes the ventricles to dilate from an increase in CSF, resulting in an increased ICP

Differential Features of Stroke Type- Thrombotic

gradual onset (minutes to hours) with an intermittent or stepwise improvement between episodes of worsening symptoms, the patient is awake, preceded by a TIA, deficits occur during the first few weeks (ex. slight headache, speech deficits, visual problems, confusion), CSF is normal but may include protein, and improvements occur over weeks to months even though permanent deficits are possible RISKS = HTN & Atherosclerosis, frequent TIAs

Communication with the Aphasic Patient

guiding principles include presenting one idea or thought in a sentence, use of simple one-step commands instead of asking of multiple tasks, speaking slowly but NOT loudly, use of cues or gestures as needed, avoiding "yes/no" questions for patients with expression difficulty, alternative communication forms, NOT rushing the patient when speaking, and SLP collaboration

Nursing Interventions for the Patient with a Brain Tumor

implement cardiac monitoring from hypoxic dysrthyhmias, I & O (pituitary involvement with SIADH), NOT putting pressure on the operative site, VTE prophylaxis, avoiding anything that increases ICP, keeping the patient NPO until they're alert (due to aspiration risk), and management of post-op dressings plus drains

DRUG ALERT & Fibrinolytic Therapy

in addition to frequent monitoring of vital signs, carefully observe for signs of intracerebral hemorrhage and other signs of bleeding during administration

Key Features of Right Hemisphere Strokes

includes an impaired sense of humor, disorientation x3, inability to recognize faces, visual spatial deficits, neglect of the LEFT visual field, loss of depth perception, cortical blindness, impulsiveness, lack of awareness of neurologic deficits, made-up stories (confabulation), euphoria/constant smiling, illness denial, poor judgment, overestimation of abilities = injury risk, and loss of the ability to hear tonal variations Unilateral Body Neglect

Signs & Symptoms of a Thrombotic Stroke

includes dizziness, cognitive changes, and seizures as plaque slowly builds

TIA Prevention

includes reducing HTN, antiplatelet or antithrombotic medications (ex. Aspirin or Plavix), blood sugar control of 100-180 mg/dL for diabetic patients, smoking cessation, healthy eating, and exercise

Key Features of Left Hemisphere Strokes

includes the inability to speak or comprehend language (aphasia), difficulty writing (agraphia), difficulty with mathematic calculations (alexia), possible memory deficit, inability to discriminate words + letters, reading problems, deficits in the RIGHT visual field, cortical blindness, slowness/cautiousness, anxiety when attempting a new task, depression or a catastrophic response to illness, guilt, worthlessness, worries over future, quick anger + frustration, intellectual impairment, and NO hearing deficit

Nursing Interventions for the Patient with Unilateral Inattention/Neglect Syndrome

interventions involve teaching the patient to touch/use both sides of their body, dress the AFFECTED side first, teach the patient a "scanning technique" when eating or ambulating in order to expand the visual field as the same half of each side is affected, place objects within the patient's field of vision, use a mirror to help visualize more of the environment, a patch can be used for diplopia, and encourage independence as much as possible

Nursing Interventions During + After IV tPA Administration

interventions require performing a double check of the dose, using a pump to program the initial dose over 60 minutes with 10% given as a bolus over a minute, do NOT MANUALLY PUSH, admit the patient to CCU or a specialized stroke unit, perform neurologic assessments + vitals every 10-15 minutes (with consistent devices), administer antihypertensives if 180/105 mmHg, wait until the patient is stable for any invasive tubes or catheters to prevent bleeding, obtain a follow-up CT after treatment BEFORE starting anticoagulant medications, and DISCONTINUE the infusion for any adverse reactions then alert the PHCP = severe headache, severe HTN, bleeding, N/V

Key Features of Increased Intracranial Pressure (ICP)

key features include a decreased LOC (ex. lethargy to coma), behavioral changes such as restlessness/irritability or confusion, headache, N/V, aphasia, pupillary changes, cranial dysfunction, ataxia (changes in sensorimotor status), seizures, abnormal posturing, and Cushing's Triad 1. Severe HTN 2. Widened Pulse Pressure 3. Bradycardia

Late Post-Op Craniotomy Complications

late signs of post-op Craniotomy complications include wound infection, Meningitis, fluid/electrolyte imbalances (ex. dehydration, hyponatremia, hypernatremia), seizures, CSF leakage, or cerebral edema

Brain Tumors

location may be primary in the CNS or secondary from mets, signs & symptoms include headache that's more severe within the morning, N/V, visual changes, seizures, facial numbness/tingling, loss of balance, dizziness, weakness, and/or paralysis

Other Stroke Nursing Interventions

maintain the head of bed, oxygen administration when SpO2 < 94%, keep head in a midline neutral position, avoid clustering nursing procedures that can increase ICP, consider the environment for photophobia, place the patient on a cardiac monitor, manage airway to decrease coughing (ex. Lidocaine) or suctioning incidence

TBI Drug Therapy (Mannitol + Lasix)

mannitol does NOT improve mortality risk and Lasix can be administered for any rebound swelling/fluid accumulation

Cerebral Ischemia

may be caused by a sudden SBP drop to < 120 mmHg with antihypertensive medication for the patient with an Ischemic Stroke

Traumatic Brain Injury

may be classified as mild, moderate, or severe

Complications of Vessel Malformation Repair: Hydrocephalus

monitor the patient for a chance in LOC, headache, pupil changes, or seizure as this complication occurs as a result of blood in the CSF

Complications of Vessel Malformation Repair: Cerebral Vasospasms

monitor the patient for a decreased LOC, motor or reflex changes, and an increase in neurological deficits (ex. weakness or aphasia); patient is at risk for this complication when blood enters the Subarachnoid Space

Complications of Vessel Malformation Repair: Re-Bleeding/Rupture

monitor the patient for severe headache, N/V, decreased LOC, and additional neurological deficits such as pupil changes; re-bleeding or rupture can happen within 24 hours or 7-10 days after the initial bleed

Aspirin & Plavix

need to be administered within 24-48 hours of onset, but aspirin can NOT be administered within 24 hours of tPA administration

Differential Features of Stroke Type- Hemorrhagic

onset is typically abrupt with a sudden onset (HTN-caused is gradual), patient is in a deepened lethargy (stupor) OR COMA, preceded by a headache as bleeding is occurring in the brain tissue, deficits are focal + severe/frequent, CSF is bloody, seizures usually occur, and the duration varies with possible permanent neurologic deficits RISKS = HTN, vessel disorders, & genetics

Motor Changes

paralysis or weakness on one side of the body, disturbed gait (ataxia), flaccid or spastic paralysis, agnosia, apraxia (previous known motor skills), blindness in half of the visual field (HEMIANOPSIA), and blindness in the same side of both eyes (Homonymous Hemianopsia) immobility = VTE prophylaxis, skin breakdown, mobility ASAP, pulmonary hygiene

The patient is admitted to the acute medical unit after 7 hours. His wife asks if her husband will receive IV thrombolytic therapy. What is the nurse's best response? Thirty minutes later, the wife asks for a glass of water or juice because her husband is thirsty. What is the nurse's best response?

patients must meet strict eligibility criteria for thrombolytic therapy with tPA including giving the drug within three hours after the first stroke symptoms. before the patient is given any liquids, food, or medications, he must be screened for the ability to swallow (gag/cough reflexes)

Positioning of the TBI Patient

positioning should be to avoid extreme flexion or extension of the neck in order to maintain the head in the midline/neutral position, use log rolling with the HOB at 30 degrees, 30-35 degrees to prevent aspiration, and avoid sudden vertical changes of the HOB (especially in the older patient) as the Dura Mater may becomes pulled away from the brain to create a Subdural Hematoma; monitor for hypotension when increased the HOB because this may result in patient harm

What is the antidote to Lovenox?

protamine sulfate

Pupils of the TBI Patient

pupils of the patient with a TBI should be checked for size and reaction to light (especially if unable to follow directions) in order to assess changes within patient level of consciousness; report AND document any changes in pupil size, shape, or reactivity immediately as the may indicate an increased ICP

Stroke Diagnostics: PT/INR & PTT

purposes to obtain a baseline before administration of anticoagulant therapy

TBI & Therapeutic Hypothermia

reduces brain metabolism

Thrombolytics/Fibrinolytics Drug Therapy

requires strict protocols such as a "double check," often requires CCU admittance, vital signs, neurological checks every 10-15 minutes during infusion, and requires informed consent

Complications of Carotid Stent Placement (Hyper-Perfusion Syndrome)

signs & symptoms include a severe temporal headache, HTN, seizures, and changes within a neurological assessment which occur one hour or up to a week after the procedure

Differential Features of Stroke Type- Emboli

sudden/abrupt onset with a steady progression, patient is awake, preceded by a TIA, maximum deficit occurs at onset (ex. paralysis or expressive aphasia, CSF is normal, and improvements are rapid; patient may have a heart murmur, dysthymia (ex. a-fib), or HTN RISKS = heart disease

Post-TBI Hemorrhage

symptoms of neurologic impairment from hemorrhage can progress quickly with a life-threatening increase in ICP and irreversible structural damage to brain tissue; monitor the patient suspected of epidural bleeding frequently (every 5-10 minutes) for change in neurologic status EMERGENCY = loss of consciousness from an Epidural/Subdural Hematoma so notification is required immediately

Mild Brain Injury (Concussion) Patient Education

teach the patient that symptoms which disturb sleep, affect enjoyment of ADLs, work performance, mood, memory, ability to learn new material, and cause personality changes require follow-up care; provide the patient with educational material which will alert them to symptoms + management options (written instructions can be found from the CDC) often unreported so focus on if the patient also has a headache, dizziness, or drowsiness

Thrombolytics/Fibrinolytics Drug Therapy: tPA/Aletplase

the ONLY drug approved for Ischemic Stroke, success is dependent on the interval administered (WITHIN THREE HOURS OF ONSET) 4.5 hours = 80+ on anticoagulants, ischemic injury involving more than 33% of tissue supplied by the MCA, NIH > 25, and history of stroke & DM

Stroke & Increased ICP

the highest risk follows 72 hours of onset interventions = monitor vitals (ex. Ischemic Stroke patients may have BP maintained higher to promote perfusion)

Communication with the Aphasic Patient- Receptive Aphasia

the patient is able to talk, but language and the ability to understand spoken words is meaningless as Wernicke's Area is affected

Communication with the Aphasic Patient- Expressive Aphasia

the patient is able to understand but NOT able to talk and occurs when Broca's Area is affected (involving motor function)

Stroke Assessment

the patient needs to be transported to a stroke center ASAP, observed for sudden LOC alterations (ruling out hypoglycemia or hypoxia)

Differential Features of Stroke Type

the three different kinds of stroke include thrombotic, embolic, and hemorrhagic (from ischemia)

Cushing's Triad

this is a late sign of increased ICP characterized by severe HTN, widened pulse pressure, and bradycardia which means IMMINENT DEATH

Stroke & Calcium Channel Blockers

treat or prevent cerebral vasospasm after subarachnoid hemorrhage that can occur 4-14 days after a stroke, eliminating ischemia

TBI Respiratory Monitoring: Hypercarbia v Hypocarbia

vasodilation contributing to increased ICP = HYPER vasoconstriction contributing to ischemia = hypo

Subdural Hematoma

venous bleeding into the space beneath the Dura (above Arachnoid), commonly occurs from the tearing of bridging veins or laceration, slow bleeding symptoms mirror an Epidural Hematoma, and often has a high mortality rate as it typically goes unrecognized until severe neurological compromise ALWAYS CONSIDER this type of bleed for patients who fall and become suddenly confused or with a change in LOC