Assessment & Interventions
Tool that scores patient's LOC by assessing Eye Opening, Best Verbal Response and Best Motor Response.
What is Glasgow Coma Scale?
Upon your next assessment your patient is drowsy and has a new onset of slurred speech. This number should be called for further evaluation of the patient.
What is #4000?
Various intracranial pathologies can produce this EKG change.
TNK can be given within this window from last seen normal.
What is 4.5 hours?
Where can you find the policy for Brain Death testing?
What is "Policy Medical"
This nursing intervention is known to help prevent ICU Delirium.
What is:
*awakening trials?
*decreased sedation?
*early mobility?
*enforcement of day/night cycle?
On patients with suspected stroke, this screening should be completed prior to any oral intake.
What is 3-D Dysphagia Screening?
This positioning is suggestive of cerebral herniation.
Post stroke patient's blood pressure is 220/110 and unresponsive to Labetalol. You anticipate initiation of this gtt.
What is Cardene?
Is consent required for brain death testing?
No
Dysfunction that affects the muscles of speech, leading to trouble articulating (slurred speech).
What is dysarthria?
DVT prophylaxis used immediately post TNK.
What is a Sequential Compression Device?
Normal range for ICP.
What is 10-15?
For patients with brain injury the nurse should assess all IVPB medications to ensure they are not mixed in this fluid.
What is hypotonic solution?
Time frame for contacting STA when patient meets trigger criteria
1 hour
Post ROSC this pupil finding would indicate severe anoxia.
What is dilated and unreactive pupils?
Day 2 post stroke ASA by mouth is ordered but patient has failed dysphagia screening. This modification should be made.
What is have ASA order modified to rectal administration?
This formula is used to determine Cerebral Perfusion Pressure (CPP).
What is MAP - ICP?
Mannitol is ordered for treatment of increased ICP. Expect to trend this lab.
What is serum osmolality?
Two required tests performed on patients with suspected brain death.
Neurologic and Apnea
Patient's blood pressure trends as follows:
140/84
152/80
159/78
You call the MD to report this finding.
What is widening pulse pressure?
Frequency of MEND and NIHSS documentation on any stroke or TIA patient (ICU Status).
What is NIHSS q12 hr. and MEND q1 hr.
Patient admitted with intracranial hemorrhage with 3mm midline shift has the following ABG:
pH: 7.39
pCo2: 52
HCO3: 25
pO2: 98
You call the provider and anticipate this adjustment to the ventilator.
What is increase respiratory rate?
Patient post TNK has worsening symptoms and complains of severe headache. You are concerned about this complication of TNK.
What is hemorrhagic transformation?
Diabetes Insipidus can occur in 90% of adults with brain death. Which medication is given as treatment?
Vasopressin or DDAVP