Neuro-Assessment
What is the sequence of monitoring post thrombolytic intervention?
Vital signs, NIHSS, Pupils
q15min x2
q30min x6
q1hr x16
What is the sequence of neurovascular monitoring post-embolectomy?
Assess puncture site and peripheral vascular status of the affected extremity post catheterization or arterial sheath removal:
Q15 minutes x 1 hour
Q30 minutes x 1 hour
Q60 minutes x 2 hours
Then Q4H
A patient arrives from VIR s/p thrombectomy, what is a key part of the RN hand-off that must take place?
NIHSS
Swallow dysfunction is a frequent complication of stroke: Name two signs and symptoms of aspiration?
1. Respiratory- dyspnea, tachycardia, cough, wet vocal quality, wheeze, rales, rhonchi, and hypoxia.
2. Systemic- fever, delirium or confusion, poor feeding, decline in functional status.
Stroke patients should be maintained in normovolemic or euvolemic state: What fluids should we avoid in patients with stroke?
Hypotonic Solutions such as Dextrose 5% and water increase glucose levels and perpetuate both cerebral injury and cerebral edema.
How does a Middle Cerebral Artery (MCA) Syndrome Present?
1. Hemiplegia for the contralateral side: Affects lower face, arm and hand. Leg often spared.
2. Contralateral sensory loss
3. If left (dominant) side is affected: expressive aphasia, receptive aphasia.
4. If right (nondominant) side is affected: neglect of the affected side, neglect or unawareness of deficits.
Pt admitted for SAH, was serial test should be performed to ensure there is no narrowing of the cerebral blood vessels?
Transcranial Doppler detect cerebral vasospasm. Angiographic vasospasm (VSP) occurs in 2/3 of patients with SAH. VSP is associated with cerebral infarction secondary to cerebral ischemia after an aneurysmal subarachnoid hemorrhage (aSAH).
The admitted neurosurgery patient has a fever of 38.7 degrees Celsius upon arrival to ICU, what is a key part of documentation for this patient?
Suspected Aspiration Pneumonia Section of ICU Stroke Flowsheets.
RN should Document: Fever present on admission (YES)
Abnormal Breath Sounds on admission (assess and document)
What are some complications the ICU RN should be assessing for in patients receiving mannitol or hypertonic saline for intracranial pressure control?
Mannitol concerns: rebound ICP elevation, Acute kidney injury, Dehydration, Hypotension
Hypertonic Saline: Rebound ICP elevation, Myelinolysis, Pulmonary Edema, Heart failure, Acute Kidney Injury, Coagulopathy, Hypernatremia, Metabolic Acidosis.
Patient being considered for thrombolytic administration following an ischemic stroke, what are the blood pressure goals pre-administration? Post-administration?
1. pre-administration: should be treated to achieve less than 185/110 mm Hg
2. post-administration: maintain a lower level than 180/105 mm Hg
How does an Anterior Cerebral Artery occlusion present?
1. Contralateral leg weakness and sensory loss
2. Behavioral abnormalities
3. Incontinence may occur
1. Hematoma- most common can lead to femoral nerve compression.
2. Arterial dissection and retroperitoneal hemorrhage- usually occurs within 12 hrs of procedure, s/s (abd pain, groin pain, back pain, diaphoresis, bradycardia, hypotension)
3. Arterial thrombosis- higher occurrence in female, frequent distal pulse checks to rule out.
4. Pseudoaneurysm- groin pain and neuropathic symptoms. Assess for bruit or pulsatile mass.
The NPO status wasnt documented in teh ED, the patient arrives to ICU s/p successful thrombectomy, the patient is waking up from anesthesia and is extubated, initial symptoms was a full L MCA syndrome. What should the ICU RN document for dysphagia screen?
Fail, there was aphasia and neglect in initial stroke. Pt should be seen by SLP for any potential risk of aspiration.
Why is Venothromboembolism (VTE) prophylaxis so important for stroke patients, name 2 interventions for VTE prophylaxis?
Stroke patients are high risk for thrombosis due to immobility, systemic inflammation, medical co-morbidities, and dehydration. Sequential compression devices, pharmacologic prophylaxis (i.e. antiplatelets, heparin), hydration, early mobilization.
Posterior Strokes are important to recognize, what are some symptoms of patients experiencing posterior circulation strokes?
1. Ataxia, Nausea/Vomiting, Nystagmus, Vertigo, Diplopia.
2. Vertebral Artery- ataxia, vertigo, N/V, Headache, Nystagmus, Dysarthria.
3. Basilar Artery- quadriplegia "locked-in" syndrome, sensory loss, weakness of facial, lingual, and pharyngeal muscles, dysconjugate gaze, abnormal respirations.
4. Posterior cerebral artery- contralateral visual field deficit, impaired depth perception, chorea, Ipsilateral third nerve palsey with contralateral hemiplegia (Weber's syndrome).
Name two potential complications the critical care nurse should be monitoring for after a craniotomy.
1. Herniation through bone window
2. Infection
3. Contralateral hematoma
4. Ipsilateral subdural effusion
5. Seizure
6. CSF leakage
What S/S are specific to Hemorrhagic Strokes?
Focal Deficits are saem as ISchemic Deficits and also may include:
Headache- in subarachnoid hemorrhage-described as "worse headache of my life"
nausea/vomiting, decreased level of consciousness, rapid LOC (usually indicative of intracranial hemorrhage), light intolerance, neck pain- nuchal rigidity is more often associated with aneurysmal subarachnoid hemorrhage (aSAH).
Who is higher risk for in-hospital complications?
1. Aneurysmal clipping
2. Endovascular coiling
Recent meta-analysis demonstrates that pts can be either clipped or coiled, coiling has better results with clinical outcomes, particularly for those with good perioperative Hunt and Hess scores.
What is the common syndrome post-acute vessel occlusion removal in a patient with uncontrolled hypertension prior to admission?
Reperfusion syndrome- pt presents with ipsilateral headache, contralateral neurological deficits, and seizure of the cortical areas.