Cranial Nerves
Which cranial nerves are assessed by having the patient cough
What are cranial nerves 9 & 10
Who is any RN
What is the frequency of completion of comprehensive neuro exams
What is Q15minutes until a de-escalation order is placed or verbally given, then they are Q1H
What does your BG need to be over for TNK administration
What is >50
What does a de-escalation order mean
What is vitals and neuro assessments are changed to Q1H.
Which cranial nerves are assessed by moving your finger in an "H" pattern and pupillary response
What are cranial nerves 3, 4, & 6
What is the difference between canceling and downgrading
What is cancel means ending the stroke alert and downgrading means will still have a stat CT but will not be a full stroke alert
What is included in completion of a comprehensive neuro
What is a basic and comprehensive neuro assessment
What is the window for TNK to be administered
What is 0-4.5 hours
How often are post TNK neuro assessments completed
What is q15 minutes x2 hours, q30 minutes x6 hours and q1hour x16 hours
How are cranial nerves 2 & 5 tested
What is the importance of calling a stroke alert
What is to clear the CT table and have the stroke team arrive
When completing a comprehensive neuro what are you assessing
What are cranial nerves
What anticoagulants are a contraindication to TNK
What are Eliquis, Xarelto and possibly Coumadin
What documentation is included for a stroke alert
What is a blood glucose, NIH, VS, neuro assessments
How are cranial nerves 11 & 12 tested
What is by applying pressure and asking the patient to shrug their shoulders; having the patient stick out their tongue and moving it side to side
Why do we bring/meet the patient in the landing zone
What is physician assessment for ABCD and if continuing stroke alert
"Prior Assessment Unchanged" can only be used when
When is only if own documentation is unchanged
What should the BP goals pre & post TNK be?
What is 185/110 (pre) and 180/105 (post)
Where is documentation completed in EPIC
What is the stroke narrator
What cranial nerve is tested by whispering or knocking on the door
What is cranial nerve 8
What should the door to drug times be
What are -
under 60 minutes
under 45 minutes
under 30 minutes
What does the comprehensive neuro assessment not test for
What cranial nerve 1 - olfactory.
What are -
Anticoagulants use
GI Bleed
History of stroke in last 3-6 months
Recent administration of TNK
When is a dysphagia screen documented
At least 1 minutes prior to medications being administered.