Neuro
Fundamentals
Fundamentals
A scale ranging from 3 - 15 (a quick and reliable way to assess and track changes in a patient's neurological status)
What is Glasgow Coma Scale?
-This is the most efficient way to quickly and objectively assess neurological status.
-Patient is given their best score for each category.
HAVE THIS WHEN YOU CALL NEUROSURGERY!!!!!
A nurse receives a patient from the cath lab s/p mechanical thrombectomy for a R M2 occlusion which was successful (TICI 3). Upon arrival to the ICU, the patients groin puncture site is a deep purple, hard to the touch, weak DP pulse and cap refill is sluggish. Vitals are as follows: 90/40, HR 52, RR 12, Sp02 97% on 3 LPM NC. What common complication of this procedure has occurred and how should the nurse intervene?
What is a Groin Hematoma?
- the nurse should immediately hold pressure directly above the puncture site on the femoral artery for at least 30 mins
-call for assistance from another nurse to switch out holding pressure as well as assess pedal pulses, atropine, and to grab other drugs or supplies as needed.
-monitor HR and BP for hemodynamic instability.
-notify the physician who performed the procedure and intensivist service (if following)
- once hemostasis is achieved massage the hematoma to disperse the blood
-frequently monitor groin site and neurovasc assessment.
-extend bedrest with flat HOB.
-expect a trend down in H&H ( however, obtaining an H&H right after or during an acute blood loss event will not reflect accurately)
What two drugs are given to achieve DAPT after placement of embolization coils or stents?
Plavix & ASA
-P2Y12 non responders will typically be placed on brilinta.
-Plavix is typically discontinued at 6 weeks post op.
This equipment is typically used for achieving homeostasis when pulling sheath or arterial oozing after a procedure accessing the femoral artery.
What is Femostop?
If using when pulling sheath SBP must be <160 and ACT <=150.
The white belt should be placed behind patient equally to create equal tension over the femoral puncture site. Place target balloon over puncture. Thread the belt through the clamps on the belt locks and tighten equally.
If you have both venous and arterial sheaths pull venous first.
Inflate balloon dressing to 20mmHg above current SBP (check your SBP q5mins while using the Femostop), slowly deflate until you reach 20mmHg. Once reaching 40mmHg will leave for 1 hours, then release pressure every 2-3 mins until leaving 0mmHg.
The Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory and Hypoglossal nerve are all....
What are cranial nerves?
The first and most important part of a nurse's neurological exam....
Level of Consciousness
- LOC is the earliest indicator of decline. It does include some of the same factors as GCS, however it is more broad in describing responsiveness/awareness.
* Awake, Disoriented/confused, Lethargic, Obtunded, Stupurous, and Comatose (Please see your handout for further explanation.)
A nurse has been taking care of a patient admitted with SAH for the past 4 days. At the 2200 neuro check the patient has a new sensory deficit in their left hand and a mild headache (3/10 numeric pain score). What neurological emergency is this patient likely exhibiting and how should the nurse intervene?
What is Cerebral Vasospasm/ DCI (delayed cerebral ischemia)?
-page neurosurgery IMMEDIATLY. Be prepared to inform the provider of your neuro exam findings, what day of the vasospasm window the patient is in, last known well, most recent TCDs. (TCDs are typically taken every morning to trend values to monitor for vasospasm, mean flow values will differ per artery assessed. However, it is important for the nurses to review and trend mfv's)
-The nurse can likely expect the patient to go to cath lab for an angioplasty or intraarterial verapamil,nicardipine or nimotop (all vasodilators)
These drugs are commonly given to treat thrombosis or prevent thrombus development in high risk patients. (answer: 3 most common drugs)
Eliquis,Heparin, Angiomax
What device is typically used as a less invasive diversion for CSF diversion?
Lumbar Drain
-NEVER take your eyes of the drain when open.
-evaluate dressing and insertion site at least q2h.
- monitor for symptoms of over drainage of CSF.
A life threating adverse reaction to TNK/TPA (hint: not bleeding)
Angioedema
A standardized tool used by healthcare professionals to assess the severity of stroke
What is NIHHS?
- A Stroke APP (call 1919), neurosurgeon or neurovascular physician should be contacted for ANY new deficits or a NIHHS score increase >= 4.
- NIHHS should be preformed at change of shift, any neuro assessment changes, and when returning from imagining or a procedure.
-Is important to remember this scale is partial to LVOs specifically LMCAs. Posterior stroke sometime will score as low as 0 on NIHHS.
A nurse is caring for a patient admitted for ischemic stroke who is currently receiving 3% hypertonic saline IV @ 30mL/hr with a Na goal of 145-150. At 1200, the patient Na level is 143. The nurse notifies the stroke neurology provider on call and is ordered to give a 250 mL 3% bolus and to increase the 3% infusion rate to 50mL/hr. After completing the orders, the nurse returns to assess the patient at 1600. The patient now has tremors, hallucinations, and nystagmus. Based on the assessment findings, what should the nurse be concerned the patient is exhibiting and how should the nurse intervene?
What is osmotic demyelination syndrome?
-ODS most often occurs with over correction of hyponatremia. However, it can also happen when driving a normal sodium level up.
-typically we correct no more than 8-10 mEqs in 24 hours to prevent ODS.
-ODS symptoms can occurs within hours or up to 14 days.
-Some patients with ODS will develop Locked-in syndrome as a result.
*The nurse in this scenario should immediately stop the 3% infusion, obtain a BMP and osmo level, contact the provider for orders.
These two drugs are most commonly given to decrease ICP by using osmotic diuresis.
Hypertonic Saline & Mannitol
-at BHL we only use 3% hypertonic saline. However, there are concentrations as high as 25%.
-need BMP q12, q6h sodium and osmo for continuous hypertonic therapy.
Mannitol will typically be given in acute rises in ICP, impending herniation, intra- op crani, etc.
Mannitol must be given with a .2 filter
*both should preferably be given via central lines
- both can cause rapid electrolyte shifts so monitor for signs of osmotic demyelination syndrome
What invasive device is used for CSF diversion?
EVD
- level to tragus
- q1h neuro check
- monitor output trends and colors
-always always always should be on antibiotics
What series of imaging make up the Stroke imaging protocol?
(you definitely know at least 2 )
Stroke imaging protocol (CTA head and neck, CTP, and CT head w/o)
-every stroke does receive an MRI brain however it technically is not apart of the initial protocol
The acronym is used to assess cranial nerves II, III, IV, and VI
What is PERRLA?
Pupils
Equal (size in mm)
Round (shape)
R L (reactive to light (sluggish, brisk, fixed, hippus- most commonly seen in NCSE patients)
Accommodation (Essentially the ability to focus on object...pupils dilate when you look at something far away and shrink when you look at things that are near)
A nurse is receiving report on a post op day 2 left parietal craniotomy, the off going nurse reports that the patient did not sleep well and since arriving to the unit from PACU has had poorly controlled hypertension despite a SBP goal of <140. At bedside shift report the patients GCS is 4-4-6, a sensory deficit on the right side, patient states that they "are very sleepy" and the craniotomy dressing is CDI. The nurse comes in to preform a neuro assessment at 1100 and the patient's GCS is now 3-3-5, has right sided neglect, withdraws on the RUE and RLE. With the nurses assessment findings, what complication of a craniotomy has likely occurred?
Post- op subdural hematoma
The first choice calcium channel blocker infusion for neurological and hypertensive emergency patients is...
Nicardipine
-typically 25mg/250mLs of saline but can be double concentration for patients we are attempting to limit fluids in.
* may cause or worsen pulmonary shunting in certain situations by inhibiting hypoxic pulmonary vasoconstriction. (pt's with lung disease, pneumonia, or post op atelectasis) *
What equipment is used for TTM following cardiac arrest or severe neurogenic fever?
Arctic Sun
-maintain therapy for the full prescribed course, do not stop sedation until normothermia has been achieved
- No subq insulin and no K+ replacement during cooling do to heating causing electrolyte shifts.
- treat shivering as this will delay achieving target temp (will be set by MD)
Cushing's Triad is characterized by these 3 assessment findings.
Widening pulse pressure, Bradycardia, and irregular or cheyne-stokes respirations.
-Seen in patients with impending herniation. By the time you see these occur there is likely no intervention to prevent brain death...
What is ICP?
-Patient positioning is a VITAL part of preventing decline especially in those who are in their peak swell window, on "crani watch", large bleeds, hydrocephalus, etc.
- Please keep in mind, once ICP compromises CPP you are not only at risk for secondary strokes but if ICP continues to climb herniation will occur. Once a patient completes herniation there is no coming back.... this can happen in minutes.
A nurse receives a patient from ER that presented with stroke like symptoms and received TNK. Initial NIH was 3 (only scoring for facial droop, left arm drift, and sensory deficit). Upon arrival to the ICU, the patients NIH is 0. After getting the patient settled and completing the admission database...the patient begins to projectile vomit multiple times, groaning and holding their head. How should the nurse intervene and what complication has likely occurred?
TNK/TPA Conversion
-HEAD CT ASAP
-Call 1919 to notify stroke provider
-Ask for PRNs for N/V control, if severe enough sometimes may place NG tube to suction.
-Monitor for signs of airway compromise
- Make sure to have line available to administer cryoprecipitate, tranexamic acid, etc.
This calcium channel blocker is given to patients with high risk of cerebral vasospasms due to it increased MOA on the cerebral arteries
Nimotop
-inhibits the transfer of calcium ions into vascular smooth muscle cells, thus inhibiting contractions and preventing vasoconstriction
-pt's with impaired liver function may need less frequent dosage due to poor drug clearance.
-given oral in tablet or NG/OG/PEG in liquid
What equipment used CSF diversion has the highest risk of secondary injury?
Lumbar Drain
This hypothesis describes the relationship between the volumes of brain tissue, cerebrospinal fluid (CSF), and blood within the rigid confines of the skull. It states that the total intracranial volume remains relatively constant, meaning an increase in one component must be compensated by a decrease in another
What is the Monroe Kellie Doctrine?