The Pressure is On
A 2 point decrease in this score will prompt the nurse to notify the HCP immediately.
What is the Glasgow Coma Scale
An episode of sudden numbness or weakness on one side, with confusion, dysarthria, blurred vision and loss of balance that most likely will resolve in an hour, but can last up to 24 hours.
What is a Transient Ischemic Attack (TIA).
A child fell from her bike, and had a loss of consciousness for ten minutes, followed by headache and vomiting, with a GCS of 13.
What are symptoms of a mild TBI/concussion.
A six-lettered tool to assess for signs and symptoms of strike.
What is BEFAST.
Cerebral Perfusion Pressure (CPP).
What isMAP-ICP = CPP
To maintain adequate brain oxygenation, a patient with increased intracranial pressure should maintain a PaO2 of this, or better.
What is a PaO2 of 80 mm Hg.
An osmotic diuretic that draws water from tissues and promotes urine production, reducing cerebral edema and intraoccular pressure.
What is Mannitol.
Things to teach patients to avoid when discharged to home after a mild TBI/concussion.
What are strenuous activity, Aspirin, NSAIDS, alcohol, sedatives, driving, and making important decisions.
The concept that allows patients with ischemic strokes to maintain a higher blood pressure in order to maintain cerebral blood flow and avoid ishcemia.
What is permissive hypertension.
Shrill cry, bulging fontanelles, increased head circumference in an infant.
What is hydrocephalus.
BP 190/56, HR 50, RR 8 and irregular.
What is Cushing's Triad.
Stroke causing right-sided hemiplegia, aphasia, and slow, cautions behavior.
What is a left-sided stroke.
Nursing interventions to decrease Intracranial pressure in a patient with severe TBI on a ventilator.
HOB 30-45 degrees, head midline, avoid hip flexion, avoid restlessness and agitation (med), avoid coughing, suctioning and hiccoughs, decrease environmental stimulation, mannitol 25%, 3% sodium chloride, antiepileptics (Keppra), fentanyl (pain).
The nurse tests CN IX (glossopharyngeal) and CN X (vagus) in her post-stroke patient for this important assessment.
What is a gag and swallow assessment.
A cardiac patient suddenly develops a facial droop and garbled speech. The nurse completes this neurological examination.
What is the National Institute of Health Stroke Scale (NIHSS).
A client with a left epidural bleed that demonstrates a fixed, dilated pupil on the left side.
What is an uncal herniation
Stroke causing left-sided hemiplegia, left-sided neglect, impulsive behavior.
What is a right-sided stroke.
Goal for oxygen (paO2) levels for and intubated patient with moderate to severe TBI.
What is 80 - 10 mm Hg.
Dosing for Alteplase for ischemic stroke.
0.9 mg/kg. Max dose 90 mg. with 10% given in an initial bolus, followed by the remaining treatment given over 60 minutes.
A breathing pattern that alternates from deep, fast breaths to slow, shallow breaths, ands stops before the next cycle.
What is Cheyne -Stoke respirations.
Therapy ordered for a patient with a Blood pressure of 120/45 mm Hg. and an ICP of 21 mm Hg.
What is Mannitol 25%.
Challenging for individuals and families of stroke of TBI, these types of changes can be difficult to navigate in the post-recovery period.
What are cognitive, behavioral and personality changes.
Bending of the big toe with fanning of the rest of the toes after stroking the bottom of the foot.
What is a positive Babinski test.
Can mimic stroke with symptoms such as sudden confusion, slurred speech, and weakness.
What is hypoglycemia.
A patient opens his eyes to his name, utters some nonsensical words, and brushes your hand away when you pinch his arm.
What is a Glasgow Coma Score of 11.