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120 Cards in this Set
- Front
- Back
What is the first sign that a patient may be having increased ICP?
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Change in level of conciousness
(subtle changes, so you need to do careful assessments) |
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In order to assess a patient and identify a change in their level of conciousness, THIS is critical information to have.
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Their baseline
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How does a nurse assess arousal in a patient suspected of having a change in level of conciousness?
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Using the GCS
(eye opening & verbal response & motor response) Do they open their eyes when you talk to them? or do you have to poke them with your pen? When you poke them with your pen, do they respond? How? Is this a change from your BASELINE? |
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What are the four GEMS to a great neuro assessment?
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Pupils
Eye Movement Motor & Sensory function Vital Signs |
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What are you actually checking when you assess motor & sensory function?
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Motor - response/movement
Sensory - feeling/sensation |
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There are three things you are looking for when you assess pupils. List them.
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Size
Response to Light Equality (remember, PERRLA....pupils EQUAL, round, REACTIVE TO LIGHT and ACCOMODATION. |
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What are the early changes that may be observed in a patient's pupils as the cranial pressure starts to increase?
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Ipsilaterial pupil reaction
(Note that this is NOT ipsilaterial pupil DILATION. Full dilation is NOT early sign. Full dilation is surgical emergency!!!) |
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What does ipsilaterial pupil reaction mean?
(describe what you will actually see) |
Pupil will be larger on the SAME SIDE of the brain as the swelling is. The reaction will be sluggish to light.
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Why does the pupil dilate with increased ICP?
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Because the CNIII nerve is being compressed on that side
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Eventually if the pressure increases in the brain, the CNIII nerve will be completely blocked. Describe the pupils of this patient.
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Both pupils will be dilated. Contralateral CNIII compressed. Bilaterial pupil dilation.
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Describe "normal" eye movement when a person is looking straight ahead.
What happens to the eye movement when you grab their head and turn their head? |
Normal is looking straight ahead at rest and no involuntary movement
eyes will move to opposite side of head turn (dolls eyes) |
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What is papilledema?
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an edematous optic disc seen on retinal examination. It is a nonspecific sign associated with persistent increases in ICP
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Increased ICP will cause the eye lid to _________. The medical term for this is __________.
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sag
ptosis |
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A patient will IICP may not be able to move his eye in THIS direction.
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upward
(inability to move the eye upward) |
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With IICP, what type of motor response would you expect? where?
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decreased motor response on contralateral side.
Opposite side of brain that is swollen. |
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THIS is a test that is an excellent measure of strength in the upper extremities.
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Palmar drift test
(aka pronator drift) |
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How do you assess movement in the unconcious patient?
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look for spontaneous movement. If non is possible, a pain stimulus should be applied to the patient and response should be noted.
Also, resistance to movement during passive ROM exercises is another measure of strength |
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What are two types of posturing?
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Decorticate (hands to the core, make a C)
Decerebrate |
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If a patient is exhibiting decerebrate posturing, you know this is even worse than decorticate. What does it signify is happening in the brain?
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Swelling is now going down to the medulla.
BAD b/c respiratory center is in medulla |
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During posturing, what are the legs doing?
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they are stiffly extended
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What is Babinski's sign?
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when you stroke up on the bottom of a foot, the toes F A N out.
Babies do Babinski NOT ADULTS. (positive Babinskin in adult is BAD) |
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If you test a patient and get a positive pronator drift, you know that you should NOT ________ them.
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feed
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A complete neuro assessment of motor weakness includes assessing both arms and ________.
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legs
(test ALL four extremities) |
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Patient is unconcious. How do you test eye movement?
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dolls eyes test
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When your restless neuro patient suddenly becomes quiet, what should you be thinking?
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phewwwww. now I can go and get that coffee.
NO! This is a change in LOC! Get in there and start assessing. |
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With IICP, what will always be the #1 priority for the patient?
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open airway
(which is why they vent these patients) |
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What do you expect the pulse of a patient with IICP to do?
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go up or down or be irregular
(kind of a crappy piece of information) **If you discover bradycardia (remember that is lower than 60...but know your patient's baseline) then you need to look at the BP trends. Is their a widening pulse pressure?? What is their respiratory pattern?? CUSHING's TRIAD ALERT |
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Vital signs and temperature are very important to document for IICP patients. What is causing the changes in temperature?
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compression of hypothalmus (our body's thermostat)
Temps from 94-105 are possible. Infection may have a less drastic rise due to the this compression. |
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What are the three components of Cushing's Triad?
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1. Widening pulse pressure (increase in SBP)
2. Change in respiratory pattern (irregular respirations) 3. Bradycardia |
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Vitals of your vented patient show HR of 55 and a sudden and sustained increase in SBP to 195. His respiratory rate is at 12 and is regular.
What are you thinking? |
Cushing's Triad. Call MD.
Vented patient will not have irregular respirations b/c they are VENTED!!! |
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What is Cheyne-Stokes?
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Cheyne Stokes is a respiratory pattern marked by periods of apnea and periods of hyperventilation
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Your patient has altered cerebral perfusion. What are your ABG goals?
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O2 sat @100
PCO2 @ 35-45...More toward 35 |
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The respiratory therapist tells you that the ABG he just pulled shows PCO2 level is at 46. He asks you if you want to adjust the vent settings. What do you say?
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After confirming the current rate and the orders that you have, you decide that you need to increase the rate in order to blow off more PCO2.
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Why do you care about PCO2 level in ABGs so much?
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PCO2 is SO critical in a patient with a neuro issue. Increased CO2 vasodilates the cerebral arteries and increases cerebral blood flow. Although this sounds good, it can be bad if there is IICP. Keeping CO2 down will keep ICP down.
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What are the issues with suctioning a patient that has altered cerebral perfusion?
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-need to hyperoxygenate them prior to suctioning (b/c you want to maintain O2 sat of 100 to prevent hypoxia which would cause secondary damage
-suctioning causes increases in ICP. This will cause a decrease in CPP. Goal is to keep CPP>60. So only two passes of less than 10 seconds |
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What is the proper positioning of a patient with IICP?
why? |
HOB at 30 degrees
(to decrease cerebral edema) (to increase respiratory exchange) Head of patient at midline (to keep jugular veing patent for drainage) |
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When you are caring for an unconcious patient, it is important to keep in mind that 2 out of 3 patients will report experiences that indicate.....
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some awareness of person, place or time
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What is the biggest fear that a patient who just came out of "unconscious state"?
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that someone may have done something to them when they were unconscious
they will have a high level of ANXIETY |
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Why do you NOT want to elevate the HOB higher than 30 degrees?
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B/C it may decrease the CPP by lowering the systemic BP.
So you want to keep it up to 30 to decrease ICP, but not so much that it decreases CPP |
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How do you turn a patient with ICP?
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slow and gentle b/c rapid changes in position can increase ICP
pain and agitation also increase pressure turn them every 2 hours |
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What is the result of extreme hip flexion of a patient with IICP?
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it raises intraabdominal pressure which increases ICP
book says not more than 30 degrees, O'Neal says not more than 45 degrees |
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A patient that is stuck in bed is at risk for:
a) b) c) |
a) atelectasis
b) breakdown of skin c) contractures |
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What type of environment do you want to create for the patient with IICP?
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calm, quiet, nonstimulating
nurse needs to use a calm, reassuring approach (create a balance between sensory overload and sensory deprivation) touch is always appropriate even when in a coma |
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What is the best score you can get on the GCS?
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15
coma at 8 |
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When planning activities and interventions for you patient with altered cerebral perfusion, what must you keep in mind?
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That you don't want to group all of the activity together b/c you will stress them and increase ICP
so you want to cluster/limit care activities and treat pain and agitation |
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Identify the highest score possible in each of the three sections of the GCS.
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Eye open 4
Best Verbal Response 5 Best Motor Response 6 |
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The increase in ICP will deprive the brain of O2 because of decreased CBF.
How does this effect a patient? |
They will become unconscious because the RAS in brain stem is not perfused. Wakefulness is not intact
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What is the true definition of a coma?
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Inability to:
speak obey commands open eyes when a verbal or painful stimulus is applied. |
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What are the FIRST two body systems to be assessed for IICP?
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cardiac (for circulation)
respiratory (for adequate respiration) |
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What is GCS score?
Eyes open only to pain No words Withdrawals from pain |
eye 2
verbal 2 motor 4 8 - (definitely going to monitor ICP) |
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What can an EEG tell you?
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brain activity
It is the second part (other than behavior) to a patient's state of consciousness. EEG is absent of activity in a coma and with certain sedatives. |
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Describe three subtle changes in LOC.
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flat affect
change in orientation decrease in level of attention |
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What is hemiparesis?
What is hemiplegia? |
hemiparesis - decrease in sensory function
hemiplegia - decrease in motor function |
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A patient with IICP will report a HA. When will they say the HA is worse?
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in the morning and with straining and movement
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What is a TIA?
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a mini stroke
temporary inadequate CBF |
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What causes a TIA?
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microemboli
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How long does a TIA last?
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less than 24 hours
may be as short as 15 minutes resolves in 3 days |
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Your patient asks you what is the big worry of TIAs since they resolve themselves. You tell her:
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They are a WARNING of PROGRESSIVE cerebrovascular disease
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What type of "temporary neurological function" is lost in a TIA?
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focal, and depend on size and location of blood vessel that is involved
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What is the treatment of TIA?
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Prevent platelet aggregation with anticoagulants.
ASA Plavix Coumadin Ticlid (inform patient to tell ALL members of health care team and dentist that drug is being taken. Drug may need to be discontinued 10-14 days prior to surgery.) |
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All strokes can be classified as either:
A) B) |
Ischemic
Hemorrhagic |
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The cause of the stroke determines the treatment. Knowing this, a patient with a hemorrhagic stroke would never be given ____________.
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anticoagulants
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What are the risk factors for strokes?
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Age (2/3 happen in over 65yo)
Gender (men, but girls die more) Race (AA 2x as many as whites) Heredity HTN**** Obesity DM hyperlipidemia alcohol decreased activity drug abuse oral contraceptives smoking ATHEROSCLEROSIS |
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Where do most strokes happen?
(what vasculature) |
circle of willis
(although this is also a place that can offer collateral circulation, the fact that there are so many connections --bifurications --creates a great place for stuff to stick) |
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How much blood does the brain require in a minute?
Why? What is the brain hungry for? |
750 to 1000ml/min
Brain needs OXYGEN & GLUCOSE |
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Of the normal CO, how much does the brain take?
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20%
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How quickly is neurologic metabolism altered?
What is neurologic metabolism? |
in 3 seconds it is altered
in 2 minutes it is stopped cell death in 5 minutes neurologic metabolism - the brain cells requirement of oxygen and glucose |
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What are the three things that affect blood flow to brain?
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CO
Systemic BP blood viscosity |
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Which type of stroke is more common?
Ischemic or Hemorrhagic? List two types of each |
Ischemic
-Thrombotic -Embolic Hemorrhagic -Intracerebral -Subarachnoid |
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What causes an ischemic stroke?
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clogged vessels
narrow vessels (partial or complete occlusion of an artery) |
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The most popular stroke is ___________________. It is characterized by ____________ ___________.
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Thrombotic Ischemic Stroke
CLOT FORMATION |
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Clots that are formed with thrombotic ischemic strokes are mostly caused by _________ and _________.
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HTN and DM
(HTN - lipid accumulation in intimal lining. This plaque can rupture and then stuff starts to stick there, or it can dislodge and travel to a smaller vessel and block it.) DM-(altered lipid metabolism due to alterations in hormonal levels from adipose tissue) |
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Extent of damage from a thrombotic ischemic stroke depends on:
Rate of __________ _______ of clot Presence of ________ |
Rate of ONSET
SIZE of clot Presence of COLLATERAL CIRCULATION (If circle of Willis is Workin, it isn't going to be as bad) |
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Biggest thing that separates thrombotic ischemic stroke from other strokes.
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NO decrease in LOC in 1st 24 hours
(unless it results from brainstem CVA, seizure, IICP, hemorrhage) |
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What is an embolism?
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A thrombus that moves
(broken free from original spot. once a thrombus breaks free, it is renamed an embolis) |
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What is an embolic ischemic stroke?
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A clot lodged in and occluded a cerebral artery
causes infarction and edema |
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Where do most embolic ischemic stroke "emboli" originate from?
Where is the clot from? location |
heart (a-fib)
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Which ischemic stroke has build up of fat in vessels?
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thrombotic ischemic stroke
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Embolic Ischemic Stroke
What is the onset of symptoms? Why is embolic ischemic worse than thrombotic ischemic? |
rapid development of severe symptoms
(may or may not be related to activity) Worse b/c there is no time for WILLIS TO BE WORKIN (circle of Willis=collateral circulation) |
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What is underlying problem that is causing an embolic ischemic stroke?
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clotting.
MUST treat underlying problem (ablation, lovenox, heparin, amiodarone.....treat problem) |
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What are the s/s of embolic ischemic stroke?
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HA & severe neurologic deficits
(NOT loss of consciousness) |
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Who has embolic ischemic strokes more?
Men or Women |
Men
(These come without warning signs...no TIAs, they happen without relation to activity, and will reoccur if you don't treat the underlying clotting issue) |
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What are the three types of emboli you can have with embolic ischemic stroke?
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blood
air (sucky SN in clinical) fat (long bone break) |
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Remember that the patient with Thrombotic/Embolic ischemic strokes will probably remain __________.
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conscious
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What is happening to a person with hemorrhagic stroke?
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bleeding in brain
-in brain tissue -in subarachnoid space -in ventricles |
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How quickly is onset of Intracerebral stroke?
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minutes to days
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A hemorrhagic intracerebral stroke is most closely linked with _______.
Why? |
HTN
The vessel pressure elevated to a point that the blood vessel blew. |
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Most often, a hemorrhagic intracerebral stroke will happen during _________. The prognosis of this patient is not good. What is % of people that will recover to function independently after this?
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activity
Only 20% will function independently in 6 months. 40-80% die and never get a chance to be in that 20% of independent people. |
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What are the s/s of hemorrhagic intracerebral hemorrhage?
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HA
N/V hemiparesis slurred speech deviation of eyes DECREASED LOC progressive signs of IICP |
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Why is there IICP with a intracerebral hemorrhagic stroke?
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b/c the brain is filling up with blood
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Where is the bleed with a subarachnoid hemorrhage?
What causes it? What is prognosis? |
In subarachnoid space (CSF is here...so you are going to have blood in CSF and IICP. NO LUMBAR PUNCTURES or you will herniate brain)
Caused by ANEURYSM (from weakening of arterial wall, av malformations and coke) |
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What type of aneurysm is the most common?
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Berry (saccular)
-caused by a weakening in the vessel from increased pressure (tractor running over waterhose=weak spot) |
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A change in LOC can happen with this type of stroke.
(May or May NOT happen) |
SAH
(subarachnoid hemorrhagic stroke) |
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What is a arteriovenous malformation?
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A congential brain lesion formed by a tangled collection of dilated arteries & veins. Causes blood to bypass capillaries and decreases perfusion
Common: seizures & HA Treat: excise or embolization |
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What type of stroke will a arteriovenous malformation cause?
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subarachnoid hemorrhagic
(increased pressure in venous system & spontaneous bleeding/expansion in subarachnoid space) |
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What type of warning do you get with thrombotic stroke?
what type of warning do you get with subarachnoid stroke? |
thrombotic ischemic = TIAs
(TI=TIA) subarachnoid hemorrhagic=HA (SAH=HA)..."worse headache of my life" |
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When assessing a patient with subarachnoid hemorrhagic stroke, what MUST you include in the assessment?
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Brudzinski & Kernig's
(blood in subarachnoid space irritates the meninges....meningitis) |
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What are the three probable complications of a SAH?
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Vasospasm (due to endothelin)...can cause infarct
Rebleed (1st 48 hrs or at 7-10 day point. ***On the 7th day, God rested b/c he had a subarachnoid rebleed) Hydrocephalus (ventricles are clogged with blood) |
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What is #1 NO NO in regards to medications for a hemorrhagic stroke?
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No anticoagulants
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What are the treatments for SAH?
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Antispasmotic
Anticonvulsant Steroid Analgesics |
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A theory of treatment for a SAH is based on Triple ____ therapy. What does that include?
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H
Induced HTN Hypervolemia Hemodilution (these are done AFTER the anerysm has been clipped or coiled) |
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What type of solution do you use to achieve hypervolemia with SAH patient?
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isotonic saline
(it will stay in the vascular space) Question any order with D5W or 1/4NS |
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What type of surgery can a patient have if they have a subarachnoid hemorrhagic?
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shunt
clipping coiling wrapping |
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Why do you want to hemodilate a SAH patient?
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blood viscosity will go down and allow for better blood flow
keep H/H at 30-35% goal is increased cerebral perfusion |
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How do you induce hypertension for SAH Patient?
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vasopressors: (dopamine, norepinephrine, Neosynephrine)
Two goals of induced HTN is to stop vasospasm and increase perfusion. Prevent ischemia. |
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What is goal standard diagnostic test for aneurysm?
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digital subtraction angiography DSA
(DiagnoSes Aneurysm) This is a variation on normal angriography. Less invasive |
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What general tests will be done for a suspected stroke?
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CT scan (serial CTs)
If clear of bleeding, then patient can have fibrolytic therapy. Book: "Single most important diagnostic tool for patient who have experienced a stroke is the non contrast CT scan." Obtain within 25 minutes, read it within 45 minutes. CT scan identifies location of stroke and differentiates between ischemic and hemorrhagic stroke. CT can be negative though (as with a ischemic stroke less than 3 hours old). So kind of not the best test. **Get back to me on this one |
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When doing a focused neuro assessment, what is a critical piece of information that is needed from family of patient?
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baseline neuro info on patient
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Stroke happened on Right Side. List some things you might see.
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R sided brain damage
L side hemiplegia L side neglect spacial perceptual deficits denies or minimizes problems fast worker, short attention span impulsive, safety problems impaired judgment impaired time concepts |
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Stroke happend on Left Side. List some things you might see.
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L sided brain damage
R sided hemiplegia impaired SPEECH/LANGUAGE Impaired R/L discrimination slow worker, cautious depression/anxiety aware of deficits can't understand math and language |
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Visual field deficits may occur from THIS sided brain damage.
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Left and Right
(hahhahaha. tricked u.) |
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What is the most obvious effect seen from a CVA?
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motor problems
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What is the deal with motor problems and eating?
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After CVA, no eating until passed barium swallow test
Need gag reflex |
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Akinesia
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loss of skilled voluntary movement
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Aphasia
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total loss of comprehension and use of language
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Dysphasia
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difficulty with comprehsnion or use of language
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Dysarthria
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decreased muscular control of speech
k |
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Homonymous hemianopsia
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blindness in same half of both eyes
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Agnosia
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unable to recognize objects (sight/touch/smell)
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Apraxia
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unable to carry out sequential movements
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