Brain

Question 1

Early s/s of increased ICP

Answer 1

Change in LOC, HA, n/v, shallow breathing, lethargy, irritability, slow decision making

Question 2

Late s/s of increased ICP

Answer 2

Pupil changes, seizure, posturing, coma

Question 3

Which electrolyte are you most concerned with in your neuro patient?

Answer 3

Sodium. Sodium under 130 can lead to cerebral edema.
If you have someone with a brain injury they are prone to SIADH or DI (tx DVVAP)

Question 4

Your patient’s CSF is leaking and they say the clear fluid tastes like this ___. You decided you should test the fluid on your own like this ____

Answer 4

Salt, grab a glucometer and test for sugar

Question 5

Parietal brain is responsible for these (4)

Answer 5

sensation, pain, temp, pressure

Question 6

This ventricle can get compressed with mid brain swelling

Answer 6

third ventricle

Question 7

What is Cushing’s triad?

Answer 7

Brainstem herniation:
- Wide pulse pressure (with systolic elevation)
- bradycardia
- irregular breathing

Question 8

Decorticate posturing can be described as this and indicates this

Answer 8

Person moves arms into core: flexion arms and fingers, internal rotation of LE. Indicates damage to one or more corticospinal tract

Question 9

Decerebrate posturing can be described as this and indicates this

Answer 9

Arched back, extended and pronated arms. Bad! Damage to brainstem

Question 10

Central brain herniation signs

Answer 10

Small fixed pupils and lack of corneal reflex

Question 11

Best position for neuro injury

Answer 11

30 degrees to drain the brain

Question 12

1st tier interventions to decrease ICP

Answer 12

HOB 30-45, align head, straight legs, decreased stim, stool softeners, normothermia, monitor pain

Question 13

Medical treatments increased ICP

Answer 13

Osmotic diuretic (like mannitol), hypertonic saline, loop diuretics

Question 14

Monitoring during mannitol (4)

Answer 14

Use filter to administer
1. Serum sodium
2. Serum osmo (no higher than 320)
3. fluid status (prone to dehydration
4. Increase in ICP

Question 15

What is the blood pressure goal for your patient with carotid stenosis as an outpatient? What 2 medications in addition to possible blood pressure medications do they need?

Answer 15

130/80. Aspirin, statins. Often goal for statins is LDL under 100

Question 16

What type of assessments should you be doing after your patient returns for a carotid endarterectomy?

Answer 16

• post op bleeding/hematoma
• airway monitoring due to incision site
• neuro assessments
• cranial nerve assessments

Question 17

How do you do a cranial nerve assessment post carotid endarterectomy?

Answer 17

VII: smile
IX/X: swallow, gag, talk
XI: shrugging shoulders against resistance
XII: stick out tongue. Is it midline?

Question 18

You know you need to be careful with your patient with increased ICP. You need to watch out for these (5) external causes

Answer 18

Suctioning, position changes, PEEP (like BiPap), external stimuli, and nursing care.

Question 19

Now that you know the 5 external causes of increased ICP what are you going to do to help your patient with increased ICP? (4)

Answer 19

1. Position: Head midline, bed tilted at 30-45 degrees, straight legs.
2. Decrease stimuli
3. Administer pain meds as needed
4. Maintain normothermia

Question 20

Your patient is BIBA on a stroke alert. You are picking up in the emergency room today and you know these 5 things should be completed in the first hour

Answer 20

1. NIHSS
2. CT wo contrast- 1st 20 mins! Interpreted in 45
3. Obtain cbg
4. If candidate, administer fibrinolytics
5. If candidate and LVO- consider for thrombectomy

Question 21

What are the time constraints for CVA and fibrinolytics?

Answer 21

• Administer within one hour of arrival to ED
• Last known normal up to 4.5 hours prior to administration UNLESS over 80, oral anticoag, hx CVA and DM, baseline NIHSS greater than 25

Question 22

What vital sign should you be on the lookout for prior to fibrinolytic administration?

Answer 22

Blood pressure needs to be controlled to prevent brain bleed. SBP less than 185, DBP less than 110

Question 23

Why are facilities switching to TNK over rTPA?

Answer 23

rTPA dosing and calculations can be complex and cumbersome. The total dose is 0.9 mg/kg up to 100 kg. In the first one minute, 10% of the dose is given and then the rest infused over an hour.

TNK is much easier. The dosage is 0.25mg/kg with a max of 100 kg

Question 24

Your patient is not a candidate for fibrinolytics. What order would you expect for this person?

Answer 24

Permissive hypertension. The bodies natural response is to increase perfusion to the brain. Up to 220/120

Question 25

Your patient received fibrinolytics before transferring to your unit. You are performing their brief neuro and notice they became lethargic, have delayed responses , a headache, are nauseated, and their blood pressure has increased. What do you do?

Answer 25

Activate an RRT. Anticipate going down for a STAT CT head, stat CBC, coags, fibrinogen. Prepare to transfuse platelets, cryoprecipitate, FFP, TXA

Question 26

Your patient is a candidate for thrombectomy. You anticipate administering

Answer 26

fibrinolytics

Question 27

You float to the neurology unit and you have a post embolic stroke, a patient with an SAH, and one with an aneurysm. You need to know this target

Answer 27

Blood pressure target. Blood pressure targets may be kept tight and low compared to the order for permissive HTN for the embolic stroke

Question 28

Your patient is young and healthy. They had an unexplained stroke. You expect to assist with this study.

Answer 28

Bubble study- PFO is often a cause of unexplained stroke