1
Q
What are some risk factors for Osteoporosis?
A
Greater than 65 years old female gender low bodyweight white/Asian ethnicity Current cigarette smoker in active lifestyle family history diet low in calcium or vitamin D excessive alcohol use Postmenopausal Long term corticosteroid/Dilantin use
2
Q
This type of fracture is due to a disease like Osteoporosis?
A
Pathological fracture
3
Q
___[1]___ break down bone tissue for use in remodeling. ___[2]___ build bone tissue.
A
1-Osteoclasts
2-Osteoblasts
4
Q
___[1]___ Osteoporosis is when the disease is gotten through natural means.
___[2]___ Osteoporosis is when the disease is gotten through unnatural means like alcohol/corticosteroid use.
A
1-Primary
2-Secondary
5
Q
What do these Clinical Manifestations indicate? Kyphosis short stature Pain Unexplained fractures Anxiety/Fear Isolation
As a Nurse, what can you emphasize to help with this disease?
A
- osteoporosis
- Nutrition (⇧Ca/VitD/Mg), Exercise (Except High Impact), and Drug Therapy.
6
Q
2 Surgical Interventions for Osteoporosis?
And what do they entail?
A
- Vertebroplasty: Bone cement is injected into collapsed vertebrae. (Stabilizes; Does not Correct)
- Kyphoplasty: Air bladder is inserted into collapsed vertebra to correct height and then bone cement injected. (Stabilizes/Corrects)
7
Q
Walking __[1]__ mins [2]-___ times per week helps strengthen bone.
A
1: 30 min
2: 3-5
8
Q
What drug therapy is used to treat Osteoporosis?
A
Estrogen/hormone replacement calcium/Vit D calcitonin Testex Evista (Estrogen Receptor Modulator) Boniva (Biophosphonate) Actonel (Biophosphonate) Fosamax (Biphosphonate)
9
Q
_____ affects 1-2% of the total Population, affects 3X more women than men, and most frequently occurs between 30-60 years of age (Or 2-5 or 9-12 years old).
A
-Rheumatoid arthritis
10
Q
_______ Lines the joint cavity and is the joint space and the fluid contained there.
A
Synovium
11
Q
What is the Pathological process of RA?
A
- Autoimmune
- Inflammation of Synovium
- RBC’s flow into inflamed space where it accumulates
- Pannus Forms (Sheet of Inflamed Granulated Tissue)
12
Q
What is JRA and what are the 3 Types?
A
-Juvenile rheumatoid arthritis
➢Pauciarticular:
Affects the knees, ankles, and elbows; more frequent in females
➢Systemic:
characterized by high fever, polyarthritis, rheumatoid rash, joints and internal organs; affects males and females equally
➢Polyarticular:
Involves five or more joints (usually small joints in the fingers and hands may also involve ankles, knees, feet, hips and neck.
13
Q
Clinical Manifestations of JRA?
A
➢Limping ➢Favoring a particular joint ➢c/o pain ➢Uneven growth in a limb ➢Swelling in large joints (knee) ➢Loss of motion and stiffness ➢Fever ➢Rash ➢Lymphadenopathy ➢Hepatomegaly ➢Splenomegaly ➢Main Complication – interference with growth and dev’t
14
Q
______ ________Can Occur in 10-15% of Patients with RA, which results in ⇣Lacrimal/Salivary gland secretion.
A
Sjogrens Syndrome
15
Q
Laboratory Manifestations for RA
A
- Rheumatoid Factor +if RA & -if OA
- ⇡ESR: indicates Inflammation
- ⇣Albumin
16
Q
Diagnostics for RA?
A
- X-Ray (Joint changes)
- CT scan (Cervical Spine involvement)
- Athrocentesis
17
Q
Drugs used to treat RA?
A
Disease-Modifying Antirheumatic Drugs (DMARDS)
(ex: Methotrexate, Sulfasalazine, Leflunomide, Penicillamine)
NSAIDS
Corticosteroids
Immunosuppresives
(ex: Imuran, Cytoxan, Cellcept)
18
Q
Nursing Interventions for RA include?
A
---Pain Relief--- •Rest •Proper positioning •Ice/heat •Adequate nutrition – avoid obesity •Promotion of self care •In acute exacerbation w/joint pain and swelling in hands Hot packs or heated paraffin wax application before exercise will decrease Joint Pain
—Alternatives—
•Hypnosis
•Acupuncture
•Stress management
19
Q
As a Nurse, what are some Teaching topics for RA?
A
➢Balance activity with rest ➢Pace yourself ➢Set priorities ➢Delegate responsibilities ➢Plan ahead ➢Children; ongoing PT; Camp
20
Q
In this disease, urate crystals deposit in the joints and other tissues causing inflammation.
What’s the difference between Primary and Secondary?
A
- Gout
- Primary: Uric Acid Production Exceeds Normal excretion by kidneys (40-50yo M/Post-mena W)
- Secondary: Uric Acid levels normal but excretion is ⇣
21
Q
Clinical Manifestations of Gout?
A
- Swelling inflammation painful joints
- Tophi – hard irregularly shaped nodules in the skin
- Low grade fever
- Malaise
- Headache
- Pruritis
- Renal stones; Depends on type of gout
- Big toe typically affected
22
Q
RN Interventions for Gout?
A
- Low purine diet (Avoid;Sardines, Mussels,Venison, Kidney/liver, Goose)
- 2000ml/day fluid
- Decrease weight if needed
- Avoid alcohol and starvation diets
- BR during acute attack; elevate extremity
- Protect affected joint
- Provide hot-cold
23
Q
Drug interventions for Gout?
A
•For Acute gout
➢colchicine, Zyloprim, Uloric
➢NSAIDS (ibuprofen, indocin)
•For Chronic – promote excretion of uric acid
➢Zyloprim/Allopurinol
➢Probenecid
(Avoid ASA; causes Uric Acid Retention)
24
Q
This Disease is a progressive joint deterioration of the articular cartilage that affects weight bearing joints. It is not a result of inflammation, and it is not systemic.
A
Osteoarthritis
25
Contributing Factors to OA?
* Age – older
* Obesity
* Smoking
* Trauma that may develop later
* Excessive/Repetitive use of joints
* MVA – Affects pt later in life
26
Clinical Manifestations of OA?
```
➢Chronic joint pain and stiffness
•Pain and tenderness on palpation – ROM
•Crepitus; Crackling in joints
•Bony hypertrophy – joint enlarged
•Large Bony Nodes appear on both hands (not a bilateraly symmetric disease)
```
27
Drug Therapies for OA?
* Tylenol
* Lidocaine patches 5%
* NSAIDS
* Opiods
* Synthetic joint fluid implants
* Intra-articular Injections; One, 3X/week (Orthovisc, Synvisc, Supartz)
* Muscle relaxants
28
Laboratory assessment for OA?
* ESR; Normal
* Rheumatiod Factor; NEG
* High sensitivity; C reactive protein (hsCRP)
29
What does CPP stand for? What is it? And what are normal values?
cerebral perfusion pressure. The pressure needed to ensure blood flow to the brain.
60-100 mmHg
30
What does ICP stand for? What is it? And what are normal values?
Intracranial Pressure, pressure exerted inside skull by brain, blood & CSF
5 - 15 mmHg
31
How is CPP calculated?
CPP = MAP - ICP
32
What does MAP stand for? What is it? And what are normal values?
Mean Arterial Pressure. The average arterial pressure in a single cardiac cycle - aka systemic perfusion pressure
(a person's average BP).
> 60 mmHg
33
What are effects of CPP <30?
CPP < 50 = ischemia, cerebral death.
| CPP < 30 = "incompatible with life" aka U R DEAD!
34
What happens to CPP if MAP decreases/increase?
| What in turn happens to the brain?
MAP decreases, CPP decreases, brain ischemia
| MAP increases, CPP increases, ICP increases, brain can herniate!
35
12 things that can alter CPP
ischemia, tumors, traumatic brain injury, brain surgery, infection, clots, bleed, stroke, aneurysms, meningitis, encephalitis, toxic or metabolic encephalopathies (Lead, arsenic, uremia)
36
Brain uses _____ % of body's O2?
| Brain uses _____________% of body's glucose
20% of body's O2
| 25% of body's glucose
37
How is MAP calculated?
MAP = (2x diastolic + systolic) /3
38
ICP = sum of the following:
pressure exerted by brain ________%
pressure exerted by blood ________%
pressure exerted by CSF ________%
brain 78%
Blood 12 %
CSF 10%
39
What is the following known as?
Any increase in the vol of 1 component must be compensated for by a decrease in the vol of one of the other components.
The total vol does not change.
Monroe-Kellie Hypothesis
40
What is the automatic adjustment of cerebral BV to meet the needs of brain tissue and to maintain cerebral blood flow known as?
autoregulation
41
How is autoregulation achieved?
vasoconstriction or vasodilation of cerebral BV to control the flow of blood to the brain.
42
If MAP increases autoregulation causes cerebral BV to ______________
If If MAP decreases autoregulation causes cerebral BV to ______________
Why?
increase in MAP cerebral BV vasoconstrict
decrease in MAP cerebral BV vasodilate
To keep CPP constant.
43
Autoregulatioon only works with MAP in what range?
| Ideally MAP should be?
50 - 150
| >60
44
How does body regulate CSF to control ICP? (3 ways)
increase production of CSF
decrease production of CSF
move CSF from brain (drain to spine)
45
What is the effect of a constantly increased MAP on CPP and what are some possible results (3 of them)?
```
inc MAP (aka HTN) leads to inc. CPP
Results: aneurysm, stroke, herniation
```
46
4 ways ICP is measured?
Which is most common "gold standard"?
Which is likely to be used in ED/trauma situation B4 OR?
Which is most likely to be used to drain CSF?
Main risk with measuring ICP?
Ventricular - Gold standard - ventriculostomy - used to drain CSF
subarachnoid bolt - ED/Trauma
Intraparenchymal - LICOX (measures brain O2, placed in healthy white matter)
epidural -
Main risk - INFECTION!
47
s/s infection in brain (7)
| Problem with Tx?
```
Change in LOC
altered mental status (surely this is the same thing!?!!!)
confusion
increased WBC
fever
change in amount of drainage
change in color of drainage (+odor)
Problem with Tx - Abx can't cross BBB
```
48
Common causes of adult & adolescent head injury include (4)
MVA
Firearms, sports,
in Elderly - Falls
49
```
Common causes of pediatric head injury include:
Infant
Toddler
School age
adolescent
```
Infant - MVA, shaken baby, falls,
Toddler - MVA, falls (stairs, windows)
School age - MVA, bike, skating, scooter, skateboard
50
What is leading cause of death among children?
traumatic brain injury
51
```
infant presents to ER with:
seizures
resp irregularities
failure to thrive
coma
What could it be? What causes it? How is it Dx?
```
Shaken baby syndrome
coup contrecoup (brain bounces back and forth inside skull)
Dx MRI
52
What is special about babies anatomy that makes shaken baby syndrome worse?
Large head
| weak neck muscles
53
```
Infant presents to ER with:
hypoxemia
retinal hemorrhages/detachments
subdural hematoma
posterior rib fractures
What could it be?
```
shaken baby syndrome
54
What does CVP stand for? What is it? And what are normal values?
central venous pressure.
The pressure of the blood in the thoracic vena cava (equal to right atrium). This Pressure determines preload and therefore stroke volume and is subsequently a measure of the hearts ability to pump.
4-6
55
```
Evaluate the following as normovolemic or hypovolemic:
CVP 5
Urinary output 30 mL/hr
Osmolality 285
BUN 14
Na 138
```
```
Normovolemic (normals)
CVP 4-6
Urinary output 30 mL/hr minimum
Osmolality 275 - 295
BUN 10 - 20
Na 135 - 145
```
56
```
Evaluate the following as normovolemic or hypovolemic:
CVP 2
Urinary output 20 mL/hr
Osmolality 300
BUN 21
Na 150
```
```
hypovolemic (normals)
CVP 4-6
Urinary output 30 mL/hr minimum
Osmolality 275 - 295
BUN 10 - 20
Na 135 - 145
```
57
Low CPP & Low MAP, normovolemic - how fix?
Increase MAP - vasoconstriction - drugs
58
Low CPP & Low MAP - how fix?
Increase MAP - vasoconstriction or increase blood volume
59
Low CPP & Low MAP, hypoovolemic - how fix?
increase MAP - IV fluids, blood, plasma - increase volume.
60
Mannitol: How administered?
onset?
Side effects?
```
Administer IV infusion over 30-60 min
onset 15 min
transient volume expansion (of vasculature)
confusion, headache, blurred vision
(pg. 810 Davis)
```
61
```
CPP = MAP -ICP
50 = 55 - 5
Is the problem MAP or ICP?
CVP 6
UO 100 ml in 2 hours, osmolality is 275
Is volume adequate or not adequate?
State Tx
```
```
Problem is MAP
adequate volume (normovolemic)
```
Tx with vasoconstrictive drugs
Digoxin - increases contractility of heart.
Dopamine - vassopressor increases BP and cardiac output.
62
```
CPP = MAP -ICP
50 = 55 - 5
Is the problem MAP or ICP?
CVP 2
UO 20 ml in 2 hours, osmolality is 320
Is volume adequate or not adequate?
State Tx
```
```
Problem is MAP
low volume (hypovolemic)
```
Tx with fluids to increase volume
Blood, NS, Plasma
Strict I&O
63
```
CPP = MAP -ICP
65 = 90 - 25
Is the problem MAP or ICP?
CVP 6
UO 60 ml in 2 hours, osmolality is 280
Is volume adequate or not adequate?
State Tx
```
```
Problem is ICP
adequate volume (normovolemic)
```
Tx REDUCE ICP
Mannitol or drain CSF
64
```
CPP = MAP -ICP
65 = 90 - 25
Is the problem MAP or ICP?
CVP 1
UO 20 ml in 2 hours, osmolality is 320
Is volume adequate or not adequate?
State Tx
```
```
Problem is ICP
low volume (hypovolemic)
```
Tx REDUCE ICP
Drain CSF & give fluids to correct volume.
NO MANNITOL BC PT. ALREADY DEHYDRATED!
65
Inability to speak,obey commands, or open eyes to verbal or painful stimulus is the definition of_________
coma
66
List the 12 steps of Ms. Hudson's quick Neuro assessment
1. VS include BS
2. A&O x3 or GCS
3. Speech
4. PERRLA EOM (extra occular movement)
5. Gag, cough, corneal (blink reflex)
6. Face symmetry
7. Tongue midline
8. Strength normal & L=R
9. No drift ( arms out with palms up ?1 drift down?)
10. Pain assessment
11. Extra ventricular drain - color & amount
12. CSF assessment (?some kind of radiology test - no idea why its part of quick neuro assess?!)
67
What do babies have in skulls that adults do not?
| Difference between pediatric nerves and adults nerves?
Fontanels - anterior is 2nd to close around 18months.
| peds lack myelination
68
What are 2 MAIN early signs of increased ICP?
change in LOC
| sluggish pupil response
69
how do you assess cranial nerve III ?
check pupil response
70
Which area of brain is likely damaged if pupils are fixed and move in same direction as head?
brainstem
71
What are Dolls Eyes?
| Are they good or bad?
turn head to right side, eyes go to left side
| positive dolls eyes - this is GOOD - indicates brain-stem is intact (test only works on comatose patient)
72
Right sided stroke with right pupil dilated is called____________
ipsilateral - same side as damage
72
What is Cushing's Triad?
| What is its significance?
widening pulse pressure,
irregular respirations,
bradycardia
Indicates brain herniation
73
How do you calculate pulse pressure?
What does a widening pulse pressure indicate?
What pulse pressure is considered dangerous?
SBP - DBP = PP
increasing ICP
>40 mmHg
74
List some late sign of Increased ICP..
N&V
severe headache
seizures
optic disc edema
75
Where are arms in decerebrate posture?
by sides with wrists flexed & backs of hands touching sides of body
76
Which is worse decorticate or decerebrate & why?
decerebrate
| possible brain stem injury - may be permanent
77
PaO2 level ____
Why?_____
pCO2 level _____
Why? - 1. ____. 2.______
PaO2 100%
Why? to meet brains metabolic demands (O2 at cellular level)
pCO2 35-45
1. CO2 potent vasodilator - if levels too high cerebral BV dilate and CPP drops = ischemia
2. respiratory acidosis = vasodilation
78
Nursing management: ABCs (2 goals)
1. patent airway - be prepared to intubate
| 2. prevent hypercapnia/hypoxia
79
Why suction cautiously for ICP?
deep suction can increase ICP
80
Position for pt. with ICP
| why?
HOB 30 degrees - NEVER FLAT
| promotes venous return
81
Best environment for pt. with ICP
| How can you help maintain this?
quiet non-stimulating
| cluster nursing activities
82
Pt. with ICP may be on ventilator - what do you need to Tx?
| What meds will you use?
```
Pain/ anxiety
morphine
ativan
diprivan
neuromuscuar blockade
```
83
Why might ICP pt have NG tube?
prevent abdominal distention which can increase ICP
84
What is a neuro fever?
| how Tx?
Pt. with head injury may have involvement of hypothalamus - loss of temp regulation
Tx with cooling blankets
85
Why should hip flexion be avoided in pt. with altered cerebral perfusion?
it can increase ICP
86
When should nutritional therapy begin for pt. with altered cerebral perfusion?
What % of needs are replaced?
Hydration considerations?
Begin within 3 days of injury
Replace 140%
maintain normovolemia
87
What 2 hormonally induced syndromes need to be assessed in a pt. with altered cerebral perfusion?
Why?
How?
SIADH - too much ADH - dilutional hyponatremia
Diabetes insipidus - too little ADH - severe dehydration
How? - watch labs, Na & UO
88
Other drugs that may be used for pt. with altered cerebral perfusion include:
loop diuretics
barbiturates
pilosec (prevent stress ulcer)
colace (stool softener)
89
7 steps to manage CPP
```
calculate CPP
is MAP or ICP problem?
evaluate volume status
fix ICP
fix MAP
OXYGENATE
standing orders
```
90
Stroke statistics:
stroke is _____ leading cause of death in US
stroke is ___________ leading cause of disability
stroke is __3rd___ leading cause of death in US
stroke is ____1st (the)_______ leading cause of disability
STROKE IS A PUBLIC HEALTH CONCERN
91
s/s stroke (6)
1. sudden numbness, weakness or paralysis of face, arm or leg - especially on 1 side
2. sudden confusion, trouble speaking, or understanding
3. slurred speech
4. sudden trouble seeing in 1 or both eyes
5. sudden trouble walking dizziness, loss of balance or coordination
6. sudden, severe headache with no known cause
92
Pt. & caregiver teaching for stroke includes:
s/s - how to recognize
call 911 immediately
NOTE TIME of ONSET
93
how much blood does the brain need per minute?
____ to ______
what % Cardiac Output?
750 mL - 1000 mL
20% CO
94
neurological metabolism is altered in ______ (time)
stops in ________
cellular death in _______________
neurological metabolism is altered in __30 sec_ (time)
stops in __2 min_____
cellular death in __5 min_____
95
When tissue dies it swells - leads to cerebral edema which reaches its maximum ________hours after injury
48 - 72 hours
96
What happens to cerebral blood flow and CPP due to edema?
decreased!
97
decreased cerebral blood flow means less O2 which leads to ________ metabolism
Build up of CO2 leads to ________
anaerobic
| Vasodilation and decreased CPP
98
cerebral blood flow affected by....(5 things)
```
systemic BP (MAP)
CO2
cardiac output , 2/3
blood viscosity
increased ICP
```
99
seriousness of stroke CVA depends upon ______ & ________
size or extent of stroke & location (area of brain affected)
100
What are some non modifiable risk factors for stroke? (4)
1. Age (risk doubles Q decade after 55 yo)
2. Gender
in number men=women, but women die more! Plus females have increased risk of hemorrhagic stroke
3. Race (AA, hispanics, native am, asian am, greater risk than caucasians)
4. Heredity
101
What are some modifiable risk factors for stroke? (11)
```
1. HTN *** MOST SIGNIFICANT RISK FACTOR
Risk reduced 42% with control of HTN!
2. Obesity
3. DM
4. Heart disease
5. Increased cholesterol
6. ETOH
7. low level activity
8. Drug abuse (COCAINE)
9. oral contraceptives
10. smoking
11. Atherosclerosis
```
102
age group most likely to have ischemic stroke
older
103
age group most likely to have hemorrhagic stroke
younger
104
What does TIA stand for and what is it?
s/s TIA
Typical time frame for s/s to resolve?
Transient Ischemic Attack
temporary neuro dysfunction r/t brief interruption in cerebral blood flow
s/s numbness, loss of vision 1 eye, hemiparesis, aphasia, ptosis, vertigo
Resolves in 30 - 60 min
105
Meds for TIA & stroke prevention (5)
```
ASA 81 - 325 mg
plavix/ clopidogel
ticlid/ticlopidine
coumadin - for A fib
statins - chronic TIAs
```
106
List 3 surgical interventions for TIA Tx/stroke prevention
carotid endartectomy (artery cut, plaque removed)
transluminal angioplasty (insert balloon)
stent (placed using balloon)
(Lewis pg 1467-68)
107
state 2 major categories of strokes
ischemic (majority are this type)
| hemorrhagic
108
2 subcategories of ischemic strokes
thrombotic (clot)
| embolic (dislodged clot)
109
what happens in thrombotic ischemic stroke?
state 2 major modifiable causes
age group commonly affected?
```
BV narrows and clogs
clot forms
infarction - cell death
1. HTN, 2. DM - both increase arteriosclerosis which leads to plaque.
middle to older adults
```
110
TIA is a warning sign for which type of stroke?
thrombotic
111
Is LOC typically decreased in 1st 24 hours with thrombotic stroke
NO
112
Best Dx test for stroke
CT without contrast
113
Tx for thrombotic stroke?
time frame?
List another anticoagulant used for acute ischemic stroke
tPA
must be given within 3-4.5 hours of onset of s/s
325 mg ASA
114
Where do emboli in embolic stroke typically come from?
plaque dislodged in heart
115
collateral circulation may help lessen which type of stroke?
thrombotic (no time for it to form in embolic)
116
key factors in embolic stroke
RAPID onset of s/s
affects any age group
headache and severe neuro deficits (LOC is rare)
117
Tx for embolic stroke
MUST tx underlying cause bc embolus often breaks up into smaller emboli - can lead to CVAs from multiple clots
118
Hemorrhagic stroke:
What causes it?
Population typically affected?
Caused by bleeding into brain - subarachnoid or ventricles due to tumors,
trauma,
uncontrolled HTN,
burst aneurysm
119
What is an aneurysm?
balloon or blister in a weakened area along an artery
120
2 (street) drugs that cause hemorrhagic stroke? (from the lecture)
cocaine
| amphetamines
121
```
sudden onset
headache
N7V
hemiaparesis
deviation of eyes
decreasing LOC
progressing to s/s severe IICP
What type of stroke?
```
hemorrhagic - key points:sudden onset
decreasing LOC
progressive nature
122
hemorrhagic stroke prognosis? _______
Stats: _______ % die within 30 days
_________ % NOT functionally independent after 6 months
hemorrhagic stroke prognosis? _POOR___
Stats: _40-80__ %die within 30 days
_80 % NOT functionally independent after 6 months
123
What specific type of hemorrhagic stroke is caused by an aneurysm?
Where is aneurysm typically located?
prognosis?
subarachnoid
circle of Willis
POOR approx 1/3 die with 1st aneurysm
124
s/s subarachnoid hemorrhage
* SILENT KILLER - may have no s/s until rupture. OR slow leak...... = warning s/s
worst headache of your life
LOC decreasing
n,v
seizures
positive BRUDZINSKI stiff neck (flex neck - hips & knees flex too)
positive KERNIGS stiff hamstrings (inability to straighten leg when hip flexed to 90 deg)
(bc blood irritates the meninges)
LP (blood test that helps identify hidden risk for HA and stroke)
125
What is the connection between vasospams and rebleeds in H stroke?
injury to BV releases endothelin (potent vasoconstrictor) - vasoconstriction leads to ischemia & infarction = pressure which increases chance of rebleed
126
Timing for rebleed risk in H stroke
| 4 times mentioned in lecture
1st 48 hours
risk peaks days 6-10
continues through day 14 - kept in ICU
50% chance in next 6 months
127
Can you treat a H stroke with tPA?
NO! - no anticoagulants
128
Drugs for H stroke (1 specific, 3 categories)
Nimotop - Ca channel blocker - risk HYPOTENSION, Tx cerebral vasospasms)
anticonvulsants
steroids
analgesics
129
Surgical Tx for H stroke
shunt - duh drill a hole!
clipping - clip aneurysm
coiling - angiogram inserted - platinum coil or liquid used to stop bleed
wrapping - (this is a WAY out of date technique and is now considered dangerous - it was state of the art in the 19freaking80s!!!!) Go Wake Tech!
130
What is triple H therapy and what is it used to Tx?
Tx H stroke - goal is to increase cerebral perfusion
Induced HYPERTENSION 150/100 using vasopressors (dopamine, nor epi, neo-synephrine)
HYPERVOLEMIA - isotonic saline for hydration
HEMODILUTION - Hct btwn 30-35% (thin blood flows better)
131
Dx for strokes (3 basics)
BASELINE Neuro assessment - can use NIH stroke scale
CT - NOTE may be -ve for ischemic embolic stroke for 1st 24h
MRI
obviously ABCs, H & P, ABGs very helpful
132
What does pronator drift mean if stroke suspected?
damage to upper motor cortex on opposite of brain to arm that drifts
133
from stroke lecture Ms. Hudson's "gems for neuro assessment (4)
pupils
eye movement
motor & sensory
VS
136
Fast, impulsive activity indicates stroke on which side of brain?
Right - lets do it RIGHT NOW!
| Left = more cautious & slow
137
Right sided body weakness = stroke on which sided of brain?
Left
137
impaired language comprehension - stroke on which side of brain?
Left - Language
138
spatial- perceptual deficits - reached for glasses on table 10 feet away = damage which side of brain
What is a major safety nursing concern with this?
Right - Can't Reach
| Falls & may not be able to reach call bell
139
Neglects left side of body - stroke on which side?
Right
140
Problems with concepts of time - stroke on which side of brain?
Right
| rIghT - TIme
141
Depression - full awareness of deficits - stroke on which side of brain?
left
| I feel like there's nothing LEFT
142
```
Functional areas of brain control what? (Ms. H said to know in test Q&A)
Motor (frontal)
prefrontal (frontal)
somesthetic (parietal)
visual (occipital)
auditory (temporal)
Wernickes (Temporal)
Short term memory (temporal)
```
```
Motor - controls small muscles, coordinates movement, controls motor part of speech
prefrontal - thinking, planning
somesthetic - sensations - pain. temp
visual - Duh!
auditory - Duh!
Wernickes - interprets language
Short term memory - Duh!
```
143
Why are HYPOtonic solution bad for ER stroke care?
Fluid moves from BV to cells - increasing swelling = Increased ICP = BAD!
144
```
Goals of ER care for strokes:
O2SATs ________
Maintain ________
Monitor (labs) _____ & Tx
Dx tests ________ & __________
Positioning head ______ & HOB ________
________ precautions
If ischemic give _______ within __________
```
O2SATs .92%
Maintain cerebral blood flow!
Monitor (labs) F&E & Tx HYPERglycemia
Dx tests CT & MRI
Positioning head MIDLINE & HOB 30 deg
__SEIZURE______ precautions
If ischemic stroke give _tPA_ within _3-4.5 hours_
145
What are some seizure precautions? (5)
```
side rails up
pad side rails
no oral temps
bite block
suction at bedside (CARE bc ICP)
```
146
Why is stroke a public health concern?
| Emphasis should be on ________ vs cure
COST & nursing man hours!
| PREVENTION is key
147
Why are neuro ICU dimly lit?
pt. photophobic, decrease stimuli
148
Precautions for pt. given tPA (3)
No foley until 30 min post tPA
no arterial sticks (problem for ABGs)
No NG tubes immediately after
149
A. Drug given for fever control in stroke?
B. Drugs given to prevent seizures in strokes (4) DANT
C. Drug given to prevent vasospasm in H stroke
D, 3 categories of drugs given for pt. comfort during stroke
```
A. Ibuprofen
B. 1. Dilantin (Phenytoin)
2. Ativan (Lorazepam)
3. Neurontin (gabapentin)
4. Topamax (topiramate)
C. Nimotop (nimodipine)
D stool softeners, analgesics, anti-anxiety
```
150
post op care for stroke pt.
What do you check?
What do you need in the room?
Check: VS, neuro, bleeding (look under pt), palpate trachea for shift.
Trach tray in room
151
What are: Vasospasms & rebleeds, Hydrocephalus, increased risk of another stroke?
Complications of H and I strokes
(dumb Q but couldn't think how else to get this ridiculous, redundant info from ppt onto brainscape!)
Been doing this for so long I'm getting a little obsessive!!!! ;)
152
When does stroke rehab begin, and who will be involved? (6)
1st day!
| PT, OT, speech T, Nutritionist, case manager, psychiatric consults.
153
Why are stroke pt. NPO and when is NPO lifted?
risk of aspiration
| NPO lifted after swallow evaluation (usually by speech therapy) checks gag reflex
154
Why is DVT risk for stroke pt?
immobility r/t motor weakness
155
What is aphasia?
inability to communicate - Aphasia causes problems with any or all of the following: speaking, listening, reading, and writing.
156
What is dysarthia?
The muscles of the mouth, face, and respiratory system may become weak, move slowly, or not move at all after a stroke or other brain injury.
"slurred speech"
157
How to communicate with pt. with aphasia (5)
```
present 1 idea at a time
simple 1 step commands
slowly NOT loudly
avoid yes & no answers
try different forms of communication e.g. white board
```
158
Stroke pt. can have urinary or bowel incontinence
why?
Temporary or permanent?
Nursing interventions
altered LOC, impaired nerve function/communication btwn urge and control
if 1 brain hemisphere affected - temporary
Nursing interventions: BRP Q2H, increase fluids, check bladder residuals, increase fiber, stool softeners.
159
Pt. with visual/perceptual/spatial deficits has CVA on which side of brain?
nursing interventions for this pt?
Right - cant Reach
objects in visual field
approach from unaffected side
unaffected side faces the door
verbal and tactile clues
160
What is homonymous hemianopsia?
blindness in same half of both eyes
161
What is agnosia?
unable to recognize objects through sight/touch/smell
162
What is apraxia?
unable to carry out previously learned skills/commands
163
stroke pt has memory deficits - which side of brain affected?
Nursing interventions?
```
Left (I can't remember where I Left it?)
ROUTINES
reorient
repetition (same nurse/CNA)
photos of family
```
164
What is unilateral neglect?
Which side does it affect relative to location of CVA?
Nursing interventions?
Pt with right CVA may act as if left side of body does not exist (contralateral) - may not bathe, groom, or cloth 1 side of body.
Interventions: teach them to dress affected side first. use verbal clues tell them use your left hand to pick up the spoon.
165
What happens to stroke pt. when they leave the acute care setting?
DC home, SNIF, rehab
| Need ongoing collaborative care major lifestyle changes for pt & family
166
What is PSD & when does it typically begin?
Post stroke depression
| 3 months post CVA
166
3 components of the Glasgow coma scale
Eye opening
verbal response
motor response
167
Drugs for TIA prevention or Tx
```
ASA 81-325 mg
Plavix (clopidogel)
Ticlid (ticlopidine)
Statins
with A. fib - Coumadin
```
168
Teaching to prevent stroke:
| If pt. has A.fib which drugs are used?
exercise, weight loss, manage HTN, stop smoking
drugs - anti coagulants or platelet inhibitors (plavix)
A. fib - Coumadin (Warfarin) or Pradaxa (dabigatran)
169
3 components of the Glasgow coma scale
Eye opening
verbal response
motor response
170
---Normal Pressures---
•CPP:_______mHg
•ICP:________mmHg
•MAP:_______
* CPP: 60-100mHg
* ICP: 5-15 mmHg
* MAP: > 60
171
Drugs for TIA prevention or Tx
```
ASA 81-325 mg
Plavix (clopidogel)
Ticlid (ticlopidine)
Statins
with A. fib - Coumadin
```
NUR 211
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