Neurological Flashcards
How do you calculate MAP?
MAP = (2 (diastolic) + systolic) / 3
What is a normal ICP range?
5-15 mmHg
What is a normal range for CPP?
60-100 mmHg
A patient’s BP is 108/72, their ICP is 13. What is their CPP? Is it normal?
CPP = 71 mmHg. Yes this is normal
What would a patient with decorticate posturing look like?
Person is stiff, bent arms, clenched fists and legs held out straight
How can a nurse help the family of a patient with a TBI?
Engage them in patient care, allow them to stay with their loved one, explain to them what is happening and what procedures are happening
How should the bed be positioned for an unconscious patient with an altered CPP from cerebral edema? And why?
Head of the bed elevated to 30 degrees to promote cerebral drainage
What discharge instructions are required for a patient with a concussion who is being discharged?
Educate the patient and family how to monitor neurological status
What is a contraindication for inserting an NG tube related to a head injury?
A skull fracture and patient has clear drainage coming from nose
What pupil finding is extremely concerning in a patient with a head injury? What are the normal sizes of pupils and what is concerning?
A dilated unresponsive pupil. Constricted pupil size is 2-4mm range, dilated pupil is 4-8mm range.
Your patient with a head injury has a change in LOC and is difficult to arouse. Is this concerning and does it require rapid action?
Yes
Signs of increased intracranial pressure? (4)
Behavioural change, irregular respirations, widening pulse pressure (increasing systolic pressure), decreased pulse rate. Also called Cushing’s triad (pulse pressure, bradycardia, resps)
How would you suction a patient with increased ICP to prevent it from worsening?
Suction less than 10 seconds, limit to 2 passes, give 100% oxygen before and after suctioning.
How would you plan your care for a patient who received tPA within the past 24 hrs? (4)
Cluster patient care activities, keep their head in a neutral position, monitor BP closely, keep lights down low
Health teaching for dysphasia patient after a stroke?
Watch for fatigue during meals, no distractions during meals, place food on the unaffected side of the mouth, sit upright when eating
A patient has low sodium levels, decreased LOC, and a headache. What are they at risk for?
Cerebral edema. Fluid will shift intro brain cells because of low sodium (will try to balance out concentration)
What deficits do you expect with a right hemisphere stroke?
Spatial deficits (spatial neglect)- lose awareness of things on one side of your body
Perceptual deficits- hearing, smell, somatosensation, taste, touch, and vision. Impaired ability to interpret sensory information, impacting their ability to interact.
How can you help prevent secondary brain injury after a severe TBI?
Ensure normal ventilation (prevent hypoxia), maintain BP (prevent hypotension), maintain normal temperature
What risk needs to be assessed after a stroke
Risk for aspiration
A patient who experiences TIAs is having repeated symptoms. Should they seek help? Why or why not?
Yes, it could be a stroke and not a TIA
What should a patient be assessed for before receiving tPA? What are some contraindications?
Risk for bleeding- hx of bleeding, hx of trauma, hemorrhagic stroke
A patient presents with new onset right sided weakness. What is the first test that should be done?
CT
How should you communicate with a patient with expressive aphasia?
Ask simple questions, yes or no questions, leave out small connecting words in sentences
A patient has left sided homonymous hemianopsia. What side should you approach them from?
Approach from the left, they only have vision of the left visual field
What are facial droop and slurred speech signs of?
Stroke
What is the battle sign? What does it is suggest the patient has?
Bruising (ecchymosis) over the mastoid process or retroauricular. Indicates a skull fracture
Ischemic vs hemorrhagic stroke?
Ischemic- most common, vessel becomes blocks and prevents blood supply to portion of the brain, resulting in tissue death
Hemorrhagic- artery ruptures and blood leaks from artery into the brain
What does FAST stand for?
Face, Arms, Speech, Time
