Stroke, IC, Head & Spinal Cord injury

Question 1

ICP

Answer 1

Cause by trauma, hemorrhage, tumors, or inflammation

Impedes circulation to the brain

Question 2

Early signs of ICP

Answer 2

1. neuro change, altered LOC
2. Headache
3. Increased respiratory effort
4. Pupillary changes
5. Weakness in one side of the body

Question 3

Later signs of ICP

Answer 3

1. Glasgow <8
2. Babinski +
3. Cushing’s Triad
4. Projectile vomiting
5. Temp increase
6. Posturing (decorticate or decerebrate)

Question 4

ICP interventions

Answer 4

1. Monitor RR
2. Maintain body temp
3. Prevent shivering
4. Decrease environmental stimuli
5. Elevate HOB 30-45 degrees, keep head midline
6. Avoid straining activities or flexion or hip and neck, no coughing
7. Maintain negative fluid balance

Question 5

ICP complications

Answer 5

1. Brainstem herniation
2. Diabetes insipidus (increased urine output)
3. SIADH (urinary retention)

Question 6

Ischemic Stroke

Answer 6

80% of strokes
Caused by a clot

Question 7

Hemorrhagic Stroke

Answer 7

Bleeding around and into the brain
Caused by weakened blood vessel rupture (aneurysm bursts, uncontrolled hypertension, old age)

Question 8

TIA (mini stroke)

Answer 8

Indicative of bigger issues, more strokes

Question 9

S&S of stroke

Answer 9

Facial drooping
Arm weakness
Speech difficulty (aphasia)
Labile mood

Question 10

Management of Stroke

Answer 10

TPA dissolves clot
1. only works if LKW is less than 4.5 hours ago
2. BP needs to be <185/110
3. Cannot have already received herpain
4. CT scan confirms no hemorrhage

Question 11

Nursing for Stroke

Answer 11

1. Risk of ICP for hours
2. Airway management
3. Neglect syndrome (encourage patient to touch affected side of body)
4. Diet: thicken liquids, crushed meds, mechanical soft food, tuck chin to chest when swallowing

Question 12

Causes of Stroke

Answer 12

Hypertension
Afib
Obesity
DM

Question 13

Battle sign

Answer 13

Brushing over the mastoid process. Indicative of basilar skull fracture

Question 14

Halo test

Answer 14

‘Double ring’ in leakage from ears or nose is a classic sign of CSF leakage

Question 15

Head Injury management

Answer 15

1. Decrease stimulation in the room, cluster care
2. Behavior changes should be expected
3. Maintain routine

Question 16

Closed head injury

Answer 16

Concussion
Contusion
Fracture

Question 17

C5

Answer 17

Full head and neck control, shoulder and elbow strength

Likely to have total paralysis of wrist, hands, trunk and legs

Maximum assistance with elimination

Question 18

C8

Answer 18

Controls hands, finger grip
Little to no control of bowel or bladder

Question 19

T3

Answer 19

Full hand and finger control
Affects muscles in the chest and upper back
Paraplegia
Manual wheelchair

Question 20

T11

Answer 20

Should be able to cough
Paraplegia
Manual wheelchair

Question 21

Spinal Shock

Answer 21

Temporary loss of all or most spinal reflexes-no sensation, paralyzed and flaccid with absent reflexes

Question 22

Autonomic Dysreflexia r/t SCI

Answer 22

1 priority: sit patient up, call MD and loosen restrictive clothing

Life-threatening hypertension after spinal cord injury usually related to distended bladder or impacted bowel

Question 23

Autonomic Dysreflexia S&S

Answer 23

Severe hypertension
Blurred vision
Headache
Diaphoresis

Question 24

Neurogenic Shock

Answer 24

Spinal cord injury causes loss of sympathetic nervous system leads to unopposed parasympathetic nervous system

Question 25

Neurogenic Shock s&s

Answer 25

Hypotension
Bradycardia
Flushed, warm skin