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4th Semester > Stroke/ ICP/ aneurysms NIHSS exam 2 > Flashcards

Stroke/ ICP/ aneurysms NIHSS exam 2 Flashcards

1
Q

What are general considerations of the neurological assessment

A

Systematic approach

Do it the same way every time

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2
Q

What is the most sensitive indicator of change in a patient

A

LOC

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3
Q

What is the order of LOC

A 
AWAKE/ ALERT
CONFUSED
LETHARGIC
OBTUNDED
STUPOR
COMA

−

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4
Q

What is lethargic

A

Severe drowsiness

The pt. cam be aroused by moderate stimuli and then drift back to sleep.

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5
Q

What is OBTUNDED

A

Patient has a lessened interest in the environment
Slowed response to stimulation
Tends to sleep more than normal with drowsiness in between sleep states

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6
Q

What is stupor

A

ONLY VIGOROUS AMD REPEATED STIMULI WILL AROUSE THE PERSON

WHEN LEFT UNDISTURBED, THE PT. WILL IMMEDIATELY LAPSE BACK INTO THE UNRESPONSIVE STATE

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7
Q

What is coma

A

State of unarousable, unresponsiveness

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8
Q

What is the left hemisphere responsible for

A

It is the primary language center

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9
Q

What is the right hemisphere responsible for

A

Visual- spatial perception
Music
Processing of information
Recognition of faces

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10
Q

For a neurological assessment, what 3 cranial nerves are tested together and what are they responsible for

A 
Cranial nerves 3,4,6 
They are MOTOR NEURONS responsible for 
1. Eye movement
2. Eye lid opening 
3. Pupil reaction
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11
Q

What is important to remember regarding documentation of pupil size

A

Do not document unequal pupils if you are not sure what the baseline pupils looked like…..
Some pupils may be uneven doe to past eye surgeries.

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12
Q

What does mental status entail?

A
  1. LOC
  2. Orientation
  3. Appearance and behavior
  4. Speech pattern
  5. Thought and perceptions
  6. Cognitive functions
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13
Q

What does a motor examination entail?

A

Strength
Tone
Symmetry
Coordination

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14
Q

If a person has loss of balance, what type of stroke would the nurse immediately assume

A

Cerebellum stroke

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15
Q

What is the cerebellar assessment

A

A assessment where balance and coordination are assessed.

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16
Q

How do you test balance and coordination

A

Pronate- supinate hand

Tap index finger to thumb

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17
Q

What is the Romberg test

A

A test that assesses balance

It is indicative of cerebellar damage on the side to which the patient leans

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18
Q

What is the Glasgow coma scale?

A

It is developed for assessment of patients in a coma

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19
Q

What are the 3 categories of the Glasgow coma scale

A
  1. Eye opening
  2. Best verbal
  3. Best motor
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20
Q

What is the score range for the Glasgow coma scale

A

3-15

The lower the score, the worse the patient and prognosis

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21
Q

What are considerations of the elderly to consider during a neurological assessment

A

Isles to consider include

  1. Decreased hearing
  2. Decreased mobility
  3. Change in cognitive ability
  4. Decreased vision
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22
Q

What is a stroke

A

A syndrome that is characterized as a sudden, non convulsive ( without seizures), onset of neurological deficits related directly or indirectly to a deficiency of the cerebral blood supply

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23
Q

What is the nations 5th leading cause of death

A

Stroke

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24
Q

What are stroke risk factors

A

Smoking
Uncontrolled HTN
Hex of stoke in family
Chronic A fib

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25
Q

Strokes can be caused by what

A 
Clot formation ( ischemic strokes)
Hemmorhage ( hemmorhagic strokes)
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26
Q

For hemmorhagic strokes what medication would the nurse seek clarification from the MD

A

Anticoagulants

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27
Q

What percentage of strokes are classified as ischemic

A

87%

Most strokes are ischemic

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28
Q

What percentage of strokes are considered ICH

A

10%

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29
Q

What is ICH

A

Intracranial hemmorhage

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30
Q

What percentage of strokes SAH

A

3%

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31
Q

What sex is more prone to strokes

A

Woman what are the 2 types of ischemic stroke

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32
Q

What are the 2 types of ischemic strokes

A
  1. Embolic

2. Lacunar

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33
Q

What is a embolic stroke

A

A type of ischemic stroke that develops from emboli such as in A fib when a emboli breaks loose and enters the brain

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34
Q

What is a lacunar stroke

A

A type of ischemic stroke that is more minor than emboli strokes. It is found in the lacuna of the brain
Can be seen on MRI’s

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35
Q

Who do lacunar strokes more commonly occur in

A

The elderly… They are generally asymptomatic

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36
Q

What are the classifications of a hemmorhagic stroke

A

Non traumatic SAH
RUPTURED CEREBRAL ANEURYSM
SPONTANEOUS ICH ( intracranial hemmorhage)

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37
Q

What can non traumatic SAH’s be caused by

A

They can be due to cerebral aneurysms

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38
Q

What is the most dangerous type of hemmorhagic stroke

A

Spontaneous ICH because there are no wearing signs… They are sudden

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39
Q

What is a transient ischemic attack ( TIA)

A

They are not strokes, there is a temporary disruption of blood flow result no in temporary deficits that are gone within minutes…. TIA’s can be a precursor to stroke

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40
Q

For a ruptured cerebral aneurysm, what will the patient complain of

A

Severe headache

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41
Q

What is AIS

A

Acute ischemic stroke

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42
Q

What is the clinical profile of AIS

A

Pt awakens with neurological deficits

They are usually sedentary when symptoms occur ( during sleep, at rest)

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43
Q

How does AIS progress

A

In a systemic manner
Hypo perfusion, then decreased cerebral perfusion, then ischemia and infarct.
Peaks in 1-3 days then stabilizes

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44
Q

What is the clinical profile of embolic stroke

A

Sudden onset
Occurs when the patent is awake and active
Very rapid onset
Maximum deficit within minutes… The deficit won’t get worse

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45
Q

What can embolic stroke occur from

A 
Cardiogenic embolism 
A fib
Valvular disease
Ventricular thrombi
Plagues of proximal aorta
Left middle cerebral artery (MCA) most often affected
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46
Q

What is a lacunar stroke

A

A small penetrating stoke

Predominately basal, ganglia, thalamus, pons

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47
Q

What are risk factors of a hemmorhagic stroke

A 
HTN, HTN, HTN, HTN,HTN, HTN,HTN,
AVM ( arterio venous malformation)
coagulopathy ( liver disease, warfarin)
Trauma
Drugs ( cocaine)
Tumor
Endocarditis
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48
Q

What is the clinical profile of ICH in the older person

A

Poorly controlled HTN
person is active with no warning signs
Occurs rapidly in minutes to hours

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49
Q

What is the clinical profile of the younger person with ICH

A

Drugs
Patent foramen ovale
Trauma

50
Q

What is initial management of ICH

A
  1. Airway, breathing, circulation
  2. Determine Glasgow coma scale and NIHS, check brain stem reflexes If comatose
  3. BP control ( keep BP under 140)
  4. If low platelets ( transfuse)
  5. If on warfarin and INR is greater than 1.4, give FFP, PCC FACTOR VII
51
Q

What does fresh frozen plasma and PCC do

A

It is reversal to decreased INR

52
Q

What does factor VII do

A

Lowers risk of ICH enlargement
Increased risk of MI, ischemic stroke, DVT/PE
it does not improve mortality or functional outcome

53
Q

Appro px 15% of all strokes are preceded by what

A

TIA’s

54
Q

Why is it important to keep BP under 140 and not 120 during ICH management

A

Keep them under 140 to keep them perfused, If BP is lowered too quickly, repercussion rebound will occur, the patient will recieve no perfusion at all

55
Q

MCA

A

Middle cerebral artery

56
Q

ACA

A

Anterior communicating artery

57
Q

What does the internal carotid supply

A

2/3 of the brain

Frontal, temporal, and parietal

58
Q

What are symptoms of a anterior stroke

A

One side of the body
Both motor and sensory
Left side of brain causes aphasia
Usually not conscience

59
Q

What are basilar arteries

A

Main blood supply to the brain.

Brain stem, thalamus, occipital, inferior temporal lobes

60
Q

What are the 4 D’s of a posterior stroke

A

Diplopia
Dysarthria ( speech)
Dysphasia ( swallowing)
Dizziness ( vertigo)

61
Q

How is a stroke diagnosed?

A 
Symptomatology
CT scan
MRI/ MRA
CBC, PLATELET COUNT, PT, PTT
serum electrolytes and glucose 
Neck and heart auscultation 
EKG,electrocardiogram, TEE
carotid and cranial ultrasound
62
Q

What is a bad value for serum lactate

A

Above 4

63
Q

Why are neuro patients one insulin drip

A

Blood glucose increases in brain tissue damage/ hypoxia

64
Q

If a patient hits their head what can be expected of the MD to order

A

A CT scan which is quicker, cheaper, takes less time… The CT will show head trauma.

65
Q

What is used as a definitive diagnosis of a stroke

A

A MRI/ MRA

A MRA looks at all the blood vessels

66
Q

If a patient is on anticoagulation therapy what diagnostic will be ordered first

A

A MRI

67
Q

What is medical treatment for a stroke

A

Anti platelet & anti thrombolic therapy
Treat hypertension
Neuroprotectives such as Calcium channel blockers ( nimodipine)

68
Q

What are surgical interventions for a stroke

A

CEA
THROMBECTOMY
LOBECTOMIES ( almost never done)

69
Q

What is CEA

A

Carotid endorectomy
It is done prophylactically so the patient won’t have a stroke.
A stethoscope is held on carotid and if a bruit is heard a ultrasound will be ordered

70
Q

What is interventional radiology of a stroke

A

TPA
STENT PLACEMENT
THROMBOLYSIS

71
Q

What is tPa

A

A enzyme found on blood vessel walls that defends against excessive clotting in normal vessels.
It dissolves thrombin clots

72
Q

What is criteria for tPa

A

Symptom onset within 3 hours

No ICB, NO SAH

73
Q

What are contraindications to tPa

A 
Rapidly improving symptoms
Serious brain trauma or intracranial surgery within last 3 months
Seizure at onset of stroke 
Active internal bleeding 
Intracranial neoplasm, AVM, aneurysm
Uncontrolled HTN ( above 185/110)
Glucose less than 50 or greater than 400
LP within last 7 days
Major surgery within 14 days
Acute MI
coagulopathies
74
Q

What does sequelae mean

A

After effects

75
Q

What is the sequelae of a stroke

A

Motor/ sensory deficits
Perceptual difficulties
Seizures
Hydrocephalus

76
Q

What risk factors can be modified for stroke prevention

A

Control HTN, arrthymias, DM
exercise
Diet ( cholesterol)

77
Q

At what age does SAH peak

A

55-60

78
Q

What is the chief complaint of SAH

A

97% complain of the worst headache of their life

79
Q

What are signs and symptoms of SAH

A 
30-60% sentinel hemmorhage or wearing headaches prior
Transient loss of consciousness 
N/V, blurred vision
Photophobia 
Seizures
80
Q

What is photophobia

A

Light sensitivity

81
Q

What are risk factors for SAH

A

HTN,
SMOKING
ORAL CONTRACEPTIVES
COCAINE

82
Q

What is the outcome of SAH

A

15% dies before reaching medical care

83
Q

What is the mortality rate for SAH

A

19% in first 2 weeks
50-60% in first month
66% never return to the same quality of life they end up with. Neurological deficits for life.

84
Q

What are risk factors for aneurysm rupture

A

Female population peaking in the 50’s and 60’s
Genetic disorders such as polycystic kidney disease, ehlers- Danlos syndrome
Smoking
Diabetes
Familial history especially in woman.

85
Q

What are the shapes of a aneurysm

A

Berry

Fusiform

86
Q

What is the pathophysiology of aneurysms

A

Blood under high pressure bleeds out of the dome of the aneurysm.
Accumulation is within the subarachnoid space at the base of the brain.
Blood may also collect in the parenchyma, ventricles, or subdural spaces, forming a hematoma.

87
Q

What is physical examination of a aneurysm

A

Nuchal rigidity ( pain when flexing neck)
Restlessness
Diminished LOC
focal neurological signs related to the vascular territory involved in the hemmorhage
Cranial nerves 3,4,6

88
Q

What is initial management of the brain aneurysm patient

A 
Admit to ICU
ABC's
Possible central/ swan- gantz/ arterial line 
Possible EVD
strict BP management 
Nimodipine 
Stool softeners
Ulcer, seizure/ DVT prophylaxis
89
Q

What is analgesia for aneurysm

A

Morphine for headaches

90
Q

What is surgical treatment for brain aneurysms

A

CEA
surgery to correct bleeding of brain
Craniotomy

91
Q

What is a coil

A

Used for fusiform aneurysms, keeps blood from going to the aneurysm. If the blood flow doesn’t go there it will die.

92
Q

What is a coil used for

A

Fusiform aneurysms

93
Q

What is surgical clips used for

A

A berry aneurysm, it cuts off blood flow,to,the aneurysm

94
Q

What are complications of endovascular amd surgical treatment for aneurysms

A

Aneurysm rupture
Compromise ( including perforation) of parent vessels and/ or their branches
Thromboembolism death

95
Q

What is nursing care and after intervention of surgical treatment for a aneurysm

A

VS/ neuro checks
Pain control ( morphine)
Fluid management ( critical)
IV line maintenance, including ensuring integrity of the line
Observation ( after coiling) for bleeding at site, loss of pulse to extremity, back pain, decreased urinary output, vomiting, tachycardia, or hypotension, watch urinary output for kidney failure.

96
Q

What are complications of aneurysm SAH

A
  1. Cerebrovascular vasospasm
  2. Fluid and electrolyte disturbances
  3. Hydrocephalus
  4. Increased ICP
97
Q

What is cerebral vasospasm

A

Narrowing of the cerebral vessels near or distant to the SAH causing cerebral ischemia

98
Q

When does cerebral vasospasm occur

A

4-14 days post SAH

99
Q

What are signs and symptoms of cerebral vasospasm

A

Focal speech/ motor deficit
Altered LOC
diagnostic imaging showing vasospasm

100
Q

What is treatment of a cerebral vasospasm

A

Cerebral angiogram with intra arterial papaverine or balloon angioplasty

101
Q

What diagnostic will show vasospasms

A

MRI/ MRA

102
Q

What is triple H therapy for cerebral vasospasm

A

Hypertensive
Hypervolemic
Hemodiutional therapy

103
Q

What is treatment for the first H in cerebral vasospasm

A

HYPERTENSION
Elevate SBP per MD
order with fluids or vasopressors ( dopamine, neosyphrine)

104
Q

What is treatment for the second H in cerebral vasospasm treatment

A

HYPERVOLEMIA

keep PCWP 10-16 and CVP 8-12 using N/S, albumin, crystalloids, colloids, or PRBC

105
Q

What is the third H in treatment of cerebral vasospasm treatment

A

HEMODILUTION

maintain HCT less than 40% using N/S and albumin

106
Q

What medication treats cerebral vasospasm

A

Nimodipine ( Nimotop)

107
Q

What are complications from triple H therapy

A

Pulmonary edema
MI ( by stress is on the heart, PAWP is increased diving the heart more workload, due to the extra fluids given)
cerebral edema

108
Q

What is a potential complication of brain aneurysms

A

Hydrocephalus
Arachnoid villi are unable to reabsorption CSF sufficiently; often laden with byproducts of blood breakdown from SAH
This results from the hemmorhage itself.

109
Q

What is treatment of hydrocephalus

A

Acutely, an EVD may be inserted

Overtime EVD level may be raised to allow patients to reabsorption their own CSF, then EVD is discontinued

110
Q

What Happens if a patient is unable to reabsorb CSF

A

A ventriculoperitoneal shunt (VP SHUNT) may be performed

111
Q

What is EVD

A

External ventricular drain. It is common after brain surgery

It can be inserted at the bedside or at time of surgery.

112
Q

Can nurses regulate and adjust EVD’s

A

YES

113
Q

What are common causes of increased ICP

A 
Hydrocephalus 
Space occupying lesions 
Cerebral edema 
Head trauma 
Intracranial hemmorhage
114
Q

What is important to note with increased intracranial hemmorhage

A

It is very dangerous

The more pressure =less perfusion

115
Q

What is CCP

A

The amount of pressure to adequately perfuse the brain

116
Q

How do you calculate CCP

A

( MAP-ICP)

117
Q

How can CCP pressure be released

A

By draining pressure in the brain

118
Q

Increased ICP diminishes what

A

Circulation to the brain

119
Q

What are signs and symptoms of increased ICP

A 
Decreased LOC 
HTN ( increased systolic, diastolic stays the same, widened pulse pressure)
Bradycardia 
Respiratory pattern changes 
Pupil dysfunction ( cranial nerve 3)
120
Q

What are SAH considerations/ interventions

A

Nurse must monitor for rebleeding, cerebral vasospasm, hydrocephalus, fluid and electrolyte disturbances

121
Q

How much time laspses before complete oxygen deprivation causes IRREVERSIBLE neuronal damage

A

2-5 minutes

122
Q

What are the categories of the NIHSS scale

A
  1. LOC, LOC questions, LOC commands
  2. Best gaze ( horizontal eye movements tested)
  3. Visual fields
  4. Facial palsy
  5. Motor arm
  6. Motor leg
  7. Limb ataxia
  8. Sensory
  9. Best language
  10. Dysarthria
  11. Extinction and inattention

4th Semester (18 decks)

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