NUR 2755 Multidimensional Care IV

MDC4 Exam 1 Review

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Normal ICP

- 5-15 mmHg

S/SX increased ICP

- Agitation/confusion**

- Pupil change

- Posturing

- HA

- Seizure

- HTN

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- Restlessness

- Decreased BP

- Vomiting

- Slurred speech

Increased ICP interventions

- Elevate HOB

- Avoid coughing, sneezing, straining

- Stool softeners

- Decrease stimulation

- SBP 140-150

- Mannitol

- Corticosteroids 

ABCDE

- Antiplatelets & anticoagulant

BP lowering meds

Cessation of smoking & cholesterol lowering (statins)

Diet low fat/cholesterol

Exercise

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What do you do first if patient shows sign of stroke??

- Check blood glucose

Hypoglycemia mimic’s stroke

BEFAST

- Balance

Eyes

Face

Arms

Speech

Time

Absolute tPA contradictions

- Hemorrhagic stroke**

>4.4 hrs.

HX intracranial hemorrhage

Known AVM, tumor, aneurysm

plt <100,000

BP> 185/100

Anticoagulant use

Pregnancy 

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Relative tPA contradictions

- NIHSS>22

NIHSS<4 w/ improvement

14-day post-op

MI within 3 months

BS <50 >400

older than 80

Hx ischemic stroke & DM

Intracerebral hemorrhage

- Bleeding into brain tissue usually s/t hypertension

Subarachnoid hemorrhage

- Bleeding into subarachnoid space usually s/t aneurysm or AVM 

Aphasia

- Unable to understand or express speech

Hemianopsia

- Blindness in half of visual field 

Homonymous hemianopsia

- Blindness on same side in both eyes

Ptosis

- Drooping eye or facial droop 

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