NUR 2755 Multidimensional Care IV MDC4 Exam 1 Review Normal ICP - 5-15 mmHg S/SX increased ICP - Agitation/confusion** - Pupil change - Posturing - HA - Seizure - HTN - 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 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 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