Test 1

not a disorder but a result of other problems

CVA, head injury, brain tumor, drug overdose

• eye
• verbal
• motor

can never have less than 3 or greater than 15

• always assume person can hear, even when no response
• aways address pt by name, tell them what you are going to do prior to nursing intervention
• refrain from conversations about their conditions around them

• if unconscious take rectal temps if possible
• report changes in vital signs
• note changes in response to stimuli
• note return of protective reflexes
• keep the room comfortable, feel their skin temp, adjust as needed

• complete head to to - focus on neuro (PERRLA - size, asymmetry in mouth/face/smile, Babinski abnormal in adult)
• if localized signs; assumed neurologic disease till ruled out

CT scan, MRI, less common PET

blood glucose, electrolytes, CBC, BUN, Creatinine, PT, PTT, Ca, toxicology screens, ABG's

• On patient - NO: pacemakers, metal plates, prosthetic joints, aneurysm clips, artificial heart valves, intrauterine devices, cochlear implants or other metallic implants
• In room - NO: credit cards, O2 tanks, traditional ventilators, stethoscopes

respiratory failure, pneumonia, aspiration, pressure ulcers, contractures, DVT

• Maintain patent airway - first priority
• position, suction (be sure equip works), NO verbal restraint order, must be written
• May require ventilation, should be monitored
• IV access
• Nutritional support (NGT, PEG) asap to maintain GI function
• weight is most objective sign of nutrition, provide mouth care a minimum of Q 4 hrs - ESPECIALLY if on on vent

• maintenance of clear airway
• protect from injury
• attainment of fluid volume balance
• achievement of intact skin integrity
• absence of corneal abrasions/irritation
• effective thermoregulation
• effective urinary/bowel elimination
• maintains family support
• absence of complications

• Position - lateral recumbent position (coma position)
• Suction - at the bedside, with equipment working, catheters at bed side
• Reposition - side to side
• Administer O2; assess cannula sites for skin breakdown, pulse oximeter

• should be available to calm, quiet the pt.
• DO NOT restrain - will lead to self injury or dangerous increase in ICP
• Physical restraints should be avoided if possible - a WRITTEN order must be obtained Q24 hrs

• Side rails padded, 2 rails are up during day, 3 at night (never 4 - this is restraint)
• Assess any tight dressing, damp bedding, dressings, monitor tubes, drains
• Protect dignity by privacy, speaking to patient while caring for, do not speak negatively about the pt's condition

• assess tissue turgo, mucous membranes, assess I/O, analyze lab values
• fluid initially by IV route (slowly administered - too rapid can cause ICP)
• may need PEG/NGT

• inspect dryness, inflammation, crusting
• care Q4 hrs
• petrolatum on lips prevent dryness, crusting
• Move ET tube side to side to prevent ulcer in corner of mouth daily

• regular turning schedule
• special beds
• do not drag, pull up in bed/creates shearing forces and friction - instead lift
• maintain correct body position - passive ROM all extremeties, use splints foam boots to prevent foot drop, trachanter rolls support hip joint, arms abducted with fingers flexed, hands slight supination, assess heels for pressure

• adjust environment
• few covers, drapes, sheets
• if elderly and no temp room should be warm

• remove bedding as possible
• admin acetaminophen as prescribed
• cool sponge bath, electric fan to blow
• use hypothermia blanket
• frequent monitor temp, PREVENT shivering and excessive drop in temp

• clean with cotton balls moistened with sterile NS
• artificial tears per protocol
• for periorbital edema post craniotomy - cold compress
• if eye patch is ever used must be sure no contact with cornea

• often incontinent/retention
• palpate bladder, bladder scan to determine if present
• can have overflow voiding - may insert foley if not voiding to BSD, and acute phase injury; inspect urinary meatus for drainage; left in place as short time as possible; monitor if voiding with bladder scan US device; may use external condom cath for males; conscious bladder training program started; incontinent pt, assess skin breakdown, implement prevention strategies

• risk for diarrhea constipation
• monitor bowel movements

• ICP not an issue
• help sensory deprivation - goal to restore daily rhythm of day and nights, touch important, talking with pt, orient x3, family can read to pt, when pt arouse from coma may be agitated, positive clinical sign, may need to minimize stimulation in these cases

• state of crisis
• reinforce, clarify info
• involve family

• irreversible loss of all function of entrie brain, including brain stem
• - pt appears to be alive (HR, breathing)
• - must provide accurate, timely, understandable, consistent info to family

• assess respiratory, v/s, labs, SaO2
• assess around every peice of med equip used on pt; place on special mattress, turn, skin care, prevent shearing forces
• s/s, can progress to PE, thigh high stockings, pneumatic compression devices

• brain tissue (1400g)
• blood (75mL)
• CSF (75mL)

10-20mmHg

• 2-6
• 3-7
• 0-10

> 20 for more than five minutes (lower number used for infant and child)

shift CSF to spinal canal, increase absorption of CSF, or decrease crebral blood flow

mechanism fails causes braint issue to herniated down through the opening in base of the skull

immediate/irreversible - can be traumatic, or nontraumatic (stroke, tomor, infection)

consequences of primary injury or of such processes as hypoxia, hypotension, hypercapnia, acidosis, reduced oxygen delivery

• that the volume of the others is reduced by equal amounts (Monroe-Kellie doctrine)
• cerebral blood volume is altered; when maximal volume is shifted, further increase in intracranial volume will markedly increase ICP

part of the healing process so they occur

can be localized or generalized and can lead to loss of auto regulation, compensatory change in diameter or intracranial blood vessels that maintains constant blood flow despite change in CPP (this loos causes increased blood for to the brain causing fluid to shift from the intravascular to the interstitial space)

• can increase blood flow and increase edema
• can cause ischemic injury, hypoxia and incnrease PACO2 levels causing vasodilation thus edema
• vasoconstriction, which diminishes blood flow to and from the brain and increases risk of secondary brain injury
• hypthalamus; triggers hyperthermia, leads to more vasodilation, increased metabolic rate, increased O2 demands

• MAP-ICP
• pressure at which cells perfuse and is important indicator if cerebral blood flow
• >70
• >50-60
• >40-50

• disorientation, restlessness, increased respiratory effort, puposeless movement, mental confusion
• pupil changes, impaired extraoccular movements, weakness on one side or in one extremity, constant HA increased in intensity and aggravated by movement or straining

Cushing's triad, decreasing LOC till comatose, projectile vomitting, hemiplegic, decorticate or decerebrate posturing

irregular resp pattern, widening pulse pattern, bradycardia

• electrolytes, O2 sat, carbon dioxide level
• s/s infection, sustained elevation of ICP, CPP>100 or less than 70 and any change in CSF drainage, amount, color, clarity

• subdural or subarachnoid space; no direct CSF access
• insterted into ventricle, more invasive; direct access to drain CSF; infection risk
• cant be zeroed once in and over time become inaccurate

• zeroed once a shift, per protocols; when taking report review, verify orders concerning monitoring parameters, leveling, drainage parameters with the off going nurse
• the foramen of Monro to ensure measurement is accurate

• obtain your reading, inspect the system for leaks, kinks; check insertion site for bleeding, infections, CSF leakage, if using drain device for CSF check output; color, amount and clarity hourly
• test for glucose with strip, report to MD immediately, glucose in CSF is about 2/3 serum value (use of strips can cause false postitive and negatives) are followed up with more precise lab test

• monitor LOC (GCS)
• assess motor responses bilaterally
• check for positvie babinski sign
• assess sensory response (emphasis on side on opposite side of injury)
• assess pupils
• monitor VS, notify MD of deviation from set parameters
• provide resp care measures
• position to maintain venous outflow from brain
• admin meds
• control noise stimuli
• provide rest/activity balance (stagger tasks)
• eye, skin, oral mucosa care
• education/emotions support to family
• be sure to zero monitor
• always sedate prior to using a paralytic
• should have a negative fluid balance

• compare size, shape, equal
• check with direct light reflex (each eye separately)
• PERRLA
• assess 6 cardinal fields of gaze (cranial nerves III, IV, VI)
• assess for doll's eye phenomenon in unconscious (indicated brain stem damage)

• PaO2 >60
• Spo2>90%
• suctioning (may give lidocain down EET prior to suctioning need MD order)
• ABG's; provide O2
• monitor O2 sat
• monitor vent settings

• elevate HOB 30 degrees (except dural tear)
• no pillow under head
• turn, log roll q 2 hrs

• craniotomy
• trassphenoidal
• craniectomy
• cranieplasty

• baseline preop assessment
• assess pt and fmly understanding
• teach re: compression stockings, SCD
• assure consent forms are signed after MD obtain informed consent

• inneffective cerebral tissue perfusion
• risk for imbalance body temp
• potential impaired gas exchange
• disturbed sensory perception
• body image disturbance

neurologic homeostasis to increase cerebral perfusion

increased ICP, bleed, hypovolemic shock, fluid electrolyte imbalance, infection, seizures

• maintain cerebral tissue perfusion
• position
• regulate temp
• treat and monitor for hypothermia
• improve gas exchange
• manage sensory deprivation
• enchance self image

• assess resp status
• monitor for s/s of cerebral edema
• avoid head rotation/flexion

place on back or side (unoperated side if a large lesion was removed) with one pillow under the head; HOB elevated 30 degree if ok with MD

patient kep flat on one side (off the back) with head on a small, firm pillow; may turn side to side with head in neutral position; may eleveate HOB as tolerated; when turning, turn body as a unit as not to strain incision Q 2 hrs and assess skin frequently

expect moderate temp elevation, treat high temp; monitor; to decrease temp remove blankeys, apply ice bags to axilla and groin areas, use a hypothermia blanket as prescribed, and admin meds;

also treat and monitor for hypothermia - frequent rectal temp if not contraindicated; rewarm pt, prevent shivering

• monitor for s/s of resp infection - high temp, increased pulse, and change in resp (decrease breath sounds)
• reposition q2hrs
• when conscious instruct to deep breath, no coughing unless MD ok
• cautiosly suction if needed
• consult resp therapy

periorbital edema is common; hematoma may form under scalp and spread down to the orbit producing an area of ecchymosis (black eye); place pt in head up and apply cold compressess; notify MD if edema worsens, indicates postoperative clot is developing or that there is increasing ICP and poor venous drainage; announce yourself when entering pt room

• encourage to tlk about feelings, frustrations
• " " image, use turban/wig
• " " support groups, social interaction

• increased ICP bleeding
• F&E
• prevent infection
• seizures
• DVT's, PE, Pulmonary or UTI's, pressure ulcers

• life threatening
• increased blood pressure with decrease in pulse and resp failure = increased ICP
• clot under bone flap may be life threatening - s/s: pt who does not waken as expected, new post op deficits (dilated pupil on side of op site)

pt is returned to OR immediately for evacuation of clot

clinical manifestations of a clot

alignment of head in a neutral position without flexion to promot venous drainage, elevate HOB to 30 degrees, admin mannitol (osmotic diuretic) and possible admin of paralytic

regimen depends on type of procedure and determined on individual basis; if cerebral edema occurs MD may restric fluids; Oral fluids are started after the first 24 hrs when gag, swalling reflex are present; then increase DAT;

infection (main) and developing hyperglycemia

diabetes insipidus

increase serum osmolality; decerased urine osmolality; hypernatremia; decreased urine specific gravity

• monitor incision/invasive lines
• monitor for CSF leak
• instruct no to blow nose, cough, sneeze

post nasal drip, trickle back of throat, frequent swallowing, salty taste

assess for, document, medicate

• trasient diabetes insipidus
• CSF leak
• visual disturbances
• post op meningitis
• pneumocephalus

• teach deep breathe, DO NOT: cough, blow nose, sneeze, suck through a straw
• usual pre op craniotomy but will not have head shaved

• monitor VS; neuro status (visual acuity fields)
• HOB elevated
• no blowing nose coughing, sneezing, straws
• I/O, weights
• specific gravity hourly/ each voiding
• check nasal packing, change nasal mustache dressing but DO NOT remove pakcing
• oral care frequent, room, O2 humidified
• no brush teeth - rinse mouth with saline wash
• HOB elevated for 2 wks post op/at home humidifier

• 280-300mOsm/kg
• <240 or >320mOsm/kg

• 50-1200mOsm/kg/h2o
• 200-800Osm/kg/kwater

135-145

1.005-1.030

over hydration or water toxicity (ha, confusion irritability) super dilute intravascular fluids

excessive intake of fluids or IV, s/s water toxicity (increased dehydration will cause increased levels, hyperosmolar due to SIADH, correct self in day or two)

increased risk of new onset d/t stroke, head injury, dementia, infection, alcoholism, and aging

monitor age group closely for s/s of toxicity, drug/drug interaction

abnormal motor, sensory, autonomic or psychic activity or combination

beginning locally

• with motor symptoms
• with special senosry or somatosensory symptoms
• with autonomic symptoms
• compound forms

• with impairment of consciousness only
• with cognitive symptoms
• with affective symptoms
• with psychosensory symptoms
• with psychomotor symptoms (automatisms)
• compound forms

• tonic-clonic seizures
• tonic seizures
• clonic seizures
• ansence seizures
• atonic seizures
• myoclonic seizures (bilaterally massive epileptic)

idiopathic

acquired - have it b/c of another d/o

• carbamazepine (tegretol)
• clonazepam (klonopin)
• ethosuximide (zarontin)
• felbamate (felbatol)
• gabapentin (neurontin)
• lamotrigine (lamictal)
• levetiracetam (keppra)
• oxacarbazepine(trileptal)
• phenobarbital (luminal)
• phenytoin (dilantin)
• primidone (mysoline)
• tiagabine (gabitril)
• topiramate (topamax)
• valproate (depakote, depakene)
• zonisamide (zonegran, excegran)

dizziness, drowsy, unsteady, N/V, diplopia, mild leukopenia

severe skin rash, blood dyscrasias, hepatitis

drowsy, behavior changes, HA, hirsutism, alopecia, palpitations

hepatoxicity, thombocytopenia, bone marrow failure, ataxia

N/V, HA gastric distress

skin rash, blood dyscrasias, hepatitis, lupus erythematosus

cog. impair, insomnia, N, HA, fatigue

aplastic anemia, hepatotoxicity

dizzy, drowsy, somnolence, fatigue, ataxia, weight gain

severe rash (stevens-johnson syndrome)

somnolence, dizzy, fatigue

unknown

dizzy, somnolence, double vision, fatigue, N/V, loss of coordination, abnormal vision, abdominal pain, tremor, abnormal gait

hepatotoxicity

sedation, irritability, diplopia, ataxia

skin rash, anemia

visual probs, hirsutism, gingival hyperplasia, dysrhythmias, dyarthria, nystagmus

severe skin reaction, peripheral neuropathy, ataxia, drowsiness, blood dyscrasias

abnormal facial hair growth on females

overgrowth of gums

motor speech disorder

involuntary eye movement

lack of muscle coordination

near sleep

lethargy, irritability, diplopia, ataxia, impotence

skin rash

dizzy, fatigue, nervous, tremor, diff concentrating, dysarthria, weak or buckling knees, abdominal pain

unknown

fatigue, somnolence, confusion, ataxia, anorexia, deppression, weight loss

nephrolithiasis

kidney stones

N/V, weight gain, hair loss, tremor, menstrual irreg.

hepatoxicity, skin rash, blood dyscrasias, nephritis

somnolence, dizzy, anorexia, HA, N, agitation, rash

leukpenia, hepatotoxicity

group of seizure activity characterized by unprovoked recurring seizures; classifed by specific features; onset, fam hx, seizure type;

3% of population - most occur in childhood

detailed developmental hx; PE; MRI; will do EEG w/ 24 hr monitoring; LAB's to make sure no other cause;

anti seizure meds make BCP less effective

time (start and stop); characteristics, conscious or not, bowel and bladder fx, LOC

start with a single antiseizure med, start slow and draw labs for therpeutic levels

may change med or use a combo of meds

suddenly withdraw/ can cause seizures to occur

tegretol, klonopin, neurontin, lamictal, triliptal, lunimal, dilantin, mysoline, depakote

idosyncratic/ allergic disorders; acute toxicity when starting meds; chronic toxicity - over time, later;

gengival hyperplasia

increased number of seizures with onset menses; effects of contraceptives is decreased due to antiseizure meds; address bone loss r/t long term use of antiseizure meds - risk for osteoporosis

• provide privacy
• ease to floor, if in bed pull up all padded rails
• protect head with pad to prevent injury
• loosen constrictive clothing
• push aside any furniture that may injure the pt
• remove all pillows
• if an aura preceds the seizure, insert an oral airway to reduce possiblity of the tongue or cheek being bitten
• DO NOT attempt to pry open mouth or jaw when seizure is happening - browken teeth and injury to lips and tongue may result
• DO NOT restrain; if possible place on side with head flexed forward
• document sequence of signs

• keep on their side
• may have short apneic time during or immediately after a generalize seizure
• when awake reorient
• if become agitated after seizure, use calm persuasion and gentle restraint of you physically not physical restraints

• assess major complications; status epileptics and medication toxicity
• major goal is prevention of injury, control seizures
• reduce fear of seizures through teaching
• improve coping
• monitor and manage complications

• medications, SE, Monitoring
• will not be addicted to meds
• need to ID any preciptating events to seizure
• reg diet avoid stimulants
• avoid phobic stimuli (flashing lights, TV)
• avoid alcohol
• carry emergency ID med info

support groups, counseling referrals

• prolonged seizure activity occurs without full revocery of consciousness between attacks, last at least 30 min;
• medical emergency
• withdrawal from meds; fever with infections
• stop seizures; airway may need ETT, give IV valium, ativan until seizures stop
• check medication levels, check for hypoglycemia
• VS
• general anesthesia, short acting barbituate

• take meds daily as prescribed to keep the drug level constant to prevent seizures; pt should never d/c meds even when no seizures
• keep medication and seizure chart, noting when meds are taken and any seizure activity
• if pt cannot take meds d/t illness
• regularly; when testing is prescrived pt should report to lab for blood sample before taking morning meds
• activities that require alterness and coordination (driving, operating machinery) until after the effects of the meds have been evaluated; OTC meds unless approved by pt MD; seizure triggers i.e. ETOH, electrical shocks, stress caffeine, constipation, fever, hyperventilation, hypoglycemia
• drowsiness, lethargy, dizzy, diff walking, hyperactivity, confusion, inapp sleep and visual disturbances
• specify name of pt anitseizure meds and MD
• to avoid drowning if seizure occurs, never swim alone
• exercise on moderation in a temp controlled environment to avoid excessive heat
• develop reg sleep patter to minimize fatigue and insomnia
• epilepsy foundation - help in getting meds, voc rehab, and coping

age (over 55), male gender, African American, low birth weight infants, genetics

HTN (primary risk factor), smoking, elevated choleterol or elevated hematocrit, obesity, diabetes, atrial fibrillation, BCP use, drug and ETOH abuse

migraine, tension, cluster, cranial arteritis

associated with organic cause

Hx, PE, meds, exposure to toxic substances, Dx test are specific to r/o the HA are not organic in nature

avoid triggers, take meds as prescribed, avoid ETOH, nitrates, vasodilators if cluster headaches

"brain attack" - sudden loss of function resulting from a disruption of the blood supply to a part of the brain

ischemic (87%); hemorrhagic (15 to 20%)

disruption of the blood supply d/t an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue

• large atery thrombosis
• small pentrating artery thrombosis
• cardiogenic embolism
• cryptogenic (no known cause)
• other

intracerebral hemorrhage, subarachnoid hemorrhage, cerebral aneurysm, arteriovenous malformation

detection, dispatch, delivery, door, data, decision, drug

functional abnormality of the CNS that occurs when the blood supply is disrupted

stroke - the third lead cause of death in US and the leading cause of serioud long-term disability in the US

direct and indirect are billions

develop over a few minustes or can worsen over hours

a warning sighn (loss of strenght in extremity; one side of the body may be different; speech can be affected; language; can complain of change in their vision or balance)

more often at night or early in the morning - not sure why

throbotic, embolic, system hypoperfusion

• need data on coagulation status; elevated INR, no thrombolytics
• may experience AMI with stroke
• r/o suspected hypoxia, acid-base disturbances; avoided if potention for thombolytics

• non contrast CT scan
• EKG, carotid ultrasound
• transcranial doppler flow studies, transhoracic or transesphageal achocardiogram, MRI, SPECT

location and size of affected area

numbness or weakness of face, arm or leg especially on one side; sudden confusion or change in mental status; trouble seeing in one or both eyes; trouble speaking or understanding speech; difficulty walking, dizziness, or loss of balance or coordination; sudden sever HA

hypogylcemia, hyperglycemia, uremia

provides info regarding H/H, Plt counts

brain injury and maximize pt recovery

rapid recognition and reaction to stroke warning signs; rapid EMS dispatch; rapid EMS system transport and hospital prenotification; rapid dx and tmt in hospital

• 10 min
• 15min
• 25 min
• 45 min
• 60min
• 3hrs

• 18 or older
• clinic dx of ischemic stroke w/ measurable neuro deficits
• time of symptom onset well established <180 min before treatment would begin

• intracranial hemorrhage on pretreatment CT
• suggestive of subarachnoid hemorrhage with normal CT
• intracranial hemorrhage
• HTN at time of tmt; S>185 or D>110 with tmt
• AVM, brain tumor, aneurysm
• 48 hrs with elevated PTT
• Coumadin with >INR
• intracranial or intraspinal surgery, serious head trauma, previous stroke
• arterial puncture at a noncompressible site

• assess ABC's/ VS
• provide o2 if hypoxemic
• obtain IV access, draw blood, limit attempts
• check glucose; treat if needed
• neurologic screening
• activate stroke team (stroke centers)
• MD order emergent CT scan of brain
• obtain 12 lead EEG
• immediate neurologic assessment including: pt hx (timeline), sx onset, neuro exam (NIH stroke scale)

• alteplase (activase)
• 0.9mg/kg
• 90mg/dose
• 60 min with 10% total dose admin initial IV bolus over 1 minute
• q 15 min during 1st hr
• local bleeding, monitor IV sites; blood, platelets

• probable acute ischemic stroke
• thrombolytic
• neuro exam; are defictis rapidly improving to norm
• review risks and benefits w/ fam if acceptable
• tPA
• anticoagulants or antiplatelet tmt for 24 hrs

• neurologist or neurosurgeon
• to stroke unit if available
• BP and treat; neuro deficit, emergent CT if worsen; blood glucose
• supportive therapy

• temporary neurologic deficit resulting from a temporary impairment of blood flow
• impending stroke
• work-up is required to treat and prevent irreversible deficits

• ongoing/frequent monitoring of all system including VS and neuro assessment: LOC and motor, speech and eye sx
• monitor for potential comp including muskuloskeletal probs, swalling difficulties, resp probs, and s/s of increase ICP and meningeal irritation

• self care ability, coping and teaching needs to facilitate rehab
• TIa or mild stroke found to be caused by sever (70-90%) carotid artery stenosis or moderate (50-68%) stenosis or other significant risk factors
• stroke, cranial nerve injuries, infection, or hematoma at incision site, and carotid artery disruption
• BP - avoid hypotension - Nipride used to reduce BP to previous levels, close cardiac monitoring
• notify MD if neurologic deficit occurs

• impaired physical mobility
• acute pain
• self care deficits
• disturbed sensory perception
• impaired swallowing
• urinary incontinence
• disturbed thought process
• impaired verbal communication
• risk for impaired skin integrity
• interrupted family process
• sexual dysfunction

• improved mobility
• avoidance of shoulder pain
• achievement of self care
• relief of sensory and perceptual deprivation
• prevention of aspiration
• continence
• improved thought process
• achievement of form of communication
• maintenance of skin integrity
• resoration of fam fx
• improved sex
• absence of comp

• monitor neck discomfort and wound expansion; report swlling, subjective feelings of pressure of theneck, diff breathing
• risk is highest in first 48 hrs after surgery; check BP freq and rept devi from base; observe and report new onset of neuro defi
• moitor BP and observe for s/s
• ovserve for sever unilateral HA improved by sitting upright or standing
• monitor neuro status and report any changes in MS or neuru funct

• turn and position in correct alignment q2hrs
• use splints
• practices passive or active ROM 4 to 5 times/day
• position hands and fingers
• prevent flexion contractures
• prevent shoulder abduction
• do not lift by flaccid shoulder
• implement measures to prevent and treat shoulder probs
• encourage pt to exercise unaffected side
• establish routine
• assist pt OOB asap; assess and help pt achieve blance and move slowly
• use quadriceps setting and gluteal exercises
• implement ambulation training

• ehance self care: realistic goals, encourage person hygiene, ensure pt does not neglect affected side, assistive devices and mod of clothing
• support and encouragement
• enhance communication
• encourage pt with visual field loss to turn his head and look side to side
• nutrition: consult speech therapist or nutritionist, sit upright to eat, use chin tuck or swallowing method, feed thickened liquids or pureed diet
• Bowel and bladder control: asses and schedule voiding; prevent constipation; provide retraining

• face pt and establish eye contact
• speak normal
• use short phrases and pause to allow pt to understand
• limit conversation to practical and concrete matters
• use gestures, pics, and obj
• as pt uses and handles obj, say what it is
• be consistent
• keep noises to minimum

• anticoagulant (heparin)
• inc ICP from brain edema and associated comp after large ischemic stroke: elevate HOB unless contrain, osmotic diuresis, maintin PaCO2, provide continuous hemodynamic monitoring and neuro assessment
• beside pulmonary and cardiac; UTI, dysrythmias, and immobility

• bleeding into brain tissue, the ventricles or subarachnoid space
• spontaneous rupture of small vessels primarily related to HTN; subarachnoid hem d/t ruptured aneurysm; or intracerebral hem r/t amyloid angiopath, arterial venous mlform (AVM's), intracranial aneurysms, or meds such as anticoagulants
• disrupted by exposure to blood
• increases d/t blood in subarachnoid space
• reduced perfusion and vasoconstriction injures brain tissue

• similar to ischemic stroke
• severe HA
• early and sudden changes in LOC
• vomitting
• syncope
• neck stiffness
• markedly elevated BP

• CT scan to determine type, size and location of hematoma and presence of ventricular blood
• any pt with neuro defi - careful hx and PE
• initial assessment focuses on airway patency, cardiovascular status and gross neuro def
• may present with temp neuro sx - transient ischemic attack

• currently no standard
• Goal: stop or decrease bleeding, remove extra vascular blood
• Admit to ICU: airway - >95%; glucose wnl; BP wnil; IV fluids to meet specific pt needs; Cardiac monitor; antiseizure meds

patency may need ETT with vent support

• leads to aspiration, pneumonia, more common in those with breathing issues; can occur with normal or near normal LOC:
• difficulty speaking, weak voluntary cough, drooling
• watch pt attempt to swallow 3 oz of water if their voice is wet there is a risk of aspiration
• until swallowing is assessed and ok'd

keep pulse ox at >95%, treat and report hypoxia

treat with antipyretics, assess for infection

stroke is associated with atrial fib, CAD; cleared cardiac in the ED, must monitor for arrythmias, AMI; notify MD if arrythmia's occur

treat HTN in hemorrhagic stroke cautiously; monitor BP trends and report; general - lower BP gradually in 1st 24 hrs to keep S<108/ D<105

goal keep <140 - use sliding scale reg insuling; test routinely

tend to suffer increased ICP = deteriorate quickly; know ICP care

• paralysis or weakness on right side of body
• right visual field deficit
• aphasia (expressive, receptive, or global)
• altered intellectual ability
• slow, cautious behavior

• paralysis or wearkness on left side of body
• left visual field deficit
• spatial-perceptual deficits
• increased distractibility
• impulsive behavior and poor judgment
• lack of awareness of deficits

loss of half of the visual field; place objects within field of vision; approach from unaffected side; instruct to turn head side to side

• place objects in center of vision
• evaluate driving ability

explain location of objects; place pt care items in same place

ROM to affected side; provide immobilization to affected side; maintain body alignment; exercise unaffected side - strength, mobility, use

place objects w/in reach of unaffected side; exercise and increase strenght on unaffected side

support pt during ambulation; provide supportive device for ambulation

alternative communication methods; allow pt time to respond verbally; support pt/fam to alleviate frustration

test pharyngeal reflex prior to eating or taking liquids; assist with meals; place food on unaffected side of mouth; allow ample time to eat

instruct pt that sensation may be altered; provide ROM to affected area; apply corrective devices if needed

pt to repeat sounds of alphabet; explore pt ability to write

speak slowly/clearly to assist in forming words; explore pt ability to read

speak clearly and in simple sentences; use gestures or pics when able; establish alternative means of communication

• reorient pt to time, place and situation
• use verbal and auditory cues to orient
• provide familiar objects
• match visual tasks with a verbl cue
• minimize distraction noises and views when teaching
• repeat and reinforce

• support pt during uncontrollable outbursts
• discuss with pt/familty that outbursts are d/t disease process
• encourge pt to participate in group activity
• provide stimulation
• control stressors
• provide safe env
• encourage pt to express feelings

• narrowing of the lumen of the involved cranial blood vessel; serious complication
• 40-50 %
• vascular resistance which impedes cerebral blood flow and causes brain ischemia and infarction
• worsening HA, decrease LOC, new focal neuro def
• 4-14 days after initial hemorrhage
• Ca channel blockers, fluid volume expanders, indcued arterial hypertension and hemodilution

result of weakness in the arterial wall; cause unknown

absolute bed rest; avoid all activity that may increase ICP or BP; implement valsalva maneuver, acute flexion and rotation of the neck or head

30 degrees to promote venous drainage or keep the bed flat to increase cerbral perfusion

exhale through mouth when voiding or defacting; prevent constipation

nurse provides all

provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV and no radio, restrict visitors

relieve sensory deprivation and anxiety; keep sensory stimulation to minimum for aneurys precautions, implement reality orientation, provide pt and fam teaching, support and reassurance, seizure precautions, strategies to regain and promote self care and rehab

• prevention of subsequent strokes, health promo, and implementation of follow up care
• prevention of and s/s of comp
• medication teaching
• safety measures
• adaptive strategies and use of assistive devices for ADL's
• nutrition: diet, swallowing techs, and tube feeding admin
• elimination: bowel and bladder programs and catheter use
• exercise and activities: recreation and diversion
• socialization, support groups, and community resource