Medical-Surgical Nursing, 10th Ed., Ignatavicius & Workman, 2020 |  Practical Nurse (LPN) School Study Aid
Types of Strokes
- Transient Ischemic Attack (TIA)
 - Reversible Ischemic Neurologic Deficit (RIND)
 - Ischemic
 - Thrombotic
 - Atherosclerosis
 - Embolic
 - Atrial Fibrillation
 - Hemorrhagic
 - Severe Hypertension
 
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
- Conscious
 - Confused
 - Delirious
 - Somnolent
 - Obtunded
 - Stuporous
 - Comatose
 
Native American Culture
- No Direct Eye Contact
 - No Organ Donation
 - No Blood Donation
 - Strong Handshakes Offensive
 - Tribal Shaman
 - Navajo Mother Massage Newborn
 
Middle Cerebral Artery
- Contralateral paralysis upper limb and face
 - Contralateral loss of sensation of upper limb and face
 - Affects Wernicke's area and Broca's area
 - Aphasia if Lesion in Dominant (Left) Hemisphere
 - Hemineglect if lesion in nondominant (right) hemisphere
 
Anterior Cerebral Artery
- Contralateral paralysis of lower limb
 - Contralateral loss of sensation in lower limb
 
Right Hemisphere Stroke Assessment
- Opposite Side Weakness (Hemiplegia)
 - Poor Proprioception
 - Disoriented to Person, Place, Time
 - Can't Recognize Faces (Prosopagnosia)
 - Loss of Judgement and Awareness
 - Impulsiveness
 - Personality Changes
 - Tonal Hearing Loss
 
Left Hemisphere Stroke Assessment
- Opposite Side Weakness (Hemiplegia)
 - Side to Side Discrimination
 - Aphasia
 - Agraphia
 - Slow Performance
 - Aware of Deficits
 - Anxiety
 - Depression
 
CN V
- Trigeminal Nerve
 - Sensory
 - Facial Sensation
 - Motor Function (Via Mandibular Nerve)
 - Mastication Muscles
 
CN VII
- Facial Nerve
 - Lacrimation
 - Salivation
 - Sensory
 - Taste from Anterior 2/3 of Tongue
 - Motor
 - Facial Movement
 - Stapedius Muscle
 - Eyelid Closing
 
CN IX
- Glossopharyngeal Nerve
 - Sensory
 - Taste from Posterior 1/3 of Tongue
 - Monitoring Carotid Body and Sinus
 - Motor
 - Stylopharyngeus
 - Swallowing
 - Salivation
 
CN X
- Vagus Nerve
 - Sensory
 - Aortic Arch Chemoreceptors and Baroreceptors
 - Taste from Epiglottic Region
 - Motor
 - Swallowing
 - Palate Elevation
 - Talking
 - Coughing
 - Midline Uvula
 
CN XII
- Hypoglossal Nerve
 - Motor
 - Tongue Movement
 
Cranial Nerve Function
- CN I
 - CN II
 - CN VIII
 - CN III
 - CN IV
 - CN VI
 - CN XI
 - CN XII
 - CN V
 - CN VII
 - CN IX
 - CN X
 
Alteplase
- Tissue Plasminogen Activator
 - Thrombosis
 - Bleeding
 - Prior Intracranial Hemorrhage
 - Active Bleeding
 - History of Bleeding Disorders
 - Minimize Bleeding
 - Monitor for Shock
 - Aminocaproic Acid
 - Platelet Transfusion
 
Vital Signs - Adult
- Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
 - Rectal
 - Tympanic
 - Oral
 - Axillary
 - Temporal
 - Respiration (12-20)
 - Oxygen Saturation (95%-100%)
 - Pulse (60-100)
 - Blood Pressure (<120/80)
 - Pain
 
Increased Intracranial Pressure (ICP) Assessment
- Change in LOC
 - Headache
 - Cushings Triad
 - Irregular Respirations
 - Widening Pulse Pressure
 - Bradycardia
 - Projectile Vomiting
 - Abnormal Pupils
 - Papilledema
 - Posturing
 
Increased Intracranial Pressure (ICP) Interventions
- Elevate Head Of Bed
 - Foley Catheter
 - Mannitol (Osmitrol)
 - High Dose Barbiturates
 - Passive Hyperventilation
 - Dexamethasone (Neoplasm or Infection)
 - Neuro Assessment
 - Maintain Normal Temperature
 - Avoid Activities That Increase ICP
 - Intracranial Monitoring System
 
Hydrocephalus
- Increased CSF in Ventricles of Brain
 - Signs of Increased ICP
 - High Pitched Cry
 - Irritability
 - Opisthotonus
 - Increased Head Circumference
 - Bulging Fontanel
 - Setting Sun Sign
 - Seizure Precautions
 - Elevate HOB
 - CSF Shunt
 
Clopidogrel (Plavix)
- ADP Receptor Antagonist
 - Prevent Platelet Aggregation
 - Acute Coronary Syndrome (ACS)
 - Prevention of Thrombotic Events
 - Bleeding
 - Thrombotic Thrombocytopenic Purpura (TTP)
 - Pancytopenia
 - Abdominal Pain
 - Withhold Before Surgery
 
Warfarin (Coumadin)
- Inhibits Clotting Factors
 - Atrial Fibrillation
 - Venous Thrombosis
 - Pulmonary Embolism
 - PT/INR Levels
 - Observe for Bleeding
 - Pregnancy
 - Vitamin K and Fresh Frozen Plasma
 - Prolonged Therapeutic Onset
 - Maintain Same Diet
 
Aspirin (Acetylsalicylic Acid)
- Inhibits Platelet Aggregation
 - NSAID
 - Thrombotic Event Prevention
 - General Pain
 - Inflammatory Conditions
 - Fever
 - Pancytopenia
 - GI Ulcers
 - Bleeding
 - Withhold Before Surgery 7-10 Days
 - Reye's Syndrome
 
Depression Assessment
- Anergia
 - Self Neglect
 - Decreased Libido
 - Vegetative Signs
 - Sad Affect
 - Worthlessness
 - Guilt
 - Anger and Irritability
 - Ineffective Problem Solving
 - Slowed Thinking
 
Types of Head Injuries
- Open Head Injury
 - Linear Fracture
 - Comminuted Fracture
 - Depressed Fracture
 - Open Fracture
 - Basilar Skull Fracture
 - Closed Head Injury
 - Coup and Contrecoup
 - Brain Contusion
 - Concussion
 
Hypoxia (Early Symptoms)
- Diaphoresis
 - Restlessness
 - Tachypnea
 - Dyspnea on Exertion
 - Tachycardia
 - Hypertension
 - Arrhythmias
 - Decreased Urine Output
 - Unexplained Fatigue
 
Hypoxia (Late Symptoms)
- Cyanosis
 - Cool, Clammy Skin
 - Use of Accessory Muscles
 - Retractions
 - Hypotension
 - Arrhythmias
 
Traumatic Brain Injury Assessment
- Change in LOC
 - Personality Changes
 - Amnesia
 - Increased Intracranial Pressure
 - Diplopia
 - Posturing
 - Basilar Skull Fracture
 - Halo or Ring Sign
 - Intracranial Bleeding
 
CSF Lab Values: Normal
- Pressure: < 20 cm H2O
 - Color/Appearance: Clear or Colorless
 - Proteins: < 40 mg/dL
 - Lactate Dehydrogenase: 10% of Serum Level
 - Cells: 0-5 Small Lymphocytes
 - Glucose: 40-70 mg/dL
 
Eye
- Sclera
 - Cornea
 - Iris
 - Lens
 - Ciliary Muscles
 - Optic Nerve
 - Rods
 - Cones
 - Retina
 
Magnetic Resonance Imaging (MRI)
- Internal Body Images
 - Detects Variations of Soft Tissues
 - No Metal Objects
 - No Pacemakers
 - Contrast is Non-Iodine
 - Safe During Pregnancy
 - Long Procedure
 - Antianxiety Medications
 
Mannitol (Osmitrol)
- Osmotic Diuresis
 - Reducing Intracranial Pressure
 - Reducing Intraocular Pressure
 - Renal Failure Prophylaxis
 - Edema
 - Fluid and Electrolyte Imbalance
 - Avoid Use in Cardiac Patients
 - IV Administration
 
Phenytoin (Dilantin)
- Blocks Na+ Channels
 - Tonic-clonic Seizures
 - Ataxia
 - Nystagmus
 - Sedation
 - Gingival Hyperplasia
 - Purple Glove Syndrome
 - Hirsutism
 - Rash
 - Anemia
 - Individualized Dosing
 
Hypernatremia
- > 145 mEq/L Na+
 - Change in LOC
 - Extreme Thirst
 - Orthostatic Hypotension
 - Dry Flushed Skin
 - Muscle Twitching
 - Seizures
 - Treat and Prevent Dehydration
 - Hypotonic Solutions (0.225% or 0.45% NaCl)
 - Sodium Restriction
 - Diuretics
 
Meningitis Assessment
- Nausea and Vomiting
 - Fever
 - Nuchal Rigidity
 - Severe Headache
 - Purpura
 - Seizures
 - Photophobia
 - Opisthotonus Position
 - High-Pitched Cry
 - Bulging Fontanel
 
Syndrome Of Inappropriate Antidiuretic Hormone (SIADH)
- Hypersecretion of ADH
 - Increased Sensitivity to ADH
 - Serum Hypoosmolality
 - Coma and Seizure
 - Dilutional Hyponatremia
 - Cramps and Tremors
 - Euvolemia
 - Change in LOC
 
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Pharmacologic Interventions
- Diuretics
 - Hypertonic IV Fluids
 - Demeclocycline
 - Tolvaptan and Conivaptan