Medical-Surgical Nursing, 9th Ed., Ignatavicius & Workman, 2018 | Registered Nurse (RN) 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
- Intracranial Hemorrhage
- Internal Hemorrhaging
- Minimize Bleeding
- Monitor for Shock
- Aminocaproic Acid
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