Exam 2 Review: Chapters 27, 28, 29, 30, 31, 41, 42, 43, 44, 45, 46, 47, 48
• Neuro Assessment:
o Assess LOC, is the patient oriented of person, place and time?
▪ Any changes in LOC is an early sign of neuro changes
o ROM, Sensation, Push/Pull, Eye movement / PERRLA-Are their pupils pinpoint or dilated,
Patients gait- steady or unbalanced
o Glasgow Coma Scale: 15 is perfect - 3 is comatose
▪ A change >2 is a problem = neuro status change
o Consent is required for a CT Scan and a MRI
▪ A CT SCAN may be used...but first check Cr., BUN (10-20), allergies (shellfish),
and EDUCATE the patient that a metallic taste in their mouth may occur
▪ MRI…Ask the patient: do you have any implanted devices such as a pacemaker or cardiac
defibrillators?
• Headaches
o Assess neurological symptoms
o What triggers the patient to have a migraine headache?
o Interventions for a headache/migraine: icepack, quiet or dark room, NSAIDS can be used for
a mild migraine
▪ Triptan preparation drugs can be used for a more serious migraine. It MUST BE GIVEN as
soon as the patient reports the headache…Pt needs to report chest pain if it occurs.
o Beta blockers, calcium channel blockers, and trigger avoidance are all precautions used to prevent
migraines
• Seizures
o Primary seizures have no identified cause
▪ More than 2 primary seizures are classified as epilepsy
▪ 2 types of Primary Seizures-
• Generalized seizures-those that include the whole brain
o Grand Mal/Tonic Clonic- the patient has convulsions with muscle
rigidity/Unconsciousness
o Absence- Brief loss of consciousness (patient will have a blank stare)
o Myoclonic- Patient will have isolated jerking movements
o Tonic- Muscle rigidity
o Clonic- Convulsions (Repetitive jerking movement)
o Atonic- loss of muscle tone
• Partial seizures- One cerebral hemisphere is involved
o Patient may black out, have amnesia, lip smacking
• Interventions for seizures:
o Turn patient to the side, time the seizure, loosen the patients’
garments, guide their movements- DO NOT restrict them, protect the
patients head and airway
▪ One seizure > 5minutes OR repeated seizures over
30minutes: call RRT (Status Epilepticus)
• Diazepam or Lorazepam may be given
o Secondary seizures are due to a metabolic cause: fever, alcohol withdrawal, electrolyte
imbalance
• MS (Multiple Sclerosis)
, o Triggers: Extreme temperatures, stress, or fatigue
o Symptoms: Muscle weakness, stiffness, diplopia, slurred speech, tinnitus, decreased coordination
o Interventions: Avoid extreme heat, stress, and fatigue. Drink extra fluids, take a cool bath,
massage/yoga, eye patches for double vision, assess the patient for depression, teach the patient
bowel and bladder training, collaborate with PT, OT, and speech therapy
• Parkinson’s Disease
o Mood, behavior, and motor abilities are affected
o Symptoms: Tremors, bradykinesia, muscle rigidity, dysphasia
o If the patient is taking MAOI’s- MAOI’s interact with tyramine- Educate the patient to not eat aged
cheese, smoked foods, or red wine
o Make sure the patient has their medications on time
▪ Monitor for orthostatic hypotension
• If orthostatic hypotension occurs-advise the patient to change positions
slowly… falls may occur
o Patient may move slow due to unsteady gait-give them extra time to perform ADL’s
o Monitor daily weights to make sure the patient is maintaining a steady weight
• Stroke
o CVA (stoke/brain attack) is a neurological deficit caused by an occlusion/rupture of a blood vessel
that leads to decreased oxygen in the brain
o Two types of Stroke:
▪ Ischemic
• Thrombolytic- Thrombus in the brain
• Embolic- Thrombus that breaks off from one area of the body and travels to the
brain
▪ Hemorrhagic- bleeding in the brain or around the brain tissue
o Right Hemisphere CVA symptoms: left sided weakness, perceptual deficits, unilateral
body neglect
o Left Hemisphere CVA: aphasia, right sided weakness, speaking and writing difficulty, difficulty
with communications
▪ Additional S/S (not specific): altered mental status, seizures, visual changes,
diplopia, hemianopia, hypertension, sensory loss, aphasia, facial palsy
• Keep patient NPO until seen by speech therapy
o TIA- Transient Ischemic Attack - (mini stroke) is considered a warning sign to ischemic stroke
▪ TIA lasts 30-60 minutes
• Blurred vision, weakness, and numbness may occur
▪ Risk factors for stroke: Hypertension, African American descent, Diabetes, Obesity,
AFIB, and Smoking
▪ Medication Prevention: Blood pressure medication, anti-platelets, aspirin can be given
to prevent a stroke
▪ Nursing priorities: ABC’s, Glasgow Coma Scale, NIHSS, NPO until further notice
(swallow study/speech therapy), CT Scan to check ischemic vs. hemorrhagic, blood sugar
to assess for hypoglycemia, EKG to assess cardiac disease, when was the patient last seen
normal?
• Less than 4 hours since “Last Seen Normal” and the patient is having an
ischemic stroke? tPA can be given with doctors and patients consent and proper
eligibility
o If it has been longer than 4 hours: consult neuro surgery…Heparin
drips, antiplatelet drugs, and statins may be given
▪ Administering tPA: admit the patient to ICU, 2 Nurses will need to verify the order:
Altepase 0.9mg/kg , NO INVASIVE PROCEDURES CAN BE DONE ONCE THE
MEDICATION
• Neuro Assessment:
o Assess LOC, is the patient oriented of person, place and time?
▪ Any changes in LOC is an early sign of neuro changes
o ROM, Sensation, Push/Pull, Eye movement / PERRLA-Are their pupils pinpoint or dilated,
Patients gait- steady or unbalanced
o Glasgow Coma Scale: 15 is perfect - 3 is comatose
▪ A change >2 is a problem = neuro status change
o Consent is required for a CT Scan and a MRI
▪ A CT SCAN may be used...but first check Cr., BUN (10-20), allergies (shellfish),
and EDUCATE the patient that a metallic taste in their mouth may occur
▪ MRI…Ask the patient: do you have any implanted devices such as a pacemaker or cardiac
defibrillators?
• Headaches
o Assess neurological symptoms
o What triggers the patient to have a migraine headache?
o Interventions for a headache/migraine: icepack, quiet or dark room, NSAIDS can be used for
a mild migraine
▪ Triptan preparation drugs can be used for a more serious migraine. It MUST BE GIVEN as
soon as the patient reports the headache…Pt needs to report chest pain if it occurs.
o Beta blockers, calcium channel blockers, and trigger avoidance are all precautions used to prevent
migraines
• Seizures
o Primary seizures have no identified cause
▪ More than 2 primary seizures are classified as epilepsy
▪ 2 types of Primary Seizures-
• Generalized seizures-those that include the whole brain
o Grand Mal/Tonic Clonic- the patient has convulsions with muscle
rigidity/Unconsciousness
o Absence- Brief loss of consciousness (patient will have a blank stare)
o Myoclonic- Patient will have isolated jerking movements
o Tonic- Muscle rigidity
o Clonic- Convulsions (Repetitive jerking movement)
o Atonic- loss of muscle tone
• Partial seizures- One cerebral hemisphere is involved
o Patient may black out, have amnesia, lip smacking
• Interventions for seizures:
o Turn patient to the side, time the seizure, loosen the patients’
garments, guide their movements- DO NOT restrict them, protect the
patients head and airway
▪ One seizure > 5minutes OR repeated seizures over
30minutes: call RRT (Status Epilepticus)
• Diazepam or Lorazepam may be given
o Secondary seizures are due to a metabolic cause: fever, alcohol withdrawal, electrolyte
imbalance
• MS (Multiple Sclerosis)
, o Triggers: Extreme temperatures, stress, or fatigue
o Symptoms: Muscle weakness, stiffness, diplopia, slurred speech, tinnitus, decreased coordination
o Interventions: Avoid extreme heat, stress, and fatigue. Drink extra fluids, take a cool bath,
massage/yoga, eye patches for double vision, assess the patient for depression, teach the patient
bowel and bladder training, collaborate with PT, OT, and speech therapy
• Parkinson’s Disease
o Mood, behavior, and motor abilities are affected
o Symptoms: Tremors, bradykinesia, muscle rigidity, dysphasia
o If the patient is taking MAOI’s- MAOI’s interact with tyramine- Educate the patient to not eat aged
cheese, smoked foods, or red wine
o Make sure the patient has their medications on time
▪ Monitor for orthostatic hypotension
• If orthostatic hypotension occurs-advise the patient to change positions
slowly… falls may occur
o Patient may move slow due to unsteady gait-give them extra time to perform ADL’s
o Monitor daily weights to make sure the patient is maintaining a steady weight
• Stroke
o CVA (stoke/brain attack) is a neurological deficit caused by an occlusion/rupture of a blood vessel
that leads to decreased oxygen in the brain
o Two types of Stroke:
▪ Ischemic
• Thrombolytic- Thrombus in the brain
• Embolic- Thrombus that breaks off from one area of the body and travels to the
brain
▪ Hemorrhagic- bleeding in the brain or around the brain tissue
o Right Hemisphere CVA symptoms: left sided weakness, perceptual deficits, unilateral
body neglect
o Left Hemisphere CVA: aphasia, right sided weakness, speaking and writing difficulty, difficulty
with communications
▪ Additional S/S (not specific): altered mental status, seizures, visual changes,
diplopia, hemianopia, hypertension, sensory loss, aphasia, facial palsy
• Keep patient NPO until seen by speech therapy
o TIA- Transient Ischemic Attack - (mini stroke) is considered a warning sign to ischemic stroke
▪ TIA lasts 30-60 minutes
• Blurred vision, weakness, and numbness may occur
▪ Risk factors for stroke: Hypertension, African American descent, Diabetes, Obesity,
AFIB, and Smoking
▪ Medication Prevention: Blood pressure medication, anti-platelets, aspirin can be given
to prevent a stroke
▪ Nursing priorities: ABC’s, Glasgow Coma Scale, NIHSS, NPO until further notice
(swallow study/speech therapy), CT Scan to check ischemic vs. hemorrhagic, blood sugar
to assess for hypoglycemia, EKG to assess cardiac disease, when was the patient last seen
normal?
• Less than 4 hours since “Last Seen Normal” and the patient is having an
ischemic stroke? tPA can be given with doctors and patients consent and proper
eligibility
o If it has been longer than 4 hours: consult neuro surgery…Heparin
drips, antiplatelet drugs, and statins may be given
▪ Administering tPA: admit the patient to ICU, 2 Nurses will need to verify the order:
Altepase 0.9mg/kg , NO INVASIVE PROCEDURES CAN BE DONE ONCE THE
MEDICATION
