NURSE-UN 1243 Adult and Elder Nursing 3 Week #3:Neuro Basics,100% CORRECT

NURSE-UN 1243 Adult and Elder Nursing 3 Week #3:NeuroB asics Glasgow Coma Scale Higher score = better you are Physical Assessment ● Vital signs ● Cushing’sTriad - a response to ischemia from rapid brain injury - Cushing's triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing's triad consists of bradycardia (also known as a low heart rate), irregular respirations, and a widened pulse pressure. ▪ Opposite the 3 symptoms of shock (↓BP, ↑HR, ↑RR) 1. Increase SBP with widening pulse pressure (gap between systolic and diastolic BP increases) 2. Bradycardia 3. Altered Respirations slowed ● Temperature Regulation ● Injury to or dysfunction of hypothalamus temperature regulation ● Hypothermia ● Hyperthermia ● Pupillary Reactions ● Provides information about location of the lesion ● Assess for size, symmetry, shape, and reaction to light ● Head to toe assessment ● Nurses watch the trend over time--3mm at 8am but 2 hrs later, change in LOC and pupillary size; make sure equally round and reactive to light Intracranial Pressure (ICP) ** Normal ICP = 5-15 mm Hg ** ICP indicators are on exam I.e. “Pt is in for MVA 3 hours ago. Which of these signs does the nurse expect to find?” ● Early Indicators ● The earliest sign of increasing ICP is a change in LOC (less alert, confusion, slurred speech) ▪ Hemorrhagic stroke is the most common cause ▪ Make sure you do head to toe assessment RIGHT AWAY in the morning or as soon as you get the neuro pt!!! ▪ Pupil size, vitals, LOC, and temperature are esp important in neuro--track the changes and check often, like every hour, get peers as witnesses and chart and escalate to dr, even if they brush you off!!! ▪ Chart it!-Write who you spoke to, the date and time and what they said ● Papilledema ↑ICP causes swollen optic nerve and visual disturbances, H/A, nausea ● Slurring of speech ● Delay in response ● Vomiting ● Late Indicators ● Further decrease in LOC ● Cushing’s triad ● Pupil changes ● Altered respiratory patterns ● Posturing Management of Increased ICP ● ABC’s o Intubate if glasgows under 8 ● IV therapy and vasoactive agents ● Temperature control ● Body positioning fowler's (30-45 degrees)--gravity helps fluid flow ● Maintain ventilation (PaO2 60 mm Hg) ● Osmotic diuretics increase urine output - mannitol ● Sedatives/paralytics since pt is high risk for seizures o LOC changes → agitated/combative o chemical restraint if risk of hurting self or others ***NCLEX--chemical restraint is last resort ● Barbiturates-sedative ● Provide safe and protective environment ● Protect patient from injury ● Bed low position ● Side rails ● Frequent checks Q 15 Min or hourly ● Reorient ● Create calm environment pt combative/overwhelmed ● Noise kept to minimum ● Dim light at night ● Limit number of visitors at one time Neurological Problems Learning outcomes 1) Implement health promotion practices related to neurological health alterations identified by Healthy People 2030 for the adult & older adult population. Specifically related to: • Stroke : Reduce Stroke Deaths • Parkinson’s disease • Normal pressure hydrocephalus (NPH). 2) Demonstrate clinical decision making based on the integration of information from multiple sources, including the patient, interprofessional team, & the best available evidence for patients with neurological health alterations. 3) Advocate for high quality, safe, & culturally competent patient-centered care for patients with neurological health alterations Stroke (Statistics not on exam) • Stroke – Ischemia to part of brain – Hemorrhage into brain that results in death of brain cells - worse • Also known as – Brain attack – Cerebrovascular accident • Fifth most common cause of death in the United States • Leading cause of serious, long-term disability • About 800,000 people have a stroke each year • 15% to 30% with permanent disability • Lifelong change for survivor and family • Severity of loss of function varies according to location and extent of brain damage – Physical, cognitive, and emotional impact on patient and family RISK Factors Non-Modifiable • Age – Stroke risk doubles each decade after 55 • Gender – More common in men; more women die (this is because they live longer and have more opportunity for stroke) • Ethnicity/race – Higher incidence and death rate in blacks • Heredity/family history • Prior Stroke/TIA Modifiable • Hypertension • Heart disease • Diabetes • Serum cholesterol • Smoking • Obesity • Sleep apnea • Metabolic syndrome • Afib/flutter • Physical Inactivity Transient Ischemic Attack (ALL IMPORTANT BUT SHE BASICALLY SKIPS EVERYTHING UNTIL NURSING ASSESSMENT) • A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, but without acute infarction of brain • Symptoms typically last 1 hour • There is no way to predict outcome – 1/3 do not experience another event – 1/3 have additional TIAs – 1/3 progress to stroke – Try this: Stroke risk Calculator – Types of Stroke • Strokes are classified based on underlying pathophysiologic findings – Ischemic • Thrombotic • Embolic – Hemorrhagic • Intracerebral** • Subarachnoid Thrombotic Stroke • Occurs from injury to a blood vessel wall and formation of a blood clot • Results in narrowing of blood vessel • Most common cause of stroke (60%) – Often associated with HTN and DM – Many times they are preceded by TIA • Extent of stroke depends on – Rapidity of onset – Size of damaged area – Presence of collateral circulation Embolic Stroke - sudden • Occurs when an embolus lodges in and occludes a cerebral artery • Results in infarction and edema of area supplied by involved vessel • 2nd most common cause of stroke; commonly caused by afib • Sudden onset with severe clinical manifestations – Warning signs are less common – Patient usually remains conscious – Prognosis is related to amount of brain tissue deprived of blood supply – Commonly recur Hemorrhagic Stroke • Results from bleeding into – Brain tissue itself 1. Intracerebral or intraparenchymal hemorrhage 2. Subarachnoid space or ventricles Intracerebral Hemorrhage • Bleeding within brain caused by rupture of a vessel – Sudden onset of symptoms – Progression over minutes to hours because of ongoing bleeding – Prognosis is poor with a 30-day mortality rate of 40%-80% • Hypertension is most common cause • Hemorrhage occurs during activity • Sudden onset with progression over minutes to hours • Extent of symptoms varies and depends on amount, location, and duration of bleeding • Manifestations – Neurologic deficits – Headache – Nausea and/or vomiting – Decreased levels of consciousness – Hypertension Subarachnoid • Intracranial bleeding into cerebrospinal fluid–filled space between arachnoid and pia mater • Commonly caused by rupture of a cerebral aneurysm, trauma, or drug abuse • Cerebral aneurysm – Majority are in Circle of Willis – Incidence ↑ with age; higher in women – Silent killer • Loss of consciousness may or may not occur • High mortality rate • Survivors often suffer significant complications and deficits Stroke: Nursing Assessment (Know these) • Primary assessment is focused on – Cardiac status – Respiratory status – Neurologic assessment • If patient is stable, obtain – Description of current illness • Pay special attention to symptom onset and duration, nature, and changes – History of similar symptoms previously experienced – Current medications – History of risk factors and other illnesses • Hypertension, etc. – Family history of stroke, aneurysm or cardiovascular disease Stroke: Nursing Assessment • Secondary assessment includes a comprehensive neurologic examination NIH Stroke Scale o Level of Consciousness o Best Gaze o Visual o Facial Palsy o Motor Arm o Motor Leg o Limb Ataxia o Sensory o Best Language o Dysarthria o Extinction and Inattention **Person should be certified to administer this scale Common Mistakes in Assessment ● Failure to adequately stimulate patient to get best response ● Inadequate/inaccurate history of patient baseline ● Failure to recognize subtle clues ● Failure to check blood glucose ● Too rapid rush to conclusion without adequate assessment Like having a code team, there is also a stroke team in most institutions. Stoke: Assessment and Diagnosis ● Signs & Symptoms ● Cognitive changes ● Motor changes ● Sensory changes ● Elimination ● Spatial-perceptual alterations ● Personality ● Affect ● Communication: aphasia (expressive, receptive or mixed) ● Diagnosis ○ Time Lost is Brain Lost ○ Designated Stroke Centers ○ Stroke Team Activation ○ CT scan/MRI – see MRI safety checklist Clinical Manifestations • Most obvious effect of stroke • Include impairments of Motor Function – Mobility – Respiratory function – Swallowing and speech – Gag reflex - check before giving meds/ food – Self-care abilities Loss of skilled voluntary movement • Akinesia – Impairment of integration of movements – Changes in muscle tone – Altered reflexes Clinical Manifestations • Aphasia occurs when stroke damages the dominant hemisphere of brain and affects language – Receptive: loss of comprehension – Expressive: loss of production of language • Global: total inability to communicate • Many patients experience dysarthria (slurring) – Problem with muscular control of speech • Both memory and judgment may be impaired because of stroke • Although impairments can occur with strokes affecting either side of brain, some deficits are related to hemisphere in which stroke occurred Clinical Manifestations • Right- and left-brain damage differ somewhat Know the difference between a left and a right sided stroke. Stroke: Nursing Diagnosis • Decreased intracranial adaptive capacity • Risk for aspiration • Impaired physical mobility • Impaired verbal communication • Unilateral neglect • Impaired swallowing • Situational low self-esteem Implementation: Acute Care • Respiratory system – Management of respiratory system is a nursing priority • Risk for atelectasis • Risk for aspiration pneumonia • Risks for airway obstruction • May require endotracheal intubation and mechanical ventilation • Monitoring lung sounds for crackles and wheezes (pulmonary congestion Implementation: Acute Care • Cardiovascular system – Nursing interventions • Monitoring vital signs frequently • Monitoring cardiac rhythms • Calculating intake and output, noting imbalances – Regulating IV infusions – Adjusting fluid intake to individual needs of the patient – Monitoring heart sounds for murmurs – Watch for orthostatic hypotension before ambulating patient for 1st time – After stroke, patient is at risk for venous thromboembolism (VTE) • Weak or paralyzed lower extremities are particularly vulnerable • Related to immobility, loss of venous tone, and ↓ muscle pumping in leg • Most effective prevention is keeping the patient moving Implementation: Acute Care • Neurologic system – Monitor closely to detect changes suggesting • Extension of the stroke • Vasospasm • Recovery from stroke symptoms • Musculoskeletal System – Maintain optimal function; prevent atrophy and contractures – ROM and positioning • Integumentary System – Skin breakdown; pressure relief and early mobility • Gastrointestinal – Constipation • Urinary – Incontinence; bladder retraining; catheterization • Need a good bladder training program, many of these patients will develop a neurogenic bladder. • Neurogenic bladder is bladder dysfunction (flaccid or spastic) caused by neurologic damage. Symptoms can include overflow incontinence, frequency, urgency, urge vesicoureteral reflux, autonomic dysreflexia) Implementation: Acute Care • Sensory-perceptual alterations – Related to hemisphere of brain in which stroke occurred – Visual problems may include • Diplopia (double vision) • Loss of the corneal reflex • Ptosis (drooping eyelid) • Homonymous hemianopia • The photo shows this, left or right side of the visual field impared ON BOTH EYES. May not see food, will need to move the tray. Left sided means you cant see out the left side of both eyes and vise versa. Implementation: Acute Care • Nutrition – Nutritional needs require quick assessment and treatment – May initially receive IV infusions to maintain fluid and electrolyte balance – May require nutrition support – First feeding should be approached carefully • Test swallowing, chewing, gag reflex, and pocketing before beginning oral feeding • Dysphagia was defined as difficulty swallowing any liquid (including saliva) or solid material. Dysphasia was defined as speech disorders in which there was impairment of the power of expression by speech, writing, or signs or impairment of the power of comprehension of spoken or written language. – Feedings must be followed by scrupulous oral hygiene – ROM exercises are important Implementation: Acute Care • Communication – Your role in meeting psychologic needs of patient is primarily supportive – Assess patient for both ability to speak and ability to understand • Speak slowly and calmly, using simple words or sentences • Gestures may be used to support verbal cues – Speech, comprehension, and language deficits are most difficult problem for patient and family • Speech therapists can assess and formulate a plan to support communication - Decrease environmental stimuli - Treat patient as an adult - Speak with normal volume and tone - Present one thought or idea at a time - Keep it simple - Do not rush person - Do not pretend to understand - Allow body contact as much as possible - Do not push if person is tired or upset as aphasia worsens with fatigue and anxiety Implementation: Acute Care • Coping – Affects family emotionally, socially, and financially – Changing roles and responsibilities – Explain diagnosis and therapeutic procedures (repeat as necessary) – Social services referral is helpful Stroke: Collaborative Management ● Emergent Management - Lifesaving techniques (ABCs) - Prevention of stroke extension - LOC (Glasgow Coma Scale), ICP - Check blood sugar - Early treatment with recombinant tissue plasminogen activator (rtPA) or endovascular intervention if possible. ● Endovascular intervention - ex stent ● Medications for acute management - Recombinant tissue plasminogen activators (rtPA) (Since 1996) ● Only for ischemic strokes ● Given within 3-4.5 hours of last known normal period (new evidence 6-9 hours?) ● Specific eligibility criteria ● Medications for ongoing management of stroke: - Anticoagulation (Aspirin) - Anti-hypertensives (BP elevated as body attempts to increase cerebral blood flow) - Steroids to reduce edema - Anti-epileptic drugs (AED) - Anti-anxiety Intracranial Pressure (ICP) - Normal ICP is 5 - 15 mm Hg ● Early Indicators ○ The earliest sign of increasing ICP is a change in LOC ○ Other early indicators: ■ Papilledema ■ Slurring of speech ■ Delay in response ■ Vomiting ● Late Indicators ○ Further decrease in LOC ○ Cushing’s triad ○ Pupil changes ○ Altered respiratory patterns ○ Posturing City Hospital Launches East Coast's First Mobile Stroke Treatment Unit Tele-Stroke Management Stroke: Planning • Goals include that patient will – Maintain stable or improved level of consciousness – Attain maximum physical functioning – Maximize self-care abilities and skills – Maintain stable body functions – Maximize communication abilities – Maintain adequate nutrition – Avoid complications of stroke – Maintain effective personal and family coping Implementation: Health Promotion • You have an important role in the promotion of a healthy lifestyle • To help reduce the incidence of stroke – Focus on stroke prevention – Teach how to reduce modifiable risk factors • Cause of most strokes Stroke: Evaluation • Return to baseline functioning or as close to it as possible – Mobility – Activities of daily living – Communication – Sensory – Sexual health – Coping Parkinson’s Disease - progressive death of dopaminergic neurons in substantia nigra → altered motored movement; May be mistaken with stroke ***Godwin said focus on clinical manifestations, nursing priorities and collaborative work ● Possibly a result of a complex interplay between environmental factors and the person’s genetic makeup ● Family history in 15% of cases ● ~60,000 people are diagnosed each year ● Risk increased by well water, pesticides, herbicides, industrial chemicals, wood pulp mills, rural residence ● Chronic, progressive neurodegenerative disorder characterized by: ○ Bradykinesia 1st signs of PD may be not able to use hand, right leg not moving like the left ○ Rigidity ○ Tremor at rest i.e. hand, shoulder trembling ○ Gait changes ○ Memory and comprehension loss Elderly should stay active physically and mentally to ease symptoms and improve body control, flexibility, strength of as many muscles as possible, i.e. dance, have sex, travel, just as important as medicine. Staying still isn’t normal. Nurses: find resources for people to stay active, even exercises while sitting Types of PD • Idiopathic PD – No identified cause – Insidious onset • Acquired “Parkinsonism” secondary to another cause – Caused by infection, drug toxicity, or trauma – When due to drug toxicity (phenothiazines, butyrophenones-both antipsychotics) progresses rapidly Parkinson’s Disease • Lack of dopamine (DA) – Degeneration of DA-producing neurons in substantia nigra of midbrain – Disrupts dopamine-acetylcholine balance in basal ganglia – Essential for normal functioning of extrapyramidal motor system – Know manifestations, collaborative work and nursing interventions Dopamine Disorder in Parkinson’s **Googled: These are all in basal ganglia (deep in brain) for motor control and executive function. Dopamine’s pathway in brain: Substantia nigra → Striatum → Globus pallidus In Parkinson’s, less DA means ACh’s effects activate globus pallidus more ??? Risk Factors for PD • Age – the most important risk factor • Family history & genetic factors (alpha-synuclein, parkin, ubiquitin) • Race/ethnicity • Male gender female • Declining estrogen levels post menopausal women • Agricultural work pesticides • Head trauma PD: Assessment and Diagnosis • Onset is gradual and insidious with ongoing progression • I.e. patient feels numbness in her legs → fall risk • TRAP: Be familiar with TRAP – Resting Tremor – usually first symptom that prompts seeking medical attention esp pill rolling tremor of hands – Rigidity – cogwheel rigidity with passive movement upper arms flexion and extension “clicks” incrementally like robot – Akinesia/Bradykinesia – no or slowness of movement also mask face – Postural Instability – disturbed balance and leaning forward hunched over • Often mistaken for signs of aging • People in their 30s can be diagnosed with Parkinson’s • Other signs & symptoms include: **Don’t memorize but think of the Patho behind it – Neuropsych: depression, dementia, personality changes, psychosis, hallucinations – Autonomic dysfunction: orthostatic hypotension, diaphoresis (sweating), drooling, weight loss, constipation, urinary symptoms – Neuromuscular: camptocormia (camptos-bent, kormos=trunk; severe forward flexion of spine), festination (speed up during repetitive movement), gait freezing, hypophonia (soft speech due to lack of coordination of vocal muscles), monotonic speech, festinating speech, dysphagia, hypomimia (facial masking-less and slower facial movements), micrographia (small cramped writing), akathisia (hard to stay still) – Sleep disturbances: vivid dreams, insomnia, daytime drowsiness • Diagnosis – Medical history and clinical features • Diagnosis of exclusion • MRI/CT used to rule out other neurological conditions – No disease-specific biological marker – Positive response to antiparkinsonian drugs confirms diagnosis • Dopamine balance Nursing Diagnoses • Risk for aspiration • Risk for injury • Self-care deficit: bathing, dressing, feeding, toileting ADL • Risk for impaired verbal communication • Chronic confusion • Imbalanced nutrition: less than body requirements can’t feed self or poor mouth/swallow control PD: Collaborative Management **Know the patho, don’t focus too much on pharm • Know the manifestations and why the drug is being presented, realistic benefits • Levodopa – levodopa/carbidopa - how its given – Most effective – Benefits decrease with time – Long-term use carries high risk of dyskinesias • Dopamine receptor agonists – Less effective – Less likely to cause dyskinesias – Frequently cause troubling side effects • Drugs that assist Levodopa – Carbidopa (with Levodopa – Sinemet) – COMT inhibitors (Entacapone, Tolcapone) – MAO-B Inhibitors (Selegiline) PD: Collaborative Management **know what to expect from Parkinson’s vs side effect of drugs • Surgical and Electrical Treatments – Deep brain stimulation • Pallidotomy neurological procedure where an electrical probe is placed in the basal nuclei of the brain and destroys small area of brain cells – Cell Implants • Other therapy options/interventions: – Communication • Allow the patient extra time to respond to questions • Teach the patient to speak slowly and clearly • Refer to speech-language pathologist – Medications • Administer promptly to retain therapeutic levels • Monitor for side effects (orthostatic hypotension, delirium, hallucinations, tardive dyskinesias) – Complications of Immobility • Implement interventions to prevent constipation, contractures, and pressure ulcers – Caregivers--emphasize being patient, take your time, and don’t be afraid of being judged in public if they speak too loudly PD: Collaborative Management • Other therapy options/interventions: – Diet • Monitor patient’s ability to eat/swallow • Give patient smaller meals and smaller pieces - bc they are at risk for choking • Collaborate with dietician • Bite-sized pieces • Six small meals a day • Limit protein intake to evening meal - due to the inability to digest -- spread out the protein through the day - protein will be absorbed instead of levodopa and carbidopa; not a huge amount at once • You should limit protein in general at night because it requires more of the digestive process and would interfere with sleep. But during the day you should spread the protein out so as to not interfere with the medication absorption. • Levodopa competes with protein for receptor sites – Exercise/Physical Therapy - PT is very important, if PT does not get there to work with patient, it is within the nursing scope of practice to ensure patient is getting enough physical activity • Collaborate with physical/occupational therapy • Strengthen and stretch specific muscles • Passive and active and ROM exercises • Including muscles for speaking and swallowing • Enhances functional ability PD: Collaborative Management – Psychosocial • Assess for depression, anxiety, and insomnia • Address body image concerns may feel like their body betrayed them, can’t control • don’t treat them as mentally incompacitated, they hear you • They are cognizant of what is going on – Daily Living • Allow the patient to perform ADLs • Use upright chairs with arms and put back legs on blocks • Remove rugs and other clutter • Simplify clothing • Elevate toilet seats • Physical therapy to regain lost function i.e. dance group for those with Alzheimer’s, boxing, chair exercises • Try to use as many muscles as possible • Supportive care don’t let ageism get in the way of being active, elderly should exercise too Normal Pressure Hydrocephalus • Normal Pressure Hydrocephalus (NPH) • Accumulation of cerebrospinal fluid (CSF) causing the ventricles of the brain to enlarge, in turn, stretching the nerve tissue of the brain causing a triad of symptoms. • This is normal in pediatrics • Unknown cause is more rare • Unknown cause- NPH is a rare condition compared with other causes of dementia in older adults, such as Alzheimer disease. – Gait disturbance** – Dementia or forgetfulness – Urinary incontinence – NPH is often mistaken for other conditions; most cases go unreported and many are left untreated. NPH: Assessment and Diagnosis • Age-dependent – Infant • Enlarged head with bulging fontanels • Scalp vein distention • Difficulty feeding • High, shrill cry • Common in spina bifida – Older children/adults • Impaired motor and cognitive function (need to know cause) • Increased intracranial pressure (Not Usually) • Diagnosis – CT or MRI – Lumbar puncture – Clinical assessment • Treatment – Shunt (ventriculoperitoneal [VP]) common for kids with hydrocephalus to drain spinal fluid; shunt revisions needed – Hydrocephalus = most common peds neurosurgery condition; choroid plexus within ventricles produce 1 oz CSF (fluid with a bit of salt and sugar) per hr - drained and absorbed by lining around the brain – Issue: not absorbed efficiently or obstruction → enlarged ventricle → pressure on brain, affects child’s brain development, enlarged head in infants → coma & death – Causes: tumor, hemorrhage, infection, congenital (fluid pathway not formed properly) – Shunt--tubing in back of head to ventricle and drains into abdominal cavity, where CSF is absorbed – Know complications: more operations needed as child grows – The end of the shunt is in the abdomen – Sometimes the shunt can kink – MUST KNOW where the shunt goes and problems that can occur -Focus on the shunt portion of the video – Physical therapy to regain lost function – Supportive care – Major takeaways are Look out for kinks and the placement of the shunt-priorities Adult & Elder III STROKE Case Study NT., a 79-year-old woman, arrives at the emergency room with expressive aphasia, left facial droop, left- sided hemiparesis, and mild dysphagia. Her husband states that when she awoke that morning at 0600, she stayed in bed, complaining of a mild headache over the right temple and feeling slightly weak. He went and got coffee, then thinking it was unusual for her to have those complaints, went back to check on her. He found she was having some trouble saying words and had developed a left-sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the emergency department. Her past medical history includes paroxysmal atrial fibrillation (PAF), hypertension (HTN), and hyperlipidemia. A recent cardiac stress test had normal findings, and her blood pressure (BP) has been well controlled. N.T. is currently taking flecainide (Tambocor), hormone replace- ment therapy, amlodipine (Norvasc), aspirin, simvastatin (Zocor), and lisinopril (Zestril). The physician suspects N.T. has experienced an acute cerebrovascular accident (CVA). 1. What role do diagnostic tests play in evaluating N.T. for a suspected CVA? CT Scan w/out contrast typically Have to determine whether or not to give tPA. Remember tPA only for ischemic (Blood clot) 2. Explain how knowing the type of CVA is an important factor in planning care. To determine whether or not you can administer TPA -ischemic stroke - You can’t give someone TPA for a hemorrhagic stroke. 3. Which factor in N.T.'s history is the most likely contributor to her having experienced a CVA? Hypertension/paroxysmal atrial fibrillation, hyperlipidemia After a non-contrast CT scan, she is diagnosed with a thrombotic CVA. The physician writes the orders shown in the chart. • IV 0.9 NaCL at 75ml /hr - • Activase (tPA) per protocol • Stat CBC, PT/INR, CPK Isoenzymes • Neuro assessment every hour • Oxygen 2 Liters NC • Obtain Patient Weight • Vital signs every hour • NPO until swallowing evaluation 4. Outline a plan of care for implementing these orders Patent airway Place her on O2 Baseline assessment, know onset of S/S Get CT scan -- takes only a few min (MRI gives much better image but takes much longer--need to screen patient, get out any metals, readings take long too) Before give TPA, get their weight on special stretcher bc TPA is weight based--TPA treats clots Swallow assessment prior to giving pt meds orally (start w/5 cc, then 50, 70, and higher etc to ensure they can tolerate swallowing) Follow up with PT/OT/Speech pathologist 5. Which interventions can you delegate to the nursing assistive personnel (NAP)? Select all that apply. a) Obtaining N.T.'s weight b) Assisting N.T. in repositioning every 2 hours c)Initiating oxygen therapy by nasal cannula d)Performing N.T.'s neurologic checks every hour e)Obtaining a manual BP per protocol 6. What is the purpose of monitoring the CK isoenzyme levels? To identify any brain tissue injury 7. The instructions on the tPA vials read to reconstitute with 50 mL of sterile water to make a total of 50 mg/50 mL (1 mg/mL). The hospital protocol is to infuse 0.9 mg/kg over 60 minutes with 10% of the dose given as a bolus over 1 minute. N.T. weighs 143 pounds 8. What is the amount of the bolus dose, in both milligrams and milliliters, you will administer in the first minute? 143 lbs / 2.2 = 65 kg 0.9 mg/kg * 65 kg = 58.5 mg 10% of dose = 5.85 mg Bolus dose: 5.85 mg over 1 minute 9. What is the amount of the remaining dose that you will need to administer? 58.5 mg - 5.85 mg = 52.65 mg Remaining dose is 52.65 mg over 59 minutes 10 Contraindications for beginning fibrinolytic therapy include which of the following? Select all that apply. a. Currently on Coumadin with an INR of 2.4 b. Major surgery in the last 14 days c. Systolic BP of 150 d. Platelet count of less than 100,000 e. Blood glucose of less than 50 mg/dL could be due to altered MS; rules out stroke f. History of myocardial infarction 1 year ago g. Improving neurologic status 11. What are your responsibilities during the administration of Activase (tPA)? Monitor BP and neuro checks Monitor bleeding Once start TPA, don’t do invasive things like additional IVs or foley start 3 IV lines in advance (1 for TPA) Case Study Continues N.T. is admitted to the neurology unit. A second CT scan (18 hours later) reveals a small CVA in the right hemisphere. She is placed on flecainide (Tambocor), amlodipine (Norvasc), clopidogrel (Plavix), aspirin, simvastatin (Zocor), and lisinopril (Zestril). 12. If N.T.'s deficits are temporary, how long might it take before they completely reverse? 6 months - 1 yr 13. During the first 24 hours after receipt of Activase (tPA), the primary concern is controlling N.T.'s: a) Cardiac rhythm b) BP Don't want patient to experience post CVA hypertension, don't want worsening cerebral edema and risk of hemorrhage c) Glucose level d) Oxygen saturation 14. While assessing N.T., you note the following findings. Which one is unrelated to the CVA? a) Headache b) Lethargy c) Lumbar pain d) Blurred vision 15. Why was N.T. placed on clopidogrel (Plavix) post-CVA? Prevent further clotting/platelet aggregation -- prevent CVA and secondary CVA 16. Because N.T. had a thrombolytic infusion, how many hours should you wait before beginning administration of any anticoagulant or antiplatelet medications? Within 24 hours 17. Is there any benefit from continuing simvastatin (Zocor) after her CVA? Controls cholesterol 18. As you walk into the nurses' station, the charge nurse is coordinating the swallowing evaluation, including a modified barium swallow study and referral for a speech-language pathologist (SLP). Give the rationale for these orders. Dysphagia risk, aspiration risk. Barium swallow sees where food goes when you swallow