Medical-Surgical Nursing, 8th Ed., Ignatavicius & Workman, 2015 | Registered Nurse (RN) School Study Aid
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
Types of Strokes
- Transient Ischemic Attack (TIA)
- Reversible Ischemic Neurologic Deficit (RIND)
- Ischemic
- Thrombotic
- Atherosclerosis
- Embolic
- Atrial Fibrillation
- Hemorrhagic
- Severe Hypertension
Alteplase
- Tissue Plasminogen Activator
- Thrombosis
- Bleeding
- Intracranial Hemorrhage
- Internal Hemorrhaging
- Minimize Bleeding
- Monitor for Shock
- Aminocaproic Acid
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
Traumatic Brain Injury Assessment
- Change in LOC
- Personality Changes
- Amnesia
- Increased Intracranial Pressure
- Diplopia
- Posturing
- Basilar Skull Fracture
- Halo or Ring Sign
- Intracranial Bleeding
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
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
Phenobarbital (Barbiturates)
- Barbiturate
- Seizures
- Ataxia
- Paradoxical Excitement
- Fatigue/Drowsiness
- Monitor Plasma Levels
- High Potential for Abuse