Term
mental status intellectual function thought content emotional status perception motor ability language ability |
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Definition
| what do you assess for cerebral function? |
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Term
vagus = gag reflex Symmetric rise uvula & soft palate |
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Definition
| what is cranial nerve 10? |
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Term
| want - negative babinski test |
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Definition
| when examining the reflexes what result do you want from the babinski test? |
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Term
biceps reflex triceps reflex brachioradialis patellar ankle clonus superficial babinski |
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Definition
| What reflexes to do you examine for neurological assessment? |
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Term
cerebral function cranial nerves motor system reflexes sensory system CV assessment |
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Definition
| what are the 6 components to a neurological assessment? |
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Term
run a pencil along the outer edge of the foot neg results = toes curl inward pos results = toes fan out |
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Definition
| what is a babinski (reflex) test? |
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Term
temp pulse resp BP - sitting & standing |
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Definition
| what do you assess in the cardiovascular assessment? |
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Term
provides info on chemical changes in the cells detects cerebral pathology earlier, monitor tumor response, etc. |
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Definition
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Term
| cath into brachial of femoral artery, under x-ray, dye, use to view intracranial & extracranial vessels |
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Definition
| what is a cerebra angiography? |
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Term
post test = bedrest pressure dressing check pulse distal to site vs neuro checks often per protocol |
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Definition
| what should the nurse do after a cerebral angiography? |
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Term
sterile procedure spinal needle inserted into the SA space send specimens to the lab immediately specimen should be clear if RBCs are present = bad tap used to measure CSF pressure, collect for lab study (cell count, culture, glucose, protein) |
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Definition
| what is a lumbar puncture? |
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Term
explain procedure, permit, have pt empty bladder assist w/positioning - edge of bed, lying in fetal position. post = keep bed flat 12-24 hrs lying prone for at least 3 hrs watch for incr temp backache/nuchal rigidity = call MD |
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Definition
| nursing resposibilities of a lumbar puncture |
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Term
| disruption of the blood supply dye to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue. |
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Definition
| what is an ischemic stroke? |
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Term
large artery thrombosis small penetrating artery thrombosis cardiogenic embolism cryptogenic other = illicit drug use, coagulopathies, spontaneous dissection of carotid or vertebral arteries |
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Definition
| types of ischemic strokes |
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Term
| atherosclerotic occlusion |
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Definition
| Large artery thrombosis = |
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Term
affects 1 or more vessels (most common) lacunar strokes because cavity created after death of infarction. |
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Definition
| small penetrating artery thrombosis = |
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Term
afib/MI usually sudden neuro deficits |
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Definition
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Term
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Definition
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Term
loss of position sense hemiplegia = flexor muscles stronger than extensors position flat in bed to prevent hip flexion elevate arm & flex fingers prone 15-30mins TID prevent foot drop, ROM, equipment, fatigue easily |
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Definition
| Impaired physical mobility rt hemiparesis, loss of balance, and coordination, spasticity, brain injury. |
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Term
70% shoulder pain never lift by flaccid shoulder subluxation may occur from force of gravity when sits or stands may need arm sling |
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Definition
| Alteration in comfort: painful shoulder rt hemiplegia & disuse |
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Term
unilateral neglect hemianopsia attend to the affected side first place items and food on unaffected side teach to turn head to look at missing visual field in all activities, especially when walking |
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Definition
| Disturbed sensory perception rt altered sensory reception, transmission, and/or integration |
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Term
npo for a few days/check residual of CVA IV nutrition, tube feedings, PEG feedings Assess swallowing reflex, airway clearance, speech therapy soft/puree less likely to aspirate than liquids wear dentures, rinse mouth after eating modified utensils HOB elevated, suction available |
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Definition
| Impaired swallowing/potential alteration in nutrition - less than |
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Term
20% of all strokes determine abilities speak slowly, speak to face on unaffected side, short sentences, pause, repeat or rephrase, use visual clues, be consistent show acceptance, allow to write |
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Definition
| Impaired verbal communication rt aphasia |
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Term
may be due to spontaneous rupture of small vessels primarily related to hypertension. subarachnoid hemorrhage due to a ruptured aneurysm. intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations, intracranial aneurysms, or medications such as anticoagulants. caused by bleeding into brain tissue, the ventricles, or subarachnoid space |
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Definition
| what is a hemorrhagic stroke? |
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Term
similar to ischemic stroke severe headache early and sudden changes in LOC vomiting - mortality rate 43% at 30 days after hemorrhage - survivors usually more severe deficits and longer recovery time. |
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Definition
| clinical manifestations of a hemorrhagic stroke |
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Term
measure of uptake of glucose in brain. pictures of actual organ function |
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Definition
| PET (positron emission tomography) scan |
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Term
Graphic record of electrical activity of brain. nsg resp - explain test, painless, wash hair well, no oils/sprays. Post test - remove electrodes, VS |
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Definition
| EEG (electroencephalography) |
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Term
| Assessment of Unconscious Patient (13) |
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Definition
LOC Pattern of Respirations Eyes Eye movemnts Cotton Wisp Facial Symmetry Swallowing Reflex Neck Response to noxious stimuli Deep tendon reflexes pathologic reflexes abnormal posturing (decorticate - turn in, decerbrate - twist out) VS |
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Term
| Ineffective Breathing Pattern RT unconscious State |
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Definition
3/4 prone or lateral with head turned to side - jaw forward. suction Resp Rate Pattern O2 BNC AFM |
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Term
| Risk for injury RT decrease LOC |
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Definition
pad rails protect raise siderails talk to them as normal |
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Term
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Definition
tissue turgor mucous membranes I & O lab Data Admin IVF & blood components slowly Use peg or ngt as ordered |
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