Final Exam Content Guide,Latest.
1. Stroke – CVA – Brain attack disruption of cerebral blood flow secondary to ischemia, hemorrhage, brain
attack, or embolism
1) Hemorrhagic – ruptured artery or aneurysm = ischemia and ↑ICP caused by expanding collection
of blood. Prognosis poor.
2) Thrombotic – d/t development of blood clot on an atherosclerotic plaque in a cerebral artery.
The clot gradually shuts off the artery causing ischemia distal to the occlusion. Symptoms evolve
over several hours to days.
3) Embolic – d/t embolus traveling from another part of the body to the cerebral artery. Blood to brain
distal to occlusion immediately shuts off causing neuro deficits, or a loss of consciousness can
instantly occur. --- This type of stroke may be reversed with rtPA if given within 4.5hrs of initial
symptoms.
Risk Factors: HTN, DM, smoking == PREVENTION == Early treatment of HTN, maintain BGL, quit smoking.
Right vs Left: Right = visual and spatial awareness and propriception. Left = language, math, and analytic
thinking (agnosia – inability to recognize familiar objects).
Interventions: Have suction equipment avail. Vitals 1-2hrs – Notify MD if BP >180/110. Temp (↑ can
cause ↑ICP). O2 and maintain > 92%. Cardiac monitor. Monitor LOC (↑ICP). Elevate HOB >30 to
reduce ICP and promote venous drainage. Maintain midline neutral position. SEIZURE
Percautions. Assist with communication. Assist with safe feeding. Intervene for complications r/t
immobility. Active ROM to unaffected exteemities, and Passive ROM to affected extremities. Vision
deficits = instruct scanning techinique (turning head). Prevent DVT. Assist with ADL’s. Provide
frequent rest.
Complitcations: – Prevent shoulder subluxation if affected arm is not supported. Unilateral neglect (nurse to
provide arm sling/foot rest). Dysphagia and aspiration (nurse assess gag reflex, monitor swallowing).
MEDS: Anticoagulant: Enoxaparin (Lovenox), warfarin (Coumadin) – Antiplatelet: Aspirin – Thrombolytic: rtPA –
Antiepileptic: phenytoin (Dilantin), gabapentin (Neurontin)
2. Traumatic brain injury – major causes, eligibility for federal programs, types, assessment,
interventions, rehabilitation, support, interdisciplinary care planning, sympathetic storming prevention
3. Mild brain injury – common types, assessment, interventions, patient education, prevention
4. Moderate brain injury – common types, assessment, interventions, treatments, interdisciplinary care
planning, patient education, prevention
5. Increased intracranial pressure – assessment, interventions, unsafe interventions, treatments,
monitoring, common medications, what to avoid, interdisciplinary care planning, patient education
Treatment: Cooling blankets to lower overall body temperature. By lowering temperature of the body, the
metabolic rate in the brain decreases, thus reducing metabolic demands and allowing the brain to begin to
recover; Sedative or neuromuscular medications may be needed to prevent shivering and anxiety, which will
increase temperature; ICP is measured by placing a small tube in the ventricles of the brain
(ventriculostomy) Nursing Interventions:
•Monitor the cerebral perfusion pressure, difference between the CPP is the difference between the ICP
and the mean arterial pressure (MAP)
•CPP is calculated by subtracting the ICP from the MAP
•Keep oxygen saturation at 100%
•Help with environmental stimuli; keep lights and noise low
•Visitors limited to one to two for short time
•Institute measures to promote healing and prevent complications; turn every 2 hours & HOB at 30
•Compression stockings
•Anticoagulant therapy
6. Brain tumor- Cancer usually originates in the lung and breast but can also start in the kidney, prostate, or
as lymphoma or melanoma, which then spreads to the brain
