normal arousal AND full cognition

• Lethargy

• severe drowsiness where the patient can be aroused by moderate stimuli and then drift back to sleep.

o    Obtundation

is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.

• only vigorous and repeated stimuli will arouse the individual, but the patient will immediately lapse back to the unresponsive state.

• Assess cerebellar function

Coordination

Gait and equilibrium

• Romberg’s sign (balance test)

• A--a&ox4
• V--responds to verbal stimuli
• P--responds to pain
• U—unresponsive

system used to describe the level of consciousness in a person following a traumatic brain injury

Also used to Gage severity of traumatic brain injury

• 4 = eye open spontaneous
• 3 =eye open  to voice
• 2 = eye open to pain
• 1 = eye open - none

• 6 = normal
• 5 = localized to pain
• 4 = withdraws to pain
• 3= abnormal flexion
• 2= Extension
• 1= none

- pain when touched

- pain with hot or cold

- touch dicrimination (touching with one or two ojects)

Measures muscle strength

0= no contractility

T= trace (slight contractility but no movement )

P= poor (full ROM no gravity )

f= fair  (Full ROM with gravity )

G= Good ( Full ROM against gravity , some resistance)

N = Normal (full ROM against , full resistance )

Coordination

Gait and equilibrium

balance test

• 0: absent reflex
• 1+: trace, or seen only with reinforcement              
• 2+: normal                                                     
• 3+: brisk                                             
• 4+: nonsustained clonus (i.e., repetitive vibratory movements)
• 5+: sustained clonus

Flaccid - Loos for limply posture

Decorticate - which a person is stiff with bent arms, clenched fists, and legs held out straight.

De cerebrate - person stiff with arms to the side and hands pointed outward

Dermatome

Areas of the skin where you feel pain where that skin is connected to parts of the spinal nerve

C- cervical control neck, shoulder, both outer arms , and upper chest

T- thoracic controls inner arms, bid chest to waist 

S- sacra l controls genitalia, lower coccyx anal and outer back of legs, outer foot, and heel 

L- Lumbar controls pubic lower waist, lower back outer hips, inner leg and lower outer leg, inner foot and toes

Corneal- eye blink itching or something in you eye

Conjunctiva-  when the eye is touched

Abdominal - tightening of ab muscles

Anal wink -

Planter ( Babinski ) stroking upward on bottom of foot and toe moves up and forward

Kernigs - when thigh is flexed at hip, knee is 90 degree , pain

Brudzinks's - bending head up and knees up at the same time

Stroke

Diagnosis -

o   Is a brain attack. Aka cerebrovascular attack

o   ==a disruption of blood flow to the brain secondary to ischemia, hemorrhage, or embolism.

o   Is either ischemic or hemorrhagic

o   Ischemic    

·         most common and results from an interruption of blood flow due to either a thrombosis (plaque buildup) or emboli (blood clot)

·         insufficient blood flow causes ischemia, or brain death, of the affected part of the brain.

o   Hemorrhagic

·         Less common

·         More serious as it results from a blood vessel rupturing and bleeding into brain tissue.

DM, smoking, htn, arteriovenous malformation, atherosclerosis, high cholesterol, clotting disorders, oral contraceptives, cerebral aneurysm, tobacco use, age over 65!

o   FAST

·         Facial droop

·         Arm drop

·         Slurred Speech

·         Time to Act!

o   Visual disturbances, dizziness, confusion, swallowing    difficulties, incontinence,

- Left side stroke - affects right sided weakness

- Right side stroke- affects left side weakness

•      Cognitive changes like aphasia, alexia (inability to see words or read), agraphia (can’t write).

•      Motor changes like hemiplegia (paralysis on one side), hemiparesis (weakness of one side), hypotonia (low muscle tone), flaccid paralysis, hypertonia (increased muscle tone)

•      Sensory changes like agnosia (inability to process sensory information), apraxia (difficulty with motor fxn), neglect syndrome(fail to be aware of one side of body), ptosis (drooping eyelid), retinal ischemia causing a brief episode of blindness, hemianopia (blindness of half the field of vision).

•      Perform cranial nerve assessment.

•      Perform CV assessment.

- Hct (hemtocrit- amount of blood cells in the blood) 

- hgb- Hemoglobin - protein in blood that carries O2 to bodys organs and carries Co2 back to lungs 

PT. Ptt, INR 

CSF sample - Cerebrospinal fluid 

CT scan 

·         Maintenance of the airway, oxygenation, and hemodynamic stability

·         Blood pressure management

·         Helping the patient adapt to specific deficits

·         Physical, speech, and occupational rehabilitation

·         Supportive, symptomatic treatment

         Inadequate perfusion,  Impaired swallowing

·         Impaired physical mobility ,   Self-care deficit

·         Aphasia,  Incontinence, Disturbed sensor perception

·         Unilateral body neglect

<0= suspected patient arrives at the hospital at ED

<10= MD eval, pt Hx, last know onset, lab work, start

         NIHSS (national institute of health stroke scale)

                     Normal function to complete impairment

<15= Notify stroke team

<25 = CT scan

<45= read CT scan and labs, eligibility for TPA

          (tPA - Tissue plasminogen activator)

<60= give tPA bolus and infuse

Intervention for stroke patient (brain attack)

What is Mnemonic ?

F.A.S.T ......

F- facial drooping

A- arm weakness

S- speech difficulties

T- time to call EMT

Acronym

B.R.A.I.N

A.T.T.A.C.K

B- B/P

R- respiration

A- airway

I- Imaging- CT scan

N- Normoglycemia

A- Aspirin- 300mg admit the continue 1-2 wks

T- temperature

T- Thrombolysis or TPA

A- assessment of swollow with in 24 hours

C- continence

K- Keep up to date on positioning head up 30 degree      to decrease IPS

Anticoagulants - Heparin, pradaxa, Warfarin  

Thrombolytics- - Aspirin, 

Anti platelets- Aspirin , Plavix, Prasigrel

Anticonvulsants- Tegretol, Clonazepam, Diazepam, valium, gabapentin

Mannitol- brain swelling, rid of axtra fluid, eye pressure

Calcium channel blockers- -

Analgesics

Antidepressants

Lipid- lowering agents

Anti-hypertensives

Anti anxiety drugs

•      Intracranial pressure monitoring

•      Cooling blankets

•      Carotid artery angioplasty with stenting (in patients with carotid stenosis)

•      Endarterectomy

•      Extracranial-intracranial bypass

o   For feedings and swallow—

·         Work with speech therapist to assess swallow and gag reflex

·         may need thickened liquid consistencies

·         have the patient sit in an upright position

·         place food on unaffected side

·         have suction on standby

o   ambulate as soon as possible

o   maintain skin integrity

o   encourage passive ROM q2h to the affected extremities and active ROM to the unaffected extremities.

When a stroke injures the frontal regions of the left hemisphere, different kinds of language problems can occur. This part of the brain is important for putting words together to form complete sentences. Injury to the left frontal area

ability to grasp the meaning of spoken words and sentences is impaired, while the ease of producing connected speech is not very affected.

•       Language, mathematics skills, and analytic thinking

•       Expressive and receptive aphasia (inability to speak and understand language)

•       Agnosia (unable to recognize familiar objects)

•       Alexia (reading difficulty)

•       Agraphia (writing difficulty)

•       Right extremity hemiplegia (paralysis) or hemiparesis (weakness)

·         Treat with carotid stenting to open up the occlusion

·         Only do one side at a time

·         Monitor pt, ptt, inr

·         Monitor for reperfusion

·         Surgical management

o    Clipping: Surgical repair involves clipping the aneurysm neck with at least one titanium clip; considered the treatment of choice

o    Coiling: Endovascular repair involves use of electrically detachable platinum coils that promote electrothrombosis within the aneurysm

o    Carotid endartectomy: surgical removal of plaque inside the carotid artery.

·         Decrease cerebral edema. Medications such as mannitol and dexamethasone can be administered every 6 hr for 24 to 72 hr postop.

·         Phenytoin or diazepam can be used to prevent seizure activity.

·         Monitor ICP. Follow written protocols to assess for changes in ICP.

·         For supratentorial surgery, maintain HOB 30 degrees with body positioning to prevent increased ICP.

·         For infratentorial craniotomy, keep client flat and on either side for 24 to 48 hours to prevent pressure on neck incision site.

• Head injury occurs as a result of blow or jolt to the head or as a result of penetration of the head by a foreign object such as a bullet.

• Amnesia
• Headache
• Dizziness
• Seizure
• Loss of consciousness or sleepiness/drowsiness
• Restlessness or irritability
• Disorientation or confusion
• Scalp bruising and tenderness
• Personality changes

• Pupil changes
• Bradycardia
• Papilledema
• High blood pressure/widened pulse pressure
• Hypotension and tachycardia (hypovolemic shock)
• Nuchal rigidity

• A score of 13-15 is MILD INJURY and loss of consciousness for up to 15 minutes
• A score of 9-12 is MODERATE INJURY with loss of consciousness for up to 6 hours
• A score of 3-8 is SEVERE with loss of consciousness for more than 6 hours.