BLUE PRINT Questions
Ischemic & Hemorrhagic Stroke
Differences between Ischemic and Hemorrhagic Strokes:
Pathophysiology: Ischemic stroke occurs due to an obstruction within a blood vessel supplying blood to the brain, while hemorrhagic stroke results from the rupture of a blood vessel, leading to bleeding in or around the brain.
Symptom Onset: Ischemic stroke symptoms may develop suddenly, often related to a temporary blockage, whereas hemorrhagic stroke symptoms usually present with a sudden severe headache, followed by neurological deficits.
Emergency Treatment Priorities: In ischemic strokes, the priority is to restore blood flow (e.g., with thrombolytic therapy), while in hemorrhagic strokes, the focus is on controlling the bleeding and managing intracranial pressure.
Clues in Patient History or Presentation:
Patient history should include previous strokes, risk factors (hypertension, diabetes), and sudden onset of symptoms, which localize affected brain regions. Symptoms such as unilateral weakness or language problems can indicate specific areas impacted (e.g., arm weakness may indicate right hemisphere involvement).
Importance of 'Last Known Normal' Time:
Determining the 'last known normal' time is critical for effective treatment planning for ischemic strokes, as thrombolytic therapy must be administered within a specific time frame (usually within 3-4.5 hours of symptom onset) to maximize effectiveness and reduce risks of complications.
Assessments Guiding Early Decision-Making:
Glasgow Coma Scale (GCS): Assesses level of consciousness.
National Institutes of Health Stroke Scale (NIHSS): Evaluates the severity of stroke symptoms.
Cranial Nerve Assessment: Identifies deficits and localizes brain damage.
Conditions Excluding Thrombolytic Therapy:
Findings Eliminating Eligibility: Active bleeding, recent surgery, history of intracranial hemorrhage, severe hypertension, or stroke symptoms lasting longer than the therapeutic window.
Nursing Actions to Protect the Ischemic Penumbra:
Actions include positioning the patient to promote cerebral perfusion, avoiding hypotension, ensuring oxygenation, and administering potentially indicated therapies promptly to minimize further injury.
Distinguishing New Stroke Symptoms from Complications:
Monitoring for signs of hemorrhagic conversion (e.g., sudden worsening of headache, neurological decline) or hypoglycemia (e.g., confusion, weakness) is essential. Assess blood glucose levels in new symptoms presentation.
Spinal Cord Injury, Autonomic Dysreflexia, Neurogenic Shock
Predicting Impairment by Level of Spinal Cord Injury:
The level of injury determines the extent of motor, sensory, and respiratory function loss. Injuries at higher cervical levels (C3 and above) can impact respiratory function severely.
Distinction between Spinal Shock and Neurogenic Shock:
Spinal Shock: Immediate loss of reflexes and motor function below the level of injury, lasting days to weeks.
Neurogenic Shock: Characterized by bradycardia and hypotension due to loss of sympathetic tone. It develops shortly after injury and can be life-threatening if not managed properly.
Triggers for Autonomic Dysreflexia:
Triggers can include bladder distention, bowel impaction, or surgical stimulation. Immediate bedside response includes sitting the patient upright and checking the urinary catheter or bowel program.
Assessment Findings Indicating Respiratory Compromise:
After cervical injury, look for shallow respirations, use of accessory muscles, decreased oxygen saturation, or abnormal lung sounds.
Monitoring and Responding to Instability after Acute SCI:
Regular assessment of blood pressure, heart rate, and neurological status. Quick intervention for changes in these parameters is crucial.
Ongoing Nursing Interventions for Long-Term SCI Care:
Interventions include regular skin assessments, bowel and bladder management, preventing complications like pressure ulcers and respiratory infections through early intervention strategies.
Traumatic Brain Injury (TBI) & Increased ICP
Differentiating Primary from Secondary Brain Injury:
Primary Injury: The initial damage from the traumatic impact.
Secondary Injury: Subsequent processes like edema, hypoxia, and metabolic disturbance that can worsen the injury over time.
Signs of Increasing Intracranial Pressure (ICP):
Early Signs: Headache, vomiting, altered consciousness.
Late Signs: Cushing’s triad (hypertension, bradycardia, irregular respirations), dilated pupils, and loss of motor response.
Impact of Positioning on ICP and Cerebral Perfusion:
Head elevation can reduce ICP and improve cerebral perfusion, while flat positioning may increase ICP.
Bedside Assessments for Neurological Deterioration:
Repeat neurological examinations, monitor GCS and check for pupil response, limb movement, and motor response.
Interventions to Reduce ICP:
Interventions include administering osmotic diuretics (e.g., mannitol), positioning to promote venous drainage, and avoiding actions that can increase ICP (e.g., coughing or straining).
Findings Requiring Emergent Escalation:
Sudden severe headache, unilateral pupil dilation, posturing (decerebrate or decorticate), or any changes in vital signs indicating herniation.
Calculating Cerebral Perfusion Pressure (CPP):
CPP can be calculated using the formula:
Adequate Cerebral Perfusion Ranges: Generally, CPP should be maintained above in adults for sufficient cerebral perfusion.
Seizure Recognition & Management
First Safety Actions During a Seizure:
Ensure the patient is safe by preventing injury (e.g., move objects away), positioning to allow for drainage of secretions, and protecting the head.
Important Seizure Triggers:
Identify and avoid triggers such as flashing lights, stress, or specific medications.
Mechanism of Benzodiazepines in Stopping Seizures:
Benzodiazepines enhance GABAergic activity, which inhibits neuronal excitability. After administration, monitor the patient for respiratory depression and sedation, especially during the postictal phase.
Characterization of the Postictal Period:
The postictal state may present with confusion, fatigue, headache, or transient weakness. Nurses should monitor vital signs and neurological status, offering reassurance and support as coherence returns.
Patient Teaching to Support Medication Adherence:
Emphasize the importance of taking medications regularly, recognizing seizure precursors, and safety measures to reduce risk of injuries (e.g., not swimming alone or operating machinery).
Trauma-Informed Care & Vicarious Trauma
Behaviors Indicative of Trauma Response:
Signs may include anxiousness, avoidance of specific topics, intense emotional reactions, or physical responses such as sweating or shaking.
Changes in Nurse Communication:
Trauma-informed care requires nurses to communicate sensitively, explaining procedures and obtaining consent before touching or treating patients to prevent triggering trauma responses.
Actions to Minimize Retraumatization:
Staff should practice active listening, validate patient experiences, and avoid coercive measures during emergency procedures.
Signs of Healthcare Provider Experiencing Vicarious Trauma:
Symptoms including emotional exhaustion, depersonalization towards patients, diminished satisfaction from work, and signs of burnout.
Support Systems for Clinicians:
Interventions may encompass regular breaks, access to counseling services, peer support groups, and practices promoting self-care to protect against burnout and secondary trauma.
Burns & Acute Injury Management
Classification of Burn Depth & Total Body Surface Area (TBSA):
Burns are classified:
1st Degree: Superficial (e.g., sunburn).
2nd Degree: Partial thickness with blisters.
3rd Degree: Full thickness, through skin into tissues.
Calculate TBSA using the Rule of Nines.
Concerns for Inhalation Injury and Airway Compromise:
Early findings include singed nasal hairs, soot in sputum, or respiratory stridor. Immediate action is necessary to secure the airway.
Fluid Resuscitation Calculation (Parkland Formula):
To calculate fluid needs in the first 24 hours:
Half of this volume is administered in the first 8 hours, followed by the remainder over the next 16 hours.
Indications of Adequate vs. Inadequate Fluid Resuscitation:
Adequate Fluid Resuscitation: Stable vital signs, urine output of at least 30-50 ml/hour.
Inadequate Fluid Resuscitation: Persistent low blood pressure, elevated heart rate, and reduced urine output.
Distinguishing Compartment Syndrome in Burn Patients:
Symptoms include severe pain, pallor, pulselessness, and paralysis. Priority action is to assess and potentially release pressure if diagnosed.
Complications Indicating Burn Infection or Sepsis:
Signs include increasing redness, purulence, fever, and tachycardia. Early intervention with cultures and antibiotics is crucial.
Discharge Teaching for Healing and Prevention of Contractures:
Education on wound care, proper skin lubrication, sun protection, and therapeutic exercises to maintain mobility and prevent contractures during recovery.