Neuro Study Guide

Early recognition is the key!

795,000 people in the United States have a stroke every year. 130,000 of them die. Stress, covid 19, mental
health issues, the pandemic increases the use of drugs and alcohol. Street drugs, they affect your heart,
increases vasospasms, hypertensive crisis, increases hypercoagulability (causes blood to clot more) which can
lead to a stroke. Most people who do cocaine it puts them in a hypertensive crisis and leads to ischemic
stroke.
American Indian, African, Hispanic (Latino), these populations are at highest risk.

Major Concepts

Perfusion (because a stroke results in ischemia and necrosis of brain tissue) there is something that has
happened where it is an ischemic stroke or hemorrhagic stroke whereas the blood circulation, the blood and
glucose(energy) that the brain needs to survive and adequately function was cut off which decreases
perfusion which led to ischemia and death of the tissues.)

Cognition (of course if there is an injury to the brain it will directly affect cognition and how the brain
functions whether it is speech, talking, movement, etc.)

Mobility (a person who has a stroke has the possibility of hemiparesis or paralysis, they can have one sided or
unilateral weakness which is paresis or paralysis in which they are unable to use it)

Sensory perception (with a stroke or brain injury, the patient may have an alteration in sensory perception
which alters how they are in an environment, they may not be able to feel discomfort or pain or depth) even
walking downstairs or a step, that sensory is altered! It affects their ability to perform ADLs, go to work and be
in certain environments.

Transient Ischemic Attacks (TIA) page 898-899

• “Warning sign”
• Transient focal neurologic dysfunction
• Brief interruption in cerebral blood flow

The patient has small intervals where they are not getting adequate blood flow. The patient often has warning
signs that are dismissed or overlooked. When a small TIA occurs, the person is experiencing some kind of
tissue damage especially in repeated attacks. Sometimes this damage can be permanent, so we have to be
very mindful and careful of that. It is brief, it can come on and resolve itself within 30 minutes to an hour. The
blood pressure plays a major role (an increase in blood pressure) has an increased risk of a TIA, make sure we
maintain the blood pressure by putting them on a BP lowering agent. Monitor clotting factors, make sure we
put the patient on an antiplatelet medication. Diabetic patient, make sure we control their blood sugar level
100-180 mg/dL to maintain adequate blood sugar levels in order to effectively maintain adequate perfusion.
Patients with possible TIA we want to teach them to stop smoking, get up exercise, move around and maintain
a proper diet.
We want to ensure adequate perfusion to the brain.
Hypertension, inadequate blood flow, thrombus (clots), food, lack of exercise, improper diet can lead to
carotid arteries building up with plaque which can possibly rupture and lead to little clots becoming dislodged,
that inhibits blood flow going directly to the brain. Teach our patients to maintain proper blood pressure, diet,
take aspirin, they are normally placed on platelets or aspirin if they have had a previous stroke, maintain blood
sugar levels, and stop smoking.

What does a TIA look like?

• Blurred vision, double vision, or become blind in one eye, tunnel vision
• Weakness in one side (ataxia), unsteady gate, weak hand grip, facial droop
• Numbness in hand/face/arm, vertigo
• Difficulty speaking, slurred speech, dysarthria (Weakness in the muscles used for speech, which often
causes slowed or slurred speech.)
• Severe headache (first thing in the morning)

If you wake up with a headache, assess your blood pressure because those increased blood pressures is what
lead to those increased TIA’s especially ischemic strokes!
TIAs lead up to a stroke whether it is ischemic or hemorrhagic!

Stroke is a medical emergency!

Stroke
• Change in normal blood supply to brain
Types
• Ischemic
• Thrombolic
• Embolic
• Hemorrhagic

• A stroke (brain attack) is a medical emergency and should be treated immediately to reduce or prevent
permanent disability.

• Does the patient have a genetic history, do they have a family background? This can increase their risk.
Look at those modifiable risk factors that we can address!

• Stroke causes an interruption of blood flow that goes to the brain which leads to ischemia, then
necrosis. The brain can only go minutes without having adequate blood flow!

• Ischemic stroke- an embolism or clot that is cutting of blood flow leading to anoxia or ischemia and
necrosis. Ischemic stroke comes on slowly.

• Thrombolytic stroke- usually caused by atherosclerosis, buildup of fat and plaque in that arterial wall.
Normally happens in the carotid artery. This atherosclerosis can rupture, and the plaque is exposed to
foam cells and the plaque builds up and the platelets come along and begin to pile up and start
creating clots and you have clot formation. The artery itself becomes occluded which leads to
decreased or diminished blood flow leading to ischemia. Complete ischemia with no flow at all leads to
necrosis. Thrombus travels to the brain or to the cerebral arteries, it can come through the carotid
artery or cerebral artery and block them. Slow onset. Due to high fat, high cholesterol, atherosclerosis.

• Embolytic stroke- caused by a dislodged clot that came from somewhere else and landed in the heart.
For example, a person with atrial fibrillation or DVT. An embolytic stroke leads to sudden and rapid
 development of signs and symptoms. It can happen a lot quicker because this clot traveled from
somewhere and found a narrow area and got stuck in and ended up cutting of the patients’ blood flow.
Sometimes that clot can break down and the signs and symptoms may begin to go away. Clot may have
originated because the person has atrial fibrillation, DVT, and that clot came from another area and
made it to the brain.

• Hemorrhagic stroke- comes on quickly! The vessel wall has an interruption in integrity due to high
blood pressure or an aneurysm, it may rupture and there is bleeding on the brain. The bleeding can
happen inside the brain tissue (Intracerebral) or the bleeding can occur in spaces outside the brain
(subdural or subarachnoid or hematoma) caused by severe hypertension, ruptured aneurysm, or
arterial venous malformation (genetic thing that people are born with). Make sure we monitor and
maintain a good blood pressure, look at modifiable risk factors and so forth. AVM the vessels are very
thin and dilated and with hypertension added it can increase those chances of it rupturing.
Hypertension is a major cause, cocaine use because cocaine can lead to a hypertensive crisis which
greatly increases the risk leading up to a stroke. Aneurysm where the arterial wall balloons out and
becomes thin and very weak and can lead to a subarachnoid hematoma. It can be due to vasospasms
that suddenly constricts the artery which can be followed by a hemorrhage especially if an aneurysm
or a AVM is present. Vasospasm>constriction>increases the pressure>aneurysm or AVM against that
thin wall can lead to a rupture of that wall and lead to an aneurysm.

• An arteriovenous malformation (AVM) is a tangle of blood vessels that irregularly connects arteries and
veins, disrupting blood flow and oxygen circulation. Arteries move oxygen-rich blood from the heart to
the brain and other organs. Veins drain the oxygen-depleted blood back to the lungs and heart.

• When an AVM disrupts this critical process, the surrounding tissues might not get enough oxygen. Also,
because the tangled blood vessels in an AVM do not form properly, they can weaken and rupture. If
an AVM in the brain ruptures, it can cause bleeding in the brain, stroke or brain damage. Bleeding in the
brain also is called hemorrhage.

Assessment:

If we think someone is having a stroke the priority is making sure we get them to the right place, if they are
home getting them to the ED. We need to recognize strokes rapidly and quickly so we can get treatment
because time is so important if we can ensure proper perfusion, we can decrease mortality and morbidity
rates. Identify signs and symtoms. Make sure patient receives proper treatment with medications or
fibrinolytic drugs or endovascular interventions.
[S/s, nursing diagnosis I expect to see, what interventions are needed]
Learn about the disease, what causes it, assessments! Page 902

• Sudden confusion or trouble speaking or understanding others

• Sudden numbness or weakness of the face, arm, or leg
• Sudden dizziness, trouble walking, or loss of balance or coordination
• Sudden severe headache with no known cause

Ischemic stroke, they can have symptoms, but it may get better if the clot breaks off or move then they can
have perfusion again! Very important to know the patients’ medical history, do they have
diabetes/hypertension/atrial fibrillation/head trauma/obesity.
Important parts of the history
• When did symptoms begin?
• What was the patient doing when the stroke began?
• How did the symptoms progress?
• Did the symptoms worsen after the initial onset, or did they begin to improve?
• What is the patient’s medical history?
• What are the patient’s current medications? (Is there a history of bleeding, are they on anticoagulants
or antiplatelet, aspirin) (cocaine or illicit drugs can increase hypertension leading to hypertensive crisis
and can increase the risk of a stroke) if it is an ischemic stroke, we may want to treat with fibrinolytic
therapy or TPA-the patient won’t be able to receive these extreme blood thinners if they have a history
of bleeding.
• What is the patient’s social history, including education, employment, travel, leisure activities, and
personal habits (e.g., [modifiable risk factors] smoking, diet, exercise pattern, drug, and alcohol use)?
• Know the progression of the signs and symptoms because that will tell you the difference between an
ischemic stroke (occur over time) and a hemorrhagic stroke (occur all of a sudden).

Stroke symptoms
• Sudden change in LOC, orientation, confusion, or trouble speaking or understanding others
• Sudden numbness or weakness of the face, arm, or leg
• Sudden trouble seeing in one or both eyes
• Sudden dizziness, trouble walking, or loss of balance or coordination (ataxia)
• Sudden severe headache with no known cause

A patient may come in with lethargy or drowsiness, disorientation. When they come in with a change of
cognitive function in order to rule out a stroke make sure we assess their blood sugar for hypoglycemia which
also have similar signs and symptoms. But when you add difficulty speaking, they can’t understand other
people or you can’t understand them, numbness on one side, vision changes, double vision, blind all of a
sudden, dizziness, that is not a blood sugar, and it may be a stroke. Blood sugar: altered LOC, orientation,
cognitive ability. Make sure we keep in mind the medical history: hypertension, hyperlipidemia, increased
cholesterol levels, cardiovascular disease, sedentary lifestyle, extreme alcohol use can increase blood pressure
and coagulability, obesity, high fat diet, anything that alters coagulation and increase the risk for clot like atrial
fibrillation we have to look at those things when it comes to s/s of a stroke! If the patient can’t answer these
questions, ask family or emt that brought them in.

We have to perform with assessment within 10 minutes of arrival. Our priority is ABCs! You need to know your
O2 stats because if they are having a stroke and there is dysfunction in the brain then it can send a signal to
disrupt our breathing so always ABCs. Check breathing, o2 stats, respiratory rate, listen to lung sounds, check
circulation, listen to the heart. Having a stroke can lead people into certain dysrhythmias from that nervous
system sending that signal to the heart to do what it does with that rate and rhythm. If they need oxygen
supply oxygen, monitor blood pressure, dysrhythmias, murmurs. Check vital signs, blood sugar levels because
hypoglycemia can mimic stroke. Perform a neuro assessment. Use pen light and assess PERRLA, assess visual
fields, eye drooping or ptosis, do the 6 gaze (move finger while they follow without moving head to see if you
notice any extraocular eye movement) When they have a stroke or some type of damage it will alter the visual
fields.

Refer to the stroke scale.

Assess their cognition (short term or long term memory may have been affected, they don’t have proper
judgement abilities, they can’t read or do math problems, decision making, they can’t concentrate, they may
have personality changes and act out) , motor abilities (ROM, lift their arm or leg, proprioception/sense of
space, unsteady gate, uncoordinated, lose control of their bladder or bowels, sensory deficit-can’t respond to
pain or touch, emotional state. They may lose their ability to read or write or follow verbal commands, they
become aphasic (cannot speak) may become very slurred, they may experience loss of vision, they may can
only see half of a vision field they may lose vision in one eye.

Cranial nerves give more information of where the stroke may have taken place.

[Link] [sniff test]

[Link] [visual acuity]
[Link] [6 cardinal gazes, pupillary constriction, opening & closing of the eyes]
[Link] [6 cardinal gazes, downward & inward movement of eyes]
[Link] [facial sensation-maxillary, mandibular, masseter strength & temporalis muscle strength]
[Link] [6 cardinal gazes, lateral movement of the eyes]
[Link] [puffing out cheeks, smile, and frown]
[Link] [whisper test, weber, rhine and Rhomberg]
[Link] [gag reflex, swallow]
[Link] [coughing, gag reflex (motor)]
[Link] Accessory [shrugging-Trapezius side to side movement-Sternocleidomastoid]
[Link] [tongue movement and strength, “light, tight, dynamite”]

In the Weber test the clinician strikes the fork, places it in the middle of the patient’s vertex, forehead, or
bridge of nose, and asks “Where do you hear the sound?”
Rhine test- The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone
conduction
Rhomberg test- The patient is asked to remove his shoes and stand with his two feet together. The arms are
held next to the body or crossed in front of the body. The clinician asks the patient to first stand quietly with
eyes open, and subsequently with eyes closed. The patient tries to maintain his balance.

If cranial nerve 5 is altered then a person cannot chew, which affects nutrition, protein and so forth and
increases risk of aspiration!
Cranial nerve 9 [gag reflex] may take a tongue blade and see if the patient will gag, 10 would be their ability to
swallow. Can they dry swallow? Speech pathologist may give them a small sip of juice.
Cranial nerve 7 looking for facial paralysis, may ask patient to smile, puff out your cheeks, frown…
Cranial nerve 12 say ahhhhh, stick tongue out and move side to side.
The speech pathologist assesses these things because an alteration or nerve damage, increase this person risk
for aspiration because the patient will have difficulty chewing, swallowing, or coughing. The person may need
rehabilitation, diets they may need-thicken, position of diet-feeding or NG tube.

Nutritional status-assess the patient ability to eat and swallow which is done by the speech pathologist. If
they do not have the ability to eat or swallow it increases the risk of dehydration for them. Assess for s/s of
dehydration.
Psychosocial- this can be major life changing which can lead to a stage of depression because it can affect
financial status and their ability to go to work, they may be worried if they have insurance or do not have
insurance, state of denial and may not want to participate in care.
Diagnostic or Laboratory exam-hemoglobin or hematocrit levels increased, WBC increased, PT/PTT for clots
but will not give a definite diagnosis of a stroke.

Definite diagnosis is CT scan or MRI. They may do a CT scan with contrast, and it has to be done within 30
minutes of arrival. Once the patient arrives you have 10 minutes to perform this assessment, in 30 minutes
they need to be in a CT or MRI. Must get the CT scan within 30 minutes because that will tell us if this is an
ischemic stroke or hemorrhagic stroke which will tell us if the patient is a candidate for fibrinolytic therapy and
if they are we can administer these in order to bust up that clot and open up blood flow if this is an ischemic
stroke. Hemmorrhagic stroke we cannot use fibrinolytic therapy, any patient with s/s or risk factors of
bleeding, use of anticoagulants and so forth we do not give them fibrinolytic damage because we can cause
them further damage and lead them into hemorrhagic shock. These patients are more incline to have a
surgical procedure. Ischemic stroke will get fibrinolytic therapy. The CT scan or MRI will let us know if the
patient is having an aneurysm or if it is an ABM (stay away from fibrinolytic therapies) we don’t want to
rupture or cause a bleed from our treatment and lead into a hemorrahgic stroke. An MRI is more specific and
can tell you more about the ischemic status of the brain. It gives you more detail in terms of anoxia. An MRI
can determine the presence of hemorrhagic/ aneurysms. The patient may have done a carotid ultrasound or a
carotid doppler which is noninvasive they can go in from the side of the neck and do a doppler and they can
decide if the carotid is occluded or not. EKG monitoring because if the brain is dysfunction then the
sympathetic nervous system is altered and they can’t send the signal to the heart which may send the patient
into dysrhythmias and we don’t want them to go into atrial fibrillation because that can be an issue that led to
the stroke.

Analysis: Interpreting

Depending on stroke severity and/or response to immediate management, the priority collaborative problems
for patients with a stroke may include
• Inadequate PERFUSION to the brain
• Decreased MOBILITY and ability to perform ADLs
• Aphasia or dysarthria
• SENSORY PERCEPTION deficits

Planning and Implementation: Responding

• Improve cerebral perfusion

-Fibrinolytic therapy
-Endovascular interventions
• Monitor for increased ICP
• Promote mobility
• Promote effective communication
• Manage changes in sensory perception

Right-sided stroke
• Vision changes
• Changes in spacial awareness
• Cognition
-deficit and vision changes
-depth perception
-sensory
 -confusion
-disorientation
-personality changes
-impulses they can’t control
-may laugh and cry unexpectedly for no reason
• Mobility- if it is a right sided hemisphere then it is going to affect the left side of the body, they may
have left sided hemiplegia or paralysis or left sided hemiparesis (weakness)
• Unilateral inattention syndrome (they are unaware that they can’t move their left arm or that they
have hemiparesis or hemiparalysis.) The perception of distance or depth is greatly altered when they
have a right sided stroke, they may not be able to tell up from down or left from right.
• Eye movement can happen on either side, eye droop, Hemianopsia (blindness in half of the vision
field) harmonious hemonoxia (blindness in either eye)
• Patient may have Left sided blindness

Left sided stroke

• Language analysis
• Math
• Thought processing
• Solving problems
• Dominant side
• Cognition
-aphasia (inability to speak)
-dyslexia (difficulty reading)
-agraphia (can’t write)
-acalculia (can’t determine math)
• Mobility- if the person has a stroke of the left side of the brain then it will affect the right side of the
body, they may have right sided hemiplegia (a condition caused by brain damage or spinal cord injury
that leads to paralysis on one side of the body) or paralysis or right sided hemiparesis (muscle
weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial
muscles.) (weakness)
• Patient may have right sided blindness
• Nystagmus (involuntary eye movement) can occur on either side
• Paresthesia (numbness or tingling sensation) on either side

-Major goal is to identify so that we can go in and treat! The major role as a nurse is to manage the patient
who is receiving this treatment and continually assess for any s/s of increased intracranial pressure.
-Fibrinolytic therapy is for ischemic stroke.
-Managing a stroke for fibrinolytic therapy, first make sure we know the patient is having an ischemic stroke.
We have done an assessment; MRI came back, and we can say this is an ischemic stroke. Ischemic stroke we
will give the patient fibrinolytics, using TPA, alteplase or activase. Should be started 3 to 4 ½ hours of onset of
the stroke, not from the time they came in.
-Fibrinolytic therapy will bust up the clot and it will restore perfusion or blood flow.
-If the patient has a had a stroke or head trauma in the last three months, if they had a hemorrhagic stroke or
a recent MI, if they have increased levels of PT, PTT, or on anticoagulant therapy, or pregnant then they are
not candidates for fibrinolytic therapy.
-If they are 80 years or older, if they been on anticoagulant therapy or evidence of ischemic stroke that
involves a third of the brain, if they have a history of stroke or diabetes, or they rate 25 or more on the stroke
scale they cannot have fibrinolytic therapy. You can go up to 4 ½ hours if the patient does not fall within these
categories. It has to be within 3 hours of onset under these conditions.
May start therapy after MD gives orders, continually assess our patients, continually assess LOC, cognitive
sensation, always assessing every 2-4 hours, constantly checking verbal ability, are they oriented, can they
open their eyes. Checking their pupil size and PERRLA, what is their motor responses. Continually assessing
their blood pressure. Blood pressure may be elevated, the goal is to keep the systolic blood pressure around
140 to 150 because we need to keep just enough pressure to allow for adequate perfusion. We don’t want it
to go above 180 or below 120 just around 140-150 systolic BP.
-Fibrinolytic therapy always assess for s/s of bleeding.
-Once started on this therapy, within the first 72 hours of a stroke there is a risk the patient may have an
increase in ICP because of the edema that occurs. Usually after this incidence the damage occurs, and it can
increase the intracranial pressure. We need to make sure we do not increase this ICP.
-Make sure the patient is maintained on bed rest.
-Make sure we keep this patient head at a neutral position, like straight. We don’t want to flex the hips or the
neck because it can increase intracranial pressure.
-Make sure we allow the patient adequate rest.
-We don’t want to do too many things at one time with them because that can increase stress and increase
intracranial pressure also. Do not cluster care. Give them adequate rest periods.
-Provide a quiet environment, keep the lights low.
-Assess the need for suction be sure to preoxygenate the patient.
-Make sure they get proper oxygenation and proper perfusion to the brain.
-Continuously monitor cardiac assessment, monitor BP-keep it at a certain range, monitor for dysrhythmias
because dysfunction of the brain alters that signal going to the heart controlling that rate and rhythm and it
can lead to new dysrhythmias on the monitor.
-Make sure when we are monitoring the patient to look for any changes so we can report them to the doctor.
-Monitor the patient for vasospasms because they narrow and close up the cerebral artery which can lead to
ischemia, and you will see changes in the level of consciousness, and it can increase neurological deficits.
-We need to assess for s/s of bleeding because of they are getting the fibrinolytic therapy. The patient can
bleed or have a hemorrhagic stroke up to 24 hours after treatment or 7-10 days later after treatment. Any
bleeding in the urine, nose bleeds (epistaxis), bleeding gums, or stool.
-Be mindful of hydrocephalus (increase of cerebrospinal fluid from the enlarged ventricles) which takes up
more space and can lead to more deficits or changes in the LOC, gait disturbances, behavioral changes, lead to
seizures and they often complain of really bad headaches because of that increased pressure because the
patient has increased fluid there.
-Major thing is getting the fibrinolytic then we start maintaining the patient with other medications/ other
drugs to treat other things that could be associated with the stroke.
-They may be placed on anticoagulant therapy after, but you have to wait up to 24-48 hours after treatment.
They may have aspirin or antiplatelet medications, at least 24-48 hours after fibrinolytic. Must wait at least 1-2
days after fibrinolytics then the patient may be placed on aspirin or Plavix to help thin the blood or warfarin or
coumadin if they have atrial fibrillation and the history of clots.
-They may be placed on calcium channel blockers to treat the vasospasms which we do not want because they
cut off blood flow. Put the patient on stool softener, analgesic for pain, antianxiety medication for high anxiety
levels, blood pressure medication.

Drug Therapy

• Thrombolytics
• Anticoagulants
• Lorazepam, other antiepileptics
 • Calcium channel blockers
• Stool softeners
• Analgesics (for pain)
• Antianxiety drugs

Medical Management

• Thrombolytic therapy
• Neuroprotective drugs
• Surgery
-Carotid artery angioplasty with stenting
-Endarterectomy
-Extracranial-intracranial bypass

-When we are treating our patients, we need to prevent any additional complications like pneumonia,
atelectasis, pressure sores.
-Turn them Q2 hours.
-Make sure you collaborate with rehab therapists, nurses, make sure you communicate the patients’ needs
and functional mobility. Can they perform ADLs or not? So, we can know what type of rehabilitation skills
is needed.
-Speech therapist will come in and make sure they can swallow without aspirating and to check those
coronary nerves before we try to give them anything to eat or drink. They will determine if the patient
needs thicken, what type of diet they are on the position and so forth. We want to prevent aspiration.
-Prevent DVTs or VTEs, turn every two hours and ambulate as quick as we can.
-Collaborate with physical therapy, occupational therapy to help them with mobility and ADLs. Patient may
have difficulty with speech so make sure speech therapist come in and we use simple one step commands
other than have the patient do multiple tasks, speak slowly do not yell.
-Do not give them close ended (yes or no) questions because we need them to try to -express themselves.
-Use alternative forms of communication, white board, computer, handheld device, flash cards, etc. based
on patient’s needs.
-Match the patient sensory perception, they can experience a change in vision, sensation, proprioceptive
or position which can increase the risk for fall.
-They may have decreased mobility, hemiparesis, hemaplasia, vision and sensation changes, sense of
positioning, unilateral neglect syndrome happens with right side stroke when they don’t realize they can’t
do things as before which can all increase the risk for fall.
-Help the patient adapt to this disability, break the task down, always help the patient do things on the
unaffected side (strong side).
-Loss of vision in one or both eyes also place the patient at risk for falls so teach the patient to turn their
head from side to side so they can have a whole visual field especially when they are eating and
ambulating.
-Teach the patient to try to use both sides of the body to gain awareness.
-When dressing teach the patient to dress the affected side first because they can use the strong hand to
put clothes on the weak side.
-Left sided stroke (reasoning, math, reading, writing, problem solving) - assist the patient with problem
solving, reorient them as much as possible, establish a routine, try to keep directions as concise and simple as
possible.

Care Coordination and Transition Management

 • Home care management
-Safety (unilateral neglect)
-Emotional support
• Self-management education
-F.A.S.T. pneumonic
• Health care resources

-Get case manager involved to help coordinate the plans for the patient to help identify or make any
suggestions to fix the home to make it more capable or safe for the patient.
-Ensure that there are family members there to help support the patient.
-Make sure that the patient and family can use the adaptive devices and equipment placed in the home.
-Make appointments for follow ups.
-Perform good patient teaching about medication use.
-Teach them about safety when it comes to motor abilities like how to safely transfer from bed to chair or how
to get out of the car, walk upstairs, how to use walker, wheelchair, or cane.
-Teach them how to use safety precautions, removing rugs.
-Discuss the reality of depression because it is an increased risk of morbidity and mortality especially in older
men because they just give up.
-Teach the family not to be overprotective, set goals and let the patient try to do them.
-Teach the patient and family about the FAST pneumonic!
-Teach them about the s/s of what it would look like if they had another stroke and when to call!

Traumatic brain injury

Anything that can cause an increase or damage to the brain tissue is of concern because the brain is very
fragile tissue, and it is prone to injury.

Brain injury
• Blow or jolt to the head
• May be result of head penetration by foreign object
• Indirect injury if you were thrown or thrust forward you slung your head back forcefully which can
cause contusions of the brain even though it was not directly. The body was hit but it causes the head
to sling backwards which can cause injury to the head.
• TBI are most common in young men
• Top causes falls and MVA or MVA as a result of drugs or alcohol.

Shearing injuries lead to anoxic or lack of oxygen especially if the brain stem is twisted or rotated. The brain
can be bruised, contused, torn, or lacerated as it moves across the cranium or if you have an open fracture.

Acceleration- external force comes in contact (direct hit to the head)

Deceleration- you run into something and hit your head. Car accident your car suddenly stops and you hit your
head on the dashboard.

Brain injury can be primary or secondary.

Primary brain injury (there is a specific spot on the brain that is injured or it can be diffuse where you have
multiple areas that was injured or contused, lacerated, etc.)
• Open versus closed head injuries
 • Mild, moderate, severe classification
• Fractures
We do a ct scan or MRI to see if there was multiple areas on the brain that has been injured.
They are either closed or open.
Open- the brain tissue is exposed
Closed-skull is still intact

Secondary brain injury (comes

• Any processes that can occur after the initial injury and worsen patient outcomes
• Damage occurs because the delivery of oxygen and glucose to the brain is interrupted
• Examples: intracranial hypertension, cerebral edema.

Vasogenic edema: abnormal permeability of those vessels inside the brain.