yeah all right I'll I'll skip over the gas exchange I'll continue with newer of course that way we we finish all the Nero and then we'll end with respiratory um or ischemic stroke you still remember what you did for outer place yes all right so recognizing signs and symptoms so how do you differentiate between ischemic and hemorrhagic stroke and then for ischemic there are two types we have thrombotic and embolic stroke a little bit oh I got the delegation okay let's start over so what is your guide again for delegation how do you know which one you can delegate we always delegate what task okay only a task a skill okay um can you ever delegate a cognitive action like assessment an intervention education and evaluation no but can you delegate a task yes yes you can delegate a skill whenever you do that though make sure the the the delegate he is competent in doing this skill all right so let's say I ask you to choose between you have an LPN because we still have LPNs and between a CNA and LPN so who would you give what to Vital Signs who would you give that to giving meds who oral meds okay all right so things like that okay so always give the the easier task to a an unlicensed a personnel concern about stroke is always the feeding correct when whenever you delegate right because we can we delegate feeding yes well depends if this is the first time this patient is eating no can you delegate it should you delegate it you're very good children so the patient must be stable okay before you even decide to delegate anything correct so we are not the experts the doctors are not the experts either who's the expert the speech language pathologist is the expert and that person will decide whether or not the patient is going to be fed all right so they decide to die classical comma scale we did this in lab you okay and the all right those is calculation what do you think this will be on it could be CPP it could be out the place sorry are you going to put it on the example go after me didn't put any which one the dosage population yeah but I don't you know I don't do um many doses questions anymore because again the NCLEX won't ask you much yeah yes I could be both could be either I don't know because I don't know which version you're getting of the tests either orange yeah remember when I tested you on the Parkland formula for burns okay so some of you did not read the question carefully so let's say I give you a question on the on auto place be careful what the question is asking so if it's asking for the 10 because the initial dose is 10 correct so what's the rate for that one so you know the what's the dose again how do you calculate out the place 0.9 verbs kilograms okay per kilogram that's your total and then how much do you how do you give that okay first ten percent over one minute the remaining 90 over one hour so be careful what the question is asking is it asking for the infusion rate for the bolus or the infusion rate for the 90 percent or is it asking for the dose or is it asking about how much you waste okay signs and symptoms and management for each type of stroke so signs and symptoms of ischemic does it matter whether it's thrombotic or embolic no because the ischemic stroke is the same okay but the risk factors do they vary yes there are different risk factors for thrombotic there are different risk factors for embolic what would be risk factors for thrombotic stroke what's the root cause of all of these for well thoughts yeah so how did this patient Adderall sclerosis right the patient had osteosclerosis and then it narrowed the artery of either the Carotid or cerebral artery and then form a blood clot okay what about embolic stroke what is the majority of these patients what do they have usually a cardiac issue give me examples of those cardiac issues what else remember you know what would cause a clot to form in the heart so what else is wrong with the patient but anyway um well an Emma is caused also by a clot but um could it be a heart failure are you dead I'm sorry what about um valve disorders okay so basically anything that will cause congestion inside the heart caused either by electrical conduction problem a structural problem Etc indications and contraindications for outer place where did you find this yeah well I mean where so the indications yeah indication so who gets it what type of stroke ischemic stroke okay foreign who gets it indication first so that's indication so definitely it's okay so we have that here so the American stroke Association advocated though that we can extend it up to so three to four and a half hours with a few exceptions to the to the extension okay if the patient misses the three to four and a half hours what do we do now okay intra arterial the doctor has to administer it in the cat lab no it depends again so so IV outer place is given within what time period two okay correct intra-arterial when can we give that Beyond yeah they missed the window they missed the three to four and a half window but they're still within six hours so we still have one more shot so patient goes to the cath lab doctor administers it intra arterially okay okay so for contraindications because we know the indications you have your entire chart 62-2 but your contraindications are the following so you miss the three to four and a half hours we still do three to four and a half hours because there are exceptions to the extension I mentioned this in class right so what are those four exceptions the patient is too old over 80 years old and then next is you said okay both diabetic and had a stroke history already and then the third is the NIH Stroke Scale is too high yeah 25 25 or high and then finally um the CAT scan shows that it's more than a third of the more than a third of the middle cerebral artery is involved meaning majority of the brain has already been um you know infected I mean there's no point for extending the the period to four and a half hours meaning if the patient meets those four older than 80 um I NIH Stroke Scale 25 or higher at history of stroke and diabetes and um what I said thank you so much yeah more than a third of the middle cerebral artery another contraindication for outer place was anticoagulation on attack violation and the inrs above 1.7 some doctors because there are two types of contraindications it's relative and absolute what's the difference between when you say relative versus absolutely contradicated okay so the doctor makes the call it can be as you mentioned here some of them can be relative right here some of these are relative contraindication the proprietor needs to weigh the risks and benefits of therapy okay so that's not our call though doctor will decide okay whether or not the patient can still benefit from it but there are of course absolute contraindications meaning uh like here so therefore if it says no infective endocarditis so if they have endocarditis and they get out of the place no here they have a history of bleeding can they get out of the place they had a history of subarachnoid hemorrhage no they had these within that within the last three months no okay do you understand or they are they have gi bleeding in the past three weeks okay so these are absolute contraindications the rest of it can be relative the doctor makes the call but again that's not our concern because we're not the doctors so Auto Place Administration you guys did that what are the vascular management so this is referring to the endovascular therapy here post-op care for these because the patient had a surgical intervention so anyone with who is post-op do they have different complications so right so are these patients at risk for dvts are they address for partial ulcers because this is a manipulation of the either the well mostly when they say endovascular it's referring to the um carotids either left or right carotid artery so what could happen during the procedure another stroke and don't forget management will of course include the risk factor management correct first can you get rid of the diabetes can you get rid of the hypertension and you get rid of the activerosclerosis okay so therefore your management will include management of those perspectives and they stop smoking what do we do for the antiverse sclerosis okay so that's all mentioned here and because hypertension is one of your risk factors so are they on the same antihypertensives as we discussed in heart failure don't forget the anti-thrombic therapy which is what are those two antiatrombics meaning when you say anti-trombics they're really saying anti-platelets so they are aspirin Clopidogrel very good children so that's surgical management and your responsibilities complications after stroke what could happen because now you have a patient who has left or right facial group now part of the tongue the entire life and what could happen Okay aspiration so aspiration Is frequent within the first six to nine months after a stroke uh usually it occurs in the rehab facility or at home did we discuss the Supra versus infrared tutorial let me see [Music] uh you can disregard that because this edition of the textbook don't have the difference anymore let me just describe what it is for the NCLEX purposes when we say the this is referring to the tentorium the tentorium is a spine so have you ever ever seen the inside of a skull maybe we have some models here so you know just observe it at the level of the ear there's a spine that looks like this right here at the level of the ear so so it's not all a smooth inside your skull so there's a spine that occurs up to here so it's shaped like this it separates the upper and the lower parts of the brain now if it's above that tentorium we call it Supra tentorial region and then of course below it is the infra-tentorial region now uh right here well that is just the brain so this doesn't show this the skull but if this was inside the skull so it would be right here so if the surgical uh incision is above the tentorium versus below the tentorium so if it's above we usually position the patient with 30 degree head of the bed elevation okay but still the same the patient is at risk for increased ICP correct because they had trauma to the brain with um because of the surgery so if it's above the tentorium the patient will be 30 degrees elevation you can still turn them side to side but if it's if it's uh infra tutorial the patient will be flat are we clear flap on that right it has something to do with the drainage of the because there will be drainage correct after you have surgery yeah because you you manipulated the brain so there will be bleeding so both will have a drain but then the positioning would be different it's super tentorial you elevate the head of the bed but if it's infra below the tentorium the incision is here patients should be flat don't worry there's no it's not there's no mention in the 15th Edition anymore so we just focus on the posts not going into Supra correct so what are the drugs we routinely give to these patients after craniectomy or craniotomy so after brain surgery diuretics what else thank you yeah that's either or okay so so which one oh steroids that what what what uh steroid is that dexamethasone only okay so we have diuretics which is Mannitol and then dexamethasone what else do we give anything else it's a surgical procedure so invasive antibiotics okay and then because there's increased ICP their accurate score so anti-seizures which one is that again we use levitaracetam and then finally number five is this a stressful event for the patient and what will there be okay PPI or H2 receptor blockers so what are those five drugs again routinely given to post craniotomy patients foreign uh depends yes what are you getting it um oh yeah yeah if that's the difference hey Emergency Management so this is again our episode I guess there's two questions on it uh drug therapy is it different from the craniotomy because after craniotomy the patient undergo did they sustain Trauma from brain surgery so is the drug management different after TBI exactly the same as far as the whether or not the patient receives antibiotics what type of head injury would likely receive antibiotics open so if the patient has an open open skull injury in an open fracture had a skull Factor then yes so what are the risk factors of stroke again we mentioned a few earlier so don't be just stuck with the other sclerosis remember there are many other risk factors including ethnicity okay ethnicity diabetes hypertension right so there's there are both modifiable and non-modifiable risk factors don't forget about age and the pathophysiology for each between ischemic which is thrombotic embolic and then hemorrhagic stroke prevention of course is managing the risk factors or taking especially if they had a TIA can they be placed on aspirin Plavix now yes and then teaching a course that would include the social or lifestyle modifications you know stop smoking and then the drug therapy as already mentioned so that includes the anti-hypertensives this is what is pathophysiology okay what happened so in stroke what is the pathophysiology okay salon right yeah ischemic it's caused by a plot how did that plot get there okay and then now there's a difference between thrombotic and anabolic then for hemorrhagic stroke what are the three risk factors most common risk factors for hemorrhagic stroke hypertension we should specify uncontrolled hypertension or untreated and then what's the other two aneurysms and finally MVA it got the acronyms the letters MVA is motor vehicle accidents AVM what is AVM uh so this one's a duplicate again difference between managing ischemic versus human rights stroke what's the management for ischemic stroke we give what out the place what's the management for hemorrhagic stroke okay here's now Aphasia please take note the difference those terms used in the chapter in a facial what are how many aphasis did the textbook mention three we have mix mix or Global that's the same so mix they have both expressive and receptive efficient what's the difference between that and dysartria is okay it's a tongue you know it's a speech it's a motor problem but do they have any problem with written communication no they can okay that's the main difference we say Aphasia it's a it's a brain issue okay they cannot express both written or verbal okay so they cannot express and or they cannot understand this art fair is simply a motor so do they have problems with texting no they can text they can write they can type okay you saw um top gun Maverick right so what did what did um Iceman have Iceman had a fascia or dysarthria this artery if they don't watch it so I'm guessing yeah because um yes because Iceman was typing his responses do something that's right so the book was specific about how to communicate okay was there a chart I think there was a chart so make sure you read the chart it was very specific about how you communicate and what what you can use and how right for and they separated it from expressive and receptive the sensory motor deficits just one or two questions on this so what are those again so we talked about uh agnosia so what is agnosia is this a butterfly recognize an object apraxia so can we repeat that because everybody said at the same time and I would not know what anyone said agnosia and um [Music] okay so here so let's start with the notion and ability to recognize objects it could be visual auditory or tactile meaning you give them something do they know what it is so therefore they don't know what it is do they know how to use it no no but remember again it could be visual auditory or tactile uh what about apraxia so when we say apraxia it is a you're asking them to because it's inability to perform so therefore is this a motor task yes so you're trying to ask them to do something okay so that's approximate they can't do that let's say sing do you know how to sing Happy Birthday yes everybody should know that right yeah so can they do this well if you have a proxy so here's the for communication say we have dysartia Aphasia and apraxia we can't speak anything oh I'm not familiar with sisters I really observe rehab ility one there oh so for a visual here's hemianopsia this is very common in stroke patients what is it when it says homonymous hemiannopsis right okay so the same half of each eye okay this homonymous meaning the same side Hemi anopsia blind in one half of the visual field and it says homonymous the same side so that means the left half of each eye is blind or the the right half of each eye is blind that's homonymous Hemi anopsis so here's the ignosia and here are your interventions see the movement yeah so it includes nursing management so that means it includes the table say a table Yeah so table 62-2 because it includes nursing management I think management is your third column you have to turn on Wi-Fi and connect to a network all right any questions so it's this should cover let's see if there's apraxia here well there's a taxi no not all so table 62-2 is a combination of visual and motor and sensor region and verbal is also there so here are your of course this is not the I think there's also some mentioned in the paragraph correct about a patient so it's well this would be included in this one what is new unilateral neglect so let's say the patient has left hemiplegia or head left hemiparesis Paris is weakness paralysis so for let's say left paraplegia uh sorry left hemiplegia hemiplegia that means can they spill or do anything on that side so that starts from the face correct so from here the eye the eyelid um the face the jaw on that side and that part of the tongue right there all the way to the toes okay cannot be they cannot feel or move it so what happens to that side okay so we call that neglect and is that prone to injury now okay so remember includes the mouth also so take time to examine the mucosa and psychosocial changes you can just stick with the there are emotional here mentioned right here so emotional deficits so that would be that would still fall under psychosocial and these are your interventions for them they take note that does the patient have control over these no no control so these are your interventions so support is very important and then educate the family tell them why in a patients acting like this take note that here it says here control stressful situations if possible if possible but basically just provide a safe environment for these patients so that's the psychosocial uh Joint Commission stroke core measures let me it's a different let me just show you on a different textbook okay um it'll be for the NCLEX especially