General Q's of SCRN
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| What areas does the ACA feed? (i.e. lobes and/or structures) | Medial portion of the frontal and parietal lobes ("mohawk"); corpus callosum
🗑
|
||||
| What areas does the MCA feed? (i.e. lobes and/or structures) | Majority of the frontal, parietal, temporal lobes; the basal ganglia, internal capsule, as well as Broca's and Werneckies Area
🗑
|
||||
| What areas does the PCA feed?(i.e. lobes and/or structures) | Occipital lobe, midbrain, THALAMUS, pineal gland
🗑
|
||||
| What are the major S/S of MCA stroke? | Contralateral hemiplegia, contralateral hemianesthesia, Arm weaker than leg, face droopy, eye deviation towards side of lesion, contralateral homonymous hemianopia, if DOMINANT SIDE, global aphasia, if NON-DOMINANT, anogsagnosia
🗑
|
||||
| What are the major S/S of ACA stroke? | Contralateral motor deficits (some/few sensory), Foot & leg weaker than arm, face and tongue usually spared, abulia (decreased activity and speech), emotionally labile
🗑
|
||||
| What are the major S/S of PCA stroke? | Depends heavily on portion occluded; on DOMINANT HEMISPHERE: alexia (inability to see words/read) with or without agraphia (inability to write), visual agnosia (inability to interpret sensation or recognize things); NON-DOMINANT HEMISPHERE: neglect on con
🗑
|
||||
| What are the major S/S of a lateral Thalamic stroke? | Hemiparesthesia, followed by isolated hemisensory deficit in face, arm, & leg, may include trunk, pain may develop resistant to treatment; can also have abnormal movements (inability to stand or walk--thalamic astasia); hyper-reflexive tendons, babinski
🗑
|
||||
| What are the major S/S of basal ganglia strokes? | Cognition & behavior, memory dysfunction, dysarthria, aphasia, motor abnormalities, if on (L), verbal amnesia, if on (R), visual amnesia
🗑
|
||||
| Is ASA recommended for a patient in A-Fib already on Warfarin? | Only if history of CAD, especially if they have stents
🗑
|
||||
| What is the target INR for stroke prevention? | 2.5
🗑
|
||||
| What is the target LDL after stroke? (Which would indicate initiation of statin therapy) | 100
🗑
|
||||
| What is the target blood pressure AFTER stroke or TIA (secondary prevention)? | 140/90
🗑
|
||||
| What cranial nerves originate from the medulla? | Cranial nerves 9-12
🗑
|
||||
| What cranial nerves originate from the midbrain? | Cranial nerves 3-4
🗑
|
||||
| What crania nerves originate from the pons? | Cranial nerves 5-8
🗑
|
||||
| What are the S/S of carotid dissection? | ptosis, myosis (pupillary constriction), and anhidrosis---known as Horner's syndrome
🗑
|
||||
| What "important feature" does the internal capsule possess? | Nerve tract for the motor cortex
🗑
|
||||
| What important "pathways" does the thalamus contain? | Nearly ALL sensory pathways coming from the cerebral cortex
🗑
|
||||
| Regarding LOC, what can a stroke cause if the thalamus is infarcted? | Hyper-somnolence
🗑
|
||||
| What can a stroke in the hypothalamus disturb? | BODY TEMPERATURE ;
also (but less prolific), affect circadian rhythm and body H20/osmo
🗑
|
||||
| What is Broca's aphasia? | Speech is 'broken,' otherwise, expressive aphasia
🗑
|
||||
| Where is Broca's area located? | Posterior aspect of frontal lobe
🗑
|
||||
| What is Werneckies aphasia? | 'What?'; otherwise, receptive aphasia
🗑
|
||||
| Where is Werneckies area located? | At the temporo-parietal junction
🗑
|
||||
| If a patient is experiencing hallucinations (but is aware of them not being real), what structure of brain is most likely being infarcted? | Midbrain
🗑
|
||||
| When is treatment for carotid stenosis considered? | Stenosis >50% and symptomatic
🗑
|
||||
| Where is the tip of a ventricular drain placed within the skull? | At the Foramen of Monro (a 'channel' that lies between the lateral ventricles and the third ventricle)
🗑
|
||||
| What is the Cerebral Amyloid Angiopathy (CAA)? | Disorder in which protein deposits in brain damage vessels, causing micro hemorrhages--and important risk factor for ICH!!
🗑
|
||||
| What medication should be avoided in patients with Cerebral Amyloid Angiopathy? | Statins
🗑
|
||||
| What is the best diagnostic tool for SAH? | NECT (Non-contrast CT)
🗑
|
||||
| What are the nursing considerations before/after cerebral angiography? | Before: NPO 4-6hrs, PT/INR, allergies to shellfish/iodine, consent
After: Bedrest 6hrs, HOB only to 30 degrees, assess for bleeding/circulation, avoid flexing & hyper flexing affected extremity for 12-24hrs, liberal fluid intake
🗑
|
||||
| What is the gold standard for diagnosing vascular deformities? (such as AVM's, aneurysms, fistulas, dissections) | Cerebral Angiography
🗑
|
||||
| What is the advantage of MRI's? | More sensitive than NECT for ischemic strokes
🗑
|
||||
| What is digital subtraction angiography (DSA) used for? Particularly, what is it "best" at detecting? | DSA helps visualize vascular lesions and atherosclerotic disease;
it is #1 to detect hight grade STENOSIS
🗑
|
||||
| What is TCD used for? | Identifies intracranial vessel abnormalities, occlusions, and stenosis;
Effective to determine VASOSPASM!
🗑
|
||||
| What is the gold standard diagnostic for vasculitis? | biopsy
🗑
|
||||
| What would be the characteristics of CSF after an LP that would indicate SAH? | rusty appearance (related to xanthrocrome, a by-product of Hgb breakdown, which is seen 4-6hrs after bleed, and up yo 3-6 days after)
🗑
|
||||
| In an echocardiogram, what does a bubble study help detect? | PFO (patent foramen ovale)
🗑
|
||||
| What is the target SpO2 in stroke patients? | Above 94%
🗑
|
||||
| What is desired EMS arrival time to possible stroke patient? | Under 8 minutes, an to ER in 15min
🗑
|
||||
| What are the three structures of the brain stem (in order)? | Midbrain, Pons, Medulla (descending order)
🗑
|
||||
| What are the structures of the basal ganglia? | Caudate nucleus, Putamen, Globus pallidus
🗑
|
||||
| What are the structures of the diencephalon? | -Thalamus (sensory pathways),
-Hypothalamus (visual pathways, body temp, H20/Osmo control)
-Pituitary gland (multiple hormone)
-Pineal gland (sleep wake cycles)
🗑
|
||||
| What are the structures of the limbic system? | -Hypothalamus (h20 and body temp)
-Amygdala (stress & emotion control, "enhancer")
-Cingulate Gyrus (emotions & ecoding memory)
-Hippocampus (memory & learning--short term)
🗑
|
||||
| Are strokes more prevalent in men or women? | More prevalent in males, except for ages 35-44 (related to OC use), and greater than 85 (women live longer)
🗑
|
||||
| Does family history of stroke affect one's risk? | Increases risk by approximately 30%
🗑
|
||||
| What is the #1 modifiable risk factor for preventing both ischemic and hemorrhagic stroke? | Hypertension
🗑
|
||||
| How much does smoking increase stroke risk? | Doubles risk
🗑
|
||||
| Having D.M increases stroke risk by how much? | 2-6x times risk (varies greatly in studies)
🗑
|
||||
| What is the target A1c for stroke patients? | Less than 7
🗑
|
||||
| Having A-Fib increasing stroke risk by how much? | 4-5x times risk; strokes usually larger
🗑
|
||||
| What are ICH risk factors? | HTN (#1), race (hispanic, black), sex (male), age
🗑
|
||||
| Are D.M are smoking risk factors for ICH? | Yes, but very weak, in comparison to ischemic
🗑
|
||||
| What are SAH risk factors? | Smoking (#1), ETOH, HTN, family history, sex (women, men only after 50 more prevalent), race (blacks)
🗑
|
||||
| Approximately how many neurons are lost every minute in large strokes? | 1.9million!
🗑
|
||||
| What is the most important 'patient history' information for EMC crews to attain from a suspected stroke patient? | Last time seen normal
🗑
|
||||
| What is the goal time for stroke patient to see MD? | 10min
🗑
|
||||
| What is the goal time for stroke patient to see stroke team? | 15min
🗑
|
||||
| What is the goal time for stroke patient to get to CT scan? | 25min
🗑
|
||||
| What is the goal time for stroke patient to get CT scan interpreted/read? | 45min
🗑
|
||||
| What is the goal time for patient to get TpA? | 60min
🗑
|
||||
| What will appear white (hyperdense) in a CT scan? | Bone, calcium deposits, blood (acute)
🗑
|
||||
| What will appear dark gray (hypodense) in CT scan? | CSF, edema, fat, infarcted tissue, blood (chronic)
🗑
|
||||
| What will appear black in CT scan? | Air
🗑
|
||||
| How long does it take for infarcted tissue to appear on a CT scan? | Approximately 6-8hrs
🗑
|
||||
| Is CT or MRI better for diagnosis of SAH? | CT scan
🗑
|
||||
| How long does it take for blood to appear on a CT scan? | Immediately
🗑
|
||||
| What is considered the acute phase of an ischemic stroke? | 24-72hrs
🗑
|
||||
| What is considered the acute phase of ICH an SAH? | Admit through discharge
🗑
|
||||
| What is one of the drawbacks of the NIH? | It does not account for posterior circulation stroke symptoms
🗑
|
||||
| If a patient has a NIH score of 14 or more, where can you anticipate he or she will be discharged to? | SNF
🗑
|
||||
| If a patient has a NIH of 6-13, where can you anticipate he or she will be discharged to? | Inpatient rehab
🗑
|
||||
| If a patient has a NIH of 5 or less, where can you anticipate he or she will be discharged to? | Home
🗑
|
||||
| What percentage of stroke patients will deteriorate in the fist 1-2days? | 25%
🗑
|
||||
| What is the ideal blood glucose for an ischemic stroke patient? | It is of DEBATE, yet current consensus is a GOAL of 140-180mg/dL
🗑
|
||||
| What is the ideal blood glucose for an ICH stroke patient? | It is of DEBATE, yet current consensus is a GOAL of 140-180mg/dL
🗑
|
||||
| What is the ideal blood glucose for a SAH stroke patient? | NO ideal glucose set; yet, research has shown glucose greater than 105mg/dL in first 10 days is associated with multi-organ dysfunction
🗑
|
||||
| What is one of the leading causes of epilepsy in the older population? | Ischemic stroke
🗑
|
||||
| Is prophylactic seizure medication recommended for strokes? | ONLY for SAH and for a short term (3-7days)
🗑
|
||||
| Seizure is more likely if a patient suffers a stroke in what areas of the brain? | temporal lobe or cerebral cortex
🗑
|
||||
| What percentage of stroke patients will get a UTI within 1month? | 25%
🗑
|
||||
| What percentage of stroke patients will get PNA (pneumonia)? | 50% in ICU and stroke unit, and up to 11% in post-acute rehab
🗑
|
||||
| What is the rate of urinary incontinence in stoke patients? | 60%
🗑
|
||||
| When can heparin safely be started as DVT prophylaxis of ICH and SAH patient? | After 24-48hrs, given hemorrhage is stable
🗑
|
||||
| What is considered ideal for chemical DVT prophylaxis--Lovenox or heparin? | Controversial, currently no 'ideal'
🗑
|
||||
| When can warfarin be safely restarted in a stroke patient? | Of debate, current practice is 10-14 DAYS, longer in larger strokes
🗑
|
||||
| What are the major functions of the parietal lobe? | Cortex for sensation in front; speech and language (Werneckies area there)
🗑
|
||||
| What are the major functions of the occipital lobe? | vision; visual cortex
🗑
|
||||
| What are the major functions of the temporal lobe? | visual memory, language comprehension, auditory processing
🗑
|
||||
| Strokes in what area can leave deficits on both 'sides' of the body? | Brain stem strokes (cerebellar strokes can have ipsilateral deficits too)
🗑
|
||||
| What are the major signs/symptoms of a lateral medulla (medullary) stroke? | Wallenberg syndrom, N/V, dysphagia, sensory loss (contralateral limbs and body, ipsilateral face), Horner's syndrome
🗑
|
||||
| What are the major signs/symptoms of a medial medulla (medullary) stroke? | Contralateral hemiparesis sparing face, ataxia, diplopia, H/A, vertigo
🗑
|
||||
| What are the major signs/symptoms of a cerebellar stroke? | Vertigo, vomiting, tinnitus, dysarthria, can have facial palsy, auditory loss, ataxia, Horner's syndrome
🗑
|
||||
| What are the major signs/symptoms of a pons (pontine) stroke? | Hemiparesis, cerebellar symptoms; Lacunar syndromes --> pure motor hemiparesis, transient dizziness, diplopia, nystagmus, dysarthria, dysphagia, ataxic hemiparesis
🗑
|
||||
| What are the major functions of the frontal lobe? | Behavior/emotions, contains motor cortex in posterior aspect; Broca's area (expressive aphasia)
🗑
|
||||
| What are major signs/symptoms of midbrain strokes? | 3rd nerve palsies (Weber's, Claude's, Benedikts); locked in syndrome, Ataxia, Upward and/or downward gaze palsies, pendicular hallucinosis (hallucinations depiste pt. knowing they are not real)
🗑
|
||||
| What is the only FDA approved Rx for acute stroke? | TPA; approved for up to 3hrs, yet endorsed for up to 4.5hrs (yet more restrictive)
🗑
|
||||
| What is the usual TpA dose? | 0.9mg/kg to a max dose of 90mg
🗑
|
||||
| At what rate is tPA administered? | 10% as a bolus over a minute, remainder over 60min
🗑
|
||||
| What should you do/anticipate if a patient has a decline in neurological status during an TPA infusion? | Stop TPA, notify MD, anticipate STAT CT--there are no standardized measures to treat patient if they have indeed bled post TPA--cryoprecipitate and/or platelets can be considered
🗑
|
||||
| What are the major S/S of a medial thalamic stroke? | CLASSIC TRIAD: Acute decreased LOC (abulia, apathy, hyper-somnolence), Neuropsychological Amnesia (disoriented, aphasia if on [L], Neglect if on [R], difficulty with new memories), Vertical Up-gaze palsies
🗑
|
||||
| What can carotid bruit indicate? | Carotid dissection
🗑
|
||||
| What can Olser nodes and Janeway lesions indicate? | Osler nodes and Janeway lesions are nodes/ulcerations on hands and feet (osler nodes are painful) that indicate INFECTIVE ENDOCARDITIS--a big risk factor for stroke
🗑
|
||||
| What is the mainstay treatment for vasculitis? | STEROIDS mainline, can consider immunosuppressants
🗑
|
||||
| What is normal CPP (Cerebral Perfusion Pressure)? | 70-90mm/hg (some say up to 150mm/hg)
🗑
|
||||
| What is the treatment for cocaine induced hypertension? | Cardene
🗑
|
||||
| What is the best position to 'place' a patient? | On the affected side
🗑
|
||||
| What is normal ICP (intracranial pressure)? | 5-15mmHg (greater than 20 is considered 'increased')
🗑
|
||||
| What is the first line treatment to reduce ICP (intracranial pressure)? | MANNITOL to reduce cerebral edema (can also consider hypertonic saline, ventricular drains, decompresive surgery, mild hypocarbbia [hyperventilation to reduce CO2, which vasodilates])
🗑
|
||||
| What is normal CO2? | 30-35mmHg
🗑
|
||||
| Are steroids recommended to reduce ICP (intracranial pressure)? | NO, not recommended
🗑
|
||||
| What is the duration of aspirin in human body? | 5-7 days, which is the same as the life of platelets themselves (therefore, considered irreversible)
🗑
|
||||
| What is the duration of Plavix in human body? | 5-7 days, which is the same as the life of platelets themselves (therefore, considered irreversible)
🗑
|
||||
| Are Brilanta and Effient ideal for secondary stroke prevention? | NO, considered only if Plavix is ineffective as demonstrated by PY12 tests
🗑
|
||||
| What is the half-life of Warfarin? What is the onset? | Onset = 48-120hrs,
Half Life = 20-60 hours
🗑
|
||||
| Are novel anticoagulants (Pradaxa, Eliquids, Xarelto) indicated for A-FIB CAUSED by a HEART VALVE ISSUE? | No! Can actually increase risk of stroke
🗑
|
||||
| Orolingual angiodema is a potential side effect of what drug? | tPA administration, ESPECIALLY if on an ACE-inhibitor
🗑
|
||||
| What should BP be BEFORE starting tPA? What about DURING & AFTER tPA? | BEFORE = 185/110
DURING & AFTER = 180/105
🗑
|
||||
| How often should vitals be checked during tPA infusion? | q15min for 2hrs
q30min for 6hrs
q60min for 16hrs
🗑
|
||||
| How long does TPA remain in body? | 80% of TPA is eliminated in 10min, the remainder is eliminated in about 24hrs
🗑
|
||||
| What are exclusion criteria for patients with stroke in the 3 - 4.5 hr window? (note, not 3hr exclusion, but the 'extended' window exclusions) | -Over 80yrs old
-Pt. on anticoagulant therapy (regardless of INR)
-NIH greater than 25
-Patients with history of stroke AND diabetes
🗑
|
||||
| What are the most common sites of ICH (intracerebral hemorrhage)? | #1 BASAL GANGLIA, #2 is thalamus
🗑
|
||||
| A stroke in what area can cause ipsilateral 'drunk-like' motor dysfunction? | Stroke in the cerebellum
🗑
|
||||
| Basilar artery syndrome is also known as what? | Locked-in syndrome
🗑
|
||||
| What is the most easily modifiable risk factor for stroke? | Atrial fibrillation
🗑
|
||||
| What is the 'threshold' GCS score that would indicate a need for intubation? | GCS of 8 or less
🗑
|
||||
| If a patient is not a candidate for tPA, what are the BP goals? | Only treat if higher than 220/120; after 24hr period, we can begin to decrease BP by 10-15%
🗑
|
||||
| What is the "goal" of TPA and all other interventions? | Re-establish blood flow and save the penumbra
🗑
|
||||
| When and for how long should nimodopine be started on a SAH patient? | Day 1-21
🗑
|
||||
| What is the usual dose of nimodopine to prevent vasospasm? | 60mg q4h for 21 days (may do 30mg q2h if patient becomes hypotensive)
🗑
|
||||
| What does nimodopine do? | DECREASES INCIDENCE/prevents vasospasm, DOES NOT TREAT IT
🗑
|
||||
| Besides testing for vasospasm, what does TCD help identify? | Lets us know if a stroke was cardioembolic (from heart) or thrombotic (from cranial arteries)
🗑
|
||||
| What is the gold standard for recognizing cavernous malformations? | MRI/MRA with gradient echo
🗑
|
||||
| When should LP be considered for SAH diagnosis? | ONLY when SAH cannot be diagnosed wit CT
🗑
|
||||
| What is constraint-induced movement therapy (CIMT)? | Retraining the 'good' arm of the patient to "force them" to use the affected (weaker) side.
ONLY USE WITH ARMS--IF USED IN LOWER EXT, CAN CAUSE FALLS!
🗑
|
||||
| What does a patient need to 'have' to qualify for an Acute In-Patiet Rehab? | Tolerate 3hrs of therapy 5 days a week, need two or more disciplines (OT/ST/PT), be medically stable
🗑
|
||||
| When is the peak incidence of vasospasm after SAH? | Day 7-10 are peak incidence (but lasts up to 21days)
🗑
|
||||
| What is Moyamoya disease? | A chronic, vaso-occlusive disease that leads to narrowing and eventual occlusion of the internal carotids and branching vessels. It is very prominent in YOUNG ASIAN WOMEN.
🗑
|
||||
| How is Moyamoya disease treated? | Generally supportive treatment, such as anticoagulation/anti-platelet, surgical revascularization procedures if needed
🗑
|
||||
| What is central venous thrombosis (CVT)? How is it treated? | CVT is a rare type of stroke in which a clot forms in the dural sinuses or the cerebral veins.
It is treated with acute anticoagulation, start with hep. drip, then oral for a few months; closely monitored
🗑
|
||||
| What is the standard treatment for arterial dissections? | Anticoagulation!!! Consider stenting
🗑
|
||||
| What is the standard treatment for AVM's? | BP management, surgical resection, embolization
🗑
|
||||
| How many stroke core measures are there? | 8!
VTE prophylaxis, d/c on antithrombotic, anticoagulation for Afib, TPA, antithrombotic by end of hospital day 2, d/c on statin, stroke education, assess for rehab)
🗑
|
||||
| What causes non-obstructive (communicating) hydrocephalus? | lack of CSF absorption
🗑
|
||||
| What causes obstructive (non-communicating) hydrocephalus? | Narrowing of canals that carry CSF, leading to obstruction
🗑
|
||||
| What is the penumbra? | Brain cells next to the 'core,' which are damaged but not infarcted. Silent but metabolically active
🗑
|
||||
| Cell death (after hypoxia) occurs via what two mechanisms? | NECROTIC pathway (cells die due to lack of O2 and sugar) and APOPTOTIC pathway (cells die due to 'programmed' death since the one's around them are dying)
🗑
|
||||
| What causes secondary injury to brain cells (apart from initial insult of lack of O2)? | Release of thrombin at site, vasogenic edema, blood-brain barrier disruption, inflammatory response
🗑
|
||||
| What are the two types of aneurysms? | Saccular (also known as berry aneurysms) [which are the most common], and fusiform
🗑
|
||||
| What is amaurosis fugax, and what can cause it? | Transient blindness in one eye; common with internal carotid (ICA) strokes [because the ophthalmic artery branches from the ICA]
🗑
|
||||
| What is Marcus Gunn pupil and what can cause it? | After shining a light to test patient's pupil reaction. the pupil continues to dilate and constrict for short period of time; it is caused by central retinal artery occlusion (CRAO)
🗑
|
||||
| What are watershed strokes? What generally causes them? | Small strokes in area between major arterial territories (for example, areas between ACA and MCA territories); usually caused by HYPOTENSION or shower emboli from cardiac or vascular surgery
🗑
|
||||
| What is reperfusion syndrome and what can cause it? | Defined as ipsilateral cerebral blood flow above brain tissue needs; can occur after revascularization (carotid stent or endarterectomy, TPA)
🗑
|
||||
| What are s/s of reperfusion syndrome? | ipsilateral headache, contralateral neurological deficits, and seizure if cortical areas involved
🗑
|
||||
| What is the treatment for reperfusion syndrome? | BP control, and ONLY IF SYMPTOMATIC. If BP greater than 180, IV Rx preferred; if less than 180, oral preferred. Goal is less than 140
🗑
|
||||
| A thunderclap headache and neck pain (nuchal rigidity) would be indicative of...? | aSAH
🗑
|
||||
| If a patient is being considered for TPA (in 3hr window) and is taking anticoagulants, what must his INR be in order to not be 'excluded?' | INR 1.7 or less (PT of 15 or less)
🗑
|
||||
| Angioedema is a common side effect of what medication? | tPA, ESPECIALLY if the are on an ace-inhibitor!
🗑
|
||||
| What is the treatment of choice for patients with SYMPTOMATIC carotid stenosis and greater than 70% occlusion? | Carotid Endarterectomy
🗑
|
||||
| In patients with a patent foramen ovale (PFO), what is the ideal treatment? | Anti-platelet and/or Anticoagulation!
Surgical closure has NOT shown to be more effective.
🗑
|
||||
| What is the mainline treatment for spasticity? | Exercise and ROM stretching
🗑
|
||||
| What is the goal of rehabilitation for a stroke patient? | Teaching a patient to be self-sufficient, decrease dependence on others, and achieve the highest functional level realistically possible
🗑
|
||||
| What is a common side effect of Coumadin (aside from bleeding)? | Osteoporosis
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
DZLJAD
Popular Nursing sets