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N103 test 3 (GRCC)
N103 test 3 (GRCC): Cognitive/perceptual
| Question | Answer |
|---|---|
| Dermatomal | area of skin where rash occurs, mainly on back and hips, face (but face is rare) rash starts from back to front. |
| Shingles | Caused by virus called varicella zoster |
| Initial shingle infection | Chicken pox, virus remains in nerve root and may reappear as shingles. |
| Shingle outbreak | Initial infection is ckn pox, then with age, rheumatoid, lupus, immunosuppressive disorder, etc can trigger a shingle outbreak. |
| Immune system is low. | Risk of getting shingles (ckn pox will not re-appear) |
| Chances of getting shingles if immune system is low later in life? | If no ckn pox or if you recieved immunization then will not get shingles. |
| Very painful, long recovery | Shingles |
| Start out with itching and tingling and then become painful lesions. | Shingles |
| What happens after shingles set in | Lesion crops up 3 - 5 days once it sets in. It oozes puss & is contagious. will crust over & lesion will appear for 3-6 weeks after outbreak. |
| Tx for shingles | Acyclovir, prevention: zostavax |
| Zostavax | Vaccine to prevent outbreak of shingles if immune system is compromised; given to people over 60. |
| Acute pain- very painful and causes another nsg dx. | Nsg dx for shingles |
| Disturbed sleep pattern- very painful acute pain | nsg dx for shingles |
| Risk for secondary bacterial infection | Nsg dx for shingles - risk for infection because they are open lesions and ooz stuff, attracting bad stuff. |
| A recurrent vascular headache related to abnormalities in cranial vlood flow, also increase of seratonin | Migraine headache |
| what percentage have a migraine headache? | 10 - 15% of population |
| Migraine headache triggers | Stress, fluctuating blood sugar, hormones, bright lights, fatigue, certain food such as redwine. |
| Headache is one sided in forehead - no pain in back of head. | Migraine headache symptom |
| Last several hours to days with throbbing pain, nausea and vomiting, and bothered by light and noises. | Migrain headache symptoms |
| Aura | Flashing with in eyses is a warning sign that person will be getting a migraine headache w/in few minutes. |
| Mechanism of migraine headaches | arteries and veins swell and put pressure on the meninges, resulting in throbbing pain in front of head. |
| A recurrent vascular headache related to abnormalities in cranial vlood flow, also increase of seratonin | Migraine headache |
| what percentage have a migraine headache? | 10 - 15% of population |
| Migraine headache triggers | Stress, fluctuating blood sugar, hormones, bright lights, fatigue, certain food such as redwine. |
| Headache is one sided in forehead - no pain in back of head. | Migraine headache symptom |
| Last several hours to days with throbbing pain, nausea and vomiting, and bothered by light and noises. | Migrain headache symptoms |
| Aura | Flashing with in eyses is a warning sign that person will be getting a migraine headache w/in few minutes. |
| Mechanism of migraine headaches | arteries and veins swell and put pressure on the meninges, resulting in throbbing pain in front of head. |
| Protects central nervous system and is made of three layers:the dura mater, the arachnoid mater, and the pia mater. The | the meninges |
| Pale, sensory motor and mood disturbance, throbbing head, nausea, may vomit. | some sx of migraine headache |
| Can't think straight and have trouble focusing. | Pt suffering from a migraine headache. |
| Aftermath sx of migraine headache | After the headache is gone, pt will be exhausted. |
| abortive medications | These meds are used to treate migraine headaches & work by constricting dilated blood vessels- its aim is to abort headache or make it go away. |
| T or F. Narcotics is an effective use of meds to treat migraine headaches? | False. Narcotics mask the problem, they don't solve it. They don't constrict dilated blood vessels resulting in very little effect on the treatment of a migraine. |
| Prophylaxis | Preventative meds |
| NSAIDS such as ibuprofen (prescription strength), decongestants or caffeine. | Prophylaxis or preventative meds to help get rid of headache by constricting of blood vessels. |
| Chocolate is another substance that could be used as a prophylactic for HA. | True. Chocolate has caffeine which constricts blood vessels and may help with migraine. |
| Beta Blockers | Blood pressure meds such as inderol to help with migraine. |
| anti-convulsants/anti-seizure | Seizure meds such as depakote ER may help with migraines. |
| Tricyclic elavil and anti-depressants | Meds thay may help in treating migraines. |
| Ergotamine | medication used for migraine headaches that are made from fungi. |
| Rare to get admitted to hospital for this condition. | Migraine headaches |
| Giving pain meds | nursing care for migraine involves giving meds and teaching pt to take drugs as ordered. |
| Room dark and quiet. | nursing care for pt with migraine |
| Education re: preventative meds and triggers towards migraine headaches | Take before pain, keep diary that helps figure out triggers. |
| T or F. Seizure has nothing to do with intellect. | true. Intellect has no bearing on seizures |
| T or F. Epilepsy is a form of seizures, but not all seizures are due to epilepsy. | True |
| Episodes of abnormal sudden, excessive discharge of electrical activity. | Seizures |
| Chronic disorder characterized by recurrent, unprovoked seizure activity. | Epilepsy |
| Disorder that is idiopathic, | Cause of seizures are unknown |
| Developmental, acquired (referred as secondary) brough on by head injuries, CNS infections (meningitis), brain tumors. | Causes that may lead to seizure |
| Brain tumor removal and CVA can cause scar tissue. | Causes that may lead to seizure |
| Birth trauma | Causes that may lead to seizure |
| Metabolism disorder such as pt with renal failure who missed dialysis | Causes that may lead to seizure |
| Alcohol/coke withdrawal, heart disease, imbalanced electrolytes, decreased blood sugar. | Causes that may lead to seizure |
| Goal in managing seizures | Control seizure activity |
| Seizure prevention | It is hard to prevent injury once seizure begins |
| Watch out for lead poisoning, monitor child hood infections (i.e. mumps), and child immunizations | Things that may prevent seizure. |
| Seat belts and helmets | Preventative measures to avoid head injury that could lead to seizure |
| Pay more attention to sports related head injury sports | Preventative measures to avoid seizure |
| Events that happen after seizure episode | confusion, fatigue, disoriented, generally lost time about an hour or so. |
| Generalized seizures | Effects function of whole brain. |
| tonic-clonic | Grand Mal seizures |
| May have aura and may smell something or cry and all these symptoms happen immeadiatley before this type of seizure. | Grand Mal Seizure |
| Type or seizure lasts 30 seconds to 5 minutes | Grand Mal Seizure |
| Tonic - clonic | Increased tone in muscles person gets rigid, then lose consciousness and fall, then start jerky rhythmic of all extremities (all skeletal muscles). |
| During seizure | Jaw muscles can bite tongue or cheek and may be incontinent of urine (maybe stool) |
| Absence seizure (petit mal) | Can have over 100 occurrences/day |
| Absence seizure (petit mal) -Characteristics | Little bad seizures; lose consciousness for 1-2 sec; stare off into space;day dream look;most common in school age (elementary) children. |
| This type of seizure doesn't last long and is considered to be full brain involvement. | Absence seizure (petit mal) |
| Partial seizures | May or may not lose consciousness; no whole body movement;Only one part of body is jerking;don't respond, but don't fall either; |
| This type of seizure individual may or may lose consciousness; last 1-3 min will not shake;will do things like pick at themselves, pat lips, etc | partial seizure |
| Post ictal stage of seizure | Is the sleepy part after the seizure. |
| Type of seizure that lasts longer than 30 minutes or series of seizures that occur in rapid succession. | Status Epilepticus seizure |
| Most common with tonic-clonic | Status Epilepticus seizure |
| Ensure airway is clear, turn on side, place oxygen mask on pt and set at 5 liters of air. | Things to do for pt having a Status Epilepticus seizure |
| What is a very important task that observers of a seizure has to look for? | They should document what was happening, what time it started, etc so that doc can figure out what type or seizure pt is having. |
| Meds control for status epilepticus seizure | IV push of Valium, versed, ativan: all are in the same of benzodine family. |
| Once initial status epilepticus seizure ends | Administer dilantin- prevents seizure from occurring. Therapeutic dilantin level is 10-20. |
| Track occurrences of seizures because | Track frequency, and occur due to excitement, angry, menstruation, fatigue, or seasonal; helps to figure out what triggers a seizure |
| Preventing injury during seizure attack | Don't restrain, move any objects, NO tongue blades; if in bed- padded bed rails, bed should be in lowest position(less distance to fall) |
| Get patient onto side;loosen tight clothing; hx of seizures must have oxygen and suction set up ; | Preventing injury during seizure attack |
| If there is a place in the body where seizure started | Observe and record seizure activity. |
| Identify what parts of the body involved. | Observe and record seizure activity. |
| Loss of consciousness | Observe and record seizure activity. |
| Skin color - blue lips, etc | Observe and record seizure activity. |
| Respiration - did pt get air in breath | Observe and record seizure activity. |
| If witness - was it tonic -clonic? Sometimes people don't have tonic clonic seizures | Observe and record seizure activity. |
| Incontinence | Observe and record seizure activity. |
| Appearance of pupils- usually dilated | Observe and record seizure activity. |
| Duration of seizure | Observe and record seizure activity. |
| Any injuries?? | Observe and record seizure activity. |
| Symptoms after swizure and how long does symptoms last | Observe and record seizure activity. |
| What are vitals | Observe and record seizure activity. |
| Did they have an aura- did they cry out or have a facial grimace | Observe and record seizure activity. |
| Get rid of people who don't need to be in room while pt is having a seizure | Maintain privacy during seizure |
| Low Self Esteem | NSG dx for seizures |
| Altered cerebral tissue perfusion | NSG dx for seizures |
| Altered self image | NSG dx for seizures |
| People with seizures need to make life adjustments | Stay away from alcohol, get enough sleep, alcohol makes seizure worse, should wear seizure ID bracelet |
| Meds only control about 60% of seizures. T or F | True. Even if the pt needs to take meds regularly. |
| How long will pt need to take meds. | Unless seizure is secondary to something then expect to stay on seizure for life. |
| Dilantin | Old stand by drug; blood test can detect therapeutic level which is between 10-20;side effect; |
| Side effects of Dilantin | Rash that covers persons chest- very uncomfortable- unless pt stops taking meds; gingival hyperplasia |
| Gingival Hyperplasia | Over growth of gum tissue - gums bleed easily and gums overtake teeth making it hard to clean. |
| Phenobarbital | Seizure meds;Controlled substance- ordered for kids whose temperature is over 103. |
| Phenobarbital side effects | Seizure meds;First 2-3 months pt will be fatigued, and then body will adjust- not feeling sleepy. |
| Tegrotol | Seizure meds; may cause rash |
| Depakote | Seizure med |
| Keppra | Seizure med- only been on market about four years. |
| If on two or more of either drugs;Delantin, phenobarbital, tegretol, depakote, keppra | Chances are, pt is being treated for seizures. |
| Concerns for people with seizures | Employment problems limit options- can't be a pilot; insurance may not cover if this is considered a pre-existing condition; can't drive |
| Time | Need to know and document for simple head injury |
| What was the cause - i.e. if they were hit with somethiing, then what direction was it coming from? | Need to know and document for simple head injury |
| Did pt lose consciousness are they easily arousable | Need to know and document for simple head injury |
| Do quick LOC eval | Need to know and document for simple head injury |
| Causes of simple head injuries | Traffic accidents; hit people on bikes, pedestrians, etc |
| Common group with head injuries | Males btwn 15-24, cuz they are daring, more option to try things, invincible, etc. |
| Simple head injury with neck injury | If moved incorrectly, can cause permanent paralysis; should place neck brace and keep pt aligned to prvent this. |
| Seatbelts, helmets, don't drink and drive | Prevention tips to avoid simple head injuries. |
| sx fractures outside of skull | If awake, alert, then pain is a predominant sx. |
| T or F. Not everyone has to be knocked to have a severe head injury. | True. |
| Linear skull fx | A break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone |
| Depressed skull fx | a type of fracture usually resulting from blunt force trauma. The force of direct impact may cause damage to the underlying physical structures contained within the skull such as the membranes, blood vessels, and brain, even in the absence of a fracture |
| Basialar skull fx | a fracture of the base of the skull, typically involving the temporal bone, occipital bone, sphenoid bone, and/or ethmoid bone. |
| Skull fx | May have concussion or brain injury. |
| Raccoon eyes | Blood in front half of head will seep into soft tissue, mainly around eyes. |
| Inside skull (CHI -closed head injury) | It no skull fracture are dx with CHI |
| Concussion | Temporary loss of neural function with complete recovery; happens a lot of sports. |
| Epidural Bleed | Bleed occurs above the dura but inside the skull; more arteries are located here;resulting in rapid bleeding. |
| Arterial bleed | Bleed occurs above the dura but inside the skull; more arteries are located here and is referred as |
| Sx of Epidural Bleed | A person who hit in the head (such as the window of a car) can walk around, may be alert, but as bleed increases, will lose consciousness. |
| SX of epidural bleed | Occurs within hour or so of injury- rapidly increased LOC. |
| Emergency situation where ends up in surgery, best to treat w/in 30 min of inury. | Epidural Bleed. |
| Subdural bleed | Are underneath dura, usually venous bleeds; not asmuch pressure with veins- bleeds occur slower. |
| SX of subdural bleed | pt c/o HA, dizziness, ittitable, may vomit. |
| Acute subdural | Occurs immeadiatley or within firts 24 hours of injury;not all go to surgery- if small will recover on own. |
| Subacute subdural hematoma | Occurs from 24 hrs to 2 wks after the injury. Not emergency |
| SX of subacute subdural hematoma | Dull HA, irritable, dizziness persists then CT scan will be ordered. |
| CT scan for subacute subdural hematoma | Will assess the size of the hematoma- may re-assess a week later and compare; if bigger then surgery, it no changes then assume it will heal it self hopefully. |
| Chronic Subdurral hematoma | May not be recognized if over 2 wees to months - CT scan may appear negative at first. |
| SX persist w/ suspected chronic subdural hematoma | If sx of confusion, and irritability persist overtime, then a new ct scan will be ordered. |
| Not safe driving if suspect for this type of brain bleed. | Chronic subdural hematoma. It's gradual and people don't suspect they have a problem. |
| Common among the elderly, because they are prone to fall, it's hard to distinguish btween injury or dementia. | Chronic subdural hematoma |
| sx of chronic subdural hematoma | May develop weakness and develop paralysis on one side of body called hemiplegia; May also have seizures; don't totally lose consciousness, but deteriorate slowly. |
| Intra-cerebral bleed | Usually very serious bleed into brain tissue r/t high blood pressure, cocaine use aneurysms, congenital malformations. |
| SX of intra-cerebral bleed | People don't know if this happens as the onset is abrupt; sudden severe HA and immediate loss of consciousness; followed by vomiting w/bleeding into tissues causes IICP. |
| Pt who comes in unconsciouss | CT will be done and if intra-cerebral detected r/t bp, then pt will be given bp meds. |
| When pt stable after getting BP meds for intra-cerebral bleed | Pt will have angio test to see if surgery can fix injury. |
| Caring for pt with head injury | Make sure pt has clear airway; ck respiratory and VS q2hrs to assess for widening pulse pressure. |
| Widening pulse pressure | Difference between systolic and diastolic; means IICP; check LOC, PERRLA; may order another CT scan depending on pt status. |
| Altered cerebral tissue perfusion | NSG dx for head trauma |
| Impaired mobility - may be dizzy, etc | NSG dx for head trauma |
| Potential for injury - person may vomit- disruptive | NSG dx for head trauma |
| T or F. Do not restrain pt with head injury. | True. don't restrain pt with head injury as this may increase the chance of IICP. |
| After pt with head injury is dc'd from the hospital. | Can have more head problems. |
| Body Image disturbance | NSG dx for head trauma |
| Altered role performance | NSG dx for head trauma |
| Trigeminal neuralgia | Occurs more often in women in mid age than in men. |
| Chronic disease of the trigeminal nerve- cranial nerve # 5, causes severe facial pain. | Trigeminal neuralgia |
| Cause of Trigemina neuralgia | Unknown |
| Severe one sided facial pain occurring any where for a few seconds up to a few minutes and can occur several 100 times/day | Trigeminal neuralgia |
| Occurs annually and there is not predicting factors on when this will occur. | Trigeminal neuralgia |
| Anything sensory, dentist, atmospheric pressure change, dentist, etc | Can trigger an attack of Trigeminal neuralgia |
| Often symptoms of this disorder goes away for several years and then suddenly comes back again. | Trigeminal neuralgia |
| Medication that pt can try to use for Trigeminal neuralgia | Tegretol (also used for seizure), neurontin, lyrica. |
| Narcotics don't work for this condition. | Trigeminal neuralgia |
| If Trigeminal neuralgia re-occurs often enought | Neuro-surgeons may agree to do surgery by wrapping nerve with fat to insulate from pressure of arteries. |
| Might see pt with this condition in long term care facility, not in hospital unless they were admitted for surgery. | Trigeminal neuralgia |
| sx of Bell Palsy | Numbness and stiffness; noticed first and progresses to side of face causing drooping. |
| Prognosis for Bell Palsy | Majority of people recover fully in 2 weeks to months and varies between people; some people may have residual paralysis for rest of life. |
| Disorder of 7th cranial nerve- cause unilateral facial analysis- 7th nerve is the motor nerve. | Bell Palsy |
| Bell Palsy occurs with | 20-60 years of age; equally in men and women; |
| Bell palsy may be caused by what? | Herpes simplex, lime disease, sarcoidosis. |
| sarcoidosis | a disease in which swelling (inflammation) occurs in the lymph nodes, lungs, liver, eyes, skin, or other tissues. |
| Meds for Bell Palsy | There are no meds- but it dx early, then they give antiviral meds ad must be given within 24 hours of symptoms. |
| Prednizone | Controversial meds- probably won't hurt, but may not help. |
| Nursing care for Bell Palsy | Eye dries out requiring artificial tears or it is recommend pt wear a patch. |
| Eye sensitive light and needs to wear sunglasses | nursing care for Bell Palsy |
| Be careful when eating or drinking, as it could either get pocketed or dribble out of affected side of face; should have small frequent portions and food should be soft. | nursing care for Bell Palsy |
| Peripheral neuropathies | Problems with nerves going to certain parts of body. |
| Peripheral neuropathy | Most common is Diabetes Mellitus neuropathies. |
| DM causes changes in blood vessel size decrease the blood flow to extremities. | Cause of DM neuropathy |
| Disorder involving blood vessels that supply nerves and result in impaired nerve conduction. | DM neuropathy |
| Diabetics commonly have problems starting in which extremities? | Toes and feet bilateral; distal parastesia (numbness and tingling in feet) Constant burning feeling in feet. |
| DM neuropathy results in altered sensation. | Because they can't feel anything. |
| Polyneuropathy | A lot different nerves |
| Distal Parasthesias (numbness tingling) | Polyneuropathy |
| Pain, including aching, burning, feeling of cold | Polyneuropathy |
| Altered or impaired sensation | Polyneuropathy |
| Visceral (autonomic) neuropathies | Actual function of area of autonomic nervous system |
| Visceral (autonomic) neuropathies: Autonomic nervous system includes | sweating, gas intestinal (can't empty) problems, sex dysfunction because itty bitty blood vessels. |
| Nurses and doctors with the pt | Collaborative mgmt to treat neuropathies. |
| Complications are irreversible, so teach prevention. | Collaborative mgmt to treat neuropathies. |
| Always were properly fitting shoes when walking anywhere | Nursing care for pt with peripheral neuropathy |
| Wear hard sole shoes | Nursing care for pt with peripheral neuropathy |
| Assess skin, especially feet for cuts, hangnails or anything that can cause infection | Nursing care for pt with peripheral neuropathy |
| Trim toe nails by podiatrist; avoid callous removers; check temp of water before placing feet into it. | Nursing care for pt with peripheral neuropathy |
Created by:
Wends1984
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