Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
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
NUR 126 Week 4
Intracranial Regulation, Thermoregulation, Cognition
| Term | Definition |
|---|---|
| Thermoregulation | The process of maintaining the core body temperature at a nearly constant value. |
| Hypothalamus | controls physiological adjustments, responsible for maintaining body temperature, “thermostat of the body” |
| Radiation | being near a cold surface, although not in contact with it |
| Conduction | direct skin contact with cold surface |
| Convection | heat taken away from body by drafts |
| Evaporation | liquid from the skin |
| Normothermia | normal body temp, must be maintained for optimal body functioning- Ranges from 97-99 degrees F. Normal is considered 98.6 degrees F |
| Hypothermia | is a body temperature below 35C (95F), can be accidental or therapeutic, causes vasoconstiction |
| Hyperthermia | is a body temperature above 37.2 C (99°F), S/S include: Flushed/warm skin Diaphoretic Dry mucous membranes Decreased urinary output Altered cognition – confused, delirious, coma, seizures Electrolyte imbalance Can lead to cardiac collapse |
| Hyperpyrexia | is an extremely high body temperature above 41.5 C (106.7°F) |
| Fever | is elevation in body temperature due to a change in the hypothetical set point, Greater than 100.4 degrees F, pathophysiological response to inhibit pathogen growth |
| Preterm babies are at risk for impaired thermoregulation due to: | large body surface area to body mass, minimal fat stores, inability to shiver, completely dependent on others, and cannot conserve heat |
| Elderly people are at risk for impaired thermoregulation due to: | diminished ability to regulate body temp due to a less effective thermoregulatory response. Reduced perception of hot and cold. Slower circulation. Slower metabolic rate. Decreased shivering response. |
| Treatment of Hyperthermia | Move to cooler environment,Remove excess clothing and blankets, external cool packs,cooling blanket Hydrate with cool fluids (PO or IV),Luke warm bath,Administer antipyretic drug therapy (ibuprofen, acetaminophen),Prevent shivering, Cool Lavage |
| Heat Exhaustion | More serious form of hyperthermia Caused by excessive fluid loss with exposure Rising body temp and metabolic rate = O2 demand Cardiac output & HR increase, then fall Loss of fluids hypovolemia & electrolyte imbalance |
| Signs and Symptoms of Heat Exhaustion | Dizziness, headache, muscle cramps, N&V, collapse, damp/pale, elevated rectal temp (as high as 41.1 C, 106 F) |
| Nursing Interventions for Heat Exhaustion | Move to cooler environment, loosen clothes, cool water to skin, offer fluids if able to drink, medical attention |
| Heat Stroke | Core temp of 41.1C (106F) or greater Temperature regulating mechanisms in brain fail Heart, kidneys, CNS functions are depressed Unable to sweat Usually associated with strenuous activity in hot, humid environment |
| Signs and Symptoms of Heat Stroke | Similar to heat exhaustion at first – dizziness, weakness, nausea As it worsens – red/hot/dry skin, no perspiration If not reversed – collapse, seizures Temp may reach 43.3C (110F) |
| Nursing Interventions for Heat Stroke | Cooling is critical Immediate transport to medical facility Move to shade/air conditioning Apply wet, cool towels, cool bath if poss Ice pack in axillae, forehead Cool IV fluids Continuing cooling until body temp below 38.3C (101F) |
| Signs and symptoms of Hypothermia | Cool skin Decreased cap refill Pale Shivering, muscle rigidity Cognition – confused, poor coordination, coma |
| S/S Hypothermia CONTINUED | Vasoconstriction -> tissue ischemia Vasoconstriction eventually fails, causing vasodilation -> acceleration of heat loss, false sense of warming Dysrhythmias (myocardial irritability) Cardiovascular collapse – decreasing HR, RR, BP |
| Nursing Interventions for Hypothermia | Remove from cold Remove wet clothing immediately –5x faster heat loss Warm water bath (rewarming is painful),internal/ external warming measures (Heated O2, IVF, lavage) Safety: Core rewarming must be done |
| Cold Stress | increased metabolic rate is required to generate body heat causes increased respiratory rate and oxygen consumption results in: Increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, lethargy |
| Complications of Cold stress in newborns | Hypoglycemia Can be both the cause and the result of hypothermia Newborn uses glucose to generate heat Respiratory Distress Higher metabolic rate consumes more O2 Requires more glucose for the increased work of breathing causing hypoglycemia |
| Signs and Symptoms of Cold Stress | Decreased skin temp (will lower before core) Increased resp rate with periods of apnea Bradycardia Mottling of the skin Lethargy |
| Normal Newborn Temperatures | Normal temperature 36 to 36.5 C (96.8 - 97.7F) – skin 36.5to 37C (97.7 - 98.6F) - axillary |
| Risk factors for Cold Stress in Preterm and Postterm babies | Preterm – no fat stores, immaturity, poor control over BS, temp Post term – have used fat stores in utero |
| Nursing Interventions for Cold Stress | Skin probe used and placed in right upper quadrant of abdomen Incubator-controlled heat and humidity in enclosed evironment Radiant warmer-overheat heat lamp Kangaroo care-skin to skin Drying of infant Hats-head largest area Wrapping infant |
| Intracranial Regulation | involves the mechanisms and conditions that affect intracranial processing and function 3 categories of impairment: Perfusion, Neurotransmission, Pathology |
| Risk Factors for impaired Intracranial Regulation | Older Adults-falls, degenerative changes, perfusion and neurotransmission deficits Adolescents-MVA, trauma, ATVs, sports |
| Assessing Intracranial Regulation | Glasgow Coma Scale most widely used, easy to follow and accurate -Peds GCS available, 1st S/S impairment is change in LOC |
| Intracranial Pressure | Sum of all components inside cranial vault, Increasing ICP is dangerous and presents as HA in adults/children, infant swill have lethargy, irritability, poor feeding, may have bulging fontanelle, high pitched cry |
| Cushing's Triad | Ominous sign, emergency, S/S include hypertension, bradycardia, decreased respiration. IMPENDING BRAIN HERNIATION |
| Nursing Interventions for Increased ICP | Goal is to lower and keep low, Positioning – HOB elevated, proper alignment Activity management – no cluster care Airway management - coughing Hyperventilation Bowel management |
| Interdisciplinary approaches to Impaired Intracranial Regulation | May need a swallow study/speech eval Education – can have devastating and long-lasting effects, may need to involve family May need physical, speech, occupational therapy, start as soon as patient is stable in acute care May take months to years |
| Hydrocephaly | increase in cerebrospinal fluid (CSF) within the ventricles of the brain, pressure changes in the brain, Increased head size Results from an imbalance between production and absorption of CSF or improper formation of ventricles Acquired or congenital |
| Common Causes of Hydrocephalus | An obstruction-tumor A sequelae of infection – encephalitis, meningitis Perinatal hemorrhage Congenital defect Neural tube defects Most often caused by failure of neural tube to close at either the cranial or the caudal end of the spinal cord |
| Signs and Symptoms of Hydrocephalus | Classic signs: Increased head size Cranial sutures separate to accommodate enlarging mass Scalp is shiny with dilated veins Symptoms depend on: Site of obstruction Age at which it develops-older children will experience HA as sutures are fused |
| Signs and Symptoms of increased ICP | High-pitched cry Unequal pupil size or response to light Bulging fontanelles in infants Headaches in children due to closed cranial sutures Irritability or lethargy Vomiting Poor feeding Cushing's Triad in extremely high pressures |
| Treatment of Hydrocephalus | Medications to reduce production of CSF-diuretic Surgery to place a shunt is common IF untreated can lead to: Lack of mobility as head size increases Delayed mental development Lack of appetite Poor resistance to infection |
| Ventriculoperitoneal Shunt (VP Shunt) | CSF is carried to another area of the body Absorbed and excreted Replaced as child grows Complications: Shunt acts as a focal spot for infection and may need to be removed if infections persist (REMEMBER IT IS FOREIGN) |
| Nursing care for Hydrocephaly BEFORE Shunt placement | Head position changes-prevent skin breakdown, Support head esp. while feeding, Quiet & calm during feed, Side lying after feed (prone to vomit after feeding) Measure head circumference, VS & ICP Observe fontanelles for bulging |
| Nursing care for Hydrocephaly AFTER Shunt placement | Prevent infection, Pump shunt as ordered Positioning (Don’t want rapid reduction in fluid) Sunken fontanelle – flat ,Bulging fontanelle - semi-fowlers Prevent op site pressure pain control, Assess ABD- malabsorption Assess for increased ICP |
| Education for parent post VP shunt placement | Teach signs that indicate shunt malfunction may be occurring. How to “pump” the shunt Signs of shunt malfunction in a child Symptoms of ICP Signs symptoms of infection |
| Cognition | mental process of acquiring knowledge and understanding through thought, experience, and the senses. |
| Consequences of Impaired Cognition | Risk for injury, complicated disease management, Increased hospitalization & long-term care, Altered functional ability, no Independent living and normal social interactions, Increased need for assistive services, Financial hardship & Caregiver burden |
| Down Syndrome | Most common chromosomal abnormality – Trisomy 21 Most common cause of genetic intellectual disability Causes behavioral disturbances Risk increases in linear fashion as maternal age advances |
| Signs and Symptoms of Down Syndrome | Physical abnormalities: Upward slant of the canthal folds of eyes Protruding tongue Short, thick neck Low set ears Straight crease in palm – Simian crease Short 5th finger Undeveloped muscles and loose joints Mild to severe mental retardation |
| Testing During Pregnancy for Down Syndrome | Ultrasound – nuchal translucency (nuchal fold) Quad screen – blood test – can indicate high risk for down syndrome Chorionic Villus Sampling Amniocentesis |
| Diagnosis of Down Syndrome | Clinical manifestations and presentation Chromosome analysis via lab testing |
| Consequences of Down Syndrome | Delayed milestones Sitting Rolling over Walking Talking Delayed self-help skills Finger feeding Using utensils Toilet training Dressing Physical Growth and development will be slower |
| Manifestations of Down Syndrome | Physical manifestations Limited intellectually Very loveable Can have difficult behavior Hypotonicity – secretions (increases risk of respiratory/ear infections) Malalignment of cervical spine |
| Common health conditions associated with Down Syndrome | Congenital Heart Disease (50%) Hearing loss (75%) OSA (50-75%) Ear infections (50-70%) Eye disease (60%) Eye issues requiring glasses (50%) Hearing loss r/t ear infec Thyroid disease Anemia Leukemia Increased risk for Alzheimers |
| Family and Healthcare Impacts of Down Syndrome | Medical care costs 12 x higher 40% reported financial problems as a result of diagnosis Members often quit work to care for pt Counseling important Community/Social resources |
Created by:
shelby.rigsby
Popular Nursing sets