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TL - Neurologic

Nursing of the Client with Neurologic Disorder

What are the variables in the Glasgow Coma Scale? Eye opening, Verbal Response, Motor response
What would a score of 15 on the GCS indicate? Maximum score - unimpaired
What would a score of 7 or less on the GCS? Indicates coma
What would a score of 8 indicate? good prognosis for recovery
What would a GCS score of 3 or 4 indicate? poor prognosis for recovery
What are the possible responses and their scores for eye opening on the GCS? Spontaneous-4, To verbal command – 3, To pain – 2, No response – 1
What are the possible responses and scoring for verbal response on the GCS? Oriented and converses – 5, Disoriented and converses – 4, Inappropiate words – 3, Incomprehensible sounds – 2, No response – 1
What are the possible responses and scores for motor response on the GCS? To verbal command – 6, Pain response: Localizes pain – 5, flexes/withdraws – 4, Flexor Decorticate – 3, Extensor Decerebrate - 2, No response – 1
Name all the components that should be included in the neurologic assessment of a client in an altered state of consciousness. GCS, Pupils, Limb movement, BP, Temp, Pulse, Respirations, Skin integrity, Corneal integrity, Bladder for fullness, Lung sounds, Cardiac Status
What assessments are pertinent to the family members of a neurologic client? knowledge of client status, coping, need for support, ability to assist and provide care at discharge
Explain why almost any NANDA diagnosis could be applicable to the severely neurologically impaired client? Because severely neurologically impaired persons require total care
List 13 applicable nursing diagnoses for the severely neurologically impaired client. Ineffective: breathing pattern, airway clearance; Impaired: gas exchange, mobility, elimination; Decreased cardiac output, Anxiety, Imbalanced Nutrition, Self-Care deficit; Risk for: imbalanced body temp, injury, impaired skin integrity, constipation
What is the rationale for feeding severely neurologically impaired clients enterally (via feeding tube) vs. by mouth? high risk for aspiration pneumonia
What would 100mL of residual from previous feeding indicate? poor gastric emptying – hold feeding
Explain the rationale for a gastric tube in comatose clients. Paralytic ileus is a common complication for the comatose client. A gastric tube aids in gastric decompression
What care is required in reqards to position and mobility when the client is immobilized? ROM exercise and frequent position changes @ least q 2hrs; Avoid positions that decrease venous return or dependent extremities
What can be done to help the severely neurologically impaired client with oxygenation? monitor respirations, Po2 & Pco2, doc & report changes; position ¾ or semiprone for maximum ventilation, provide frequent suctioning – hyperventilate with 100% o2 before & after, Chest physiotherapy per rx, prepare for emergency airway
What nursing responsibilities address the neurologically impaired client’s need for fluid/electrolyte balance and nutrition? NPO till responsive, mouth care q 4hrs, count calories, feeding per rx, I&O, daily weight
What nursing interventions address risk for impaired skin integrity? assess skin integrity, turn q 2hrs, assess boney prominences, special mattresses, minimal linens/underpads
What nursing interventions address the clients increased risk for thrombus formation? Passive ROM to lower extremities Q4 hrs, SCDs remove and reapply q 8 hrs, position to encourage venous return, keep extremities nondependent, no pillows or gatch under knees
What nursing interventions decrease the risks for developing urinary calculi? ensure adequate hydration, balance I&O, assess urine for high specific gravity
What nursing interventions prevent contracture? passive ROM q 4 hrs, sit client up in bed or chair if possible, reposition q 2hrs, proper body alignment, use assistive devices to prevent foot/wrist drop
Why are pulse changes important to monitor in the neurologically impaired client? pulses <60 or >100 can indicate ICP. >100 can indicate infection, thrombus formation, or dehydration
What BP changes would indicate increased ICP? rising BP and widening pulse pressure
What is widening pulse pressure? the difference between the systolic and diastolic BP. The normal value is around 40mmHg
What is the Cushing’s triad? widening pulse pressure, bradycardia, irregular breathing pattern – notify physician immediately – indicates increasing ICP
Why is it important to monitor temperature for the neurologically impaired client? elevation can indicate worsening condition, infection, or damage to the temperature controlling area of the brain
Why is it important to quickly take measures to decrease elevating temperature in the neurologically impaired client? fever increases cerebral metabolism and can increase cerebral edema
What is the most important indicator of increased ICP? change in level of consciousness
What should the nurse suspect as a possible cause of irritability, restlessness, or confusion in a client with a closed head injury? increased ICP
Give all the signs and symptoms associated with increased intracranial pressure. changes in LOC, slowed or irregular respirations, increased/decreased pulse, rising BP, widening pulse pressure, temperature elevation, HA, projectile vomit, changed pupil size, unequal pupils, non-conjugate movement, papilledema
What signs indicate CSF leakage? Runny nose or liquid from ear
What are the dangers with CSF leakage? indicate deteriorating condition, could lead to meningitis, usuals signs of increased ICP may be masked
What can CT scans and MRIs tell us about head injuries? They can detect lesions such as epidural or subdural hematoma that may require surgery
What can be detected by an Electroencephalograph? seizure activity
We know that increased temperature causes increased blood flow to the brain resulting in cerebral edema. What measures should be taken to reduce temperature and thus reduce risks? ASA, acetaminophen, cooling blanket
Disucss intracranial pressure monitoring. a catheter is inserted into the lateral ventricle, a sensor on the dura, or a screw into the subarachnoid space attached to a pressure transducer. Pressure is monitored. Elevations above 20mmHg are reported STAT
What kinds of medications may be prescribed to decrease ICP? Diuretics/hyperosmotics like urea and mannitol, steroids like Dexamethasone (Decadron), Solu-medrol, or barbiturates to reduce brain metabolism and systemic BP
How does passive hyperventilation on the ventilator assist with lowering ICP? leads to respiratory acidosis which constricts cerebral blood vessels thus reducing blood flow and pressure in the brain
What is the therapeutic use of phenytoin (Dilantin) in head injury? Sometimes orders for seizure prophylaxis
We should educate the head injury client of possible aftereffects of head injury at discharge. What should be included in this education? Possible to develop post traumatic stress syndrome, posttraumatic epilepsy or posttraumatic neuroses or psychoses
Describe the action of mannitol (Osmitrol). acts on renal tubules to prevent water reabsorption and pulls fluid from the extra cellular spaces into the plasma in the blood stream
What are the adverse reactions of mannitol? disorientation, confusion, headache, N&V, convulsions and anaphylactic reactions
How long would you expect your client to receive mannitol? used for short term therapy only
How is mannitol usually administered and dosed? Usually given by IV and adjusted to urine output
What does the nurse monitor for in urine while the patient is receiving mannitol? crystals
When is mannitol contraindicated? cerebral hemorrhage, anuria or <30mL/hour
What can happen if a patient’s output is impaired and they receive mannitol? it can accumulate and cause pulmonary edema and water intoxication
List the most common sites for spinal cord injuries to occur? C-5, C-6, and C-7; T-12 and L-1
Why can’t we tell what kind of permanent damage has been sustained until about a week after an injury to the spinal cord? It takes that long for spinal cord edema to subside
Which assessment is especially pertinent to client’s with injury at C-3 to C-5? Why? respiratory status because the cervical plexus innervates the diaphragm
Discuss assessments pertinent to the client with a spinal cord injury. breathing pattern, lung sounds, neurologic vitals esp sensory and motor function, cardiovascular status, abdominal girth, bowels sounds, bladder distention, temperature esp for hyperthermia, psychosocial status, BP
What symptoms are common with an injury above T-6? Why? hypotension and bradycardia because sympathetic outflow is affected
What are some potential nursing diagnoses for the client with a spinal cord injury? ineffective breathing pattern, tissue perfusion, coping; Impaired skin integrity, Self-care deficit, Urinary retention
Differentiate between the symptoms related to language when the damage is in the right vs. the left hemisphere. Left – aphasia and agraphia; Right – may be alert and oriented
Define Aphasia loss of ability to speak
Define agraphia loss of the ability to write
How would memory be affected differently by damage to the left hemisphere vs the right? no deficit in memory – left hemisphere; disorientation and inability to recognize faces – right hemisphere
What visual symptoms would be indicative of damage to the left hemisphere? unable to discern words/letters; reading problems; deficits in the right visual field
What visual symptoms would be indicative of damage to the right hemisphere? visual/spatial deficits, neglect of the left visual field, loss of depth perception
What behavioral changes are linked to damage in the left hemisphere? behavior may become slow, cautious; anxiety with new task, depression, sense of quilt, feelings of worthlessness, worry over future, quick anger and frustration
What behavioral changes are linked to damage in the right hemisphere? Impulsiveness, not aware of neurologic deficits, confabulation, euphoric, constant smile, denies illness, poor judgement, overestimates abilities, impaired sense of humor
Differentiate between left and right hemispheric damage as it affects hearing. left- no deficit, right – lost ability to hear tonal variances
Define apraxia inability to perform purposeful movements
Define dysarthia difficulty with pronunciation
Define dysphasia difficulty with speech and verbal comprehension
Define alexia loss of ability to read
Define dysphagia dysfunctional swallowing
What diagnostic tests could be used to confirm the diagnosis of stroke? CT scan, MRI, Doppler flow studies, Ultrasound imaging
What symptoms would you expect to see in the patient who has suffered from stroke? motor loss such as hemiplegia/hemiplasia, communication loss, perceptual disturbance, impaired mental acuity or psychological changes, bladder dysfunction (incontinence or retention)
When does rehab need to start for the stroke patient? as soon as the client is able
What assessments are pertinent to the client with stroke? LOC, language impairments, parethesias, paralysis, memory impairment, vision impairment, bladder/bowel function, behavioral changes, functional abilities (mobility, ADLs, elimination, communication, ability to eat w/o risk of aspiration)
What nursing diagnoses are applicable to the client with stroke? impaired physical mobility, verbal communication, urinary elimination; ineffective coping, family coping; Self-Care deficit, Disturbed body image
Why is control of HTN an important intervention for the client with stroke? To prevent future stroke
Discuss positioning and mobility as it relates to the client with stroke. maintain proper alignment and functional position with splints or pillows, prevent contracture and edema, maintain skin integrity and mobility with ROM
Discuss nursing interventions related to Self-care and the client with stroke. Encourage client participation, set realistic goals with new tasks daily, encourage client to assist with dressing and wear street clothes during waking hours.
Discuss nursing interventions regarding bladder elimination and the patient with stroke. offer bedpan or urinal as appropriate, reassure client bladder control tends to be regained quickly
What is the therapeutic value of steroids after stroke? to decrease cerebral edema and retard permanent disability
What is the therapeutic value of H2 inhibitors after a stroke? prevention of peptic ulcers