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Med Surg Neuro.

neuro

QuestionAnswer
conduct impulses toward CNS Afferent
conduct impulses away from CNS Efferent
Neurons consist of what? cell body, dendrites, axon
What forms the gray matter of the CNS? Cell bodies
What forms the white matter of the CNS? Axons (which are myelinated)
Which neurons have the ability to regenerate after injury? only peripheral neurons
What is action potential? rapid changes in membrane electrical charges that transmit impulses
What are the three stages of action potential? resting, depolarization, repolarization
What is a synapse? location where impulses move from neuron to neuron via neurotransmitters
What is nerve impulse affected by? pH, supply of transmitter, ECF, O2, medications
What is dopamine? a catecholamine
What is dopamine required for? complex movement, emotional response, attention
What is serotonin needed for? Onset of sleep, Mood control, Pain pathway inhibitor in spinal cord
What is Acetylcholine (ACh) needed for? Nerve and muscle transmission, Parasympathetic usually, Preganglionic sympathetic system
What disease is Ach very important in the treatment of? Alzheimer’s
What is Gamma-aminobutyric acid (GABA)? Affects 1/3 of brain neurons, Inhibits nerve and muscle transmission, R/T anxiety and seizures
What do the skull and vertebral column protect? brain and spinal cord
What are the meninges for? cover brain and spinal cord to provide support and protection
What is the dense, fibrous outer layer of the brain that forms fissures in the brain that separate hemispheres and lobes? Dura mater
What is the delicate, vascular, middle layer of the brain? Arachnoid
What is very delicate and adheres closely to the surface of the brain and spinal cord? Pia mater
What are the three spaces formed by the meningeal layers and skull called? Meningeal spaces
How much of the blood and oxygen supply does the brain require? The brain requires 750ml/min of blood and uses 20% of the oxygen supply
What do the Internal carotids and basilar artery combine to form? Circle of Willis
Where is the Circle of Willis located? at the base of the skull
What are the three pairs of vessels that branch off the Circle of Willis? anterior, middle, and posterior cerebral arteries
How is venous drainage accomplished in the brain? Dural venous sinuses found between the dura drain into the internal jugular veins
What is the tight junction between capillaries and cells that form spinal fluid and selectively permits substances to pass from the blood to the neurons called? blood brain barrier
What does the blood brain barrier prohibit? many meds and albumin from passing into the brain such as polar medications, fat-soluble meds
How do some meds get past the blood brain barrier? enter via the choroid plexus and then diffuse into the brain
Where is CSF formed? in the cerebral ventricular system, by the choroid plexus in the lateral ventricles
How much CSF is formed per hour? 25-30ml/hr
Areas that hold large amounts of CSF are called what? cisterns
CSF is reabsorbed into venous system constantly by what? arachnoid villi
What receives CSF from the subarachnoid space and empty into the internal jugular vein? dural venous sinuses
What increases the surface area of the brain? Gyri (peaks) and sulci (valleys)
What are the cerebral hemispheres connected by? the corpus collosum
What does ipsilateral refer to? same side
What does contralateral refer to? the opposite side
Which hemisphere is responsible for language in 95% of people and is considered dominant? left (but it depends on handedness)
Which hemisphere processes information such as spatial orientation and perspective? right
Which lobe is 1/3 of each hemisphere; is responsible for abstract thinking, judgment, emotion, motor function and motor aspects of speech (Broca’s area)? frontal
Which lobe is responsible for perception of verbal material (Wernicke’s area), memory, behavior, emotion? temporal
Which lobe is responsible for analyze sensation, spatial-perceptual ability? parietal
Which lobe is responsible for vision, visual interpretation? occipital
What is at base of cerebrum, made of gray matter, and works with cerebellum in coordination and control of fine motor activity? Basal ganglia
What plays role in sleep/wakefulness, pain perception, relay of ascending impulses? thalamus
What works with autonomic nervous system in regulating pituitary hormones, heart rate, body temp, lyte balance, appetite ? hypothalamus
What does the brain stem do? Connects spinal cord and brain, contains reticular formation
What is the brain stem divided into? midbrain, pons, medulla oblongata, reticular activating system (RAS)
What does the midbrain do? Aqueducts, pain, cranial nerves III and IV
What does the pons control? Rate and pattern of respirations
What does the Medulla oblongata control? Swallowing, vomiting, respirations, vasomotor activities
What does the reticular activating system (RAS)control? Sleep and wakefulness
What does the cerebellum do? Coordination of gross and fine motor activities, equilibrium, proprioception , Skilled and voluntary movement
What transmits sensory impulses from the spinal cord to the brain? spinal cord major sensory pathways (ascending)
All spinal cord major sensory pathways (ascending) do what? cross over (decussate) and end in the thalamus, which interprets and sends to appropriate area of cerebral cortex
What are the two tracts of descending messages? corticospinal (pyramidal) tract, extrapyramidal tract
What does corticospinal (pyramidal) tract descending messages control? Voluntary movement, (they cross over)
What does extrapyramidal tract descending messages do? Functions with the basal ganglia and cerebellum to ensure coordination, accuracy, and smoothness of muscle movement
What includes cranial nerves that arise in the brain stem? peripheral nervous system (PNS)
How many cranial nerves are there? 12 pairs
How many spinal nerves are there and where are they? 31 pairs, adjacent to vertebra
Where does the spinal cord ends at? L1-L2
What does each spinal nerve have? Dorsal (sensory/afferent), Ventral root (motor/efferent)
What are dermatomes? Correspond to the level of the spinal cord at which the spinal nerves innervating that region enter and exit
What equipment would you need for a neuro assessment? cotton, flashlight, newspaper, Ophthalmoscope, otoscope, reflex hammer, safety pins, Snellen chart,tape measure, tongue depressor, tuning fork, different shaped objects, stoppered vials
How would you assess mental status with a physical exam? Mini-mental status exam, Evaluation of cerebral cortex, Includes orientation, judgment, Serial sevens, Recent and remote memory, Abstract thinking
How would you assess speech and language? Identify objects, Repeat phrases, Follow commands, Draw a simple object
What are the manifestations of neurologic dysfunction? Altered level of consciousness (LOC) – awareness of self and the environment; Content (thinking, communication, and feeling); Headache, restlessness, irritability, unusual quiet, slurred speech
What is decerebrate posturing? Rigidity of extremities, Extension of arms and legs
What is opisthotonos posturing? usually brain stem pathology, sign of meningeal irritation
What is decorticate posturing? Usually corticospinal pathology, Upper extremities are flexed with internal rotation
What does normal CSF look like? clear, colorless
What is a lumbar puncture? obtain sample of CSF from subarachnoid space
What is a possible complication of a LP? meningeal irritation
What should you look for after LP? Observe for change in neuro stats, Assess vitals, vomiting, restlessness, headaches, Inspect puncture site, Position flat for at least 3hrs, Encourage fluids
If headache after LP, what should you do? administer meds and fluids, keep room dark and quiet, may need blood patch
What does an EEG do? Records electrical activity of brain (Cannot read thoughts)
How are electrodes attached for an EEG? with glue or needles
Nursing interventions for an EEG: No stimulants, Ok to eat, Shampoo immediately, Keep pt awake
What does Electromyography (EMG) & Nerve Conduction measure? electrical impulse as it moves through nerves and muscles
What is Electroencephalography? ultrasound of the brain
Narcotics interfere with assessment of what? pupils and LOC
What are normal changes of aging r/t neuro? decrease in brain size, slower reaction time, decrease short term memory, slower pupils response
If dementia it is more difficult to assess. What should you do to aid in assessing this patient? Include someone who knows pt well, give brief instructions one at a time, consider medication toxicity
What can cause increased intracranial pressure? Brain tumor, Head trauma, Infectious and inflammatory disorders
How do you assess for increased intracranial pressure? Decreased LOC, papilledema, Cushing’s triad, Cheyne-Stokes respirations
What is Cushing’s triad? pulse initially increases, then decreases, systolic increases causing a wide pulse presser, respirations become irregular
What are the goals in treatment of increased intracranial pressure? maintain blood pressure, prevent hypoxia, ensure cerebral perfusion
What drugs are used to manage IICP? Osmotic diuretics, and glucocorticoids
How do osmotic diuretics work on IICP and which one is used? Hyperosmolality draws water from the edematous brain into the vascular system; mannitol
What do you want to carefully measure when a patient is on osmotic diuretics? Measure output carefully
How do glucocorticoids work for IICP and which one is used? Reduce localized (focal) edema from around a mass ; decadron
How would you position a patient with IICP? Head of bed elevated w/head midline, Avoid hip flexion
How would you decrease stimuli for a patient with IICP? Limit movement, move gently, Avoid bright light, loud noise
What do you want to prevent in patients with IICP? constipation, coughing, vomiting
What should you restrict for patients with IICP? fluids
What should a nurse do if there is impaired verbal communication due to IICP? Observe for nonverbal signs of pain (Grimacing, moaning, restlessness), Position comfortably, provide: Paper & pencil, Communication board
What are the signs and symptoms of meningitis? Nuchal rigidity, Photophobia, Kernig’s sign, Brudzinksi sign, Opisthotonos, Petechiae
What diagnostic test would confirm a diagnosis of meningitis? Lumbar puncture and analysis of CSF
What is the medical management of meningitis? Reduction of IICP, IV access, Antimicrobial therapy, Anticonvulsants, Immunizations
Who should be immunized against meningitis? College students, Especially living in dorms
What is the name of the meningitis vaccine? Menomune (Hib offers some protection)
What drug is given for close contacts of meningitis? Rifampin (Rifadin)
What do you assess in patients with a neurologic infectious or inflammatory disorder? Health history, vital signs, neurologic exam
Possible problems for patients with meningitis include: Risk for impaired gas exchange, hyperthermia, acute pain, seizures
What are the nursing interventions for patients with hyperthermia? Administer antipyretics, remove unnecessary clothing and blankets, tepid sponge bath without shivering, maintain hydration, cooling blanket
What are the nursing interventions for patients having seizures? Side rails x 4, padded, Stay with patient during seizure, Turn to side, Do not restrain, Provide privacy, Tongue blade, Observe length and nature of seizure After: Suction, O2, Reorient client, Check for injuries
How is encephalitis contracted? Vector-borne – tic, mosquitoes, birds, Viral infection i.e. West Nile, St. Louis, equine
How can encephalitis be prevented? with vaccination – MMR
How quickly do symptoms of encephalitis come on? hours to weeks
What tests are done to diagnose encephalitis? Lumbar puncture, EEG, MRI
What does encephalitis cause? Severe destruction of nerve tissue, Paralysis, dysphasia, respiratory failure, shock, seizure disorder
What is the medical management of encephalitis? Supportive treatment, Medications
What is the nursing management of encephalitis? Vital signs, LOC, I&O, Assess: bowel elimination, Client education: Avoid exposure to mosquitoes
What is Guillain-BarrÉ Syndrome? Autoimmune reaction; peripheral nerve myelin destruction
What are the assessment findings of a patient with Guillain-Barre syndrome? Tingling, Progressive weakness; paralysis, Ascending; bilateral
Diagnostic tests for Guillain-Barre Syndrome: LP has increased protein, Pressure
What is the medical management of Guillain-BarrÉ Syndrome? Plasmaphoresis; IV immune globulin, Gabapentin, amitriptyline
What is the Nursing Management of Guillain-BarrÉ Syndrome? Monitor respiratory distress, vital signs, Prevent immobility complications, Meticulous skin care
What can cause a brain abscess? Infection – sinusitis, mastoiditis, Intracranial surgery; head trauma; dental surgery
Assessment findings of a brain abscess: IICP; fever; headache; neurolgic changes, Laboratory tests; diagnostic tests
Medical and Surgical Management of brain abscess: Antimicrobial therapy; craniotomy
Nursing Management of brain abscess: Assess LOC, sensory and motor function, signs of IIC, Monitor vital signs, fluid intake and output
What causes Multiple Sclerosis? Autoimmune; genetic; progressive demyelinating disease
What can exacerbate symptoms of MS? Exacerbation r/t infection, stress, heat
What are the Signs & Symptoms of MS? Fatigue, weakness, numbness, tingling, Diplopia, nystagmus, blindness, Ataxia, paraplegia, tremor, Incontinence (neurogenic bladder),Decreased cognitive function
What diagnostic tests are done for MS? Lumbar puncture, CSF with electrophoresis
Medical treatment of MS: Maintain functional capacity, Drug threapy , Antidepressants, steroids
Baclofen or dantrolene is used for patients with MS for what? for muscle spasticity
Oxybutynin & bethanechol is used for patients with MS for what? for urinary symptoms
Glatiramer (Copazone) IM daily for patients with MS for what? Alters T cells to prevent myelin destruction
What can you do for a nursing diagnosis of ineffective coping? Suggest support group, encourage expression of feelings, provide choices to enhance control, facilitate social support, diversional activities for personal achievement
What can you do for a nursing diagnosis of Risk for caregiver role strain? listen empathetically, give permission to meet own needs, develop respite care resources
What causes myasthenia gravis (MG)? Autoimmune, ACh receptor antibodies
Assessment Findings for MG: Muscle weakness; difficulty swallowing, Ptosis; diplopia; mask-like expression, IV: edrophonium (Tensilon); + ACh antibodies
Medical & Surgical Management of MG: Drug therapy; plasmapheresis; thymus removal; respiratory support
Nursing Management of MG: Rest; ventilation; emotional support, Effects of drug therapy and overdose
What is Amyotrophic Lateral Sclerosis (ALS? Degeneration of spinal & brain stem motor neurons, M > F; death within 3-5 years
Assessment Findings of patients with ALS: Progressive muscle weakness, wasting, fasciculations; dysphasia, dysphagia, paralysis, Inappropriate laughing and crying
Medical Management of ALS: Manage respiratory complications; tamoxifen research
Nursing Management of ALS: Comprehensive assessment, assistance with ADLs; caregiver teaching
What causes Trigeminal Neuralgia (Tic Douloureux)? Possible fifth cranial nerve root compression
Assessment Findings of Trigeminal Neuralgia (Tic Douloureux): Severe cyclic pain, Skull radiology; MRI; CT
Medical Management of Trigeminal Neuralgia (Tic Douloureux): Narcotic analgesics; anticonvulsants, Correction of dental malocclusion
Surgical Management of Trigeminal Neuralgia (Tic Douloureux): Surgical division of the trigeminal nerve
Assessment of patients with trigeminal neuralgia: Complete history, Affected area; oral cavity
Nursing Interventions for patients with trigeminal neuralgia: Record weight and ability to eat food, Avoid stimuli that exacerbate attacks, Suppress attacks with Tegretol, alcohol, Injection to nerve, resection of nerve, Avoid rubbing eye, Chew on opposite side of mouth
What causes Bell’s Palsy? Suspected viral link, Inflammation of 7th cranial nerve (motor nerve)
What are the assessment findings for Bell’s Palsy? Facial pain; numbness; decreased blink reflex; ptosis: Diagnostics: symptoms; r/o CVA and tumor
Medical Management of Bell’s Palsy: Short-term steroid w/prednisone, Analgesics; electrotherapy
What are the nursing interventions for Bell’s Palsy? Day: patch, Night: eye shield
Patient’s with Bell’s Palsy are at risk for what? Eye infection; impaired oral mucous membranes, verbal communication
What are the goals for patients with Bell’s Palsy? Understanding eye medication techniques, No infection; unaffected vision, Intact mouth tissue and teeth, Satisfactory verbal communication
Extrapyramidal disorders are disorders of what? Cerebellum and basal ganglia disorders
What causes Parkinson’s disease? Deficiency of dopamine + overactive response to ACh (Slow deterioration, affects > 50 yo )
Assessment Findings for patients with Parkinson’s disease: Hypophonia (low volume voice), Pill-rolling, tremors rigidity, Drooling – dysphagia, increase in salivation, weight loss, Bradykinesia, Shuffling gait, rigid arms
Patients with Parkinson’s are at risk for what? Risk for falls r/t impaired mobility
How is Parkinsons diagnosed? based on exam
Medical Management of Parkinson’s: Drug therapy – dopaminergic, anticholinergics, Meds for depression, PT, OT
What is the Surgical Management (experimental) for Parkinson’s? Stereotaxic pallidotomy – reduce tremor & movement problems, DBS – deep brain stimulation (brain pacer), Gene therapy – increased GABA production, Stem cell therapy
Nursing Management for Parkinson’s: Drug therapy – many side effects, Level of activity; ADLs (goal is to keep the patient as functional as possible)
What causes Huntington’s disease? Genetic transmission
What are the Signs & Symptoms of Huntington’s? Choreiform movements; intellectual decline; elimination difficulties, Diagnosed: history, PET, genetic testing
What is the Medical Management for Huntington’s? Antiparkinson drugs; genetic counseling
Nursing Interventions for Huntington’s: Preventing complications; counseling, Client education: Exercise, medical regimen, ADLs
What is a Seizure? Brief episode of abnormal electrical activity in the brain
What is a Convulsion? Spasmodic contractions of muscles as a result of seizure activity
What is Epilepsy? Chronic, recurrent pattern of seizures
What causes seizure disorders? Idiopathic or acquired, Fever, lyte imbalance, Uremia, hypoglycemia, Hypoxia, tumor, Substance abuse & withdrawal
What causes Epilepsy? Injury; inborn metabolism
Where do Partial/Focal seizures begin? Begin in specific area of brain
What is an elementary focal seizure? < 1min, without loss of consciousness, Motor – uncontrolled jerking movement of body part (Jacksonian), Sensory – hallucination, mumbling, nonsense words
What is a Complex focal seizure? > 1min, confused afterwards, Automatisms/repetitive movement, Lip smacking, picking at clothes
What are the characteristics of generalized seizures? involve entire brain, lose consciousness, seconds to minutes
What are absence seizures (petit mal)? brief seizures, Stares blankly, eyelids flutter, lips move
What are myoclonic seizures? brief seizures, Sudden jerking of arms, legs, entire body
What are tonic-clonic seizures (grand mal)? Pre-ictal phase: aura, epileptic cry, Jerking, thrashing , Impaired air exchange, Incontinence, Post-ictal
What is status epilepticus ? A life-threatening condition in which the brain is in a state of persistent seizure.
Assessment Findings for status epilepticus: Description by witness, Neurologic exam; EEG; CT scan; MRI; serology; serum electrolyte levels
What is the Medical Management of status epilepticus? Anticonvulsant drugs, serum levels
When is Surgical Management done for status epilepticus? Seizures caused by brain tumor, brain abscess, and other disorders
Assessment of patient’s with status epilepticus: Complete history; head injury; infection, Observer description
Nursing Process for status epilepticus: Knowledge deficit: type, medication, and precaution, Epilepsy Foundation, Risks: Injury; impaired oral membrane; anxiety
What causes brain tumors? Congenital; head trauma; viral infection, Radiation; immunosuppression; mets
What percent of brain tumors are malignant? 50% malignant
What are the Signs & Symptoms of brain tumors? IICP; seizures; neurologic function, Headache AM, nausea, vomiting, seizures, visual changes, dysphasia
What tests are done for brain tumors? CT; brain scan; MRI; angiography
What is the Medical Management of brain tumors? Radiation, chemotherapy, and drug therapy
What is the Surgical Management of brain tumors? Craniotomy; craniectomy , Gamma-knife; radiosurgery
Nursing Interventions for brain tumors: Area; tumor; treatment type, Client and family teaching, Medication regimen; home care, Chemotherapy and its effects, Nutritional support; rehabilitation, Support services
Assessment of the patient with a brain tumor: Health history; neurologic examination, Physical assessment
Diagnosis, Planning, and Interventions of the patient with a brain tumor: Acute pain related to IICP; imbalanced nutrition; grieving, Impaired oral mucous membranes
Evaluation of Expected Outcomes of the patient with a brain tumor: Pain relief; balanced nutrition; intact oral mucosa; post-discharge care
What are the nutritional considerations for the patient with a neurological disorder? Promote normal weight range, avoid: Malnutrition, constipation, aspiration
What should a patient on levodopa be aware of nutritionally? eat high protein foods, B6 decreased effectiveness
What should patients on Steroids be aware of nutritionally? decreased sodium, DM diet
What should patients on Anticonvulsants be aware of? vitamin D and calcium imbalance
What is a Ketogenic diet? high fat leads to ketosis which leads to decrease seizures. Can cause mild dehydration and is not proven to be effective.
Client teaching for Drug administration for patients with neurological disordes: Do not skip doses!
What should patients on anticonvulsant therapy wear? medic alert bracelet
Older adults with meningitis have what kind of symptoms? Atypical signs and symptoms, Altered mental status, minimal fever, No nuchal rigidity or headache, Have higher mortality rates
What is the incidence of brain tumors in elderly clients? It is decreased in the elderly
What causes tension headaches? Prolonged contraction of neck and face muscles, Temporomandibular joint disorder (TMJ)
Assessment Findings of tension headaches: Bilateral mild to severe pain, R/O pathology CT scan; brain scan; radiographs; angiography
Medical Management of tension headaches: Rest; mild analgesia, Stress management; counseling
How does a migraine come about? Constriction, then dilation, then pulsation
What are migraines r/t? familial tendency, certain foods, reproductive hormones
Signs & Symptoms of migraines: Aura; mood change, Fatigue; nausea, vomiting, Vertigo; sensitivity to light, Severe pain unilateral
Chemical developments in migraine headaches: Cerebral blood vessels dilate in response to serotonin from platelets. Peptides released from the trigeminal nerve intensify pain.
Medical Management of migraines: Rest , Drug therapy, Prevent or abort, Biofeedback techniques
Nursing Management of migraines: Client instruction: Self-administration of medications, Measures to abort the migraine, Lying in a dark room, Minimizing noise and other stimuli
What causes cluster headaches? Physiologic biorhythms, Lower-than-normal levels of serotonin
Assessment Findings of cluster headaches: Severe pain on one side of the head, Rhinorrhea; symptoms; thermography
Medical Management of cluster headaches: Corticosteroids; ergotamine derivatives, Vasoconstricting drugs; anticonvulsants, Oxygen; rhizotomy
Nursing Process: The Client with a Headache, Assessment: Location; type of pain; past history; duration, Factors that trigger, worsen, or relieve the headache, Other symptoms
Nursing Process: The Client with a Headache, assessment; Clients with chronic headaches: Complete medical, allergy, and family history, Frequency and description of pain, Vital signs
What are the four classes of cerebrovascular disorders? TIA, Reversible ischemic neurologic deficit, Progressive stroke, Completed stroke
What causes TIA? Impaired blood circulation, common in diabetes mellitus
TIAs are sudden and brief. Patients usually get what kind of return of function? Full return of function
Assessment Findings of TIA: Speech and visual disturbances, Confusion; partial paralysis, Bruit
Medical & Surgical Management of TIA: Antiplatelet and anticoagulant therapy, Drug and diet therapy, Carotid endarterectomy, Balloon angioplasty
Nursing Management of TIA: Complete client history, Vital signs and weight, Capillary blood sugar check, Neuro examination, Client monitoring after carotid artery surgery, Client education, Hydration, Medication, Control DM and HTN
What happens in a TIA that’s on the left hemisphere of the brain Disruption in language and speech 95% of patients (depends on handedness), Slow and cautious behavior style, Motor paralysis on right side, Memory deficits
What happens in a TIA that’s on the right hemisphere of the brain? Left side paralysis, Spatial/perceptual deficits, Quick/impulsive behavior, Memory deficits
Diagnosis of CVA: Exam and history, CT or MRI to differentiate type, Doppler, EKG (r/o cardiac cause of early symptoms)
What kind of CVA can be fixed and which kind cannot? Can fix clot, cannot fix ruptured blood vessel
Management of CVA: Treat predisposing conditions such as hypertension, Anticoagulation, platelet anti-aggregation, Carotid endarterectomy, microvascular bypass, Research into utilizing “clot busting meds” for occlusive CVA is ongoing
Nursing diagnosis r/t CVA Risk for ineffective breathing pattern interventions: HOB elevated 30 degrees, Pulmonary, toilet q2h, O2, Ventilation
Nursing diagnosis r/t CVA Risk for aspiration r/t dysphagia interventions: Suction at bedside, HOB elevated 30 degrees, Prevent aspiration by avoiding solid and liquid foods and providing semisolid foods
Nursing diagnosis r/t CVA Impaired physical mobility interventions: HOB elevated 30 degrees, Position prone 30min per day to prevent flexion contractures
Nursing diagnosis r/t CVA Risk for altered circulation interventions provide anti-embolism stockings
Nursing diagnosis r/t CVA Self care deficit interventions: Suggest clothing one size larger than normal constructed of stretchy fabric, Use mirror to dress
Nursing diagnosis r/t CVA Risk for altered nutrition interventions: weigh weekly initially, Teach patient to chew on unaffected side of mouth, Low salt, low cholesterol diet, Provide supplemental feedings as necessary, Consult speech therapist
Nursing diagnosis r/t CVA Risk for constipation interventions: Bowel regimen
Nursing diagnosis r/t CVA Altered urinary elimination interventions: Indwelling catheter initially, Then institute a bladder program
Nursing diagnosis r/t CVA Risk for injury interventions: Encourage patient to think through steps before initiating activity, Give simple instructions, one step at a time, Careful attention to affected shoulder joint to prevent subluxation, Support arm on pillow, Never lift by affected shoulder
Nursing diagnosis r/t CVA Unilateral neglect interventions: Approach patient from unaffected side, Place items on unaffected side, Encourage patient to scan full visual field by turning head toward affected side, Encourage activities that cause the patient to pass midline i.e. hair brushing with mirror
Nursing diagnosis r/t CVA Impaired verbal communication r/t aphasia interventions: Reduce environmental distraction, Establish eye contact, Speak slowly and clearly using questions that can be answered “yes” or “no”, Utilize picture board or written messages, Consult speech therapy
What causes cerebral aneurysms? Congenital; secondary to hypertension and atherosclerosis
Where do cerebral aneurysms usually occur? Most often in the Circle of Willis
Assessment findings for cerebral aneurysms: Sudden, severe headache (“worst headache of my life”), Dizziness; nausea, vomiting, Loss of consciousness, Cerebral angiography, CT scan, MRI, Lumbar puncture, Hunt-Hess classification system (Grade I-V)
Medical Management of cerebral aneurysms: Complete bed rest, Prevention of rebleeding (prevent fluctuation of blood pressure) , Treatment of complications, Anticonvulsants; tranquilizers, Mechanical ventilation, Careful observation
Surgical Management of cerebral aneurysms: Craniotomy, Ligation of carotid artery
What does the nurse assess for cerebral aneurysm? Neurologic examination; vital signs; history
Diagnosis, Planning, & Interventions for cerebral aneurysms: IICP, Seizures, Pain, Self-care deficit r/t imposed rest and decreased LOC, Risk for ineffective peripheral tissue perfusion; impaired skin integrity
Expected Outcomes for patients with cerebral aneurysms: IICP maintained within a safe range, No seizures, Tolerable level of discomfort, Nutrition, hydration, ventilation, and elimination needs are met, Peripheral circulation is adequate, Skin integrity preserved, Discharge teaching
People who gets migraines should journal what? foods eaten
People with migraines should inform physician about what herbal supplement because it can be a trigger? herbal feverfew
What drugs should be taken for the prevention of thromboembolic disorders? Clopidogrel (Plavix), Dipyridamole (Persantine), ASA given prophylactically for TIAs
What is the antidote for oral anticoagulants? parenteral vitamin K
What causes a concussion? Blow to head that jars the brain
What is a concussion? Temporary neurologic impairment
Assessment Findings for concussion: Brief lapse of consciousness; disorientation, Headache; blurred or double vision, Emotional irritability; dizziness, Skull radiography, CT scan, MRI
Medical Management of concussion: Halting of activity causing concussion, Mild analgesia, Observation for neurologic complications
Nursing Management of concussion: Neurologic assessment, Close observation for signs of IICP, Client instruction: contact MD or return to ER if symptoms of IICP occur
Pathophysiology & Etiology of contution: Coup and contrecoup injury, Cerebral edema
Assessment Findings contusion: Hypotension; rapid, weak pulse, Shallow respirations; pale, clammy skin, Temporary amnesia, Effects of permanent brain damage, Skull radiography; CT scan; MRI
Medical Management contusion: Drug therapy; mechanical ventilation
Nursing Management contusion: Periodically monitor: LOC; neurologic changes; respiratory distress; signs of IICP; vital signs
Steps to prevent head injuries: Seatbelts; infant car seats; protective headgear; neck restraints; no alcohol or drugs while driving
What causes cerebral hematomas? Head trauma, Cerebral vascular disorders
What are the types of cerebral hematomas? epidural, subdural, intracerebral
Assessment Findings of cerebral hematomas? Depends on location, rate of bleeding, size of hematoma, autoregulation , MRI, CT scan, ICP monitoring
Indications of surgical emergency r/t cerebral hematomas: rapid change in LOC, Signs of uncontrolled IICP
What surgeries are done for cerebral hematomas? Burr holes, Intracranial surgery: craniotomy, craniectomy, and cranioplasty
All head injuries are how urgent? All head injuries are emergencies.
Nurse’s role r/t head injury: History; neurologic exam; vital signs; LOC, Movement in limbs; pupil exam
What should nurse check in a patient who has had a trauma ? Head exam, Respiratory status, Neurologic changes
Preoperative nursing care r/t cerebral hematoma: Hair removal; vital signs; neurologic assessment; antiembolism stockings, If indicated: IV, catheter, Restrict: fluids
Postoperative nursing care r/t cerebral hematoma: Supine or side-lying (on unaffected side) position, Regular monitoring; observe for IICP, Control thrombus or embolus; cerebral edema
What are the types of head injuries? open, closed
What are the types of skull fractures? simple, depressed, basilar
Signs & Symptoms of skull fractures? Localized headache, bump, bruise, laceration, hemiperesis; shock, Rhinorrhea, otorrhea, Periorbital ecchymosis, Battle’s sign, Conjunctival hemorrhages, seizures
What is the medical management of a simple fracture? bed rest, observation for IICP
What is the medical/surgical management for lacerated scalp? clean, debride, and suture
What is the medical/surgical management of depressed skull fracture? craniotomy, antibiotics, osmotic diuretics, anticonvulsants
Nursing Management skull fracture: Signs of head trauma, Drainage from the nose or ear, Halo sign, Neurologic assessment
What is the neurologic assessment for skull fx? Hourly: LOC; pupil, motor, and sensory status, Every 15-30min: vital signs, Prepare for the possibility of seizures
Pathophysiology & Etiology of SCI: Accidents (vehicular); violence, Spinal shock (Areflexia): Poikilothermia (inability to regulate one’s own body temperature), Autonomic dysreflexia (hyperreflexia)
Assessment Findings of SCI: Pain, difficulty breathing, Numbness, paralysis, Neurologic exam, Radiography, myelography, MRI, CT scan
Medical Management of SCI: Cervical collar; cast or brace; traction; turning frame, IV; stabilization of vital signs, Corticosteroids, Surgical intervention
Surgical Management of SCI: Remove bone fragments, Repair dislocated vertebrae, Stabilize the spine
How long can spinal shock last? May last several weeks
What happens in spinal shock regarding the impulses? Impulses cannot move past the injured area, Flaccid paralysis below injury
What might spinal shock require? May require vasoactive meds and ventilation
What happens with spinal shock? Urinary and fecal retention occur, paralytic ileus, BP very unstable r/t lost vasomotor tone, perspiration absent below injury, males may have priapasm
Autonomic dysreflexia is a life threatening complication that may cause what? May cause CVA or MI
Autonomic dysreflexia is usually related to what? full bladder or constipation
What happens with autonomic dysreflexia? Massive sympathetic discharge from the autonomic nervous system, Vasoconstriction, Extreme hypertension, Bradycardia, profuse sweating above level of injury, cyanosis below level of injury
Autonomic dysreflexia triggers: Full bladder, Constipation, Drafts, Too hot or too cold, Pain, Injury
Treatment of autonomic dysreflexia is to avoid: triggers or relieve distention
Nursing Process: Care of the Client with Spinal Trauma Assessment: Injury; treatment given at scene, Neurologic assessment: document findings, Vital signs; respiratory status, Movement and sensation below injury level, Signs of worsening neurologic damage, Respiratory distress, Spinal shock
Nursing Process: Care of the Client with Spinal Trauma Diagnosis, Planning, & Interventions: Ineffective breathing pattern, Ineffective airway clearance, Neuropathic pain, Impaired physical mobility, Anxiety, Risks: Impaired gas exchange, Disuse syndrome, Ineffective coping
Nursing Process: Care of the Client with Spinal TraumaEvaluation of Expected Outcomes: Adequate breathing, Pain relief, Mobility using minimal assistive devices, Reduced complications from inactivity, Coping with the challenge of rehabilitation
What causes spinal nerve root compression? Trauma, Herniated intervertebral discs, Tumors of the spinal cord
Assessment Findings of spinal nerve root compression: Weakness; paralysis, Pain; paresthesia, Spinal radiography, CT, MRI, myelography , Electromyography
Medical Management of spinal nerve root compression: Cervical collar or brace; bed rest; skin traction; hot moist packs, Skeletal muscle relaxants; drug therapy; corticosteroids; analgesics
Surgical Management of spinal nerve root compression: Diskectomy, Laminectomy, Spinal fusion, Chemonucleolysis (Inject papain to dissolve disc)
Nursing Management of spinal nerve root compression: Neuro examination, Conservative therapy, Spinal support and alignment, Bed rest in Williams’ position (Knees and head slightly elevated), Tractions, Proper body mechanics, Muscle relaxants and analgesics; moist heat application, eval response to therapy
Nursing Management after spinal surgery for spinal nerve root compression: Monitor vital signs, Hourly deep breathing exercises, Examine the dressing for CSF leakage or bleeding, Assess neurovascular status, Voiding status, Fracture bed pan
Why is hypercalcemia a concern for patients with SCI? The immobilization from SCI stimulates osteoclastic bone resorption. This results in calcium loss from the bones and hypercalciuria. Hypercalcemia results when the efflux of calcium is massive or the glomerular filtration rate of the kidneys is reduced
Nutritional considerations for patients with SCI: Adequate, regular fluid intake, High-fiber diet
What does mannitol do after surgery? reduction of ICP after surgery
Older adults Often respond less favorably to therapies for what? a neurologic deficit
Older adults may incur a chronic fluid volume deficit. How much fluid should they be encouraged to take in? Encourage a fluid intake of 1,500 to 2,000ml per day
Phases of a Neurologic Deficit: Acute Phase Medical and Surgical Management: Stabilization; prevention of further neurologic damage, Drug therapy, Mechanical ventilation, Surgical intervention
Phases of a Neurologic Deficit: Acute Phase Nursing Management: Frequent neurologic assessments: Glasgow coma scale & Mini-Mental Status Examination, Basic rehabilitation measures, Assess vital signs, Maintain BP, Observe: Signs of electrolyte imbalances, Dehydration
Phases of a Neurologic Deficit: Recovery Phase Medical & Surgical Management: Keeping the client stable, Preventing or treating complications
Phases of a Neurologic Deficit: Recovery Phase Nursing Management: Rehab program Planning and implementation, Assess Client’s level of functioning & Potential for improvement
Phases of a Neurologic Deficit: Chronic Phase Medical & Surgical Management: Therapies and treatments, Control of BP, Physical therapy, Dietary management, Treatment of complications, Surgery: Muscle and skin grafts, Contracture deformity correction, Kidney stone removal
Phases of a Neurologic Deficit: Chronic Phase Nursing Management: Preventing physical and psychological complications, Rehabilitation center therapy: Retraining in skills
Nursing assessment of the patient with a neurologic deficit: Thorough history, Vital signs, level of comfort, General neuro assessment (Babinski reflex), Evaluation: airway, breathing, circulation, and LOC, Skin inspection, Bowel sounds, bladder distention, bowel and bladder control, Emotional and mental status
Nutritional considerations for the patient with a neurologic deficit: Adequate fluid intake prevents renal stone formation, Fiber aids in normalizing bowel movements
Nutritional considerations for Paraplegics and tetraplegics : Reduce calories to avoid weight gain, Diet requires nutrient-dense foods to be nutritionally adequate
What kind of diet is good for a patient with pressure ulcers? A diet high in protein, vitamin C, and zinc helps prevent or heal pressure ulcers
What do glycerin suppositories do? soften the stool in the lower rectum
What does bisacodyl (Dulcolax) do? stimulates peristalsis in the terminal section of the colon
What are the kinds of enemas? plain water, glycerin, Fleet brand enema
Gerontologic Considerations r.t neurologic deficit: Involve social services and other agencies to assist with rehabilitation, Aging-related functional problems may complicate recovery, Allow extra time to answer questions, perform activities, Regularly palpate the bladder for distention
Created by: angepu