2900 Exam Two Flashcards
1
Q
what are some signs of decreased cardiac output?
A
hypotension fatigue tachycardia weak peripheral pulses cool extremities hypoxemia
2
Q
what is cardiac output?
A
volume of blood in liters pumped by the heart in one minute
3
Q
what can cause acute hypertension?
A
not adhering to BP meds cocaine/amphetamines/PCP/LSD pre-eclampsia rebound hypertension from stopping beta blockers head injury renovascular hypertension
4
Q
hypertensive urgency
A
rapid increase in BP that does not include target organ damage
5
Q
hypertensive emergency
A
rapid increase in BP (usually at or above 180/110) with target organ damage. requires hospitalization and prompt treatment with IV meds
6
Q
which organs are target organs?
A
brain
heart
kidneys
eyes
7
Q
what brain issue can occur in hypertensive crisis?
A
hypertensive encephalopathy
8
Q
T/F: rate of BP rise in hypertensive crisis is more important than the BP number itself
A
true
9
Q
what reading is used during hypertensive emergencies to guide and evaluate drug therapies?
A
MAP: mean arterial pressure
10
Q
what is the goal with MAP during a hypertensive crisis?
A
decrease by 20-25%
11
Q
what is the most effective drug to treat HTN crisis?
A
sodium nitroprusside
12
Q
what other drugs can be given in a HTN crisis?
A
adrenergic inhibitors like labetelol
calcium channel blockers
13
Q
what should the nurse remember when giving IV meds for hypertensive crisis?
A
meds work in seconds when given IV, so assess BP every 2 minutes
we don’t want to drop the BP too quickly, as that can cause stroke, MI, or renal failure
monitor ECG
monitor I&O
have patient change position slowly and possibly initiate bed rest
14
Q
etiology of coronary artery disease
A
atherosclerosis
15
Q
what is collateral circulation in CAD?
A
growth of arterial anastamoses. ischemia in some areas leads to angiogenesis in other areas to allow for adequate blood supply to organs
16
Q
CAD modifiable risk factors
A
elevated serum lipids hypertension tobacco use inactivity obesity diabetes metabolic syndrome stress increased homocysteine
17
Q
CAD non-modifiable risk factors
A
age gender ethnicity family history genetics
18
Q
physical activity recommendations to reduce risk of CAD
A
FITT activity
30 minutes of walking at least 5 days a week
19
Q
what are the most widely used lipid lowering drugs?
A
statins
20
Q
what do niacins do?
A
interfere with LDL synthesis and increase HDL levels
21
Q
why is low dose asprin recommended for most CAD patients?
A
to prevent clotting/platelet aggregation
22
Q
chronic stable angina
A
chest pain that is present upon exertion but goes away at rest. Intermittent pain that usually has similar onset, duration, and intensity. not a medical emergency but doctor still needs to evaluate
23
Q
PQRST pain assessment
A
Precipitating event Quality of Pain Region/radiation of pain Severity Timing
24
Q
what is the first line drug of choice for angina?
A
nitroglycerin
25
what does nitroglycerin do?
dilate coronary blood vessels
26
what do long acting nitrates do? give an example
they reduce the frequency of anginal attacks
| example: isosorbide dinitrate
27
what do ace inhibitors do to help angina? give an example
vasodilate and reduce blood volume
| example: lisinopril
28
what do beta blockers do to help angina? give an example
decrease myocardial contractility, BP, and HR
| examples: carvedilol or metoprolol
29
what do calcium channel blockers do to help angina? give an example
vasodilation
decreased myocardial contractility
decreased heart rate
examples: amlodopine, diltiazem
30
what do patients need to be taught regarding taking nitroglycerin?
can be taken repeatedly every five minutes for up to three doses
contact emergency response if symptoms don't improve
sit down to take and place it under the tongue
31
what are some diagnostic studies for CAD?
```
cardiac catheterization
ECG
chest x-ray
labs
echocardiogram
stress test
```
32
what is cardiac catheterization?
radiation with IV contrast dye to image coronary circulation and identify blockages
33
chronic unstable angina
chest pain not relieved with rest. pain increased in frequency over time. requires acute intensive drug therapy and prompt treatment
34
unstable angina is a warning sign of...
impending MI
35
how much time does it take for prolonged ischemia to do irreversible damage?
20 minutes
36
what three conditions are included in acute coronary syndrome?
unstable angina
NSTEMI
STEMI
37
how quickly does the artery need to be opened up in STEMI?
within the first 90 minutes
38
what is occurring in a NSTEMI?
the thrombus is non-occlusive. patient usually has procedure to fix the problem 1-2 days later
39
what are clinical manifestations of MI?
```
severe unrelieved chest pain or pressure that may radiate to other parts of the body
SNS stimulation leading to increased HR/BP, clammy skin, and diaphoresis
decreased cardiac output
abnormal heart sounds
crackles
decreased renal perfusion
N/V
fever
```
40
how might MI present differently in women?
women may have more anxiety and shortness of breath than traditional pain
41
what are diagnostic studies for MI?
```
ECG
serum cardiac biomarkers
coronary angiography
chest x-ray
lipid profiles
Holter monitor
stress test
cardiac catheterization
```
42
what changes might be seen on the ECG with an MI?
changes in ST segments or T waves
43
what serum cardiac biomarkers are looked at when assessing for an MI?
cardiac troponins
CK-MB
myoglobin
44
what is a PCI?
percutaneous coronary intervention: it's angioplasty to open a blocked artery
45
when is thrombolytic therapy used? what are some examples of those drugs?
used when patients have a STEMI to dissolve the thrombus
| tPA, streptokinase, urokinase
46
what are some other options to remove a clot in MI?
artherectomy: catheter insertion to remove clot
endarterectomy: surgically open artery to remove plaque
47
what does a coronary artery bypass graft (CABG) do?
provide blood between aorta and other major arteries to the ischemic heart muscle
**open heart surgery**
48
what are nursing management priorities in acute MI?
```
continuous monitoring (EKG, chest, lungs, heart sounds)
pain relief
rest/comfort/anxiety relief
support healthy coping
education
```
49
what are some teaching points that nurses should tell patients about nitroglycerin?
how to take it and when to call 911
light and heat sensitive med
throw away once past expiration date
50
what is clopidogrel (plavix)? what specific instruction do patients need in regards to taking it?
a long acting antiplatelet/anticoagulant
| they must stop taking it 5-7 days before surgery
51
when should statins be taken, and why?
in the evening, because the body gets rid of more cholesterol at night
52
what is malfunctioning diastolic heart failure?
ventricular filling
53
what is malfunctioning in systolic heart failure?
ventricular ejection
54
in what ways does the body try to compensate in heart failure?
pumping faster
dilation/enlargement of heart chambers over time
hypertrophy of ventricle muscle over time
RAAS
55
left sided heart failure
most common type, caused by inability of left ventricle to fill or empty properly
fluid backs up into lungs and causes pulmonary symptoms
56
right sided heart failure
usually caused by left sided heart failure. right ventricle fails to pump properly, causing backup of fluid into the venous system
57
right sided heart failure symptoms
```
edema
ascites
nocturia
skin changes (dusky, shiny, swollen)
weight changes
```
58
what are some possible meds that can be used in heart failure?
```
digoxin
beta blockers
diurectics
vasodilators
ace inhibitors
ARBs
```
59
what are some manifestations of acute decompenstated heart failure?
```
pulmonary and systemic congestion
increased RR
decreased o2 sats
interstitial edema
jugular venous distension
anxious
pale
cyanotic
```
60
what are some nursing interventions for acute decompensated HF?
```
high fowlers
oxygen
intraaortic balloon pump
positive pressure ventilation
monitor BNP and potassium
monitor urine output
continuous ECG and pulse oximetry
drug treatment
ultrafiltation
hemodynamic monitoring
```
61
what is ultrafiltration?
rapidly removing excess fluid buildup
62
what electrolyte problem can be caused by digoxin?
hypokalemia
63
what is telemetry?
monitoring cardiac vitals remotely
64
what is an intraaortic balloon pump?
balloon placed in thoracic aorta to reduce afterload and help aortic pressures
65
what are indications for the use of an intraaortic balloon pump?
unstable angina
bridge to a transplant
acute MI
before, during, or after heart surgery
66
why does an intraaortic balloon pump help with worsening heart failure?
it decreases pulmonary artery pressures and systemic vascular resistance to improve cardiac output
67
how does morphine help in heart failure?
it decreases anxiety, preload, and afterload
68
what are some examples of positive inotropes and what do they do?
digoxin, dobutamine, and dopamine
| they increase contractility and cardiac output
69
what are some signs of digoxin toxicity?
nausea/vomiting
visual changes (green/yellow halos)
hypokalemia
70
what needs to be monitored before taking digoxin or other positive inotropes?
apical or radial pulse
71
when is a cardiac defibrillator used?
to end v-fib or v-tach; used in emergency situations only
72
when is cardioversion used?
used for v-tach to deliver a synchronized shock
73
with an implanted pacemaker, what can hiccups indicate?
generator is stimulating the diaphragm
74
what are some teaching points for client with new pacemakers?
carry a pacemaker ID
don't lift arm above shoulder for 1-2 weeks
take daily pulse and notify doctor if different than pacemaker pace
no contact sports or heavy lifting for two months
inform dentists/doctors/airport security about pacemaker
no strong magnets
75
what lab is 98% effective in diagnosing or ruling out HF?
BNP
76
why do we encourage all patients to report pain?
because unrelieved pain has adverse consequences
77
should the nurse rely on physical signs of pain as the sole source of pain assessment?
no, not unless the patient cannot self report, as these signs are not reliable or specific
78
what is included in subjective data in a pain assessment?
health history, including pain info/history, coping factors, treatments tried
drug and non-drug measures used for pain
functional health assessment (health perception, elimination, activity/exercise, sexuality, coping, stress tolerance)
79
what is included in objective data in a pain assessment?
physical exam
| psychosocial evaluation and patient mood
80
what is breakthrough pain?
moderate to severe pain in patients whose baseline persistent pain is normally well controlled
81
what is end of dose failure?
pain occurring before the expected duration of a specific analgesic
82
what is episodic/procedural/incident pain?
transient pain increase caused by specific activity or event
83
what do we want to ask about pain location?
where it is (localized, multiple locations, or all over)
| if it radiates
84
what do we want to assess about pain intensity?
rating on pain scales or observation for nonverbal patients
85
what is FLACC and on whom is it used?
a pain scale looking at face, legs, activity, cry, and consolability
used for those between 2 months and 7 years old
86
what do we want to know about quality of pain?
nature or characteristics of the pain (using descriptive words)
87
what are some associated symptoms that might be seen with pain?
anxiety
fatigue
depression
insomnia
88
what are some management strategies that patients might use to deal with pain?
```
drugs
non-drug methods
acupuncture
imagery
cold/heat
```
89
what do we want to know about the impact of pain when assessing pain?
what effect it has on quality of life, sleep, functioning, and mood
90
why do we assess patients beliefs, expectations, and goals when doing pain assessment?
because some beliefs and attitudes about pain and pain management can hinder effective treatment
91
what is the PAIN-AD scale?
pain scale for advanced dementia patients
92
how often should pain be reassessed?
every 2 hours, and reassessed 15-30 minutes after giving pain medications IV
93
what should pain treatment be based on?
patient goals
94
what is a multimodal approach to pain management?
using two or more analgesic agents to take advantage of various mechanisms of action
95
what are some main side effects/risks of opioids?
```
constipation/N/V
sedation
respiratory depression
urinary retention
delayed gastric emptying
```
96
what patient groups are at higher risk of respiratory depression with opioids?
```
those over 65
opioid naive patients
those with history of snoring/apnea
those with cardiac or lung disease
smoking history
obese patients
```
97
what is the risk of meperidine (demerol)? how long can it be used for?
neurotoxicity risk, use for less than 48 hours
98
what should the nurse do if the patient becomes oversedated?
administer oxygen
reduce opioid dose
stimulate patient to keep awake
99
what are the benefits of nondrug therapies for pain?
they can reduce dose of analgesic needed, minimizing side effects of drug therapy
100
what are some examples of nondrug pain management strategies?
```
massage
acupuncture
exercise
TENS units
heat and cold
cognitive therapies
distraction
hypnosis
relaxation
```
101
what is a TENS unit?
transcutaneous electrical nerve stimulation - delivers an electric current through electrodes attached to the skin over the painful region
102
define tolerance
needing an increased opioid dose to maintain the same degree of analgesia
103
define dependence
withdrawal syndrome occurs when drug is abruptly stopped
104
define addiction
patient having a drive to obtain and take drugs for reasons other than prescribed therapeutic value
105
what are gerontological considerations for pain assessment and management?
geriatric pain his highly prevalent but poorly assessed and managed
use age appropriate assessment tools and watch for different language choices in describing pain
may need lower doses of analgesic due to buildup in body/slower metabolism
106
what are some things to remember when assessing pain in nonverbal patients?
obtain a self report if possible (never assume they cannot communicate at all)
investigate pain causes
observe behaviors
get reports from family and caregivers
try analgesics and reassess pain-related behaviors
107
what are nursing considerations for acetaminophen?
oral daily dose not to exceed three grams due to hepatotoxicity risk
108
why is asprin mainly prescribed now?
cardioprotective benefits
109
what is the risk of prolonged asprin use?
upper GI bleed
110
what are nursing considerations for NSAIDs like ibuprofen and naproxen?
use lowest dose for shortest possible time
| high risk of serious GI events like bleeding or ulcers, especially in older adults
111
what are nursing considerations for ketorolac?
limit use to 5 days, renal failure risk in dehydrated patients
112
what assessment tool should be used specifically for angina?
PQRST assessment
113
what kind of pain is opioid medication prescribed for?
moderate to severe pain
114
what are adjuvant drugs?
drugs originally made for another purpose that also help in pain management. can be used alone or in combination with other pain meds
115
what is amitriptyline and what is it often used for outside of its original purpose?
its an antidepressant that is often also used for neuropathic pain
116
what is bupropion and what is it often used for outside of its original purpose?
an antidepressant thats often used for neuropathic pain
117
what is carbamazepine and what is it often used for outside of that purpose?
an antiseizure drug often used for neuropathic pain
118
what is baclofen and what is it often used for outside of that purpose?
a muscle relaxant, often also used for neuropathic pain
119
what is a nerve block and when is it often used?
infusion of local anesthetics into a particular area to produce pain relief (regional anesthesia)
often used during and after surgery for pain management
120
what are some adverse effects of nerve blocks?
```
dysrhythmias
confusion
N/V
blurred vision
tinnitus
metallic taste
```
121
what are neuroablative techniques and when are they used?
destruction of the nerve to interrupt pain transmission
| used for severe pain unresponsive to other treatments
122
what is neuroaugmentation?
electrically stimulating the brain and spinal cord, often used for back pain or other pain unresponsive to other therapies
123
what kind of patients are most likely to die from burns?
children under four and adults over 65
124
what is the most common type of burn injuries?
thermal burns, from things like flash, flame, scald, or hot objects
125
what kind of chemical burns are harder to manage and why?
alkali burns, because it adheres to tissues and causes protein hydrolysis and liqeufaction
126
what happens in metabolic asphyxiation?
inhalation of smoke elements like carbon monoxide causes hypoxia
127
what are some signs and symptoms of upper airway injury with smoke inhalation?
```
blisters
edema
difficulty swallowing
copious secretions
stridor
retractions
total airway obstruction
```
128
what causes lower airway injury in burn situations?
duration of exposure to smoke or heat
129
what are signs and symptoms of lower airway injury in burns?
```
facial burns
dyspnea
carbonaceous sputum
wheezing
hoarseness
altered mental status
```
130
what are common causes of thermal burns?
```
cooking
smoking
burning leaves
gasoline/hot oil
hot steam or liquid
```
131
what are common causes of chemical burns?
cement
oven/drain cleaner
industrial cleanser
petroleum products
132
what are common causes of smoke and inhalation injury?
house/structure fires
133
what are common causes of electric burns?
frayed or defective wiring
extension cords
power lines
live electric sources
134
what is meant by the "iceberg effect" in electrical burns?
majority of damage is unseen, and damage can continue to muscles or bones hours to days after the initial injury occurs
135
why might bones fracture with electrical burn situations?
muscles might tense severely enough to fracture bones if electric current is strong enough
136
how can electrical burns cause acute tubular necrosis?
muscle injury and breakdown releases myoglobin into the bloodstream, blocking the renal tubules
137
cold burns are normally attributed to..
frostbite
138
what are some examples of friction burns?
road rash or rugburn
139
what four factors determine severity of burns?
depth of burn
extent of burns (TBSA)
location of burns
patient risk factors
140
when calculating total body surface area, over what percentage of burns should trigger immediate relocation to burn unit?
over 20%
141
what locations for burns are the most risky?
face, head, neck, and torso (especially circumferential around torso)
142
what are some risk factors that will hinder burn healing?
```
diabetes
heart failure
children/elderly
lung and kidney disease
PVD
weakness/malnutrition
alcoholism/drug addiction
other injuries or trauma
```
143
what is the greatest initial threat to a patient with a major burn?
hypovolemic shock
144
what happens to BP and HR in hypovolemic shock?
decreased BP, increased HR
145
what is second spacing?
fluid moving from vascular space to surrounding tissues
146
what is third spacing?
fluid moving to areas that normally have minimal to no fluid
147
what are signs and symptoms of hypovolemic shock?
```
decreased BP and increased HR
exudate
edema/extreme swelling
shivering
changes in LOC
```
148
how will first degree burns look?
pink or red with no blisters and warm to the touch
149
how will second degree burns manifest?
very painful
blisters
shiny/moist/red skin
150
how will full thickness burns manifest?
dry/leathery
will have eschar
no pain due to destruction of nerve endings
coagulation necrosis will be present
151
what does healing/treatment look like for full thickness burns?
will not heal on its own, must have skin grafts
152
what is an escharotomy?
cutting through eschar and other damaged tissue to prevent compression of organs and vessels. done in burns due to intense swelling and constricting features of circumferential burns
153
what is the goal in the emergent phase of burn management?
preventing hypovolemic shock and preserving organs
154
what areas, when burned, will have an especially hard time healing?
ears, nose, hands, feet, joints
155
how are airways usually maintained in burns?
early intubation and likely oxygen administration
156
what is compartment syndrome?
tight eschar band in burn areas
157
how would one assess for compartment syndrome?
assess pulses, temperature, and capillary refill distal to the burned area
158
what are some major risks to burn patients as the burns heal?
infection
contractures
compartment syndrome
159
what formula is used to calculate fluid resuscitation?
parkland baxter formula
160
what does the parkland baxter formula say?
give 4 ml of lactated ringers per kg of body weight per percent of TBSA over the first 24 hours
161
how should the fluid calculated by the parkland baxter formula be given in that first 24 hours?
half in the first 8 hours
one fourth in the second 8 hours
one fourth in the last 8 hours
162
why is lactated ringers given to burn patients?
to expand intravascular compartment
163
why might colloids (albumin) be given to burn patients?
because albumin is lost to the interstitial space, and colloids help get the fluid back into the intravascular space
164
how does the nurse determine if fluid resuscitation is working?
monitoring urine output (want 30 or more ml/hour)
165
what is debridement?
removal of necrotic tissue so new tissue can grow
166
what are the two methods of wound care for burns?
open (topical ointment only)
| closed (topical ointment and sterile covering)
167
what is the most commonly used topical antimicrobial for burns?
silver sufladiazine
168
what are some other common drugs given to burn patients?
tetanus shot
analgesics for pain control
antidepressants
anticoagulants
169
why would burn patients receive heparin?
to reduce risk of venous thromboembolism
170
why should burned areas of the body never be touching one another?
so skin doesnt heal together in a webbed fashion
171
what should the nurse remember about burn patients and pillows?
do not use them, as they will compromise circulation to ears and neck
172
how can the nurse/IDT help prevent contracture formation for burn patients?
PT
ROM activities
splinting
173
what should the nurse teach the burn patient about continuing skin care?
use compression hose to tighten skin
moisturize skin often
use good sun protection, skin will not grow back as strong as before!
174
what is the best route for pain medication for burn patients?
IV
175
what are some specific nutrition needs for burn patients?
high calorie/protein/carbs
lots of extra calories (sometimes 2-3 times normal needs)
vitamins A, C, E, zinc, iron
176
what are some diagnostic studies for DVT?
d-dimer
venography scans
pTT or INR
177
what are some common causes of DVT?
bed rest
a-fib
dehydration
hypercoagulation
178
what are some s/s of DVT?
leg edema
pain/warmth/redness at side of thrombus
numbness
179
what are some key prevention measures for DVT?
```
early and aggressive mobilization
compression stockings
compression devices
position changes
flexing and extending feet and knees
sitting in chair for meals and walking 4-6 times a day
```
180
what is the main vitamin k antagonist anticoagulant?
warfarin
181
what is the antidote to warfarin?
vitamin K
182
what are some examples of thrombin inhibitor anticoagulants?
heparin/enoxaparin
183
how does one check the effectiveness of heparin therapy?
pTT lab draw
184
how does one check the effectiveness of warfarin therapy?
INR lab draw
185
what is the antidote to heparin?
protamine sulfate
186
what is an example of a factor Xa inhibitor?
rivaroxaban
187
what is a risk of rivaroxiban?
no antidote
188
what is a benefit of rivaroxaban?
no need for periodic blood draws
189
what is the most serious complication of DVT?
pulmonary embolism
190
what should not be taken in conjunction with anticoagulants?
NSAIDs
antiplatelets
some herbals
191
what are manifestations of PE?
```
dyspnea (most common presenting symptom)
mild hypoxemia
tachypnea
cough
chest pain
crackles/wheezing
fever
tachycardia
shortness of breath
```
192
what are PE's normally made up of?
clot, fat, air, or tumor piece
193
what are complications of PE?
pulmonary infarction
| pulmonary hypertension
194
what drug might be given if a PE occurs?
thrombolytic
195
what do vena cava filters do?
sit in the veins and catch blood clots to prevent PE
196
what is an embolectomy and when might it be used?
surgical removal of embolism if thrombolytics dont resolve a PE
197
what are nursing cares for PE?
```
bed rest
oxygen administration
head of bed elevated
frequent assessment of heart/lungs/oxygen sats
IV fluid
monitor PTT or INR
monitor for bleeding/bruising
fall prevention
explain situation to patient and help manage anxiety
```
198
what is a stroke?
when blood cannot reach brain cells and brain starts to die
199
what are the two types of strokes?
ischemic or hemorrhagic
200
what are causes of ischemic strokes?
vessel blockage from a blood clot (embolus) or from stenosis. common causes are a-fib and carotid stenosis
201
what are common causes of hemorrhagic strokes?
brain aneurysm rupture/leakage or uncontrolled hypertension wearing out the vessels in the brain
202
what is a TIA?
transient ischemic attack: an ischemic event caused by some form of blockage that dissolves/passes on its own after a few minutes or hours. However, it is a warning sign of impending stroke and should be evaluated
203
functions of the frontal lobe
thinking, speaking, memory, movement
204
functions of the parietal lobe
language, touch
205
functions of the temporal lobe?
hearing, learning, feeling
206
functions of the occipital lobe
vision and color perception
207
functions of the cerebellum
balance and coordination
208
functions of the brainstem
breathing, heart rate, temperature
209
general functions of the right side of the brain
creativity, memory, music, art, and motor control of the left side of the body
210
general functions of the left side of the brain
logic, language, math, reading, analysis, planning, and control of right side of the body
211
what are manifestations of right sided stroke?
left side paralysis and neglect
spatial-perceptual deficits
denying and minimizing problems/stroke manifestations
rapid performance and short attention span
impulsivity
impaired judgement and time concepts
problems recognizing faces
212
what are manifestations of left sided stroke?
```
paralysis/deficits on right side of body
speech and language issues/aphasias
impaired L/R discrimination
slow, cautious performance
awareness of deficits (leading to depression and anxiety)
impaired language and math comprehension
```
213
which type of stroke is more likely to experience a field cut?
right brain stroke
214
a stroke on what side of the brain is more likely to impact memory?
right brain stroke
215
what are some risk factors for stroke?
```
smoking
blood thinners
a fib or flutter
oral contraceptives
family history
obesity
elderly
uncontrolled HTN
atherosclerosis
inactivity
previous TIA or stroke
uncontrolled diabetes
brain aneurysm
```
216
what does the FAST acronym stand for?
Facial drooping
Arm Weakness, numbness
Slurred Speech
Time to call 911
217
what is receptive aphasia? what area of the brain is affected?
inability to comprehend language
| Wernickes area
218
what is expressive aphasia? what area of the brain is affected?
understands speech but has trouble responding/expressing self
Broca's area
219
what is global aphasia?
complete inability to understand or produce speech
220
dysarthria
inability to speak due to weak muscles
221
apraxia
inability to perform voluntary movements even with normal muscle function
222
agraphia
inability to write
223
alexia
inability to read
224
agnosia
inability to understand sensations or recognize known objects
225
dysphagia
swallowing issues
226
hemainopsia
vision in only half of the visual field (aka field cut)
227
what are some diagnostic tests for stroke?
CT scan to rule out brain bleed
| MRI
228
what drug is given only for ischemic strokes?
tPA
229
what are time limits for giving tPA?
must be given within 4.5 hours of onset of stroke signs and symptoms
230
what are criteria for receiving tPA?
must have negative CT scan
labs (glucose, INR, platelets) must be within normal limits
BP must be under control (can be medication controlled)
no recent heparin or anticoagulants
231
what are nursing actions and interventions following tPA administration?
```
monitor for bleeding
neuro checks every hour for 24 hours
BP meds to control HTN
vital signs
check labs
monitor glucose
maintain bedrest
avoid needlesticks
keep patient in ICU for first 24 hours
```
232
what tool should be used when doing hourly neuro checks following tpa administration?
NIH stroke scale
233
how is the NIH stroke scale scored?
it assesses 11 areas and is scored from 0-42. higher numbers (total score between 21 and 42) is worse
234
why are the first several hours post-stroke the most dangerous?
patient is at high risk for developing increased ICP
235
what vital sign changes does the nurse want to monitor for and avoid post-stroke?
avoid high BP and decreased HR/RR
236
what will the nurse needs to monitor regarding airway post-stroke?
swallowing ability and secretions, may need to suction patient
237
what bladder/bowel issues might a patient experience post-stroke?
incontinence or retaining
238
what are some nursing actions for skin and limb integrity post-stroke?
repositioning every 2 hours
PROM exercises
skin care
ensuring proper body alignment
239
what can the nurse do to help a stroke patient who has neglect syndrome?
remind them to touch the disabled side
| have them scan room with eyes to take in full visual field
240
who should the stroke patient see before initiating any oral intake?
speech language pathologist
241
what diet/nutrition help might the stroke patient need?
thickened liquids, crushed meds, mechanical soft diet
assistance with eating
have them tuck chin to avoid aspiration
242
what are some useful tips for communicating with patients with receptive aphasia?
```
short phrases and simple details
use gestures and point
be patient
remove distractions
repeat yourself
```
243
what are some useful tips for communicating with patients with expressive aphasia?
be patient and let them speak
ask one question at a time
ask direct/simple questions
use communication board or pen and paper
244
what three components combined make up intracranial pressure?
cerebrospinal fluid
blood
brain tissue
245
what is normal ICP?
5-15 mmHg
246
what ICP indicates need for immediate treatment?
above 20 mmHg
247
what are some things that can cause ICP to fluctuate?
```
body temperature
oxygenation status
body position
arterial and venous pressures
anything that increases intra-abdominal or thoracic pressure (vomiting, bearing down)
```
248
what body position is best to reduce ICP?
neck midline with head of bed elevated 30 degrees
249
what does the monroe-kellie hypothesis say?
if there is an increase in one element that makes up ICP, the other two will decrease or change to try to compensate
250
what manifestations occur when the brain cannot compensate for increasing ICP?
Cushings triad: hypertension with widening pulse pressure, bradycardia, and irregular respirations
251
what is CPP?
the pressure that pushes the blood to the brain
252
what is normal CPP?
60-100 mmHg
253
what happens if the CPP is too low?
brain will not be adequately perfused
254
what are some causes of increased ICP?
```
head trauma
brain injury
hemorrhage
hematoma
brain tumor
hydrocephalus
infection
```
255
what happens if the body cannot compensate for increasing ICP and the brain continues to swell?
brain will herniate in several directions and compress down on the brainstem, eventually leading to patient death
256
what is the earliest sign of increasing ICP?
mental status change
257
what kind of irregular breathing will be seen with increased ICP?
cheyne stokes respirations
258
what kind of nerve changes will occur with increasing ICP?
optic and oculomotor nerve changes, such as double vision, unequal pupils, abnormal Doll's Eye response
259
how do you check for Doll's eye?
lay patient flat, open their eyes, and move head from side to side. normally eyes will move to opposite side as where the head is moving. if eye stays in fixed position, this indicates brainstem damage
260
what types of posturing could be seen with increased ICP?
decorticate, decerebrate, or flaccid
261
decorticate posturing
arms and legs rotated internally and pulled in towards the core
262
decerebrate posturing
extension posturing. arms and legs straight with feet and hands extended
263
which type of posturing is worse?
decerebrate: indicates that damage has progressed further down the brainstem
264
what abnormal reflex is sometimes positive with increased ICP?
babinski
265
is unconsciousness and early or late sign of increased ICP?
late sign
266
what kind of vomiting might a patient with increased ICP experience?
possible projectile vomiting without nausea **give antiemetics**
267
how should a patient with increased ICP be positioned?
head of bed at 30 degrees
head midline
no flexion of neck or hips (dont want to increase abdominal pressure)
reposition slowly and carefully
268
what respiratory interventions should the nurse take for patients with increased ICP?
```
monitor ABGs (oxygen and CO2)
suction as needed but no longer than 15 seconds
hyperoxygenate before and after suctioning
if on mechanical ventilation, keep PaCO2 between 30 and 35 with low PEEP
```
269
what are some nursing interventions if a patient with increased ICP develops a high temperature?
antipyretics
cool bath
remove extra blankets and use cooling blankets
decrease room temp
270
what are other systems/things to monitor with increased ICP?
Neuro status
frequent glasgow coma scale assessment
pressures from ventriculostomy
271
what pressures from a ventriculostomy should be reported to the doctor?
anything above 20 mmHg
272
what is a ventriculostomy?
a catheter inserted into the lateral ventricle of the brain. it monitors ICP, drains CSF, and can be used to administer medications
273
what procedure can patients with a ventriculostomy not receive? why?
lumbar puncture, because it puts them at risk for brain herniation
274
what kind of straining activities should patients with increased ICP avoid?
vomiting
sneezing
valsalva
coughing
275
what renal issue are patients with increased ICP at risk for?
renal stones due to laying flat (kidneys arent draining well)
276
why should we avoid oversedating patients with increased ICP?
it can mask signs and symptoms of increasing ICP
277
how do barbituates help head injury/increased ICP patients?
they help decrease brain metabolism and blood pressure
278
what diuretic might be given with increased ICP?
mannitol
279
what should be closely monitored with mannitol?
BP
renal function
signs of fluid depletion or overload
280
which head injury patients should NOT receive mannitol?
those with aneuric or cerebral hemorrhage
281
what is meningitis?
acute inflammation/infection of the meninges, which surround the brain and spinal cord
282
which form of meningitis is the most serious?
bacterial
283
who is at highest risk for bacterial meningitis?
elderly people
| college students/prisoners/those living in dorms and institutions
284
what are manifestations of meningitis?
fever
severe headache
nausea and vomiting
nuchal rigidity
285
what are complications of meningitis?
increased ICP
altered mental status
neuro deficits
286
how is meningitis diagnosed?
blood culture and CT scan
287
how is meningitis treated?
rapid diagnosis and quickly starting them on antibiotics
288
why should fever be treated promptly and aggressively with meningitis?
to prevent cerebral edema
289
why should a fever not be brought down too far with meningitis?
it can lead to shivering which will cause a rebound effect
290
what are priority nursing management considerations for meningitis?
```
fever treatment
dehydration assessment/I&O
nutritional support
calm environment
monitor for delirium
seizure precautions and meds
neuro assessments
lung and skin evaluations
```
