Pn2 Final

Question 1

o Mentation

 Assessment:

Answer 1

-Level of consciousness
Can be alert but not necessarily orientated:
Lethargic-drowsy, awakes easily
Stuporous-drowsy, difficult to wake
Comatose- Unconscious, cannot wake

Question 2

an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person’s ability to perform everyday activities.

Memory loss is an example.

Alzheimer’s is the most common cause of this

Answer 2

Dementia

Question 3

?? is the most common type of dementia that typically affects people older than 65 years.

Cause:

Patho:

Course of dementia:

Risk factors:

Management:

Answer 3

Alzheimer’s disease (AD)

Cause: Genetic and environmental factors; possibly viral

Patio: Chronic, terminal disease that is characterized by formation of neuritic plaques, neurofibrillary tangles, and vascular degeneration in the brain

Course of dementia: Steady and gradual decline of cognitive, mobility, and ADL function from mild through severe stages; patients usually die from complications of immobility

Risk factors: Female Over 65 years of age Down syndrome Traumatic brain injury

Management: Safety measures to prevent injury, wandering, or falls Cholinesterase inhibitors Behavior management ADL and mobility assistance as needed based on stage

Question 4

Strokes or other vascular disorders that decrease blood flow to the brain

Stepwise progression of dementia symptoms that get significantly worse after each vascular event, such as a stroke or series of mini-strokes; symptoms may improve as collateral circulation to vital neurons develops

Male Over 65 years of age History of diabetes mellitus (DM), high cholesterol, myocardial infarction, atherosclerosis, hypertension, smoking, obesity

Identification of risk factors and management of the risk for or actual vascular event (e.g., antidiabetes drugs for DM, antihypertensive drugs, low-fat diet, smoking cessation, weight loss) Safety measures to prevent injury or falls Behavior management

Answer 4

Vascular dementia

Question 5

also known as tic douloureux.

The trigeminal nerve has three branches:

• the first branch controls sensation in a person’s eye, upper eyelid, and forehead;
• the second branch controls sensation in the lower eyelid, cheek, nostril, upper lip, and upper gum;
• the third branch controls sensations in the jaw, lower lip, lower gum, and some of the muscles used for chewing.

According to the National Institute of Neurological Disorders and Stroke:

**trigeminal neuralgia has these characteristics:
• Affects the trigeminal (fifth cranial) nerve

• Occurs more often in people older than 50 years and in women more often than men
• *Causes a specific type of **facial pain, which results in sudden, intense facial spasms
• • Is usually provoked by minimal stimulation of a trigger zone (such as dental procedures)
• • Is unilateral (one-sided) and confined to the area innervated by the trigeminal nerve, most often the second and third branches (Fig. 44-3)

***a chronic syndrome causing impaired comfort, most often severe pain.
It can be categorized into two types of pain: classic and atypical.

**When describing trigeminal pain, patients use terms such as excruciating, sharp, shooting, piercing, burning, and jabbing.

Atypical pain descriptions may include migraine-like headache.

Between bursts of pain, which last from seconds to minutes, there is usually no pain.

 Nursing considerations
Often no sensory or motor deficits are found on examination.
*Pain can be initiated by light touch, a change in facial expression (e.g., smiling), or chewing.

The fear of precipitating agonizing attacks often causes patients to avoid talking; smiling; eating; or attending to hygienic needs such as shaving, washing the face, and brushing the teeth.

The pain can cause uncontrollable facial twitching.

The course of TN involves bouts of classic pain for several weeks or months followed by spontaneous remissions.

The length of these remissions may vary from days to years, but attack-free periods tend to become shorter as the patient grows older.

The patient suspected of It usually has a CT scan and MRI to determine whether there is a reversible cause of trigeminal compression or inflammation.
The diagnosis is made based on patient history and the results of these imaging tests.
 Nursing care
 **The priority for care of the patient with It is pain management.

Specific interventions are determined by the amount of pain he or she is experiencing. Drug therapy is the first choice, but surgery can provide satisfactory pain relief in patients who do not respond to drug management or who experience profound adverse drug reactions.

           Action Alert  Teach the patient who has had percutaneous stereotactic rhizotomy to *avoid rubbing the eye on the affected side because the protective mechanism of pain will no longer warn of injury. 

• Instruct him or her to inspect the eye daily for redness or irritation and report to the health care provider any change or blurred vision.
• Stress the importance of regular dental examinations because the absence of pain may not warn the patient of potential problems.

Answer 5

o Trigeminal neuralgia

Question 6

Decreased dopamine levels, resulting in an imbalance between excitatory and inhibitory neuronal movements

Answer 6

o Parkinson’s Disease

Question 7

Cardinal s/s of Parkinson’s

Answer 7

Cardinal s/s:

Tremor, 
muscle ridgety, 
bradykinesia (slow movement), 
masked face, 
drooling, 
dysphasia, 
slow shuffling gait, 
postural instability. 

More common in men

Question 8

Parkinson’s stages 
1-5
Initial
Mild
Moderate
Severe
Complete

Nursing care:education

Answer 8

Stages:
1- Initial: unilateral limb movement, minimal weakness, hand and arm trembling-increase with stress.
2- Mild: bilateral limb movement, masklike face, slow, shuffling gait
3- Moderate: postural instability, increased shuffling gait disturbances
4- Severe: Akinesia, rigidity
5- Complete: ADL dependence
Language may be slow, slurred, rapid monotone speech.
ANS changes
No dx test

Pt./caregiver education:

• Be patient and allow extra time
• proper nutrition
• PT and OT
• medications
• fall precautions
• deep brain stimulations
• promote self esteem
• assess depression, anxiety, insomnia

Nursing care: monitor swallowing/eating, thicken foods, sit upright when eating, suction equipment available, ROM/exercise.

Question 9

Changes in the brain as a result of vascular degeneration- exact cause is unknown.

Answer 9

o Alzheimer’s dementia

Question 10

Risk factors for Alzheimer’s:

Stages-
Mild:
Moderate:
Severe:

Priority is

Pt./caregiver Education:

In early stage: do what for patient?
In advanced stage: ??

Med that improves ADL ability and function/memory:

Educate care giver on burn out/fatigue:

Answer 10

over 65, female, Downs/TBI, genetics, PTSD/veterans.

Studies suggest that war veterans who have a current or past history of post-traumatic stress disorder (PTSD) are at an increased risk of AD and other dementias

Priority is SAFETY:
Prevent elderly abuse, support groups, medications for memory, prevent injuries r/t wandering, clutter, difficulty with transfers.

Pt./caregiver Education:
Honest and open discussions
Keep things familiar
Consistency 
Don’t change rooms or furniture
Reduce noise, stimulation, distractions
Proper sleep/rest
Memory training/reminiscence

In early stage: reorientation to reality
In advanced stage: validation therapy

Promote dependence with ADL’s
Toileting program/routine
Assistive devices as needed
Pt. ID badge/bracelet
Chair, bed alarms, video monitoring, sitter
Recognize that physical behaviors may be a way of communication something
Redirection techniques
Wills and advanced directives/proxy/POA
Door locks
No reasoning, confronting, or arguing with pt. 
Use a calm and positive voice
Wrap IV lines, avoid urinary catheters (may pull out and be confused)
Diversional activities
Avoid physical or chemical restraints
Give short directions/few choices
No scatter rugs (may cause tripping) and remove clutter
Post calendars and signs
Orientation
Use good lighting
Mark step edges with tape 

Med that improves ADL ability and function/memory: Donepezil

Educate care giver on burn out/fatigue:
Manage stress
Find case manager early on
Maintain realistic expectations
Support groups
Advanced directives early on
Spiritual support
Schedule rest time away from patient/respite
Home care options
Refer Alzheimer’s Association: seminars, audiovisual aids, publications, telephone support, etc.

Question 11

Alzheimer’s Disease

Stage 1

Stage 2

Stage 3

Answer 11

Early (Mild), or
Stage I (First Symptoms up to 4 Years)
• Independent in ADLs
• Denies presence of symptoms
• Forgets names; misplaces household items
• Has short-term memory loss and difficulty recalling new information
• Shows subtle changes in personality and behavior
• Loses initiative and is less engaged in social relationships
• Has mild impaired COGNITION and problems with judgment
• Demonstrates decreased performance, especially when stressed
• Unable to travel alone to new destinations
• Often has decreased sense of smell Middle (

Moderate), or
Stage II (2 to 3 Years)
• Has impairment of all cognitive functions
• Demonstrates problems with handling or unable to handle money and finances
• Is disoriented to time, place, and event
• Is possibly depressed and/or agitated
• Is increasingly dependent in ADLs
• Has visuospatial deficits: has difficulty driving and gets lost
• Has speech and language deficits: less talkative, decreased use of vocabulary, increasingly nonfluent, and eventually aphasic • Incontinent
• Has episodes of wandering; trouble sleeping

Late (Severe),
or Stage III
• Completely incapacitated; bedridden
• Totally dependent in ADLs
• Has loss of MOBILITY and verbal skills
• Has agnosia (loss of facial recognition)

Question 12

Recurrent, attacks of head pain: throbbing, unilateral, behind eye, sensitive scalp, nausea, sensitivity to light or sound or movement.

Lasts 4-72 hours.

Answer 12

Migraines

Question 13

Migraine triggers

Answer 13

Triggers: Caffeine, red wine, MSG’s, Tyramine, etoh, missed meals, smells, fatigue, light glare, stress, weather.

Question 14

Migraine

Priority of care?

Answer 14

is pain management:

Drugs:
Abortive and preventative therapy:
Alternative therapy:
???

Question 15

Inflammation in the brain and spinal cord

Bacteria enters the CNS directly or via the blood stream

Bacterial-strepococcus pneumonia & meningococcal meningitis- very deadly!!
Put in what precautions ? Change in LOC may indicate what?

Viral- not as deadly but serious- can go away on its own

Labs: CSF- gold standard dx (cerebral spinal fluid) -if clear it can be viral, if cloudy and decrease glucose-bacterial
Elevated WBC and protein with both types, droplet precautions if bacterial, otherwise standard precautions.

Vaccine-??

S/s:

Keep patient in quiet, dim room, elevate HOB 30 degrees, coughing and sneezing may cause ICP, seizure precautions.

MEDS:

Dx by: Lumbar puncture
Lay how? During? After? How long?

Cryptococcal meningitis: most life threatening fungal infection in AIDS patients

s/s: headache, LOC, N/V, stiff neck, blurry vision,

preventions: handwashing, infection control

Complications: fatal; may lead to brain damage or hydrocephalus

Answer 15

Meningitis

• put on seizure precautions with padded rails and bed lowered to the ground. Call light.
• neuro checks every 4 hours
• Change in LOC may indicate increased ICP or hydrocyohalus
• Vitals
• Standard precautions except when bacterial by droplets
• educate family

HIB vaccine prevents

MEDS: , anticonvulsant/antibiotics may be needed, hyperosmolar agents for increased ICP, steroids, prophylaxis

S/s: headache, nuchal ridgity, neck aches, photophobia (bright light sensitivity), n/v, kernig, straight at knee, and brewvinski sign- lay on back and flex knees-if pain it indicates meningitis.

Keep patient in quiet, dim room, elevate HOB 30 degrees, coughing and sneezing may cause ICP, seizure precautions.

Question 16

Seizure patient care?
May be caused from ?

Patient care:

Post seizure-

s/s??

A.
1. A seizure is an episode of excessive and abnormal electrical activity in brain that is manifested by disturbances in skeletal motor activity, sensation, autonomic dysfunction of viscera, behavior, or consciousness

2. Seizures are classified as partial or generalized; partial seizures begin in one area of cortex; generalized seizures involve both hemispheres and deeper brain structures
3. Risk factors in adults include acute febrile state, head injury, infection, metabolic or endocrine disorders, and exposure to toxins
4. If seizure activity is chronic (reoccurs within minutes, days, or even years), a diagnosis of epilepsy is made
5. Metabolic needs, O2O2 requirements, metabolic by-products, and cerebral blood flow increase dramatically during seizure
6. As long as cerebral blood flow can meet demands of seizure, brain is protected from cellular exhaustion and destruction

B. Nursing assessment
1. NCLEX® Simple partial seizures are limited to one hemisphere; manifestations include

*altered motor function, sensory signs, or autonomic or psychic symptoms

2. NCLEX® Complex partial seizures originate in temporal lobe and may be preceded by an aura; an impaired LOC and repetitive, nonpurposeful movements such as lip-smacking, picking, or aimless walking are noted; amnesia is common
3. Generalized partial seizure is a partial seizure that has spread to both hemispheres and deeper structures of brain
4. Absence seizure is a generalized seizure that lasts 5–30 seconds; there is a sudden, brief cessation of motor activity and a blank stare; they may occur occasionally or up to 100 per day; they may be accompanied by eyelid fluttering or automatisms such as lip-smacking; more common in children than adults
5. NCLEX® Tonic-clonic seizures (grand mal) are most common type of seizure
   a. May be preceded by an aura but often occur without warning
   b. Typically start with a loss of consciousness and sharp muscle contractions
   c. Client falls to floor and may have urinary and/or bowel incontinence
   d. Breathing ceases and cyanosis develops during tonic phase (about 15–60 sec); see Figure 57–3A

Figure 57–3 Tonic-clonic contractions in grand mal seizures. (A) Tonic phase, (B) clonic phase.
Figure 57–3 Full Alternative Text
e. Clonic phase (60–90 sec) follows with alternating muscle contraction and relaxation in all extremities, hyperventilation, and eyes rolled back in head; see Figure 57–3B
f. In next phase (postictal period), client is relaxed with quiet breathing and is unconscious and unresponsive; client gradually regains consciousness and may have transient confusion and disorientation; clients often report headache, muscle aches, and fatigue and may sleep several hours
g. Clients will have amnesia of seizure and events just prior to seizure
6. NCLEX® Status epilepticus is a life-threatening emergency that can occur during seizure activity; it is characterized by continuous cycles of tonic-clonic activity with short periods of calm between them; this cumulative effect can interfere with respiration; client is in great danger of developing hypoxia, hyperthermia, hypoglycemia, and exhaustion if seizure activity is not stopped
7. NCLEX® During a seizure, observe order of events and duration; for tonic-clonic seizures, be certain to time length of seizure until jerking stops; tonic indicates continuous muscle contraction; clonic indicates alternating contraction and relaxation of muscles; for all other types of seizures, note duration from start of seizure to time that consciousness is regained; describe any precipitating events or unusual behavior; note parts of body involved and whether it begins in a specific body part
8. Observe face for any color change, perspiration, and lack of expression; note any sound or cry uttered at beginning of seizure; observe mouth for deviation to one side or other, clenched teeth, tongue-biting, frothing, and/or flecks of blood or bleeding; if able to assess pupils, note any change in size, equality, reaction to light, and accommodation
9. Observe for presence or length of apnea; other general observations may be involuntary urination or defecation
10. Postictally, it is important to note duration of postictal period and LOC; orientation to time, person, place; any alterations in motor ability or speech, and whether client experienced an aura
11. Diagnostic and laboratory tests: complete neurologic examination, EEG, skull x-ray series, CT scan, LP with CSF analysis, blood studies, and electrocardiogram
C. Therapeutic management
1. Provide interventions during seizure to maintain airway patency
a.

• *NCLEX® Remain with client and turn client to side if necessary in recumbent position to maintain airway and promote drainage of secretions without aspiration
  b. Have O2O2 and suction equipment at bedside; administer oxygen as prescribed or have “blow-by” oxygen near client’s face; turn client to side to drain secretions from mouth or suction as needed
  c. NCLEX® Do not try to force an object, such as a bite stick, into mouth of client who is seizing, as this may break teeth or cause other injury
  2. NCLEX® Provide interventions during a seizure to reduce the risk of injury; do not restrain client but provide an environment that will not create further injury; teach family members how to protect client during seizures
  3. Document seizure activity promptly and report it as appropriate
  4. Provide support to client that concerns are normal; help client identify leisure activities that are safe; provide information about resources and support groups; provide accurate information about hiring practices and legalities of driving or operating heavy/dangerous equipment

5. Medication therapy
   a. Antiepileptics that raise seizure threshold or limit spread of abnormal electrical activity are mainstay of epilepsy treatment; see also Chapter 38
6. Encourage client and family to express feelings
   D. Client teaching
7. Correct misconceptions, fears, and myths about epilepsy
8. Provide information about community and national resources for epilepsy
9. Stress importance of follow-up care
10. Review laws (e.g., driving a motor vehicle) that apply to those with epilepsy
11. Refer for employment or vocational counseling as needed
12. Stress importance of wearing a medical identification
13. Emphasize aura alert so client is aware of impending seizure
14. **NCLEX® Stress importance of medication adherence and possible periodic blood draws to measure antiepileptic blood levels
15. **Stress importance of avoiding triggers, including inadequate sleep, stress, alcohol use, and strobe lights
16. **NCLEX® Avoid alcohol and limit caffeine; take showers instead of baths to avoid risk of drowning if seizure occurs
17. Families need to know what to do when client has a seizure; teach safety measures and when to call emergency medical services
18. Do not use over-the-counter (OTC) drugs without first consulting with healthcare provider (e.g., antihistamines since side effects are increased)
19. Educate adults and older children about type of seizure and past and present medication, and they should be able to give a history of seizure control or number of seizures experienced and their timing

Answer 16

Seizures

Caused from stress, fatigue, caffeine, flashing lights

Patient care: side rails up and padded

Oxygen

Suctions available- PRN

Airway

IV access

Fall precautions

Protect head, remove constrictive clothing, do not restrain, nothingin mouth, side lying after, document start to finish, movement, and neuro status, vitals

Post seizure- VS, neuro check, reorientate, seizure precautions, padded bed rails

s/s?? aura , ridgity in armsm legs, loc , incontinence , alters mobility, amnesia after episode.

Question 17

Prolonged seizure that last more than 5 minutes or repeated seizure over course of 30 minutes
Establish airway
IV fluids/large bore???
IV push lorazepam/diazepam
Rectal diazepam
IV phenytoin only with NS
ABG’s, r/t toxicity or acidosis 

Pt. education:

Anterior temporal lobe resection:
Continuous EEG monitoring while off medications
Removal of focal area of brain tissue
..???

Answer 17

Status epilepticus

Pt. education:
Good oral cares with drugs
Stick to med regimen 
Be aware of food drug interactions
Maintain proper blood levels for best effectiveness
Do NOT give warfarin with phenytoin
Report and document adverse effects
Vagal nerve stimulation

Question 18

key: prevention ..how?
a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above).

Book:
autonomic hyperreflexia, is a potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in people with high-level SCI. The signs and symptoms of AD are listed in Chart 43-2. Severely elevated blood pressure can cause a hemorrhagic stroke,

Key Features

• Sudden, significant rise in systolic and diastolic blood pressure, accompanied by bradycardia
• Profuse sweating above the level of lesion—especially in the face, neck, and shoulders; rarely occurs below the level of the lesion because of sympathetic cholinergic activity
• Goose bumps above or possibly below the level of the lesion
• Flushing of the skin above the level of the lesion—especially in the face, neck, and shoulders
• Blurred vision
• Spots in the patient’s visual field
• Nasal congestion
• Onset of severe, throbbing headache
• Flushing about the level of the lesion with pale skin below the level of the lesion • Feeling of apprehension

Answer 18

o Autonomic dysreflexia

Question 19

is widespread abnormal cellular metabolism that occurs when gas exchange with oxygenation and tissue perfusion needs are not met sufficiently to maintain cell function

Loss of sensation and motor paralysis after injury

It is a condition rather than a disease and is the “whole-body” response that occurs when too little oxygen is delivered to the tissues.

All body organs are affected by shock and either work harder to adapt and compensate for reduced gas exchange or perfusion or fail to function because of hypoxia.

Shock is a “syndrome” because the problems resulting from it occur in a predictable sequence.

Any problem that impairs PERFUSION and GAS EXCHANGE to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency.

Shock is often a result of cardiovascular problems. Patients in acute care settings are at higher risk, but shock can occur in any setting. For example, older patients in long-term care settings are at risk for sepsis and shock related to urinary tract infections. When the body’s adaptive adjustments (compensation) or health care interventions are not effective and shock progresses, it can lead to cell loss, multiple organ dysfunction syndrome (MODS), and death. Shock is classified by the type of impairment causing it into the categories of hypovolemic shock, cardiogenic shock, distributive shock (which includes septic shock, neurogenic shock, and anaphylactic shock), and obstructive shock. Table 37-1 describes this classification and common causes of shock.

Most signs and symptoms of shock are similar regardless of what starts the process or which tissues are affected first. Symptoms result from physiologic adjustments (compensatory mechanisms) that the body makes in the attempt to ensure continued PERFUSION of vital organs. Compensatory actions are triggered by the sympathetic nervous system’s stress response activating the endocrine and cardiovascular systems. Symptoms unique to any one type of shock result from specific tissue dysfunction.

The common features of shock are listed in Chart 37-1. Chart 37-1

Key Features Shock Cardiovascular Symptoms • Decreased cardiac output • Increased pulse rate • Thready pulse • Decreased blood pressure • Narrowed pulse pressure • Postural hypotension • Low central venous pressure • Flat neck and hand veins in dependent positions • Slow capillary refill in nail beds • Diminished peripheral pulses Respiratory Symptoms • Increased respiratory rate • Shallow depth of respirations • Increased PaCO2 • Decreased PaO2 • Cyanosis, especially around lips and nail beds Gastrointestinal Symptoms • Decreased motility • Diminished or absent bowel sounds • Nausea and vomiting • Constipation Neuromuscular Symptoms Early • Anxiety • Restlessness • Increased thirst Late • Decreased central nervous system activity (lethargy to coma) • Generalized muscle weakness • Diminished or absent deep tendon reflexes • Sluggish pupillary response to light Kidney Symptoms • Decreased urine output • Increased specific gravity • Sugar and acetone present in urine Integumentary Symptoms • Cool to cold • Pale to mottled to cyanotic • Moist, clammy • Mouth dry; pastelike coating present PaCO2, Partial pressure of arterial carbon dioxide; PaO2, partial pressure of arterial oxygen

Types of Shock Types of shock vary because shock is a problem caused by a pathologic condition rather than a disease state (see Table 37-1). More than one type of shock can be present at the same time. For example, trauma caused by a car crash may trigger hemorrhage (leading to hypovolemic shock) and a myocardial infarction (leading to cardiogenic shock). Hypovolemic shock occurs when too little circulating blood volume decreases MAP, resulting in inadequate total body PERFUSION and GAS EXCHANGE. Common problems leading to hypovolemic shock are dehydration and poor CLOTTING with hemorrhage. A complete discussion of the pathophysiology and management of hypovolemic shock begins with the PERFUSION concept exemplar. Cardiogenic shock occurs when the heart muscle is unhealthy and pumping is impaired. Myocardial infarction is the most common cause of direct pump failure (Warise, 2015). Other causes are listed in Table 37-1. Any type of pump failure decreases cardiac output and MAP. Chapter 38 discusses the pathophysiology and care for the adult with shock from myocardial infarction. Distributive shock occurs when blood volume is not lost from the body but is distributed to the interstitial tissues where it cannot perfuse organs. It can be caused by blood vessel dilation, pooling of blood in venous and capillary beds, and increased capillary leak. All these factors decrease MAP and may be started either by nerve changes (neural-induced) or by the presence of some chemicals (chemical-induced). Neural-induced distributive shock is a loss of MAP that occurs when sympathetic nerve impulses are decreased and blood vessel smooth muscles relax, causing vasodilation and poor PERFUSION. Shock results when vasodilation is widespread. Problems leading to loss of sympathetic tone are listed in Table 37-1. Chemical-induced distributive shock has three common origins: anaphylaxis, sepsis, and capillary leak syndrome. It occurs when certain body chemicals or foreign substances in the blood and vessels start widespread changes in blood vessel walls. The chemicals are usually exogenous (originate outside the body), but this type of shock also can be induced by substances normally found in the body, such as excessive amounts of histamine. Anaphylaxis is an extreme type of allergic reaction. It begins within seconds to minutes after exposure to a specific allergen in a susceptible adult. The result is widespread loss of blood vessel tone, with decreased blood pressure and cardiac output. Chapter 20 describes the pathophysiology, prevention, and care of the patient with anaphylactic shock. Sepsis is a widespread infection that triggers whole-body inflammation. It leads to distributive shock when infectious microorganisms are present in the blood and is most commonly called septic shock. A complete discussion of the pathophysiology, prevention, and care for the patient with sepsis and septic shock begins with the IMMUNITY concept exemplar. Capillary leak syndrome is the response of capillaries to the presence of histamine and other chemicals that enlarge capillary pores and allow fluid to shift from the capillaries into the interstitial tissues. These fluids are stagnant, and no GAS EXCHANGE occurs. Problems causing fluid shifts include severe burns, liver disorders, ascites, peritonitis, large wounds, kidney disease, hypoproteinemia, and trauma. Obstructive shock is caused by problems that impair the ability of the normal heart to pump effectively. The heart itself remains normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle. The most common cause of obstructive shock is cardiac tamponade (see Table 37-1). Care of the adult with cardiac tamponade is presented in Chapter 35 (pericarditis) and Chapter 38. Although the causes and initial signs and symptoms associated with the different types of shock vary, eventually the effects of hypotension and anaerobic cellular metabolism (metabolism without oxygen) result in the common key features of shock listed in Chart 37-1. NCLEX Examination Challenge 37-1 Physiological Integrity A client thought to be at risk for distributive shock is given a drug that constricts blood vessels. What effect does the nurse expect the drug to have on the client’s mean arterial pressure (MAP)? A. Increased MAP without a change in vascular volume B. Increased MAP by increasing vascular volume C. Decreased MAP from widespread capillary leak D. Decreased MAP by decreasing vascular volume

Stages of Shock The syndrome of shock progresses in four stages when the conditions that cause shock remain uncorrected and poor cellular oxygenation continues. These stages are: 1. Initial stage 2. Nonprogressive stage 3. Progressive stage 4. Refractory stage

Distributive Shock Overall Cause Fluid shifted from central vascular space (total body fluid volume normal or increased). Specific Cause or Risk Factors • Neural-induced • Pain • Anesthesia • Stress • Spinal cord injury • Head trauma • Chemical-induced • Anaphylaxis • Sepsis • Capillary leak • Burns • Extensive trauma • Liver impairment • Hypoproteinemia Obstructive Shock Overall Cause Cardiac function decreased by noncardiac factor (indirect pump failure). Total body fluid is not affected, although central volume is decreased. Specific Cause or Risk Factors • Cardiac tamponade • Arterial stenosis • Pulmonary embolus • Pulmonary hypertension • Constrictive pericarditis • Thoracic tumors • Tension pneumothorax

Answer 19

o Spinal shock

Question 20

Usually caused by trauma; young adults and adolescents are most at risk

Disrupts nerve tracts because of cord transection, partial transection, contusion, compression, or lacerations; leads to loss of sensory and motor function at level of injury and below

Usually results from excessive force applied to spinal cord and vertebral column;

four types of injuries occur:
Hyperflexion compresses vertebral bodies and disrupts ligaments and discs

Hyperextension disrupts ligaments and causes vertebral fractures

Axial loading is an application of excessive vertical force and may cause compression fractures

Excessive rotation tears ligaments and fractures articular surfaces and causes compression fractures (see Figure 57–2) Figure 57–2

Spinal cord injury mechanisms. (A) Hyperflexion, (B) hyperextension, (C) axial loading, a form of compression.

Figure 57–2 Full Alternative Text Classified by complete versus incomplete cord injury, cause of injury, and level of injury; in clinical practice, these overlap Levels of injury (named for corresponding level of vertebrae)

Cervical: injury above C4 interferes with respiration and paralysis of all extremities (C4 provides major innervation to phrenic nerve and diaphragm); involvement at C5 to C8 allows some shoulder movement but there is decreased respiratory reserve

Thoracic: depending on specific level, injury may involve loss of sensation and movement of chest, trunk, bladder, bowel, and legs

Lumbar and sacral: loss of sensation and movement to legs; injury results in neurogenic bladder and interference with erection and ejaculation in men Most frequently involved vertebrae are C5 to C7 (cervical), T12 (thoracic), and L1 (lumbar) Nursing assessment

NCLEX® Depends on level of injury, which is defined as lowest area of spinal cord that has intact sensory and motor function

**Assess respiratory rate, depth, and pattern Assess sensory and motor function Paraplegia is paralysis of lower body; occurs when injury level is in thoracic spine or lower Tetraplegia, formally quadriplegia, is paralysis of arms, trunk, legs, and pelvic portions of body; occurs when level of injury is in cervical spine NCLEX® Assess other body systems for status and signs of concurrent injury Assess for spinal shock (a temporary loss of reflex function): symptoms include bradycardia; hypotension; flaccid paralysis of skeletal muscles; loss of pain, touch, temperature, pressure, visceral, and somatic sensations; bowel and bladder dysfunction; and loss of ability to perspire; spinal shock has resolved once spinal reflexes return Assess for autonomic hyperreflexia (an exaggerated SNS response that occurs with injuries at T6 or higher but is seen only after recovery from spinal shock); occurs when stimuli cannot ascend cord; a noxious stimulus triggers massive vasoconstriction below injury, vasodilation above injury, bradycardia, and rapid-onset systolic hypertension with widening pulse pressure Diagnostic and laboratory test findings: x-rays visualize fractures; CT and MRI scans show changes in vertebrae, spinal cord, and tissues surrounding cord; an EMG may be done after acute injury to locate level of injury Incomplete spinal cord injury syndromes Central cord syndrome: loss of motor function more pronounced in upper extremities; varying patterns of intact sensation remain Anterior cord syndrome: sensations of touch, position, and vibration remain intact below level of iniury, while motor function, pain, and temperature sensation are lost Posterior cord syndrome: motor function is intact, but there is loss of position, vibration, and crude touch sensation Brown-Séquard syndrome: Loss of motion function, vibration, proprioception, and deep-touch sensation are lost on same side as cord damage (ipsilateral losses) Conus medullaris syndrome: flaccid lower extremities and bladder and bowel arreflexia; possible intact micturition (voiding) and loss of ability for penile erection if damage is located to upper sacral segment of spinal cord Cauda equina syndrome: arreflexia of bowel, bladder, and lower body reflexes Therapeutic management Acute management involves immobilizing injury to prevent further damage and assessing and stabilizing client Assess for and maintain a patent airway Keep head immobilized without flexion, extension, or rotation; maintain manual traction on head if needed by placing hands on head by ears If client needs to be moved, logroll client without twisting or turning spine; keep head of bed flat so spine remains extended Stabilize injury with devices such as skeletal traction using Gardner-Wells tongs, halo traction, or surgery as indicated Treat complications: respiratory distress (with measures ranging from oxygen to intubation and mechanical ventilation), atonic bladder (insertion of indwelling urinary catheter), paralytic ileus (preventing constipation by initiating bowel regimen), and cardiovascular instability (with vasoactive drugs as needed)

NCLEX® Monitor vital capacity and respiratory effectiveness; high cervical cord injuries (C4 or above or lower if edema ascends cord) may inhibit respirations, requiring mechanical ventilation Monitor for signs of ascending edema; may cause respiratory compromise Assist client with quad coughing by pushing in and up at xiphoid process when client is coughing

NCLEX® Institute bowel and bladder training programs to restore a regular schedule for elimination

NCLEX® Treat autonomic hyperreflexia immediately Elevate HOB and remove antiembolism stockings or sequential compression devices Assess BP every 2–3 minutes while assessing for stimuli that initiated response; remove stimulus immediately when found (offending stimuli are often distended bladder, stool in rectum, or mechanical or thermal stimuli affecting skin) With severe hypertension unresolved by removing offending stimulus, notify healthcare provider and administer antihypertensives per protocol Provide ongoing care to client with Gardner-Wells tongs (using principles of skeletal traction) or halo brace because of fracture or dislocated cervical vertebrae Encourage client to verbalize feelings about loss of function and care Assist client with techniques and adaptive devices recommended by rehabilitation team to increase independence in activities of daily living (slider board, wheelchair, plate guard, utensils with built-up handles as examples) Encourage self-care and independent decision making Include family and important others in discussions

NCLEX® Medication therapy: corticosteroids (such as methylprednisolone) may control edema of cord; vasoactive drugs treat hypotension or hypertension due to spinal shock or autonomic hyperreflexia; antispasmodics (such as baclofen) treat spasticity; analgesics and tricyclic antidepressants treat pain Client education Teach client and family to promote independence in self-care, such as self-catheterization technique, bowel evacuation, activities of daily living Educate client and family about variety of community resources needed

NCLEX® If client has a halo vest, teach that it raises center of gravity; avoid bending over to reduce risk of falls; neck is immobilized in midline so client must learn to turn entire body to scan environment; eat soft foods and cut food into small pieces and use straw for liquids; driving is prohibited
***Number 1 cause of spine injuries in adults: falls

Be aware that a change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined! If a decline occurs, contact the Rapid Response Team or PHCP immediately. Perform a focused neurologic assessment as described later in this chapter to determine if additional changes are present

A special spinal cord assessment flow sheet may be used to document sensory and/or motor findings for the patient with a spinal cord injury. Pain and temperature sensation are transmitted by the same nerve endings. Therefore if one sensation is tested and found to be intact, it can safely be assumed that the other is intact.
Testing temperature sensation can usually be accomplished using a cold reflex hammer and the warm touch of the hand for patients with known or suspected spinal problems. Assess for pain perception with any sharp or dull object, such as the tips of a cotton-tipped applicator. While the patient’s eyes are open, demonstrate what will be done. Then ask him or her to keep eyes closed and to indicate whether the touch is sharp or dull. The sharp and dull ends should be changed at random so he or she does not anticipate the next type of stimulus for SENSORY PERCEPTION. Not all areas need to be tested unless a spinal cord injury has occurred. If testing begins on the hands and feet, there is no need to test the other parts of the extremities because the tracts transmitting pain and temperature sensations are intact. Compare reactions on each side. A sensation reported as dull when the stimulus was actually sharp requires further testing. A patient with sensory loss as a result of diabetes mellitus or peripheral vascular disease may or may not be aware of the loss until tested. Some patients with chronic illness may report that they have had sensory losses for a long time. Before testing for pain, the nurse must check to determine whether the patient is on anticoagulant therapy. If the patient is on anticoagulant therapy, avoid any testing with a sharp object because it can cause bleeding. Light touch discrimination is likely to be normal if pain and temperature sensory tracts are intact. Touch discrimination and two-point discrimination may be assessed as part of a complete neurologic examination by the PHCP. For testing touch discrimination, the patient closes his or her eyes. The practitioner touches the patient with a finger and asks that he or she point to the area touched. This procedure is repeated on each extremity at random rather than at sequential points. Next, the practitioner touches the patient on each side of the body on corresponding sites at the same time. The patient should be able to point to both sites. The clinician then touches the patient in two places on the same extremity with two objects, such as cotton-tipped applicators. A person can normally identify two points fairly close together, depending on the location of the stimuli. When an area is heavily innervated, the two-point discrimination will feel closer. Abnormal sensory findings may have a CNS or a peripheral nervous system (PNS) cause. The neuropathies of diabetes, malnutrition, and vascular problems have a PNS cause. Damage to a specific spinal nerve may not result in significant sensory loss because the spinal nerves overlap. Injury to several nearby spinal nerves is manifested as decreased or absent SENSORY PERCEPTION in the dermatomes of those nerves. CNS problems in the brainstem, thalamus, and cortex generally result in loss of sensation on the contralateral (opposite) side of the body. Cerebellar lesions result in sensory deficits on the same side of the body. Assessment of Cerebellar Function. Most of the assessment of cerebellar function can be performed with the patient sitting on the side of the bed or examining table. Fine coordination of muscle activity is tested. If cerebellar problems are suspected or diagnosed, ask the patient to perform these tasks with his or her eyes closed: • Run the heel of one foot down the shin of the other leg and repeat with the other leg (the patient should be able to do this smoothly and keep the heel on the shin). • Place the hands palm-up and then palm-down on each thigh, repeating as fast as possible (this can normally be done rapidly). • With arms out at the side, touch the finger to the nose two or three times, with eyes open and then with eyes closed (this can be done with alternating arms or with each arm individually). For the last part of the cerebellar assessment, the ambulatory patient stands for testing of gait and equilibrium. Gait and equilibrium are usually tested at the end or beginning of the entire neurologic assessment. Ask the patient to walk across the room, turn, and return. Observe for uneven steps, difficulty walking, and so forth. To evaluate balance, ask him or her to stand on one foot and then on the other. Tiptoe and heel-to-toe walking can also demonstrate gait problems. For patients with sciatic nerve involvement, pain may worsen when they walk on their toes or heels. To test equilibrium, ask the patient to stand with arms at the sides, feet and knees close together, and eyes open. Check for swaying and then ask him or her to close his or her eyes and maintain position. The examiner should be close enough to prevent falling if the patient cannot stay erect. If he or she sways with the eyes closed but not when the eyes are open (the Romberg sign), the problem is probably proprioceptive (awareness of body position). If the patient sways with the eyes both open and closed, the neurologic disturbance is probably cerebellar in origin (Jarvis, 2014). If the patient cannot perform any of these activities smoothly, the problem is manifested on the same side as the cerebellar lesion. If both lobes of the cerebellum are involved, the incoordination affects both sides of the body (bilateral). Rapid/Focused Neurologic Assessment A rapid/focused neurologic assessment, or “neuro check,” is completed when the patient is admitted to a health care facility on an emergent basis. It is also a major part of frequent ongoing patient assessment and performed in the event of a sudden change in neurologic status. The typical record contains data related to alertness, orientation, movement of arms and legs, and pupil size and reaction to light. Be sure to document all aspects of the rapid neurologic assessment frequently in the designated or standardized part of the electronic record as needed per agency protocol or health care provider request. An example of a standard rapid neurologic assessment tool is the Glasgow Coma Scale (GCS) (Fig. 41-9). The GCS is used in many acute care settings to establish baseline data in each of these areas: eye opening, motor response, and verbal response. The patient is assigned a numeric score for each of these areas. The lower the score, the lower the patient’s neurologic function. For patients who are intubated and cannot talk, record their score with a “t” after the number for verbal response. FIG. 41-9 The Glasgow Coma Scale. The GCS is easy to teach and has demonstrated a consistent score among trained assessors. The reliability of the GCS is based on recording the patient’s “best” response. If the patient does not follow commands or is unresponsive to voice, the nurse proceeds to increasingly noxious (painful) stimuli to elicit an eye and motor response. Typically the patient’s response to central pain (brain response) is assessed first. On the basis of this response, peripheral pain may then be assessed. Failure to apply painful stimuli appropriately may lead to an incorrect conclusion about the patient’s neurologic status. If the patient responds fully to voice or light touch, there is no need to progress to more vigorous or painful stimuli. Start with the least noxious irritation or pressure and proceed to more painful stimulation if the patient does not respond. Begin each phase of the assessment by speaking in a normal voice. If no response is obtained, use a loud voice. If the patient does not respond, gently shake him or her. The shaking should be similar to that used in attempting to wake up a child. If that is unsuccessful, apply painful stimuli using one of these methods: • Supraorbital (above eyes) pressure by placing a thumb under the orbital rim in the middle of the eyebrow and pushing upward (Do not use this technique if the patient has orbital or facial fractures.) • Trapezius muscle squeeze by pinching or squeezing the trapezius muscle located at the angle of the shoulder and neck muscle • Mandibular (jaw) pressure to the jaw by using your index and middle fingers to pinch the lower jaw • Sternal (breastbone) rub by making a fist and rubbing/twisting your knuckles against the sternum The tissue in these areas is tender, and bruising is not unusual. Therefore do not use this technique for older adults or for patients who may experience severe bruising (e.g., recipients of anticoagulant therapy). Peripheral pain is assessed with pressure at the base of the nail on one finger or one toe, both on the right and left. The patient may respond to painful stimuli in several ways. Although the initial response to pain may be abnormal flexion or extension, continued application of pain for no more than 20 to 30 seconds may demonstrate that he or she can localize or withdraw. If the patient does not respond after 20 to 30 seconds, stop applying the painful stimulus.

Nursing Safety Priority Critical Rescue A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and should be communicated to the primary health care provider (PHCP) immediately. Other findings requiring urgent communication with the health care provider include a new finding of abnormal flexion or extension, particularly of the upper extremities (decerebrate or decorticate posturing); pinpoint or dilated nonreactive pupils; and sudden or subtle changes in mental status. Remember, a change in level of consciousness is the earliest sign of neurologic deterioration. Communicate early recognition of neurologic changes to the Rapid Response Team or primary health care provider for the best opportunity to prevent complications and preserve CNS function.

Physiological Integrity

The nurse is assessing a client who opens both eyes when spoken to, obeys commands, and seems confused during conversation. Which Glasgow Coma Score (GCS) will the nurse document?
A. 15
B. 14
C. 11
D. 9

Age may also be a factor in how a patient accepts the illness. For instance, a young adult who has a motorcycle crash causing a traumatic brain injury (TBI) may react differently from an older adult who has a spinal injury. In some cases, the patient’s emotional responses result from the health problem itself, especially for TBI patients. Men may feel differently about their illness than women. Male patients who have had strokes are typically depressed more often than women who have had strokes. Discussions of these response differences can be found in the following chapters on specific neurologic health problems. Regardless of what the health problem is, do not assume that everyone reacts the same way to his or her illness or injury. Consider the cultural and spiritual background of the patient because this will influence his or her reaction. Patients experiencing the grieving process may fluctuate among denial, anger, and depression. Encourage patients to express their feelings and have hope. Refer them to the appropriate support services as needed, including counseling, social work, or clergy, depending on patient preference and service availability. Assess the patient’s support systems, including family members and friends, if available. Be sure to document your assessment and interventions.

Answer 20

o Spinal cord injuries

Question 21

When a patient with Alzheimer’s disease is in a new setting or environment:

Answer 21

collaborate with the staff and admitting department to select a room that is in the quietest area of the unit and away from obvious exits, if possible.
A private room may be needed if the patient has a history of agitation or wandering.

The television should remain off unless the patient turns it on or requests that it be turned on.

Question 22

Meds for Alzheimer’s disease:

How they work

Family education?

Answer 22

Cholinesterase inhibitors are drugs approved for treating AD symptoms.

They work to improve cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine (ACh) by the enzyme cholinesterase.

This action slows the onset of cognitive decline in some patients, but none of these drugs alters the course of the disease. In some cases, cholinesterase inhibitors can improve functional ADL ability.

Examples include donepezil (Aricept), galantamine (Reminyl), and rivastigmine (Exelon)

Education:
Teach the family to monitor the patient’s heart rate and report dizziness or falls because these drugs can cause bradycardia. Therefore they are used cautiously for patients who have a history of heart disease.

Question 23

Promoting Communication With the Patient With Alzheimer’s Disease:

Answer 23

• Ask simple, direct questions that require only a “yes” or “no” answer if the patient can communicate.
• Provide instructions with pictures in a place that the patient will see if he or she can read them.
• Use simple, short sentences and one-step instructions.
• Use gestures to help the patient understand what is being said.
• Validate the patient’s feelings as needed.
• Limit choices; too many choices cause frustration and increased confusion.
• Never assume that the patient is totally confused and cannot understand what is being communicated.
• Try to anticipate the patient’s needs and interpret nonverbal communication.

Question 24

Minimizing Behavioral Problems for Patients With Alzheimer’s Disease at Home

Answer 24

• Carefully evaluate the patient’s environment to ensure it is safe:
• Remove small area rugs.
• Consider replacing tile floors with nonslippery floors.
• Arrange furniture and room decorations to maximize the patient’s safety when walking.
• Minimize clutter in all rooms in and outside of the house.
• Install nightlights in patient’s room, bathroom, and hallway.
• Install and maintain smoke alarms, fire alarms, and natural gas detectors.
• Install safety devices in the bathroom such as handles for changing position (sit-to-stand).
• Install alarm system or bells on outside doors; place safety locks on doors and gates.
• Ensure that door locks cannot be easily opened by the patient.
• Help the patient with mild-stage disease remain oriented to the extent possible:
• Place single-date calendars in patient’s room and in kitchen.
• Use large-face clocks with a neutral background.
• Communicate with the patient based on his or her ability to understand:
• Explain activity immediately before the patient needs to carry it out.
• Break complex tasks down to simple steps
• Allow and encourage the patient to be as independent as possible in ADLs:
• Place complete outfits for the day on hangers; have the patient select one to wear.
• Develop and maintain a predictable routine (e.g., meals, bedtime, morning routine).
• When a problem behavior occurs, divert patient to another activity; minimize excessive stimulation:
• Take the patient on outings when crowds are small.
• If crowds cannot be avoided, minimize the amount of time the patient is present in a crowd. For example, at family gatherings, provide a quiet room for the patient to rest throughout the visit.
• Arrange for a day-care program to maintain interaction and provide respite for home caregiver.
• In the United States (www.alz.org); in Canada, register the patient with the Alzheimer Society of Canada Medic Alert® Safely Home® program (www.alzheimer.ca).

Question 25

Reducing Family/Informal Caregiver Stress

Answer 25

• Maintain realistic expectations for the person with Alzheimer’s disease (AD).
• Take each day one at a time.
• Try to find the positive aspects of each incident or situation.
• Use humor with the person who has AD.
• Use the resources of the Alzheimer’s Association, including attending local support group meetings.
• Explore alternative care settings early in the disease process for possible use later.
• Establish advance directives with the AD patient early in the disease process.
• Set aside time each day for rest or recreation away from the patient, if possible.
• Seek respite care periodically for longer periods of time.
• Take care of yourself by watching your diet, exercising, and getting plenty of rest.
• Be realistic about what you or they can do and accept help from family, friends, and community resources.
• Use relaxation techniques, including meditation and massage.
• Seek out clergy or other spiritual counselor or support.
• Be mindful about what gives meaning to your life.

Question 26

Approaches to Prevent and Manage Wandering in Hospitalized Patients

Answer 26

• Identify the patients most at risk for wandering through observation and history provided by family.
• Provide appropriate supervision, including frequent checks (especially at shift-change times).
• Place the patient in an area that provides maximum observation but not in the nurses’ station.
• Use family members, friends, volunteers, and sitters as needed to monitor the patient.
• Keep the patient away from stairs or elevators.
• Do not change rooms to prevent increasing confusion.
• Avoid physical or chemical restraints.
• Assess and treat pain.
• Use re-orientation methods and validation therapy, as appropriate.
• Provide frequent toileting and incontinence care as needed.
• If possible, prevent overstimulation, such as excessive noise.
• Use soft music and nonglare lighting if possible.

Question 27

Restraints ??

What to use and when

Why

Answer 27

In inpatient health care agencies,

**use the least restrictive physical restraints such as waist belts and geri-chairs with lapboards only as a last resort

**because they often increase patient restlessness and cause agitation.

Federal regulations in long-term care facilities in the United States mandate that all residents have the right to be free of both physical and chemical restraints. (Meds)

All health care agencies accredited by The Joint Commission are required to use alternatives to restraints before resorting to any physical or chemical restraint.

Question 28

NCLEX® Some commonly used antiepileptics are??

c. * used intermittently to stop seizure during
acute episodes

Answer 28

NCLEX® Some commonly used antiepileptics are phenytoin, divalproex sodium, valproic acid, carbamazepine, gabapentin, and lamotrigine

c. **Diazepam, lorazepam, and sometimes phenobarbital are also used intermittently to stop seizure activity during acute episodes
6. If drug therapy fails to control seizures, surgery to excise tissue involved in seizure activity may be an alternative

Question 29

Prevention of autonomic dysreflexia

Cause?

Who is at greatest risk?

Priority ?

Answer 29

Prevention:
• DO NOT let the bladder become too full.
• Pain should be controlled.
• Practice proper bowel care to avoid stool impaction.
• Practice proper skin care to avoid bedsores and skin infections.
• Prevent bladder infections.

The causes of AD are typically:
GI, gynecologic-urologic (GU), and vascular stimulation.
Specific risk factors are bladder distention, urinary tract infection, epididymitis or scrotal compression, bowel distention or impaction from constipation, or irritation of hemorrhoids.

Pain; circumferential constriction of the thorax, abdomen, or an extremity (e.g., tight clothing); contact with hard or sharp objects; and temperature fluctuations can also cause AD.

Patients with altered SENSORY PERCEPTION are at great risk for this complication.

May be at risk for high risk for complications that result from prolonged immobility, including skin breakdown and venous thromboembolism (VTE). Assess skin integrity with each turn or repositioning.

Assess breath sounds every 2 to 4 hours during the first few days after SCI and document and report any adventitious or diminished sounds.

Monitor vital signs with pulse oximetry.

Watch for changes in respiratory pattern or airway obstruction. Intervene per agency or PHCP protocol when there is a decrease in oxygen saturation (SpO2) to below 95%.

Airway management is the priority for a patient with cervical spinal cord injury!

Question 30

Emergency Care of the Patient Experiencing Autonomic Dysreflexia: Immediate Interventions

Answer 30

• Place patient in a sitting position (first priority!), or return to a previous safe position.
• Notify the primary health care provider or Rapid Response Team.
• Assess for and treat the cause:
• Check for urinary retention or catheter blockage:
• Check the urinary catheter tubing (if present) for kinks or obstruction.
• If a urinary catheter is not present, check for bladder distention and catheterize immediately if indicated:
• Consider using anesthetic ointment on tip of catheter before catheter insertion to reduce urethral irritation.
• Determine if a urinary tract infection or bladder calculi (stones) are contributing to genitourinary irritation.
• Check the patient for fecal impaction or other colorectal irritation, using anesthetic ointment at rectum. Disimpact if needed.
• Examine skin for new or worsening pressure injury symptoms.
• Monitor blood pressures every 10 to 15 minutes.
• Give nifedipine or nitrate as prescribed to lower blood pressure as needed.
• (Patients with recurrent autonomic dysreflexia may receive an alpha blocker prophylactically.)

NCLEX Examination Challenge 43-2 Safe Effective Care Environment A client who sustained a recent cervical spinal cord injury reports feeling flushed. The client’s blood pressure is 180/100. What is the nurse’s best action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Turn on a fan to cool the patient. D. Place the patient in a sitting position.

Question 31

Critical Rescue Monitor the patient with acute spinal cord injury at least hourly for:

Answer 31

• Pulse oximetry (SpO2) <95% or symptoms of aspiration (e.g., stridor, garbled speech, or inability to clear airway)
• Symptomatic bradycardia, including reduced level of consciousness and deceased urine output
• Hypotension with systolic blood pressure (SBP) <90 or mean arterial pressure (MAP) <65 mm Hg Notify the PHCP immediately if these symptoms occur because this problem is an emergency!
Respiratory compromise from aspiration may be treated with intubation or bronchial
endoscopy.
Similar to interventions for any type of shock, neurogenic shock is treated symptomatically by providing fluids to the circulating blood volume, adding vasopressor IV therapy, and providing supportive care to stabilize the patient.