Adult 4 Flashcards
(172 cards)
1
Q
what are 2 types of strokes
A
hemorrhagic and ischemic
2
Q
what is a hemorrhagic stroke
A
ruptured artery or aneurysm, poor prognosis
3
Q
name the 3 types of hemorrhagic strokes
A
nontraumatic subarachnoid, intracerebral, and intraventricular
4
Q
cause of nontraumatic subarachnoid hemorrhage
A
ruptured aneurysm, AV malformation
5
Q
manifestations of a hemorrhagic stroke
A
severe “thunderclap”, stiff/pain in the neck, photosensitivity, decreased LOC, seizures
6
Q
surgical interventions for hemorrhagic stroke
A
titanium clips, platinum coils, wrapping of aneurysm
7
Q
complications of a hemorrhagic stroke
A
cerebral vasospasms, ischemic strokes
8
Q
treatment of hemorrhagic stroke
A
Triple H: HTN, hypervolemia, hemodilution
9
Q
2 types of ischemic strokes
A
thrombolytic and embolic
10
Q
what is a thrombolytic stroke
A
blood cot forms and shuts off arterial blood supply; ischemia is distally to clot
11
Q
what is an embolic stroke
A
clot travels from somewhere else in the body; it gets stuck in the artery; ischemia is distally to clot
12
Q
what is the only med given for an ischemic stroke
A
ateplase
13
Q
what does alteplase do to the clot
A
dissolves already formed clots, destroys fibrinogen from other clot factors
14
Q
what is the time frame for alteplase
A
under 80: 4.5hrs
over 80: 3hrs
15
Q
contraindications to alteplase
A
prior hx of hemorrhagic stroke, ischemic within 3 months, known cerebral lesions (AV malformations)
16
Q
considerations AFTER giving alteplase
A
avoid causing bleeding, little venipuncture, monitor changes in LOC and VS, alteplase is to be given ALONE
17
Q
what determines stroke manifestations
A
area of the brain deprived of oxygen
18
Q
manifestations= same side as stroke
A
false; opposite
19
Q
what is the left cerebral hemisphere responsible for
A
language, math, analytical thinking
20
Q
S/S of left hemisphere stroke
A
expressive/receptive aphasia, agnosia, agraphia, alexia, right sided paralysis, slowed behavior, visual changes, hemianopsia
21
Q
what is angosia
A
lack of recognizing familiar objects
22
Q
what is agraphia
A
inability to write
23
Q
what is alexia
A
inability to read
24
Q
what is hemianopsia
A
only seeing 1/2 of visual field
25
what is the right hemispheres responsibility
spatial awareness, vision, proprioception
26
S/S of right hemisphere stroke
altered deficit perception, unilateral neglect syndrome, loss of depth perception, poor impulse/judgement, left sided paralysis, hemianopsia
27
diagnostic testing for strokes
CT, scan, MRI, cerebral angiography, lumbar puncture, glasgow coma scale
28
when should the CT scan be done and what does it determine
within 25 min of arrival to ED, determines type of stroke and treatmen
29
what does the lumbar puncture determine
if positive for blood in CSF= hemorrhagic stroke
30
what does the cerebral angiography determine
hemorrhage or vessel abnormality (AV malformation)
31
what does along with a cerebral angiography that finds the clots
thrombectomy
32
what time frame should the thrombectomy be performed
within 24hrs of onset
33
what does the MRI identify in strokes
necrosis, ischemia, edema
34
BP to notify to provider (stroke)
systolic over 180 and diastolic over 110
35
O2 to notify to provider (stroke)
less than 92%
36
Temp to notify to provider (stroke)
elevated; increased ICP
37
blood sugar to notify the provider (stroke)
hyperglycemia; poor neuro outcomes
38
post stroke precautions
seizure precautions
39
what is the nursing care post stroke
HOB 30 degrees, assess gag and swallow, request swallow screen, thickened liquids, change in food level, no distractions when eating, prevent immobility complications, ROM q2, safe environment, chew on unaffected side, dressed affected side first
40
what is a seizure
abnormal, uncontrolled, electrical discharge of neurons in the brain
41
what is epilepsy
chronic, recurring, abnormal brain activity (2 or more seizures with no identifiable cause)
42
what is a tonic-clonic seizure
tonic first (muscle stiffness), then LOC, followed by 1-2 mins of jerking movements (clonic)
43
what can occur during a tonic clonic seizure
cyanosis, breathing may stop or be irregular during clonic, biting cheeks or tongue, incontinence
44
what are the types of generalized seizures
tonic and clonic
45
what are the atypical seizures
myoclonic (muscle jerking) atonic (sudden loss of strength)
46
what are the local/focal/partial seizures
complex and simple partial seizures
47
what is a complex partial seizure
automatisms (lip smacking, touching clothes), amnesia
48
what is a simple partial seizure
no LOC, has unusual sensations
49
diagnostic tests for seizures
labs (ETOH, HOV, toxins), EEG (electrical brain issues), CT, MRI, PET [determine other causes]
50
what are the nursing interventions DURING a seizure
keep pt safe, position to ensure patent airway, oral suction prn, turn to side to prevent aspiration, loosen restrictive clothing
51
what should not be done during a seizure
do not open jaw, restrain, insert oral airway, use tongue blade
52
what are the nursing interventions AFTER a seizure
post ictal care, side lying position, check for injuries, assess neuro, reorient and remain calm, ask about auras/triggers
53
what medications are used for seizures
anti-epileptics (phenytoin)
54
what do pts avoid when taking phenytoin
oral contraceptives and warfarin
55
nursing implications when taking phenytoin
take at same time every day, monitor levels, some cause gingival hyperplasia
56
what is the ONLY procedure done for partial seizures
vagal nerve stimulator (implanted in cell wall, magnet held to chest)
57
what should the pt avoid after the placement of a vagal nerve stimulator
microwave ovens, shortwave radios, MRI, ultrasounds
58
what is the procedure used for BOTH generalized and partial seizures
conventional surgery (removes part of brain that is causing seizure)
59
if a pt cannot have conventional surgrey then what
partial corpus callosotomy
60
what is status epilepticus
repeated seizure activity within 30 min or a single seizure lasting longer than 5 mins
61
nursing actions during a status epilepticus
IV access, EKG monitoring, pulse ox, give IV diazepam or lorazepam, then phenytoin or fosphenytoin
62
what is a sprain
injury to a ligament
63
what is a strain
injury to a tendon/muscle
64
nursing intervention for sprain
RICE (rest, ice, compression, elevation)
65
Sprain 1st degree
mild, stretching or minimal tearing of ligament, pain/edema, joint function intact
66
Sprain 2nd degree
moderate ligament tear, pain/swelling, bruising, altered weight bearing
67
Sprain 3rd degree
severe tear of ligament (complete), severe pain/bruise/swelling, no ambulation
68
nursing interventions of strains
cold/heat application, exercise, activity limitations, anti-inflammatory or muscle relaxants
69
Strain 1st degree
mild inflammation/pain, normal ROM, swelling, bruising
70
Strain 2nd degree
moderate, partial tear of tendon/muscle fibers, impaired muscle function
71
Strain 3rd degree
severe, ruptured muscle/tendon, severe pain (may need surgery)
72
post op care for arthroplasty
immobile for 4-6 wks, needs physical therapy
73
what is an arthroplasty
reconstruction or replacement of joint
74
how does a nurse assess for a sprain or strain
inspection, palpation, neurovascular 7Ps
75
List the 7 P's
pain, pallor, pulselessness, pressure, protrusion, paralysis, paresthesia
76
diagnosis of both sprains and strains
MRI, x-ray, history, ultrasound
77
complications post sprain and strain
instability, tendonitis, bursitis
78
what are 2 types of meniscus tears
medial and lateral
79
manifestations of a meniscus tear
pain, fluid in the joint
80
diagnostic tests for meniscus tear
MRI, physical exam, McMurray and Steinman test, radiograph
81
what is McMurray
flexed knee as much as possible
82
what is Steinman
rotating leg inward and outward
83
what is not recommended for meniscus recovery
complete immobilization
84
surgery for meniscus
arthroplasty
85
when are casts applied after fracture
when swelling goes down
86
nursing implications for cast
monitor neuro q1hr for 24hrs, ice for 24-48hrs, avoid setting on hard or sharp objects, watch for drainage
87
pt teaching for casts
dont put stuff down cast use cool air from hair dryer, cover in plastic bag to avoid moisture
88
what is traction in fractures
pulling force to promote and maintain alignment
89
what is included in the traction order
type, weight, if can be removed when doing nursing tasks
90
3 types of traction
manual, skin (straight/running), skeletal (balanced suspension)
91
what is skin (straights/running)
movement pts body can alter the traction (decrease muscle spasms, immobilzes prior to surgery)
92
what is skeletal (balanced suspension)
screws inserted into bone, may use heavier weight or longer traction time
93
how often do the ropes need to be changed in traction
q8-12 hrs
94
how should pins be cared for
inspect site for infection, done once per shift or twice depending on protocol, use diff swab for each pin, use dry gauze
95
What should the nurse do for a traumatic amputation limb
apply direct pressure, elevate the extremity above the heart
96
what should nurse to with amputated limb
wrap in sterile gauze, place in baggie, submerge in ice
97
how should post op amputated be postitioned
dependent to promote blood flow
98
the nurse should compare _____ to the most proximal and unaffected extremity
pulses
99
what med is used to reduce phantom limb pain the 1st week of amputation
calcitonin
100
what can indicate a complication post amputation
swelling above stump
101
what is a complication of an amputation
flexion contractures
102
nursing care for avoiding flexion contractures
ROM exercises, proper positioning post op, elevate in 1st 24-48hrs (reduce swelling), lie prone for 20-30 mins several times a day, discourage prolonged sitting
103
what is carpal tunnel
repetitive motions of the wrist causing inflammation on tendons and ligaments (compression on median nerve)
104
manifestations of carpal tunnel
sharp pain, numbness, tingling in hands, commonly worse at night, decreased grip strength
105
diagnostic test for carpal tunnel
phalens test, tinels sign (tapping on median nerve), nerve conduction
106
treatment for carpal tunnel
modify work environment, ROM, ultrasound therapy, NSAIDs, steroid injections, splinting at night, OT
107
carpal tunnel surgery availiable
carpal tunnel release surgery
108
how long should hand movement be restricted after carpal tunnel surgery
4-6 months
109
what needs to be reported immediately post op carpal tunnel
neurovascular status
110
lifespan of arthroplasty
10-15 yrs
111
contraindications to arthroplasty
recent or active UTI, arterial impairment, inability to follow post op regimen
112
pre op tests done for arthroplasty
blood work, chest x-ray, ECG
113
what modifications need to be made for a post op hip replacement
raised toilet seat, long shoehorn, dressing sticks, straight chair with arms, abduction pillow between legs
114
what should post op hip replacement be taught
early ambulation is important, avoid 90 degree flexion, do not cross legs, do not internally rotate toes, avoid turning on operative side
115
education post op knee replacement
have a continuous passive motion machine, flexion of knees limited to avoid contractures, place single pillow under lower calf/foot, limit kneeling indefinitely
116
complications of arthroplasty
venous clot, joint dislocation, infection, anemia, neurovascular compromise
117
cause of encephalitis
viral infection, vector borne viral infections, fungal infections
118
encephalitis manifestations
fever, neurological deficits, headache, photophobia, phonophobia, stiff neck
119
how is encephalitis diagnosed
lab tests, lumbar puncture, EEG, CT, MRI
120
medications given for encephalitis
antivirals and antifungals, stool softeners and laxative PRN
121
what degree should the bed be kept in for encephalitis
30-45
122
nursing care for encephalitis
dim lights, quite environment, reposition, every 2hrs, seizure precautions
123
what is amyotrophic lateral sclerosis AKA Lou Gehrig's disease
cause unknown, rapidly progressing and fatal disease affecting voluntary muscle control with no cognitive impairment
124
once the diaphram and chest wall are affected what will the pt need
artificial airway
125
manifestations of ALS
muscle cramps/weakness, weakness in one part of body, slurred speech, dysphasia, spasticity, flaccidity
126
how ALS diagnosed
lumbar puncture, CT, MRI, hx, tumors can mimic the s/s so rule other causes out
127
ALS: meds used for muscle cramps
bacolfen
128
ALS: meds used for not straining/muscle weakness
stool softeners
129
ALS: meds used for weakness and fatgue
CNS stimulants
130
ALS: meds for slowing the disease progression
riluzole
131
ALS respiratory related complications
aspiration, pneumonia, respiratory failure, PE
132
ALS complications related to immobility
DVT, pressure sores
133
ALS nursing care
ROM, meds, HOB elevated, discuss ventilator support when s/s are mild and can be informed, report swallow difficulty
134
how brain tumors classified
cells or tissue or origin and location
135
location classification of brain tumor: supratentorial
occurs above tenrotium cerebellum
136
location classification of brain tumor: infratentorial
below brainstem and cerebellum
137
brain tumor manifestations from increased pressure on brain
increased ICP, decreased outflow of CSF, neurological deficits, pituitary gland tumors= endocrine function
138
brain tumor manifestations
dysarthria, dysphagia, positive romberg, positive babinski, vertigo, hemiparesis, cranial nerve dysfunction, papilledema
139
possible findings for supraintentorial specificly
sever headache, seizures, loss of voluntary movement, change in personality and cognitive function, N/V
140
possible findings for infratentorial specificly
hearing loss/tinnitus, facial drooping, diff swallowing, nystagmus, cross eyed, decreased vision, ANS dysfunction, cranial nerve dysfunction
141
types of brain tumors: primary malignant
originate in neurological tissue, rarely metastasize outside of brain
142
types of brain tumors; secondary malignant brain tumor
metastasis from primary cancer elsewhere in body
143
types of brain tumors: benign brain tumors
meninges or cranial nerves= no metastasis, has distinct boundaries
144
brain tumors diagnosed
x-ray, CT, MRI, EEG, lumbar puncture, cerebral biopsy
145
when should a lumbar puncture not be performed
increased ICP, can cause brain herniation through the foramen magnum
146
what medication for cerebral biopsy must continue
anticonvulsants
147
what med should pt getting a cerebral biopsy discontinue how long before procedure
ASA 72 hrs
148
headache brain tumor what med
non opioid pain meds
149
reduced cerebral edema (brain tumor med)
corticosteroids
150
osmotic diuretic for brain tumor med
mannitol
151
seizures for brain tumor med
anitconvulsants
152
nausea brain tumor med
antiemetics
153
what med should not be given to brain tumor pt
opioids; cause a change in neuro status during intoxication
154
therapeutic procedure for brain tumor
craniotomy (partial or complete resection of tumor)
155
when should pt discontinue the use of alcohol, NSAIDs, anticoagulation, tobacco
5 days prior
156
post op wound dressing craniotomy
assess for drainage q1-2 hrs, should not have drainage
157
how should pt with supratentorial tumor be positioned
HOB 30 degrees, head in neutral
158
how should pt with intratentorial be positioned
flat, side lying, turn q2
159
what are complications that can happen due to a brain tumor
SIADH, diabetes insipiduc
160
what is myasthenia gravis
autoimmune disease causing a motor disorder with fluctuating, localized, skeletal muscle fatigue and weakness
161
how is MG diagnosed
serological antibody testing, repetitive nerve stimulation test, tensilon test
162
tensilon test?
give edrophonium IV, observe the weak muscles, if improve then returns to poor baseline= positive test
163
adverse effect of edrophonium? reversal agent
bradycardia and bronchospasms (give atropine)
164
what are med for MG
pyridostigmine, neostigmine, immunotherapy, cyclophophamide
165
what surgery could help MG? who is qualified
thymectomy, pts less than 65 and within 3 yrs diagnosis
166
what are 2 MG complications
myasthenic crisis, cholinergic crisis
167
what is myasthenic crisis
exacerbation of weakness lasting 2 weeks resulting in respiratory failure (bacterial or viral infection)
168
myasthenic crisis manifestations
tachycardia, flaccid muscles, pale/cool skin
169
what is cholinergic crisis
occurs from over taking meds
170
manifestations of cholinergic crisis
muscle twitching, sweating, pallor, excess secretions, small pupils
171
what should the nurse do in the event of a cholinergic crisis
temporarily discontinue med
172
nursing care/education for pt with MG
HOB elevated, meals when meds are at peak effect to prevent aspirations, rest periods, medical alert bracelets, avoid public spaces, get vax
