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NRSG 110: Med Surg 2 > [Exam 4] Chapter 66: Management of Patients with Neurologic Dysfunction (Page 1972-1979, 1996-2007) > Flashcards

[Exam 4] Chapter 66: Management of Patients with Neurologic Dysfunction (Page 1972-1979, 1996-2007) Flashcards

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1
Q

What is the most important indicator of the patients condition?

A

Level of responsiveness and consciousness

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2
Q

What is LOC?

A

A continuum from normal alertness and full cognition (consciousness) to coma

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3
Q

What is altered LOC?

A

Present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve state of alertness

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4
Q

What is a Coma?

A

Unconsciousness, unarousable unresponsiveness, may occasionally make non-purposeful movements. This includes patient squeezing hand once, but they are in fact not responding

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5
Q

What is akinetic Mutism?

A

State of unresponsiveness to the environment in which the patient makes no voluntary movement

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6
Q

What is a Persistent-Vegative State?

A

Devoid of cognitive function but has sleep-wake cycles. They are not aware of surroundings, but can have reflexive responses. If they smile, its just reflexive. A fake smile

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7
Q

What is Locked-In Syndrome?

A

Inability to move or respond except for eye movements due to lesion affecting the pons. Completely aware of surrounding, only able to move eyes.

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8
Q

Altered LOC is not a disorder itself, but instead…

A

a symptom of another pathology

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9
Q

Patient with Altered LOC: What do you assess for?

A

Verbal Response and Orientation

Alertness

Motor Responses

Respiratory Status

Eye Signs

Reflexes

Postures

Glasgow Coma Scale

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10
Q

Patient with Altered LOC: What is Decorticate Posturing?

A

A neural reflex that is done in response to stimuli. Done early in brain damagedamage

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11
Q

Altered LOC: Signs of Decorticate Posturing?

A

Hands Flexed, Arms Adducted, Elbows flexed, and legs internally rotated

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12
Q

Altered LOC: Signs of Decerebrate Posturing?

A

Shoulders Adducted, Arms Extended, Wrists Pronated, and Hands Flexed

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13
Q

Altered LOC: When does Decerebrate Posturing occur?

A

When pons affected, meaning they have severe brain damage.

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14
Q

Altered LOC: Why would Diarrhea be assed?

A

Cause from infection, meds, or hyperosmolar fluid administration

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15
Q

Altered LOC: What labs would you check?

A

I/O, BUN, H&H for fluid statis, along with Tugor.

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16
Q

Altered LOC: Sayins to remember risk factors?

A

DIMS

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17
Q

Altered LOC: What are the Risk Factors?

A

(D) Drugs and Alcohol
(I) Infections
(M) Metabolic- Hypoglycemia, hypercapnia, hypoxia, acidosis, electrolytte imbalance, ammonia
(S) Structural : Trauma, Blood Clot, Tumor, Stroke, ICP

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18
Q

Altered LOC: How to prevent this?

A

Prevention is specific to causative factors

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19
Q

Altered LOC: Labs and Diagnostic?

A

Neuro Systems

BMP and CBC

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20
Q

Altered LOC: Complications?

A

Respiratory Distress/Failure

Pneumonia

Aspiration

Pressure Ulcer

DVT

Contractures (Can’t be fixed once occured)

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21
Q

Altered LOC: Nursing Diagnosis for this?

A

Ineffective airway Clearance

RF Injury

Deficient Fluid Volume

Impaired Oral Mucosa

RF Impaired Skin Integrity and Tissue Integrity

Ineffective thermoregulation

Impaired Urinary/Bowel Elimination

Disturbed Sensory Perception

Interrupted Family Processes

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22
Q

Altered LOC: Goals for this?

A

Clear Airway

Fluid Volume Balance

SKin/Tissue Integrity

Effective Thermoregulation

Accurate perception of environmental stimuli

Intact family support and coping

Absence of complications

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23
Q

Altered LOC: Medical Management for this?

A

IV Fluids/Tube Feedings

Artifical Tears

Foley Catheter or Bladder Training

Stool softeners / Suppositories r Enemas

Acetaminophen for fever

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24
Q

Altered LOC: What is the major nursing goal here?

A

To compensate for the patient’s loss of protective reflexes and to assume responsibility for total patietn care. This includes patients dignity and privacy

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25
Altered LOC: How to Maintain an Airway?
Frequent monitoring of respiratory status, including checking lungs Positioning to promote movement of secretions. HOB elevated to 30 degrees. Lateral or Semiprone if doing oral care Suctioning, Oral Hygiene, and CPT
26
Altered LOC: How would you maintain tissue integrity?
Assess skin frequently, with frequent turning. Carefully position in correct body alignment Possive ROM Use of splints, foam boots, Clean eyes with cotton balls moistened with saline and use artifical tears as prescribed. Measures to protect eyes Frequent oral care
27
Altered LOC: How to maintain fluid status
Assess fluid status by examining skin turgor, mucosa, lab test data, and I/O Administer IVs, tube feedings, and fluids via feeding tube. Keep HOB elvated
28
Altered LOC: How to maintain body temperature
Adjust environment and cover appropriately If temp elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, cool sponge bath, and allow fan to blow on patient Monitor temp freq and prevent shivering
29
Altered LOC: How to promote bowel and bladder function?
Assess for urinary retention and incontinence Catherization/ Bladder Training Assess for abdominal distention, constipation, or incontinence Monitor bowel movements Promote elimination with stool softeners, glycerin, suppositories Diarrhea may result from infection, meds, or hyperosmolar fludis
30
Altered LOC: How to help with sensory stimulation and communication
Talk/Touch Patient and Encourage Family to Talk Maintain Normal Day/Night Pattern Orient Pt Frequently Programs for sensory stimulation Allow family to ventilate and provide support Reinforcec and provide and consistent information to family Referral to support groups and services to family
31
Altered LOC: Note for when patient arousing form coma?
Patient may experience period of agitation, minimize simulation at this time
32
Altered LOC: How often should oral care be done?
Every 2 hours
33
Altered LOC: How often should ROM be done?
Every 4 hours
34
Altered LOC: Education for this?
Encourage family to talk and touch the patient. When waking, patient may be agitated. Reorient pt often. Provide consistent information to family Support group referrals
35
Seizures: What is a seizure?
Abnormal episodes of motory, sensory, autonomic, or psychic activity ( or combo) resulting from sudden abnormal uncontrolled electrical discharge from cerebral neurons (epileptogenic focus)
36
Seizures: What is a epileptogenic focus?
Location or point in the brain where the hypersensitive neurons are located causing teh seizure activity
37
Seizures: All people have what threshold?
Seizure threshold, and when exceeded, seizure occurs
38
Seizures: What can cause a seizure?
Patient how low seizure threshold, or pathologic condition has altered the seizure threshold
39
Seizures: What is needed to make diagnosis of epilepsy?
2 or more seizures that can be minutes or years apart
40
Seizures: What are kids diagnosed as if they have a seizure while having a fever?
Febrile Seizure, and does not count toward epilepsy
41
Seizures: What are the two classifications of seizures?
Partial Seizures (Begin in one hemisphere of the brain) Generalized Seizures: (Involve the whole brain)
42
Seizures: Two parts of Partial Seizures?
Simple Partial: LOC remains intact Complex Partial: Impairment of Consciousness
43
Seizures: What specific information for Simple Partial Seizure? Motor, Sensory, ,Autonomic, and Psychic
Depends on part of brain Motor: Jacksonian March (Starts at one part of body, then moves to the adjacent body part on one side. Fingers twitch, move up arm, to shoulder) Sensory: Hallicinations or Abnormal Sesnation (Taste/Smell) Autonomic: Increase HR, Flushing, Change in BP Psychic: Deja Vu, Anger, Fear
44
Seizures: What specific information for Complex Partial Seizure? With Automatisms and Aura
Impairment of LOC Automatisms: Repetitive, non-purposeful movements (lip smcking, tapping foot) May or may not have aura (Symptoms they had before seizure occured), but amnesia will follow
45
Seizures: What are some types of Generalized Seizures?
Absence (Petit Mal) : LOC Impaired Tonic-Clonic (Grand Mal): LOC Impaired
46
Seizures: What happens with an Absence Seizure?
LOC Impaired Brief cessation of motor movements (Don't fall, just stand there) , blank stare (Don't respond to teacher), automatisms may occur 5-30 seconds in length. Occasional episodes or many per day
47
Seizures: What happens in Tonic-Clonic Seizures?
LOC Impaired (What people often think for seizures) Step 1 lasts 15 seconds to 1 minute. May or may not have aura, but amnesia up to 1 hr before and 2 after Follows set pattern: Sudden LOC, tonic contraction (every muscle in body, including vocal cords and diaphragm. ), opisthotonic posture, THEN.. Clonic contraction/relaxation (60-90 seconds), THEN.. postictal (after seizure, changes in thinking, memory, breathing relaxed)
48
Seizures: Some signs of a Tonic-Clonic Seizure?
Foaming coming from mouth, hyperventilaiton. Happens during the clonic contraction/relaxation phase. May sleep for several hours after events
49
Seizures: How to prevent these?
Avoid Triggers Prevent Status Epilepticus - Do not Stop meidcations Medicate fevers for febrile seizures
50
Seizures: What are the risk factors for getting this?
Cerebrovascular Disease Hypoxemia Fever (Child) Head Injury/Hypertension CNS Infections Metabolic /Toxic Condition Brain Tumor Drug/Alcohol Withdrawal Allergies Hypoglycemia
51
Seizures: How to assess for this?
Observe patient signs and symptoms How long does it last Any Triggers? (Flashing lights, menses, fatigue) Assess respiraotry status during and after
52
Seizures: What is Status Epileptics?
Seizure activity becomes continuous and we cannot stop it. Requires immediate intervention
53
Seizures: What can Status Epilepticus lead to?
Hypoxia (Not Breathing), Acidosis (Not blowing off CO2), Hypoglycemia (Takes energy to have body in full contraction/relaxation), Hyperthermia (Bc of increased metabolism), Exhaustion (Leading to death)
54
Seizures: Medical Management for Status Epilepticus?
Maintain airway (Priority) 50% dextrose to prevent hypoglycemia Ativan, Valium Repeat q 10 min
55
Seizures & Interventions of Seizures: Observe and document what?
Patient signs and symptoms before, during, and after seizures
56
Seizures & Interventions of Seizures: Perform after seizure care to prevent
complications
57
Seizures & Interventions of Seizures: What is Epilepsy?
Chronic disorder of recurring, excessive, or self-terminating electrical discharge from neurons
58
Seizures & Interventions of Seizures: What can you do if someone is having a seizure?
Maintain Airway Turn on Side Seizure Pads Protect Head Do not hold patient down Suction airway if needed Loosen clothing around neck
59
Seizures: What are some nursing diagnosis?
RF Ineffective Airway Clearance RF Injury Anxiety REadiness for Enhanced Knowledge Unstable Blood GLucose Impaired Gas Exchange
60
Seizures: What do to with Risk for Ineffective Airway Clearance?
Provide oxygen, turn patient to side, loosen clothing around neck, and do not force anything in mouth suction if needed
61
Seizures: What to do for Risk for Injury?
Do not hold down pad area
62
Seizures: What should the driver do driving wise?
No driving for 6 months - 2 years
63
Seizures: When should you call 911?
If seizure lasts over 5 mins, difficulty breathing after seziure, or second seizure occurs
64
Seizures: What are some goals for this?
Avoid complications, maintain airway, prevent injury, maintain blood glucose, and adhere to medical management
65
Seizures: Labs to test for this?
EEG Medication Levels in Serum CT, MRI
66
Seizures: How to help an individual have Readiness for Enhance Knowledge?
Avoid or have awareness or triggers(flashing lights, fatigue, menses) Recognize Auras Wear medic alert bracelet Avoid alcohol and coffee (lowers seizure threshold) Shower rather than bathe
67
Headache: Also known as
cephalgia
68
Headache: What happens here?
Cerebral blood vessels first narrow and reduce blood flow, then there is vasodilation, swelling, and pain
69
Headache: What is a primary headache?
No known organi cause and includes migraine, tension headache, and cluster headache
70
Headache: What is a secondayr headache?
Symptom with an organic cause such asb brain tumor or aneurysm
71
Headache: Headaches may cause what in terms of lifestyle?
Significant discomfort for the person and can interfere with activites and lifestyle.
72
Headache: Risk Factors for this?
Exposure to toxins Medication side effects Family History Stress
73
Headache & Migraine: How long does this last?
4-72 hours
74
Headache & Migraine: Where does the pain radiate?
Unilateral throbbing pain, intensifies with movement (can become bilateral)
75
Headache & Migraine: What signs can occur?
Chills, N/V, Fatigue, Sensitivity to Light, Sound, or Odor Blurred Vision, Anorexia, Hunger, Diarrhea, Abdomminal Cramping, Facial Pallor, Sweating, Stiffness, or Tenderness of neck
76
Headache & Cluster Headache: What is this?
Extremely severe, unilateral, burning pain behind or around the eyes
77
Headache & Cluster Headache: What are signs do they have?
Rhinorrhea (Nose Runs), facial edema, miosis (excessive shrinking of pupil), ptosis (dropping of upper eyelid)
78
Headache & Cluster Headache: How long do these last for?
Several weeks or months, followed by remission (episode lasts 15 mins to 3 hours)
79
Headache & Cluster Headache: What time of year do these occur?
Fall or spring
80
Headache & Cluster Headache: What time do they begin?
2-3 hours after going to sleep
81
Headache & Migraine: Patients may have what before a migraine headache?
An Aura, where they can tell its coming
82
Headache & Assessment: What should you obtain?
Detailed description of headache. Include medication history and use Types of headaches manifest differently, so they may change over time
83
Headache & Assessment: Persistent headaches requires what?
Investigation
84
Headache & Assessment: What is required of a person undergoing a headache evaluation?
Detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes
85
Headache & Assessment: Diagnostic testing may be used to evaulate
underlying cause if there are abnormalities on the neurologic exam
86
Headache & Assessment: What labs will be performed?
None for Primary Neurological Exam CT, MRI
87
Headache: What complications can occur??
Impairment in ability to carry out life tasks
88
Headache: What can be used be used for recurrent migraines?
Prophylatic medications (Topamax). Taken everyday
89
Headache: Migraines and Cluster headaches requires what meds
abortive medications instituted as soon as possible with onset
90
Headache: What comfort measures can be provided?
Quiet, dark room Massage Local heat for tension
91
Headache: Goals for this?
Pain relief Prevention of headache Ability to complete ADLs
92
Headache: What can be dome triggers to cause this?
Rapid Change in Glucose Emotional Exictemenet Fatigue Alcohol Tyramines (Chocolate, Red Wine, Aged, Cheese, Bagged Veggies) Artifical Sweeteners Menses
93
Headache: What education can be provided?
Avoid Triggers Take Aboritive medicine as soon as headahcne appears
94
Headache: What should patient do to prevent headaches?
Medication instruction adn treatment regimen Stress reduction techniques Nonpharmacologic therapies followup care Encourage healthy lifestyle
95
Headache: What Tyramine foods can cause headaches?
Chocolate, Red Wine, Aged Cheese
96
Headache: Nursing Diagnosis for this?
Acute pain Nausea Impaired Sensory Perception Diarrhea Fatigue
97
Headache: Medical Management for this?
Prophylaxis Meds (Topamax) Oxygen for Cluster headaches Abortive Medicine (Relpax, Imitrex)

NRSG 110: Med Surg 2 (29 decks)

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