Midterm Flashcards
(155 cards)
1
Q
2 types of Seizures
A
Generalized & Focal
Focal , pt is somewhat conscious & aware during the event
2
Q
Common Causes of Seizures
A
- Very high fever (more common in children, Febrile seizure)
- CNS infection (bacterial meningitis)
- Hypoglycemia (severely low glucose level)
- Alcohol withdrawal (seizure precautions!)
- Epilepsy
- Acid-base imbalances (acidosis/hypoxia)
- Brain tumor
3
Q
Epilepsy
A
A chronic condition.
Causes:
- severe brain trauma
- congenital birth defect
- Massive stroke
- Long lasting effects from an illness like bacterial meningitis
4
Q
Stages of a Seizure - Prodromal
A
S&S appear days before big event like depression, anger, anxiety, GI & urinary issues
5
Q
Stages of a Seizure - Aura
A
Happens prior to a seizure within seconds to mins!
Manifests as spots in vision, Deja vu, sudden weird smell or taste.
common with generalized tonic/clonic seizures (gran mal)
6
Q
Stages of a Seizure - Ictus
A
The seizure itself, typically lasts 1-3mins.
Status Epilepticus lasts MORE than 5mins or 2 shorter seizures back to back
MUST TIME THE EVENT!!
For Status Epilepticus, pt needs to be medicated to STOP seizure! Usually IV push diazepam!
7
Q
Stages of a Seizure - Post Ictus
A
Recovery of the brain post seizure. Tonic-Clonic seizures have the LONGEST recovery time, typically hours to days.
Absent seizures have immediate recovery!
8
Q
Tonic-Clonic Seizure
A
aka Grand Mal
Most common type of generalized seizures!
Typically present w/ aura prior to it starting
9
Q
Absent Seizure
A
Aka Petit Mal
More common in PEDIATRIC population!
Talking to someone & all of a sudden they go blank
They come back & don’t know what just happened
10
Q
Seizure Precautions - Before Seizure
A
- assess risk factors
- seizure precautions in place:
- oxygen
- suction
- IV access
- Padded side rails
11
Q
Seizure Precautions - During Seizure
A
- untie or loosen pt’s gown (choking risk)
- TURN PT TO THEIR LEFT SIDE TO ENSURE OPEN & PATENT AIRWAY
- Nothing in the mouth to prevent aspiration
- Time the seizure!! Important part of the assessment
- Assessing if there is bowel or bladder incontinence
- bed should be in lowest position & locked!
- how are the limbs moving? Assessing/documenting
- Did they cry out prior?
12
Q
Seizure Precautions - After Seizure
A
- ensure pt is stable
- maintain airway
- neuro assessment
- vital signs
- blood draw to monitor drug levels/electrolytes
- Meds administered
- EEG , no caffeine, seizure meds, or stimulants prior!
13
Q
Multiple Sclerosis (MS)
A
Autoimmune disorder that affects the myelin sheaths of neuron in the CNS
- affects women more than men, ages 20-40yo at highest risk
- can be relapsing or remitting, symptoms often appear & disappear in 85-90% of pts
- primary progressive type = progression of disability without relief
- cause unknown, no cure
14
Q
Diagnosis of MS
A
- MRI to look for lesions (scarring/inflammation in brain & spinal cord)
- Lumbar puncture (look for oligoclonal bands signaling inflammation in CNS)
- Evoked potential study = electrode on scalp measuring how long it takes brain to process signals from nerves
15
Q
S&S of MS
A
- muscle stiffness or spasms
- Ataxia
- pos Romberg sign = pt stands w/ eyes closed & feet together loses balance/sways
- Lhermet’s sign = pt moves their head in different ways & feels electric shock down their spine
- Uhthoff’s Sign = heat makes S&S worse (can also be heat from physical exertion)
- feel drained, depressed, mood swings
- Nystagmus (invol movements of the eyes)
- Optic neuritis (double or dull/gray vision)
- Overactive bowel/bladder or the opposite
16
Q
Nursing Care & Management of MS
A
- Assistive devices for ADL like shower chair, commode, walker, Sara-steady
- Edu on what to avoid (heat, stress, infection prev)
- Clear understanding of bowel & bladder needs to Tx accordingly
- Exercise & PT
- connect w/ support groups
17
Q
Myasthenia Gravis (MG)
A
Autoimmune condition that attacks muscle receptors that control VOLUNTARY muscles at the neuromuscular junction
Much more common in females.
18
Q
Myasthenia Gravis S&S
A
- Hallmark sign is muscle weakness that gets worse w/ continued activity
- Initial S&S involve ocular muscles: diploid (double vision), Ptosis (drooping eyelid), strabismus (lazy eye)
- Weakness of facial muscles (mask face) mastication may become affected!
- Dysphonia (voice impairment)
- Generalized weakness of extremities
Resp failure in SEVERE cases
19
Q
Myasthenic Crisis
A
Sudden, temporary exacerbation of symptoms of MG, commonly caused by INFECTION.
SEVERE RESP DISTRESS + Severe presentations of the normal S&S
- often caused by under medicating
- pt will likely require intubation & mech vent
- suctioning to prevent aspiration!
20
Q
Cholinergic Crisis
A
Happens from OVER MEDICATING!
Too much ACh is hitting receptor sites, over stimulated receptors become desensitized.
Results in SLUDGEM:
Salivation
Lacrimation
Urination
Defecation
GI upset
Emesis
Miosis
21
Q
Diagnosing MG
A
- Tensilon Test = Edrophonium chloride (ACh-esterase INHIBITOR) is administered , if immediate improvement in muscle strength , positive test for MG!
- CT scan showing enlargement of Thymus gland (thought to correlate to autoimmune pathology)
- Ice pack test = ice on eyes for 2min, if ptosis IMPROVES, MG is likely the culprit
22
Q
Care & Management of MG
A
- Respiratory assessments!!!
- Assess swallowing (speech & swallow test)
- Risk for falls!
- No cure, just Tx S&S to improve quality of life
23
Q
Guillain-Barre Syndrome (GBS)
A
Autoimmune attack on the peripheral nerve myelin causing paraesthesia (weakness) in the lower extremities THAT PROGRESSES FROM THE BOTTOM UP! TOE TO HEAD!
Most often a viral infection (usually resp or GI) proceeds clinical presentation of GBS by 2-6 weeks!!
24
Q
Nursing care & Management of GBS
A
- As it ascends to torso, can cause RESP FAILURE! Monitor breathing
- Want to prev complications from potential to develop DVT & pressure injuries (think SCDs, repositioning, mepilex)
- High risk for paralytic ileus!!
-
Plasmaphoresis to try to rid body of autoimmune abs and replace with IVIG
can take up to 2 years to recover
25
Parkinson’s Disease
Slowly progressing neurological movement disorder that eventually leads to disability. Death of dopaminergic receptors.
26
S&S of Parkinson’s
- **“TRAP”** = Tremor, Rigidity (cogwheel), **Akinesia/bradykinesia** (lack of movement or slowwww movement), Postural disturbances (bent over to try and walk d/t ataxia)
- ANS responses like ortho hypoT, constipation, gastric&urinary retention, sexual dysfunction
- **hypokinesia = freeze ups**
- **Micrographia** = small hand writing
- Often when taking meds like Carbidopa Levodopa for long periods of time, they experience “wearing off” randomly stops working like an on/off switch
27
Amyotrophic Lateral Sclerosis (ALS)
aka Lou Gehrig’s disease
Degenerative, debilitating, fatal disease characterized by the loss of both upper and lower extremity neurons.
28
ALS Diagnosis
- diagnosed by observing S&S
- Electromyelogram (EMG) looking for fibrillations, this may indicate denervation of muscles
29
S&S of ALS
- gradual onset of asymmetric, progressive limb weakness
- trouble talking, walking, breathing
- **pt has complete mental awareness of what is happening to them “locked in”**
- death typically occurs 3-5 years after diagnosis
30
Systemic Lupus Erythematosus (SLE)
Chronic inflammatory, multi-system autoimmune disease with variable presentations, courses, and prognoses characterized by remissions & exacerbations!
- Cells broken down by normal apoptosis -> immune system has inappropriate response to the cell fragments -> wherever apoptosis sensitization happened = body system where Lupus S&S manifest
- Can affect ANY body system
- occurs 10-12x more in females than males (esp female of childbearing age)
31
S&S of SLE
- **Butterfly rash on face**
- Discoid rash (almost looks like ringworm)
- sun exposure to skin can exacerbate symptoms , wear SPF + protective clothing
- HIGH RISK OF INFECTION!
- HIGH RISK OF BLOOD CLOTS DURING PREG & DELIVERY
- alopecia
- proteins left behind from apoptosis can cause edema & renal failure!
32
Diagnosis of SLE
- Positive ANA (anti-nuclear abs, demonstrates body has created abs against itself)
- Anti- Sm antibodies (not definitive)
- Elevated ESR (erythrocyte sedimentation rate)
33
Tx of SLE
- manage triggers like stress, avoid certain meds, try to avoid illnesses
- steroids to decrease inflammation (immune risk!)
- NSAIDs
- Anti malaria drug
- Immunosuppressants (again immune risk!)
34
Cerebral Blood Flow (CBF)
Auto-regulation to maintain adequate blood flow
- brain uses 15% of cardiac output!
- It uses 20% of O2
- It uses 25% of available glucose
35
Metabolic factors affecting CBF
CO2 - hypercapnia = vasodilation, hypocapnia = vasoconstriction
O2 - hypoxia = vasodilation
H ion - lactic acid build up = vasodilation
36
Cerebral Perfusion Pressure (CPP)
Pressure needed to ensure adequate cerebral blood flow.
CPP 60-100 = normal
> 100 = increased ICP
40-50 = ischemia to brain tissue
< 40 = **irreversible** ischemia & infarction
0-40 = brain death
37
How to determine CPP
CPP = MAP - ICP
To determine MAP….
MAP = DBP + 1/3(SBP-DBP)
38
Blood Supply to Brain - Carotid arteries
Supply anterior & middle brain
39
Blood Supply to Brain - Basilar arteries
Supplies cerebellum & brainstem + most of posterior brain.
Formed from the 2 vertebral arteries joining.
Venous blood drain through jugular veins
40
CSF
Clear, colorless fluid
Shock absorber, exchanges nutrients btwn plasma & cellular compartments, similar to plasma
41
Glasgow Coma Scale
Assesses eye opening, motor, & verbal response
Scored 3-15, lower score is BAD
GCS of 15 = alert
GCS of < 8 = coma/poor prognosis, likely need to be intubated
“GCS of 8, intubate!”
42
ICP
Pressure inside the cranio-spinal compartment
Normal ICP = 5-15 mmHg
**Sustained elevated ICP > 20mmHg is CONCERNING, MEDICAL EMERGENCY!**
Temporary increases to ICP are caused by sneezing, coughing, emesis, bearing down
43
Monroe-Kellie Doctrine
When there’s an increase in 1 part of the skull compartment, there MUST be a decrease in the other compartments, otherwise ICP will increase.
*eventually this compensatory measure will fail*
44
Factors that increase ICP
- Body temp / hyperthermia
- Oxygenation status (hypoxia & hypercapnia)
- Body position
- Arterial & venous pressure
- Anything that increases intra-abdominal or intra-thoracic pressure (coughing, sneezing, vomiting)
- Head trauma
- High CSF ie. Hydrocephalus
- Bleeding/hemorrhage
- Tumor
45
S&S of Increased ICP
- mental status changes (confusion, agitation, restlessness, obtundant)
- Irregular breathing, **Cheyenne Stoke’s** = cyclical pattern of rapid then slow breathing
- **Papilledema** = swelling of the optic nerve
- Unequal pupils
- **Doll’s eyes** = eyes don’t move opposite direction of head movement
- Posturing (decorticate/decerebrate)
- **Cushing’s Triad (very late sign!)** body’s ability to auto-regulate has failed = increased BP, decreased pulse, decreased respirations!
46
Interventions for Increased ICP
- Position HOB 15-30 degrees **NO FLEXION IN NECK OR HIPS!**
- MAINTAIN AIRWAY! Suction for < 10sec
- Control body temps w/ antipyretics & removing excess clothing/blankets
- avoid straining activities with anti-emetics & stool softeners
- DVT prev
- Care of mouth & Eyes
- ROM exercises/positioning to reduce pressure injuries
- Neuro checks / GCS
47
Meds for Increased ICP
- High dose barbiturates, decreases brain metabolism, BP, and ICP
- Vasopressors & IVF to try to maintain SBP 90-150
- Anticonvulsants to prevent seizures
- Hyperosmotic drugs / Fluids like Mannitol or 3% NS
48
If you give pt mannitol or 3% NS and now they have crackles in lungs, what’s happening?
They have fluid overload / pulmonary edema
49
ICP Monitoring indications
- Monitoring is indicated for comatose pts (GCS 3-8), abnormal CT, and post neurosurgery, or if hematoma or hydrocephalus
50
Types of ICP Monitoring - Ventriculostomy
catheter inserted into lateral ventricle that drains CSF & monitors ICP **BIG INFECTION RISK**
51
Types of ICP Monitoring - Subarachnoid bolt
Hollow device inserted through skull & dura mater into arachnoid space. ONLY monitors ICP
52
External Ventricular Drain
ONLY drains CSF , Does NOT monitor ICP
53
Traumatic Brain Injury (TBI)
Brain injury caused by external force
Damage can be temporary or permanent
Most common cause is falls!
Followed by MVAs
54
Types of TBIs - Primary
Initial damage (contusions, lacerations)
55
Types of TBIs - Secondary
Cerebral edema, seizures, infection, etc
56
Types of TBIs - Closed (blunt) injury
Acceleration/deceleration injury (MVA or walking into wall)
57
Types of TBIs - Open injury
Penetrating injury or severe blunt trauma
58
Types of TBIs - Contrecoup
Occurs on the opposite side of the site of impact
59
S&S of TBI
- altered level of consciousness
- confusion
- pupil abnormalities
- changes in vital signs
- headache, seizures
- vision & hearing impairment
60
Syndrome of Inappropriate (Increased) Antidiuretic Hormone (SIADH)
**caused by damage to hypothalamus or pituitary gland!**
Increased ADH causes fluid retention -> hemodilution
Artificially low levels of Na, low BUN, Specific gravity of urine > 1.025
Goal is remove excess fluid!
61
Diabetes Insipidus (DI)
**caused by injury to brain (hypothalamus or pituitary)**
Dysfunction between production and storage of ADH.
Not enough ADH -> diuresis -> dehydration
Kidneys excrete VERY DILUTE urine, up to 20L/day!
62
Concussion
Mild TBI.
Alteration in mental status that may or may not result in LOC. May have headache, nausea, vomiting, photophobia, amnesia, blurry vision.
**should wake pt up every several hours at home to make sure mental status has not DECREASED or CHANGED**
63
Cerebral Contusion
Bruising of the brain.
Significant alteration in LOC!
S&S = faint pulse, shallow respirations, cool/pale skin
64
Skull Fractures
Break in continuity of the skull caused by forceful trauma.
Can be open = scalp laceration or tear in Dura mater
Or Closed = dura mater is intact!
Classified as:
- simple
- comminuted (splintered)
- depressed (bone frag imbedded in brain tissue)
- Basilar (base of the skull)
65
S&S of Skull Fx
- may or may not cause swelling
- basilar fx tends to traverse the paranasal sinus of the frontal bone or middle ear. **look for CSF draining from nose/ ears**
- Persistent, localized pain suggests skull fx is present
66
Interventions for Skull Fx
- close monitoring
- Depressed skull fx typically requires Sx!
- penetrating wounds require debridement & abx!
- Blood products given to dural laceration pts as needed
67
Basilar Skull Fx
Can be identified by hemorrhage from ears, nose, throat as well as CSF from those areas.
Look for battle sign & raccoon eyes!
**Halo sign** = blood with a pale yellow halo on something like a pillowcase (indicates CSF present)
Dextrose stick can test fluid for glucose to determine if there’s CSF in it
**CANNOT PLACE NGT IN PT WITH BASILAR FX!**
68
Epidural Hematoma
**Arterial blood** pools btwn dura mater & inner aspect of the skull. (Typically from middle menigeal artery d/t a fx of Pterion (where frontal, parietal, temporal, & sphenoid bones fuse together, FRAGILE area)
69
Epidural Hematoma S&S
- present w/ period of LOC!! Followed by lucid interval where they feel fine & forget what happened. **High risk of not seeking medical attention d/t this!**
- Headache
- N/V
- HIGH RISK FOR BRAIN HERNIATION! EMERGENCY!
70
Subdural Hematoma (SDH)
**Venous hemorrhage** between dura & arachnoid layers
Typically caused by rapid acceleration/deceleration injuries
*can develop over 2 days to 4 months. SLOW BLEEDS!*
**CT shows a conclave, CRESCENT SHAPE density that crosses suture lines (may see midline shift)**
71
Acute Subdural Hematoma
- results from major head injury
- forms within 24 to 48HRS
- change in LOC, pupil reactivity, hemiparesis, headache
- hyper dense on CT
72
Chronic Subdural Hematoma
- Evolves over weeks to months
- SLOW BLEED
- Common in elderly and alcoholics
- HYPOdense on CT
73
Intracerebral Hemorrhage (ICH)
Arterial bleeding into the parenchyma of the brain.
Commonly seen in the Circle of Willis, caused by **saccular aneurysms**
74
S&S of Intracerebral Hemorrhage
- **thunderclap headache “worst in my whole life”**
- Nuchal rigidity
- Seizure like activity
75
Interventions for Intracerebral Hemorrhage
- prevent post traumatic vasospasm of subarachnoid vessels (CCB relaxes smooth muscle to prevent vasospasm)
- Control ICP
- monitoring for re-bleeding
- shunts, burr holes, or craniotomy
76
“C3, C4, C5…
Keep the diaphragm alive!”
77
The higher the spinal cord injury….
The worse it is!
78
Thoracic spine injury can cause…
Damage to bladder innervation! Incontinence
79
Injury to lumbar spine can cause…
Paralytic ileus!
80
Coccyx spinal injury , we worry about…
Skin innervation!
81
Dermatome
Areas on the skin / body that correlate to certain spinal nerves and injury to those nerves
82
Spinal Cord Injury (SCI)
Damage to nerves that send & receive signals from the brain to/from the rest of the body.
Damage can be directly to spinal cord or to the tissues and vertebrae.
- damage can be temporary or permanent
- Chronic disease can damage spinal cord like a tumor or spina bifida (spinal cord doesn’t fully form and close)
83
Primary SCI
- trauma to spinal cord from contusion & laceration
- compression
- cord transection *paralyzed below level of injury!*
- Narrowed foramen (spinal stenosis/arthritis)
- herniated disk
- subluxation / dislocation of vertebrae
*flexion & hyperextension injuries are 2 of the most common causes of SCIs!*
84
Secondary SCI
- process of ischemia from prolonged compression
- scarring from inflammation
85
Paraplegia
- Occurs from injuries to **thoracic spine and lower**
- loss of sensation/movement in all or part of the trunk and lower extremities
- affects pelvic organs , loss of voluntary bowel/bladder and sexual fx
86
Quadriplegia (tetraplegia)
- occurs from **cervical spine** injuries
- may or may not be able to breath on their own
- no movement or sensation from the neck down!
87
Central Cord Syndrome
- Caused by **hyperextension injury**
- slow growing lesion
- damage is to medial cortico-spinal tract
- **weakness in ARMS is GREATER than legs**
- loss of pain and temp sensation in affected/adjacent dermatomes (above & below injury)
- may have urinary retention
88
Lateral (Brown-Sequard) Cord Syndrome
- damage to the dorsal column , corticospinal tract , spinothalamic tract, on the ipsothalamic tract
- weakness and loss of proprioception on **ipsilateral side**
- loss of pain and temp on **Contralateral side**
89
Anterior (Ventral) Cord Syndrome
- damage to anterior spinal column, responsible for motor fx, pain, and temp sensation, and lateral horns t1-L2
- **acute onset of back pain localized at level of lesion**
- caused by **ischemia** to anterior **spinal artery**
90
Posterior (Dorsal) Cord Syndrome
**Rare!**
- Damage to dorsal column that is responsible for **proprioception, vibration sense*
91
Conus Medullaris Syndrome
**Rare!**
- Damage to sacral nerve roots T12-L2
- flaccid paralysis of bladder, rectum, impotence, **saddle anesthesia**, leg muscle weakness
- caused by disc herniation, tumor, spinal fracture
92
Cauda Equina Syndrome
- damage to 2 or more nerve roots in the cauda equina
- often assoc w/ **radiating low back pain into 1 or both legs!**
- Damage to S1&S2 = weak plantar flexion
- Damage to S3-S5 = bladder & rectal sphincter paralysis
93
Diagnosis Acute SCI - Xray
- see vertebral fx
- vertebral dislocation
- Tumor(s)
94
Diagnosis Acute SCI - MRI
- visualize the extent of damage to the spinal cord
- areas of inflammation, bleeding, or compression caused by injury to surrounding structures like ligaments or discs
95
Diagnosis Acute SCI - CT Scan
- Determine the **degree of injury**
- visualize damage to ligaments
- see hemorrhage/swelling
- CT angio to determine blood vessel damage **contraindicated in renal fl pts! Or contrast dye allergies**
96
Neurogenic Shock
**Urgent!!**
- Form of DISTRIBUTIVE shock
- SCI interrupts the autonomic nervous system
- Severe peripheral vasodilation -> hypotension
- bradycardia
- hypothermia
97
Spinal Shock
*immediately after injury! Can last for days to weeks, resolves on its own*
- loss of ALL reflexes below injury with slow return
- flaccid paralysis
- no DTRs
- Hypotension
- Anhidrosis (cannot regulate body temp)
- Paralytic ileus
98
Spinal Traction
*For cervical spinal injuries with dislocation/misalignment *
- goal is to realign the spine and reduce compression on spinal cord
- use of skull tongs or halo headpiece
- initial weight applied is 5-15lbs
- may require muscle relaxant such as diazepam or Valium
- **every time weight is added, x-ray to ensure spine is in correct alignment**
- worried about infection around pin sites!!
99
Complications of SCI by Body System - CV, Resp, Muscol, Psych, Nutrition, GI/GU, Skin, Pain
**CV** = orthohypoT, increased risk for VTE , cannot regulate body temp below injury
**Resp** = C3-C5, keep diaphragm alive!
**Musculoskeletal** = contractures
**Psychosocial** = depression, suicide rate 5x higher!
**Nutrition** = self feeding ability, enteral feeding
**GI/GU** = retention/incontinence/constipation
**Skin** = pressure injuries
**Pain** = neuropathic pain
100
Autonomic Dysreflexia
**SCI at or above T6!**
- loss of coordinated autonomic response = **uninhibited sympathetic response**
- caused by **noxious stimuli (painful)** below level of injury like:
- **bladder dissension (MOST COMMON CAUSE)**
- visceral disturbance **sheet crumpled under pt!!**
- pressure ulcer
- bowel impaction
- bone fx
- medical procedure
101
S&S of Autonomic Dysreflexia
- SEVERE HTN (up to 300sbp!)
- Bradycardia
- MASSIVE throbbing headache **often first symptom**
- flushing
102
Intrathecal Baclofen Pump
*baclofen is a muscle relaxer*
- small catheter to pump & spine
- Medication is infused continuously
- pump/reservoir needs to be filled at regular intervals
- **MUST be tapered off and NOT stopped abruptly**
103
TIA
Aka “Mini-stroke”
- defined as a brief episode of neurologic dysfunction, **typically lasting < 24hrs**
- S&S of stroke BUT only lasts a few mins to hours and **resolves spontaneously**
- *it is a warning sign that an impending stroke may occur*
104
Ischemic Stroke
**MOST COMMON**
- occurs d/t
105
Care of a Sprain
“RICE”
Rest
Ice (20-30min at a time during first 24hrs)
Compression
Elevation
106
Compartment Syndrome
Buildup of pressure around muscles that cuts off blood supply and nerve impulses. 3 different types.
107
Chronic Compartment Syndrome
Pain, aching, and tightness in muscle group. Muscle vol increases in short period of time, as much as 20%!
108
Crush Compartment Syndrome
Massive external compression , cuts off blood supply , may lead to **rhabdomyolysis**
109
Acute Compartment Syndrome
Pressure in space is SO high compromises blood supply and nerve impulses. Marked by a SUDDEN decrease in perfusion to the tissues.
**May be limb threatening!**
110
Compartment Syndrome Nursing Interventions
- Keep limb at heart level, NOT ABOVE!
- loosen or cut off restrictive clothing
- cut cast or decrease traction weight to examine site
- **Fasciotomy** may be necessary to relieve pressure
111
Emergency Management of bone Fx
- ABCs -> control bleeding w/ direct pressure!
- Elevate extremity above heart level
- Do NOT straighten fx/dislocated joints
- Do NOT manipulate protruding bone ends
- Apply ice packs! 30min on, 30 off
- Obtain XRays
- Tetanus shot if skin broken!
112
Nursing Interventions for Fx
- Immobilize with splints *need order!*
- If cervical/thoracic injury, immobilize with C-Collar or backboard, **log roll pt**!
- Med hx for ACs
- Pt at risk of **hypovolemic shock** from open/compound fx!!
- NPO until evaluated (may need OR)
- Assess for compartment syndrome, pulses, neuro checks
113
Risk of Fat Embolism w/ Fx
- With Pelvic or long bone fx’s , fat globules released , can travel to lung, brain, kidneys causing PE, stroke!
- **will see S&S 12-72hrs after fx!**
- Triad of Pulmonary, CNS, Skin S&S = resp compromise/dyspnea , AMS/disorientation/restless, Petechial rash
114
Osteoarthritis - Risk Factors
- Age > 40
- Repeated joint injuries (sports)
- physically strenuous job
- Obesity (increased p on joints)
- Genetics
115
Osteoarthritis - Clinical manifestations
- NOT SYMMETRICAL!
- **Heberden’s node** = distal interphalangeal joint
- **Bouchard’s node** = proximal interphalangeal joint
- pain’s worse with ACTIVITY, better with REST
- **Sunrise stiffness* = improves within 30min of waking
- Pain is worse at EOD d/t use
- crepitus!
116
Osteoarthritis - nursing interventions
- Exercise/PT with low impact
- weight loss if obese
- promote rest and reduce overuse of joints
- cold/heat application to relieve pain
117
Rheumatoid Arthritis
Autoimmune disease attacking synovial joint tissue causing inflammation!
- Can happen at any age (20-60)
- Affects joints BILATERALLY!
- Systemic disease!! Inflamm causes kidneys not to create EPO -> anemia
- may have periods of remission with flare ups!
118
Rheumatoid Arthritis - Manifestations
- Sunrise stiffness
- **Ulnar deviation** = fingers point toward ulna
- **Boutonniere** = flexion of PIP joints
- **Swan neck** = hyperextension of PIP joints
- **Pannus** = vascular granulation tissue
119
Rheumatoid Arthritis - Nursing Interventions
- Risk for falls!
- Edu to rest when inflamed, exercise during remissions
- keep stress low to decrease flare ups
- may need Fe for anemia, EPO supplementation
120
Osteomyelitis
Infection of the bone!
- Commonly Caused by Staph Aureus on the skin
- can be extension of soft tissue infection like pressure ulcer
- directly impacting bone from fx, trauma, Sx
- hematogenous or blood borne spread from other site of infection like teeth, UTI, etc
- needs Sx debridement and IV abx!!
121
122
Spinal Cord Concussion
transient disturbance to the spinal cord, resolves within 24-72hrs
123
Most common cause of SCIs
- MVA & catastrophic falls (diving into pool) are the most common causes of SCI in US!
- effects males, highest risk 16-30yo!
124
125
During the first 24hrs after thrombolytic therapy Tx for an ischemic stroke, the **primary** goal is to control…?
Blood pressure
126
Ischemic Stroke
**More common than hemorrhagic**
- caused by embolism or thrombosis
127
Lacunar Stroke
Most common type of ischemic stroke!
- caused by HTN, HLD, DM
128
Large artery thrombotic stroke
Atherosclerotic plaques in large blood vessels of the brain, accounts for 20% of strokes
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Cardio embolic strokes
Associated with arrhythmias, valvular disease, or left ventricle thrombus
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Cryptogenic strokes
No identified cause
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Hemorrhagic Stroke
- blood vessel in brain breaks -> no perfusion to section of brain fed by that vessel
- bleed causes increased ICP -> extra pressure on brain cells, damage
- can be caused by rupture of aneurysm , uncontrolled HTN, aging vessels
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Arteriovenous Malformations (AVM)
Tangle of arteries and veins in the brain that lacks a capillary bed.
**Common cause of stroke in younger pts!**
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Modifiable risk factors for Stroke
- HTN (SBP > 140) **#1 risk factor for both ischemic & hemorrhagic strokes!**
- Smoking
- HLD
- Uncontrolled DM
- Pts at high risk of clotting
- Obstructive sleep apnea
- Diet
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Left Brain Stroke S&S
**Affects R side of the body!**
- Language & Logic
- Dysphasia = difficulty speaking
- reading and writing problems
- R sided hemiparesis
- R visual field deficit, ignores r side of body
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Right Brain Stroke
**Affects L side of the body!**
- R brain = reckless & really creative
- lack of impulse control
- behavioral changes
- L hemiparesis
- L side neglect
- Spatial/perceptual deficits
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Homonymous Hemianopsia
**most common visual impairment after a stroke!**
Loss of HALF of the visual field (same in both eyes)
Can be temp or permanent
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Dysarthria
Aka slurred speech
Difficulty in ARTICULATING speech caused by the paralysis of muscles responsible for speech
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Apraxia
Inability to put sounds and syllables together in the correct order to form words.
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Broca’s aphasia
Inability to EXPRESS speech. Unable to speak but can still understand. **pt easily frustrated when trying to speak.** May be able to say short phrases.
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Wernicke’s aphasia
Inability to UNDERSTAND speech, can speak words but they’re typically meaningless. Weak understanding and comprehension.
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“BE FAST”
**B**alance, headache, or dizziness
**E**yes, blurry vision
**F**acial/smile droop
**A**rm drift (1 sided weakness)
**S**peech impairment
**T**ime to call 911
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Modified Rankin Scale
Assesses disability in pts who have suffered a stroke and score is compared over time to check for recovery & degree of continued disability.
0 = no disability, 5 = disability requiring constant care , 6 = death
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National Institute of Health Stroke Scale (NIHSS)
Standardized stroke assessment tool to quantify stroke severity and to assess pt outcomes after Tx.
0 = no neurological deficits
42 = the worst possible score
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Contraindications for tPA
- GI bleed, head trauma, or stroke within last 3 months
- Major Sx in past 14 days
- Internal bleeding in past 22 days
- INR > 1.7
- PT > 15sec
- PTT > 40sec
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tPA
Tissue plasminogen activator
**Must be admin within 4.5hrs of onset of stroke symptoms!**
- monitor for anaphylaxis and/or angioedema
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A patient being cared for on the neurologic unit has a diagnosis of acute ischemic stroke. It has affected the left hemisphere of the patient’s brain. The nurse would expect to assess which deficit in this patient?
A. Left side of the body weakness
B. Aphasia
C. Left field visual deficit
D. Lack of awareness of deficits
B
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A patient diagnosed with a stroke is exhibiting slurred speech. The nurse would accurately document this finding as which clinical manifestation of a stroke?
A. Aphasia
B. Dysphasia
C. Dysarthria
D. Apraxia
C
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What would the nurse expect to document in a patient diagnosed with a right hemispheric stroke?
A. Aphasia
B. Slow, cautious behavior
C. Right visual field deficit
D. Impulsive behavior
D
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The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of bed 15-30 degrees.
3. Contact the healthcare provider if ICP is greater than 20 mmHG.
4. Monitor neurologic status using the Glasgow coma scale.
5. Stimulate the client with active range-of-motion exercises.
2, 3, 4
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What is the most common initial symptom that a nurse might expect a client with MS to
complain about?
a. Diarrhea
b. Headaches
c. Skin infections
d. Visual disturbances
D
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A patient sustained a c6 SCI 4 hours ago. what nursing diagnosis is a priority?
a. urinary retention
b. risk for impaired skin integrity
c. ineffective breathing pattern
d. powerlessness
C
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Strain vs Sprain
Strain - injury to a muscle or a tendon
Sprain - injury to a ligament, usually from sudden twisting or bending of joint
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A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect?
A. Avascular necrosis
B. Pulmonary embolism
C. Infection
D. Hypovolemic shoc
A
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