Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Neuro > Neuro > Flashcards

Neuro Flashcards

1
Q

Unconscious Patient

Ineffective Breathing Pattern

A
  1. Suction as needed
  2. HOB up 30 degrees
  3. Lateral or semi-prone position
  4. Assess lung sounds and airway Q 8 hrs
  5. Also position their head in “head tilt chin lift” which is the position for CPR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Unconscious Patient

Risk for Injury

A
  1. Pad side rails
  2. Provide privacy
  3. Speak during care
  4. Eye patches
  5. Watch when turning
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Unconscious Patient

Fluid Volume Deficit

A
  1. Watch skin
  2. Daily weights
  3. Turgor
  4. Mucous membranes
  5. I & O
  6. Labs
  7. IVF slowly
  8. Feeding tube or G-tube
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Unconscious Patient

Risk for Imbalanced Nutrition

A
  1. Albumin
  2. Prealbumin
  3. NGT
  4. PEG
  5. Weights
  6. HOB up
  7. Hold if residuals > 100 mL
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Unconscious Patient

Impaired Oral Mucous Membranes

A
  1. Careful oral care

2. Thin coating of lip balm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Unconscious Patient

High Risk for Altered Skin Integrity

A
  1. Turn Q2h
  2. Splints
  3. Foam boots
  4. Special mattress
  5. High top sneakers to prevent foot drop
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Unconscious Patient

High Risk for Impaired Tissue Integrity (corneal)

A
  1. Moist cotton balls with sterile saline
  2. Artificial tears
  3. Cold compresses
  4. Use patches cautiously
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Unconscious Patient

Ineffective Thermoregulation

A
  1. Minimize amount of bleeding
  2. Cool room
  3. “Neuro temps” - damage to brain stem, increased ICP, poor prognosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Unconscious Patient

Impaired Urinary Elimination

A
  1. Palpate or scan bladder at intervals
  2. I & O
  3. Bladder re-training when conscious
  4. Condom cath (you don’t need an order for this)
  5. Absorbent pads (NO DIAPERS)
  6. Observe for UTI and skin breakdown
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Unconscious Patient

Bowel Incontinence

A
  1. Fecal management systems
  2. Liquid stool may mean impacted
  3. Assess abdomen and bowel sounds
  4. Stool softeners
  5. Suppositories
  6. Enema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Potential Complications with unconscious patients

A
  1. Respiratory distress/failure
  2. Pneumonia
  3. Aspiration
  4. Pressure ulcer
  5. DVT
  6. Contractures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Interventions for patient with contractures

A
  1. Passive ROM

2. Hand rolls to prevent clenching hands

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Two main things nurses have to do for unconscious patients

A
  1. Maintain patent airway

2. Maintain safety

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Assessment Steps of the unconscious patient (5)

A
  1. Verbal response
  2. Alertness
  3. Motor response
  4. Posturing (decorticate, decerebrate, flaccidity)
  5. Body functions (temp, HR, BP, elimination, F/E are assessed in systemic and ongoing manner)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Assessment of Stroke

A

FAST

  1. Face (facial droop; ask to smile)
  2. Arms (raise both arms = uneven)
  3. Speech (expressive aphasia; dysarthria)
  4. Time (treatment has to be in certain amt of time)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Dysarthria

A

Difficult or unclear articulation of speech that is otherwise linguistically normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Nursing Care for patient post-carotid endarterectomy

A
  1. Monitor for primary complications (CVA, cranial nerve injuries, infection, and hematoma)
  2. Maintain proper BP levels
  3. Close neuro checks, cardiac monitoring
  4. Difficulty swallowing or hoarseness
  5. Keep emergency airway available, trach set
  6. Monitor for bleeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Nursing Care for client with stroke and increased ICP

A
  1. Monitor for changes in LOC
  2. Elevate HOB 30 degrees
  3. Avoid extreme flexion or extension of neck
  4. Maintain head midline/neutral position
  5. Maintain normal CO2 levels
  6. Control fever
  7. Maintain patent airway (discourage coughing, suction only prn <15 seconds
  8. Avoid hip flexion
  9. Avoid Valsalva maneuver
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the earliest sign of increased ICP?

A

Change in LOC

20
Q

Nursing care for client with stroke after ICP normalizes

A
  1. Encourage mobility
  2. Avoid external rotation of the hip
  3. Prevent arm adduction
  4. Prevent hip flexion
  5. No handrolls
  6. Active ROM Q2h to unaffected side
  7. Passive ROM Q2h to affected side
  8. Elevated affected extremities
  9. Maintain skin integrity
21
Q

How can you help a patient avoid external rotation of the hip?

A

Trochanter rolls

22
Q

How can you help a patient avoid arm adduction?

A

Pillow in the axilla

23
Q

How can you help a patient avoid hip flexion?

A

Help position them in a prone position TID (prone position also protects the airway better than the supine position)

24
Q

Hemianopsia

A

Blindness over half the field of vision

25
Q

CVA Patient

Impaired Swallowing

A
  1. Assist with safe feeding
  2. Assess swallowing and gag reflexes before feeding
  3. Speech therapy
  4. Thicken liquids
  5. Eat upright with head and neck flexed slightly forward
  6. Place food in the back of the mouth on unaffected side
  7. Have suction available
  8. Maintain distraction free environment
26
Q

CVA Patient

Impaired Communication

A
  1. Face the client
  2. Assess ability to understand (follow simple commands)
  3. Observe for consistently affirmative answers
  4. Supply with picture board
27
Q

Non-Modifiable Risk Factors for CVA

A
  1. Age (over 55)
  2. Male
  3. African American
28
Q

Modifiable Risk Factors for CVA

A
  1. Cerebral aneurysm
  2. AVMs
  3. DM
  4. Obesity
  5. HTN
  6. Atherosclerosis
  7. Hyperlipidemia
  8. Hypercoagulability
  9. A-fib
  10. Birth control pills
  11. Smoking
  12. Cocaine use
  13. Excessive alcohol
  14. Sleep apnea
  15. Periodontal disease
29
Q

Causes of hemorrhagic stroke

A
  1. Primarily caused by intracranial or subarachnoid hemorrhage
  2. Uncontrolled HTN
  3. Ruptured aneurysm
  4. AVMs
30
Q

Non-Modifiable Risk Factors for Hemorrhagic sttroke

A
  1. Increased age (over 55)

2. Male

31
Q

Modifiable Risk Factors for Hemorrhagic stroke

A
  1. HTN

2. Excessive alcohol

32
Q

Clinical Manifestations for Hemorrhagic stroke

A
  1. Neuro deficits similar to ischemic stroke
  2. Most severe headache of their lives
  3. Vomiting
  4. Sudden change in LOC
  5. Possible focal seizures
  6. Pain in back of the neck (nuchal rigidity)
  7. Visual disturbances
33
Q

Diagnostic Tests used to confirm hemorrhagic stroke

A
  1. CT scan or MRI to determine type, size, and location

2. Cerebral angiography (confirm aneurysm, AVM)

34
Q

Causes of Ischemic Stroke

A
  1. Atherosclerosis
  2. Small emboli
  3. Cardiac arrhythmias
35
Q

What kinds of drugs are administered to patients with TIA?

A
  1. Anticoagulant/antiplatelet therapy
  2. Statins
  3. Antihypertensives
36
Q

Diagnostics tests to confirm a seizure disorder

A
  1. History and physical
  2. Witness seizure description
  3. EEG
  4. CT, MRI
  5. Skull X-rays
  6. SPECT scan
37
Q

Tonic phase of a seizure

A

Rigidity; simultaneous contractions of diaphragm and chest muscles produce characteristic “epileptic cry”; jaw clamps shut

38
Q

Clonic phase of a seizure

A

Jerking; may “foam at the mouth”, chew tongue, or experience incontinence of urine or stool, convulsion-type movements may last 1-5 minutes

39
Q

Post-ictal phase of a seizure

A

Relaxes and lies in a deep coma, breathing nosily, difficult to arouse, may sleep for several hours, turn to recovery position (side-lying), may c/o sore muscles, fatigue, headache and depression

40
Q

Causes of status epilepticus

A
  1. Fever
  2. Withdrawal of antiepileptic drugs
  3. Alcohol
  4. Sleep deprivation
  5. Trauma
41
Q

Treatment for status epilepticus

A
  1. IV benzodiazepines

2. Watch for respiratory depression

42
Q

Nursing care post-ictal

A
  1. Recovery position
  2. VS
  3. Neuro checks
  4. Reorient (use calm persuasion and gentle restraint to assist to stay calm and safe)
43
Q

Under what circumstances would you take someone who just had a seizure to the hospital?

A
  1. No history of seizures
  2. Status epilepticus
  3. Injury has occurred
  4. Neuro deficits after
44
Q

Home safety education for patients with seizure disorders

A
  1. Do NOT swim alone
  2. Take showers instead of baths
  3. Do not operate dangerous equipment
  4. No alcohol
  5. Check OTC medications with pharmacist
  6. Wear medic alert bracelet
45
Q

Four cardinal symptoms of Parkinson’s disease

A
  1. Tremors
  2. Rigidity
  3. Bradykinesia
  4. Postural instability
46
Q

Parkinson’s Patient

Interventions to maintain mobility as long as possible

A
  1. Encourage exercises such as yoga
  2. Assistive devices as disease progresses
  3. ROM
  4. Slow walking to reduce injury
  5. Assist with ADLs as needed

Neuro (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions