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Nursing 221-222 > 222- Test 3 ! > Flashcards

222- Test 3 ! Flashcards

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1
Q

discharge teaching for cataracts pt

A

Make sure client can instill their own eye drops

  • *- have them demonstrate adminstration
  • report any s/s infection**

if intense pain-notify surgeon (may be hemorrhage, infection or increase intraoccular pressure)

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2
Q

Myasthenia Graves tx

A

Anticholinesterase drugs- Mestinon inhibit breakdown of ACH

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3
Q

What is Decorticate posturing?

A

Abnormal posturing seen in the pt with lesions that interrupt corticospinal pathways. To the cord.

Wrist, arms, and fingers are flexed, towards the cord, internal rotation and plantar flexion of legs

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4
Q

pt that presents with c/o blindess you should..

A

perform a head to to assess on anyone that presents with an eye injury

design your plan of care around safety.

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5
Q

what is indictive of an increase in ICP

A

urine output of 400ml in 2 hrs

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6
Q

What is decerebation posture?

A

Abnormal posture and rigidity characterozed by extension of the arms and legs, pronation of arms, plantar flexion and opisthotonos (body spams in which body is bowed forwards)

poorer prognosis then decoritcate.

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7
Q

manifestations of glaucoma

A

Gradual visual field loss

tunnel vision - all peripheral vision is lost

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8
Q

Spinal shock

A

Pt has flaccid paralysis and loss of reflex activity below the level of the lesion. often lass less than 48 hrs but may continue for several weeks.

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9
Q

nursing care post stapedectomy

A
  • cotton ball inserted into ear canal and covered with band-aid (aboid changing dressing until seen by surgeon)
  • immediate improvement in hearing- level then decreases due to accumulation of blood and serosanguinous fluid in the middle ear –> returns to near normal
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10
Q

Decadron does what to labs

A

hyperglycemia and hyponatremia, also decreases capillary permeability and stabilizes the membrane

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11
Q

Mydriatics do what..

(Phenylephrine HCL (neo-synephrone, mydfrin)

A

Dilate

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12
Q

Parkinsons -bradykinesia

A

lack of spontaneous actvity, stooped posture, masked faces/deadpan expression, drooling, shuffled gait/fenistation, difficult movements-getting out of chair.

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13
Q

Expressive aphasia

A

Damage to the broca’s area in frontal lobe/

A motor speech problem in which the pt generally understands what is said but cannot communicate verbally. Pt may still be able to write but may have difficulty with it. They are aware of the problem and can become frustrated.

Give them yes or no questions

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14
Q

Meniere’s disease

A

episodic, sudden severe attacks with no warning
- vertigo, nausea, vomiting, tinnits(constant ringing in ears), nystagmus, fluctuating sensorineural hearing loss

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15
Q

Glasgow coma scale

A

describes the patients level of consciousness. Measures eye openging, motore respones, and verbal response. highest score is 15, 7 describes comatose state. lower the score, lower the LOC

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16
Q

Function of the lens

A

bend light rays (refacts)

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17
Q

nursing intervention for meniere’s

A

low Na+ diet, avoid caffeine, ETOH and nicotine, teach patient to avoid sudden postions changes

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18
Q

clinical manifestations for cataracts

A
  • c/o decreased vision
  • abnormal color perception
  • if you notice a slightly cloudy appearance to the lens, ask if they have had any blurred or distorted vision
  • gradual vision acuity decline
  • nighttime glare
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19
Q

Epidural hemorrhage

A

results from arterial bleeding into the space between the dura and the inner skull. often casued by fracture of the temporal bone.

These pts will be wake up after the injury, be luccid, say they feel fine, in a few mins they start to decline, and are usually dead within an hour.

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20
Q

Receptive aphasia

A

Due to an injury involving Wernicke’s area in the temporoparietal are.

The pt cannot understand the spoken and often the written word. They may be able to talk, the language is often meaningless. Neologism (made-up words) are common parts of speech.

demonstrate simple cues, talk slowly.

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21
Q

nursing dx and interventions for meniere’s

A

risk for fluid volume depletion r/t vomiting

nursing interventions
-admin antiemetics, teach low-salt diet components

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22
Q

Levodopa-carbidopa (Sinemet)

A

drug used to treat parkinson.

Avoid B6! and toxicity could cause hallucinations

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23
Q

Med Tx for Bells palsy

A

Antivirals - famvir, corticosteroids, use non-opiod pain meds.

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24
Q

When is MRI contraindicated?

A

If person has a internal pacemaker, some sort of metal used to fix an injury (ie knee/hip replacement), some veterans that may have shrapnel in them

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25
Q

Nursing interventions for Bells palsy

A

Massge, gentle upward not vigirious, warm moist heat, they may have body image disturbance so tend to that.

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26
Q

Health promotion for people with a cataract

A
  • Wear sunglasses outdoors and in bright areas
  • wash hands before eye gtt admin
  • contact dr. if any green drainage
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27
Q

Post-op cataract surgery

A

Activity restrictions to prevent increase intraocular pressure
-no lifting, no bending, no stooping, no coughing, no sexual intercourse, sneezing, no straining of stool

(need to be on stool softeners)—-totally got that wrong on hessi, too bad i didnt do these before hessi…… -_-

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28
Q

post op scleral buckling and intraoccular procedures

A

limited head movements, teach s/s retinal detachment (visual field loss and the appearance of flashing lights)

29
Q

What can occur if retinal detachment is untreated?

A

blindness

30
Q

Petit mal seziure

A

Seen in children 12 and under, hx of starring off, blinking, rolling or turning of eyes, lasts only 5-10 seconds, usually undiagnosed. dont loose consciousness.

31
Q

ICP - s/s Cushing triad

A

Widening pulse pressure, bradycardia, irregular resp pattern, increase temp, systolic pressure increase, diasytolic stays the same, LOC changes.

32
Q

ISchemica stroke pt when do you give tPA?

A

within 3 hours of stroke.

33
Q

Lumbar puncture

A

For Dx of CNS infection, intracranial bleed or lesions, menigitis

PREP: client on L side in fetal position, local anestic, consent, need to lie still. do neuro check

POST: client lie flat for 2 hrs (may get headache), encourage fluids, make sure not leaking by checking dressing. do neuro check

34
Q

s/s of retinal detachment?

A
  • sudden or gradual increase in number of floaters
  • light flashes (photopsia) in the affected eye
35
Q

normal intraocular pressure

A

10-21 mmHg

36
Q

Myasthenic crisis

A

increased pulse and resp, rise in BP, anoxia, cyanosis, bowel and bladder incontinence, decreased urine output, abscence of cough and swallow reflex

37
Q

Glaucoma patho

A

Elevated IOP (intraoccular pressure)

38
Q

What should you do with functional (legal) blindness..

A

assess visual acuity, plan safety strategies.

20/200=functional blind

39
Q

When transfering a stoke pt, place the wheelchair where?

A

on the unaffected side.

40
Q

with any eye injury what should you first do?

A

flush eye w/ NS - in case of foreign object

41
Q
A
42
Q

If a patient comes in with c/o loss of hearing, what med would you ask if they have took recently?

A

Gentamycin, its ototoxic.

43
Q

Manifestations of Bells palsy

A

Damage to cranial nerve VII andmay effect cranial nerve V as well.

Patient cant close eye, wrinkle the forehead, smile, whistle, or grimace, may lose ability for eye to tear or have excessive tearing, face appears to sag, taste may be impaired, tinnitus (ringing of ears) may also occur.

44
Q

Emergency care for head injury

A

keep in neutral position, manage the ariway, tx the cause.

pts are usually hyperventalating, mildly dehydrated, on seziure precautions.

45
Q

Pt teaching for neurontin

A

take with foods

46
Q

First s/s of MS (Shadia you should know this)

A

Optic neuritis (blurred vision, blindpspots, pain) and complaints of random frequent falls.

fatigue and emotionally liable.

47
Q

The goal for a parkinsons pt is..

A

to keep them as active as possible.

random- give thicken liquids

48
Q

Cholinergic crisis

A

nause, vomiting, diarrhea, abd cramps, blurred vision, pallow, facial muscle twitching, pupillary miosis, HTN

49
Q

Food for parkinsons pts?

A

give thicken foods not soups

50
Q

Nursing Dx for vision

A

Risk for injury r/t visual impairment

51
Q

Parkinsons -rigidity (second sign)

A

jerking quality, cog wheel rigidit (can hear clicking when moving), slowness of movement, cant excute smoot movements.

52
Q

A Patient with dysphagia, what should be checked before they eat?

A

gag reflex

53
Q

after stapedectomy, avoid doing what to not exacerbate dizziness?

A

coughing, sneezing, lifting, bending, straingin during BM

54
Q

Cerebellum tumor, you would expect issues with what?

A

muscle tone, locomotion, posture, equilibrium, gait.

55
Q

Snellen chart (eye exam)

A

Leave corrective lens on when reading the chart, read with one eye at a time.

56
Q

increase tonometry readings could be indictive of…

A

optic nerve damage and glaucoma

57
Q

Patients with ICP should be keep in mild state of what and why?

A

Resp alkalosis because CO2 is a vasodilator. keep between 30-35

58
Q

Eye drops 101

A
  • *Cover the lacrimal duct with tissue for a few sconds after eye drop admin.
  • Do not allow the noxxle to touch the eye or anythin else
  • Do not allow other people to use your eye drops
  • Replace the cap of the eye drops immediately after use
  • wait 5 mins between drops, when more then one kind
  • use drops wait 5 mins, then use ointment, if have both**
59
Q

Pre-op nursing intervetion for cataract surgery

A

assess function (visual aquity) of the unoperative eye

60
Q

subdural hemorrhage

A

Results from venous bleeding into the space beneath the dura and above the arachnoid. Occurs most often from a tearing of the bridging veins within the cerebral hemispheres or from a laceration of brain tissue.

Occurs slower then epidural bleed

usually have hx of anti-coag use, alcohol abuse, alzhimers(sp? eff it), or dementia

61
Q

Glaucoma

A

Start tx immediately —> long teram increase IOP —> irrversible damage to the retina and optic nerve

62
Q

Intervention when retinal detachment is suspected..

A

Bedrest/ limit head movement

63
Q

What to ask someone when cataract is suspected?

A

If they have had any blurred or distorted vision.

64
Q

Ear med admin

A

WARM the drops before administering them

65
Q

Accommodation

A

Focus on object 2-3 feet away (pupils should dilate)

Distance=Dilate

Close=Constrict

66
Q

Parkinsons (Triad-tremor)

A

Prominent at rest, aggravted by stress, concentration, micrographia, pill rolling

67
Q

Administration of eye medications..

Timoptic and betoptic 0 decreases tonometer readings, decrease aqueous humor

A

occlude the puncta after instillation of eye gtts (for glaucoma)
-monitor pulse and report if < 58

68
Q

Health promotion for glaucoma

A

Comply with prescrived therapies, comply with suggested opthalmic evaluations.

Will be on meds for life

69
Q

Dx for MG - tensilon test

A

IV only, if you start the IV and the pt starts to improve then it is MG (improved muscle tone),if they start to delcline then it is cholinergic state.

Nursing 221-222 (9 decks)

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