222- Test 3 ! Flashcards
discharge teaching for cataracts pt
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)
Myasthenia Graves tx
Anticholinesterase drugs- Mestinon inhibit breakdown of ACH
What is Decorticate posturing?
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
pt that presents with c/o blindess you should..
perform a head to to assess on anyone that presents with an eye injury
design your plan of care around safety.
what is indictive of an increase in ICP
urine output of 400ml in 2 hrs
What is decerebation posture?
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.
manifestations of glaucoma
Gradual visual field loss
tunnel vision - all peripheral vision is lost
Spinal shock
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.
nursing care post stapedectomy
- 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
Decadron does what to labs
hyperglycemia and hyponatremia, also decreases capillary permeability and stabilizes the membrane
Mydriatics do what..
(Phenylephrine HCL (neo-synephrone, mydfrin)
Dilate
Parkinsons -bradykinesia
lack of spontaneous actvity, stooped posture, masked faces/deadpan expression, drooling, shuffled gait/fenistation, difficult movements-getting out of chair.
Expressive aphasia
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
Meniere’s disease
episodic, sudden severe attacks with no warning
- vertigo, nausea, vomiting, tinnits(constant ringing in ears), nystagmus, fluctuating sensorineural hearing loss
Glasgow coma scale
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
Function of the lens
bend light rays (refacts)
nursing intervention for meniere’s
low Na+ diet, avoid caffeine, ETOH and nicotine, teach patient to avoid sudden postions changes
clinical manifestations for cataracts
- 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
Epidural hemorrhage
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.
Receptive aphasia
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.
nursing dx and interventions for meniere’s
risk for fluid volume depletion r/t vomiting
nursing interventions
-admin antiemetics, teach low-salt diet components
Levodopa-carbidopa (Sinemet)
drug used to treat parkinson.
Avoid B6! and toxicity could cause hallucinations
Med Tx for Bells palsy
Antivirals - famvir, corticosteroids, use non-opiod pain meds.
When is MRI contraindicated?
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
Nursing interventions for Bells palsy
Massge, gentle upward not vigirious, warm moist heat, they may have body image disturbance so tend to that.
Health promotion for people with a cataract
- Wear sunglasses outdoors and in bright areas
- wash hands before eye gtt admin
- contact dr. if any green drainage
Post-op cataract surgery
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…… -_-
post op scleral buckling and intraoccular procedures
limited head movements, teach s/s retinal detachment (visual field loss and the appearance of flashing lights)
What can occur if retinal detachment is untreated?
blindness
Petit mal seziure
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.
ICP - s/s Cushing triad
Widening pulse pressure, bradycardia, irregular resp pattern, increase temp, systolic pressure increase, diasytolic stays the same, LOC changes.
ISchemica stroke pt when do you give tPA?
within 3 hours of stroke.
Lumbar puncture
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
s/s of retinal detachment?
- sudden or gradual increase in number of floaters
- light flashes (photopsia) in the affected eye
normal intraocular pressure
10-21 mmHg
Myasthenic crisis
increased pulse and resp, rise in BP, anoxia, cyanosis, bowel and bladder incontinence, decreased urine output, abscence of cough and swallow reflex
Glaucoma patho
Elevated IOP (intraoccular pressure)
What should you do with functional (legal) blindness..
assess visual acuity, plan safety strategies.
20/200=functional blind
When transfering a stoke pt, place the wheelchair where?
on the unaffected side.
with any eye injury what should you first do?
flush eye w/ NS - in case of foreign object
If a patient comes in with c/o loss of hearing, what med would you ask if they have took recently?
Gentamycin, its ototoxic.
Manifestations of Bells palsy
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.
Emergency care for head injury
keep in neutral position, manage the ariway, tx the cause.
pts are usually hyperventalating, mildly dehydrated, on seziure precautions.
Pt teaching for neurontin
take with foods
First s/s of MS (Shadia you should know this)
Optic neuritis (blurred vision, blindpspots, pain) and complaints of random frequent falls.
fatigue and emotionally liable.
The goal for a parkinsons pt is..
to keep them as active as possible.
random- give thicken liquids
Cholinergic crisis
nause, vomiting, diarrhea, abd cramps, blurred vision, pallow, facial muscle twitching, pupillary miosis, HTN
Food for parkinsons pts?
give thicken foods not soups
Nursing Dx for vision
Risk for injury r/t visual impairment
Parkinsons -rigidity (second sign)
jerking quality, cog wheel rigidit (can hear clicking when moving), slowness of movement, cant excute smoot movements.
A Patient with dysphagia, what should be checked before they eat?
gag reflex
after stapedectomy, avoid doing what to not exacerbate dizziness?
coughing, sneezing, lifting, bending, straingin during BM
Cerebellum tumor, you would expect issues with what?
muscle tone, locomotion, posture, equilibrium, gait.
Snellen chart (eye exam)
Leave corrective lens on when reading the chart, read with one eye at a time.
increase tonometry readings could be indictive of…
optic nerve damage and glaucoma
Patients with ICP should be keep in mild state of what and why?
Resp alkalosis because CO2 is a vasodilator. keep between 30-35
Eye drops 101
- *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**
Pre-op nursing intervetion for cataract surgery
assess function (visual aquity) of the unoperative eye
subdural hemorrhage
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
Glaucoma
Start tx immediately —> long teram increase IOP —> irrversible damage to the retina and optic nerve
Intervention when retinal detachment is suspected..
Bedrest/ limit head movement
What to ask someone when cataract is suspected?
If they have had any blurred or distorted vision.
Ear med admin
WARM the drops before administering them
Accommodation
Focus on object 2-3 feet away (pupils should dilate)
Distance=Dilate
Close=Constrict
Parkinsons (Triad-tremor)
Prominent at rest, aggravted by stress, concentration, micrographia, pill rolling
Administration of eye medications..
Timoptic and betoptic 0 decreases tonometer readings, decrease aqueous humor
occlude the puncta after instillation of eye gtts (for glaucoma)
-monitor pulse and report if < 58
Health promotion for glaucoma
Comply with prescrived therapies, comply with suggested opthalmic evaluations.
Will be on meds for life
Dx for MG - tensilon test
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.
