2900 Exam Two Flashcards
what are some signs of decreased cardiac output?
hypotension fatigue tachycardia weak peripheral pulses cool extremities hypoxemia
what is cardiac output?
volume of blood in liters pumped by the heart in one minute
what can cause acute hypertension?
not adhering to BP meds cocaine/amphetamines/PCP/LSD pre-eclampsia rebound hypertension from stopping beta blockers head injury renovascular hypertension
hypertensive urgency
rapid increase in BP that does not include target organ damage
hypertensive emergency
rapid increase in BP (usually at or above 180/110) with target organ damage. requires hospitalization and prompt treatment with IV meds
which organs are target organs?
brain
heart
kidneys
eyes
what brain issue can occur in hypertensive crisis?
hypertensive encephalopathy
T/F: rate of BP rise in hypertensive crisis is more important than the BP number itself
true
what reading is used during hypertensive emergencies to guide and evaluate drug therapies?
MAP: mean arterial pressure
what is the goal with MAP during a hypertensive crisis?
decrease by 20-25%
what is the most effective drug to treat HTN crisis?
sodium nitroprusside
what other drugs can be given in a HTN crisis?
adrenergic inhibitors like labetelol
calcium channel blockers
what should the nurse remember when giving IV meds for hypertensive crisis?
meds work in seconds when given IV, so assess BP every 2 minutes
we don’t want to drop the BP too quickly, as that can cause stroke, MI, or renal failure
monitor ECG
monitor I&O
have patient change position slowly and possibly initiate bed rest
etiology of coronary artery disease
atherosclerosis
what is collateral circulation in CAD?
growth of arterial anastamoses. ischemia in some areas leads to angiogenesis in other areas to allow for adequate blood supply to organs
CAD modifiable risk factors
elevated serum lipids hypertension tobacco use inactivity obesity diabetes metabolic syndrome stress increased homocysteine
CAD non-modifiable risk factors
age gender ethnicity family history genetics
physical activity recommendations to reduce risk of CAD
FITT activity
30 minutes of walking at least 5 days a week
what are the most widely used lipid lowering drugs?
statins
what do niacins do?
interfere with LDL synthesis and increase HDL levels
why is low dose asprin recommended for most CAD patients?
to prevent clotting/platelet aggregation
chronic stable angina
chest pain that is present upon exertion but goes away at rest. Intermittent pain that usually has similar onset, duration, and intensity. not a medical emergency but doctor still needs to evaluate
PQRST pain assessment
Precipitating event Quality of Pain Region/radiation of pain Severity Timing
what is the first line drug of choice for angina?
nitroglycerin
what does nitroglycerin do?
dilate coronary blood vessels
what do long acting nitrates do? give an example
they reduce the frequency of anginal attacks
example: isosorbide dinitrate
what do ace inhibitors do to help angina? give an example
vasodilate and reduce blood volume
example: lisinopril
what do beta blockers do to help angina? give an example
decrease myocardial contractility, BP, and HR
examples: carvedilol or metoprolol
what do calcium channel blockers do to help angina? give an example
vasodilation
decreased myocardial contractility
decreased heart rate
examples: amlodopine, diltiazem
what do patients need to be taught regarding taking nitroglycerin?
can be taken repeatedly every five minutes for up to three doses
contact emergency response if symptoms don’t improve
sit down to take and place it under the tongue
what are some diagnostic studies for CAD?
cardiac catheterization ECG chest x-ray labs echocardiogram stress test
what is cardiac catheterization?
radiation with IV contrast dye to image coronary circulation and identify blockages
chronic unstable angina
chest pain not relieved with rest. pain increased in frequency over time. requires acute intensive drug therapy and prompt treatment
unstable angina is a warning sign of…
impending MI
how much time does it take for prolonged ischemia to do irreversible damage?
20 minutes
what three conditions are included in acute coronary syndrome?
unstable angina
NSTEMI
STEMI
how quickly does the artery need to be opened up in STEMI?
within the first 90 minutes
what is occurring in a NSTEMI?
the thrombus is non-occlusive. patient usually has procedure to fix the problem 1-2 days later
what are clinical manifestations of MI?
severe unrelieved chest pain or pressure that may radiate to other parts of the body SNS stimulation leading to increased HR/BP, clammy skin, and diaphoresis decreased cardiac output abnormal heart sounds crackles decreased renal perfusion N/V fever
how might MI present differently in women?
women may have more anxiety and shortness of breath than traditional pain
what are diagnostic studies for MI?
ECG serum cardiac biomarkers coronary angiography chest x-ray lipid profiles Holter monitor stress test cardiac catheterization
what changes might be seen on the ECG with an MI?
changes in ST segments or T waves
what serum cardiac biomarkers are looked at when assessing for an MI?
cardiac troponins
CK-MB
myoglobin
what is a PCI?
percutaneous coronary intervention: it’s angioplasty to open a blocked artery
when is thrombolytic therapy used? what are some examples of those drugs?
used when patients have a STEMI to dissolve the thrombus
tPA, streptokinase, urokinase
what are some other options to remove a clot in MI?
artherectomy: catheter insertion to remove clot
endarterectomy: surgically open artery to remove plaque
what does a coronary artery bypass graft (CABG) do?
provide blood between aorta and other major arteries to the ischemic heart muscle
open heart surgery
what are nursing management priorities in acute MI?
continuous monitoring (EKG, chest, lungs, heart sounds) pain relief rest/comfort/anxiety relief support healthy coping education
what are some teaching points that nurses should tell patients about nitroglycerin?
how to take it and when to call 911
light and heat sensitive med
throw away once past expiration date
what is clopidogrel (plavix)? what specific instruction do patients need in regards to taking it?
a long acting antiplatelet/anticoagulant
they must stop taking it 5-7 days before surgery
when should statins be taken, and why?
in the evening, because the body gets rid of more cholesterol at night
what is malfunctioning diastolic heart failure?
ventricular filling
what is malfunctioning in systolic heart failure?
ventricular ejection
in what ways does the body try to compensate in heart failure?
pumping faster
dilation/enlargement of heart chambers over time
hypertrophy of ventricle muscle over time
RAAS
left sided heart failure
most common type, caused by inability of left ventricle to fill or empty properly
fluid backs up into lungs and causes pulmonary symptoms
right sided heart failure
usually caused by left sided heart failure. right ventricle fails to pump properly, causing backup of fluid into the venous system
right sided heart failure symptoms
edema ascites nocturia skin changes (dusky, shiny, swollen) weight changes
what are some possible meds that can be used in heart failure?
digoxin beta blockers diurectics vasodilators ace inhibitors ARBs
what are some manifestations of acute decompenstated heart failure?
pulmonary and systemic congestion increased RR decreased o2 sats interstitial edema jugular venous distension anxious pale cyanotic
what are some nursing interventions for acute decompensated HF?
high fowlers oxygen intraaortic balloon pump positive pressure ventilation monitor BNP and potassium monitor urine output continuous ECG and pulse oximetry drug treatment ultrafiltation hemodynamic monitoring
what is ultrafiltration?
rapidly removing excess fluid buildup
what electrolyte problem can be caused by digoxin?
hypokalemia
what is telemetry?
monitoring cardiac vitals remotely
what is an intraaortic balloon pump?
balloon placed in thoracic aorta to reduce afterload and help aortic pressures
what are indications for the use of an intraaortic balloon pump?
unstable angina
bridge to a transplant
acute MI
before, during, or after heart surgery
why does an intraaortic balloon pump help with worsening heart failure?
it decreases pulmonary artery pressures and systemic vascular resistance to improve cardiac output
how does morphine help in heart failure?
it decreases anxiety, preload, and afterload
what are some examples of positive inotropes and what do they do?
digoxin, dobutamine, and dopamine
they increase contractility and cardiac output
what are some signs of digoxin toxicity?
nausea/vomiting
visual changes (green/yellow halos)
hypokalemia
what needs to be monitored before taking digoxin or other positive inotropes?
apical or radial pulse
when is a cardiac defibrillator used?
to end v-fib or v-tach; used in emergency situations only
when is cardioversion used?
used for v-tach to deliver a synchronized shock
with an implanted pacemaker, what can hiccups indicate?
generator is stimulating the diaphragm
what are some teaching points for client with new pacemakers?
carry a pacemaker ID
don’t lift arm above shoulder for 1-2 weeks
take daily pulse and notify doctor if different than pacemaker pace
no contact sports or heavy lifting for two months
inform dentists/doctors/airport security about pacemaker
no strong magnets
what lab is 98% effective in diagnosing or ruling out HF?
BNP
why do we encourage all patients to report pain?
because unrelieved pain has adverse consequences
should the nurse rely on physical signs of pain as the sole source of pain assessment?
no, not unless the patient cannot self report, as these signs are not reliable or specific
what is included in subjective data in a pain assessment?
health history, including pain info/history, coping factors, treatments tried
drug and non-drug measures used for pain
functional health assessment (health perception, elimination, activity/exercise, sexuality, coping, stress tolerance)
what is included in objective data in a pain assessment?
physical exam
psychosocial evaluation and patient mood
what is breakthrough pain?
moderate to severe pain in patients whose baseline persistent pain is normally well controlled
what is end of dose failure?
pain occurring before the expected duration of a specific analgesic
what is episodic/procedural/incident pain?
transient pain increase caused by specific activity or event
what do we want to ask about pain location?
where it is (localized, multiple locations, or all over)
if it radiates
what do we want to assess about pain intensity?
rating on pain scales or observation for nonverbal patients
what is FLACC and on whom is it used?
a pain scale looking at face, legs, activity, cry, and consolability
used for those between 2 months and 7 years old
what do we want to know about quality of pain?
nature or characteristics of the pain (using descriptive words)
what are some associated symptoms that might be seen with pain?
anxiety
fatigue
depression
insomnia
what are some management strategies that patients might use to deal with pain?
drugs non-drug methods acupuncture imagery cold/heat
what do we want to know about the impact of pain when assessing pain?
what effect it has on quality of life, sleep, functioning, and mood
why do we assess patients beliefs, expectations, and goals when doing pain assessment?
because some beliefs and attitudes about pain and pain management can hinder effective treatment
what is the PAIN-AD scale?
pain scale for advanced dementia patients
how often should pain be reassessed?
every 2 hours, and reassessed 15-30 minutes after giving pain medications IV
what should pain treatment be based on?
patient goals
what is a multimodal approach to pain management?
using two or more analgesic agents to take advantage of various mechanisms of action
what are some main side effects/risks of opioids?
constipation/N/V sedation respiratory depression urinary retention delayed gastric emptying
what patient groups are at higher risk of respiratory depression with opioids?
those over 65 opioid naive patients those with history of snoring/apnea those with cardiac or lung disease smoking history obese patients
what is the risk of meperidine (demerol)? how long can it be used for?
neurotoxicity risk, use for less than 48 hours
what should the nurse do if the patient becomes oversedated?
administer oxygen
reduce opioid dose
stimulate patient to keep awake
what are the benefits of nondrug therapies for pain?
they can reduce dose of analgesic needed, minimizing side effects of drug therapy
what are some examples of nondrug pain management strategies?
massage acupuncture exercise TENS units heat and cold cognitive therapies distraction hypnosis relaxation
what is a TENS unit?
transcutaneous electrical nerve stimulation - delivers an electric current through electrodes attached to the skin over the painful region
define tolerance
needing an increased opioid dose to maintain the same degree of analgesia
define dependence
withdrawal syndrome occurs when drug is abruptly stopped
define addiction
patient having a drive to obtain and take drugs for reasons other than prescribed therapeutic value
what are gerontological considerations for pain assessment and management?
geriatric pain his highly prevalent but poorly assessed and managed
use age appropriate assessment tools and watch for different language choices in describing pain
may need lower doses of analgesic due to buildup in body/slower metabolism
what are some things to remember when assessing pain in nonverbal patients?
obtain a self report if possible (never assume they cannot communicate at all)
investigate pain causes
observe behaviors
get reports from family and caregivers
try analgesics and reassess pain-related behaviors
what are nursing considerations for acetaminophen?
oral daily dose not to exceed three grams due to hepatotoxicity risk
why is asprin mainly prescribed now?
cardioprotective benefits
what is the risk of prolonged asprin use?
upper GI bleed
what are nursing considerations for NSAIDs like ibuprofen and naproxen?
use lowest dose for shortest possible time
high risk of serious GI events like bleeding or ulcers, especially in older adults
what are nursing considerations for ketorolac?
limit use to 5 days, renal failure risk in dehydrated patients
what assessment tool should be used specifically for angina?
PQRST assessment
what kind of pain is opioid medication prescribed for?
moderate to severe pain
what are adjuvant drugs?
drugs originally made for another purpose that also help in pain management. can be used alone or in combination with other pain meds
what is amitriptyline and what is it often used for outside of its original purpose?
its an antidepressant that is often also used for neuropathic pain
what is bupropion and what is it often used for outside of its original purpose?
an antidepressant thats often used for neuropathic pain
what is carbamazepine and what is it often used for outside of that purpose?
an antiseizure drug often used for neuropathic pain
what is baclofen and what is it often used for outside of that purpose?
a muscle relaxant, often also used for neuropathic pain
what is a nerve block and when is it often used?
infusion of local anesthetics into a particular area to produce pain relief (regional anesthesia)
often used during and after surgery for pain management
what are some adverse effects of nerve blocks?
dysrhythmias confusion N/V blurred vision tinnitus metallic taste
what are neuroablative techniques and when are they used?
destruction of the nerve to interrupt pain transmission
used for severe pain unresponsive to other treatments
what is neuroaugmentation?
electrically stimulating the brain and spinal cord, often used for back pain or other pain unresponsive to other therapies
what kind of patients are most likely to die from burns?
children under four and adults over 65
what is the most common type of burn injuries?
thermal burns, from things like flash, flame, scald, or hot objects
what kind of chemical burns are harder to manage and why?
alkali burns, because it adheres to tissues and causes protein hydrolysis and liqeufaction
what happens in metabolic asphyxiation?
inhalation of smoke elements like carbon monoxide causes hypoxia
what are some signs and symptoms of upper airway injury with smoke inhalation?
blisters edema difficulty swallowing copious secretions stridor retractions total airway obstruction
what causes lower airway injury in burn situations?
duration of exposure to smoke or heat
what are signs and symptoms of lower airway injury in burns?
facial burns dyspnea carbonaceous sputum wheezing hoarseness altered mental status
what are common causes of thermal burns?
cooking smoking burning leaves gasoline/hot oil hot steam or liquid
what are common causes of chemical burns?
cement
oven/drain cleaner
industrial cleanser
petroleum products
what are common causes of smoke and inhalation injury?
house/structure fires
what are common causes of electric burns?
frayed or defective wiring
extension cords
power lines
live electric sources
what is meant by the “iceberg effect” in electrical burns?
majority of damage is unseen, and damage can continue to muscles or bones hours to days after the initial injury occurs
why might bones fracture with electrical burn situations?
muscles might tense severely enough to fracture bones if electric current is strong enough
how can electrical burns cause acute tubular necrosis?
muscle injury and breakdown releases myoglobin into the bloodstream, blocking the renal tubules
cold burns are normally attributed to..
frostbite
what are some examples of friction burns?
road rash or rugburn
what four factors determine severity of burns?
depth of burn
extent of burns (TBSA)
location of burns
patient risk factors
when calculating total body surface area, over what percentage of burns should trigger immediate relocation to burn unit?
over 20%
what locations for burns are the most risky?
face, head, neck, and torso (especially circumferential around torso)
what are some risk factors that will hinder burn healing?
diabetes heart failure children/elderly lung and kidney disease PVD weakness/malnutrition alcoholism/drug addiction other injuries or trauma
what is the greatest initial threat to a patient with a major burn?
hypovolemic shock
what happens to BP and HR in hypovolemic shock?
decreased BP, increased HR
what is second spacing?
fluid moving from vascular space to surrounding tissues
what is third spacing?
fluid moving to areas that normally have minimal to no fluid
what are signs and symptoms of hypovolemic shock?
decreased BP and increased HR exudate edema/extreme swelling shivering changes in LOC
how will first degree burns look?
pink or red with no blisters and warm to the touch
how will second degree burns manifest?
very painful
blisters
shiny/moist/red skin
how will full thickness burns manifest?
dry/leathery
will have eschar
no pain due to destruction of nerve endings
coagulation necrosis will be present
what does healing/treatment look like for full thickness burns?
will not heal on its own, must have skin grafts
what is an escharotomy?
cutting through eschar and other damaged tissue to prevent compression of organs and vessels. done in burns due to intense swelling and constricting features of circumferential burns
what is the goal in the emergent phase of burn management?
preventing hypovolemic shock and preserving organs
what areas, when burned, will have an especially hard time healing?
ears, nose, hands, feet, joints
how are airways usually maintained in burns?
early intubation and likely oxygen administration
what is compartment syndrome?
tight eschar band in burn areas
how would one assess for compartment syndrome?
assess pulses, temperature, and capillary refill distal to the burned area
what are some major risks to burn patients as the burns heal?
infection
contractures
compartment syndrome
what formula is used to calculate fluid resuscitation?
parkland baxter formula
what does the parkland baxter formula say?
give 4 ml of lactated ringers per kg of body weight per percent of TBSA over the first 24 hours
how should the fluid calculated by the parkland baxter formula be given in that first 24 hours?
half in the first 8 hours
one fourth in the second 8 hours
one fourth in the last 8 hours
why is lactated ringers given to burn patients?
to expand intravascular compartment
why might colloids (albumin) be given to burn patients?
because albumin is lost to the interstitial space, and colloids help get the fluid back into the intravascular space
how does the nurse determine if fluid resuscitation is working?
monitoring urine output (want 30 or more ml/hour)
what is debridement?
removal of necrotic tissue so new tissue can grow
what are the two methods of wound care for burns?
open (topical ointment only)
closed (topical ointment and sterile covering)
what is the most commonly used topical antimicrobial for burns?
silver sufladiazine
what are some other common drugs given to burn patients?
tetanus shot
analgesics for pain control
antidepressants
anticoagulants
why would burn patients receive heparin?
to reduce risk of venous thromboembolism
why should burned areas of the body never be touching one another?
so skin doesnt heal together in a webbed fashion
what should the nurse remember about burn patients and pillows?
do not use them, as they will compromise circulation to ears and neck
how can the nurse/IDT help prevent contracture formation for burn patients?
PT
ROM activities
splinting
what should the nurse teach the burn patient about continuing skin care?
use compression hose to tighten skin
moisturize skin often
use good sun protection, skin will not grow back as strong as before!
what is the best route for pain medication for burn patients?
IV
what are some specific nutrition needs for burn patients?
high calorie/protein/carbs
lots of extra calories (sometimes 2-3 times normal needs)
vitamins A, C, E, zinc, iron
what are some diagnostic studies for DVT?
d-dimer
venography scans
pTT or INR
what are some common causes of DVT?
bed rest
a-fib
dehydration
hypercoagulation
what are some s/s of DVT?
leg edema
pain/warmth/redness at side of thrombus
numbness
what are some key prevention measures for DVT?
early and aggressive mobilization compression stockings compression devices position changes flexing and extending feet and knees sitting in chair for meals and walking 4-6 times a day
what is the main vitamin k antagonist anticoagulant?
warfarin
what is the antidote to warfarin?
vitamin K
what are some examples of thrombin inhibitor anticoagulants?
heparin/enoxaparin
how does one check the effectiveness of heparin therapy?
pTT lab draw
how does one check the effectiveness of warfarin therapy?
INR lab draw
what is the antidote to heparin?
protamine sulfate
what is an example of a factor Xa inhibitor?
rivaroxaban
what is a risk of rivaroxiban?
no antidote
what is a benefit of rivaroxaban?
no need for periodic blood draws
what is the most serious complication of DVT?
pulmonary embolism
what should not be taken in conjunction with anticoagulants?
NSAIDs
antiplatelets
some herbals
what are manifestations of PE?
dyspnea (most common presenting symptom) mild hypoxemia tachypnea cough chest pain crackles/wheezing fever tachycardia shortness of breath
what are PE’s normally made up of?
clot, fat, air, or tumor piece
what are complications of PE?
pulmonary infarction
pulmonary hypertension
what drug might be given if a PE occurs?
thrombolytic
what do vena cava filters do?
sit in the veins and catch blood clots to prevent PE
what is an embolectomy and when might it be used?
surgical removal of embolism if thrombolytics dont resolve a PE
what are nursing cares for PE?
bed rest oxygen administration head of bed elevated frequent assessment of heart/lungs/oxygen sats IV fluid monitor PTT or INR monitor for bleeding/bruising fall prevention explain situation to patient and help manage anxiety
what is a stroke?
when blood cannot reach brain cells and brain starts to die
what are the two types of strokes?
ischemic or hemorrhagic
what are causes of ischemic strokes?
vessel blockage from a blood clot (embolus) or from stenosis. common causes are a-fib and carotid stenosis
what are common causes of hemorrhagic strokes?
brain aneurysm rupture/leakage or uncontrolled hypertension wearing out the vessels in the brain
what is a TIA?
transient ischemic attack: an ischemic event caused by some form of blockage that dissolves/passes on its own after a few minutes or hours. However, it is a warning sign of impending stroke and should be evaluated
functions of the frontal lobe
thinking, speaking, memory, movement
functions of the parietal lobe
language, touch
functions of the temporal lobe?
hearing, learning, feeling
functions of the occipital lobe
vision and color perception
functions of the cerebellum
balance and coordination
functions of the brainstem
breathing, heart rate, temperature
general functions of the right side of the brain
creativity, memory, music, art, and motor control of the left side of the body
general functions of the left side of the brain
logic, language, math, reading, analysis, planning, and control of right side of the body
what are manifestations of right sided stroke?
left side paralysis and neglect
spatial-perceptual deficits
denying and minimizing problems/stroke manifestations
rapid performance and short attention span
impulsivity
impaired judgement and time concepts
problems recognizing faces
what are manifestations of left sided stroke?
paralysis/deficits on right side of body speech and language issues/aphasias impaired L/R discrimination slow, cautious performance awareness of deficits (leading to depression and anxiety) impaired language and math comprehension
which type of stroke is more likely to experience a field cut?
right brain stroke
a stroke on what side of the brain is more likely to impact memory?
right brain stroke
what are some risk factors for stroke?
smoking blood thinners a fib or flutter oral contraceptives family history obesity elderly uncontrolled HTN atherosclerosis inactivity previous TIA or stroke uncontrolled diabetes brain aneurysm
what does the FAST acronym stand for?
Facial drooping
Arm Weakness, numbness
Slurred Speech
Time to call 911
what is receptive aphasia? what area of the brain is affected?
inability to comprehend language
Wernickes area
what is expressive aphasia? what area of the brain is affected?
understands speech but has trouble responding/expressing self
Broca’s area
what is global aphasia?
complete inability to understand or produce speech
dysarthria
inability to speak due to weak muscles
apraxia
inability to perform voluntary movements even with normal muscle function
agraphia
inability to write
alexia
inability to read
agnosia
inability to understand sensations or recognize known objects
dysphagia
swallowing issues
hemainopsia
vision in only half of the visual field (aka field cut)
what are some diagnostic tests for stroke?
CT scan to rule out brain bleed
MRI
what drug is given only for ischemic strokes?
tPA
what are time limits for giving tPA?
must be given within 4.5 hours of onset of stroke signs and symptoms
what are criteria for receiving tPA?
must have negative CT scan
labs (glucose, INR, platelets) must be within normal limits
BP must be under control (can be medication controlled)
no recent heparin or anticoagulants
what are nursing actions and interventions following tPA administration?
monitor for bleeding neuro checks every hour for 24 hours BP meds to control HTN vital signs check labs monitor glucose maintain bedrest avoid needlesticks keep patient in ICU for first 24 hours
what tool should be used when doing hourly neuro checks following tpa administration?
NIH stroke scale
how is the NIH stroke scale scored?
it assesses 11 areas and is scored from 0-42. higher numbers (total score between 21 and 42) is worse
why are the first several hours post-stroke the most dangerous?
patient is at high risk for developing increased ICP
what vital sign changes does the nurse want to monitor for and avoid post-stroke?
avoid high BP and decreased HR/RR
what will the nurse needs to monitor regarding airway post-stroke?
swallowing ability and secretions, may need to suction patient
what bladder/bowel issues might a patient experience post-stroke?
incontinence or retaining
what are some nursing actions for skin and limb integrity post-stroke?
repositioning every 2 hours
PROM exercises
skin care
ensuring proper body alignment
what can the nurse do to help a stroke patient who has neglect syndrome?
remind them to touch the disabled side
have them scan room with eyes to take in full visual field
who should the stroke patient see before initiating any oral intake?
speech language pathologist
what diet/nutrition help might the stroke patient need?
thickened liquids, crushed meds, mechanical soft diet
assistance with eating
have them tuck chin to avoid aspiration
what are some useful tips for communicating with patients with receptive aphasia?
short phrases and simple details use gestures and point be patient remove distractions repeat yourself
what are some useful tips for communicating with patients with expressive aphasia?
be patient and let them speak
ask one question at a time
ask direct/simple questions
use communication board or pen and paper
what three components combined make up intracranial pressure?
cerebrospinal fluid
blood
brain tissue
what is normal ICP?
5-15 mmHg
what ICP indicates need for immediate treatment?
above 20 mmHg
what are some things that can cause ICP to fluctuate?
body temperature oxygenation status body position arterial and venous pressures anything that increases intra-abdominal or thoracic pressure (vomiting, bearing down)
what body position is best to reduce ICP?
neck midline with head of bed elevated 30 degrees
what does the monroe-kellie hypothesis say?
if there is an increase in one element that makes up ICP, the other two will decrease or change to try to compensate
what manifestations occur when the brain cannot compensate for increasing ICP?
Cushings triad: hypertension with widening pulse pressure, bradycardia, and irregular respirations
what is CPP?
the pressure that pushes the blood to the brain
what is normal CPP?
60-100 mmHg
what happens if the CPP is too low?
brain will not be adequately perfused
what are some causes of increased ICP?
head trauma brain injury hemorrhage hematoma brain tumor hydrocephalus infection
what happens if the body cannot compensate for increasing ICP and the brain continues to swell?
brain will herniate in several directions and compress down on the brainstem, eventually leading to patient death
what is the earliest sign of increasing ICP?
mental status change
what kind of irregular breathing will be seen with increased ICP?
cheyne stokes respirations
what kind of nerve changes will occur with increasing ICP?
optic and oculomotor nerve changes, such as double vision, unequal pupils, abnormal Doll’s Eye response
how do you check for Doll’s eye?
lay patient flat, open their eyes, and move head from side to side. normally eyes will move to opposite side as where the head is moving. if eye stays in fixed position, this indicates brainstem damage
what types of posturing could be seen with increased ICP?
decorticate, decerebrate, or flaccid
decorticate posturing
arms and legs rotated internally and pulled in towards the core
decerebrate posturing
extension posturing. arms and legs straight with feet and hands extended
which type of posturing is worse?
decerebrate: indicates that damage has progressed further down the brainstem
what abnormal reflex is sometimes positive with increased ICP?
babinski
is unconsciousness and early or late sign of increased ICP?
late sign
what kind of vomiting might a patient with increased ICP experience?
possible projectile vomiting without nausea give antiemetics
how should a patient with increased ICP be positioned?
head of bed at 30 degrees
head midline
no flexion of neck or hips (dont want to increase abdominal pressure)
reposition slowly and carefully
what respiratory interventions should the nurse take for patients with increased ICP?
monitor ABGs (oxygen and CO2) suction as needed but no longer than 15 seconds hyperoxygenate before and after suctioning if on mechanical ventilation, keep PaCO2 between 30 and 35 with low PEEP
what are some nursing interventions if a patient with increased ICP develops a high temperature?
antipyretics
cool bath
remove extra blankets and use cooling blankets
decrease room temp
what are other systems/things to monitor with increased ICP?
Neuro status
frequent glasgow coma scale assessment
pressures from ventriculostomy
what pressures from a ventriculostomy should be reported to the doctor?
anything above 20 mmHg
what is a ventriculostomy?
a catheter inserted into the lateral ventricle of the brain. it monitors ICP, drains CSF, and can be used to administer medications
what procedure can patients with a ventriculostomy not receive? why?
lumbar puncture, because it puts them at risk for brain herniation
what kind of straining activities should patients with increased ICP avoid?
vomiting
sneezing
valsalva
coughing
what renal issue are patients with increased ICP at risk for?
renal stones due to laying flat (kidneys arent draining well)
why should we avoid oversedating patients with increased ICP?
it can mask signs and symptoms of increasing ICP
how do barbituates help head injury/increased ICP patients?
they help decrease brain metabolism and blood pressure
what diuretic might be given with increased ICP?
mannitol
what should be closely monitored with mannitol?
BP
renal function
signs of fluid depletion or overload
which head injury patients should NOT receive mannitol?
those with aneuric or cerebral hemorrhage
what is meningitis?
acute inflammation/infection of the meninges, which surround the brain and spinal cord
which form of meningitis is the most serious?
bacterial
who is at highest risk for bacterial meningitis?
elderly people
college students/prisoners/those living in dorms and institutions
what are manifestations of meningitis?
fever
severe headache
nausea and vomiting
nuchal rigidity
what are complications of meningitis?
increased ICP
altered mental status
neuro deficits
how is meningitis diagnosed?
blood culture and CT scan
how is meningitis treated?
rapid diagnosis and quickly starting them on antibiotics
why should fever be treated promptly and aggressively with meningitis?
to prevent cerebral edema
why should a fever not be brought down too far with meningitis?
it can lead to shivering which will cause a rebound effect
what are priority nursing management considerations for meningitis?
fever treatment dehydration assessment/I&O nutritional support calm environment monitor for delirium seizure precautions and meds neuro assessments lung and skin evaluations
