301 test 3 Flashcards
CAGE assessment
C= have you ever tried to cut back on your use?
A= have you ever been annoyed/angered when questioned about your use?
G= have you ever felt guilt about your use?
E= have you ever had an eye-opener to get started I the morning?
quick questionnaire to help determine if an alcohol assessment is needed
if pt answers yes to two or more then assessment is advised
dysphasia
also called aphasia - difficulty speaking or understanding due to neurological changes
dysarthria
slurring
dysphagia
difficulty swallowing
first major component regarding care
safety
A&O X 4?
patient is aware of person, place, time, and situation
delirium
acute disorder of attention and global cognition (memory and perception)
essential features of delirium include:
acute onset, fluctuating course, inattention or distraction, disorganized thinking to altered LOC
delirium risk factors
dementia, electrolyte disorder/emotional, lung, liver, heart, kidney, brain, infection, Rx drugs, retention of urine, injury, pain, stress, unfamiliar environment, metabolic, MI
dementia
progressive decline in memory and as least one other cognitive area in an alert person
MMSE
mini mental status exam
dementia that occurs in younger people
Korsakoff’s dementia and pick’s disease
risk factors for dementia
age, brain/head injury, fewer years of education, female, genetics, alcohol
use opioids for
acute pain
two types of nerve fibers
A-delta and C-fibers
A-delta
large nerve fibers that conduct rapid pain impulses
C-fibers
small nerve fibers that conduct pain impulses slowly
Bradykinin
pain and inflammatory facilitating substance that is released at the site of injury and causes continued irritation at the site of injury
A-delta and C-fibers carry signals to
Central Nervous System
blocking impulses
stop pain
facilitating impulses
pass on pain
if pain continues the signal will
pass through the spinal cord to the thalamus ending in the limbic system
limbic system
emotions which control pain are produced. stimulus passed on to the cerebral cortex when sensation is recognized
opioids suppress pain
going up
visceral pain
originates from the abdominal organs. is crampy or gnawing
somatic pain
originates from the skin, muscle, bones, and joints. aching or throbbing
cutaneous pain
originates from the dermis, epidermis, and subcutaneous tissue. described as sharp
referred pain
called radiculopathy. originates from a specific site but pain is at another site
phantom pain
originates from the nerve pathway from the amputated extremity
pain is
what the patient says it is, and exist whenever the patient says it is
acute pain
meant to warn the body that some type of injury has occurred. cause in known. duration is short, treatment consists of treating underlying cause
chronic pain
pain that lasts beyond the normal health period and has no role. cause if often unknown, treatment is often pain control not cure
neuropathic pain
peripheral sensitization by which peripheral nociceptors are sensitized to pain stimuli. causes cytokines and growth factors to be recruited prolonging inflammatory response.
analgesia
the inability to feel pain.
who is most likely to experience more side effects from analgesia
elderly
hierarchy of pain assessment
- self report
- pathological conditions
- observe patient behaviors
- surrogate reporting
- attempt an analgesic trial
surrogate reporting
ask family members
self report
asking patient their pain based off of numerical scale
mild pain
1-3 range
moderate pain
4-6 range
severe pain
7-10 range
2 pathologic conditions
searching for potential causes of pain
observe patient behaviors
can include CPOT, BPS, NIPS. when in absence of self report, observation of behavior is valid approach
CPOT
critical care pain observation tool
BPS
behavioral pain scale
NIPS
neonatal infant pain scale
examples of behavioral observations of pain
restlessness, guarding, pacing, grimacing, bracing, muscle tension
diaphoresis
sweating
wrong baker faces
designed for children 3 years and oldeirand with patients with language barrier. use six faces ranging from happy to face with tears
patient barriers to pain treatment
fear of side effects, addiction, tolerance, and lack go knowledge
different nervous systems
central, peripheral, somatic, and autonomic
central nervous system
brain and spinal cord. processes, interprets, and stops info. issues orders to muscles, glands, and organs
peripheral nervous sytem
transmits info to and from the CNS
protective structures of the central nervous system
meninges
layers of the meninges
dura matter - outer layer, arachnoid - middle layer, Pia matter - inner meningeal layer that contains blood vessels
cerebral spinal fluid contains
glucose, electrolytes, oxygen, water, CO2, protein, leukocytes
where is cerebral spinal fluid made
in the ventricle
how many ventricles are there
4- 1 lateral in each hemisphere, 3rd ventricle adjacent to the thalamus, 4th ventricle adjacent to the brainstem
grey matter
consists of cell bodies
white matter
myelinated nerve fibers
carotid arteries supply
blood to the brain
vertebral arteries branch into
posterior and anterior
frontal lobe
primary motor cortex responsible for functions related to voluntary motor activity. controls intellectual function, awareness of self, personality, and autonomic responses related to emotion
broca’s area
in the left frontal lobe. formulation of words
parietal lobe
contains sensory cortex contains position sense, touch, shape, and texture objects
temporal lobe
contains primary auditory cortex, wernickes area
wernickes area
responsible for comprehension of speech, speech production, and interpreting sounds
when Broca and wernickes areas are damaged patient has
global aphasia
occipital lobe
primary visual cortex. responsible for reviewing visual information
diencephalon
made up of thalamus, hypothalamus, epithalamus, and subthalamus
hypothalamus
regulation of body temperature, hunger, thirst, formation of autonomic nervous system responses, storage and secretion of hormones from the pituitary gland
basal ganglia
creates smooth, coordinated voluntary movement by balancing the production of acetylcholine and dopamine
brain stem
10 of the 12 cranial nerves originate from the brainstem
medulla oblongata
contains reflux centers for controlling involuntary functions such as breathing, sneezing, swallowing, coughing, vomiting, and vasoconstriction
what is the number one cause of disability
stroke
first 7 pair of nerves exit _____ their corresponding vertebrae
above
remaining spinal nerves exit _____ the corresponding vertebrae
below
contributing factors to neurological conditions
PMH-HTN, HLP, DMII
HLP
Hyperlipoproteinemia
parkinsons causes
tremors at rest
cerebellar disorders cause
tremor with intentional movement
dysphagia
difficulty swallowing
dysphasia
difficulty speaking
aphasia
defective or absent language
Cranial nerve 2
optic nerve - presence of peripheral vision indicates function of CN
cranial nerve 3
oculomotor
cranial nerve 4
trochlear
cranial nerve 5
trigeminal - test for movement and sensation. wipe a cotton ball along branches of face
cranial nerve 6
abducens
what do cranial nerve 3,4,6 do
six cardinal fields of gaze and assessment of pupils via light for constriction
ptosis
eyelid dropping
cranial nerve 7
facial nerve - test for movement - have pt perform facial expressions
cranial nerve 8
acoustic nerve - test for hearing
cranial nerve 9
glossopharyngeal
cranial nerve 10
vagus nerve
what are you testing with cranial nerve 9 and 10
movement of the soft palate and gag reflex
cranial nerve 11
spinal accessory muscle
cranial nerve 12
hypoglossal nerve - movement of tongue
rombergs test
arms are by sides and assess sway
types of stroke
hemorrhagic and ischemic
primary cause for stroke
HTN
ASHD
Arteriosclerotic heart disease
what do you not want to have during a stroke
acute hypotension
what to do during a ischemic stroke
glycemic fluids should not be given, should be NPO to control sugars, anticoagulants should be avoided short term
what to do during hemorrhagic stroke
strict protocols for BP management, ICP monitoring, ventricular drain is placed
ICP
intracranial pressure
FAST
face- facial droop
arm - hemiparesis
speech - dysarthria/aphasia
timing - 3 hr window for t-PA
hemiparesis
Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles.
stroke signs and symptoms
Facial droop Hemiparesis-Unilateral weakness opposite side of lesion Recent TIA-Transient ischemic event-This is essentially a stroke that symptoms resolve with in 24 hr. Dysphagia Dysphagia Dysarthria Apraxia Double vision Field cut Sexual disfunction
triad of doom
HTN,HLP, DMII - diseases that contribute to stroke
how do you differentiate between a DVT and cellulitis
use a doppler
CIPN
chronic illness polyneuropathy
Glioblastoma
A malignant tumor affecting the brain or spine. the most common brain cancer
SDH
subdural hematoma
SCI
spinal cord injury
SCI considerations
skin breakdown bowel and bladder programs - risk for UTI autonomic dysreflexia DVT and PE depression and 90% divorce rate
atherosclerosis
The build-up of fats, cholesterol, and other substances in and on the artery walls.
coronary vascular disease is a risk for
stroke
dementia vs delirium
delirium - Serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings.
dementia - A group of thinking and social symptoms that interferes with daily functioning.
