Adult 2 - Unit 1 Flashcards
In the identification of a stroke, what does FAST stand for?
Facial palsy
Arm weakness
Slurred speech
Two out of three of the above
What is a TIA?
(Transient ischemic attack)
Acute reversible fleeting episodes of focal neurological deficits
- without infarction of the brain
- Clinical symptoms typically last less than an hour
What are the S/S of a TIA?
Partial vision loss in one eye Weakness Numbness and tingling Severe HA Speechlessness and dizziness
What is the #1 cause of a TIA?
Carotid artery stenosis
What are the three categories of strokes?
Reversible ischemic neurological deficit (RIND)
Stroke in evolution
Stable/complete stroke
What is a RIND? (stroke)
(Reversible ischemic neurological deficit)
S/S of a stroke that last longer that 24 hours but resolve themselves within several days
What are the warning signs of a stroke?
- Sudden weakness, numbness, or paralysis (often 1 side, contra-
lateral) - Sudden dimness or loss of vision
- Sudden difficulty speaking or understanding simple statements
- Sudden severe HA with no known cause
- Unexplained dizziness, unsteadiness, or sudden falls
Expressive aphasia
Garbled speech, difficulty time talking
Receptive aphasia
More difficult to assess than expressive; they can hear and speak, but their brain cannot translate your speech
- may look at you like you are speaking another language
- Speak without using gestures if you are assessing them
What are the three types of ischemic stokes
Thrombotic
Embolic
Hypoxic
Thrombotic stroke
A clot that forms in the brain due to atherosclerotic plaque
- Creates a stenotic blood vessel, interrupting blood flow
Embolic stroke
A stroke resulting from a clot that is formed somewhere else in the body which travels to the brain
- DVT of the legs, valve disease, a-fib
What is a presentation that may be confused with/for a stroke?
Hypoglycemia (similar S/S)
- Slurred speech, confused, etc…
What are the 7 D’s of emergency management of a stroke
Detect Dispatch Delivery Door Data Decision Drug
Detection (7 Ds of stroke management)
Facial droop, unilateral arm droop, speech difficulties, confused
Dispatch (7 Ds of stroke management)
Call 911 and rapid transport to hospital
- Also calling “code stroke”
Delivery (7 Ds of stroke management)
Alert hospital to the arrival of a possible stroke patient
Door (7 Ds of stroke management)
< 25 minutes:
- check blood sugar - GCS
- neuro assessment - CT scan (read w/in 45 minutes)
- hx of onset
Data (7 Ds of stroke management)
Is this an ischemic stroke or not?
Decision (7 Ds of stoke management)
Do we administer a thrombolytic?
- if yes, within 180 minutes of onset of symptoms
What is the window of opportunity of a Thrombolytic in a stroke patient?
180 minutes
- some doctors are extending this to 4.5 hours
Why is a stroke patient put on anti-coagulation therapy?
Prevent another stroke from newly forming clots
- will not do anything for the already formed clots
What is the medical treatment in a stroke?
Anticoagulant therapy Anti-platelet Carotid endarterectomy Clot retriever (MERCI) ?(Antihypertensives)? ?(Thrombolytic)?
What are the parameters for treating HTN in a stroke patient?
Systolic > 220 mm Hg
Diastolic > 120 mm Hg
What are the inclusive criteria for using a thrombolytic in a stroke patient?
< 4.5 hours since onset of symptoms
CT of ischemic stroke w/ deficits
Age > 18 yrs
What are reasons to exclude the use of thrombolytics in the treatment of a stroke patient?
> 4.5 hrs since onset of symptoms; HTN; rapidly improving
Hx stroke w/in 3mo; Lumbar pnct. w/in 7/days
Major surgery w/in 21/day, active internal bleed w/21 days
Evidence of Intracerebral bleed
Major trauma w/in 30/day; Head trauma w/in 90/day
SAH
(Sub arachnoid hemorrhage)
- Hemorrhagic stroke
What are presentation S/S of a SAH?
worse HA of their life Seizures May have N&V with HA Hemiparesis Change in LOC Photophobia and visual disturbances Nuchal rigidity + Kernig and low back pain
Treatment for SAH
(If you can get pt to a treatment facility in time)
- Surgery (Clipping with craniotomy)
- Coiling (interventional radiology)
(if possible and when ready)
what are some “aneurysm precautions”? (hemorrhagic stroke)
Quiet, dark room, Mng pain, Mng stress Limit visitors & env. stimuli Stool softeners Maintain B/P No coughing, sneezing, nose blowing, bearing down
What are some complications of a SAH?
Rebleeding
Vasospasm
Increased ICP
Seizures
What is involved in managing vasospasms? (SAH)
Calcium channel blockers Triple H therapy Transcranial doppler (daily)
What is ‘Triple H therapy’ and why is it used? (SAH)
Hypervolemic, hemodilution, hypertensive
- prevent vasospasm
- fill and dilute the vessels, once bleed is secure, hypertense the patient (puts pressure on vessel walls)
(Done prophylacticaly, 50% of pts will vasospasm)
Multiple sclerosis (MS)
A chronic, progressive, degenerative disorder of the CNS characterized by disseminated demyelination of nerve fibers of the brain and spinal cord
(usually onset: 20-50, women more affected)
What pathophysiology characterizes MS?
(in the CNS)
- chronic inflammation
- demyelination
- gliosis (scarring)
- Autoimmune disease
What characterizes the manifestation of MS?
Chronic, progressive deterioration in some
Remissions and exacerbations in others (overall degen trend)
What are the common categories of MS S/S?
Motor
Sensory
Cerebellar
Emotional
Parkinson’s Disease (PD)
Chronic, progressive neurodegenerative disorder characterized by slowness in the initiation and execution of movements (bradykinesia), increased muscle tone (rigidity), tremor at rest, and gait disturbances
What are the initial S/S of PD?
Mild tremor, slight limp, and decreased arm swing
Classic triad of PD
Tremor
Rigidity
Bradykinesia
What are some complications involved in PD?
Dysphagia – malnutrition and aspiration
General debilitation – pneumonia, UTI, skin breakdown
Decreased mobility – constipation, ankle edema, contractors
orthostatic hypotension – falls
Depression & sleep disorders
Nursing goals for Parkinson’s disease (3)
1) Maximize neurological function
2) maintain independence in ADLs as long as possible
3) Optimize psychosocial well-being
Nursing goals for MS
1) Maximize neuromuscular function
2) Maintain independence in ADLs for as long as possible
3) Manage disabling fatigue
4) Optimize psycho-social well being
5) adjust to illness
6) Reduce factors that precipitate exacerbations
Myasthenia gravis (MG)
an autoimmune disease of the neuromuscular junction characterized by the fluctuating weakness of certain skeletal muscle groups.
What causes myasthenia gravis? (pathophysiology)
autoimmune process in which antibodies attack acetylcholine (ACh) receptors, resulting in decreased number of ACh receptors (AChR) sites at neuromuscular junctions.
- prevents ACh molecules from attaching and stimulating muscle contractions
What is the primary feature of MG?
Fluctuating weakness of skeletal muscles – Strength is usually restored after a period of rest
How does MG affect sensory and reflexes?
How fast do muscles atrophy
There is no sensory loss in MG, and reflexes remain normal
Muscle atrophy is rare
Myasthenic crisis
an acute exacerbation of muscle weakness triggered by infection, surgery, emotional distress, drug overdose, or inadequate drugs.
What are the major complications of a myasthenic crisis?
The major complications result from muscle weakness in areas that affect swallowing and breathing
- Aspiration, respiratory insufficiency, respiratory infection
What are the major drug categories used in the treatment of MG?
Anticholinesterase drugs (enhance NMJ function)
Corticosteroids (suppress immune response)
immunosuppressants
What surgical therapy may be used in MG?
Thymectomy
- Thymus appears to enhance the production of AChR antibodies
- Results in improvements for most patients
What are the major nursing goals for MG?
1) Have a return of normal muscle endurance
2) Manage fatigue
3) Avoid complications
4) Maintain a quality of life appropriate to the disease course
(NCLEX)
A 65-year-old woman was just diagnosed with Parkinson’s disease. The priority nursing intervention is:
Promoting physical exercise and a well-balanced diet
What are the types of SCIs (6)
Concussion Transection
Compression Hemorrhage
Laceration Injury to blood vessels
What is the peak time for vasospasms following a SAH?
6-10 days after initial bleed
- often kept in ICU for 14 days until threat of vasospasm is reduced
What are the two types of hemorrhagic strokes?
Intracerebral hemorrhage Subarachnoid hemorrhage (SAH)
What is the most important cause of an intracerebral hemorrhage?
HTN
What are some initial s/s of an intracerebral hemorrhage?
Severe headache w/ N/V
Weakness of one side
Slurred speech
deviation of the eyes
what are some later/progression s/s of an intracerebral hemorrhage?
hemiplegia
fixed and dilated pupils
abnormal body positioning
coma
What is a characteristic symptom of a ruptured aneurysm in the sub-arachnoid space (or brain)?
“Worst headache of one’s life”
- cerebral aneurysms are considered a “silent killer”; often no warning signs until it has ruptured
What are two complications of an aneurysmal SAH?
Rebleeding before surgery
Cerebral vasospasm
What is the difference in the effect on judgment between a left side and a right side stroke
left-brain strokes often cause person to be very cautious
right-brain strokes tend to cause the person to be impulsive
What is the most important initial diagnostic study following a TIA?
CT of the brain
- need to confirm s/s of TIA are not related to other brain lesions
What are the goals for therapy during an acute phase of a stroke?
Preserving life, preventing further brain damage, reducing disability
How will urine output respond to an increase of ADH secretion in a stroke patient?
Urine output will decrease?
- Hyponatremia may occur
What kind of IV solution may be used in stroke management
Hypertonic solutions are showing to be effective in reducing ICP
- Hypotonic solutions and glucose solutions should be avoided
- Hypotonic may further increase cerebral edema and ICP
- Hyperglycemia may be associated with further cerebral damage
What are three strategies in reducing ICP?
Elevating HOB
Maintaining head and neck alignment
Avoiding hip flexion
What are ideal temperatures in a stroke patient?
Between 36 and 37 C
- aggressive cooling therapy if greater than 38 C (e.g. cooling blanket)
- Temperature increases brain metabolism
What are the recommendations of prophylactic seizure therapy in stroke patients
Not recommended for an ischemic stroke
Recommended for a hemorrhagic stroke
What constitutes the main drug therapy for a hemorrhagic stroke?
Management of HTN
What drug is given to prevent vasospasms in a hemorrhagic stroke patient?
Nimodipine (Nimotop)
- Calcium channel blocker
What must you do before giving Nimodipine?
Assess blood pressure and apical pulse
- if < 90, hold medication and contact doc
What is the primary cause of a stroke?
Uncontrolled HTN
What are some things that may cause an airway obstruction in a stroke patient
Problems with chewing/swallowing
food pocketing
Tongue falling back
What are some important nursing interventions related to respiratory function in a stroke patient?
freq assessment of airway patency and function Oxygenation suctioning mobility Positioning to prevent aspiration Encouraging deep breathing
What is the major concern with the first feeding in a stroke patient?
Dysphagia and diminished/absent gag reflex
- approach first oral feeding carefully
- Swallowing evaluation should be done first
Pneumothorax
Air in the pleural space
- creates a partial or complete collapse of the lung
- as volume increases in pleural space, lung volume decreases
Spontaneous pneumothorax
Accumulation of air in the pleural space without an apparent antecedent event
- caused by rupture of small blebs on the visceral pleura
- Smoking increases risk
- Most common form of a closed pneumothorax
What may occur in a penetrating chest wound?
(also called a sucking chest wound)
Air may/will enter the pleural space through the chest wall during inspiration
What is the emergency treatment of a penetrating/sucking chest wound include?
Covering the wound with an occlusive dressing that is secured on 3 sides
What is the initial response if the object that caused the chest wound is still in place?
Do not remove the object until a physician is present
– stabilize the impaled object with a bulky dressing
What are some possible causes of a tension pneumothorax?
- Open chest wound with a flap that allows air in during inhalation but not out
- Clamped/blocked chest tubes
Your patient is developing what you expect to be a tension pneuomothorax, what might one of your first responses be?
Check to ensure that the chest tube is not clamped or blocked
What are some s/s of a tension pneumothorax?
dyspnea, chest pain radiating to the shoulder
tracheal deviation, neck vein distention
Decreased/absent breath sounds on affected side
Cyanosis
What is a chylothorax
The presence of lymphatic fluid in the pleural space
S/S of a pneumothorax
Mild: tachycardia and dyspnea If larger: respiratory distress, shallow rapid respirations dyspnea, air hunger, O2 desaturation Chest pain and a cough may be present No breath sounds over the affected area
What is the emergency management of a tension pneumothorax
large bore needle into the anterior chest wall at the fourth or fifth intercostal space to release trapped air
Thoracentesis
The aspiration of the pleural space with a large bore needle
Clinical manifestations of a rib fx
pain at site of injury (esp during inhalation and cough)
Splinting of affected area
Shallow breathing /w reluctance to deep breath
What are possible complications of a rib fx
Pneumonia and atelectasis
- due to reluctance to take deep breaths, decreased ventilation, and retained secretions
What should patient teaching include for a rib fx patient?
Emphasize deep breathing, coughing, and using incentive spirometry, and use of pain medications
What is the main goal in treating a rib fx?
Decrease pain so the patient can breathe adequately to promote good lung expansion
What are the manifestations of a flail chest injury?
Area moves paradoxically to uninjured areas, increase WOB
Rapid, shallow breathing with tachypnea
Splinting of chest may hide flail chest
Asymmetric and uncoordinated thorax movements
What is the initial therapy for flail chest?
Airway management, adequate ventilation
Supplemental O2
Careful administration of IV fluid and pain control
– Re-expand the lungs and ensure adequate oxygenation
What is the process of removing a chest tube
Pain medication 15 minutes prior
Suture is cut, sterile airtight petroleum jelly gauze prepared
Patient holds breath and bears down as tube is removed
Immediately covered with gauze
What are the priorities in chest trauma?
(ABCD) Airway (with cervical spine control) Breathing Circulation Disability (neurological)
What are important items to address during patient history with a chest trauma patient
(AMPLE) Allergies Medications Past illness Last meal Events related to the injury
Pulmonary contusion
Bruising of the lungs
- Starts showing up 24-48 hours after initial injury
- hospital for a couple days while it plays out
What is chest tube suction measured in?
cmH20
With water suction, what is suction dependent on?
Water level in suction chamber
– NOT the amount of suction dialed in on the regulator
What are some nursing care items for chest tubes?
ID chest tube type; check dressing and security
Avoid dependent loops; Do not strip tubers
Check drainage; look for bubbling in water seal
Look for tidaling in water seal; check h20 level in suction chamber
Suction until gentle bubbles appear; ensure tubing is open
Respiratory assessment; no clamping tubes
Lhermitte’s sign
Seen in MS patients; A transient sensory symptom described as an electric shock radiating down the spine or into the limbs with flexion of the neck
Motor s/s of MS
Weakness/paralysis of the limbs, trunk or head
diplopia
scanning speech
spasticity of the muscles
sensory s/s of MS
numbness and tingling; other paresthesias
patchy blindness (scotomas); blurred vision
vertigo; tinnitus; decreased hearing
Chronic neuropathic pain
How may bowel and bladder be affected by MS?
- Constipation
- Spastic bladder – small capacity, urgency and frequency w/ dribbling or incontinence
- Flaccid bladder – large capacity, urinary retention
What are the major drug classes used in MS patients?
Corticosteroids (for exacerbations) Immunomodulators Immunosuppressants Cholinergics Anticholinergics (bladder symptoms) Muscle relaxants (muscle spasms)
What drug alert must you be aware of for a MS patient?
Relates to the Immunomodulator beta-interferon
- Rotate injection sites with each dose
- Assess for depression, suicidal idealization
- Wear sunscreen and protective clothing in sun
- Flu-like symptoms are common following initial therapy
What are some triggers that may exacerbate MS?
Infection, trauma, immunizations, delivery after pregnancy, stress, change in climate
What are some important teaching points to MS patients?
1) Achieve a good balance of exercise and rest
2) Eat nutritious and balanced meals
3) avoid hazards of immobility
4) Know and minimize triggers
What is the pathology of Parkinson’s disease? (PD)
degeneration of the dopamine-producing neurons in the midbrain, which disrupts the normal balance between dopamine (DA) and acetylcholine (ACh) in the basal ganglia
What are some automatic movements that are diminished in PD pts? (Bradykinesia)
Blinking of eyelids, swinging of the arms while walking, swallowing of saliva, self-expression with facial and hand movements, minor movements of postural adjustments
What is often the first drug used in PD?
Levodopa w/ carbidopa (Sinemet)
What is the drug alert associated with PD?
Related to Sinemet;
- monitor for signs of dyskinesia
- Effects may be delayed for several months
- Report any uncontrolled movements of the face, eyelids, mouth, extremities; mental changes; palpitations; severe N/V
Cholinergic crisis (MG)
Overdose of anticholinesterase drugs
- weakness w/in 1 hr of ingesting anticholinesterase
- increased weakness of skel muscles (ptosis, dyspnea, etc)
Differential diagnosis of myasthenic crisis and cholinergic crisis
Myasthenic crisis may be caused by failure to take a drug, while cholinergic may be caused by too much
- Strength will improve after admin of drug during myasthenic c.
- Weakness w/in 1 hour after admin of drug during chol. c.
Amyotrophic lateral sclerosis (ALS) – Lou Gehrig’s disease
Progressive neurologic disorder characterized by loss of motor neurons
– motor neurons in brainstem and spinal cord gradually degenerate
S/S of ALS
weakness of upper extremities, dysarthria, dysphagia
– death usually results from respiratory infection secondary to compromised respiratory function
Focus of nursing care in ALS
1) facilitating communication
2) reducing risk of aspiration
3) early identification of respiratory insufficiency
4,5) Decreasing pain and risk for injury (falls)
6) providing diversional activities
7) Helping pt and family manage disease process
What are some nursing management items in regards to a patient with delirium?
Protecting the patient from harm
Creating calm and safe environment – reduce stimuli
Encourage family and friends to attend to pt – familiar objects
Provide reassurance and reorienting info – consistent staff
Personal contact (touch and communication)
Ensure sensory aids are available (hearing aids, glasses, etc.)
Guillain-Barre Syndrome
An acute, rapidly progressing form of polyneuritis
– characterized by ascending, symmetric paralysis
Pathophysiology of GBS
Immune reactions attack nerves causing loss of myelin and edema and inflammation of the affected nerves.
- Muscles innervated undergo denervation and atrophy
- In recovery phase, remyelination occurs slowly and function returns in a proximal to distal fashion
What are dangerous autonomic dysfunctions that may occur with GBS?
Orthostatic hypotension hypertension abnormal vagal responses (bradycardia) -- also bowel and bladder -- also SIADH --> urinary retention
What is the most serious complication of GBS?
Respiratory failure
– constantly monitor rate and depth
How might you manage mild dysphagia? (e.g. in a GBS pt)
Placing the patient in an upright position and flexing the head forward during feedings.
– Also mentioned messaging neck in class
What must routine assessment include for a GBS pt in acute phase?
Respiratory function
ABGs
Gag, corneal, swallowing reflexes
B/P and cardiac rate/rhythm
What are the main goals for a GBS pt
1) maintain adequate ventilation
2) be free from aspiration
3) controlled pain
4) maintain acceptable method of communication
5) maintain adequate NTDT
6) return to usual physical function
Spinal shock
temporary neurological syndrome following an acute spinal cord injury
- characterized by decreased reflexes, loss of sensation, and flaccid paralysis below the level of injury
- may last days to months
Neurogenic shock
Occurs after acute spinal cord injury, and is due to the loss of vasomotor tone caused by injury
- characterized by hypotension and bradycardia
- Peripheral vasodilation, venous pooling, decreased CO
Defer spinal shock from neurogenic shock
Spinal – decreased reflexes, loss of sensation, flaccid paralysis
Neurogenic – hypotension and bradycardia, peripheral vasodilation, venous pooling, and decreased CO
Autonomic Dysreflexia
May occur in patients with an SCI at T6 or higher; a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system
- Life threatening
- HTN, throbbing headache, diaphoresis, bradycardia, flushing of the skin, blurred vision, nasal congestion, anxiety, nausea
Differentiate the most observable symptom between neurogenic shock and autonomic Dysreflexia
neuro shock – hypotension
Auto D – Hypertension (severe)
What are the three main causes of autonomic dysreflexia?
Bowl (constipation)
Bladder (distention)
Pain (UTI, kidney stone, pressure ulcer, ingrown nail, etc.)
Your SCI patient complains of a headache, what is an important response?
Measure blood pressure
- headache may signify developing autonomic Dysreflexia, if so severe HTN will accompany it
What are initial nursing interventions for a patient in autonomic dysreflexia
elevate HOB to 45 degrees or sit the patient upright
Notify physician
assess to determine the cause
– bladder irritation most common, immediate cath to relieve
An SCI above what level will greatly decrease the influence of the sympathetic nervous system?
T6
- Bradycardia, peripheral vasodilation, hypotension
- Cardiac monitoring needed
- Increase in vagal stimulation can cause cardia arrest (turning or suctioning)
Neurogenic bladder
Bladder dysfunction related to abnormal or absent bladder innervation
– Patients usually have some degree of it after a SCI
What are some common problems with a neurogenic bladder?
- Urgency
- frequency
- incontinence
- Inability to void
- High bladder pressure –> reflux to kidneys
