Ch. 36 & 37 Flashcards
1
Q
meningitis is (definition)
A
inflammation of the meninges (membranes/layers of protection: pia mater and arachnoid) of the brain and spinal cord
2
Q
viral meningitis
A
- aseptic ( no infectious organisms) - so not contagious
- present w/ meningitis sx then have lumbar puncture and CSF will not isolate organisms from the culture
- herpes (HSV)
- varicella/shingles
- better outcomes
3
Q
bacterial meningitis
A
- very highly contagious: outbreaks (college campuses, prisons, military: anywhere people are in close proximity)
- caused by: streptococcus pneumoniae & neisseria meningitidis
- MEDICAL EMERGENCY
- rapid onset
4
Q
general sx of meningitis
A
fever
5
Q
neuro s/sx of meningitis
A
- HA
- photophobia: sensitivity to light
- indications of increased ICP: AMS
- nuchal rigidity
- positive kernig’s & brudzinski’s signs
- decreased mental status
- focal neurological deficits
6
Q
GI sx of meningitis
A
nausea and vomitting
7
Q
kernig’s sign
A
elicit pain or limited extension when knee is extended
1. knee flexed to 90°
2. hip flexed to 90°
3. extension of knee is painful or limited in extension
8
Q
brudzinski’s sign
A
elicits hip and knee flexion
1. passive flexion of neck
2. hip and knee flex
9
Q
lab assessment of meningitis
A
- CSF analysis
- CT/MRI
- blood cultures
- CBC
- x-ray study to determine presence of infection
10
Q
meningitis neuro assessment (expected findings)
A
- increased ICP
- decreased LOC
11
Q
meningitis medication therapy
A
- broad-spectrum ABT initially to kill bacteria
- anticonvulsants for seizure risk
- steroids (controversial)
- prophylaxis treatment for those who have been in close contact with the meningitis-infected patient
12
Q
meningitis nursing interventions
A
- medication therapy
- safety and infection control
- activity level monitoring
- monitoring for complications
13
Q
encephalitis is (definition)
A
- inflammation of the brain tissue and surrounding meninges
14
Q
encephalitis is caused by
A
- viral agents
- bacteria
- parasites
15
Q
what happens (in the brain) as a result of encephalitis
A
- degeneration of neurons of the cortex
- hemorrhage, edema, necrosis, small lacunae develop in cerebral hemispheres
16
Q
s/sx of encephalitis
A
- fever
- N/V
- dizziness
- blurred vision
- HA
- nuchal rigidity: stiff neck
- AMS
- motor dysfunction
- increased ICP
17
Q
encephalitis: nursing assessments
A
- ICP monitoring
- neuro checks!!
- VS monitoring
- pupils*
18
Q
ventricle herniation
A
MEDICAL EMERGENCY
- complication of meningitis
- this is why frequent neuro checks are so important
- if can catch early with neuro changes, can save the patient
- blood pressure
- low HR
- CNS: LOC, pupil response affected, confusion
19
Q
encephalitis treatment management
A
- antivirals: acyclovir
- sx management: anticonvulsants for seizure risk, steroids for swelling
- therapy after (PT?)
20
Q
multiple sclerosis (MS) is (definition)
A
chronic autoimmune disease with periods of exacerbations/remission that affects the MYELIN SHEATH and conduction pathway of the CNS
- body’s WBCs attack the myelin sheath
- progressive disease
- can take a long time to dx (typically need 2 episodes to dx)
- normal life expectancy if effects of disease are treated
- vision, mobility, sensory changes
21
Q
most common type of MS
A
relapsing-remitting type occurs in most cases
22
Q
MS incidence and prevalence
A
- age: 20-40
- familial
- usually females
- 400,000 in US
- 2.3 million people worldwide
- 100,000 in Canada
- more frequently occurs in white people of Northern European ancestry, but if people of all races and ethnicity
23
Q
MS assessment: history
A
- vision changes
- mobility changes
- sensory perception changes
24
Q
physical assessment/ s/sx of MS
A
- muscle weakness and spasticity
- tremors
- weakness can progress to paralysis
- ataxia
- vertigo
- dysmetria: difficulty with depth perception
- dysphagia: difficulty swallowing
- tinnitus: ringing ears
- decreased hearing
- nystagmus
- diplopia: double vision
- blurred vision
- dysarthria
- urinary retention
- spastic bladder
- constipation
(think affects whole body because it affects all the nerves)
25
psychosocial assessment/consideration with MS
- anger and frustration because it takes a long time to dx
26
MS: lab/dx assessment
- CSF
- MRI of the brain (shows plaques on the brain- 2 or more is definitive dx MS)
27
MS patient problems
- impaired immunity due to the disease and drug therapy for disease management
- decreased or impaired mobility due to muscle spasticity, intention tremors, and/or fatigue
- decreased visual acuity and cognition due to dysfunctional brain neurons
28
MS interventions
- focus management of symptoms and avoiding triggers
- drugs: goal to slow progression of disease
- NO CURE
29
MS: management of symptoms
- c/o weakness and easily fatigued: rest periods
- teach patient to avoid rigorous activity
- ROM exercises and stretching and strengthening exercises
30
MS: drugs
- interferon beta: immunomodulator*, lowers rate of relapses
- natalizumab: monoclonal antibody*, binds to WBC to prevent further damage to myelin
- steroids* for exacerbations (not on all the time, just flare up): methylprednisolone
31
guillain-barre syndrome is (definition)
demyelination of the peripheral nerves, progressive motor weakness and sensory abnormalities
32
guillain-barre syndrome is a result of
a variety of related immune-mediated pathologic processes
- segmented demyelination
- post-vaccine, post-surgery
33
risk factors for guillain-barre syndrome
- possibly autoimmune
- association with immunizations
- frequently preceded by mild respiratory or intestinal infection
^ recent (within few weeks) vaccine, surgery, illness, not last year
34
guillain-barre syndrome progresses over
hours to days
- rapid progression, can happen quickly
- creeps up the body (starts low, and works up)
35
guillain-barre syndrome s/sx
- minimal muscle atrophy
- systemic paralysis (PROGRESSIVE)
36
guillian-barre syndrome progression of disease/disease process
begins in lower extremities and ascends bilaterally
- weakness
- ataxia
- bilateral paresthesia progressing to paralysis
- concerned about when it reaches the diaphragm and now the patient cant breathe and needs a ventilator
37
guillian-barre syndrome causes problems with
- respirations
- talking
- swallowing
- bowel and bladder function
38
guillian-barre syndrome interventions
- monitor respiratory status; manage airway: intubate and ventilate prophylactically and treat GBS to get it under control
- manage cardiac dysfunction
- drug therapy (IVIG, pain meds, propofol for intubation)
- plasmapheresis
- improving mobility and preventing complications of immobility
- managing pain
- promoting communication
- emotional support/psychosocial support
39
plasmapheresis is (definition)
removes the circulating antibodies assumed to cause the disease (guillian-barre syndrome)
40
how does plasmapheresis work?
- plasma selectively separated from whole blood; blood cells returned to patient without plasma
- plasma usually replaces itself, or patient is transfused with albumin
- start close to onset of illness
- 3-4 treatments; 1-2 days apart
41
migraine headaches are (definition)
- recurrent, episodic attacks of head pain (come and go)
42
migraine headaches s/sx
- HA
accompanied by
- nausea & vomiting
- sensitivity to light, sound, head movement
43
migraine headache triggers
- red wine
- MSG, chocolate
- strobe lights
44
priority care management for patient with migraine headache
pain management
- drug therapy: abortive and preventive therapy
45
abortive therapy for migraine HA pain (drug)
triptans: imitrex
- when patient feels aura coming on, take the abortive medication
46
preventive therapy for migraine HA pain (drug)
we take these every day regardless of if you have a HA or not, take to prevent migraine
- beta blockers (-lols)
- antiepileptics/anti-seizure meds
47
spinal cord injury (SCI) leading cause
trauma
- vehicle trauma, diving injuries, violence, falls
- cervical cord injuries more common than thoracic or lumbar cord injuries
- 12-18K new SCI each year
48
average age of SCI
average age 43 years old
- mostly male (80% young males)
49
primary mechanisms of injury with SCI
- hyperflexion
- hyperextension
- axial loading or vertical compression (ie. caused by jumping, diving head first or jump and land on feet because the energy is transferred up)
- excessive head rotation beyond its range
- penetration (ie. caused by bullet or knife)
50
types of SCI injuries
- flexion (chin to chest)
- extension (look up)
- lateral bending (side to side)
- rotation (turning head)
51
cervical, thoracic, lumbar vertebrae (#s)
cervical: breakfast at 7 (8 spinal nerves, 7 vertebrae)
- worse, worse outcomes, harder to keep alive
thoracic: lunch at 12
lumbar/sacral: dinner at 5
51
cervical spine controls
- diaphragm
- chest wall muscles
- arms
- shoulders
52
thoracic spine controls
- upper body
- GI function
53
lumbar/sacral spine controls
- lower body
- bowel and bladder
54
SCI primary injuries
- acute compression
- impact
- missile
- distraction
- laceration
- shear wound
- flexion/extension
- rotation
55
secondary injury to acute compression
- vascular changes (ie. ischemia, impaired autoregulation, neurogenic shock, hemorrhage, microcirculatory derangements, vasospasms, thrombosis)
56
secondary injury to impact
- ionic derangements (ie. increased intracellular calcium, increased sodium permeability)
57
secondary injury to missile
- neurotransmitter accumulation (serotonin, catecholamines, extracellular glutamate)
58
secondary injury to distraction
- arachidonic acid release, free radical production, lipid peroxidation
59
secondary injury to laceration
- endogenous opioids
60
secondary injury to shear wound
- inflammation, edema
61
secondary injury to flexion/extension
- loss of ATP-dependent cellular processes
62
secondary injury to rotation
- programmed cell death or apoptosis
63
paresis and paralysis related to level of SCI: C4
tetraplegia: (bilateral) neck down
aka quadriplegia
64
paresis and paralysis related to level of SCI: C6
tetraplegia: (bilateral) shoulders down
aka quadriplegia
65
paresis and paralysis related to level of SCI: T6
paraplegia: (bilateral) chest down; excludes arms/hands
66
paresis and paralysis related to level of SCI: L1
paraplegia: (bilateral) legs down
67
plegia definition
paralysis
68
paresis definition
weakness
69
initial assessment for SCI patient
- ABCs: airway, breathing, circulation; C-spine is part of ABC's- need to keep c-spine stabilized to prevent further damage
- head tilt chin lift will affect the c-spine DO NOT USE; use the jaw thrust maneuver- this opens the airway without hurting the c-spine, essentially dislocates the lower jaw to open the airway
- person at the head calls the move to prevent damage to the head/c-spine; keep head in alignment
- s/ of internal hemorrhage r/t trauma (treat as full-body trauma)
- GCS : always want to get a baseline at initial assessment (concerned about a change)
- American spinal cord injury association (ASIA) scale
- diagnostic imaging: spiral CT (you go with pt to hold their head)
70
diagnostic imaging for SCI
- spiral CT
- nurse go with patient to hold their head stable and in alignment with the c-spine
71
SCI: complete injury
Complete injury is one in which the cord has been severed or damaged in a way that eliminates ALL innervation below the level of the injury
72
SCI: incomplete injury
Incomplete injury may allow SOME function or movement below the level of the injury
- more common than complete SCIs
73
tetraplegia (aka quadriplegia)
- Complete C1-C4 - no motor function of the arms or legs. Can move the neck and possibly shrug the shoulders
- C1-C4 -may be able to use a power wheelchair that can be controlled with the chin or the breath (straw)
- priority is airway; respiratory
- C2 and up: on ventilator
74
Thoracic Paraplegia
- T1-T12 paraplegia have nerve sensation and function of all their upper extremities
-Wheelchair level mobility, drive special individualized adaptive vehicles
- T2-T9 injury, and they may be able to walk short distances with the aid of a walker or crutches
- bowel, bladder, leg movement issues
- GI
- have less mobility than lumbar paraplegics
75
Lumbar Paraplegia
- Sacral or lumbar paraplegia can be functionally independent in all of their self-care and mobility needs
- They can learn to skillfully handle a manual wheelchair and can drive specially equipped vehicles
- bowel, bladder, leg movement issues
76
spinal shock
- Immediate temporary loss of total control of sensation, reflexes, and movement below level of injury
- nerves, muscles, sensation
- Acute, often resolves in 48 hrs (up to 7 days)
- we need to let this ride out to determine the effects of the SCI
- BP: increased (HTN)
- HR: decreased (bradycardia)
- Skin: normal, loss of sensation (loss of motor)
77
neurogenic shock
- Combination of-Primary and secondary SCI injuries
-May also be caused by nervous system toxins or Gullain-Barre syndrome
- Acute loss of sympathetic tone and thus unopposed parasympathetic response driven by vagus nerve (vasodilation) resulting in poor circulation
- falls under distributed shock- vasodilation opens blood vessels, not enough blood in arteries
-Unstable blood pressure, heart rate and ineffective temperature regulation
- more common with higher SCI, cervical
- 6 weeks and management of symptoms (critical care)
- BP: decreased (hypotension)
- HR: decreased (bradycardia)
- Temp: decreased (cant maintain temperature- hypothermic)
- skin: warm at first then cool and clammy
- need fluid resuscitation
78
autonomic dysreflexia is seen in patients with
seen in patients with spinal cord injuries above T6
- sympathetic NS overreaction
- life-threatening response- can cause stroke and death
79
autonomic dysreflexia s/sx
- severe HTN
- bradycardia
- severe HA
- nasal stuffiness
- flushing
vasodilation above level of injury, vasoconstriction below level of injury
- above: flushed face, increased BP, HA, distended neck veins, decreased HR, increased sweating
- below: pale, cool, no sweating
80
rapid assessment for AD
- CV: result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra
- Resp: interruption of spinal innervations to the respiratory muscles (nothing tells the diaphragm to move to breathe; need to bag patient, intubate and ventilate)
- GI: paralytic ileus (gut stops, paralyzed intestine- no bowel sounds, distention)
- GU: neurogenic bladder (spastic or flaccid- cant pee or keep leaking)
81
long-term complications of SCI
- prolonged immobility: muscle wasting, spasticity and contractures
- skin: risk of pressure injuries
- GI: at risk for paralytic ileus for 72 hours
-high grade SCI (cervical or high thoracic injury may have spastic bowel and bladder)
- heterotrophic ossification: muscle turns into bone, rare, will need surgery to scrape down sides
- psychosocial considerations
- contractures: preventable with ROM exercises and stretching
82
SCI: care coordination and transition management
- home care
- self-management education
- health care resources
83
self-management education for the patient with a SCI
- Mobility skills
- Pressure injury prevention
- ADL skills
- Bowel and bladder program
- Sexuality education
- Prevention of autonomic dysreflexia (AD)
84
immobilization for cervical injuries
- Neurologic positioning –log roll technique
- Fixed skeletal traction to realign the vertebrae, facilitate bone healing and prevent further injury
- Halo Fixation and Cervical Tongs
- if patient is moving, hold halo and patient head
85
Halo Fixation and Cervical Tongs: rules
- Never turn patient by pulling on halo device
- Daily pin care
- site care at pins
- Monitor balance
- Monitor skin for rashes, breakdown
- patient cannot drive
- Use straw for drinking
- At risk of aspiration- monitor when eating
- Pad metal in cold temperatures
86
immobilization for thoracic injuries
- bedrest and possible immobilization with a fiberglass or plastic body cast
- clamshell brace
- take off to wash and then put back on
- monitor skin under the brace/cast
87
immobilization for lumbosacral injuries
- immobilization with brace or corset worn when the patient is out of bed
- custom-fit thoracic sacral orthoses preferred
- monitor skin under the brace/cast
88
SCI drug therapy
- Methylprednisolone : IV steroid, to reduce inflammation
- Dextran: plasma expander, put in IV, makes the circulating plasma thicker to bring BP up
- Atropine sulfate: to increase the HR (pick up the pace)
- Dopamine hydrochloride: for neurogenic shock; constricts blood vessels to bring BP up
- Intrathecal baclofen: antispasmodic that prevents contractures and spasticity; used later on, like after shock is resolved
89
SCI: emergency surgery needed for
- spinal cord decompression*
- a fracture with bony fragments
- if wound penetrates the cord
- if neuro status is deteriorating
90
SCI surgical options
- Decompressive laminectomy: shave a disc; same day surgery & go home
- Spinal fusion: fuse spine
- Harrington rods to stabilize thoracic spinal injuries: place metal rods in the spine; most invasive
91
interventions for the patient with an ineffective airway clearance or breathing pattern as a result of SCI
- airway management
- provide measures to maintain airway
- assisted coughing, quad cough: patient sits up right, take nice breath, patient tries to cough and nurse presses on the diaphragm at same time to give muscles extra power to clear the airway
- always want suction set up in the room incase it is needed
- Use incentive spirometer: will need nurse, tech or family to help depending on level of SCI and mobility level
92
patient with injuries at what location are at an increased risk for respiratory complications?
- patients with injuries at or above the 6th thoracic vertebrae are at increased risk of respiratory complications
93
interventions for SCI patient: impaired mobility/self-care deficit
- in patients with spinal cord injury, monitor for risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli.
- proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings, splints to prevent drop foot
- ask for help
- use a slide board to move the patient
- prevent orthostatic hypotension: change position very gently; may need to use a tilt board: little by little
- promote self-care
94
interventions for SCI patient: impaired urinary elimination
- A bladder retraining program
- Spastic bladder—manipulating external area
- Flaccid bladder—Valsalva maneuver
- Encouraging consumption of 2000 to 2500 mL of fluid daily to prevent urinary tract infection
- Long-term renal complication
- Signs and symptoms of urinary tract infection not perceived by the patient
95
bowel retraining program includes
- Consistent time for bowel elimination (allow time)
- High fluid intake
- High-fiber diet
- Rectal stimulation (with or without suppositories)
- Stool softener medications, as needed
- laxative
- enema
- positioning: up right
96
interventions for SCI patient: impaired adjustment to their current state
- invite patients to ask questions about significant life changes; reply openly and honestly
- encourage patients to discuss their perceptions of their situation and coping strategies that can be used
- begin a patient education program to clarify misconceptions
97
how do you know how severe the SCI is?
- higher the injury, the worse condition the patient is
- motor and sensation below site of injury is affected/lost
98
GCS is
extra value menu costs 4.56
eyes: 4-1
verbal: 5-1
movement: 6-1
99
neurogenic shock interventions
- IVF (need fluid resuscitation)
- close monitoring
- pressers
- circulation- keep patient warm
(think interventions for distributive shock)
100
interventions for patient in AD
- raise the HOB
- call for help
- noxious stimuli: full bladder, pinched skin, pinched foley, too hot, impacted stool, restrictive clothing (caused by something below the level of SCI)
- take VS
- administer antihypertensives
101
ways to stimulate the bladder
- stimulate thigh
- run water
- run water over the perineum
- 2000-2500/day fluid intake
- external catheters
- teach pt to straight cath themself: will need to teach pt catheter care
- crede manuever: push on the bladder
