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NU 360 > Ch. 36 & 37 > Flashcards

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

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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
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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
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4
Q

general sx of meningitis

A

fever

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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
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6
Q

GI sx of meningitis

A

nausea and vomitting

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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

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8
Q

brudzinski’s sign

A

elicits hip and knee flexion
1. passive flexion of neck
2. hip and knee flex

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9
Q

lab assessment of meningitis

A
  • CSF analysis
  • CT/MRI
  • blood cultures
  • CBC
  • x-ray study to determine presence of infection
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10
Q

meningitis neuro assessment (expected findings)

A
  • increased ICP
  • decreased LOC
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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
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12
Q

meningitis nursing interventions

A
  • medication therapy
  • safety and infection control
  • activity level monitoring
  • monitoring for complications
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13
Q

encephalitis is (definition)

A
  • inflammation of the brain tissue and surrounding meninges
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14
Q

encephalitis is caused by

A
  • viral agents
  • bacteria
  • parasites
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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
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16
Q

s/sx of encephalitis

A
  • fever
  • N/V
  • dizziness
  • blurred vision
  • HA
  • nuchal rigidity: stiff neck
  • AMS
  • motor dysfunction
  • increased ICP
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17
Q

encephalitis: nursing assessments

A
  • ICP monitoring
  • neuro checks!!
  • VS monitoring
  • pupils*
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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
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19
Q

encephalitis treatment management

A
  • antivirals: acyclovir
  • sx management: anticonvulsants for seizure risk, steroids for swelling
  • therapy after (PT?)
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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

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21
Q

most common type of MS

A

relapsing-remitting type occurs in most cases

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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
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23
Q

MS assessment: history

A
  • vision changes
  • mobility changes
  • sensory perception changes
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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)
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25
Q

psychosocial assessment/consideration with MS

A
  • anger and frustration because it takes a long time to dx
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26
Q

MS: lab/dx assessment

A
  • CSF
  • MRI of the brain (shows plaques on the brain- 2 or more is definitive dx MS)
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27
Q

MS patient problems

A
  • 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
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28
Q

MS interventions

A
  • focus management of symptoms and avoiding triggers
  • drugs: goal to slow progression of disease
  • NO CURE
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29
Q

MS: management of symptoms

A
  • c/o weakness and easily fatigued: rest periods
  • teach patient to avoid rigorous activity
  • ROM exercises and stretching and strengthening exercises
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30
Q

MS: drugs

A
  • 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
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31
Q

guillain-barre syndrome is (definition)

A

demyelination of the peripheral nerves, progressive motor weakness and sensory abnormalities

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32
Q

guillain-barre syndrome is a result of

A

a variety of related immune-mediated pathologic processes
- segmented demyelination
- post-vaccine, post-surgery

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33
Q

risk factors for guillain-barre syndrome

A
  • possibly autoimmune
  • association with immunizations
  • frequently preceded by mild respiratory or intestinal infection
    ^ recent (within few weeks) vaccine, surgery, illness, not last year
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34
Q

guillain-barre syndrome progresses over

A

hours to days
- rapid progression, can happen quickly
- creeps up the body (starts low, and works up)

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35
Q

guillain-barre syndrome s/sx

A
  • minimal muscle atrophy
  • systemic paralysis (PROGRESSIVE)
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36
Q

guillian-barre syndrome progression of disease/disease process

A

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

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37
Q

guillian-barre syndrome causes problems with

A
  • respirations
  • talking
  • swallowing
  • bowel and bladder function
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38
Q

guillian-barre syndrome interventions

A
  • 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
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39
Q

plasmapheresis is (definition)

A

removes the circulating antibodies assumed to cause the disease (guillian-barre syndrome)

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40
Q

how does plasmapheresis work?

A
  • 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
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41
Q

migraine headaches are (definition)

A
  • recurrent, episodic attacks of head pain (come and go)
42
Q

migraine headaches s/sx

A
  • HA
    accompanied by
  • nausea & vomiting
  • sensitivity to light, sound, head movement
43
Q

migraine headache triggers

A
  • red wine
  • MSG, chocolate
  • strobe lights
44
Q

priority care management for patient with migraine headache

A

pain management
- drug therapy: abortive and preventive therapy

45
Q

abortive therapy for migraine HA pain (drug)

A

triptans: imitrex
- when patient feels aura coming on, take the abortive medication

46
Q

preventive therapy for migraine HA pain (drug)

A

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
Q

spinal cord injury (SCI) leading cause

A

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
Q

average age of SCI

A

average age 43 years old
- mostly male (80% young males)

49
Q

primary mechanisms of injury with SCI

A
  • 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
Q

types of SCI injuries

A
  • flexion (chin to chest)
  • extension (look up)
  • lateral bending (side to side)
  • rotation (turning head)
51
Q

cervical, thoracic, lumbar vertebrae (#s)

A

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
Q

cervical spine controls

A
  • diaphragm
  • chest wall muscles
  • arms
  • shoulders
52
Q

thoracic spine controls

A
  • upper body
  • GI function
53
Q

lumbar/sacral spine controls

A
  • lower body
  • bowel and bladder
54
Q

SCI primary injuries

A
  • acute compression
  • impact
  • missile
  • distraction
  • laceration
  • shear wound
  • flexion/extension
  • rotation
55
Q

secondary injury to acute compression

A
  • vascular changes (ie. ischemia, impaired autoregulation, neurogenic shock, hemorrhage, microcirculatory derangements, vasospasms, thrombosis)
56
Q

secondary injury to impact

A
  • ionic derangements (ie. increased intracellular calcium, increased sodium permeability)
57
Q

secondary injury to missile

A
  • neurotransmitter accumulation (serotonin, catecholamines, extracellular glutamate)
58
Q

secondary injury to distraction

A
  • arachidonic acid release, free radical production, lipid peroxidation
59
Q

secondary injury to laceration

A
  • endogenous opioids
60
Q

secondary injury to shear wound

A
  • inflammation, edema
61
Q

secondary injury to flexion/extension

A
  • loss of ATP-dependent cellular processes
62
Q

secondary injury to rotation

A
  • programmed cell death or apoptosis
63
Q

paresis and paralysis related to level of SCI: C4

A

tetraplegia: (bilateral) neck down
aka quadriplegia

64
Q

paresis and paralysis related to level of SCI: C6

A

tetraplegia: (bilateral) shoulders down
aka quadriplegia

65
Q

paresis and paralysis related to level of SCI: T6

A

paraplegia: (bilateral) chest down; excludes arms/hands

66
Q

paresis and paralysis related to level of SCI: L1

A

paraplegia: (bilateral) legs down

67
Q

plegia definition

A

paralysis

68
Q

paresis definition

A

weakness

69
Q

initial assessment for SCI patient

A
  • 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
Q

diagnostic imaging for SCI

A
  • spiral CT
  • nurse go with patient to hold their head stable and in alignment with the c-spine
71
Q

SCI: complete injury

A

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
Q

SCI: incomplete injury

A

Incomplete injury may allow SOME function or movement below the level of the injury
- more common than complete SCIs

73
Q

tetraplegia (aka quadriplegia)

A
  • 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
Q

Thoracic Paraplegia

A
  • 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
Q

Lumbar Paraplegia

A
  • 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
Q

spinal shock

A
  • 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
Q

neurogenic shock

A
  • 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
Q

autonomic dysreflexia is seen in patients with

A

seen in patients with spinal cord injuries above T6
- sympathetic NS overreaction
- life-threatening response- can cause stroke and death

79
Q

autonomic dysreflexia s/sx

A
  • 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
Q

rapid assessment for AD

A
  • 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
Q

long-term complications of SCI

A
  • 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
Q

SCI: care coordination and transition management

A
  • home care
  • self-management education
  • health care resources
83
Q

self-management education for the patient with a SCI

A
  • Mobility skills
  • Pressure injury prevention
  • ADL skills
  • Bowel and bladder program
  • Sexuality education
  • Prevention of autonomic dysreflexia (AD)
84
Q

immobilization for cervical injuries

A
  • 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
Q

Halo Fixation and Cervical Tongs: rules

A
  • 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
Q

immobilization for thoracic injuries

A
  • 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
Q

immobilization for lumbosacral injuries

A
  • 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
Q

SCI drug therapy

A
  • 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
Q

SCI: emergency surgery needed for

A
  • spinal cord decompression*
  • a fracture with bony fragments
  • if wound penetrates the cord
  • if neuro status is deteriorating
90
Q

SCI surgical options

A
  • 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
Q

interventions for the patient with an ineffective airway clearance or breathing pattern as a result of SCI

A
  • 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
Q

patient with injuries at what location are at an increased risk for respiratory complications?

A
  • patients with injuries at or above the 6th thoracic vertebrae are at increased risk of respiratory complications
93
Q

interventions for SCI patient: impaired mobility/self-care deficit

A
  • 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
Q

interventions for SCI patient: impaired urinary elimination

A
  • 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
Q

bowel retraining program includes

A
  • 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
Q

interventions for SCI patient: impaired adjustment to their current state

A
  • 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
Q

how do you know how severe the SCI is?

A
  • higher the injury, the worse condition the patient is
  • motor and sensation below site of injury is affected/lost
98
Q

GCS is

A

extra value menu costs 4.56
eyes: 4-1
verbal: 5-1
movement: 6-1

99
Q

neurogenic shock interventions

A
  • IVF (need fluid resuscitation)
  • close monitoring
  • pressers
  • circulation- keep patient warm

(think interventions for distributive shock)

100
Q

interventions for patient in AD

A
  • 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
Q

ways to stimulate the bladder

A
  • 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

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