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PNC 103 lecture > chapter 48: nursing care of patients w/ central nervous system disorders > Flashcards

chapter 48: nursing care of patients w/ central nervous system disorders Flashcards

1
Q

meningitis: pathophysiology

A
  • infection/inflammation of brain and spinal cord
  • purulent exudate
  • increased intracranial pressure (ICP)
  • possible cranial nerve involvement
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2
Q

etiology of meningitis: bacterial

A
  • neisseria meningitidis
  • streptococcus pneumoniae
  • group b strep
  • haemophilus influenzae type b
  • may also be viral
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3
Q

signs and symptoms of meningitis

A
  • severe headache
  • no appetite or thirst
  • fever
  • photophobia
  • petechial rash
  • nuchal rigidity
  • positive kernig and bruzinski signs
  • nausea and vomiting
  • encephalopathy
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4
Q

kernig’s sign

A

test for this by bending the knee

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5
Q

brudzinski’s sign

A

test for this by lifting the back of the head

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6
Q

complications of meningitis

A
  • seizures
  • cranial nerve damage
  • occasional permanent neurological deficits
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7
Q

diagnostic tests for meningitis

A
  • lumbar puncture
  • culture and sensitivity
  • CT scan, MRI
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8
Q

therapeutic interventions for meningitis

A
  • antibiotics
  • antipyretics
  • cooling blanket as needed
  • dark, quiet environment
  • analgesics: codeine products
  • corticosteroids
  • antiemetics
  • droplet isolation if bacterial
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9
Q

encephalitis: pathophysiology

A
  • inflammation of brain tissue
  • nerve damage, edema, necrosis
  • increased ICP
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10
Q

encephalitis: etiology

A
  • viruses: west nile, infectious mononucleosis, herpes simplex virus
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11
Q

signs and symptoms of encephalitis

A
  • headache
  • fever
  • nausea and vomiting
  • nuchal rigidity
  • confusion
  • decreased level of consciousness (LOC)
  • seizures
  • photophobia
  • ataxia
  • hemiparesis
  • tremors
  • coma
  • death
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12
Q

complications of encephalitis

A
  • cognitive disabilities
  • personality changes
  • ongoing seizures
  • motor deficits
  • blindness
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13
Q

diagnostic tests

A
  • CT scan
  • MRI
  • electroencephalogram (EEG)
  • lumbar puncture w/ CSF analysis
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14
Q

therapeutic interventions for encephalitis

A
  • analgesics
  • anticonvulsants
  • antipyretics
  • corticosteroids
  • antivirals
  • sedatives
  • neurological assessment
  • symptomatic care
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15
Q

increased intracranial pressure: pathophysiology

A

= increase in brain, blood, csf

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16
Q

etiology of increased ICP

A
  • brain trauma
  • brain tumor
  • intracranial hemorrhage
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17
Q

increased ICP: signs & symptoms

A
  • restlessness
  • irritability
  • decrease in LOC
  • hyperventilation
  • pupil changes
  • Cushing triad
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18
Q

monitoring of increased ICP

A
  • external ventricular drain
  • subarachnoid bolt
  • intraparenchymal monitor
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19
Q

Cushing’s triad

A

bradycardia
irregular respirations
widened pulse pressure (MAP)

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20
Q

Nursing Diagnoses for Central Nervous System Infections

A
  • hyperthermia
  • risk for acute confusion
  • self care deficit (dressing/feeding/toileting)
  • acute/chronic pain
  • risk for injury
  • impaired physical mobility
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21
Q

primary headaches

A
  • migraine
  • tension
  • cluster
  • others
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22
Q

secondary headaches

A
  • head and/or neck trauma
  • infection
  • other
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23
Q

nursing care for headaches

A
  • “what’s up”
    W here is the pain
    H ow does the headache feel?
    A ggravating or alleviating factors
    T iming: when does it typically occur? how long does it last?
  • ask pt to rate severity
  • ask about other useful data
  • determine the pts perception of the headache
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24
Q

patient education for headaches

A
  • keep diary
  • record triggers, timing, symptoms
  • teach relaxation and stress reduction
  • teach about medications
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25
Q

seizures

A
  • abnormal electrical discharges in the brain related to instability of neuronal cell membranes
  • classification:
    partial
    generalized
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26
Q

partial seizures

A

begin on one side of cerebral cortex

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27
Q

generalized

A

both hemispheres involved

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28
Q

etiology

A

idiopathic
acquired

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29
Q

idiopathic

A

no cause identified

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30
Q

acquired

A

underlying neurological disorder

brain injury

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31
Q

signs and symptoms of seizures: aura

A
  • visual distortion
  • odor
  • sound
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32
Q

partial seizures

A
  • automatisms
  • maintain consciousness
  • usually <1 minute
  • paresthesias
  • visual disturbances
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33
Q

complex partial

A
  • lose consciousness, 2-15 minutes
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34
Q

generalized seizures

A
  • absence (petit mal)
  • staring
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35
Q

tonic clonic

A

-m may have aura
- usually lose consciousness
- rigidity followed by muscle contraction and relaxation
- incontinence
- postictal period

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36
Q

diagnostic tests for seizures

A
  • eeg
  • look for underlying cause
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37
Q

therapeutic interventions for seizures

A
  • correct cause
  • anticonvulsant medication
  • surgical resection
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38
Q

emergency care with seizures

A
  • monitor airway
  • turn on side to prevent aspiration
  • pad side rails
  • prevent injury
  • do not restrain
  • suction as needed
  • observe and document
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39
Q

nursing diagnoses

A
  • risk for injury
  • risk for ineffective health management
  • risk for situational low self esteem related to negative perception of self worth due to perception of disease
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40
Q

status epilepticus

A
  • 30 minutes of continuous seizure activity
  • therapeutic interventions
  • ensure airway and oxygenation
  • administer diazepam or lorazepam
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41
Q

traumatic brain injury

A
  • trauma: hemorrhage, contusion, laceration
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42
Q

traumatic brain injury can cause

A
  • cerebral edema
  • hyperemia
  • hydrocephelus
  • brain herniation
  • death
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43
Q

etiology of traumatic brain injury

A
  • motor vehicle collision most common
  • falls
  • assaults
  • sports related injuries
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44
Q

mechanisms of injury

A
  • acceleration
  • deceleration
  • acceleration-deceleration
  • rotational
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45
Q

types of injury

A

concussion
contusion

46
Q

hematoma

A

subdural
epidural

47
Q

diagnostic tests for TBi

A

ct scan
MRI
neuropsychological testing

48
Q

therapeutic interventions

A
  • surgical removal of hematoma
  • control increased ICP
  • therapeutic coma
49
Q

ways to control increased ICP

A

icp monitoring
osmotic diuretic
mechanical ventilation

50
Q

complications of TBI

A
  • brain herniation
  • diabetes insipidus
  • acute hydrocephalus
  • labile vital signs
  • ptsd
  • cognitive and personality changes
51
Q

Nursing diagnoses

A
  • ineffective cerebral tissue perfusion
  • ineffective airway clearance
  • ineffective breathing pattern
  • risk for acute confusion
  • self care deficit
  • acute/chronic pain
  • disturbed sensory perception
  • impaired physical mobility
  • risk for injury
52
Q

brain tumor: pathophysiology

A
  • neoplastic growth of the brain or meninges
  • primary or metastatic
  • compress or infiltrate brain tissue
  • cause increased ICP
53
Q

signs and symptoms of brain tumor

A
  • seizures
  • motor and sensory deficits
  • headaches
  • speech and vision disturbances
  • personality changes
  • hormone disturbances
54
Q

diagnosis for brain tumors

A
  • mri
  • angiogram
  • magnetic resonance angiogram
  • hormone levels
55
Q

therapeutic interventions for brain tumor

A
  • surgical removal
  • radiation therapy
  • chemotherapy
  • symptom control
56
Q

symptom control for brain tumors

A

anticonvulsants
steroids

57
Q

complications of brain tumor

A
  • seizures
  • headaches
  • memory impairment
  • cognitive changes
  • ataxia
  • hemiparesis
  • aphasia
  • lethargy
  • coma
  • death
58
Q

nursing diagnoses for brain tumors

A
  • risk for acute or chronic confusion
  • self care deficit
  • acute or chronic pain
  • risk for injury secondary to disturbed sensory perception
  • impaired physical mobility
  • risk for injury
59
Q

intracranial surgery: indications

A
  • hematoma
  • tumor
  • arteriovenous malformation
  • trauma
  • seizures
60
Q

types of intracranial surgery

A
  • craniotomy (skull removal)
  • craniectomy (put bone back)
  • cranioplasty (metal/titanium plate)
61
Q

preoperative care for intracranial surgery

A
  • patient education
  • anxiety management
  • intensive care unit visit
62
Q

postoperative nursing diagnoses

A
  • risk for ineffective cerebral tissue perfusion
  • risk for infection
  • disturbed body image
  • deficient knowledge
63
Q

herniated disk: pathophysiology

A
  • herniation of nucleus pulposus
  • compression of nerve root(s)
  • cervical, lumbar most common
64
Q

herniated disk: etiology

A
  • injury
  • may be unknown
65
Q

signs and symptoms of herniated disk

A
  • pain
  • muscle spasm
  • numbness or tingling of extremity
  • weakness
  • atrophy
66
Q

diagnostic tests for herniated disk

A

mri
myelogram

67
Q

herniated disk: therapeutic interventions

A
  • rest
  • physical therapy
  • traction
  • muscle relaxants
  • NSAIDs, analgesics
  • epidural anesthetic/steroid caution excessive use
  • surgery
68
Q

types of surgery for herniated disks

A
  • laminectomy
  • diskectomy
  • spinal fusion
  • artificial disk
69
Q

complications of surgery

A
  • hemorrhage
  • nerve root damage
  • reherniation
  • herniation of another disk
70
Q

preoperative care for herniated disks

A

routine teaching
teach log rolling technique

71
Q

postop nursing diagnoses for herniated disks

A

acute pain

impaired urinary elimination

impaired physical mobility

72
Q

pathophysiology of spinal cord injuries

A
  • damage to nerve fibers
  • interference w/ communication between brain and body
73
Q

causes of spinal cord injuries

A
  • mvc’s
  • falls
  • sports injuries
  • assault
74
Q

signs and symptoms of cervical injury

A
  • paralysis
  • paresthesias
    0 impaired respiration
  • loss of bladder and bowel control
  • quadriplegia/paresis
  • c3 or above fatal
75
Q

signs and symptoms of thoracic/lumbar injury

A
  • paraplegia/paresis
  • altered bowel and bladder control
76
Q

spinal shock: sympathetic nervous system disruption

A
  • vasodilation
  • hypotension
  • bradycardia
  • hypothermia
  • urine and feces retention
77
Q

diagnostic tests for spinal cord injury

A
  • x ray
  • ct scan
  • mri
78
Q

emergency management for spinal cord injuries

A
  • respiratory
  • gastrointestinal
  • genitourinary
  • immobilization
79
Q

surgical management of spinal cord injuries

A

stabilize spine
- halo brace
- rods
- corset
- brace
- body cast

80
Q

nursing diagnoses for spinal cord injuries

A
  • impaired gas exchange
  • ineffective airway clearance
  • risk for autonomic dysreflexia
  • reflex urinary incontinence
  • constipation
  • impaired physical mobility
  • self care deficit
  • risk for impaired skin integrity
  • ineffective role performance
  • risk for sexual dysfunction
  • anxiety
81
Q

dementia

A
  • significantly impaired intellectual functioning
  • impaired normal activities and relationships
  • impaired problem solving and emotional control
  • personality changes
  • behavioral problems
82
Q

dementia etiology

A
  • Huntington disease
  • Parkinson disease
  • Alzheimer disease
  • vascular dementia
  • chronic alcoholism
  • medications
83
Q

lower risk for dementia

A
  • higher education
  • higher socioeconomic status
  • engagement in simulating intellectual and leisure activities
84
Q

dementia signs and symptoms

A
  • recent memory affected first
  • remote memory affected later
  • forget how to perform simple tasks
  • wandering
  • aphasia
  • behavioral problems
  • total dependence
85
Q

diagnostic tests for dementia

A
  • neuropsychological testing
  • depression testing
  • medication review
  • MRI, CT scan, positron emission tomography (PET) scan for underlying cause
86
Q

therapeutic interventions for dementia

A
  • medications
  • end of life decision making
87
Q

types of medications that delay dementia progression

A
  • cholinesterase inhibitors
  • n methyl d aspartate (NMDA) agonist
88
Q

nursing diagnoses for dementia

A
  • risk for injury
  • imbalanced nutrition
  • chronic confusion
  • risk for caregiver role rstrain
89
Q

delirium

A
  • temporary mental disturbance
  • medical emergency
  • underlying cause must be corrected
90
Q

some causes of delirium

A
  • pain
  • hypoxia
  • medications
  • illness
91
Q

parkinson disease

A
  • destruction of substantia nigra
  • decreased dopamine production
  • relative excess of acetylcholine
  • impairment of semiautomatic movements
92
Q

parkinson disease etiology

A
  • unknown
  • genetic
  • certain drugs
  • encephalitis
93
Q

signs and symptoms of parkinson disease

A
  • muscular rigidity
  • bradykinesia
  • change in posture
  • pill rolling tremor
  • difficulty initiating movement
  • shuffling and freezing gait
  • masklike facial expression
  • soft voice
  • drooling, dysphagia
  • hand tremors at rest
  • constipation
  • frequent urination
  • flexion of knees an hips shifts center of gravity forward
94
Q

symptoms of autonomic nervous system dysfunction

A
  • diaphoresis
  • constipation
  • orthostatic hypotension
  • drooling
  • dysphagia
  • seborrhea
  • frequent urination
95
Q

diagnostic tests for parkinson disease

A
  • history
  • physical examination
  • MRI
96
Q

therapeutic interventions for parkinson disease

A
  • dopamine agonist
  • monoamine oxidase b inhibitors
  • catechol o methyltransferase (COMT) inhibitor
  • pallidotomy
  • deep brain stimulation
97
Q

nursing diagnoses

A
  • impaired physical mobility
  • self care deficit
  • risk for injury
  • also diagnoses for dementia
98
Q

pathophysiology/etiology

A

genetic
- autosomal dominant
- degeneration of parts of brain

99
Q

signs and symptoms of huntington’s disease

A
  • personality changes
  • inappropriate behavior
  • paranoia
  • violence
  • choreiform movements
  • dysphagia
  • depression
  • death
100
Q

diagnostic tests for Huntington’s

A
  • family history
  • mri
  • ct scan
  • genetic testing
  • counseling
101
Q

therapeutic interventions

A
  • antipsychotics
  • antidepressants
  • antichoreic agents
  • stem cell transplants: experimental
102
Q

pathophysiology of Alzheimer’s disease

A
  • progressive degenerative disease
  • neurofibrillary tangles
  • neuritic plaques
103
Q

etiology of alzheimer disease

A
  • unknown
  • may be genetic
  • down syndrome
104
Q

signs and symptoms of alzheimer’s: stages

A

stage 1
stage 2
stage 3

105
Q

stage 1of alzheimer’s

A
  • increasing forgetfulness
106
Q

stage 2 of alzheimer’s disease

A
  • progressive memory loss
  • irritability
  • depression
  • aphasia
  • sleep disruption
  • hallucinations
  • seizures
107
Q

stage 3 of alzheimer’s disease

A
  • complete dependency
  • bowel and bladder control lost
  • emotional control lost
  • inability to recognize significant others
  • death
108
Q

diagnostic tests for Alzheimer’s

A
  • history
  • physical examination
  • MRI
  • PET scan, single photon emission computed tomography (SPECT) scan
  • autopsy
109
Q

therapeutic interventions for Alzheimer’s

A
  • cholinesterase inhibitors
  • NMDA antagonists
  • antidepressants
  • antipsychotics
  • antianxiety agents
110
Q

nursing diagnoses for Alzheimer’s

A
  • risk for injury
  • imbalanced nutrition
  • chronic confusion
  • risk for caregiver role strain
111
Q

the LPN will…

A
  • promote positive self esteem of client
  • promote a therapeutic environment
  • assist in the care of the cognitively impaired client
  • provide care to immobilized client based on need
  • evaluate client oxygen saturation
  • participate in staff education

PNC 103 lecture (31 decks)

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