Deck 3 Flashcards
A nurse is planning care for a client who had a stroke and is experiencing dysphagia. Which of the following actions should the nurse include inn the plan? (SATA)
*Have suction equipment available
*Eliminate distractions during mealtime
*Place food on the unaffected side of the client’s mouth
Inform the client to swallow with the neck flexed forward
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following actions should the nurse take?
left homonymous hemianopsia - left side of your vision is lost in both eyes- cannot see left side of anything
Place the client’s bedside table on the right side of the bed
A nurse is caring for a client who is receiving an IV infusion of alteplase for the management of a suspected ischemic stroke. Which of the following findings is an adverse effect of this medication?
Epistaxis (nose bleed)
In the field, (think motor vehicle accident) What are your top three priorities?
Assess Airway
Stabilize cervical spine (neck)
Hemodynamic status - watch for signs of spinal shock that could lead to neurogenic shock (brady and hypotensive)
Interventions for neurogenic shock
IV fluids first (0.9NS)
Pressors (levophed) for BP
Have two large bore IVs (fluids and levo each need their own line)
Atropine (for bradycardia)
What are catecholamines?
neurotransmitters and hormones from the sympathetic nervous system that help keep up our BP and HR
dopamine, norepinephrine, and adrenaline (epinephrine)
What are you at risk for with myelosuppression?
low red cells = anemia
low white cells = infection -sepsis - death
low platelets = bleeding
With DKA is your patient going to be hyperkalemic or hypokalemic?
● Initially, they’re going to be HYPERkalemic → metabolic acidosis initially results in hyperkalemia
The acidotic state releases potassium from the intracellular fluid resulting in hyperkalemia. Then you have polyuria, which dumps the K+ therefore resulting in hypokalemia later on
Monitor for arrhythmias
What is global aphasia?
Both receptive and expressive
receptive = trouble understanding
expressive = trouble speaking or writing
When you have a patient with global aphasia (receptive and expressive) Which interventions should you implement? SATA
Speak slowly to the client
Assist the client to use cards with pictures
Give instructions to the client one step at a time
Complications of a TBI (Traumatic Brain Injury)
Increased ICP due to possible arterial epidural hematomas, or venous subdural hematomas
SIADH(damage to pituitary=overexpression of ADH)
brain herniation
hydrocephalus (swelling).
What is your intervention if your patient’s ICP is 19?
Notify provider (normal range is 10-15)
Your patient’s BP is 272/190 and HR is 38, What is likely happening with this patient?
autonomic dysreflexia
Interventions for autonomic dysreflexia
SIT PATIENT UP
IVP hydralazine or Clonodine (BP)
possible atropine (HR)
What is the time window to administer TPA for an ischemic stroke?
3-4.5 hours
What are the typical interventions for increased ICP / TBI? (SATA)
Sit patient up if possible/raise head of bed
decrease noise level of surroundings
stool softeners (no straining)
Clinical Manifestations (S/S) of Sickle Cell
Abdominal pain
guarding abdomen
fever (103)
pale, yellow hard palette (breakdown of RBCs=Release of bilirubin)
pain (vascular occlusions happening all over body)
signs of ischemia in lower extremities
signs of vascular occlusion (ulcers)
**this can sometimes lead to amputations
What do you do if your patient’s ICP is 12?
Continue to monitor/document (normal)
Interventions for Back surgery that require hardware (laminectomy, discectomy, fusions)
AVOID TORSION (any twisting)
Log roll (with draw sheet)
place hands on shoulder and hip area
give adequate pain/spasm relief (pain meds)
TLSO (thoracic lumbar sacral orthosis) must be used
*advance diet slowly *(gastric motility is slow due to opioids)
stool softeners
describe addisonian crisis
body cannot keep up with stressful situation
adrenals fail and cannot produce stress hormones
(lack of cortisol, aldosterone, catecholamines)
Manifestations of Addisonian Crisis
cardiac collapse
hypoglycemia - r/t lack of cortisol
hyponatremia - r/t lack of aldosterone
hyperkalemia - r/t hyponatremia
dysrhythmias - r/t imbalance of potassium and sodium
widespread vasodilation (lack of aldosterone)
bradycardia (lack of catecholamines)
Adrenal Crisis is also known as…
Adrenal Insufficiency
HHNKS (hyperosmolar hyperglycemic nonketotic syndrome) or (HHS)
type 2 diabetes - has some insulin to get some glucose into cells but not enough- when these patients get sick - glucose levels go crazy
HHS pulls fluids out of cells into the vessels and you pee it out (think HHS has a similar mechanism of action as the drug Mannitol)
More dangerous than DKA
Clinical findings of HHNKS (HHS)
BG >600 ** significantly worse than DKA
Neuro decline - seizure, coma, death
polydipsia (excessive thirst)
hypotension
SLE (systemic lupus erythematosus)
autoimmune
Hypersensitivity 3 reaction
affects many parts of the body, including kidneys
requires lifelong immunosuppressants (steroids)
What is the normal range for platelets?
150,000-400,000
What happens with leukemia?
Uncontrolled growth (proliferation) of immature (useless) WBCs
These useless WBCs take up space leaving no room for healthy WBCs, platelets, or RBCs - leading to myelosuppression
How are clotting disorders diagnosed?
Blood Tests
Fibrinogen
Hemoglobin
PTT/APTT
platelet/thrombocyte count
clotting factors
Thrombocytopenia
low platelet count
What is loss of sympathetic tone?
synonymous with neurogenic shock (hypotension and Brady)
means the sympathetic nervous system is not working
no catecholamines
causing widespread vasodilation = hypotension
not enough stimulation to SA node = causing bradycardia
What is the treatment for neurogenic shock or (loss of sympathetic tone)
IV fluids
Pressor (possibly Levophed) for BP and HR
possibly atropine for HR
