Exam 2 Flashcards
B.E. F.A.S.T
Balance issues
Eye changes
Facial drooping
Arm weakness
Slurred speech
Time to call 911
What do you need to teach family members if their loved one is having a stroke?
teach family member to take note of when the symptoms start
What foods to avoid when on anticoag therapy
foods high in vitamin K
What do thrombolytics do?
dissolve clots; they are clot busters
GI Bleeding
GU Bleeding
Intracranial bleeding
Allergic RXN
BP
Arrhythmias
Ecchymosis
Flushing
N/V
Hemoptysis
Nose/Gums bleeds
are all S/E of what?
Thrombolytics
S/E of thrombolytics
GI Bleeding
GU bleeding
Intracranial bleeding
Allergic RXN
BP
Arrhythmias
Ecchymosis
Flushing
N/V
Hemoptysis
Nose/gum bleeds
What is the antidote for thrombolytics?
Amicar
or
Amnicaproic Acid
Amicar or Amnicaproic Acid is the antidote for what?
thrombolytics
What to check before administering thrombolytics
weight
PT/INR
PTT
HGB/HCT
plt
CT (what kind of stroke it is. Do not give if hemorrhagic)
order-have a 2 person witness
BP-do not give if BP is uncontrolled
Interventions for Dysphagia and Aspiration
- Implement aspiration precautions
- Assess gag reflex, if present try sip of water
- Order speech consult to do swallow study
- Adhere to prescribe liquid consistency regimen
- RN should provide initial feeding
- Educate: sit upright, head forward when swallowing to decrease risk of choking
Interventions for Unilateral neglect
- observe affected side for injury
- Apply arm sling of a client cannot remember to care for affected arm
- ensure foot rest is on wheelchair
- Education: dress affected side first, use unaffected hand to pull affected extremity to midline for protection
Interventions for Constipation
- Assess abdomen for bloating and tenderness
- Implement bowel training program
- Administer stool softeners PRN
- Administer laxatives PRN
- Education: increase fluid intake (if no swallowing deficits), fiber intake, and movement
Interventions for Urinary Incontinence
- Palpate bladder for distention
- Anticipate foley catheterization
- Implement bladder training program
- Education: Teach kegel exercise, or pelvic muscle exercise
____________ is the main nursing diagnosis for a stroke unless neurological deficits worsen. As patient weakens and LOC decreases ____________ becomes the main priority
Ineffective cerebral tissue perfusion
Airway patency
Bladder training interval times
Gradually increase time between voiding by 15-min intervals. Start with every 2 hours while awake, then increase as tolerated. At night, go when you feel the need.
modifiable
Risk factors for a stroke
- HTN
- Atherosclerosis
- History of DVT
- Diabetes Mellitus
- Stress
- Obesity
- Cigarette smoking
- Hypercholesterolemia
- Oral Contraceptive use
- Illicit drug use
All of the following are risk factors for what?
- HTN
- Atherosclerosis
- History of DVT
- Diabetes Mellitus
- Stress
- Obesity
- Cigarette smoking
- Hypercholesterolemia
- Oral Contraceptive use
- Illicit drug use
modifiable
a stroke
non-modifiable
risk factors of a stroke
- Age > 55
- Gender
- Race: Mexican Americans, Latin Americans, African Americans, Japanese, and Chinese are at higher risk for hemorrhagic stroke
All of the following are risk factors for what?
- Age > 55
- Gender
- Race: Mexican Americans, Latin Americans, African Americans, Japanese, and Chinese
A stroke
Left hemisphere stroke assessment findings
- Aphasia; both expressive and receptive
- Impaired L/R discrimination
- Agnosia
- Alexia
- Agraphia
- R-sided hemiplegia and hemiparesis
- Depression, anxiety, quick to become angered or frustrated
- Hemianopsia
Think Left = Language
Assessment findings for right hemisphere stroke
- Altered perception of deficits (they think they can do more than they can)
- Unilateral neglect syndrome (ignore left side of the body – they cannot see, feel, or move that side so they are unaware it exists)
- Loss of depth perception
- Poor impulse control and judgement
- Impaired time concepts
- Left Hemiplegia or hemiparesis
- Hemianopsia
Think Right = Reckless
All of the following are assessment findings for what?
- Altered perception of deficits (they think they can do more than they can)
- Unilateral neglect syndrome (ignore left side of the body – they cannot see, feel, or move that side so they are unaware it exists)
- Loss of depth perception
- Poor impulse control and judgement
- Impaired time concepts
- Left Hemiplegia or hemiparesis
- Hemianopsia
Right hemisphere stroke
Think right = reckless
All of the following are assessment findings for what?
- Aphasia; both expressive and receptive
- Impaired L/R discrimination
- Agnosia
- Alexia
- Agraphia
- R-sided hemiplegia and hemiparesis
- Depression, anxiety, quick to become angered or frustrated
- Hemianopsia
Left hemisphere stroke
Think Left = language
If a patient with a hemorrhagic stroke is is experiencing hypotension what needs to be done?
HCP needs to be notified ASAP
ACE Inhibitors
Suffix, Example, Action, S/E, NI
- -Pril
- Enalapril
- Prevents vasoconstriction
- S/E: Angioedema, cough, increased K, hypotension
- NI: Monitor for S/E, K, BP, Pulse
Beta Blockers
Suffix, Example, Action, S/E, NI
- -lol/-olol
- atenolol
- Blocks the effect of epinephrine at the receptor site
- S/E: Bradycardia, dizziness, hypotension, hyperglycemia
- NI: Do not give to pt with asthma. Monitor glucose, BP, pulse
Calcium Channel Blockers
Suffix, Example, Action, S/E, NI
- -pine, -amil, -zem
- Amlodipine, cardiazem, verapamil
- prevents calcium ion movement across cell membranes
- S/E: orthostatic hypotension, dizziness, bradycardia
- NI: Monitor BP and pulse, educate pt to change positions slowly
Diuretics
Suffix, Example, Action, S/E, NI
- -semide or -thiazide
- furosemide, HCTZ
- Promotes diuresis which in turn promotes NA and fluid loss
- S/E: Decreased K, NA, and BP
- NI: Monitor BP, pulse, ECG, electrolytes
What type of medication is this?
- -lol/-olol
- atenolol
- Blocks the effect of epinephrine at the receptor site
- S/E: Bradycardia, dizziness, hypotension, hyperglycemia
- NI: Do not give to pt with asthma. Monitor glucose, BP, pulse
Beta Blockers
What type of medication is this?
- -Pril
- Enalapril
- Prevents vasoconstriction
- S/E: Angioedema, cough, increased K, hypotension
- NI: Monitor for S/E, K, BP, Pulse
ACE Inhibitors
What type of medication is this?
- pine, -amil, -zem
- Amlodipine, cardiazem, verapamil
- prevents calcium ion movement across cell membranes
- S/E: orthostatic hypotension, dizziness, bradycardia
- NI: Monitor BP and pulse, educate pt to change positions slowly
Calcium Channel Blockers
What type of medication is this?
- -semide or -thiazide
- furosemide, HCTZ
- Promotes diuresis which in turn promotes NA and fluid loss
- S/E: Decreased K, NA, and BP
- NI: Monitor BP, pulse, ECG, electrolytes
Diuretics
Purpose of a CT for stroke patients
Used to detect intracranial hemorrhage, space occupying masses, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, and shifts in the brain structures. Should be initial diagnostic test to determine if tPA is needed. Door to CT time is 25 mins, Door to CT results time is 45 mins
Door to CT time
25 mins
Door to CT results
45 mins
What type of stroke is this?
Occurs d/t plaque build up in the vessel walls, and eventually the blood can not get through. Onset is gradual
Ischemic Stroke
What type of stroke is this?
Symptoms gradually worsen as occlusion worsens, usually over a period of several hours to days
Thrombolic
type of ischemic stroke
What type of stroke is this?
Instant onset of S/S or instant loss of consciousness
Embolic
type of ischemic stroke
What type of stroke is this?
think clot causes vessel to ruptured cerebral aneurysm. Poor prognosis d/t ischemia and increasing ICP; ICP is increasing d/t accumulating blood in the brain. Prognosis can improve by surgery to remove the clot and stop the bleed. Do not use Thrombolytics or Anticoags
Hemorrhagic
What Lobe is this?
Smell, speech, concentration, planning, problem solving, motor control. Contains Broca’s area.
Frontal Lobe
What lobe is this?
Touch, pressure, taste, body awareness, language, and reading.
Parietal lobe
What lobe is this?
Hearing, facial recognition, language, and reading. Also contains Wernicke’s area. Contains Hippocampus which is responsible for learning and memory.
Temporal lobe
What lobe is this?
Vision, language, and reading
Occipital lobe
What lobe of the brain controls this?
Coordination
Cerebellum
either the right or the left side of the brain. Remember it is the clients right or left.
Hemisphere
pt can understand what is being said but is unable to communicate verbally. Damage occurs in the Broca’s area of the frontal lobe
expressive aphasia
pt is unable to understand the spoken and often written word. Damage occurs in the Wernicke’s area in the temporal lobe.
Receptive aphasia
Dysfunction occurs in expression and reception
Global Aphasia
A stroke symptom
unable to recognize familiar objects
Agnosia
A stroke symptom
difficulty reading
Alexia
A stroke symptom
difficulty writing
Agraphia
A stroke symptom
paralysis
Plegia
A symptom of a stroke
one-sided paralysis
Hemiplegia
A stroke symptom
Weakness
Paresis
A stroke symptom
one-sided weakness
Hemiparesis
A stroke symptom
loss of half of the field of vision in one eye or both eyes
Hemianopsia
A stroke symptom
loss of vision in the same half of the visual field of each eye
Homonymous Hemianopsia
A stroke symptom
The bodys ability to sense it’s location, movements, and actions
Propriception
A stroke symptoms
Impaired balance or coordination
ataxia
A stroke symptom
Difficulty swallowing
dysphagia
A stroke symptom
difficulty or inclear articulation (garbled speech)
Dysarthria
A stroke symptom
inability to execute skilled movement or gestures despite having the ability and desire to preform them
Apraxia
What do you need to teach patients who have hemianopsia
Turn head from side to side to compensate for the loss of vision
LOC
awake with appropriate speech and behavior
Conscious
LOC
Disorientation, bewilderment, difficulty following commands
Confusion
LOC
Sleepiness; slow and delayed response to stimulus
Lethargic
LOC
somnolence with drowsiness between sleep states, lessened interest in the environment, slowed responses to stimulation.
Obtundation
LOC
minimal movement without stimulus; requires strong vigorous stimulus and then drifts back to unresponsiveness.
Stupor
LOC
Not arousable
Coma
What mode of conlifct resolution is this?
- Unassertive
- Uncooperative
- Do not pursue their own needs, goals or concerns
- Do not assist other to pursue theirs
- Postpone dealing with issues
Avoidance
What mode of conflict resolution is this?
- Neglect their own needs, goals or concerns while trying to satisfy those of others
- Obeys and serves others
- Feels resentment and disappointment because they “get nothing in return”
Accommodation
What mode of conflict resolution is this?
- Pursue their own needs and goals at the expense of others
- Stands up for right
- Defends important principles
Competition
What mode of conflict resolution is this?
- Assertive
- Cooperative
- Works creatively and openly to find solutions that satisfies most all-important objectives and goals
Compromise
Action: affects serotonin, norepinephrine and dopamine
Classification: SNRI & DNRI / Antidepressant
S/e:
* Headache
* Dizziness
* Vertigo
* Photosensitivity
* Agitation/tremors
* Insomnia
* Dry mouth/ thirst
* Dehydration
* Constipation
Cymbalta (Duloxetine)
Nursing interventions for cymbalta
Duloxetine
Monitor BP , appetite and nutritional intake
Assess sexual dysfunction before taking medication
Asses for Serotonin syndrome
Educate family/patient on importance of adherence to medication
Advise patient to change position slowly d/t orthostatic Hypotension.
Notify pcp of any attacks , insomnia or worsening depression
Action: binds to calcium channel in CNS tissue which regulate neurotransmitter release: does not bind to opioid receptors
Classification: Anticonvulsant, Analgesics
S/E:
* Vertigo
* PR interval prolongation
* Peripheral edema
* Dry mouth
* Abd pain
* Constipation
* N/v/D
* Thrombocytopenia
* Increase appetite
* Increased creatine kinase
* Sucidal ideation
* Angioedema
* Dizziness/drowsiness/headache
* Resp depression
Lyrica or Pregablin
Side effects of Cymbalta or Duloxetine
- Headache
- Dizziness
- Vertigo
- Photosensitivity
- Agitation/tremors
- Insomnia
- Dry mouth/ thirst
- Dehydration
- Constipation
- Nausea/diarrhea
Side effects of Pregabalin
- Vertigo
- PR interval prolongation
- Peripheral edema
- Dry mouth
- Abd pain
- Constipation
- N/v/D
- Thrombocytopenia
- Increase appetite
- Increased creatine kinase
- Sucidal ideation
- Angioedema
- Dizziness/drowsiness/headache
- Resp depression
Nursing interventions of Lyrica or Pregabalin
Monitor closely for note able changes in behavior
Assess pain location, characteristics, and intensity of pain during therapy
For seizures assess location , duration and characteristics
Instruct family to take medication as directed
Inform pt to report unexplained muscle pain, tenderness weakness.
Inform pt of weight gain and edema
Advise patient and family to notify HCP if thoughts of suicide or dying.
Action: inhibits mycobacteria’s cell wall synthesis and interferes with metabolism
Classification: Antituberculars
S/e:
* DRESS
* Toxic Epidermal Necrolysis
* Visual disturbances
* Gynecomastia
* Hepatoxicity
* N/V
* Peripheral neuropathy
* Psychosis/ seizures
* Fever
* Bloody dycrasias
isoniazid or Isotamine
Side effects of Isotamine or Isoniazid
- DRESS
- Toxic Epidermal Necrolysis
- Visual disturbances
- Gynecomastia
- Hepatoxicity
- N/V
- Peripheral neuropathy
- Psychosis/ seizures
- Fever
- Bloody dycrasias
Nursing interventions for Isoniazid or isotamine
Importance of medication adherence medication can be continued for 6 mo- 2 yr
Notify HCP of signs of Hepatitis (yellowing skin or eyes)
Caution pt to avoid alcohol.
Hepatic function should be evaluated prior to medication therapy (monthly)
Importance of regular follow up with pcp and ophthalmologist to monitor for s/e.
Monitor for symptoms of DRESS
If Isoniazid overdose occurs, antidote with pyridoxine( Vitamin B)
All of the following are S/E of what medication
- Vertigo
- PR interval prolongation
- Peripheral edema
- Dry mouth
- Abd pain
- Constipation
- N/v/D
- Thrombocytopenia
- Increase appetite
- Increased creatine kinase
- Sucidal ideation
- Angioedema
- Dizziness/drowsiness/headache
- Resp depression
Lyrica or pregabalin
All of the following are side effects of what medication
- Headache
- Dizziness
- Vertigo
- Photosensitivity
- Agitation/tremors
- Insomnia
- Dry mouth/ thirst
- Dehydration
- Constipation
- Nausea/diarrhea
Cymbalta of Duloxetine
All of the following are s/e of what medication
- DRESS
- Toxic Epidermal Necrolysis
- Visual disturbances
- Gynecomastia
- Hepatoxicity
- N/V
- Peripheral neuropathy
- Psychosis/ seizures
- Fever
- Bloody dycrasias
Isoniazid or isotamine
Action: binds to cell receptors enhancing the effects of GABA.
Classification: Benzodiazepine
S/e:
* Drowsiness/sedation
* Lightheadedness/ Dizziness/ Ataxia
* Visual disturbances
* Anger, restlessness
* N/D/ constipation
* Lethargy, Apathy, fatigue
* Dry mouth
* Weight gain
* Physical dependence/psychological dependence/ tolerance
Xanax or alprazolam
All of the following are side effects of what medication
- Drowsiness/sedation
- Lightheadedness/ Dizziness/ Ataxia
- Visual disturbances
- Anger, restlessness
- N/D/ constipation
- Lethargy, Apathy, fatigue
- Dry mouth
- Weight gain
- Physical dependence/psychological dependence/ tolerance
Xanax or alprazolam
Nursing interventions for xanax or alprazolam
Inform importance of medication adherence and do not stop abruptly
Advise pt to avoid grapefruit
Inform pt the use of other CNS and alcohol can cause resp depression
Inform pt medication is only for short term use
May cause drowsiness/dizziness, for older adults inform family how to reduce the risk of falls at home
May be administer with food if GI is upset
Assess degree of anxiety and mental status
Assess for risk of addiction
Monitor cbc and liver/renal function during therapy
FLUMAZENIL is antidote if toxicity is noticed
Antidote for xanax
Flumazenil
Flumazenil is the antidote for what?
xanax
How long can Isoniazid therapy last?
6 months to 2 yrs
Isoniazid or isotamine antidote
Pyridoxine or Vitamin B
Pyridoxine or Vitamin B is the antidote for what?
Isoniazid or Isotamine
7 levels of cognitive ability
Knowledge
Understanding
Applying
Analyzing
Synthesizing
Evaluating
Creating
7 Levels of cognitive ability
Know You’re Almost Always Saying Everything Correct
KUAASEC
K-knowledge
U-understanding
A-applying
A-analyzing
S-synthesizing
E-evaluating
C-creating
