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Adult Health Nursing II > Exam 3 > Flashcards

Exam 3 Flashcards

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1
Q

Normal Neurologic Changes with Aging

A

Loss of brain mass

Decreased dendrite connections

Decreased cerebral blood flow/oxygenation

Do not need as much sleep

Decreased thermoregulation

Fine motor skills decrease, tremors increase

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2
Q

Level of Consciousness

A

MOST ACCURATE AND RELIABLE INDICATOR OF NEUROLOGICAL STATUS

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3
Q

Alert

A

Responsive and oriented and alert, open eyes spontaneously

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4
Q

Disorientation

A

Cannot follow simple commands, flat affect

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5
Q

Incoherent

A

Disconnected thought and speech

Unrelated thoughts that don’t make sense

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6
Q

Lethargic

A

Delayed response to stimulation

Drowsy, but easily awakened

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7
Q

Stupor

A

When patient wakes up only with vigorous or painful stimulation

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8
Q

Coma

A

A prolonged state of unconsciousness, unable to arouse

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9
Q

Altered Level of Consciousness

A

Caused by neurological issues, drugs, metabolism

Initial S/S include restlessness and anxiety, progresses to no response to voice or command

Pupils sluggish and progress to fixed and dilated

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10
Q

Posturing

A

Indicates a deterioration of condition

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11
Q

Decorticate

A

Abnormal flexion and extension

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12
Q

Decerebrate

A

Abnormal extension

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13
Q

Flaccid

A

No motor response in any extremities

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14
Q

Altered LOC Treatment

A

Suction, assess lungs, give oxygen, position lateral/side-lying or semi-prone

Padded side rails, avoid restraints

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15
Q

Lumbar Puncture

A

Putting a hollow needle into the subarachnoid space

Sterile procedure performed at bedside in order to examine the CSF

Have patient lay on their side with knee and head flexed

Contraindications include increased ICP

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16
Q

Normal Cerebrospinal Fluid

A

Normal clear, colorless

WBC: 0-5 cells/microliters

RBCs: 0

Glucose: 50-75 mg/dL

Protein: 15-45 mg/dL

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17
Q

Abnormal Cerebrospinal Fluid

A

Cloudy indicates infection

Yellow indicates bilirubin

Pink indicates hemorrhage

Brown/orange indicates elevated protein levels or RBC breakdown

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18
Q

Monro-Kellie Hypothesis

A

A change in volume of one of the contents in the brain leads to a decrease in another, or else intracranial pressure will increase

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19
Q

Early Recognition of Increased Intracranial Pressure

A

Decreased cerebral perfusion

Change in level of consciousness, irritability, diplopia, nausea, headache, sluggish pupils

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20
Q

Complications of Increased Intracranial Pressure

A

Supratentorial shift

Herniation

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21
Q

Later Signs of Increased Intracranial Pressure

A

Increased systolic blood pressure, bradycardia, deepening irregular respirations

Increased temperature

Posturing, vomiting, hiccups, chocken corneal disk

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22
Q

Diagnostic Tests for Increased Intracranial Pressure

A

CT scan, MRI

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23
Q

Treatment of Increased Intracranial Pressure

A

Craniotomy, craniectomy, drainage, internal monitoring

Mannitol, corticosteroids, anticonvulsants, barbiturates, paralyzing agents

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24
Q

Craniotomy

A

Removing a bone flap from the skull which is eventually replaced

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25
Q

Craniectomy

A

Bone flap is removed and not replaced

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26
Q

Nursing Interventions for Increased Intracranial Pressure

A

VS with Neuro checks q1h/prn

Reduce venous volume by elevating HOB, neck in neutral position, avoid hip flexion, restrict fluids

Maintain patent airway

Maintain body temperature

Avoid exercise

Space nursing procedures

Seizure precautions should be instituted

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27
Q

Intracranial Surgery

A

Supratentorial, infratentorial, transsphenoidal

Burr holes

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28
Q

Cranioplasty

A

Repair of a cranial defect using a plastic or metal plate

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29
Q

Craniotomy Nursing Interventions

A

Maintain airway, assess frequently, look for signs of increased ICP, seizure precautions

Medications include phenytoin and phenytoin sodium

Align head in neutral position, HOB 30 degrees

Avoid coughing, sneezing, or nose blowing

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30
Q

Transsphenoidal Pre-Op

A

Sinus culture, corticosteroids, no nose blowing or coughing, no sucking through a straw

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31
Q

Transsphenoidal Post-Op

A

Check VS, visual acuity, keep HOB elevated

Provide good oral care due to breathing through the mouth, check for bleeding/CSF leakage

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32
Q

Complications of Transsphenoidal Surgery

A

Transient diabetes insipidus

CSF leakage

Visual disturbances, post-op meningitis

Pneumocephalus

Syndrome of Inappropriate Antidiuretic Hormone

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33
Q

Seizure

A

Abnormal electrical activity of brain cells

Can be caused by structural, metabolic, or idiopathic origin

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34
Q

Epilepsy

A

Recurrent episodes of seizures

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35
Q

Aura

A

Some kind of sensory change before a seizure occurs

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36
Q

Postictal Period

A

Rest period after a seizure, varies in time frame

Patient feels groggy and disoriented, common to experience headache, muscle aches

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37
Q

Status Epilepticus

A

Multiple seizures without a postictal period

Most often caused by sudden withdrawal of anti-seizure medications

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38
Q

Tonic-Clonic Seizures

A

Grand mal

Most common, bilateral movement of extremities, whole body is involved

Tonic is stiffening, clonic is jerking of extremities

Associated with an aura, postictal period, loss of consciousness, incontinence, biting of tongue

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39
Q

Absence Seizures

A

Petit Mal

More frequent during childhood and adolescence

No aura, no postictal period, does not last very long, no loss of consciousness

Sit upright and have a blank stare, might lose muscle tone

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40
Q

Modifiable Risk Factors for Cerebrovascular Disorders

A 
Hypertension
Cardiovascular disease
Elevated cholesterol or hematocrit
Obesity
Diabetes
Oral contraceptive use
Smoking and drug and alcohol use
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41
Q

Transient Ischemic Attack

A

Temporary focal loss of neurologic function caused by ischemia

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42
Q

Preventive Treatment and Secondary Prevention of TIA

A 
Healthy diet, exercise, prevention of periodontal disease
Carotid endarterectomy
Anticoagulant therapy
Antiplatelet therapy
"Statins"
Antihypertensive medications
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43
Q

Carotid Endarterectomy

A

Usually performed to remove atherosclerotic plaque that has significantly reduced the lumen of the artery

Symptoms in carotid disease are caused by a significant reduction in cerebral blood flow

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44
Q

Nursing Management of Carotid Endarterectomy

A

Assess pain and treat

Neuro checks every hour (cough/gag reflex, visual fields, motor/sensory integrity)

Assess patency of carotid artery by palpating temporal artery

VS hourly

Continuous EKG monitoring

Dressing check, HOB elevated, TCDB

Antiplatelet therapy

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45
Q

Watch for These After Carotid Endarterectomy

A

Hemiplegia/hemiparesis, pupil irregularity, aphasia

Difficulty breathing, stridor, tracheal deviation

Excessive bleeding from drains

Dysrhythmias, hypotension, hypertension

Cranial nerve injuries

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46
Q

Stroke

A

Sudden loss of function resulting from a disruption of the blood supply to a part of the brain

Ischemic (80-85%)
Hemorrhagic (15-20%)

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47
Q

Thrombotic Stroke

A

Cerebral thrombosis is a narrowing of the artery by fatty deposits called plaque

Plaque can cause a clot to form, which blocks the passage of blood through the artery

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48
Q

Embolic Stroke

A

An embolus is a blood clot or other debris circulating in the blood

When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood

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49
Q

Hemorrhagic Stroke

A

A burst blood vessel may allow blood to seep into and damage brain tissues until clotting shuts off the leak

Severe headache, early and sudden changes in LOC, vomiting

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50
Q

If blood flow to the brain is totally interrupted…

A

Neurologic metabolism altered in 30 seconds

Metabolism stops in 2 minutes

Cellular death occurs in 5 mintues

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51
Q

If adequate blood flow can be restored in less than 3 hours…

A

Less brain damage = less function loss

Area around dying cells are ischemic cells (penumbra)–target for reperfusion

Use of thrombolytics

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52
Q

Manifestations of Ischemic Stroke

A

Symptoms depend on the location and size of the affected area

Numbness or weakness of face, arm, or leg, especially on one side

Confusion or change in mental status

Trouble speaking or understanding speech

Difficulty in walking, dizziness, or loss of balance or coordination

Sudden, severe headache

Perceptual disturbances

53
Q

Medical Management of Acute Phase of Stroke

A

NIHSS assessment tool

Thrombolytic therapy

Elevate HOB

Maintain airway and ventilation

Continuous hemodynamic monitoring and neurologic assessment

54
Q

Nursing Management of Acute Phase of Stroke

A

Ongoing, frequent monitoring of all systems, including VS and neurological assessment (LOC, motor symptoms, speech, eye symptoms)

Monitor for potential complications, including musculoskeletal problems, swallowing difficulties, respiratory problems, and s/s of increased ICP and meningeal irritation

55
Q

Nursing Management After a Stroke

A

Focus on patient function, self-care ability, coping, and education regarding needs to facilitate rehabilitation

56
Q

Medical Management of Hemorrhagic Stroke

A

Control hypertension

CT scan, cerebral angiography, lumbar puncture

Supportive care

Bed rest with sedation

Oxygen

Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further breathing

57
Q

Nursing Management of a Hemorrhagic Stroke

A

Complete and ongoing neurological assessment

Monitor respiratory status and oxygenation

Patients with intracerebral or subarachnoid hemorrhage should be monitored in the ICU

Monitor fluid balance

58
Q

Collaborative Problems and Potential Complications of Stroke

A

Vasospasm

Seizures

Hydrocephalus

Rebleeding

Hyponatremia

59
Q

Myoclonic Seizures

A

Characterized by muscle jerking, no aura or postictal phase, no loss of consciousness

60
Q

Diagnosis of Epilepsy/Seizures

A

Blood tests

CT/MRI

EEG

61
Q

Medications for Epilepsy

A

Valium

Phenobarbital

Dilantin

62
Q

ADLs with Epilepsy/Seizures

A

Avoid driving for a specific period of time, avoid operating machinery or swimming

Promote a healthy lifestyle

Wear a medical alert bracelet

63
Q

Nursing Interventions during a Seizure

A

Never leave alone

Lower to floor and remove objects from area

Support and protect the head, turn to side if possible

Loosen clothing around the neck

Do not restrain the patient or pry open the jaw

64
Q

Patient Education for Epilepsy

A

Good oral hygiene–Dilantin can cause gingival hyperplasia

Avoid alcohol because it lowers the seizure threshold and interacts with antiseizure medication

For women, seizures may increase during menstruation and antiseizure medications may make birth control less effective

65
Q

Primary Headache

A

No organic cause identified

Migraines, cluster headaches, cranial arteritis

66
Q

Secondary Headache

A

Symptom associated with another organic cause

Brain tumor, aneurysm

67
Q

Migraine Headache

A

Unknown cause, Vascular type

Prodrome phase, aura phase, headache phase, recovery phase

68
Q

Cluster Headache

A

Named for a pattern of headaches

Caused by histamine or serotonin release

One-sided burning, sharp and steady pain, presents with watering of the eyes and nasal stuffiness

Tends to be more common in men

Steroids and opioids usually prescribed

69
Q

Headaches

A

Assess pain, stressors, anxiety

Can be caused by tyramine *(aged cheeses and cured meats), nitrates (cured meats), glutamates (Chinese food), vinegar, chocolate, yogurt, alcohol, caffeine

Tension headaches should not be given opioids

70
Q

Primary Injury–Head Trauma

A

Head is directly injured

Acceleration-Deceleration

Coup-Countrecoup

71
Q

Secondary Injury–Head Trauma

A

Occurs after the primary injury

72
Q

Epidural Hemorrhage

A

Life-threatening, arterial bleed

73
Q

Subdural Hemorrhage

A

Needs to be monitored, venous blood loss, not as fast as epidural

74
Q

Positive Glucose in Drainage

A

Indicates cerebrospinal fluid

75
Q

Signs/Symptoms of Head Trauma

A 
Headache
Nausea/Vomiting
Abnormal sensations
Loss of consciousness
Bleeding from ears or nose
Abnormal pupil size/reaction
Battle's Sign (discoloration behind ear; basilar fracture)
Raccoon eyes (basilar fracture)
76
Q

Nursing Interventions for Head Trauma

A

Stabilize cervical spine

Give mannitol, Dexamethasone

Monitor signs of bleeding

Control temperature

77
Q

Epidural Hematoma

A

Treatment is Burr holes

Post-Op: report CSF leak immediately, give quiet non-stimulating environment, check Neuro and VS frequently

78
Q

Neurologic Level of Spinal Cord Injury

A

Refers to lowest level at which sensory and motor function are intact

79
Q

Spinal Cord Trauma Complications

A

Loss of sensory/motor function

Areflexia (all neurological activity below area of injury is gone)

Neurogenic shock (ANS not working, all vital organs are affected due to decreased BP)

Hyperreflexia (abnormal CV response to stimulation that leads to high blood pressure)

Venous thrombosis

80
Q

Autonomic Dysreflexia

A

Medical emergency that can lead to seizures, stroke, and death

Caused by noxious stimuli below the spinal cord injury

Severe bradycardia, HTN, diaphoresis, dilated pupils, severe headache

Sit patient upright to lower BP

81
Q

Brain Tumor Causes

A

Mostly unknown but linked to radiation

82
Q

S/S of Brain Tumors

A

Caused by inflammation and compression

IICP, cerebral edema, headache, vision changes, cognitive changes, new onset seizure, focal neurologic signs, hyrocephalus

Altered pituitary function with hormonal effects

83
Q

Primary Brain Tumor

A

Originates from cells within the brain; rarely metastasizes

Gliomas: projecting tumors, difficult to remove

Meningiomas: encapsulated, slow growing, benign, compression

Acoustic Neuromas: grow slowly, loss of hearing, tinnitus, vertigo, benign

84
Q

Secondary Brain Tumor

A

Originate outside of the brain, twice as common as primary

Lung, breast, lower GI, pancreas, kidney, and skin

85
Q

Diagnosis and Treatment of Brain Tumors

A

Dx: CT, EEG, CSF analysis

Surgery: craniotomy/craniectomy

Radiation, chemotherapy

Corticosteroids to relieve headaches

Mannitol, anti-seizure medications

86
Q

Nursing Interventions for Brain Tumors

A

Assess LOC and headaches

Position upright to alleviate IICP

Aspiration precautions

Seizure precautions, do not stop anti-seizure medications

DVT precautions

87
Q

Pathophysiology of Parkinsonism

A

Chronic, progressive, degenerative disease

Onset at age 60, genetically linked, associated with exposure to different environmental factors

No cure, damage to dopamine producing cells

Can be drug-induced (anti-psychotics)

88
Q

Characteristic Features of Parkinsonism

A

Bradykinesia (slowed movements)

Rigidity (resistance to passive movement, leads to poor balance and shuffling gait, mask-like appearance)

Tremor (pill-rolling characteristic, may go away while sleeping but flare up with stress)

89
Q

Other Characteristics of Parkinsonism

A

Dysphagia, drooling

Postural instability, stooped over posture

Depression, dementia

Dysphonia

90
Q

Diagnosis of Parkinson’s Disease

A

H&P is used

Requires 2 S/S to diagnose

Diagnosis confirmed with positive response to Levodopa

91
Q

Treatment for Parkinson’s Disease

A

LEVODOPA

Drug holidays may be necessary due to disabling side-effects

Physical therapy to help maintain ADLs

Surgery: ablation to portion of brain responsible for rigidity and tremors; deep brain stimulation

92
Q

Nursing Interventions for Parkinson’s Disease

A

Mobility (learn how to walk erect, ROM to prevent contractures, frequent rest periods)

Nutrition (risk of choking/aspiration, give appetizing meals, easy to chew and swallow)

Elimination (promote fiber and fluids and stool softeneners)

Teach to keep active, take medications, and take small bites

93
Q

Huntington’s Disease

A

Chronic, progressive, degenerative disease

Premature death of cells in the basal ganglia, cortex, and cerebellum

Genetically-inherited, 50% chance of child having it if parent has it

94
Q

S/S of Huntington’s Disease

A

Chorea (abnormal, excessive, involuntary movements)

Facial movements (involves speech, chewing, swallowing; problems with aspiration and malnutrition)

Gait deterioration

Mental deterioration

Loss of bowel and bladder control

95
Q

Treatment for Huntington’s

A

Palliative treatment to control symptoms

Tetrabenazine is the only approved medication

Thiothixene HCL and Haloperidol are also used to block dopamine receptors

96
Q

Nursing Interventions for Huntington’s

A

Safe environment

Emotional support

High-calorie diet (4,000-5,000 calories/day)

Genetic counseling

97
Q

Pathophysiology of ALS

A

Loss of upper and lower motor neurons; degenerate in the brain and spinal cord

Death is within 2-6 years of diagnosis

Males affected more than females, occurs between ages of 40-70

No known cause or cure

98
Q

S/S of ALS

A

Weakness, difficulty speaking/swallowing, muscle wasting

Eventually muscle paralysis, respiratory failure

99
Q

Nursing Interventions for ALS

A

Exercise to decrease spasticity

Support cognitive/emotional functions

Diversional activities

Human companionship

Advanced care planning

Anticipatory grieving

100
Q

Meningitis

A

Inflammation of the membranes and the fluid space surrounding the brain and spinal cord

101
Q

Manifestations of Meningitis

A

Headache, fever, changes in LOC, behavioral changes, nuchal rigidity, positive Kernig’s sign, positive Brudzinki’s sign, and photophobia

102
Q

Diagnosis of Meningitis

A

Blood cultures, H&P, urine cultures

CT scan

Lumbar puncture (decreased glucose, increased protein and WBCs, cloudy appearance)

103
Q

Medical Management of Meningitis

A

Prevention by vaccination

Early administration of high doses of appropriate IV antibiotics for bacterial meningitis

Dexamethasone (treat inflammation)

Treatment for dehydration, shock, and seizures

Anti-epileptic medications

Droplet precautions

104
Q

Nursing Management of Meningitis

A

Frequent or continual assessment, including VS and LOC

Protect patient from injury r/t seizure activity or altered LOC

Monitor daily weight, serum electrolytes, urine volume, specific gravity, osmolality

Infection control precautions

Supportive care

105
Q

Autoimmune Neurologic Disorders

A

Multiple sclerosis

Myasthenia gravis

Guillain-Barre Syndrome

106
Q

Multiple Sclerosis

A

A progressive immune-related demyelination disease of the CNS

Frequently relapsing and remitting

107
Q

Clinical Manifestations of Multiple Sclerosis

A

Vary and have different patterns

Exacerbations and recurrences of symptoms including fatigue, weakness, numbness, difficulty in coordination, loss of balance, pain, and visual disturbances (diplopia)

108
Q

Medical Management of Multiple Sclerosis

A

CT scan

Disease-modifying therapies; interferon B-1a and interferon B-1b, glatiramer acetate, and IV methylprednisolone

Symptom management of muscle spasms, ataxia, fatigue, bowel and bladder control

109
Q

Major Goals for the Patient with Multiple Sclerosis

A 
Promotion of physical mobility
Avoidance of injury
Achievement of bowel and bladder continence
Promotion of speech and swallowing mechanisms
Improvement of cognitive function
Development of coping strengths
Improved home maintenance
Adaptation to sexual function
110
Q

Myasthenia Gravis

A

Autoimmune disorder affecting the myoneural junction

Antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses

111
Q

Manifestation of Myasthenia Gravis

A

Motor disorder

Initially symptoms involve ocular muscles, diplopia and ptosis

Weakness of facial muscles, swallowing and voice impairment (dysphonia), generalized weakness

112
Q

Medical Management of Myasthenia Gravis

A

Cholinesterase inhibitor (Mestinon)
Immunomodulating therapy
Plasmapheresis
Thymectomy

113
Q

Care of the Patient with Myasthenia Gravis

A

Energy conservation
Strategies to help with ocular manifestations
Prevention and management of complications and avoidance of crisis
Measures to reduce risk of aspiration
Avoidance of stress, infections, vigorous physical activity, high environmental temperatures

114
Q

Myasthenic Crisis

A

Result of disease exacerbation or precipitating event, most commonly a respiratory infection

Severe generalized muscle weakness with respiratory and bulbar weakness

Patient may develop respiratory compromise and failure

GIVE CHOLINESTERASE INHIBITOR

115
Q

Cholinergic Crisis

A

Caused by overmedication with cholinesterase inhibitors

Severe muscle weakness with respiratory and bulbar weakness

Patient may develop respiratory compromise and failure

GIVE ATROPINE AS ANTIDOTE

116
Q

Guillain-Barre Syndrome

A

Autoimmune disorder with acute attack of peripheral nerve myelin

Rapid demyelination may produce respiratory failure and ANS dysfunction with CV instability

Most often follows a viral infection

117
Q

Management of Myasthenic Crisis

A

Patient education in signs and symptoms of myasthenic crisis and cholinergic crisis

Ensuring adequate ventilation; intubation and mechanical ventilation may be needed

Measures to ensure airway and respiratory support

ABGS, serum electrolytes, I&O, and daily weight

If patient cannot swallow, NG feeding may be required

Avoid sedatives and tranquilizers

118
Q

Manifestations of Guillain-Barre Syndrome

A

Weakness, paralysis, paresthesias, pain, and diminished or absent reflexes starting with lower extremities and progressing upward

Bulbar weakness, cranial nerve symptoms, tachycardia, bradycardia, hypertension, or hypotension

119
Q

Medical Management of Guillain-Barre

A

Requires intensive care management with continuous monitoring and respiratory support

Plasmapheresis and IVIG are used to reduce circulating antibodies

Recovery rates vary, but most patients recover completely

120
Q

Care of the Patient with Guillain-Barre Syndrome

A

Ongoing assessment with emphasis on early detection of life-threatening complications of respiratory failure, cardiac dysrhythmias, and deep vein thrombosis

Monitor for changes in vital capacity and negative inspiratory force

Assess VS frequently or continuously, including continuous monitoring of ECG

121
Q

Collaborative Problems/Potential Complications of Guillain-Barre

A 
Respiratory failure
Autonomic dysfunction
Deep vein thrombosis
Pulmonary embolism
Urinary retention
122
Q

Cranial Nerve Disorders

A

Trigeminal neuralgia

Bells’ palsy

123
Q

Trigeminal Neuralgia

A

Condition of the 5th cranial nerve characterized by paroxysms of pain

Most commonly occurs in the 2nd and 3rd branches of this nerve; vascular compression ad pressure is the probable cause

Occurs more in the 50s and 60s and in women and people with MS

Pain can occur with any stimulation such as washing face, brushing teeth, eating, or a draft of air

Patients may avoid eating, neglect hygiene, and may isolate themselves

124
Q

Medical Management of Trigeminal Neuralgia

A

Antiseizure medications such as carbamazepine, gabapentin, phenytoin, or baclofen

Surgical treatment such as microvascular decompression of the trigeminal nerve, radiofrequency thermal coagulation, percutaneous balloon microcompression

125
Q

Nursing Interventions for Trigeminal Neuralgia

A

Pain prevention and treatment regimen

Avoidance of triggers

Measures to maintain hygiene

Strategies to ensure nutrition

Recognize and provide interventions to address anxiety, depression, and insomnia

126
Q

Bells’ Palsy

A

Facial paralysis due to unilateral inflammation of the 7th cranial nerve

Most patients recover completely in 3-5 weeks and this disorder rarely occurs

127
Q

Manifestations of Bells’ Palsy

A

Unilateral facial muscle weakness or paralysis with facial distortion, increased lacrimation, painful sensations in the face, may have difficulty with speech and eating

128
Q

Medical Management of Bells’ Palsy

A

Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder

129
Q

Nursing Management of Bells’ Palsy

A

Provide and reinforce information and reassurance that stroke has not occurred

Protection of the eye from injury; cover eye with shield at night, instruct patient to close eyelid, use of eye ointment and sunglasses

Facial exercises and massage to maintain muscle tone

Adult Health Nursing II (22 decks)

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