EXAM 4 Flashcards

Question

What is pronator drift?

Answer 1

If there is a cerebral or brainstem reason for muscle weakness, the arm on the weak side will start to fall, or “drift,” with the palm pronating (turning inward).

Answer 2

a dorsiflexion of the great toe and fanning of the other toes, is abnormal in anyone older than 2 years and represents the presence of central nervous system (CNS) disease. POSITIVE (abnormal) which is "up going" of the toes. It can mean drug and alcohol intoxication, after a seizure, or in patients with multiple sclerosis or liver disease.

Answer 3

Hyperactive reflexes indicate possible upper motor neuron disease, tetanus, or hypocalcemia.

Answer 4

Hypoactive reflexes may result from lower motor neuron disease (damage to the spinal cord), disease of the neuromuscular junction, muscle disease, or health problems such as diabetes mellitus, hypothyroidism, or hypokalemia.

Answer 5

Face (symmetrical/ smile/ stick out tong) Arms (raise both equally) Speech (slurred?/ can they make a sentence? Recognition and recall) Time (window of time for intervention/ orientation x3) Time is brain cells. A tool used to recognize a stroke.

Answer 6

Ask the person to smile or stick out their tong. Ask the person to make a complete sentence. Ask the person to raise both arms.

Answer 7

``` Cerebral Spinal Fluid 10% Intravascular Blood 12% Brain Tissue 78% Skull ICP ```

Answer 8

 Arterial pressure  Venous pressure  Intraabdominal and intrathoracic pressure  Posture  Temperature  Blood gases (CO2 levels) • Cushing’s Triad increase pulse pressure (BP),decrease pulse, irregular respirations 10-15mm/Hg Elevated if greater than 20mm/Hg

Answer 9

Normal is 60-100mm Hg. | Less than 55mm Hg is associated with ischemia death.

Answer 10

Increase in CO2=vessel dilation=increased ICP. Decrease in O2=edema=increased ICP Hydrogen ion concentration= anaerobic metabolism: Acidosis= decrease in oxygen and Alkalosis= increased CO2

Answer 11

LIFE THREATNING. Increase in any of the following: Brain tissue/Blood/CFS and increased cerebral edema(caused by hypoxia)

Answer 12

Migraine: A migraine headache is a common clinical syndrome characterized by recurrent episodic attacks of head pain that serve no protective purpose. Migraine headache pain is usually described as throbbing and unilateral. Migraine can be accompanied by associated symptoms such as nausea or sensitivity to light, sound, or head movement. At risk for Stroke and epilepsy. Most common in women.

Answer 13

Generalized:may occur in adults and involve both cerebral hemispheres. The tonic-clonic seizure lasting 2 to 5 minutes begins with a tonic phase that causes stiffening or rigidity of the muscles, particularly of the arms and legs.

Answer 14

``` metabolic disorders Acute alcohol withdraw Electrolyte imbalance Heart disease High fever Stroke Substance abuse ```

Answer 15

``` Oxygen Suction equipment Airway IV access Side rails up and padded. ```

Answer 16

 Medication depends on type of seizure  Medication for tonic-clonic seizure activity may include:  Lorazepam (Ativan)  Diazepam (Valium)  Diastat  IV phenytoin (Dilantin) or fosphenytoin (Cerebyx)

Answer 17

```  Prolonged seizures that last more than 5 min or repeated seizures over course of 30 min – medical emergency!  Establish airway  ABGs  IV push lorazepam, diazepam  Rectal diazepam  Loading dose IV phenytoin ```

Answer 18

```  General symptom  Fever  Neurologic symptoms  Headache  Photophobia  Indications of increased ICP  Nuchal rigidity  Positive Kernig’s, Brudzinski’s signs  Decreased mental status  Focal neurologic deficits  GI symptoms  Nausea and vomiting ```

Answer 19

```  CSF analysis  CT scan  Blood cultures  Counterimmunoelectrophoresis  Polymerase chain reaction  CBC  X-rays to determine presence of infection ```

Answer 20

```  Broad-spectrum antibiotic  Hyperosmolar agents  Anticonvulsants  Steroids (controversial)  Prophylaxis treatment for those in close contact with meningitis-infected patient ```

Answer 21

A. Eating a balanced diet that includes lots of soy products can prevent Alzheimer’s disease. B. Cholinesterase inhibitor drugs such as donepezil (Aricept) can slow the progression of the disease. C. Removal of neuritic plaques can prevent vascular degeneration and improve brain cell function. D. Decreasing the levels of neurotransmitters in the brain can slow the progression of the disease.

Answer 22

A. Ensure that door locks can be easily opened by the patient. B. Take the patient out into crowds of people as often as possible. C. Vary times for meals, bedtime, and getting up in the morning. D. Place outfits on hangers, then allow the patient to choose what to wear.

Answer 23

A. Apraxia B. Aphasia C. Anomia D. Agnosia

Answer 24

A. Sertraline (Zoloft) B. Amitriptyline (Elavil) C. Imipramine (Tofranil) D. Desipramine (Norpramin)

Answer 25

A. “Enroll him in the Safe Return program.” B. “Have him wear an ID bracelet or badge at all times.” C. “Place him in a geri-chair when you can’t be with him.” D. “Ask your doctor to prescribe a sedative drug to keep him calm.” E. “Take him for a walk two or three times a day in different neighborhoods.”

Answer 26

A. “Can you return home sooner than 3 days?” B. “Why are you choosing to care for your cousin instead of your spouse?” C. “Your husband only has mild Alzheimer’s disease, so staying home alone is acceptable.” D. “There are organizations that may be able to provide an interim caretaker for your husband.”

Answer 27

is done to visualize the cerebral circulation to detect blockages in the arteries or veins in the brain, head, or neck. It remains the gold standard for the diagnosis of intracranial vascular disease and is required for any transcatheter therapy or for surgical intervention.

Answer 28

``` Informed consent Allergies Renal disease(liver failure) Diabetic Nephropathy HF Dehydration Old age NSAIDS/Metformin Contrast w/in 72 hours Kidney function ```

Answer 29

CT scanning is an accurate, quick, easy, noninvasive, painless, and least-expensive method of diagnosing neurological problems. CT scans distinguish bone, soft tissue (e.g., the brain, vascular system, and ventricular system), and fluids such as cerebrospinal fluid (CSF) or blood. Tumors, infarctions, hemorrhage, hydrocephalus, and bone malformations can also be identified. Claustrophobic (pre-procedure sedation) Remove hairpins/wigs/hair pieces. May feel warm cool sensation with contrast or metallic taste.

Answer 30

Magnetic resonance imaging (MRI or MR) has advantages over CT in the diagnostic imaging of the brain, spinal cord, and nerve roots. It does not use ionizing radiation but, instead, relies on magnetic fields. NO METAL. Some tattoos are lead based, so make sure to ask. Ask about metal implants.

Answer 31

Lumbar puncture (spinal tap) is the insertion of a spinal needle into the subarachnoid space between the third and fourth (sometimes the fourth and fifth) lumbar vertebrae. A lumbar puncture (LP) is used to: • Obtain cerebrospinal fluid (CSF) pressure readings with a manometer • Obtain CSF for analysis • Check for spinal blockage caused by a spinal cord lesion • Inject contrast medium or air for diagnostic study • Inject spinal anesthetics • Inject selected drugs Not recommended for SEVERE ICP.

Answer 32

``` Less than 20cm H2O pressure Clear and colorless 0-5 small lymphocytes 15-45mg/dl or proteins (up to 70 in older adults) 8:1 albumin/globulin ratio 50-75 or 60-70% glucose ```

Answer 33

Electroencephalography (EEG) records the electrical activity of the cerebral hemispheres. Hair is clean w/o hair products. Avoid sedative or stimulants w/in 12-24 hrs. Do not fast, can cause hypoglycemia. Ensure quite room with sign to ensure people know.

Answer 34

Electromyography (EMG) is used to identify nerve and muscle disorders as well as spinal cord disease. Especially used for MS and Mysthasia Gravis.

Answer 35

It is where all three, anterior,middle, and posterior arteries are joined together.

Answer 36

Pt will be in side-lying fetal position. Keep pt prone for 4-8hrs. Encourage fluid. Check for leakage. Ask about headache and notify position if persistent with medication.

Answer 37

Aged cheese or other foods with tyramine • Caffeine found in beverages such as coffee, tea, cola OR caffeine withdrawal • Chocolate • Foods with yeast such as pastry and fresh breads • Monosodium glutamate (MSG) • Nitrates (meats), pickled or fermented foods • Nuts • Artificial sweeteners • Smoked fish Stress/Fatigue/Anger/Conflict

Answer 38

* Cimetidine (Tagamet) * Estrogens * Nitroglycerin * Nifedipine (Procardia, Nifed )

Answer 39

``` Mild: Acetaminophen NSAIDS Severe: Triptan, Midrin and Ergotamine can cause rebound headaches Chronic: Botox Prevention: CCB Beta Blockers NSAIDS Antieptileptic drugs ```

Answer 40

Migraine with an aura (classic) Migraine w/o an aura (common) Atypical

Answer 41

1) Prodrome: • Aura develops over a period of several minutes and lasts no longer than 1 hour. • Pain may be preceded by: Visual disturbances Flashing lights Lines or spots Shimmering or zigzag lights • A variety of neurologic changes, including: Numbness, tingling of the lips or tongue Acute confusional state Aphasia Vertigo Unilateral weakness Drowsiness 2)• Headache is accompanied by nausea and vomiting. • Pain usually begins in the temple. It increases in intensity and becomes throbbing within 1 hour. 3)• Pain changes from throbbing to dull. • Headache, nausea, and vomiting usually last from 4 to 72 hours. (Older patients may have aura without pain, known as a visual migraine.)

Answer 42

• Migraine begins without an aura before the onset of the headache. • Pain is aggravated by performing routine physical activities. • Pain is unilateral and pulsating. • One of these symptoms is present: Nausea and/or vomiting Photophobia (light sensitivity) Phonophobia (sound sensitivity) • Headache lasts for 4 to 72 hours. • Migraine often occurs in the early morning, during periods of stress, or in those with premenstrual tension or fluid retention.

Answer 43

• Status migrainous: Headache lasts longer than 72 hours. • Migrainous infarction: Neurologic symptoms are not completely reversible within 7 days. Ischemic infarct is noted on neuroimaging. • Unclassified: Headache does not fulfill all of the criteria to be classified a migraine.

Answer 44

``` Yoga Meditation Massage Exercise Biofeedback Vitamin B12 (riboflavin) Coenzyme Q10 Magnesium supplement to maintain normal serum values have a role in migraine prevention. Acupuncture Herbal medication ```

Answer 45

Cluster headaches are manifested by brief (30 minutes to 2 hours), intense unilateral pain that generally occurs in the spring and fall without warning. It is classified as the most common chronic short-duration headache with pain lasting less than 4 hours. Typically in Men 20-50 years old. Neuroimaging studies suggest that cluster headaches are related to an overactive and enlarged hypothalamus. The headaches occur at about the same time of day for about 4 to 12 weeks (hence the term cluster), followed by a period of remission for 9 months to a year

Answer 46

Question the patient about prescribed drugs for both the prevention and relief of the headache, as well as OTC drugs and herbal preparations he or she may be taking. . Ask the patient to recall a typical week's activities and any recent changes in lifestyle. Explore the relationship of cluster headache onset with emotional and behavioral precipitating factors such as bursts of anger, prolonged anticipation, excessive physical activity, and excitement. Ask him or her to identify bedtimes and waking times to help assess changes in activity or lack of continuity in the sleep-wake cycle. The patient often paces, walks, or sits and rocks during an attack. The headache usually occurs with: • Ipsilateral (same side) tearing of the eye • Rhinorrhea (“runny nose”) or congestion • Ptosis (drooping eyelid) • Eyelid edema • Facial sweating • Miosis (constriction of pupils)

Answer 47

``` Consistent sleep-wake cycle Same medications a migraine PLUSE: Lithium Corticosteroids OTC civamide (a capsaicin isomer), available as a nasal spray Oral melatonin Oral glucosamine Wear sunglasses Sit away from window O2 12L via Mask for 15-20min For CHRONIC resistant to meds SURGERY LAST RESORT. ```

Answer 48

Partial: also called focal or local seizures, begin in a part of one cerebral hemisphere. They are further subdivided into two main classes: Complex partial seizures: may cause loss of consciousness (syncope), or “black out,” for 1 to 3 minutes. Simple partial seizure: remains conscious throughout the episode. In addition, some partial seizures can become generalized tonic-clonic, tonic, or clonic seizures. Partial seizures are most often seen in adults and generally are less responsive to medical treatment when compared with other types.

Answer 49

Unclassified, or idiopathic, seizures account for about half of all seizure activity. They occur for no known reason and do not fit into the generalized or partial classifications.

Answer 50

Secondary seizures result from an underlying brain lesion, most commonly a tumor or trauma. They may also be • Metabolic disorders • Acute alcohol withdrawal • Electrolyte disturbances (e.g., hyperkalemia, water intoxication, hypoglycemia) • Substance abuse • High fever • Stroke • Head injury Heart Disease

Answer 51

Prolonged seizure that lasts more than 5 minutes. Or repeated seizures over a course of 30min. MEDICAL EMERGENCY. Airway/ABGs/IV push diazepam, lorazepam/loading dose of IV phenytoin.

Answer 52

``` Fever Headache Photophobia ICP Nuchal rigidity + Kernigs/babinski signs Decreased mental status N/V ```

Answer 53

``` CSF analysis CT scan Blood cultures Counterimmunoelectrophoresis Polymerase chain reaction CBC X-ray Lumbar puncture ```

Answer 54

Broad-spectrum antibiotic Hyper-osmolor agents (mannitol) Steroids Prophylaxis treatment for those who were in close contact.

Answer 55

Meningitis is an inflammation of the meninges, specifically the pia mater and arachnoid. Bacterial and viral organisms are most often responsible for meningitis.

Answer 56

BACTERIAL VIRAL Appearance Cloudy,turbid Clear WBCs. Increased Increased Protein Increased Slightly increased Glucose Decreased Most often normal, but may be decreased CSFpressure Elevated Normal or elevated

Answer 57

``` ABC VS 2-4hr Manage pain Stay ontop of ordered drugs Routine labs Is&Os ROM q4hr Rotation to prevent bed sores Bed rest w/ HOB elevated 30 degrees ```

Answer 58

Encephalitis is an inflammation of the brain tissue and often the surrounding meninges. It affects the cerebrum, the brainstem, and the cerebellum. A viral agent most often causes the disease, although bacteria, fungi, or parasites may also be involved (e.g., malaria)

Answer 59

is a progressive neurodegenerative disease that is the one of the most common neurologic disorders of older adults. It is a debilitating disease affecting motor ability and is characterized by four cardinal symptoms: tremor, muscle rigidity, bradykinesia or akinesia (slow movement/no movement), and postural instability.

Answer 60

``` • Posture: Stooped posture Flexed trunk Fingers abducted and flexed at the metacarpophalangeal joint Wrist slightly dorsiflexed • Gait: Slow and shuffling Short, hesitant steps Propulsive gait Difficulty stopping quickly • Motor: Bradykinesia (slow movement) Muscular rigidity Akinesia Tremors “Pill-rolling” movement Masklike face Difficulty chewing and swallowing Uncontrolled drooling, especially at night Fatigue Difficulty getting into and out of bed Reduced arm swinging on one side of the body when walking Micrographia (change in handwriting or handwriting gets smaller) • Speech: Soft, low-pitched voice Dysarthria (slurred speech) Echolalia (automatic repetition of what another person says) and repetition of sentences Hypophonia (soft voice), change in voice volume or articulation • Autonomic dysfunction: Orthostatic hypotension Excessive perspiration Oily skin Seborrhea Flushing Changes in skin texture Blepharospasm (eyelid spasm) • Psychosocial assessment: Emotionally labile Depressed Paranoid Easily upset Rapid mood swings Impaired cognition (i.e., dementia or delirium) Delayed reaction time Sleep disturbances ```

Answer 61

Care of the Patient with Parkinson Disease • Allow the patient extra time to respond to questions. • Administer medications promptly on schedule to maintain continuous therapeutic drug levels. • Provide medication for pain, tingling in limbs, as needed. • Monitor for side effects of medications, especially orthostatic hypotension, hallucinations, and acute confusional state (delirium). • Collaborate with physical and occupational therapists to keep the patient as mobile and as independent as possible in ADLs. • Allow the patient time to perform ADLs and mobility skills. • Implement interventions to prevent complications of immobility, such as constipation, pressure ulcers, and contractures. • Schedule appointments and activities late in the morning to prevent rushing the patient, or schedule them at the time of the patient's optimal level of functioning. • Teach the patient to speak slowly and clearly. Use alternative communication methods, such as a communication board. Refer to speech-language pathologist. • Monitor the patient's ability to eat and swallow. Monitor actual food and fluid intake. Collaborate with the dietitian. • Provide high-protein, high-calorie foods or supplements to maintain weight. • Recognize that Parkinson disease affects the patient's body image. Focus on the patient's strengths. • Assess for depression and anxiety. • Assess for insomnia or sleeplessness.

Answer 62

Dementia is a loss of brain function that is chronic and progressive. Dementia affects the ability to learn new information. It also impairs language, judgment, and behavior.

Answer 63

``` Memory • Communication and language • Attention span or ability to focus and pay attention • Reasoning and judgment • Visual perception ```

Answer 64

Huntington disease (HD) is a hereditary disorder transmitted as an autosomal dominant trait at the time of conception. HD is called an autosomal dominant disorder because only one copy of the defective gene, inherited from one parent, is necessary to produce the disease. This movement disorder causes both neurologic and behavioral symptoms that usually begin between the ages of 30 and 50 years and worsen during the next one to two decades. Patients typically die from pneumonia, heart failure, or other complication of immobility.

Answer 65

``` Changes in support structures: Spinal Stenosis Hypertrophy of the intraspinal ligaments Osteoarthritis Osteoporosis Changes in vertebral support and malalignment: Scoliosis Lordosis Vascular changes: Diminished blood supply to the spinal cord or cauda equina Blood dyscrasias ```

Answer 66

Good posture Proper lifting Excersize Ergonomics Equipments that can be used (I.E. LIFTS) • Use safe manual handling practices, with specific attention to bending, lifting, and sitting. • Assess the need for assistance with your household chores or other activities. • Participate in a regular exercise program, especially one that promotes back strengthening, such as swimming and walking. • Do not wear high-heeled shoes. • Use good posture when sitting, standing, and walking. • Avoid prolonged sitting or standing. Use a footstool and ergonomic chairs and tables to lessen back strain. Be sure that equipment in the workplace is ergonomically designed to prevent injury. • Keep weight within 10% of ideal body weight. • Ensure adequate calcium intake. Consider vitamin D supplementation if serum levels are low. • Stop smoking. If you are not able to stop, cut down on the number of cigarettes or decrease the use of other forms of tobacco.

Answer 67

Nonsurgical conservative management of LBP includes positioning, drug therapy, physical therapy, weight control, and smoking cessation.

Answer 68

Williams position is typically more comfortable and therapeutic for the patient with LBP from a bulging or herniated disk. In this position, the patient lies in the semi-Fowler's position with a pillow under the knees to keep them flexed or sits in a recliner chair.

Answer 69

Patients having chronic low back pain (LBP) are treated with NSAIDs, opioids, and/or antidepressants (as adjunctive therapy)

Answer 70

Percutanious lumbar diskectomy Thermodiskectomy Laser-assisted laparoscopic lumbar diskectomy

Answer 71

Diskectomy Laminectomy Spinal fusion

Answer 72

``` Prevention/assessment of complications Neurologic assessment Vital signs Pt's ability to void Wound care CSF check Pt positioning/ mobility Discharge teaching: home care management/community resources ```

Answer 73

• Avoid lifting objects of more than 10 pounds without assistance or aid until the surgeon approves. • Push objects rather than pull them. • Do not twist your back during movement. • Use handles or grips to prevent unintended shifting of the object during movement. • Avoid prolonged sitting or standing. Use a footstool to lessen back strain. • Sit in chairs with good support. • Avoid shoulder stooping; maintain proper posture. • Do not walk or stand in high-heeled shoes for prolonged periods (for women).

Answer 74

• Establish an interdisciplinary team responsible for reviewing and implementing OSHA guidelines for the prevention of musculoskeletal disorders. Originally developed for nursing homes, these guidelines provide guidance for education and practice and programs for health care workers and other stakeholders involved in patient handling, transfers, and movement. • Build and support a culture of safety in health care settings that protects staff as well as patients from injury. • Improve communication channels among nurses, physical therapists, and family caregivers to facilitate safe patient handling and movement tasks. • Develop policies and procedures for the therapeutic use of patient handling equipment: Select equipment that first provides safety of patients, staff, and family caregivers. Train all staff and family caregivers in the proper and safe operation of all ergonomic-appropriate equipment. Encourage patient participation in the use of assistive equipment like sit and stand lifts that are used as an ambulation aid. • Develop competency-based assessments that demonstrate proficiency for use of all patient handling approaches and equipment. • Encourage quality improvement projects and research that support safe and effective patient handling and movement while maximizing patient-assisted or patient-independent movement. For example, investigate the cost-effectiveness of ergonomic interventions.

Answer 75

Cervical neck pain most often results from a bulging or herniation of the nucleus pulposus (HNP) in an intervertebral disk. The disk tends to herniate laterally where the annulus fibrosus is weakest and the posterior longitudinal ligament is thinned. The result is spinal nerve root compression with resulting motor and sensory manifestations, typically in the neck, upper back (over the shoulder), and down the affected arm. The disk between the fifth and sixth cervical vertebrae (C5-6) is affected most often.

Answer 76

1) HYPERFELXTION: injury occurs when the head is suddenly and forcefully accelerated forward. 2)HYPEREXTENSION injuries occur most often in vehicle collisions in which the vehicle is struck from behind or during falls when the patient's chin is struck.. The head is suddenly accelerated and then decelerated. 3) AXIAL LOADING (vertical compression) allow to the top of the head or jumping forcefully and landing hard. 4) ROTATION injuries are caused by turning the head beyond the normal range. 5) PENETRATING TRAUMA to the spinal cord is classified by the speed of the object (e.g., knife, bullet) causing the injury.

Answer 77

* Hemorrhage * Ischemia (lack of oxygen, typically from reduced/absent blood flow) * Hypovolemia (decreased circulating blood volume) * Impaired tissue perfusion form neurogenic shock (a medical emergency) * Local edema

Answer 78

Therefore the first priority for the patient with an SCI is to assess the patient's airway, breathing pattern, and circulation status. Indications for intra-abdominal hemorrhage/bleeding around fractured sights. LOC (Glascow's coma scale) Leavel of injury is the lowest neurologic segment with intact or normal motor and sensory function. Tetraplegia (also called quadriplegia) (paralysis) and quadriparesis (weakness) involve all four extremities, as seen with cervical cord and upper thoracic injury. Paraplegia (paralysis) and paraparesis (weakness) involve only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions.

Answer 79

Spinal shock, also called spinal shock syndrome, occurs immediately as the cord's response to the injury. The patient has complete but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks. NOT THE SAME AS NEUROGINIC SHOCK.

Answer 80

Bradycardia, hypotension, and hypothermia occur because of loss of sympathetic input. These changes may lead to cardiac dysrhythmias. A systolic blood pressure below 90 mm Hg requires treatment because lack of perfusion to the spinal cord could worsen the patient's condition.

Answer 81

Assess the patient's abdomen for manifestations of internal bleeding, distention, or paralytic ileus. Hemorrhage may result from the trauma, or it may occur later from a stress ulcer or the administration of steroids. Assess serum glucose levels to avoid complications from hypoglycemia and sustained hyperglycemia. Autonomic dysfunction initially causes an areflexic (neurogenic) bladder (no reflex ability for bladder contraction), which later leads to urinary retention. Assess for bladder distention and urine stasis.

Answer 82

1. Risk for respiratory distress/failure related to aspiration or diaphragmatic denervation (e.g., impaired phrenic nerve impulses in patients with cervical injury) 2. Potential for cardiovascular instability related to loss or interruption of sympathetic innervation or hemorrhage 3. Potential for secondary spinal cord injury related to hypoperfusion, edema, or delayed spinal column stabilization 4. Impaired Physical Mobility related to spinal compression and edema (NANDA-I) 5. Spastic or flaccid bladder and bowel related to direct neurologic damage or disruption in nerve impulses 6. Risk for Compromised Resilience from injury requiring need for life change (NANDA-I)

Answer 83

Monitor the patient with acute spinal cord injury at least hourly for: • Pulse oximetry (Spo2) <90% or symptoms of aspiration (e.g., stridor, garbled speech, or inability to clear airway) • Symptomatic bradycardia, including reduced level of consciousness and deceased urine output • Hypotension with systolic blood pressure (SBP) <90 or mean arterial pressure (MAP) <65 mm Hg Notify the physician immediately if these symptoms occur, because this problem is an emergency! Respiratory compromise from aspiration may be treated with intubation or bronchial endoscopy. Neurogenic shock is treated symptomatically by providing fluids to the circulating blood volume, adding vasopressor intravenous therapy, and providing supportive care to stabilize the patient.

Answer 84

The halo fixator is a static traction device. Four pins (or screws) are inserted into the skull. The metal halo ring may be attached to a plastic vest or cast when the spine is stable, allowing increased patient mobility.

Answer 85

Never move or turn the patient by holding or pulling on the halo device. Do not adjust the screws holding it in place. Check the patient's skin frequently to ensure that the jacket is not causing pressure. Pressure is avoided if one finger can be inserted easily between the jacket and the patient's skin. Monitor the patient's neurologic status for changes in movement or decreased strength. A special wrench is needed to loosen the vest in emergencies such as cardiopulmonary arrest. Tape the wrench to the vest for easy and consistent accessibility. Do not use sharp objects (e.g., coat hangers, knitting needles) to relieve itching under the vest; skin damage and infection will slow recovery.

Answer 86

• Be aware that the weight of the halo device alters balance. Be careful when leaning forward or backward. • Wear loose clothing, preferably with hook and loop (Velcro) fasteners or large openings for head and arms. • Bathe in the bathtub, or take a sponge bath. (Some physicians allow showers.) • Wash under the lambs wool liner of the vest to prevent rashes or sores; use powders or lotions sparingly under the vest. • Have someone change the liner if it becomes odorous. • Support the head with a small pillow when sleeping to prevent unnecessary pressure and discomfort. • Try to resume usual activities to the extent possible; keep as active as possible. (The weight of the device may cause fatigue or weakness.) However, avoid contact sports and swimming. • Do not drive because vision is impaired with the device. • Keep straws available for drinking fluids. • Cut meats and other food into small pieces to facilitate chewing and swallowing. • Before going outside in cold temperatures, wrap the pins with cloth to prevent the metal from getting cold. • Have someone clean the pin sites as recommended by physician or hospital protocol. • Observe the pin sites daily for redness, drainage, or loosening; report changes to the physician. • Increase fluids and fiber in the diet to prevent constipation. • Use a position of comfort during sexual activity.

Answer 87

Dextran, a plasma expander, may be used to increase capillary blood flow within the spinal cord and to prevent or treat hypotension. Atropine sulfate is used to treat bradycardia if the pulse rate falls below 50 to 60 beats per minute. Hypotension, if severe, is treated with continuous intravenous sympathomimetic agents such as dopamine or other vasoactive agent. Centrally-acting skeletal muscular relaxants, such as tizanidine (Zanaflex, Sirdalud), may help control severe muscle spasticity. However, these drugs cause severe drowsiness and sedation in most patients and may not be effective in reducing spasticity. As an alternative to these drugs, intrathecal baclofen (ITB) (Lioresal) therapy may be prescribed.

Answer 88

``` The patient with an SCI is especially at risk for pressure ulcers (impaired skin tissue integrity), venous thromboembolism (VTE), contractures, orthostatic hypotension, and fractures related to osteoporosis. Frequent positioning (1-2 h) Low weight heparin and pressure stockings for VTW prevention. ```

Answer 89

sometimes referred to as autonomic hyperreflexia, is a potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in people with high-level SCI.

Answer 90

• Sudden, significant rise in systolic and diastolic blood pressure,accompanied by bradycardia • Profuse sweating above the level of lesion—especially in the face, neck, and shoulders; rarely occurs below the level of the lesion because of sympathetic cholinergic activity • Goose bumps above or possibly below the level of the lesion • Flushing of the skin above the level of the lesion—especially in the face, neck, and shoulders • Blurred vision • Spots in the patient's visual field • Nasal congestion • Onset of severe, throbbing headache • Flushing about the level of the lesion with pale skin below the level of the lesion • Feeling of apprehension

Answer 91

• Place patient in sitting position (first priority!), or return to previous safe position. • Page/notify care provider. • Assess for and treat the cause: • Check for urinary retention or catheter blockage: • Check the urinary catheter tubing (if present) for kinks or obstruction. • If a urinary catheter is not present, check for bladder distention and catheterize immediately if indicated: • Consider using anesthetic ointment on tip of catheter before catheter insertion to reduce urethral irritation. • Determine if a urinary tract infection or bladder calculi (stones) are contributing to genitourinary irritation. • Check the patient for fecal impaction or other colorectal irritation, using anesthetic ointment at rectum. Disimpact if needed. • Examine skin for new or worsening pressure ulcer symptoms. • Monitor blood pressures every 10 to 15 minutes. • Give nifedipine or nitrate as prescribed: • Patients with recurrent autonomic dysreflexia may receive an alpha blocker prophylactically.

Answer 92

• Mobility skills • Pressure ulcer prevention • ADL skills • Bowel and bladder program • Education about sexuality and referral for counseling to promote sexual health • Prevention of autonomic dysreflexia with appropriate bladder, bowel, and skin care practices and recognition of early signs or symptoms of autonomic dysreflexia

Answer 93

NURSING INTERVENTION: RATIONALES Follow guidelines for adult vaccination, particularly influenza and pneumococcus vaccination recommendations. Respiratory complications are the mostcommon cause of death after spinal cord injury (SCI). The vaccine to prevent herpes zoster (shingles) can help prevent skin breakdown. For women, have Papanicolaou (Pap) smears and mammograms as recommended by the American Cancer Society or your health care provider. Limitations in movement may make breast self-examination difficult. Take measures to prevent osteoporosis, such as increasing calcium intake, avoiding caffeine, and not smoking. Exercise against resistance can maintain muscle strength and slow bone loss. Women older than 50 years often lose bone density, which can result in fractures. Men can also have osteoporotic fractures as a result of immobility. Practice meticulous skin care, including frequent repositioning, using pressure-reduction surfaces in bed and chairs/wheelchairs, and applying skin protective products like Mepilex. As a person ages, skin becomes dry and less elastic, predisposing the patient to pressure ulcers. Take measures to prevent constipation, such as drinking adequate fluids, eating a high-fiber diet, adding a stool softener or bowel stimulant daily, and establishing a regular time for bowel elimination. Constipation is a problem for most patients with SCI, and bowel motility can slow, contributing to constipation later in life. Modify activities if joint pain occurs; use a powered rather than a manual wheelchair. Ask the health care provider about treatment options. Arthritis occurs in more than half of people older than 65 years. Patients with SCI are more likely to develop arthritis as a result of added stress on the upper extremities when using a wheelchair

Answer 94

Multiple sclerosis (MS) is a life-long inflammatory disease of unknown etiology that affects the brain and spinal cord. It is one of the leading causes of neurologic disability in young adults. This chronic disease is characterized by periods of remission and exacerbation (flare), which is commonly referred to as a relapsing-remitting course. Patients progress at different rates and over different lengths of time. However, as the severity and duration of the disease progress, the periods of exacerbation become more frequent. Patients with MS have a normal life expectancy as long as the effects of the disease are treated.

Answer 95

• Muscle weakness and spasticity • Fatigue • Intention tremors • Dysmetria (inability to direct or limit movement) • Numbness or tingling sensations (paresthesia) • Hypalgesia (decreased sensitivity to pain) • Ataxia (decreased motor coordination) • Dysarthria (slurred speech) • Dysphagia (difficulty swallowing) • Diplopia (double vision) • Nystagmus (involuntary eye movements) • Scotomas (changes in peripheral vision) • Decreased visual and hearing acuity • Tinnitus (ringing in the ears), vertigo (dizziness) • Bowel and bladder dysfunction • Alterations in sexual function, such as impotence • Cognitive changes, such as memory loss, impaired judgment, and decreased ability to solve problems or perform calculations • Depression

Answer 96

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease, is an upper and lower motor neuron disease of adult onset. It is characterized by progressive weakness, muscle wasting, and spasticity that eventually lead to paralysis. Beginning in one area of the body, motor weakness and deterioration spread until the entire body is involved, including the ability to talk, swallow, and breathe. As a result of loss of lower motor neurons (LMNs) found in the spinal cord and brainstem, the muscles to which they connect weaken, atrophy, and die.

Answer 97

* Tongue atrophy * Weakness of the hands and arms * Beginning muscle atrophy of the arms * Fasciculations (twitching) of the face or tongue * Difficulty controlling crying or laughing (emotional incontinence) * Nasal quality of speech * Dysarthria (slurred speech) * Dysphagia (difficulty swallowing) * Fatigue while talking * Stiff or clumsy gait * Abnormal reflexes

Answer 98

• Weakness or paralysis of one or more extremities • Report of decreased sensation in one or more extremities • Muscle spasticity or flaccidity • Forward bent position when ambulating • Limp or altered gait • Bladder incontinence or retention • Bowel incontinence or retention • Report of pain at or above the site of injury along the spinal column and/or in one or more extremities • Difficulty breathing

Answer 99

• Assessing airway patency and breathing pattern • Assessing use of accessory muscles, pattern of respiratory effort, and rate and depth of breathing • Assessing level of consciousness • Taking vital signs • Performing a complete physical assessment • Performing a complete neurologic assessment

Answer 100

• Establishing an airway as needed • Stabilizing the spine by positioning until surgery or other treatment is provided • Preparing for imaging assessment tests • Inserting an indwelling urinary catheter • Collaborating with the health care team, especially the physical therapist and the occupational therapist, if needed

Answer 101

• Monitor the patient for changes in condition, including deterioration of neurologic status. • Consider how to best collaborate with the health care team when caring for patients with spinal cord injury or illness. • Think about family reaction to the injury or illness and what additional resources could have been used or should be used in the future.

Answer 102

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy that affects the axons and/or myelin of the peripheral nervous system, causing motor weakness and abnormalities in sensory perception. It is an uncommon disorder, affecting males slightly more than females and peaking after age 55 years.

Answer 103

``` Ascending muscle weakness Decreased DTRs Ataxia Pain(cramping) Facial weakness Difficulty speaking Tachycardia Cardiac dysrythmias ```

Answer 104

The patient may receive either plasma exchange (also | known as plasmapheresis) or IVIG.

Answer 105

Plasmapheresis removes the circulating antibodies thought to be responsible for the disease. In this procedure, plasma is selectively separated from whole blood. The blood cells are returned to the patient without the plasma.

Answer 106

In the initial phase of Guillain-Barré syndrome, monitor the patient closely with each interaction for signs of respiratory distress, such as dyspnea, air hunger, adventitious breath sounds, decreased oxygen saturation, and cyanosis. In addition, assess respiratory rate, rhythm, and depth every 1 to 2 hours. In collaboration with the respiratory therapist (RT), check vital capacity every 2 to 4 hours and auscultate the lungs at 4-hour intervals. Monitor the patient's ability to cough and swallow for any change. Assess cognitive status, especially in older adults; a decline in mental status often indicates hypoxia.

Answer 107

Myasthenia gravis (MG) is an acquired autoimmune disease characterized by muscle weakness. There are two types of MG: ocular and generalized. About two thirds of patients initially present with reports about vision that arise from disturbances of the ocular muscles. MG may take many forms—from mild disturbances of the cranial and peripheral motor neurons to a rapidly developing, generalized weakness that may lead to death from respiratory failure. MG can present at any age, and the incidence is slightly higher among men. It is a progressive disease. MG is caused by distorted acetylcholine receptors (AChRs) in the muscle motor end plate membranes. Antibodies are attached to the AChRs. As a result, nerve impulses are reduced at the neuromuscular junction; nerve impulses do not result in muscle contraction. MG and hyperplasia (abnormal growth) of the thymus gland are related because thymoma (encapsulated thymus gland tumor) occurs in a few cases.

Answer 108

``` Motor Manifestations • Progressive (proximal) muscle weakness that worsens with repetitive use and usually improves with rest • Poor posture • Ocular palsies • Ptosis; incomplete eyelid closure • Diplopia • Respiratory compromise • Loss of bowel and bladder control • Fatigue Sensory Manifestations • Muscle achiness • Paresthesias • Decreased sense of smell and taste ```

Answer 109

``` Tensilon testing (Tensilon) is given intravenously; muscle movement improves immediately in patients with myasthenia or myasthenia crisis. ``` 1. Myasthenic crisis—an exacerbation (flare-up or worsening) of the myasthenic symptoms caused by not enough anticholinesterase drugs 2. Cholinergic crisis—an acute exacerbation of muscle weakness caused by too many anticholinesterase drugs Sudden increases in weakness accompanied by hypersalivation, sweating, and increased bronchial secretions help identify this as a cholinergic crisis rather than a myasthenic crisis. A cholinergic crisis is more likely to be associated with nausea, vomiting, and diarrhea.

Answer 110

Two groups of drugs are typically prescribed for the treatment of myasthenia gravis (MG): anticholinesterases and immunosuppressants. Be sure to give these drugs on time to maintain blood levels and thus improve muscle strength. Monitor and document the patient's response to drug therapy. Provide information for the patient and the family about the indications for, effectiveness of, and side effects of the drugs used in the treatment of MG.

Answer 111

In cholinergic crisis, do not give anticholinesterase drugs while the patient is maintained with mechanical ventilation. Atropine 1 mg IV may be given and repeated, if necessary. When atropine is prescribed, observe the patient carefully. Secretions can be thickened by the drug, which causes more difficulty with airway clearance and possibly the development of mucus plugs.

Answer 112

• Assess the patient's gag reflex and ability to chew and swallow. • Provide frequent oral hygiene as needed. • Collaborate with the dietitian, speech-language pathologist, and occupational therapist to plan and implement meals that the patient can eat and enjoy. • Cut food into small bites or request a soft or edentulous diet, and encourage the patient to eat slowly. • Observe the patient for choking, nasal regurgitation, and aspiration. • Provide high-calorie snacks or supplements (e.g., puddings). • Keep the head of the bed elevated during meals and for 30 to 60 minutes after the patient eats. • Consider thickening liquids to avoid choking or aspiration. • Monitor caloric and food intake. • Weigh the patient daily. • Monitor serum prealbumin levels. • Administer anticholinesterase drugs as prescribed, usually 45 to 60 minutes before meals.

Answer 113

For patients with MG, thymectomy (removal of the thymus gland) is usually performed early in the disease. The procedure is not always immediately effective. Those who have surgery within 2 years of the onset of myasthenic symptoms show the most improvement, but many patients do not experience a change in status despite thymectomy.

Answer 114

For the patient having a thymectomy, monitor respiratory effort and promote effective gas exchange. Observe for signs of pneumothorax or hemothorax, including: • Chest pain • Sudden shortness of breath • Diminished or delayed chest wall expansion • Diminished or absent breath sounds • Restlessness or a change in vital signs (decreasing blood pressure or a weak, rapid pulse) If respiratory distress or symptoms of ineffective gas exchange occur, provide oxygen to the patient and raise the head of the bed to at least 45 degrees. Then report any of these signs and symptoms to the surgeon or Rapid Response Team immediately!

Answer 115

Stress the importance of lifestyle adaptations such as avoiding heat (e.g., sauna, hot tubs, sunbathing), crowds, overeating, erratic changes in sleep habits, or emotional extremes.

Answer 116

• Affects the trigeminal (fifth cranial) nerve • Occurs more often in people older than 50 years and in women more often than men • Causes a specific type of facial pain, which occurs in sudden, intense facial spasms • Is usually provoked by minimal stimulation of a trigger zone (like dental procedures) • Is unilateral (one-sided) and confined to the area innervated by the trigeminal nerve, most often the second and third branches • Is familial due to an inherited pattern of blood vessel formation

Answer 117

The cause of trigeminal neuralgia is thought to be related to impaired inhibitory mechanisms in the brainstem caused by excessive firing of irritated fibers in the trigeminal nerve. Trauma and infection of the teeth, jaw, or ear may be contributing factors. Patients younger than 30 years with pain in more than one branch of the trigeminal nerve may be further evaluated to rule out the possibility of a tumor or multiple sclerosis

Answer 118

Pain management.

Answer 119

The first choice for drug therapy is carbamazepine (CBZ, Tegretol), an antiepileptic drug (AED) Other drugs, such as gabapentin (Neurontin), pregabalin (Lyrica), and baclofen (Lioresal, Kemstro), a muscle relaxant, may be used. Some patients also achieve pain relief with complementary therapies, such as acupuncture.

Answer 120

Teach the patient who has had percutaneous stereotactic rhizotomy to avoid rubbing the eye on the affected side because the protective mechanism of pain will no longer warn of injury. Instruct him or her to inspect the eye daily for redness or irritation and report to the health care provider any change or blurred vision. Stress the importance of regular dental examinations because the absence of pain may not warn the patient of potential problems.

Answer 121

Bell's palsy, is an acute paralysis of cranial nerve VII but may also affect cranial nerves V (trigeminal) and VIII (vestibulocochlear [auditory]). The condition is also known as cranial polyneuritis. Although the incidence may be slightly higher among people with diabetes, Bell's palsy occurs in all ages; however, it is more commonly seen in young adults.

Answer 122

Medical management usually includes corticosteroids, 30 to 60 mg daily, during the first week after the onset of symptoms. Antiviral drugs such as acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) may be prescribed for 7 to 10 days after symptoms begin. Mild analgesics may help relieve the pain. Nursing care is directed toward managing the major neurologic deficits and providing psychosocial support. Because the eye does not close, the cornea must be protected from drying and subsequent ulceration or abrasion can occur.

Answer 123

• Report of muscle weakness in face, arms, or legs • Inability to swallow or clear the upper airway • Changes in respiratory rate and pattern indicating respiratory compromise or failure • Loss of sensation in face or extremities • Report of burning, tingling sensations in face or extremities • Report of pain in extremities or face • Ptosis and either dry eye or excessive tearing

Answer 124

* Completing a neurologic assessment * Assessing a patient's airway and breathing ability * Performing a comprehensive pain assessment

Answer 125

• Notifying health care provider or contacting Rapid Response Team if patient has problems with breathing or experiences a sudden change in neurologic status • Establishing an airway and promoting ease in breathing (e.g., put patient in sitting position, provide oxygen, set up suction) • Having emergency equipment like ventilator and tracheostomy set available for patient who has respiratory compromise • Assisting with ADLs as needed • Providing analgesics and other pain-relief measures

Answer 126

• Continue to observe patient for changes in functional ability and gas exchange. • Consider multiple approaches to managing pain. • Think about ways to promote independence in mobility and self-care. • Think about health care team members with whom you will need to collaborate to improve mobility. • Consider how to provide a safe environment for patients with decreased sensory perception. • Develop a teaching plan for the patient and family for continuing care.

Answer 127

Ischemic strokes often follow warning signs such as a transient ischemic attack (TIA). Temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow is easy to ignore or miss, particularly if symptoms resolve by the time the patient reaches the emergency department (ED). Typically resolve within 30-60min.

Answer 128

``` Transient Ischemic Attack Symptoms resolve typically within 30 to 60 minutes. Visual Deficits • Blurred vision • Diplopia (double vision) • Blindness in one eye • Tunnel vision Motor Deficits • Weakness (facial droop, arm or leg drift, hand grasp) • Ataxia (gait disturbance) Sensory Perception Deficits • Numbness (face, hand, arm, or leg) • Vertigo Speech Deficits • Aphasia • Dysarthria (slurred speech) ```

Answer 129

• Reducing high blood pressure, the most common risk factor for stroke, by adding or adjusting drugs to lower blood pressure • Taking aspirin or another antiplatelet drug (e.g., clopidogrel [Plavix]) to prevent strokes (Aw & Sharma, 2012) • Controlling diabetes and keeping blood sugar levels in a target range, typically 100-180 mg/dL • Promoting lifestyle changes such as quitting smoking, eating heart- healthy foods, and being more active

Answer 130

A stroke is caused by an interruption of perfusion to any part of the brain. The National Stroke Association uses the term brain attack to convey the urgency for acute stroke care similar to that provided for acute myocardial infarction. A stroke is a medical emergency, and it should be treated immediately to reduce permanent disability. Third leading cause of death in the U.S.

Answer 131

An acute ischemic stroke is caused by the occlusion (blockage) of a cerebral artery by either a thrombus or an embolus. A stroke that is caused by a thrombus (clot) is referred to as a thrombotic stroke, whereas a stroke caused by an embolus (dislodged clot) is referred to as an embolic stroke.

Answer 132

In this | type of stroke, vessel integrity is interrupted and bleeding occurs into the

Answer 133

``` Intracerebral hemorrhage (ICH) describes bleeding into the brain tissue generally resulting from severe or sustained hypertension ```

Answer 134

Subarachnoid hemorrhage (SAH) is much more common and results from bleeding into the subarachnoid space—the space between the pia mater and arachnoid layers of the meninges covering the brain. This type of bleeding is usually caused by a ruptured aneurysm or arteriovenous malformation.

Answer 135

An aneurysm is an abnormal ballooning or blister along a normal artery, which usually develops in a weak spot on the artery wall, typically along the posterior circulation such as the basilar artery, vertebral artery, or the superior cerebral artery. Larger aneurysms are more likely to rupture than smaller ones.

Answer 136

An arteriovenous malformation (AVM) is an uncommon abnormality that occurs during embryonic development. It is a tangled collection of malformed, thin-walled, dilated vessels without a capillary network. Normally the capillary network lowers the pressure between the arterial and venous systems. In the absence of the capillary network, the thin-walled veins are subjected to arterial pressure. The abnormal vessels may eventually rupture, causing bleeding into the intracerebral tissue or spaces.

Answer 137

Vasospasm, a sudden and periodic constriction of a cerebral artery, often follows SAH or bleeding from an aneurysm or AVM rupture. Blood flow to distal areas of the brain supplied by the damaged cerebral vessel is markedly diminished. Reduced perfusion from vasospasm contributes to secondary cerebral ischemia and infarction and further neurologic dysfunction.

Answer 138

Preserve cognition, mobility, and quality of life.

Answer 139

* Smoking * Substance use (particularly cocaine) * Obesity * Sedentary lifestyle * Oral contraceptive use * Heavy alcohol use * Use of phenylpropanolamine (PPA), found in antihistamine drugs

Answer 140

American Indian/Alaskan Native groups have the highest prevalence of stroke. Black men and women have more strokes than white men and women. Hispanic or Latino men have more strokes than non-Hispanic men. About half of the excess stroke risk in blacks between ages 45 and 65 years is attributable to traditional risk factors such as elevated systolic blood pressure and socioeconomic factors. These data suggest a critical need to study the role that nontraditional risk factors play in stroke development and severity in this group

Answer 141

They can grow a tolerance and some of the side effects are extreme.

Answer 142

In the ED, assess the stroke patient within 10 minutes of arrival. This same standard applies to patients already hospitalized for other medical conditions who have a stroke. The priority is assessment of ABCs —airway, breathing, and circulation. Many hospitals have designated stroke teams and centers that are expert in acute stroke assessment and management.

Answer 143

* Sudden confusion or trouble speaking or understanding others * Sudden numbness or weakness of the face, arm, or leg * Sudden trouble seeing in one or both eyes * Sudden dizziness, trouble walking, or loss of balance or coordination * Sudden severe headache with no known cause

Answer 144

• Denial of the illness • Spatial and proprioceptive (awareness of body position in space) dysfunction • Impairment of memory, judgment, or problem-solving and decision-making abilities • Decreased ability to concentrate and attend to tasks Dysfunction in one or more of these areas may be severe depending on the hemisphere involved

Answer 145

1. Inadequate perfusion to the brain related to interruption of arterial blood flow and a possible increase in ICP 2. Impaired Swallowing related to neuromuscular impairment (NANDA- I) 3. Impaired Physical Mobility and self-care deficit related to neuromuscular impairment or cognitive impairment (NANDA-I) 4. Aphasia or dysarthria related to decreased circulation in the brain or facial muscle weakness 5. Urinary and/or Bowel Incontinence related to reflex bladder and bowel (NANDA-I) 6. Sensory perception deficits from altered neurologic reception, transmission, and perception 7. Unilateral Neglect related to disturbed perceptual abilities or hemianopsia (NANDA-I

Answer 146

the standard of practice is to start two IV lines with non-dextrose isotonic saline (Hughes, 2011). Consider placing the patient in a supine position with a low head-of-bed elevation to maximize cerebral perfusion. The immediate primary role of the nurse is to manage the patient receiving treatment and continuously assess for increasing intracranial pressure.

Answer 147

Intravenous (systemic) fibrinolytic therapy (also called thrombolytic therapy) for an acute ischemic stroke dissolves the cerebral artery occlusion to re-establish blood flow and prevent cerebral infarction. Alteplase (Activase) is the only drug approved at this point for the treatment of acute ischemic stroke.

Answer 148

• Perform a double check of the dose. Use a programmable pump to deliver the initial dose of 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose given as a bolus over 1 minute. Do not manually push this drug. • Admit the patient to a critical care or specialized stroke unit. • Perform neurologic assessments, including vital signs, every 10 to 15 minutes during infusion and every 30 minutes after that for at least 6 hours; monitor hourly for 24 hours after treatment. Be consistent regarding the device used to obtain blood pressures because blood pressures can vary when switching from a manual to a noninvasive automatic to an intra-arterial device. • If systolic blood pressure is 180 mm Hg or greater or diastolic is 105 mm Hg or greater, give antihypertensive drugs as prescribed. • To prevent bleeding, do not place invasive tubes, such as nasogastric (NG) tubes or indwelling urinary catheters, until the patient is stable. • Discontinue the infusion if the patient reports severe headache or has severe hypertension, bleeding, nausea, and/or vomiting; notify the health care provider immediately. • Obtain a follow-up CT scan after treatment before starting antiplatelet or anticoagulant drugs.

Answer 149

The best practice for all suspected and diagnosed stroke patients is to maintain a NPO status until their swallowing ability is assessed. Before the patient is given any liquids, food, or medication, he or she must be screened for the ability to swallow. Follow agency guidelines for screening or use an evidence-based bedside swallowing screening tool to determine if dysphagia is present. If dysphagia is present, develop a plan of care to prevent aspiration and support nutrition.

Answer 150

``` Thrombolytics Anticoagulants Lorazepam (antiepileptics) CCB=Hemmorahge Still softeners Analgesics Antianxiety drugs ```

Answer 151

Be sure to support the affected flaccid arm of the stroke patient, and teach UAP to avoid pulling on it. Position the arm on a pillow while the patient is sitting to prevent it from hanging freely, which could cause shoulder subluxation. The physical or occupational therapist provides a sling-like device to support the arm during ambulation.

Answer 152

• Be flexible and adapt to the health and learning needs of the patient (e.g., aphasia is/is not present). • Use multiple types of education materials (written, audiovisual, interactive strategies). • Focus on key points, and be repetitive; as many as five or six repetitions are associated with retention. • Group meetings may be beneficial to patient understanding, motivation, and quality of life. • Use reading materials with a low literacy level, large font type, and short (15 minute) learning sessions. • Identify sources of emotional support, encourage social support, and locate community education groups for caregivers to enhance their well-being.

Answer 153

Leakages out of anywhere: Clear? 4x4 in half and half again. Take center corner and touch to fluid, if it is CSF it will look like a "halo" with yello like substance in the middle and serosangounous fluid surrounding it.

Answer 154

• Maintains blood pressure and blood sugar within a safe, prescribed range • Performs self-care and mobility activities independently, with or without assistive devices • Learns to adapt to sensory perception changes • Adjusts and uses techniques to compensate for one-sided neglect • Communicates effectively or develops strategies for effective communication • Has adequate nutrition and avoids aspiration • Controls elimination of urine and stool

Answer 155

1. Venous thromboembolism (VTE) prophylaxis 2. Discharge with antithrombotic therapy 3. Anticoagulation therapy for atrial fibrillation/flutter 4. Thrombolytic therapy (in the presence of a thrombotic stroke of <4 hours from symptom onset) 5. Antithrombotic therapy is evaluated by end of hospital day (e.g., diagnostic testing for therapeutic range of values following thrombolytic or anticoagulant therapy) 6. Discharged on statin medication 7. Stroke education provided and documented 8. Assessed for rehabilitation

Answer 156

Traumatic brain injury (TBI) is damage to the brain from an external mechanical force and not caused by neurodegenerative or congenital conditions. TBI can lead to temporary and permanent impairment of cognitive, physical, and psychosocial functions.

Answer 157

A force produced by a blow to the head is a direct injury, whereas a force applied to another body part with a rebound effect to the brain is an indirect injurY. An acceleration injury is caused by an external force contacting the head, suddenly placing the head in motion. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object.

Answer 158

``` Primary brain damage occurs at the time of injury and results from the physical stress (force) within the tissue caused by blunt force. ```

Answer 159

An open traumatic brain injury occurs when the skull is fractured or when it is pierced by a penetrating object. The integrity of the brain and the dura is violated, and there is exposure to environmental contaminants. Damage may occur to the underlying vessels, dural sinus, brain, and cranial nerves. In a closed traumatic brain injury, the integrity of the skull is not violated.

Answer 160

The terms mild traumatic brain injury (MTBI) and concussion are used synonymously. MTBI is characterized by a blow to the head, transient confusion or feeling dazed or disoriented, and one or more of these conditions: (1) loss of consciousness for up to 30 minutes, (2) loss of memory for events immediately before or after the accident, and (3)

Answer 161

A moderate TBI is characterized by a period of loss of consciousness (LOC) for 30 minutes to 6 hours and a GCS score of 9 to 12. Often but not always, focal or diffuse brain injury can be seen with a diagnostic CT or MRI scan. Post-traumatic amnesia (memory loss) may last up to 24 hours. Moderate TBI may occur with either closed or open brain injury. A short acute or critical care stay may be needed for close monitoring and to prevent secondary injury from brain edema, intracranial bleeding, or inadequate cerebral perfusion.

Answer 162

A severe TBI is defined by a GCS score of 3 to 8 and loss of consciousness for longer than 6 hours. Focal and diffuse damage to the brain, cerebrovascular vessels, and/or ventricles are common. Both open and closed head injuries can cause severe TBI, and injury can be focal or diffuse. When the damage is present in a localized area of the brain, it is usually extensive. CT and MRI scans can capture images of tissue damage quite early in the course of this illness. Patients with severe TBI require management in critical care, including monitoring of hemodynamics, neurologic status, and possibly, intracranial pressure (ICP). Patients with severe TBI are also at high risk for secondary brain injury from cerebral edema, hemorrhage, reduced perfusion, and the biomolecular cascade.

Answer 163

An epidural hematoma results from arterial bleeding into the space between the dura and the inner skull (Fig. 45-8). It is often caused by a fracture of the temporal bone, which houses the middle meningeal artery. Patients with epidural hematomas have “lucid intervals” that last for minutes during which time the patient is awake and talking. This follows a momentary unconsciousness that occurs within minutes of the injury.

Answer 164

A subdural hematoma (SDH) results from venous bleeding into the space beneath the dura and above the arachnoid (see Fig. 45-8). It occurs most often from a tearing of the bridging veins within the cerebral hemispheres or from a laceration of brain tissue. Bleeding from this injury occurs more slowly than from an epidural hematoma.

Answer 165

Hydrocephalus is an abnormal increase in CSF volume. It may be caused by impaired reabsorption of CSF at the arachnoid villi (from subarachnoid hemorrhage or meningitis), called a communicating hydrocephalus. It may also be caused by interference or blockage with CSF outflow from the ventricular system (from cerebral edema, tumor, or debris). The ventricles may dilate from the relative increase in CSF volume. Ultimately, if not treated, this increase may lead to increased ICP.

Answer 166

In the presence of increased ICP, the brain tissue may shift and herniate downward. It is clinically manifested by Cheyne-Stokes respirations, pinpoint and nonreactive pupils, and potential hemodynamic instability. All herniation syndromes are potentially life threatening, and the physician must be notified immediately when they are suspected.

Answer 167

• Brain injury is the fifth leading cause of death in older adults. • The 65- to 75-year age-group has second highest incidence of brain injury of all age-groups. • Falls and motor vehicle crashes are the most common causes of brain injury. • Factors that contribute to high mortality are: Falls causing subdural hematomas (closed head injuries), especially chronic subdural hematomas Poorly tolerated systemic stress, which is increased by admission to a high-stimuli environment Medical complications, such as hypotension, hypertension, and cardiac problems Decreased protective mechanisms, which make patients susceptible to infections (especially pneumonia) Decreased immunologic competence, which is further diminished by brain injury

Answer 168

alert is a normal response. Drowsy generally indicates arousal by voice. Lethargy indicates that voice and light touch are used to obtain a client response. Stuporous is a deeper level of unresponsiveness that responds to more vigorous touch or tactile stimulation. Comatose indicates no response to painful or noxious stimuli.

Answer 169

The MRI scan provides better contrast between normal tissue and pathologic tissue

Answer 170

Fluid intake should be increased after the test because this helps to remove the radioisotope more quickly. Caffeine should be avoided for 24 hours before the test. The client is NPO for 4 to 12 hours before the test, and insulin is not given to diabetic clients before a PET scan. Tobacco should be withheld for 24 hours before PET.

EXAM 4 Flashcards

(195 cards)