[Exam 4] Chapter 66: Management of Patients with Neurologic Dysfunction (Page 1972-1979, 1996-2007) Flashcards
What is the most important indicator of the patients condition?
Level of responsiveness and consciousness
What is LOC?
A continuum from normal alertness and full cognition (consciousness) to coma
What is altered LOC?
Present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve state of alertness
What is a Coma?
Unconsciousness, unarousable unresponsiveness, may occasionally make non-purposeful movements. This includes patient squeezing hand once, but they are in fact not responding
What is akinetic Mutism?
State of unresponsiveness to the environment in which the patient makes no voluntary movement
What is a Persistent-Vegative State?
Devoid of cognitive function but has sleep-wake cycles. They are not aware of surroundings, but can have reflexive responses. If they smile, its just reflexive. A fake smile
What is Locked-In Syndrome?
Inability to move or respond except for eye movements due to lesion affecting the pons. Completely aware of surrounding, only able to move eyes.
Altered LOC is not a disorder itself, but instead…
a symptom of another pathology
Patient with Altered LOC: What do you assess for?
Verbal Response and Orientation
Alertness
Motor Responses
Respiratory Status
Eye Signs
Reflexes
Postures
Glasgow Coma Scale
Patient with Altered LOC: What is Decorticate Posturing?
A neural reflex that is done in response to stimuli. Done early in brain damagedamage
Altered LOC: Signs of Decorticate Posturing?
Hands Flexed, Arms Adducted, Elbows flexed, and legs internally rotated
Altered LOC: Signs of Decerebrate Posturing?
Shoulders Adducted, Arms Extended, Wrists Pronated, and Hands Flexed
Altered LOC: When does Decerebrate Posturing occur?
When pons affected, meaning they have severe brain damage.
Altered LOC: Why would Diarrhea be assed?
Cause from infection, meds, or hyperosmolar fluid administration
Altered LOC: What labs would you check?
I/O, BUN, H&H for fluid statis, along with Tugor.
Altered LOC: Sayins to remember risk factors?
DIMS
Altered LOC: What are the Risk Factors?
(D) Drugs and Alcohol
(I) Infections
(M) Metabolic- Hypoglycemia, hypercapnia, hypoxia, acidosis, electrolytte imbalance, ammonia
(S) Structural : Trauma, Blood Clot, Tumor, Stroke, ICP
Altered LOC: How to prevent this?
Prevention is specific to causative factors
Altered LOC: Labs and Diagnostic?
Neuro Systems
BMP and CBC
Altered LOC: Complications?
Respiratory Distress/Failure
Pneumonia
Aspiration
Pressure Ulcer
DVT
Contractures (Can’t be fixed once occured)
Altered LOC: Nursing Diagnosis for this?
Ineffective airway Clearance
RF Injury
Deficient Fluid Volume
Impaired Oral Mucosa
RF Impaired Skin Integrity and Tissue Integrity
Ineffective thermoregulation
Impaired Urinary/Bowel Elimination
Disturbed Sensory Perception
Interrupted Family Processes
Altered LOC: Goals for this?
Clear Airway
Fluid Volume Balance
SKin/Tissue Integrity
Effective Thermoregulation
Accurate perception of environmental stimuli
Intact family support and coping
Absence of complications
Altered LOC: Medical Management for this?
IV Fluids/Tube Feedings
Artifical Tears
Foley Catheter or Bladder Training
Stool softeners / Suppositories r Enemas
Acetaminophen for fever
Altered LOC: What is the major nursing goal here?
To compensate for the patient’s loss of protective reflexes and to assume responsibility for total patietn care. This includes patients dignity and privacy
Altered LOC: How to Maintain an Airway?
Frequent monitoring of respiratory status, including checking lungs
Positioning to promote movement of secretions. HOB elevated to 30 degrees. Lateral or Semiprone if doing oral care
Suctioning, Oral Hygiene, and CPT
Altered LOC: How would you maintain tissue integrity?
Assess skin frequently, with frequent turning. Carefully position in correct body alignment
Possive ROM
Use of splints, foam boots,
Clean eyes with cotton balls moistened with saline and use artifical tears as prescribed.
Measures to protect eyes
Frequent oral care
Altered LOC: How to maintain fluid status
Assess fluid status by examining skin turgor, mucosa, lab test data, and I/O
Administer IVs, tube feedings, and fluids via feeding tube. Keep HOB elvated
Altered LOC: How to maintain body temperature
Adjust environment and cover appropriately
If temp elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, cool sponge bath, and allow fan to blow on patient
Monitor temp freq and prevent shivering
Altered LOC: How to promote bowel and bladder function?
Assess for urinary retention and incontinence
Catherization/ Bladder Training
Assess for abdominal distention, constipation, or incontinence
Monitor bowel movements
Promote elimination with stool softeners, glycerin, suppositories
Diarrhea may result from infection, meds, or hyperosmolar fludis
Altered LOC: How to help with sensory stimulation and communication
Talk/Touch Patient and Encourage Family to Talk
Maintain Normal Day/Night Pattern
Orient Pt Frequently
Programs for sensory stimulation
Allow family to ventilate and provide support
Reinforcec and provide and consistent information to family
Referral to support groups and services to family
Altered LOC: Note for when patient arousing form coma?
Patient may experience period of agitation, minimize simulation at this time
Altered LOC: How often should oral care be done?
Every 2 hours
Altered LOC: How often should ROM be done?
Every 4 hours
Altered LOC: Education for this?
Encourage family to talk and touch the patient. When waking, patient may be agitated.
Reorient pt often.
Provide consistent information to family
Support group referrals
Seizures: What is a seizure?
Abnormal episodes of motory, sensory, autonomic, or psychic activity ( or combo) resulting from sudden abnormal uncontrolled electrical discharge from cerebral neurons (epileptogenic focus)
Seizures: What is a epileptogenic focus?
Location or point in the brain where the hypersensitive neurons are located causing teh seizure activity
Seizures: All people have what threshold?
Seizure threshold, and when exceeded, seizure occurs
Seizures: What can cause a seizure?
Patient how low seizure threshold, or pathologic condition has altered the seizure threshold
Seizures: What is needed to make diagnosis of epilepsy?
2 or more seizures that can be minutes or years apart
Seizures: What are kids diagnosed as if they have a seizure while having a fever?
Febrile Seizure, and does not count toward epilepsy
Seizures: What are the two classifications of seizures?
Partial Seizures (Begin in one hemisphere of the brain)
Generalized Seizures: (Involve the whole brain)
Seizures: Two parts of Partial Seizures?
Simple Partial: LOC remains intact
Complex Partial: Impairment of Consciousness
Seizures: What specific information for Simple Partial Seizure? Motor, Sensory, ,Autonomic, and Psychic
Depends on part of brain
Motor: Jacksonian March (Starts at one part of body, then moves to the adjacent body part on one side. Fingers twitch, move up arm, to shoulder)
Sensory: Hallicinations or Abnormal Sesnation (Taste/Smell)
Autonomic: Increase HR, Flushing, Change in BP
Psychic: Deja Vu, Anger, Fear
Seizures: What specific information for Complex Partial Seizure? With Automatisms and Aura
Impairment of LOC
Automatisms: Repetitive, non-purposeful movements (lip smcking, tapping foot)
May or may not have aura (Symptoms they had before seizure occured), but amnesia will follow
Seizures: What are some types of Generalized Seizures?
Absence (Petit Mal) : LOC Impaired
Tonic-Clonic (Grand Mal): LOC Impaired
Seizures: What happens with an Absence Seizure?
LOC Impaired
Brief cessation of motor movements (Don’t fall, just stand there) , blank stare (Don’t respond to teacher), automatisms may occur
5-30 seconds in length. Occasional episodes or many per day
Seizures: What happens in Tonic-Clonic Seizures?
LOC Impaired (What people often think for seizures)
Step 1 lasts 15 seconds to 1 minute.
May or may not have aura, but amnesia up to 1 hr before and 2 after
Follows set pattern: Sudden LOC, tonic contraction (every muscle in body, including vocal cords and diaphragm. ), opisthotonic posture, THEN..
Clonic contraction/relaxation (60-90 seconds), THEN..
postictal (after seizure, changes in thinking, memory, breathing relaxed)
Seizures: Some signs of a Tonic-Clonic Seizure?
Foaming coming from mouth, hyperventilaiton. Happens during the clonic contraction/relaxation phase.
May sleep for several hours after events
Seizures: How to prevent these?
Avoid Triggers
Prevent Status Epilepticus - Do not Stop meidcations
Medicate fevers for febrile seizures
Seizures: What are the risk factors for getting this?
Cerebrovascular Disease
Hypoxemia
Fever (Child)
Head Injury/Hypertension
CNS Infections
Metabolic /Toxic Condition
Brain Tumor
Drug/Alcohol Withdrawal
Allergies
Hypoglycemia
Seizures: How to assess for this?
Observe patient signs and symptoms
How long does it last
Any Triggers? (Flashing lights, menses, fatigue)
Assess respiraotry status during and after
Seizures: What is Status Epileptics?
Seizure activity becomes continuous and we cannot stop it. Requires immediate intervention
Seizures: What can Status Epilepticus lead to?
Hypoxia (Not Breathing), Acidosis (Not blowing off CO2), Hypoglycemia (Takes energy to have body in full contraction/relaxation), Hyperthermia (Bc of increased metabolism), Exhaustion (Leading to death)
Seizures: Medical Management for Status Epilepticus?
Maintain airway (Priority)
50% dextrose to prevent hypoglycemia
Ativan, Valium Repeat q 10 min
Seizures & Interventions of Seizures: Observe and document what?
Patient signs and symptoms before, during, and after seizures
Seizures & Interventions of Seizures: Perform after seizure care to prevent
complications
Seizures & Interventions of Seizures: What is Epilepsy?
Chronic disorder of recurring, excessive, or self-terminating electrical discharge from neurons
Seizures & Interventions of Seizures: What can you do if someone is having a seizure?
Maintain Airway
Turn on Side
Seizure Pads
Protect Head
Do not hold patient down
Suction airway if needed
Loosen clothing around neck
Seizures: What are some nursing diagnosis?
RF Ineffective Airway Clearance
RF Injury
Anxiety
REadiness for Enhanced Knowledge
Unstable Blood GLucose
Impaired Gas Exchange
Seizures: What do to with Risk for Ineffective Airway Clearance?
Provide oxygen, turn patient to side, loosen clothing around neck, and do not force anything in mouth suction if needed
Seizures: What to do for Risk for Injury?
Do not hold down pad area
Seizures: What should the driver do driving wise?
No driving for 6 months - 2 years
Seizures: When should you call 911?
If seizure lasts over 5 mins, difficulty breathing after seziure, or second seizure occurs
Seizures: What are some goals for this?
Avoid complications, maintain airway, prevent injury, maintain blood glucose, and adhere to medical management
Seizures: Labs to test for this?
EEG
Medication Levels in Serum
CT, MRI
Seizures: How to help an individual have Readiness for Enhance Knowledge?
Avoid or have awareness or triggers(flashing lights, fatigue, menses)
Recognize Auras
Wear medic alert bracelet
Avoid alcohol and coffee (lowers seizure threshold)
Shower rather than bathe
Headache: Also known as
cephalgia
Headache: What happens here?
Cerebral blood vessels first narrow and reduce blood flow, then there is vasodilation, swelling, and pain
Headache: What is a primary headache?
No known organi cause and includes migraine, tension headache, and cluster headache
Headache: What is a secondayr headache?
Symptom with an organic cause such asb brain tumor or aneurysm
Headache: Headaches may cause what in terms of lifestyle?
Significant discomfort for the person and can interfere with activites and lifestyle.
Headache: Risk Factors for this?
Exposure to toxins
Medication side effects
Family History
Stress
Headache & Migraine: How long does this last?
4-72 hours
Headache & Migraine: Where does the pain radiate?
Unilateral throbbing pain, intensifies with movement (can become bilateral)
Headache & Migraine: What signs can occur?
Chills, N/V, Fatigue, Sensitivity to Light, Sound, or Odor
Blurred Vision, Anorexia, Hunger, Diarrhea, Abdomminal Cramping, Facial Pallor, Sweating, Stiffness, or Tenderness of neck
Headache & Cluster Headache: What is this?
Extremely severe, unilateral, burning pain behind or around the eyes
Headache & Cluster Headache: What are signs do they have?
Rhinorrhea (Nose Runs), facial edema, miosis (excessive shrinking of pupil), ptosis (dropping of upper eyelid)
Headache & Cluster Headache: How long do these last for?
Several weeks or months, followed by remission (episode lasts 15 mins to 3 hours)
Headache & Cluster Headache: What time of year do these occur?
Fall or spring
Headache & Cluster Headache: What time do they begin?
2-3 hours after going to sleep
Headache & Migraine: Patients may have what before a migraine headache?
An Aura, where they can tell its coming
Headache & Assessment: What should you obtain?
Detailed description of headache. Include medication history and use
Types of headaches manifest differently, so they may change over time
Headache & Assessment: Persistent headaches requires what?
Investigation
Headache & Assessment: What is required of a person undergoing a headache evaluation?
Detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes
Headache & Assessment: Diagnostic testing may be used to evaulate
underlying cause if there are abnormalities on the neurologic exam
Headache & Assessment: What labs will be performed?
None for Primary
Neurological Exam
CT, MRI
Headache: What complications can occur??
Impairment in ability to carry out life tasks
Headache: What can be used be used for recurrent migraines?
Prophylatic medications (Topamax). Taken everyday
Headache: Migraines and Cluster headaches requires what meds
abortive medications instituted as soon as possible with onset
Headache: What comfort measures can be provided?
Quiet, dark room
Massage
Local heat for tension
Headache: Goals for this?
Pain relief
Prevention of headache
Ability to complete ADLs
Headache: What can be dome triggers to cause this?
Rapid Change in Glucose
Emotional Exictemenet
Fatigue
Alcohol
Tyramines (Chocolate, Red Wine, Aged, Cheese, Bagged Veggies)
Artifical Sweeteners
Menses
Headache: What education can be provided?
Avoid Triggers
Take Aboritive medicine as soon as headahcne appears
Headache: What should patient do to prevent headaches?
Medication instruction adn treatment regimen
Stress reduction techniques
Nonpharmacologic therapies
followup care
Encourage healthy lifestyle
Headache: What Tyramine foods can cause headaches?
Chocolate, Red Wine, Aged Cheese
Headache: Nursing Diagnosis for this?
Acute pain
Nausea
Impaired Sensory Perception
Diarrhea
Fatigue
Headache: Medical Management for this?
Prophylaxis Meds (Topamax)
Oxygen for Cluster headaches
Abortive Medicine (Relpax, Imitrex)
