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NRSG 110: Med Surg 2 > [Exam 4] Chapter 66: Management of Patients with Neurologic Dysfunction (Page 1972-1979, 1996-2007) > Flashcards

[Exam 4] Chapter 66: Management of Patients with Neurologic Dysfunction (Page 1972-1979, 1996-2007) Flashcards

1
Q

What is the most important indicator of the patients condition?

A

Level of responsiveness and consciousness

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2
Q

What is LOC?

A

A continuum from normal alertness and full cognition (consciousness) to coma

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3
Q

What is altered LOC?

A

Present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve state of alertness

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4
Q

What is a Coma?

A

Unconsciousness, unarousable unresponsiveness, may occasionally make non-purposeful movements. This includes patient squeezing hand once, but they are in fact not responding

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5
Q

What is akinetic Mutism?

A

State of unresponsiveness to the environment in which the patient makes no voluntary movement

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6
Q

What is a Persistent-Vegative State?

A

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

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7
Q

What is Locked-In Syndrome?

A

Inability to move or respond except for eye movements due to lesion affecting the pons. Completely aware of surrounding, only able to move eyes.

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8
Q

Altered LOC is not a disorder itself, but instead…

A

a symptom of another pathology

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9
Q

Patient with Altered LOC: What do you assess for?

A

Verbal Response and Orientation

Alertness

Motor Responses

Respiratory Status

Eye Signs

Reflexes

Postures

Glasgow Coma Scale

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10
Q

Patient with Altered LOC: What is Decorticate Posturing?

A

A neural reflex that is done in response to stimuli. Done early in brain damagedamage

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11
Q

Altered LOC: Signs of Decorticate Posturing?

A

Hands Flexed, Arms Adducted, Elbows flexed, and legs internally rotated

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12
Q

Altered LOC: Signs of Decerebrate Posturing?

A

Shoulders Adducted, Arms Extended, Wrists Pronated, and Hands Flexed

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13
Q

Altered LOC: When does Decerebrate Posturing occur?

A

When pons affected, meaning they have severe brain damage.

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14
Q

Altered LOC: Why would Diarrhea be assed?

A

Cause from infection, meds, or hyperosmolar fluid administration

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15
Q

Altered LOC: What labs would you check?

A

I/O, BUN, H&H for fluid statis, along with Tugor.

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16
Q

Altered LOC: Sayins to remember risk factors?

A

DIMS

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17
Q

Altered LOC: What are the Risk Factors?

A

(D) Drugs and Alcohol
(I) Infections
(M) Metabolic- Hypoglycemia, hypercapnia, hypoxia, acidosis, electrolytte imbalance, ammonia
(S) Structural : Trauma, Blood Clot, Tumor, Stroke, ICP

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18
Q

Altered LOC: How to prevent this?

A

Prevention is specific to causative factors

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19
Q

Altered LOC: Labs and Diagnostic?

A

Neuro Systems

BMP and CBC

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20
Q

Altered LOC: Complications?

A

Respiratory Distress/Failure

Pneumonia

Aspiration

Pressure Ulcer

DVT

Contractures (Can’t be fixed once occured)

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21
Q

Altered LOC: Nursing Diagnosis for this?

A

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

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22
Q

Altered LOC: Goals for this?

A

Clear Airway

Fluid Volume Balance

SKin/Tissue Integrity

Effective Thermoregulation

Accurate perception of environmental stimuli

Intact family support and coping

Absence of complications

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23
Q

Altered LOC: Medical Management for this?

A

IV Fluids/Tube Feedings

Artifical Tears

Foley Catheter or Bladder Training

Stool softeners / Suppositories r Enemas

Acetaminophen for fever

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24
Q

Altered LOC: What is the major nursing goal here?

A

To compensate for the patient’s loss of protective reflexes and to assume responsibility for total patietn care. This includes patients dignity and privacy

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25
Q

Altered LOC: How to Maintain an Airway?

A

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

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26
Q

Altered LOC: How would you maintain tissue integrity?

A

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

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27
Q

Altered LOC: How to maintain fluid status

A

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

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28
Q

Altered LOC: How to maintain body temperature

A

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

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29
Q

Altered LOC: How to promote bowel and bladder function?

A

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

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30
Q

Altered LOC: How to help with sensory stimulation and communication

A

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

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31
Q

Altered LOC: Note for when patient arousing form coma?

A

Patient may experience period of agitation, minimize simulation at this time

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32
Q

Altered LOC: How often should oral care be done?

A

Every 2 hours

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33
Q

Altered LOC: How often should ROM be done?

A

Every 4 hours

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34
Q

Altered LOC: Education for this?

A

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

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35
Q

Seizures: What is a seizure?

A

Abnormal episodes of motory, sensory, autonomic, or psychic activity ( or combo) resulting from sudden abnormal uncontrolled electrical discharge from cerebral neurons (epileptogenic focus)

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36
Q

Seizures: What is a epileptogenic focus?

A

Location or point in the brain where the hypersensitive neurons are located causing teh seizure activity

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37
Q

Seizures: All people have what threshold?

A

Seizure threshold, and when exceeded, seizure occurs

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38
Q

Seizures: What can cause a seizure?

A

Patient how low seizure threshold, or pathologic condition has altered the seizure threshold

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39
Q

Seizures: What is needed to make diagnosis of epilepsy?

A

2 or more seizures that can be minutes or years apart

40
Q

Seizures: What are kids diagnosed as if they have a seizure while having a fever?

A

Febrile Seizure, and does not count toward epilepsy

41
Q

Seizures: What are the two classifications of seizures?

A

Partial Seizures (Begin in one hemisphere of the brain)

Generalized Seizures: (Involve the whole brain)

42
Q

Seizures: Two parts of Partial Seizures?

A

Simple Partial: LOC remains intact

Complex Partial: Impairment of Consciousness

43
Q

Seizures: What specific information for Simple Partial Seizure? Motor, Sensory, ,Autonomic, and Psychic

A

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

44
Q

Seizures: What specific information for Complex Partial Seizure? With Automatisms and Aura

A

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

45
Q

Seizures: What are some types of Generalized Seizures?

A

Absence (Petit Mal) : LOC Impaired

Tonic-Clonic (Grand Mal): LOC Impaired

46
Q

Seizures: What happens with an Absence Seizure?

A

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

47
Q

Seizures: What happens in Tonic-Clonic Seizures?

A

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)

48
Q

Seizures: Some signs of a Tonic-Clonic Seizure?

A

Foaming coming from mouth, hyperventilaiton. Happens during the clonic contraction/relaxation phase.

May sleep for several hours after events

49
Q

Seizures: How to prevent these?

A

Avoid Triggers

Prevent Status Epilepticus - Do not Stop meidcations

Medicate fevers for febrile seizures

50
Q

Seizures: What are the risk factors for getting this?

A

Cerebrovascular Disease

Hypoxemia

Fever (Child)

Head Injury/Hypertension

CNS Infections

Metabolic /Toxic Condition

Brain Tumor

Drug/Alcohol Withdrawal

Allergies

Hypoglycemia

51
Q

Seizures: How to assess for this?

A

Observe patient signs and symptoms

How long does it last

Any Triggers? (Flashing lights, menses, fatigue)

Assess respiraotry status during and after

52
Q

Seizures: What is Status Epileptics?

A

Seizure activity becomes continuous and we cannot stop it. Requires immediate intervention

53
Q

Seizures: What can Status Epilepticus lead to?

A

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)

54
Q

Seizures: Medical Management for Status Epilepticus?

A

Maintain airway (Priority)

50% dextrose to prevent hypoglycemia

Ativan, Valium Repeat q 10 min

55
Q

Seizures & Interventions of Seizures: Observe and document what?

A

Patient signs and symptoms before, during, and after seizures

56
Q

Seizures & Interventions of Seizures: Perform after seizure care to prevent

A

complications

57
Q

Seizures & Interventions of Seizures: What is Epilepsy?

A

Chronic disorder of recurring, excessive, or self-terminating electrical discharge from neurons

58
Q

Seizures & Interventions of Seizures: What can you do if someone is having a seizure?

A

Maintain Airway

Turn on Side

Seizure Pads

Protect Head

Do not hold patient down

Suction airway if needed

Loosen clothing around neck

59
Q

Seizures: What are some nursing diagnosis?

A

RF Ineffective Airway Clearance

RF Injury

Anxiety

REadiness for Enhanced Knowledge

Unstable Blood GLucose

Impaired Gas Exchange

60
Q

Seizures: What do to with Risk for Ineffective Airway Clearance?

A

Provide oxygen, turn patient to side, loosen clothing around neck, and do not force anything in mouth suction if needed

61
Q

Seizures: What to do for Risk for Injury?

A

Do not hold down pad area

62
Q

Seizures: What should the driver do driving wise?

A

No driving for 6 months - 2 years

63
Q

Seizures: When should you call 911?

A

If seizure lasts over 5 mins, difficulty breathing after seziure, or second seizure occurs

64
Q

Seizures: What are some goals for this?

A

Avoid complications, maintain airway, prevent injury, maintain blood glucose, and adhere to medical management

65
Q

Seizures: Labs to test for this?

A

EEG

Medication Levels in Serum

CT, MRI

66
Q

Seizures: How to help an individual have Readiness for Enhance Knowledge?

A

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

67
Q

Headache: Also known as

A

cephalgia

68
Q

Headache: What happens here?

A

Cerebral blood vessels first narrow and reduce blood flow, then there is vasodilation, swelling, and pain

69
Q

Headache: What is a primary headache?

A

No known organi cause and includes migraine, tension headache, and cluster headache

70
Q

Headache: What is a secondayr headache?

A

Symptom with an organic cause such asb brain tumor or aneurysm

71
Q

Headache: Headaches may cause what in terms of lifestyle?

A

Significant discomfort for the person and can interfere with activites and lifestyle.

72
Q

Headache: Risk Factors for this?

A

Exposure to toxins

Medication side effects

Family History

Stress

73
Q

Headache & Migraine: How long does this last?

A

4-72 hours

74
Q

Headache & Migraine: Where does the pain radiate?

A

Unilateral throbbing pain, intensifies with movement (can become bilateral)

75
Q

Headache & Migraine: What signs can occur?

A

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

76
Q

Headache & Cluster Headache: What is this?

A

Extremely severe, unilateral, burning pain behind or around the eyes

77
Q

Headache & Cluster Headache: What are signs do they have?

A

Rhinorrhea (Nose Runs), facial edema, miosis (excessive shrinking of pupil), ptosis (dropping of upper eyelid)

78
Q

Headache & Cluster Headache: How long do these last for?

A

Several weeks or months, followed by remission (episode lasts 15 mins to 3 hours)

79
Q

Headache & Cluster Headache: What time of year do these occur?

A

Fall or spring

80
Q

Headache & Cluster Headache: What time do they begin?

A

2-3 hours after going to sleep

81
Q

Headache & Migraine: Patients may have what before a migraine headache?

A

An Aura, where they can tell its coming

82
Q

Headache & Assessment: What should you obtain?

A

Detailed description of headache. Include medication history and use

Types of headaches manifest differently, so they may change over time

83
Q

Headache & Assessment: Persistent headaches requires what?

A

Investigation

84
Q

Headache & Assessment: What is required of a person undergoing a headache evaluation?

A

Detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes

85
Q

Headache & Assessment: Diagnostic testing may be used to evaulate

A

underlying cause if there are abnormalities on the neurologic exam

86
Q

Headache & Assessment: What labs will be performed?

A

None for Primary

Neurological Exam

CT, MRI

87
Q

Headache: What complications can occur??

A

Impairment in ability to carry out life tasks

88
Q

Headache: What can be used be used for recurrent migraines?

A

Prophylatic medications (Topamax). Taken everyday

89
Q

Headache: Migraines and Cluster headaches requires what meds

A

abortive medications instituted as soon as possible with onset

90
Q

Headache: What comfort measures can be provided?

A

Quiet, dark room

Massage

Local heat for tension

91
Q

Headache: Goals for this?

A

Pain relief

Prevention of headache

Ability to complete ADLs

92
Q

Headache: What can be dome triggers to cause this?

A

Rapid Change in Glucose

Emotional Exictemenet

Fatigue

Alcohol

Tyramines (Chocolate, Red Wine, Aged, Cheese, Bagged Veggies)

Artifical Sweeteners

Menses

93
Q

Headache: What education can be provided?

A

Avoid Triggers

Take Aboritive medicine as soon as headahcne appears

94
Q

Headache: What should patient do to prevent headaches?

A

Medication instruction adn treatment regimen

Stress reduction techniques

Nonpharmacologic therapies

followup care

Encourage healthy lifestyle

95
Q

Headache: What Tyramine foods can cause headaches?

A

Chocolate, Red Wine, Aged Cheese

96
Q

Headache: Nursing Diagnosis for this?

A

Acute pain

Nausea

Impaired Sensory Perception

Diarrhea

Fatigue

97
Q

Headache: Medical Management for this?

A

Prophylaxis Meds (Topamax)

Oxygen for Cluster headaches

Abortive Medicine (Relpax, Imitrex)

NRSG 110: Med Surg 2 (29 decks)

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