exam 4 study guide Flashcards
What causes an increased intracranial pressure?
- Changes to the components of the brain ( CSF, intravascular blood, brain tissue
- Monro-Kelli Doctrine
• sum of the volumes of the brain tissues, CSF and intracranial pressure
• Changes lead to compensatory efforts to stay in homeostasis
• Inability to compensate leads to increased ICP - Pressure itself…any pressure changes in the body ( INCREASED BP, intrathoracic and abdominal pressure )
What are some of the key characteristic symptoms of an increased intracranial hemorrhage?
- Changes in LOC (first sign)
- Changes in motor function (loss of strength, loss of coordination)
- Stroke like symptoms (vague for ex: like headache, vomiting)
What are some of the late clinical manifestations of increased intracranial pressure?
- Decerebrate (extension) and Decorticate (flexion) positioning
- Herniation of the brain stem or contents
- Cushing triad
o Widen pulse pressure (systolic HTN)
o Bradycardia (bounding, very loud)
o Irregular respirations (irregular tachycardia)
- Changes in oculus o Dilation o Symmetry o Reaction o Coma or unconscious
What are some treatment and intervention options for increased intracranial pressure?
- Assess neuro function
- Diagnostic studies
o CT o MIR o PETS o Doppler o Angiography o Labs o Measuring ICP (using ventriculostomy to measure and drain ICP and using spiral drain for the same thing) o NO LUMBAR PUNCTURES
- Surgical interventions
o Craniotomy - Drugs
o Anti-seizure
o Antipyretics
o Sedatives
o Analgesics
o Barbiturates
o Mannitol (plasma expansion, osmotic effect, monitor fluid and electrolytes)
o Hypertonic saline (moves H2O out of the cells and into the blood, monitor b/p and serum Na+ levels)
o Nimodipine (CCB—hypertensive management of ICP)
Ischemic strokes ( thombolic, embolic)
most common = inadequate blood flow to brain from partial or complete occlusion of an artery
CAUSES o Occurs from injury to a blood vessel wall and formation of a blood clot o Results in narrowing of blood vessel o Often associated with HTN & DM o Can be proceeded by TIA
Thrombotic ischemic strokes
clot formation narrowing of the lumen blocks the passage of blood through the artery.
CAUSES
o Occurs when an embolism lodges in and occludes a cerebral artery
o Results in infarction and edema of area supplied by involved vessel
Embolic ischemic stroke
blood clot or other debris circulating in the blood reaches an artery in the brain that is too narrow to pass through lodges and block blood flow.
Hemorrhagic strokes ( intracerebral, subarachnoid, cerebella )
most dangerous = burst blood vessel allow blood to seep into and damage brain tissues until clotting shuts off the leak.
Intracerebral hemorrhagic stroke
bleeding within the brain tissue itself caused by a ruptured vessel
CAUSE: hypertension is the most common cause
Subarachnoid hemorrhagic stroke
Intracranial bleeding into CSF-filled space between arachnoid and pia mater
CAUSE: Commonly cause by rupture of a cerebral aneurysm, trauma, drug abuse
Hemorrhagic stroke manifestations
o Neurological deficits o Severe headache o Nausea and vomiting o Deceased LOC o Hypertension
- Sudden onset with progression over mins to hours
- Extent of Sx varies and depends on amount, location and duration of bleeding
- Loss of consciousness may or may not occur
- Survivor suffer complications & deficits
Ischemic stroke manifestations
o Numbness or weakness of the face, arm or leg, esp. on 1 side of the body
o Confusion and change in mental status
o Trouble speaking or understanding speech
o Visual disturbances
o Difficulty walking, dizziness, loss of balance or coordination
o Sudden severe headache
- Warning signs are less common
- Patient usually remain conscious
What are some appropriate nursing interventions for taking care of stroke patients?
- Assessments
o Neurological system
o Skeletal, cardiovascular, respiratory
o NIH stroke scale
- Diagnostics o Early diagnosis is the key o CTA o MRA o MRI o CT’s early diagnosis of a stroke ▪ CT Angiography ▪ CT Perfusion o Doppler o Lumbar punctures o Lab studies
What are some drug therapy interventions for stroke patients?
- Anticoagulants o For ischemic patients only o Aspirin, antiplatelet - All strokes o Antihypertensive ▪ Nomodipine o Anti-seizures o Cholesterol medications
Tissue Plasminogen Activator (tPA). What is this for?
- Clot buster
o Converts plasminogen to plasmin
o Must screen patient prior to use, frequently monitor, assess for bleeding
o Cut off time is 3-4.5 hours for medications to be effective
What are the criteria for this clot busters (TPA)?
- Inclusion
o Age 18 and older
o Onset of symptoms <3 hours
o Ischemic stroke causing neurological deficits
o Patient and family verbalize understanding risk vs benefits of IV tPA - contraindicated
o Elevated b/p systolic >185 or diastolic >110
o Patients with a bleed or taking anticoagulants, history of bleed or brain injury
What are risk factors for the development of a stroke?
- Non-modifiable o Age ▪ Risk doubles each decade after 55 o Gender ▪ More common in men ▪ More women die o Ethnicity/race ▪ Higher in African Americans o Hereditary and family Hx
- Modifiable o HTN o Heart disease o DM o Cholesterol o Smoking o Obesity and lack of exercise o Sleep apnea o Metabolic syndrome o Drug and alcohol abuse o Poor diet
What are some factors that triggers or worsen strokes?
- Worsen hemorrhagic stroke o Active bleeding o Use of anticoagulants, antiplatelet, aspirin o Blood thinners - Hypertension makes all strokes worst - Buildup of plaques - Deoxygenation
What are some diagnostic tests for strokes? What diagnostic test is most important to order first?
- All as mentioned previously
- CT’s and MRI are the most important—order CT first
Scalp Lacerations (head injury)
- External head trauma
- Scalp is highly vascular à profuse bleeding
- Blood loss and infection are major complications
head fractures
- Linear fracture
- Depressed fracture
- Diastatic fracture
- Basilar fracture
• Infection, hematoma, and tissue damage are complications
Focal injuries localized
- Contusions
- Hematomas
Diffuse injuries generalized
- Concussions
- DAI
What some of the key characteristic symptoms of those types of basilar head injuries
o Raccoon eyes
o Battle’s signs
What some of the key characteristic symptoms of those types of focal head injuries
Pounding, excruciating headache
confusion = retrograde amnesia
What are some treatment and intervention options for those head injuries?
- Early diagnosis and early planning = best nursing intervention
- Surgeries
o Craniotomy—burr holes
o Craniectomy if extreme swelling
o Devices such as braces and helmets - Check for ICP
- Assessment
- Diagnosing
- Maintain level of temperature
- Management of medications
LUPUS Clinical Manifestations
lupus = connective tissue disorder
- photosensitivity = careful when it comes to sunlight
- oral ulcers
alopecia - morning stufness
- tachypnea ( rapid respiration)
- cough
- sezures
anemia
increased risk for infection - WHEN IT STRATS TO AFFECT KIDNEYS WE KNOW THAT THE LUPUS HAS REALLY PROGRESSED (may need dialysis, transplant)
- different types of rashes (discoid rash, malar rash)
MOST COMMON= BUTTERFLY RASH (rash on their nose and their cheeks)
LUPUS labs
- Antinuclear antigen (ANA) = 97% of ppl with lupus has a positive ANA
- C reactive Protein INCREASED
- Sed Rate/ESR INCREASED
- CBC decreased cus they have anemia
- Blood, Protein and casts (sediment) in urine
- Positive antiphospholipid antibody
Osteoporosis with LUPUS
Teach and watch for
- fall
- safety
- weight bearing exercises
- calcium and vitamin D ( check the levels )
DEPENDING ON THE OSTEOPOROSIS THEY CAN BE ON MEDICATIONS
Teaching FO LUPUS
- Prevent infection
- watch the sun (photosensitivity) even if they have sunblock
- TELL THEM THEY CAN GET ARTHRITIS
- NO SURGERY - theres meds
- WANT THEM TO DECREASE STRESS
- check their weight ( LOSS OR GAIN)
LUPUS findings requiring further assessment
- report signs of infections
- fever, weight loss, malaise, very tired, lethargic, sore throat
GOUT assessments
Assessment ASK ABOUT - pain, subcutaneous nodules, fatigue, fever anorexia, weight loss - is the joint red, hot, swollen - difficulty moving their joint
ONE THING YOULL SEE IS TOPHI (uric crystals which can start to break up through the skin)
when a patient has high uric acid level
- they cant metabolize purine (protein) which leads to a build up of uric acid
- any patient with build up uric acid due to cancer or kidney problems can develop gout
- starts in the big toe (trauma, lack of circulation
Diet for GOUT
- low purine diet NO PURINE OR SOME AVOID - meats - seafood - broth - oatmeal - pasta - noodles - alcohol - dry beans
they can have some of these foods (limited amount) but they may be a trigger leading to GOUT ATTACK
medications for gout
some of these medications are actually for inflammation and to reduce uric acid in our body
anti inflammation drugs
- COLCHICINE ( colcrys) = can also prevent an attack
- Indomethacin (indocin)
Reduce uric acid drugs
- ANTURANE/sulfinpyrazone
- probenecid
- allopurinol (zyloprim)
CAN THEY BE ON COLCHICINE AND ALLOPURINOL = YES because they don’t do the same thing! one is for inflammation one is uric acid reducer
OSTEOARTHRITIS risk factors
- OBESITY!!! most important
- age
- decreased estrogen at menopause
- trauma or injury (anterior cruciate ligament)
- frequent kneeling and stopping
- another form of arthritis
- family history
- more females
- ## REMEMBER TO ASK ABOUT childhood orthopedic condition = CONGENITAL HIP DISLOCATION, slipped capital femoral epiphysis, leg cath perthes disease
OSTEOARTHRITIS assessments
DO THEY HAVE
- pain
- stiffness
- crepitation ( rubbing of bones together )
- any nodules? ( subscue, herberden nodules, BUSCHAR NODULES
- parenthesia ( they feel it before it even rain or is cold )
OSTEOARTHRITIS teachings
- wanna make sure they exercise ( daily moderation exercise of what they can do to help with their pain and discomfort
- can manage their pain ( Tylenol, motrin, topical )
- ice for inflammation
- heat for stiffness
- medication teachings
hyaluronic acid = they put in joint to lubricate the joint NOT USED AS MUCH
HIP FRACTURE pre op
- immobilize the fractured part
- neurovascular assessment
- type of traction they’ll be in for a hip/leg fracture = bucks traction
BUCK TRACTION (SKIN TRACTON): patient put in before hip surgery
FRACTURES complication
- fat embolism = blood clots that travels and has fat in it
- compartment syndrome
infection - delay union, nonunion, malunion
- SHOCK
• hypovolemic shock from loss of blood and fluid
• septic shock from infection
maybe anaphylaxis
Fractures: Fat embolism CM
- blood clot that travels and have fat in it
CLINICAL MANIFESTATIONS
- depends on where it’s going
- confusion
- petechiae
- dyspnea
- tachycardia
- HYPERTHERMIA
- pallor leading to cyanosis
- cough
- chest pain
fractures: compartment syndrome
- build of fluid blood nowhere to go, pressing on bone
TREATMENT
- if they have dressing or cast: take them off
- fasciotomy
LAST POSSIBLE THING: amputation
HOW DO WE KNO THEY HAVE COMPARTMENT SYNDROME
- take the dressing off and feel for warm, hard, swollen
TEST TO DO
- wick catheter: measures the amount of MERCURY ( it can be a small fluid or mass )
Total hip replacement post op care
WATCH FOR
- severe pain (limping with walkin)
- leg appear shorter than the other leg
- raised toilet seat
- abduction pillow so hip does not turn in
- do not extend operation med
- no crossing of leg
- no driving FOUR TO SIX WEEKS
- no bending
- blood clots and infections
total knee replacement CPM Machine
purpose of CPM (continuous passive motion) MACHINE
- to promote flexion if the artificial joint
skin vs skeletal traction
SKIN TRACTION
- goes around the skin
- splint or ACE bandage
- like to stay in bed but if they like to use to the bathroom, REMOVE WEIGHT FIRST then they can go
SKELETAL TRACTION ( to the bone )
- use of pins
- go down to the procedure in their bed
- don’t get outta bed = use foley, bed pan, urinal
- check weights at the end of bed, top of the bed or both
RHEUMATOID ARTHRITIS pathophysiology
know the stages
- Synovitis= inflamed synovium
- pannus formation = granulation tissue
- ankylosis = stiffness hardness of the joint
RHEUMATOID ARTHRITIS diagnostics
- rheumatoid factor in the blood and synovial fluid
- x ray
- sed rate HIGH 0-20
- elevated C reactive protein (CRP)
- bone scan
IF THEY THINK GENETIC: can do genetic markers ( HLA, DR4 D27)
RHEUMATOID ARTHRITIS medications
DMARDs = disease modifying anti-rheumatic drugs • methotrexate • plaquenil - biological response modifiers - antibiotics - immunosuppressant - corticosteroids - nsaids
RHEUMATOID ARTHRITIS teachings
- teach about drugs they’re taking
- teach about disease process
- how they take care of themselves at home
- nutrition
- balance of rest and exercise ( rest if they have an attack)
- teach about pain management and what may work
- prevent contractures
- self help devices
- if surgery = post op care
OSTEOPOROSIS: FOSAMAX Teaching
brittle bone
improves bone loss
ALOT OF PATIENT CANT TAKE CUS OF ALOT OF INSTRUCTION
- irritate the esophagus and even cause bleeding
MAKE SURE THEY KNOW
- sit or stand for 30 mins after taking the drug
- take with full glass or water
- 30 mins before food or other meds
- DO NOT CHEW, SUCK THE PILL OR AT BEDTIME
if they cannot take fosamax, kno how to take it.
can they also take calcium? YES but monitor calcium levels!! speak to provider about which calcium is best for them cus you don’t want HYPERCALCIUM
- weight bearing exercise
- prevent fractures
- decrease alcohol
- decrease fatigue
CAUSES OF OSTEOMYELITIS
- osteomyelitis = bone infection and soread to other areas causing sepsis
CAUSES
- blunt trauma
- open wound
- foreign body
OSTEOMYELITIS clinical manifestations
- swelling
- tenderness
- warmth
- fever
- night sweats
- diaphoresis
- chills
- restlessness
- nausea
- malaise
LATER: drainage from the extremities
LABS OSTEOMYELITIS
- Sed rate ESR
- CRP ( c reactive protein ) elevate
- WBC elevated
complications osteomyelitis
- septic arthritis/septicemia
- pathological fractures
- amyloidosis = hardened, build ups that happens in some of the organs
SPINAL CORD INJURY plan of care
- cough and deep breath VERY IMPORTANT whether quadriplegic
- self catherization
• WE DONT KEEP A FOLEY IN PATIENT WITH SPINAL CORD INJURY( initially we do but when they go home = SELF CATHERIZATION)
• if they quadriplegic they cannot do it and need to have a family member or home aid
• if they are paraplegic they can do self catherization even though it won’t be an easy task - THEY NEED TO KNO WHEN TO CALL THE DOCTOR
• fever
• flushing
• headache
if they cannot see part of their body = USE MIRROR - WORRY ABOUT BOWEL AND BLADDER TRAINING
- THEY MOST LIKELY HAVE CONSTIPATION AND IMPECTION
- skin and hair breakdown important ( they won’t even kno cus they laying down and paralyze and can’t feel )
quadriplegic: limbs = HIGH INJURY = MORE COMPLICATIONS ( respiratory )
paraplegic: thoracic, lumbar area
SPINAL CORD complication
- Autonomic dysreflexia or HYPERteflexia
- they can die from it
CHECK THE TRIGGERS FOR AUTONOMIC dysreflexia/hyperreflexia
- if it’s a woman, menstrual cramps
- tight clothing
- UTI
- distended bladder
- foley if they have one
- HYPERTROPIC OSSIFICATION: extra brown forming around their joint = GIVE THEM Etidronate (DIDRONEL)
COMPLICATIONS MORE IMPORTANT THAN OTHERS
- spinal shock can be weeks or months
LEADING CAUSE OF DEATH IN SPINAL CORD INJURIES = pulmonary embolism
- constipation (bowel evaluation)
INCOMPLETE SPINAL CORD INJURY
- Anterior Cord Syndrome ( could recover )
• damaged to anterior spinal artery causing compromise blood flow from a FLEXION INJURY
• loss of pain and temperature sensation below the level of injury
• mortorparalysis - Brown-Sequard Syndrome
• damage to one half of the cord ( stabbed or shot )
• AFFECTED SIDE: loss of motor function, pressure position and vibration issue
• OTHER SIDE/ CONTRALAERAL: loss of light touch, pain and temperature sensation - Central cord syndrome
• damage to center of the spinal cord
• caused by HYPEREXTENSION OR HYPEFLEXION
• motor weakness and sensory loss and burning pain in UPPER EXTREMITIES
nursing diagnosis of spinal cord injury
- depends on the level of injury
CERVICAL = priority is respiratory
- skin integrity ( more important
- bladder and bowel alteration (more important)
- nutrition
- immobility
(more important) = those can cause autonomic dysreflexia and infection. reason why they’re more important than immobility cus they won’t even be able to walk
medications for spinal cord injur
- Etidronate (Didronel) = steroid given to patients who develop hypertrophic ossicatuon ( formation of new bone around their joint )
if a patient comes in the hospital and you suspect they have spinal cord injury GIVE STEROID!!!!
