Final Exam Module 1 & 2 Flashcards
Status epilepticus is a medical emergency. It is continuous or rapidly occurring seizures. What does it cause?
brain damage, arrhythmias, hypoxemia, & acidosis
What is considered to be “impending status epilepticus?”
Seizure activity lasting longer than 5 minutes
What do we do for status epilepticus?
Initially, intravenous lorazepam/diazepam is administered to stop motor movements. This is followed by the administration of phenytoin.
May require endotracheal intubation for airway protection
Steps to Seizures
What do we do first?
Seizure Management Pearls
Protect the patient from injury.
Do not force anything into the patient’s mouth.
Turn the patient to the side to prevent aspiration and keep the airway clear.
Remove any objects that might injure the patient.
Suction oral secretions if possible without force.
Loosen any restrictive clothing the patient is wearing.
Do not restrain or try to stop the patient’s movement; guide movements if necessary.
Steps to Seizures
What medications?
IV push lorazepam or diazepam.
What do all anticonvulsants cause?
All anticonvulsants can cause drowsiness, ataxia (lack of coordination) and CNS depression (resp. depression)
Levetiracetam (Keppra): best choice for outpatient,
most popular, monitor CBC.
Phenytoin: causes gingival hyperplasia, bone marrow
suppression, rash, IV vesicant, monitor blood levels
and CBC (q3 months).
Carbamazepine: causes bone marrow suppression,
monitor blood levels and CBC.
Divalproex (Depakote): causes hepatotoxicity, bone
marrow suppression, monitor CBC, blood levels and
LFTs.
Steps to Seizures
What do we do once the seizure has stopped?
Reorient the pt.
Record the time the seizure began and ended.
Check blood glucose levels. Seizures can occur due to hypoglycemia.
Make sure airway is clear.
Ask if they have felt an aura before the seizure or have triggers.
How do we differentiate between bacterial
and viral meningitis? Which one is worse?
Meningitis is an acute infection and inflammation of meninges.
Differentiate by CSF analysis w/ lumbar puncture
Bacterial meningitis is an acute, life threatening emergency.
Good prognosis for viral meningitis.
What type of precautions is used for meningitis?
droplet
Clinical Presentation of Meningitis
-Headache like they have never felt before
-Nuchal rigidity, back of the neck is stiff
-Nausea/vomiting
-Photophobia: eye discomfort due to exposure to light
-Brudzinski Sign: flexion of the neck elicits flexion of hips and knees
-Kernig Sign: bilateral hamstring pain prevents straightening of the leg
What is the most important thing to monitor for meningitis?
level of consciousness
What do we do stat with bacterial meningitis?
Requires STAT LP followed by immediate IV antibiotics.
Do not give antibiotics before the LP, can skew the results.
What do we do for viral meningitis?
supportive care- antipyretics, hydration, and rest
What is the priority assessment post craniotomy?
-Monitor for and prevent increased ICP is the PRIORITY
Followed by:
-Observe dressing
-Prevent infection (handwashing)
-Monitor neurological status
-Monitor fluid and electrolytes
-Monitor for diabetes insipidus: during surgery the pituitary gland be affected
-Prevent complications of immobility: DVT prophylaxis, skin breakdown
What is the drug of choice for cerebral edema?
Dexamethasone (Decadron)
What is the difference between a primary spinal cord injury and a secondary injury?
Primary Injury: Initial disruption of cord.
Secondary injury: on-going damage from ischemia, inflammation, toxic metabolites, and edema.
What types of shock should you look out for w/ spinal cord injuries?
Neurogenic- damage to the nerves themselves
Hypovolemic- fluid loss
What is our priority with cervical spinal injuries?
Above C4 requires mechanical ventilation
C3, 4, & 5 keep the diaphragm alive.
All cervical injuries cause respiratory insufficiency meaning the pt will have
-Decreased cough
-Decreased vital capacity
-High risk of atelectasis and pneumonia
What do we see in spinal shock?
Due to acute spinal injury
Loss of motor, sensory and reflex activity at the level of injury and below:
-Flaccid paralysis
-Flaccid bladder
-Paralytic ileus- gut is going to slow down or stop
-Loss of sensation
-Decreased or absent reflexes
Can last days to months. Spasticity may emerge after spinal shock resolves.
Who has the highest risk of developing neurogenic shock?
High risk w/ injury above T6
What sets neurogenic shock apart from spinal shock?
hemodynamic phenomenon
What are the three critical features of neurogenic shock?
Hypotension
Bradycardia
Poikilothermia
All other shocks have hypotension and TACHYcardia
What is the cause of autonomic hyperreflexia?
distended bladder and fecal impaction
We need to dis-impact them or drain their bladder or their BP will continue to go through the roof.
What are the priority symptoms of autonomic hyperreflexia?
Severe, life-threatening hypertensive crisis.
Other sx include: HA, blurred vision, diaphoresis, & flushing
What is the nursing care for autonomic hyperreflexia?
-Elevate HOB to help reduce BP (PRIORITY)
-Monitor BP
-Remove noxious stimuli
-If BP remains elevated administer BP medication
-Close neuro assessment
Immediate Post- Spinal Cord Injury
-Immobilize injury w/ backboard & neck brace
-Prioritize ABCs
-Comprehensive neuro assessment (touch, pain, muscle strength)
-Methylprednisolone (Solu-Medrol) can help w/ inflammation
-Maintain MAP between 80-90 (may require dopamine)
-NG tube for ileus
-Stress ulcer prophylaxis with a PPI
-DVT prophylaxis (SCDs & Lovenox)
What is the formula to calculate MAP?
(SBP + 2DBP) / 3
What is a Transient Ischemic Attack (TIA)?
“Mini-stroke”
Reversible cerebral ischemia. Usually precedes thrombotic stroke: “Warning sign”. Commonly caused by carotid stenosis.
What is the ABCD assessment tool for stroke risk?
Age of at least 60 years
BP of at least 140/90 (either SBP, DBP, or combination)
Clinical TIA features
Duration of symptoms
What is the medication management for TIA?
Antiplatelets drugs such as aspirin or Plavix
What are other management techniques for TIA?
ABCS of stroke management
-Blood pressure management
-Controlling diabetes, if necessary
-Lifestyle changes: smoking cessation, encouraging physical activity, dietary management
What are the two types stroke?
Ischemic (occlusive) and Hemorrhagic (bleeding)
What are the two types of ischemic strokes? What is the main cause of each type?
-Thrombotic –> Atherosclerosis
-Embolic –> A-Fib
What are the 4 types of hemorrhagic strokes? What is the main cause if each type?
-Intracerebral hemorrhage –> severe or sustained HTN
-Subarachnoid hemorrhage –> ruptured aneurysm or AVM rupture
-Aneurysm
-Arteriovenous malformation (AVM) –> congenital abnormality
What is FAST?
Facial dropping, arm pain, slurred speech, & time=brain
Interventions for cerebral aneurysms
clipping and coiling
Thunder clap headache
Subarachnoid hemorrhage
What are the hallmark signs/sx of a stroke?
-Sudden weakness
-Difficulty talking
-Difficulty understanding
-Severe headache with no known cause
What is the first priority for stroke patient?
Ensure pt is transported to a stroke center.
Complete focused/rapid assessment. Remember that there is always a risk that LOC will change.
Broca’s aphasia vs Wernicke’s aphasia
difficulty talking vs difficulty understanding
Emergent Care Stroke
-Assess ABCs
-Provide oxygen (this is an ischemic issue)
-2 Large bore IVs
-Take blood samples and blood glucose
-Perform NIH Stroke Scale
-Order a non-contrast CT- must be read within 45 minutes
-Obtain 12-lead to look for A-fib
-Do not delay CT to get ECG
Within 45 minutes of the patient’s arrival, the specialist must decide, based on the CT scan, if a hemorrhage is present.
Take these actions if a hemorrhage is present:
-Note that the patient is not a candidate for fibrinolytics.
-Arrange for a consultation with a neurologist/neurosurgeon.
-Consider transfer, if available.
If it is hemorrhagic you need to get a
neurosurgeon consult ASAP
Within 45 minutes of the patient’s arrival, the specialist must decide, based on the CT scan, if a hemorrhage is present.
Take these actions if a hemorrhage is NOT present:
-Decide if the patient is a candidate for fibrinolytic therapy.
-Review criteria for IV fibrinolytic therapy
-Repeat the neurological exam (NIHSS)
If ischemic- assess criteria for tPA
What is the criteria?
Period of time between symptom onset and arrival time to the stroke center.
FDA approves use of tPA within 3 hours of stroke symptom onset.
The American Stroke Association endorses 4.5 hours, if no exclusion criteria are present.
Exclusion criteria for tPA
Age older than 80 years
Anticoagulation therapy
Baseline NIHSS score greater than 25
History of both stroke and diabetes
Evidence of active bleeding
BP greater than 185 systolic or 110 diastolic
History of cerebral bleed
Elevated PT/INR
If they are not a candidate for tPA, what is next?
Endovascular interventions
Mechanical embolectomy- MERCI Retrieval System
Intra-arterial thrombolysis: tPA is delivered directly to the thrombus within 6 hrs of symptom onset
Carotid artery angioplasty with stenting
Carotid Endarterectomy (CEA)
Mechanical embolectomy- MERCI Retrieval System is for patients that do not qualify for tPA or fail tPA therapy. Has to be completed
within 8 hours of stroke onset
If we do a carotid endarterectomy, what do we watch for?
swelling in the airway
Nursing Care for Stroke
-FALL PRECAUTIONS
-Transfer to the strong side
-Place objects in their visual field and approach them from the unaffected side
-NPO until swallow study
-Sit up 90 degrees
-Assess gag reflex
Concussion
What is second impact syndrome?
A second concussion that occurs before the brain can completely recover from the first.
Can result in massive cerebral edema.
What are the clinical manifestations of an epidural hematoma?
Arterial bleeding into the space between the skull and the dura. Faster bleed.
-Immediate post-traumatic unconsciousness, followed by “lucid interval”
-Rapid deterioration in LOC may follow, up to and including death
-Ipsilateral pupil enlargement
-Increasing headache
-Seizures
-Motor weakness
What do we do for an epidural hematoma?
Requires emergent surgical evacuation
Is a subdural hematoma emergent or nonemergent?
nonemergent, but can be fatal.
Sx are less severe and is a slower bleed.
What are the three components of ICP?
Normal ICP is 10-15 mm Hg
-Brain tissue
-Blood
-Cerebrospinal fluid (CSF)
How do we calculate Cerebral Perfusion Pressure (CPP) and what does it mean?
MAP-ICP= CPP
Pressure needed to ensure adequate perfusion of brain
CPP ranges
CPP 70-100 normal
CPP 50-60 minimum required for adequate cerebral perfusion
CPP < 50 brain ischemia, neuronal death
CPP <30 incompatible with life
What are the clinical manifestations of increased ICP?
-Change in level of consciousness (LOC)
-Headache and projectile vomiting.
-Compression of CN III Oculomotor (“blown pupil”)
-Cushing’s Triad (systolic hypertension, widened pulse pressure, bradycardia)
-Decorticate & Decerebrate posturing
-Brain stem herniation
-Death
ICP Management
Priority is to manage ICP
*Mechanical ventilation to maintain PO2 > 100
*Maintain SBP between 100-160
*Maintain CPP > 70 (70-100 is normal)
*Osmotic Diuretic (Mannitol)- treats cerebral edema, takes swelling out of the brain by pulling water out of the
extracellular space decreasing brain edema
*Loop Diuretics
*Anticonvulsants- increased ICP= increased risk for seizures
*Fentanyl may be used to help manage agitation when patients are ventilated
*HOB elevated to 30 degrees and head midline
*Limit suctioning and stimulation
Eye Trauma Priorities
-Assess peripheral vision
-Antibiotics can be given to prevent infection
-NEVER TAKE OUT THE FOREIGN BODY
-MRI is contraindicated because it can pull out the object and the eye
Eye Trauma – Foreign Bodies
Particles may come in contact with the conjunctiva or cornea
Patient complaints:
Blurry vision; feeling like something is in the eye
Sensory perception is assesses prior to treatment
Irrigate with 0.9% NS
Eye dressing or patch may be applied after foreign body is removed
What is the RN’s priority?
Priority is to assess peripheral vision!
To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be assessed. The patient may or may not need enucleation. The object is only removed by the ophthalmologist.
Name COPD complications
Hypoxemia
Acidosis
Respiratory infections
Right sided HF
Cardiac dysrhythmias
Respiratory failure
What would a chest x-ray look like for a COPD pt?
Often hyperinflation > flattened diaphragm + widely spaced ribs
Oxygen therapy for COPD
- SPO2 levels *
All hypoxic patients, including patients with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SPO2 levels between 88-92%.
Anything above that can decrease respiratory drive.
What type of medications do we use for COPD pts?
Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
NSAIDs
Mucolytics
What type of breathing technique can we teach COPD pts?
pursed lip breathing
What is the diet for a COPD patient?
high protein & high calorie
Seasonal influenza is a highly contagious acute viral respiratory infection. Sx include:
Rapid onset of severe headache, muscle ache, fever, chills, fatigue, weakness, anorexia.
What is the time limit for antiviral agents when treating seasonal influenza?
- Drugs end in -ivir *
24-48 hours
Not effective after 48 hours
When is seasonal influenza contagious?
Contagious between 24 hours before symptoms occur – 5 days after symptoms begin.
Isolation is key to prevent spread
What are the complications associated with seasonal influenza?
pneumonia & death
Supportive care for seasonal influenza
-Rest
-Increase fluid intake (take precautions with fluid restrictions)
-Saline gargles to reduce throat pain
-Antihistamines for rhinorrhea
Rapid influenza diagnostic test has high false-negative rates. Do you retest?
No, provide supportive care based on sx.
Prevalent among animals and birds. Virus can mutate and become infectious to humans.
Examples: H1N1 (swine flu), H5N1 (bird flu), MERS, SARS, COVID-19
Strict isolation precautions- contact and airborne until specific type of pandemic influenza is identified w/ routes of transmission known
Pandemic influenza
Pandemic influenza tx includes:
Treatment is often supportive:
-recover at home and avoid exposures
-encourage rest and fluids
-acetaminophen for myalgias
Antiviral drugs can be started within the first 48 hrs of symptom onset
*Oseltamivir (Tamiflu), zanamivir (Relenza)
Pneumonia is caused by excess fluid in lungs resulting from inflammatory process.
What are some symptoms?
purulent sputum, fever, pleuritic chest pain
other sx: increased RR/dyspnea, hypoxemia, cough
What should we see on a chest x-ray for pneumonia pt?
consolidation in lobes
What should we always monitor for pneumonia pts?
always monitor pulse ox and vital signs
Nursing care for pneumonia
Improve gas exchange
-Oxygen therapy, incentive spirometry
Prevent airway obstruction
-Cough and deep breathing exercises Q2 hours
-Fluid promotion to thin secretions
-Bronchodilators for bronchospasms
-Inhaled or IV steroids for inflammations
-Expectorants (guaifenesin)
Prevent sepsis
-Anti-infectives for bacterial sources
-Prevent aspiration
Prevent/manage empyema
-Antibiotic management
-Chest tube may be needed to promote lung expansion and drainage
What are two ways we can prevent pneumonia?
smoking cessation and immunization
What is the most common substance to cause Pulmonary Embolus (PE)?
Collection of particulate matter—solids, liquids, air—that enters venous circulation and lodges in pulmonary vessels usually occurs when a blood clot from a venous thromboembolism in leg or pelvic vein breaks off and travels through the vena cava into the right side of the heart.
blood clots
Sx of PE
sense of impending doom, dyspnea, coughing up blood (hemoptysis), syncope, distended neck veins
Risk factors for PE
prolonged immobilization, central venous catheters, surgery, pregnancy, obesity, advancing age, conditions that increase blood clotting, hx of thromboembolism, other causes- Air, amniotic fluid and fetal debris, foreign objects, injected particles, fat, and infected clots.
Health Promotion & Maintenance Lifestyle changes for PE
No smoking, weight reduction, increased physical activity, DO NOT massage leg muscles
- If traveling, drink plenty of water, change positions often, avoid crossing legs, and get up from sitting position 5 minutes of each hour.
PE Treatment includes
-Oxygen, elevate HOB, comfort patient
-Anticoags/fibrinolytic
-IV fluids for hypotension –> vasopressors used if it persists
-Surgical management may be necessary
Acute Respiratory Failure
What is the problem with ventilatory (hypercapnic) failure?
-Physical problem of lungs or chest wall
-Defect in respiratory control center in brain
-Poor function of respiratory muscles, especially diaphragm
Acute Respiratory Failure
What causes ventilatory (hypercapnic) failure?
CNS depression, neuromuscular disorders
Acute Respiratory Failure
What is the problem with oxygenation (gas exchange) failure?
-Insufficient oxygenation of pulmonary blood at alveolar level
-Ventilation normal, lung perfusion decreased
-Right to left shunting of blood
-Ventilation/perfusion (V/Q)mismatch
-Low partial pressure of O2
-Abnormal hemoglobin
Acute Respiratory Failure
What causes oxygenation (gas exchange) failure?
Pneumonia, ARDS, pulmonary edema
Can you have combined? If so, what causes it?
yes, often occurs in patients with lung disease: Chronic bronchitis, Emphysema, asthma
Diseased bronchioles and alveoli cause oxygenation failure; work of breathing increases; respiratory muscles unable to function effectively.
Acute Respiratory Failure symptoms include:
*restlessness, irritability, and agitation
*Dyspnea
*Decreased responsiveness
*Confusion
*Increased dyspnea or decreased effort (especially in hypercapnic failure in patients with COPD)
What is refractory hypoxemia?
hypoxemia that persists even when 100% oxygen is given
What do we see on a chest X-ray in ARDS pt?
Dense pulmonary infiltrates on chest x-ray
What is the main site of injury in ARDS?
Alveolar-capillary membrane is main site on injury
-Increased permeability to larger molecules (debris, protein and fluid). Lungs are going to get stiff.
-Thick exudate inhibits gas exchange
What will vital signs shows in ARDS pt?
HTN, tachycardia, & dysrhythmias
ARDS pts require intubation and PEEP. What is PEEP?
Positive end-expiratory pressure, is a pressure applied by the ventilator at the end of each breath to ensure that the alveoli are not prone to collapse.
What are the three phases of ARDS?
Exudative phase
Fibrosing alveolitis phase
Resolution phase
What do we see during the Exudative phase?
Pulmonary shunting and atelectasis (alveoli becoming fluid filled). Appears as lung infiltrates on CXR. Pulmonary edema in the absence of heart failure. Inactivation of surfactant.
Presentation:
Acute onset
Dyspnea
Restlessness and confusion
Tachycardia
Diffuse crackles
Dry cough
What do we see during the Fibrosing alveolitis phase?
What complication are they at risk for?
Increased lung injury > pulmonary HTN and fibrosis. Decreased gas exchange and oxygenation.
MODS
What is happening during the Resolution phase?
Usually occurs after 14 days
Resolution of injury may occur or damage has resulted in chronic lung disease
Mortality rate very high if patient reached this phase
What happens if the pt is bucking the vent?
sedate pt
What is the VAP Bundle?
-Elevation of the HOB between 30 and 45 degrees
-Oral care per facility policy (including antimicrobial rinse)
-Preventing aspiration
-Peptic ulcer disease prophylaxis
-Pulmonary hygiene (chest physiotherapy, postural drainage, turning and repositioning)
Pulmonary Contusion occurs after chest trauma & inhibits gas exchange. Sx include:
Bloody sputum, decreased breath sounds, crackles, wheezes
How do we treat a pulmonary contusion?
Maintenance of ventilation and oxygenation
Rib fractures are often caused by direct blunt trauma to the chest. Chest usually not splinted by tape or other materials.
Uncomplicated rib fractures reunite spontaneously.
Focus is on pain management, why?
Decrease pain so that adequate ventilation is maintained
Encourage incentive spirometer
Flail Chest is r/t two or more rib fractures causing the chest wall to destabilize.
What will you see on assessment with flail chest?
Paradoxical chest movement—“Sucking inward” of loose chest area during inspiration, “puffing out” of same area during expiration.
What will you see on the assessment of tension pneumothorax?
-Asymmetry of thorax
-Tracheal movement away from midline toward unaffected side
-Respiratory distress
-Absence of breath sounds on one side
-Distended neck veins (r/t increase in central venous pressure)
-Cyanosis
-Hypertympanic sound on percussion
How do we treat tension pneumothorax?
chest tube to decompress the area and help lung expand
