human needs final: nervous system Flashcards
1
Q
what is considered IICP
A
> 20
2
Q
early S+S IICP (4)
A
- pupil changes
- change in LOC
- headache
- vomiting not preceded by nausea
3
Q
late S+S IICP (6)
A
- HTN
- bradycardia
- hypoventilation
- decreased LOC
- abnormal motor function
- abnormal response to pain
4
Q
cushings triad (seen in IICP)
A
- increased Sbp
- bradycardia
- irregular respirations
5
Q
nursing considerations IICP (3)
A
- hob 30
- O2/ventilator
- keep head midline
6
Q
emergency Tx head injury (6)
A
- patent airway
- stabilize neck
- O2 through nonrebreather
- IV
- intubate if GCS<8
- control external bleeding
7
Q
pt teaching after head injury (5)
A
- notify HCP of any complications (drowsiness, N/V, seizures, vision changes, motor/sensory problems)
- have someone stay with you
- no alcohol
- check with HCP before taking drugs that can cause drowsiness
- avoid driving, hot baths, and sports
8
Q
Tx bacterial meningitis (5)
A
- antibiotics
- manage fever
- pain control
- seizure precautions
- resp isolation
9
Q
pt teaching of S+S of stroke
A
FAST:
- face drooping
- asymmetry
- slurred speech
- time to call 911
10
Q
stroke prevention (7)
A
- limit alcohol
- healthy weight
- regular exercise
- no smoking
- normal blood glucose
- low fat, low salt diet
- bp management
11
Q
emergency management stroke
A
- assess ABCs
- call stroke team
- remove dentures
- SpO2 (give O2 if needed)
- IV
- CT
12
Q
cause of most strokes
A
uncontrolled HTN
13
Q
what can UAP do for pt with stroke (4)
A
- VS
- measure urine output
- position and turn pt q2h
- passive and active ROM
14
Q
what does bladder retraining look like for stroke pt (4)
A
- adequate fluid intake
- scheduled toileting q2h
- observe for signs of restlessness
- assess for bladder distention
15
Q
initial interventions for seizure (5)
A
- ensure patent airway
- protect from injury
- turn to side
- remove/loosen tight clothing
- ease pt to floor
