human needs final: nervous system Flashcards
what is considered IICP
> 20
early S+S IICP (4)
- pupil changes
- change in LOC
- headache
- vomiting not preceded by nausea
late S+S IICP (6)
- HTN
- bradycardia
- hypoventilation
- decreased LOC
- abnormal motor function
- abnormal response to pain
cushings triad (seen in IICP)
- increased Sbp
- bradycardia
- irregular respirations
nursing considerations IICP (3)
- hob 30
- O2/ventilator
- keep head midline
emergency Tx head injury (6)
- patent airway
- stabilize neck
- O2 through nonrebreather
- IV
- intubate if GCS<8
- control external bleeding
pt teaching after head injury (5)
- 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
Tx bacterial meningitis (5)
- antibiotics
- manage fever
- pain control
- seizure precautions
- resp isolation
pt teaching of S+S of stroke
FAST:
- face drooping
- asymmetry
- slurred speech
- time to call 911
stroke prevention (7)
- limit alcohol
- healthy weight
- regular exercise
- no smoking
- normal blood glucose
- low fat, low salt diet
- bp management
emergency management stroke
- assess ABCs
- call stroke team
- remove dentures
- SpO2 (give O2 if needed)
- IV
- CT
cause of most strokes
uncontrolled HTN
what can UAP do for pt with stroke (4)
- VS
- measure urine output
- position and turn pt q2h
- passive and active ROM
what does bladder retraining look like for stroke pt (4)
- adequate fluid intake
- scheduled toileting q2h
- observe for signs of restlessness
- assess for bladder distention
initial interventions for seizure (5)
- ensure patent airway
- protect from injury
- turn to side
- remove/loosen tight clothing
- ease pt to floor
what can UAP do for pt with seizure (4)
- place suction equipment and O2 at bedside
- remove harmful objects and pad bedrails
- report seizures to RN
- VS after seizure
pt teaching of triggers to avoid with MS (3)
- fatigue
- extreme temps
- exposure to infection
nursing considerations for pts with parkinsons (5)
- remove rugs
- simplify clothing
- elevated toilet seats
- elevate legs when sitting
- manage sleep problems
important assessment for pt with myasthenia gravis
-respiratory distress
emergency management spinal cord injury (4)
- patent airway
- SpO2 (give O2 if needed)
- IV (keep Sbp above 90)
- stabilize C spine
Tx autonomic dysreflexia (4)
- hob 45
- assess for and remove cause (bladder, bowel, clothing)
- notify HCP
- monitor bp and VS
how often should pt reposition in chair
q15-20 mins
