Med Surg: Neurologic Nursing Care Flashcards
What are rapid neurologic assessments?
Glasgow coma scale: lowest score is 3 (eyes open, verbal and motor response), more cerebral cognition the higher the score with 15 highest
Response to painful stimuli: meaure interaction with environment, assess depth of unresponsivenedd, dont hurt patient
LOC
Posturing
Pupil assessment
What are neuro lab and diagnostic tests?
blood cultures: meningitis, bacterial, viral, inflammation issues, abcess or encephalitis
Skill & spine x-ray: bony prominences, fragments of skull, depression of bone-rupture
Cerebral angiography: blood supply and flow
CT scan: tumors, other abnormalities
What is an electroencephalography?
Graphically records the electrical activity of the cerebral hemispheres
Sleep deprivation requirement
Anticonvulsants possibly withheld
What are clinical manifestations of neurological disease: Headaches?
Migraine headache
Often accompanied by a sensitive scalp, anorexia, photophobia, phonophobia, nausea
Aura often present
Three R’s
- Recognize
- Respond
- Relieve
What is drug therapy for Migraine?
Abortive therapy: use auras or onset for best results
Aceaminophen or NSAIDS are usually effective for mild migraines
May need anti-nausea drugs
What is Migraine Preventative Therapy?
NSAID prescription: may take around click if not controlled well
Beta-adrenergic blocker: peripheral vasodialtion because migraines caused by constriction
Antidepressants and antiepiletptic drugs: migraine control
What are other interventions for migraines?
Yoga, meditation, massage, exercise, biofeedback, relaxation techniques
Acupuncture
Diet
Avoidance of trigger events
What are cluster headaches?
Histamine headaches:
- uncommon
- cause unknown
- attributed to vasoreactivity and oxyhemoglobin desaturation
Unilateral, radiating to forehead, temple or check
Ipsilateral tearing of the eye, rhinorrhea, ptosis and miosis
What are interventions for cluster headaches?
same types of drugs used for migraines
clinet to wear sunglesses and avoid sunlight
oxygen via mask
avoidance of precipitating factors, such as anger, excitement: avoid oxygen desaturation, such as emtotional distress
What are the seizure types?
Single
Multiple
Spontaneous
What is epilepsy?
Chronic disorder with recurrent, unprovoked seizures
Can occur after severe head trauma
What are seizure risk factors?
metabolic disorders
Acute alcohol withdrawal
electrolyte diturbances
Hypoxic states
What are seizure precautions?
oxygen and suctioning equipment
saline lock
place bed in lowest position: safety, protection, get to floor, pillow under head, on side/belly prevent aspiration
never insert padded tongue blades into clinets mouth during seizure
What is seizure management?
If simple partial seizure, observe clinet and document seizure
turn client on side during generalized tonic-clonic seizure
cyanosis usally is self-limiting
do not restrain
Drug therapy for a seizure?
Combination drugs
Take with or without food
Maintain therapeutic blood levels for maximal effectiveness
