module 5 Flashcards
neuro assessment 5
- glasgow coma scale: LOC eye opening, motor response, verbal response
- PERRLA
- Hand grips- strength and command
- babinski reflex abnormal if >1 year old
- deep tendon reflexes
ICP s/s
S/S:
Early: change in LOC, slowed speech/response, restless,
confusion
Late: Marked change in LOC, vital sign changes,
Cushing’s triad: systolic HTN, widening pulse pressure,
slow bounding pulse, irregular respirations (Cheyne‐
Stokes)
psych depression s/s
tx
loss of interest, negative view, anhedonia-loss of pleasure, related to loss
appearance: unkept, weight gain w mild, weight loss w severe, crying, no energy, tired
suicide risk- ask them.
tx: needs accomplishments, no false praise, need activity., need assistance
suicide assessment 5
tx
- increase risk when medication started
- sudden change in mood for the better
- increase risk in elderly men and native americans
- plan- have one? how lethal?
- watch: will writing, isolation, giving away things
tx: direct closed ended statements, safe environment
hemothorax and pneumothorax a/p
s/s
tx
a/p: pleural space should be slammed shut! hemo: blood/fluid. pneumo: air
s/s: SOB, increase hr, diminished breath sounds and movement, chest pain, cough, subc emphysema,
tx: chest tube
thoracentesis
pre: consent form, stop anticoags, chest x ray and baseline vs, position: lean over chair or table or lie on unaffected side with HOB 45
post: be still- dont cough, fluid removed from pleural space and lungs re expand, check VS and compare with baseline, watch for FVD and re- xray chest for success
what does a positive babinski mean
there is a severe problem in the central nervous system that is affecting an upper motor neuron
ICP early and late signs
early: change in LOC, slurred or slow speech, increase drowsiness, confusion, restlessness for no apparent reason
late: LOC progressing to stupor then coma, cushings triad
- systolic HTN with a widening pulse pressure. slow/full bounding pulse, irregular respirations
anytime you have a client with a head injury, if they start complaining of a headache…
assume icp is going up
treatment for IICP
reducing cerebral edema, reducing volume in the brain
maintain cerebral perfusion for oxygenation
maintain adequate cerebral perfusion- no hypotension because that would decrease brain perfusion
keep temp below 100.4
kep head midline
elevate HOB
nursing interventions should be spaced
HYPERTONIC SOLUTIONS
what diuretic is good to pull fluid off the brain and filter it out through the kidney; decreases ICP
mannitol
meningitis
what is it
s/s
tx
- inflammation of the covering of the spinal cord and brain. can be viral or bacterial which is transmitted through the respiratory system
- chills, high fever, severe headache, nuchal rigidity, disorientation, seizures, positive kernig and brudzinski signs, photophobia
tx: antibiotics, corticosteroids, analgesics, droplet precaution for bacterial,contact precautions for viral
difference between a closed tbi and a open tbi
closed: brain is injured but the skull is not broken, fractured, or penetrate. the dura is not torn
open: brain injury where the skull is broken, fractured, or penetrated. the dura is torn in a penetrating injury.
when to bring patient to ED with concussion
difficulty awakening/speaking, confusion, severe headache, vomiting, pulse changes, unequal pupils, on sided weakness; ICP IS GOING UP
autonomic dysreflexia
what is it
s/s
tx
upper spinal cord injury (t6) with exaggerated response to certain stimuli that are harmless to someone without a spinal cord injury
s/s: severe HTN, distended bladder or impaction of stimuli, bradycardia, nasal stiffness, flushing, sweating, blurred vision.
tx: sit client up to lower BP, treat the cause, remove any impaction
CT scan
takes pictures in layers to allow seeing inside the objects
MRI
magnetic use that looks at organs and structures inside the body. examining the brain and spinal cord
pet scan
image test to view parts of the brain or any organ as it is working
this is has the colors
cerebralangiography
series of timed xrays of the cerebral circulation using dye; images of blood vessels in and around the brain
EEG
records electrical brain activity
diagnosis for seizures, sleep disorders, cerebral infarcts; evaluates LOC and dementia, indicator of brain dead
mania
s/s
tx
continuous high, flight of ideas, delusions of grandeur and persection, constant motor activity , manipulation and poor judgement
tx: decrease stimuli, dont argue or try to reason, set limits and be consistent, supply finger foods and fluids
ECT
pre and post
used for severe depression
pre: NPO, void, atropine to dry up secretions, signed consent
post: position client on side, stay with them, temporary memory loss, reorient them repeatedly, return to day to day activities ASAP
schiz
s/s
tx
inappropriate affect, flat affect, or blunted affect. looseness of associates, ineffective communication skills (echolalia- repeating words they hear)
(neologism- making up new words), word salad, hallucinations
tx: decrease stimuli, keep conversations reality, observe frequently and observe for hallucinations
let client know you dont share the preception
paranoid personality
s/s
tx
always suspicious, pathologic jealousy, unemotional, abnormal anger response
tx: be reliable and build trust! consistent nurses and brief visits. always ID meds, sealed foods
restraints
orders must be renewed: every 4 hours for adults every 2 hours for 9-17 every hour for less than 9 years old check on client q 15 minutes
with psych clients
stay away from sedation meds and restraints
anxiety
universal emotion but becomes a disorder when it interferes with day to day functioning
need step by step instructions
generlized anxiety disorders
s/s
tx
chronic anxiety, always seeks help, fatigue
tx: short term use of anxiolytics, relaxation techniques, re channel anxiety through exercise
* pick most exerting answer*
panic disorders
client may be seen as having an MI
TX: stay with the client in a non threatening way, breathe with them, use simple words
phobias
desensitizations is key to recovery and must occur overtime (gradual exposure to fear)
do not talk about phobias a lot
OCD
obsessive thoughts and compulsion is a recurrent act
tx: structured schedule, provide distraction techniques to distance themselves from anxiety producing thoughts
anorexia
lanugo, decreased sexual development, lose weight, hypothermia
tx: weight them in their underwear, monitor exercise, allow clients input into choosing healthy foods
bulimia
overeat then vomit
teeth erosion, laxative and diuretic use, normal weight
tx: sit with client 1 hour after eating, allow 30 minutes to eat
ptsd
emotional numbness, difficulty with relationships, isolate themselves
tx: establish sense of safety, support groups,
alcohol med
chlordiazepoxide- anxiolytic that is frequently used for outpatient detox
B vitamins for brain function
alcohlists defense mechanisms
rationalization and denial
opiate intoxication
pinpoint pupils, respiratory depression, coma
opioid withdrawl
tx
anxious, nausea, vomiting, muscle aches, excessive tearing and running nose, sweating, pupil dilation
tx: methadone- dont get addicted to this
s/s of hemothorax/pneumothorax
tx
SOB, diminished breath sounds on affected side, less movement on affected side, chest pain
tx: thoracentesis, chest tube, daily chest x ray
tension pneumo
what is it
causes
s/s
pressure has built up in the chest/pleural space and has collapsed the lung
- too much PEEP, clamping a chest tube, taping all 4 sides without an air valve
- asymmetry of thorax, resp distress, cyanosis, JVD, absence of breath sounds on one side
open pneumo thor
what is it and tx
opening through chest that allows air into the pleural space
tx: have client inhale and hold or valsalva or hummmmm to increase the intra-thoracic pressure so no more outside air can get into the body then tape 3` sides down
what is the purpose of a water seal chamber
to promote one way flow out of the pleural space which will prevent air from moving back up the system and into the pleural space
may see bubbling in this chamber when the client coughs, sneezes, or exhales
might see a slight rise and fall of water as the client breathes - tidaling. NORMAL
suction control chamber
controls the amount of pressure applied. slow, gentle bubbling is normal
anytime you see peep, cpap, or bi pap your priority is
check lung sounds bilaterally
bipap
pressure applied at two different pressure settings. one on inhalation and a lower pressure on exhalation
cpap
pressure is delivered continuously during inspiration and expiration
pulmonary embolism
s/s
best test
thrombosis that has broken off and lodges in a lung artery
s/s: hypoxemia, chest and back pain on inspiration increase RR, restlessness, petechiae over chest, hemoptysis (coughing up blood), increase pulse, increase BP
test: pulmonary angiography
aPTT
30-40 seconds
PT
11-12.5 seconds
INR
0.8-1.1
prevention of pulmonary embolism
change position every 2 hours, TED hose, hydrate by forcing fluid,prevent stasis by flexing and extnding feet, knees, and hips every 2-4 hours
while on warfarin
limit green leafy vegetable servings to what is normally eaten. do not increase servings
complications of alcohol use disorder
thiamine and niacin korsakoffs syndrome wernickes syndrome gastritis Mg and K SEIZURES delirium tremens liver and pancreas prob
