Module 7 Flashcards
For patients with cognitive impairments it is more effective to communicate using one step rather than two step questioning and/or instructions. Explain the difference and give examples.
A way of communicating with those with cognitive impairment, by clear succinct instructions or questions. One main point or ask at a time.
One step Process Preferred:
Pick up the pen.
Now write your name.
Two Step Process:
Pick up the pen and write your name.
One-Step Question Preferred:
We need to order your lunch for tomorrow; do you feel like chicken? (Yes/No)
How about beef? (Yes/No)
Would you prefer a sandwich instead? (yes/no)
Multi-step Question
We need to order lunch for tomorrow. Do you feel like chicken, beef or a sandwich?
Describe the trajectory of deterioration if signs and symptoms of rising intercranial pressure are missed and there is failure to act?
Failure to act on elevated ICP can result in a higher risk of mortality and permanent neurological impairment.
Delayed treatment worsens tissue hypoxia within the brain, further increase oedema and injury.
Under normal circumstances, cerebral blood flow is maintained constant over a range of cerebral perfusion pressures by auto regulation. Changes in ICP and blood pressure may alter blood volume as a result of dilation or constriction of cerebral blood vessels. This in turn will have an influence on ICP, further increasing pressure.
Compression of the optic nerve due to oedema will result in impaired pupillary responses.
The cranial vault is divided into compartments by the dura of the falx cerebri and tentorium cerebelli. Raised ICP frequently results in pressure gradients between these compartments and a shift in brain structures, known as herniation.
Changes in blood pressure, pulse and respiratory pattern are usually late signs of raised ICP in clinical practice. These signs are related to brain stem distortion, herniation or ischaemia.
What is the Monro-Kellie Hypothesis?
The Monro-Kellie doctrine states that the cranial cavity is a closed rigid box and that therefore a change in the volume of blood, tissues or CSF will result in the displacement of one or two of the other components. For example, if the quantity of intracranial blood increases this will result in the displacement of CSF.
Describe how you would assess neurological functioning using the acronym AVPU?
The AVPU scale is a system easily applied to initially assess a patient’s neurological status. Can measure and record a patient’s responsiveness, indicating their LOC. Following this initial assessment, a formal assessment of GCS is performed.
A = Alert: is the patient alert and responsive? V = Verbal: does the patient respond to verbal commands? P = Pain: does the patient respond to painful stimulus? U = with no response to any of the above, the patient is considered Unconscious.
Falls and the consequences in the elderly population are becoming increasingly common. What interventions would you put in place to minimise the risk for an elderly patient in hospital?
Falls risk assessment and plan. MMSE Non-slip socks Aids and equipment nearby (hearing aids, walking frames/sticks, glasses, urinal bottle) Call bell within reach Bed lowered to the ground Supervised mobilisation Nurse near nursing station PCA/HAS 'guard' if patient is confused Medication review and minimise agents known to cause falls such as antidepressants, diuretics, sedatives and antihistamines.
Define the following:
Alzheimer’s Disease
Progressive mental deterioration that can occur in middle or old age, due to generalised degeneration of the brain. It is the commonest cause of premature senility.
Define the following:
Multiple Sclerosis
Progressive disease involving damage to the myelin sheaths of nerve cells in the brain and spinal cord. Symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue.
Define the following:
Parkinson’s Disease
Also known as idiopathic or primary Parkinsonism, hypo kinetic rigid syndrome (HRS) or paralysis agitans.
Progressive degenerative disorder of the CNS mainly affecting the motor system.
Define the following:
Motor Neuron’s Disease (MND)
Progressive disease involving degeneration of the motor neurone and wasting of the muscles.
Define the following:
Huntington’s Chorea
Generic neurodegenerative disorder that affects muscle coordination and leads to mental decline and behavioural symptoms. Symptoms usually appear when person is in their 40s. Behavioural problems are thought to be caused by a combination of events, including damage to the brain as the disease progresses and the understandable frustration and depression that people feel when challenged by chronic illness.
Define the following:
Epilepsy/Seizures
“Chronic disorder of the brain characterised by recurring seizures” (WHO, 2012). Neurone (nerve cells) carry messages via discharging electrochemical energy. In normal function the impulses occur in bursts when the cell has a task to perform. In epilepsy, there is continual firing of impulses after cell task is finished, causing erratic performance of the body parts controlled by the errant neurons. This results in dysfunction which ranges from mild to severe and incapacitating seizures which often causes unconsciousness. Causes are varied but categorised as idiopathic (unknown) and acquired.
Types of seizures are simple partial, complex partial and generalised (Grand-Mal).
What is the nursing management of a patient during a seizure?
DRABCDE
Call MET
DO NOT attempt to pry open jaws that are clenched during a seizure as this may cause injury to teeth, lips or tongue.
Provide privacy (close door, pull curtain, portable screen)
If possible, ease the patient to the floor.
Protect the head from injury with a pillow, blanket or other padding.
Loosen constrictive clothing.
Remove risks such as furniture that may cause injury.
If the patient is in bed, remove pillows and raise bed rails (check hospital policy regarding this as it is considered a form of physical restraint).
What is the nursing management of a patient post seizure?
DRABCD
Place patient in the recovery position.
Ensure airway is patent (short apnoeic period may occur)
Patient may be confused for a time after a generalised seizure.
Reorient patient to environment when regain consciousness.
If patient is agitated post seizure, use calm gentle persuasion and seek assistance if required.
Vital signs (patient at risk of hypoxia, pulmonary aspiration)
Document seizure in integrated progress notes.
