NS Flashcards
1
Q
GCS
Scoring system range?
Range for severe head injury or coma?
Range for moderate head injury?
Scoring system?
A
Score between 3-15
Between 3-8 = severe head injury and/or coma
Between 9-12 = moderate head injury
Eye opening: (4) spontaneous (3) response to voice (2) response to pain (1) no eye opening
Verbal Response: (5) coherent (4) incoherent/disoriented (3) inappropriate words (2) sounds, no words (1) none
Motor Response: (6) follows commands (5) local reaction to pain (4) general w/d to pain (3) decorticate (2) decerebrate (1) none
2
Q
MS
What is it? Age of onset? Triggers? S/s? Hint: EE Meds (3)?
A
- Autoimmune disorder; plaque develops in CNS white matter; periods of relapsing and remitting
- Around 20-40 years; more common in women
- Temp extremes, stress/injury, pregnancy, fatigue
- Eye problems (diplopia, nystagmus), ear problems (tinnitus, hearing issues), dysphagia, fatigue, muscle spasticity, weakness, bowel/bladder dysfunction, cognitive changes
- Immunosuppressants (cyclosporine), anti-inflammatory (prednisone) muscle relaxants (dantrolene, baclofen)
3
Q
Amyotrophic Lateral Sclerosis (ALS)
What is it?
S/s?
Nursing care? Monitor for…
Primary med?
A
- Degenerative disorder of upper & lower body neurons; leads to progressive paralysis , eventually causing respiratory paralysis in 3-5 years. Cognitive function is NOT impacted. No cure.
- Muscle weakness & atrophy
- Maintain airway (suction/intubate as needed), monitor for PNA & RF
- riluzole (slows down deterioration of the motor neurons, extends the patient’s life by 2-3 months)
4
Q
Myasthenia Gravis
What is it? Neurotransmitter? Associated with? S/s? Hallmark? Diagnosis method? Antidote? Care? Eye care? Meds? Procedures/surgery?
A
- Autoimmune disorder that causes severe muscle weakness. Caused by antibodies that interfere with acetylcholine @ NMJ. Characterized by periods of exacerbation and remission. Assoc. with thymus hyperplasia
- muscle weakness (worse with activity), diplopia, dysphagia, impaired respirations, incontinence. Hallmark: drooping eyelids
- Give edrophonium, which increases Ach at NMJ. If improves = myasthenic crisis. If worsens = cholinergic crisis. Antidote is atropine.
- Maintain airway (oxygen, suction, intubation equipment at bedside), encourage rest periods, provide small, frequent high-calorie meals, have patient sit upright when eating, thicken liquids. Administer lubricating eyedrops. Tape eyes shut at night to prevent cornea damage
- Anticholinesterase agents and immunosuppressants
- plasmapheresis (removes antibodies from the plasma) also thymectomy (removal of thymus)
5
Q
Meningitis
What is it? Types? Prevention? S/s? Diagnosis? Nursing care? Teaching? Meds?
A
- Inflammation of the meninges (membranes around the brain and spinal cord). Viral = most common and resolves without treatment and Bacterial = contagious with high mortality rate
- immunizations to prevent bacterial meningitis. Hib vaccine given to infants & MCV4 given to students living in dorms
- headache, nuchal rigidity, photophobia, N/V, positive Brudzinski’s and Kernig’s sign. Fever, altered LOC, tachycardia, seizures
- CSF: bacterial = cloudy CSF, low glucose content. Viral = clear. BOTH elevated WBC and protein
- Droplet precautions until atbx are administered for 24 hours. Quiet environment, LOW lights. HOB 30 degrees. Monitor for increased ICP, instruct patients to avoid coughing/sneezing, implement seizure precautions
- atbx, anticonvulsants
6
Q
Lumbar puncture
What is it?
Indications?
Pre-procedure?
Post-procedure?
A
- CSF sample taken from spinal cord for analysis
- Diagnose MS, syphilis, meningitis, infection from CSF
- HAVE PT VOID. Position in cannonball position on their side, or patient can stretch over table while sitting. Back is rounded.
- Patient should LAY FLAT for several hours. If the dura puncture site does not heal, CSF may leak which causes a headache (give pain meds and encourage fluid intake). Epidural blood patch can be used to seal off the hole (puncture site)
7
Q
Spinal Cord Injury
Paraplegia? Quadriplegia? Upper motor neuron injuries? Lower motor neuron injuries? Meds (4) Main concern(s)?
A
- Paraplegi: Injuries below T1; paralysis/paresis of lower extremities
- Quadriplegia: Injuries in the cervical region; paralysis/paresis of all 4 extremities
- Upper Motor: Above L1/L2; spastic muscle tone, spastic neurogenic bladder (higher = spastic)
- Lower Motor: Below L1/L2; flaccid muscle tone, flaccid neurogenic bladder (low = slow)
- Meds: glucocorticoids (reduce spinal cord edema), vasopressors (treat hypotension r/t neurogenic shock), muscle relaxers (baclofen, dantrolene), stool softeners
(in addition to bowel/bladder schedule/cathing) - Neurogenic shock & autonomic dysreflexia
8
Q
Autonomic dysreflexia
What is it? Hint: Stimulation of _____ with inadequate ____ response.
S/s? Hallmark?
Nursing care?
A
- for spinal cord injuries above T6; stimulation of the SNS with inadequate PNS response
- extreme HTN (hallmark), severe headache, diaphoresis, blurred vision, flushing above injury/pallor below, tachypnea, bradycardia
- sit the patient up (lowers BP), notify MD, determine the cause (distended bladder, fecal impaction, tight clothing, undiagnosed injury). Treat the cause (cath patient, remove the impaction, removing tight clothing), administer anti-HTN meds
9
Q
Neurogenic shock
What is it? Occurrence?
S/s? (2 main ones)
Care?
A
- occurs after SCI for several days to weeks
- (Bradycardia, hypotension) = main, dependent edema, temperature regulation issues (poikilothermia);
- Keep patient warm
10
Q
Macular degeneration
What is it?
S/s?
A
- central loss of vision. #1 cause of vision loss in patients > 60 y/o. No cure
- blurred vision, loss of central vision, blindness
11
Q
Cataracts?
What are they?
S/s?
Operation and considerations?
Teaching?
A
- opacities in lens of the eye impairing vision; common with aging
- decreased visual acuity, progressive PAINLESS loss of vision, diplopia, halo around lights, photosensitivity, absent red reflex
- wear sunglasses, avoid increasing ICP; teach the patient to not bend over at the waist, avoid sneezing & coughing/straining, avoid hyperflexion of the head and restrictive clothing, avoid tilting the head back to wash the hair, limit housework and rapid/jerky movements
- Teach that best vision occurs about 4-6 weeks after surgery
12
Q
Glaucoma
What is it? Types? IOP? Meds (3)? Teaching? Post-op?
A
- Increase in IOP due to issue with the optic nerve. Leading cause of blindness
- Open angle: most common, Aqueous humor outflow is decreased leading to a GRADUAL increase in IOP. Causes mild eye pain, loss of peripheral vision
- Closed angle: less common. Angle between the iris and sclera close completely, leading to a SUDDEN increase in IOP, causing severe eye pain, nausea
- Normal is 10-21 mmHg. Measured using tonometry. Measure drainage angle with gonoscopy
- pilocarpine (constricts the pupil), beta blockers (timolol, which reduces aqueous humor production), mannitol (osmotic diuretic quickly reduces IOP ; for closed angle)
- administer 1 drop in each eye BID. wait 5-10 between eye drops. don’t touch tip of the applicator to eye. Place the pressure at lacrimal duct (puncta) after installation
- same teaching with cataract surgery
13
Q
Meniere’s Disease
What is it? RF? Otoscopic exam? Ear pull/what should you see? Meds (3) & Considerations? .. Hint: Cole has Meniere's Teaching? : Diet? Lifestyle? Surgery?
A
- inner ear disorder resulting in tinnitus, unilateral sensorineural hearing loss, vertigo, vomiting, balance issues
- viral/bacterial infections, ototoxic medications
- pull auricle BACK & UP for adults and children >3, DOWN & BACK for children <3. Tympanic membrane should be pearly gray and intact. Light reflex 5 o’clock right ear, 7 for left
- antihistamines, anticholinergics, antiemetics (meclizine, droperidol, diphenhydramine, scopolamine). Watch for signs of urinary retention and sedation
- avoid caffeine and ETOH, rest in a quiet/dark place when experiencing severe vertigo, space the intake of fluids throughout the day, lower salt intake
- stapedectomy, cochlear implant, labyrinthectomy
14
Q
Migraine Headaches
RF/Triggers?
Top 3 S/s? Pain persistence duration? Aura?
Nursing care?
Meds?
A
- allergies, bright lights, fatigue, stress/anxiety, menstrual cycles, foods containing MSG, tyramines, and nitrates
- photophobia, N/V, unilateral pain (usually behind one eye or one ear), can happen with or without an aura (visual disturbances, numbness/tingling). Pain persists for about 4-72 hours
- provide cool, dark, quiet environment, teach patient to reduce stress and avoid triggering foods
- NSAIDs (mild migraine), antiemetics, sumatriptan or ergotamine for more severe migraines
15
Q
Cluster Headaches
What kind of pain, how long does it persist and where does it radiate?
2 Factors unique to cluster headaches…?
More common in..?
Meds?
A
- severe, unilateral non-throbbing pain that radiates to forehead, temple, cheek. Persists for 30 min-2 hours; usually occurs daily at the same time for 4-12 weeks. More frequent in the spring and fall (seasonal).
- Facial sweating and nasal congestion
- More common in men between 20-50 years old
- sumatriptan, ergotamine
