Test 1 Flashcards
What is myasthenia Gravis and what are medications to treat it?
An auto immune disease where body has inability to transmit nerve impulses to voluntary muscles.
Meds- mestinon (neotigmine bromide), prostigmin, and mytelase (ambenonium chloride) to increase acetylcholinesterase neuromuscular function
What is Glasgow’s coma scale?
Score of 15 indicates-
Score of 7 or less -
Score of 3 or less -
And objective tool used for assessing consciousness and clients
15- fully oriented person
7- consider state of coma
3- lowest possible score/deep coma (no response )
What to do for low Glasgow’s coma scale scores?
Physician must be notified immediately and measures taken to decrease intracranial pressure
Pulpillary reactions and how to get a response ?
Size (symmetry), equality, and rounded of pupils may change and are assessed
Measure in mm
React to light by shinning a penlight obliquely into clients eye from outer edge of eye toward the center of eye.
Reaction may be brisk, sluggish, consensual,or non reactive
PERRLA is used when reaction is normal
What is a TIA?
Mini strokes and frequently precede a stroke. Which is caused by temporary impairment of blood flow to the brain
Risk factors of TIAs?
HTN , diabetes, atherosclerosis, aneurysm, cardiac disease , high blood cholesterol, obesity, sedentary lifestyle, smoking, stress, drug abuse (cocaine) , use of oral contraceptives, ppl with more than one of these are at greater risk
Types of TIA strokes -
Occurs as a result of an obstruction with in a blood vessel supplying blood to the brain.
Occurs when weakened blood vessel ruptured and bleeds.
Caused by a temporary clot.
Ischemic (clots)
Hemorrhagic
Transient ischemic attack
What meal safety precautions one should take with Parkinson’s disease ? When taking levodopa
Avoid a high protein diet
Protein may interfere with the medication absorption of levodopa into the brain.
Diagnostic testing of meningitis and encephalitis (swelling of brain)
Lumbar puncture
CBC
Treatment of meningitis / encephalitis and nursing interventions
Give Fluids to rehydrate client
Place client in isolation to avoid spreading virus
Antibiotics or anti-infectives
Corticosteroids and diuretics given for cerebral edema
Anticonvulsants to prevent seizures
What to teach a pt about anticonvulsant medications ?
Used to control seizures
Start one at a time and gradually increase doses
When d/c gradually decrease
Abrupt withdrawal can cause status epilepticus which is a prolonged seizure lasting at least 30 min
Monitor blood level for therapeutic range
Monitor for side effects of drug toxicity
Head injuries include trauma to where ?
Scalp, skull, brain
Caused by injuries of accreditation such as Baseball bat, car fourth, rotational force or whiplash, bullet
Brain injuries
Type of injury ? Skull fractures and penetrating injuries : bleeding from nose, ears , mouth , eyes.
*fluid may leak from ears
Open head injury
These Injuries are caused by blunt force it to the head such as concussion and laceration
Hemorrhage in the brain, hematomas,Cerebral Adema
Closed head injury
Device used for draining and maintaining adequate O2 levels and perfusion in brain after head injury
ICP
Other treatment for head injury?
Surgical decompression - alllows excess drainage
Meds - corticosteroids, muscle relaxants, diuretics, antacids
Early warning signs of severe head injury?
Consciousness, abnormal eye movement , pupil changes, abnormal vital signs, abnormal pulse , muscle weakness, muscle twitching, nausea, vomiting, visual or hearing disturbances
Nursing interventions for head injury?
Monitor I &O
Elevate head 30-40 degrees
Maintain airway and O2
Fluid restrictions
What is the purpose of suctioning in severe head injury patients ? Risks?
To decrease pulmonary complications
Risks include possible sudden increase in intercranial pressure (icp) and may cause further cerebral damage
Repositioning after back surgery?
Reposition using log roll turning to prevent injury to vertebrae and spine
Avoid twisting and limit sitting and bending
Chronic progressive degenerative disease of central nervous system - loss of myelin
MS - multiple sclerosis
What causes MS ?
What can trigger it ?
Autoimmune disease -
inflammation in the CNS the inflammation damages myelin which decreases nerve impulses in the body.
Stress , infections , pregnancy , trauma , fatigue,hit bathes or strenuous activity
Goals of MS ?
Reduce flare ups by:
taking medications ,
eating healthy diet,
exercise and staying active and independence
reduce stress, infections, and fatigue
Proper fluid intake
What kind of paralysis can spinal cord injuries cause?
Spinal shock
Areflexia
Flaccid paralysis
Neurogenic shock
Quadriplegia
Autonomic dysreflexia
Cessation of motor , sensory, autonomic and reflex impulses
Spinal shock
Absence of reflexes
Areflexia
Hypotension situation resulting from loss of sympathetic control of vital functions from the brain such as loss of ability to sweat below injuried area - can occur after CNS damage
Neurogenic shock
Complete under motor neuron injury , paralysis of both arms , legs , bowel and bladder and all four limbs
Quadriplegia
Can cause hypertensive crisis , bradycardia , severe headache , stroke or seizures - spinal cord injury at or above the sixth thoracic vertebral level T6
Autonomic dysreflexia
What will help ADLs and assessment with spinal cord injuries
Immobilization of headband neck and vertebral column , spinal column
Surgery : realignment of vertebral column
Medications- nifedipine, nitroprusside sodium
ROM and slow movements to prevent hypotension
Turn client frequently
Give calll light in reach
Adequate nutrition and fluid intake
Monitor vitals
Implement bowel and bladder training regimen
Assessment - Client input on pain , sensation and hx of accident
Clients respiratory status, airway breathing, circulation, disability, exposure, bowel and bladder function , skin condition, neuro assesment
Nursing interventions for autonomic dysreflexia?
Client education on causes and symptoms
Prevent bladder distention and fecal
Impaction
Observe for bradycardia , vasodilation, flushing, diaphoresis above site of injury
Raise HOB and lower legs to reduce bp and remove constrictive clothing
Asses urine for infection
Monitor bp q few min
Chronic sensory deprivation can cause what?
Inability to concentrate
Poor memory
Impaired problem solving ability
Confusion
Irritability
Mood swings
Hallucinations
Depression
Boredom and apathy
Drowsiness
A disorder that causes lens or its capsule to lose transparency and or become opaque
Clouding develops in the eyes as well as visual impairmentsAnd is associated with aging and usually affects both eyes
Cataracts
What to avoid with cataracts
Avoid reaching for objects
to maintain stability since depth perception is altered
Heavy lifting , straining during defecation, vigorous coughing and sneezing
Drugs for glaucoma
Drugs that enhance pupillary constriction
Miotics and choleinesterase inhibitors (cholinergic agonists)
timolol maleate
Pilocarpine hydrochloride
Betagan, diamox, alphagan
What does a hearing aide do?
It amplifies sounds to make them louder in order for one to hear better
Convert environmental sound and speech into electronic signals that are amplified and converted to acoustic signals
Nursing diagnosis of hearing loss
Social isolation related to hearing impairment
Nursing diagnosis of cataracts
Disturbed visual sensory perception
Risk for injury - due to processing visual images and depth perception
Home impaired maintenance- related to age limited vision or activity restrictions due to surgery
Interventions for hearing loss:
Hearing aids , surgical cochlear implant, how to mange such as using interpreter , writing notes, texting, computer, inform people who
Hearing loss caused by damage to the inner ear or the nerve from the ear to the brain.
Sensorineural hearing loss
occurs when there is a problem conducting sound waves anywhere along the route through the outer ear, tympanic membrane (eardrum), or middle ear (ossicles).
Conductive hearing loss
caused by a combination of conductive damage in the outer or middle ear and sensorineural damage in the inner ear (cochlea) or hearing/auditory nerve.
Mixed hearing loss
Also know as endolymphatic hydrops
An inner ear disorder that causes episodes of vertigo (spinning, tinnitus , uninlateral fluctuating hearing loss)
Ménière’s disease
Delivers radioactive isotopes directly within the body by sealed or unsealed sources. To kill cancer in the body.
Internal radiation
Nursing interventions for internal radiation ?
Prepare pt outside of room
Several nurses for lessened time
Wear lead apron or shield device ??
What labs to look for with chemotherapy
Look at platelet levels count <50,000 or less indicates bone marrow dysfunction , wbc of <500 indicates neutropenia
and RBC levels ?
A general state of ill health involving marked weight loss and muscle loss.
Cachexia
What foods to eat with cachexia ?
Small portions of complex carbohydrates
High calorie diet , no sugar
How to treat pain with cancer ?
Non invasive techniques such as heat, cold pack, massage, relaxation techniques, imagery, and hypnosis.
Drugs- Skin patches , slow release tablets, client controlled pumps
Nonopiods are the first step in nonopiods for mild to moderate pain
Morphine
Neurosurgical procedures such as nerve blocks
Telepathy Or High energy radiation delivered on outpatient basis
External radiation
Side effects of external radiation
Skin reactions, G.I. discomfort abdominal cramping, diarrhea, loss of appetite, and fatigue
What is used to protect skin and main gain position in external radiation
Customized shielding blocks and immobilization device ??
Radioactive implants place under anesthesia using radiological guidance. Lower dose permanent implants typically used . For internal radiation
Brachytherapy
Risks for cancer ?
Smoking or tobacco use
Family hx
Age
Hormones
Over exposure to the sun and indoor tanning
Unhealthy diet
Not exercising
Not getting tested /examinations
Not getting enough sleep
Unhealthy weight
Unprotected sex
Chronic inflammation
Immunosuppression
Alcohol
Fair complexion
Foods that increase cancer risk?
High fat foods/ red meats and high fat meats
Processed meat
Salt, sugar , and oily foods
Alcoholic beverages
How to decrease risk of cancer ?
Do not smoke , or use tobacco
Avoid tanning beds and sun
Healthy diet
Exercise
Physical examination
Sleep
Self exam
Healthy weight
Protected sex
Safety in work place client
What to monitor with thrombocytopenia?
Signs of bleeding , labs (low platelet count, Hgb, Hct, prolonged bleeding time. Bowel movements/constipation, pain, vital signs, and mental status.
Low level
Of platelets in the blood
Thrombocytopenia
Abnormally low count of a type of white blood cells?
Neutropenia
What kinda of food to eat with neutropenia?
Nothing that could be undercooked.
PasteriZed dairy
Cooked veggies and fruit
Starches
Protein
Care for people who are terminally ill who are expected to die In 6 months or less woh dignity in the comfort of the persons choice surrounded by loved ones
Hospice
seizure that involves loss of consciousness and violent muscle contractions
Tonic clonic seizure
Nursing interventions for tonic clonic seizures?
Turn client to the side to allow secretions to drain from the airway.
Prepare to suction oropharynx if necessary
Asses skin color and respiratory rate and depth after seizure
Give O2 PRN
Do not insert anything into mouth
Loosen restrictive clothing
Observe for injuries
After seizure , asses airway and turn to side
Ease client to the floor when it begins in supine positions
If I’m bed, use blankets or protective pads to line side rails
Low stimulative environment
Wear medical id tag
Client teaching of safe environment
Prepares the body for intense physical activity (fight or flight response)
SNS
Relaxes the body and inhibits it slows high energy functions ? (Conserves and restores)
PNS
Response to stress and prepares the body to react to danger part of the autonomic nervous system. Maintains homeostasis
Fight or flight response
The loss of full control of bodily movements
Ataxia
Posture of abnormal posturing in which a person is stiff with bent arms, clenched fists , and legs held out straight. Arms are bent in torwards body and the wrists and fingers are bent and held on the chest.
The posture is a sign of severe damage in the brain
Decorticate
A sensation perceived by a patient that proceeds a condition affecting the brain. It often occurs before a migraine or seizure. It may consist of flashing lights, a gleam of light, blurred vision, and order, the feeling of a breeze, numbness, weakness, or difficulty in speaking.
Aura
What may leak through ears in open head injury?
Cerebral fluid make leak through ears
What to do when some one has IV site pain?
Inspect site and remove needle if swelling
What causes diarrhea in ppl with cancer
And what to eat and drink?
Chemo, Radiation, surgery, bone marrow stem cell transplant, Infections, stress and anxiety, cancer it’s self
Drink clear liquids, eat low fiber foods, frequent small meals, foods that are high in potassium, probiotics, avoid foods that irritate your digestive tract
Earliest indicator in neurological status? Exam
Level of consciousness
, motor function, eye movement, pupil size and reaction, protective reflexes and vital signs
What is mental status and
What to look for in change of mental status?
Ones Orientation, Memory, calculation, and fund of knowledge
Level of consciousness
What is an internally planted device falls out?
Do not touch , put into a radioactive container, inform radioactive officer
Seizure med side effects?
Drowsiness , diZzy, gastric distress, rash , blood dyscarsias, ataxia
Signs and symptoms of ICP?
Headache nausea vomiting confusion , increased bp, pupils don’t respond to light , coma, seizures,shallow breathing
Signs and symptoms of ICP?
Headache nausea vomiting confusion , increased bp, pupils don’t respond to light , coma, seizures,shallow breathing
Most important vital sign to take with stroke ?
Bp
Goal of cataracts for pts ?
20/20 vision
Eyelashes, lids , conjunctiva and structures inside eye do not have defects
Affects only one limb and is associated with cerebral palsy
Monoplegia
Affects one arm and one leg on the same side of body
Hemiplagia
Paraplegia affects what?
Affects both legs
Affects both arms and legs
Quadriplegia
Assessment of spinal cord injury?
Neuro evaluation of motor and sensory function of extremities below herniated area
Reflex testing
ROM of affected area
Clients knowledge about disease , treatment and pain management and surgery and post care
Bowel and bladder elimination
Note gait alterations and bending limits
Vitals Skin conditions O2 status B and B Immobility complications
_____ is the pressure exerted by a source. When light is hitting a surface it is also pushing down on the surface
Radiation pressure
is a mixture of electromagnetic waves ranging from infrared (IR) to ultraviolet rays (UV). It of course includes visible light, which is in between IR and UV in the electromagnetic spectrum
Radiation from the sun
