Test 3. - 222 Flashcards
Pt has difficulty hearing, what is the nurse most concerned with?
-History of Gentamyin (or Vancomycin, Lasix)
Symptoms of Parkinsons
- Tremor (worse at rest) pill rolling
- Ridigity (no smooth movements)
Cogs-wheel/jerking
3.Bradykinesia- shuffled gait/difficult movements
Nursing DX for Bells Palsy?
Disturbed Body Image
Meds for Bells Palsy?
Antivirals! Zovirax, Valtrex
(Prognosis is very good, usually goes away within 6 months)
Tensilon Test
- If muscle function improves, the test is positive and pt is in a MYATHENIC STATE.
- if it gets worse, the pt is in a CHOLINERGIC STATE.
(Prepare to administer Atropine for Bradycardia)
Post Op Discharge for ear problems
Nurse will teach proper way to administer ear drops.
Tilt head to unaffected side
Adul pull ear up and out
Child pull ear down and back
What part of the brain controls gait, balance, and posture?
-Cerebellum
What part of the brain controls the vital signs?
The Brainstem- (medulla, pons)
What does the frontal lobe control?
impulses, personality, sexual desires
Temporal part controls
hearing
MRI is contraindicated with?
-Any metal in the body (pacemaker, hip or knee replacements, lumbar fixation)
Three components of neuro assessment
- LOC
- Pupils
- Motor Ability
Glasgow Coma Scale?
Measures eye opening, verbal, and motor response.
7- Pt is in a coma state
15- is normal
What should you teach pt to avoid with hearing problems?
-Avoid LOUD music
Snellen Chart
If pt wears glasses, tell patient to leave them on during test.
Spinal Shock (cord damage) what may occur?
- lose motor, sensory and autonomic activity below the level of injury may result in decrease in BP.
- Parts of body below level of cord lesion are paralyzed/
- Condition persist for several days to months after injury.
FLACCID PARALYSIS BELOW LEVEL OF INJURY.
-DECORTICATE (flexor posturing)
-flexed in toward the cord.
-Drug for maintainence of Meniere’s
-Antivert (antivertigo)
Maintainence drug for Meniere’s Disease
-Antivert (Antivertigo)
Nsg Dx for Meniere’s Disease
Fluid Volume Depletion r/t vomiting
What drug do give for ischemic stroke?
-tPa within 3 hours
(Ischemic stroke is decreased blood flow to brain secondary to occlusions… two types: thrombotic and embolic)
Grand Mal Seizure
- Most common. Person loses conciousness.
- jerking/ cyanosis/ excessive salivation/ incontinence
- usually last 1-5 min
Grand Mal Post Ictal
-Maintain airway and check for injury
Lumbar Puncture
- Dx for CNS infection, intracranial bleed
- Lay client in FETAL position, local anesthetic, consent
(Fetal position opens up spinal vertebrae for tap;; stay still to avoid injury.)
Post test: lay flat for 2 hrs, encourage fluids
IF YOU SUSPECT BRIAN BLEED, THIS TEST IS CONTRAINDICATED B/C HEMORRHAGE CAN MOVE DOWN, MRI FIRST.
Should you give narcotics to neuro patients?
-No,
Multiple Sclerosis med tx
- ABC therapy (Avenox, Betaserone, Copaxane)
- Interferon B
What is scleral buckling?
- Reattaches sclera to retina
- Post op: BED REST/ LIMITED HEAD MOVEMENT, check with dr about activity
s/s of retinal detachment
visual field loss and the appearence of flashing lights
Manitol (for ICP)
Osmotic Diuretic, pulls fluid from the third space into vascular space then diuresis the pt, fliters through kidneys.
CHECK RENAL FUNCTION AND ELETROLYTES
Decadron (FOR icp)
-corticosteroid- stabilizes capillary membrane permiability (leaky) doesnt leak to 3rd space in brain
-Ear drops
-WARM them before administration
Cushings Triad
-Widening Pulse Pressure, respirations, bradycardia
s/s Menieres
- vertigo, sensorineural loss, tinnitus
- avoid getting up suddenly
Injury above C6, assess what?
-Respirations and need for ventilator because of weakness in intercostal muscles
Autonomic Dyspreflexia
- caused by visceral stimulations (visceral organs include bowel, bladder, and skin)
- urinary retention= straight cath
- skin= remove clothes
Pt develops increases HTN, LOC changes, pounding headache, goosebumps, stroke if left untx
Normal IntraOcular Pressure
10-21 mm
Pt has functional blindness, how should nurse plan the care?
functional blindness 20/200
- check visual acquity
- orient to environment
- Promote safety
Pt has pain in eye after post op cataract surgery
-REPORT to dr. Could be infection, hemorrhage, or increase IOP.
Photopsia, Floaters, and loss of peripheral vision are clinical manifestations of
-retinal detachment
Increased IOP and peripheral vision loss indicate
Glaucoma
Betoptic, Timoptic, Diamox (beta blockers)
Decreases aqueous humor production which then decreases IOP.
Pilocarpine
- Constricts pupil
- increases outflow of aqueous humor
When patient has clear discharge from the nose or ear….
do glucose test to detect CSF leakage.
bells palsy
Cranial 7.
- Antivirals.
- Gentle upward massage of face, use heat, avoid cold.
ALS (Lou Gherigs)
- 2-5 YRS after prognosis, terrible prognosis.
- check gag reflex
- end stage- pt on vent or hospice because respiratory system affected.
- Rilutek- drug slows progression.
How do you know that Sinemet (Levadopa/Carpadopa) is no more effective?
-bradykinesia, tremors, and shuffling gait return
What to teach pt taking Dilantin? (Anti-seizure)
Maintainence drug for seizures normal level 10-20
-do oral care, and have regular visits with dentist to check for gingival hyperplasia.
During seizure what do you document?
-What pt was doing before seizure, what part of body was affected, and where twitching started first.
As patient is having seizure..
- turn them on their sside to prevent aspiration, and do not put anything in their mouth.
- loosen any restrictive clothing.
- do not restrain
Pt has brain tumor what symptom will they most likely experience?
-Early morning headache.
ICP- prevent increase
- treat cause
- elevate HOB30 degress!
- fluid restrictions
- Manitol, Decadron, Diuretics
- Seizure precautions ( padded bed rails, dim lights, decrease stimuli, let them rest. )
Open Angle Glaucoma
>50
Labs for pt on decadron
hyperglycemia, hyponatremia, hypokalemia
Pt with Na of 129 would be most concern to RN
Pt presents with eye injury
-do head to toe assessment
Pt with dysplasia, what do you check before they eat?
-gag reflex
First symptom of cataracts
-nighttime glare (probs driving at night)
First thing people complain of with Multiple Sclerosis?
- optic neuritis (blurred vision)
- falls
Epidural Hemorrhage
- EMERGENCY SITUATION:collection of blood btwn skull and dura
- Always go to surgery
- Epidural bleed is arterial bleed
Subdural Hemorrhage
- Venous bleed
- depends how quickly the bleed is. if slow, or stopping, the neurosurgeon will let it absorb itself…
- family can sometimes miss the symptoms
Mestinon
- Treatment for Myasthenia Gravis
- take p.o on schedule with meals
Neurontin
- given for seizures, safer for elderly
- come back to check serum levels
Petit mal seizure
- children
- blinking, brief staring spell, rolling of eyes
- 5-10 seconds
- no post ictal symptoms
- do not lose conciousness
- often misdiagnosed.
Midriatics
-Dilate the pupil
Post op eye surgery are patients encouraged to cough and deep breath?
- NO!
- avoid coughing, sneezing, cant drive 4-6 weeks, avoid anything that increases IOP. sex, bending, lifting
Bilateral eye patching should be done in tauma or in possible retinal detachment because
-eyes are consensual, they move together
goal is to prevent further ischemia to retina
Humonymous Hermianopsia
-blindness on same side in both eyes , put everything in their line of vision!!!!
approach from unaffected side and manually scan environment!
