Unit 9 Med surg

Question 1

Define and describe the concept of intracranial and glucose regulation.

Answer 1

*Think about how you can tell that someone is “normal” *
Cognitively aware, cranial nerves intact, symmetrical face, normal vitals, normal vision (PERRL), active deep tendon reflex

Question 2

Recognize when an individual has problems with intracranial regulation and compromised glucose regulation.

Answer 2

Changes in lvl of consciousness (1st sign)
Headache due to brain swelling
Seizures
Changes in VS (Cushing’s triad = High SBP, low HR, low RR)
Vomiting
Changes in speech
Decreased motor function
Posturing (decerebrate, decorticate)
Eye changes (papilledema, pupillary changes, impaired eye movement
With infants watch for bulging fontanels, cranial suture separation, increased head circumference, high-pitched cries

Question 3

Provide appropriate nursing and collaborative interventions to optimize intracranial and glucose regulation.

Answer 3

Minimize stress (don’t do all the cares at once)
Elevate HOB to 30 degrees
Stool softeners (constipation increases ICP)
Align the neck with the body (remember to log roll)

Question 4

What is the pathophysiology of seizures and epilepsy?

Answer 4

Sudden, uncontrolled, and excessive discharge of neurons withing the brain

Question 5

What are risk factors of seizures and epilepsy?

Answer 5

Brain injury or tumor
Trauma
Genetic factors
Stroke
Drug toxicity

Question 6

What are generalized seizures?

Answer 6

A seizure that affects both sides of the brain

Question 7

What is a Tonic-Clonic seizure?

Answer 7

Stiff muscles and loss of consciousness; jerking of whole body

Question 8

What is a tonic-abrupt seizure?

Answer 8

Increase muscle tone, may lose consciousness

Question 9

What is a clonic seizure?

Answer 9

Muscle contraction/relaxation

Question 10

What is a myoclonic seizure?

Answer 10

Brief jerking or stiffening in extremities, can be symmetric or asymmetric

Question 11

WHAT ARE ATONIC SEIZURES?

Answer 11

CLIENT FALLS BECAUSE OF A SUDDEN LOSS OF MUSCLE TONE AND POSTICTAL CONFUSION

Question 12

What is status epilepticus?

Answer 12

A seizure lasting longer than 5 min or repeated over 30 minutes
ABCs  might need to intubate (a), call rapid response (b), and insert 2 large bore IVs (c)
Get ABGs
May shift into metabolic acidosis (hypoglycemia, low BP, hypoxia)

Question 13

What is a complex partial seizure?

Answer 13

Loss of consciousness; “blacking out”; don’t remember event

Question 14

What is a simple partial seizure?

Answer 14

Aura or “Deja-vu” feeling, with strange sensations/smells

Question 15

What is Epilepsy?

Answer 15

2 or more seizures.
Primary = no cause
Secondary = triggered by something (stroke, hypoglycemia, water intoxication, fever)

Question 16

What can trigger epilepsy?

Answer 16

Stress, FATIGUE, alcohol, foods/chemicals, bright lights, sickness

Question 17

Describe the interventions for seizures.

Answer 17

Never leave patient alone
Have suctioning set up and ready to use
Lower to floor and turn on side
Secure ABCs
Have oxygen set up and ready to use
Loosen restrictive clothing
Don’t attempt to restrain patient
Allow for rest

Question 18

What should be included in client education about seizures?

Answer 18

Take medication on a regular basis
Get into safe position if possible before they start
Keep track of what triggers them
WEAR A MEDICAL BRACELET
Report if lasts longer than 5 minutes
Educate family and friends on what to do.

Question 19

Define meningitis and describe its causes.

Answer 19

Inflammation of the membranes surrounding the brain and spine

Question 20

With antiepileptic drugs, what should a nurse monitor and watch for?

Answer 20

Labs (liver and WBC)
Gingival hyperplasia
Don’t mix coumadin a no-no with phenytoin (Dilantin) and citrus fruits can raise blood levels of drug = toxicity

Question 21

What is bacterial meningitis?

Answer 21

Can cause death within 24 hours
Place in isolation and on droplet
Ask the patient about living status (do they live in close quarters: dorms, military, etc.)
CSF fluid will be cloudy because of WBCs
Can cause petechial rash

Question 22

What is viral meningitis?

Answer 22

Common organisms, no organisms will be present in CSF
CSF will be clear
Increased protein
Normal glucose
Can cause maculopapular rash

Question 23

Recognize cues of meningitis.

Answer 23

Kernig’s and Brudzinski’s sign
Decreased LOC
NECK STIFFNESS
Fever, rash, headache
Photophobia
N/V
Tachycardia

Question 24

What is Kernig’s and Brudzinski’s sign?

Answer 24

Kernig’s: knee and hip are both at a 90 deree angle, but extension of the knee is painful
Brudzinski’s: passive flexion of neck elicits hip and knee flexion

Question 25

Describe the interventions for meningitis.

Answer 25

Monitor for neurological changes, increased ICP, and Cushing’s Triad
Prevent by vaccination
Assess neurovascular status and VS every 2-4hrs
DO THOROUGH HAND HYGIENE
DECREASE STIMULI
Use Mannitol for ICP or seizures
Give broad-spectrum ABX
Perform vascular assessment Q4hr (cap refill, peripheral pulse, skin temp)

Question 26

What are the cues for type 1 diabetes?

Answer 26

Abrupt onset
Thirst
Hunger
Polyuria
Weight loss

Question 27

What are the cues for type 2 diabetes?

Answer 27

Thirst
Fatigue
Blurred vision
Neural complications
Fasting blood sugar >126mg/dl

Question 28

What are the values of A1C, fasting glucooose, and 2-hr blood glucose to be diagnosed with diabetes?

Answer 28

A1C = >6.5
Fasting = >126
2 hr = >250

Question 29

What are the symptoms of hyperglycemia?

Answer 29

Polyphagia and polydipsia
Dry and hot
Dehydration
Hyperventilation

Question 30

What are the symptoms of hypoglycemia?

Answer 30

Hunger
Diaphoresis
Tremors, weak
Blurred vision
Irritable
Cold and clammy
Seizures

Question 31

What are the risk factors for type 2 diabetes?

Answer 31

Elevated BP
Obese
Recurrent infections
High cholesterol
Race: Native Americans, Alaskan Indians, Mexicans
Sedentary lifestyle

Question 32

True/False: the brain can store glucose for emergencies

Answer 32

FALSE

Question 33

Describe the education the nurse would provide regarding nutrition and exercise.

Answer 33

ADA diet (no empty cards; increase veggies, grains, dairy, beans, and fruit
Don’t exercise if BS <100 or >250; extreme temps; or within 1 hr of injection of insulin

Question 34

How does a diabetic manage sick days?

Answer 34

Continue taking insulin, test BS every 4 hrs, and track the results
Check daily weight, temperature, and ketones

Question 35

What are risk reductions taken for diabetics?

Answer 35

See eye doctor yearly
Reduce bad fats and cholesterol in diet
Stop smoking
Exercise
Increase omega-3
Foot care (not too hot of water, daily inspection of feet, larger shoes) – basically loose on the feet

Question 36

Describe the chronic complications of diabetes.

Answer 36

Poor tissue perfusion and cell ischemia (micro and macro vascular)

Question 37

What are microvascular complications of diabetes?

Answer 37

Kidney, nerve, and retinopathy (blindness, vision problems)

Question 38

What are macrovascular complications of diabetes?

Answer 38

Heart disease and stroke

Question 39

Describe the nursing interventions for a hypoglycemia reaction.

Answer 39

Dextrose and glucagon
BS > 60 for proper brain function

Question 40

Discuss the ABGs and signs and symptoms of a client with DKA.

Answer 40

Tachycardia
Hyperglycemia
Hypotension
Polyuria
Hyperkalemia
Fruity breath
Kussmaul’s respiration (Rapid and deep)
Dehydration, thirsty

Question 41

Describe the nursing interventions for a client with DKA.

Answer 41

Assess airway, LOC, VS, hydration, electrolytes, and BG lvls
Cardiac monitor
IV NS 15-20mL/kg over 1 hr, then D5 ½ NS and regular insulin bolus 0.1unit/kg, then infusion