VN 22 Test 7 Flashcards
- How would you assess the motor response of an unconscious client?
A change in vital sign or assessment details with a patient with neurological disease. You need to notify the provider
Comatose patient: you need to use motor stimulation to get your information
- Administer pain stimulation
2.What is
A. Decorticate Posturing
B. Decerebrate Posturing
C. Flaccid
A. A position in which the arms are flexed, fists are clenched, and the legs are extended
B. When the extremities are stiff and rigid; decerebrate posturing is more serious than decorticate posturing
C. When the client makes no motor response
- What is a Glasgow Coma Scale? What does the scale consist of?
Eye opening response
4. Spontaneously
3. To speech
2. To pain
1. No response
Verbal response
5. Oriented to time, person and place
4. Confused
3. Inappropriate words
2. Incomprehensible sounds
1. No response
Motor Response
6. Obeys command
5. Moves to localized pain
4. Flex to withdraw from pain
3. Abnormal flexion
2. Abnormal extension
1. No response
- At what level is the client considered to be in a coma?
A score of 8 or less
- How do you check for neck rigidity? Brudzinski? Kernig? Nuchal rigidity?
Brudzinski: head flex towards the chin and the knee and hopes goes up and flex is a positive sign
Kernig: severe stiffness in the hamstrings is a positive sign
Nuchal rigidity: stiff neck; head goes down towards the chest and there is resistance
- Manifestations of increased intracranial pressure?
Decreasing level of consciousness (LOC) early manifestation
Changes in pupils
Stuporous, semi-comatose; confusion, restlessness, periodic disorientation
Headache- more severe in the morning
Cushing’s triad: a pulse rate that increases initially but then decreases, and a respiratory rate that is irregular
Cheyne-Stokes respirations
Other: vomiting, papilledema, decorticate or decerebrate posturing
Pulse pressure; difference between systolic and diastolic ex. 140/40
- Nursing considerations for intracranial pressure
Maintain head in midline at 30 degrees of elevation
Maintain BP and ensure cerebral perfusion/fluids as ordered
Maintain airway: monitor O2 levels
Monitor neurologic status: change in LOC
Seizure precaution
Decreases stimuli-may sedate
Indwelling catheter to monitor I&O
Stool softener; Avoid straining
Avoid hypothermia
Avoid hypotonic solution: it will swell cells and increase ICP
- What is Cushing’s Triad?
A pulse rate that increases initially but then decreases and a respiratory rate that is irregular
- What is meningitis and what is it caused by?
An infection of the meninges which surround and protect the brain and spinal cord.
Cause may be a virus, bacteria or fungi
- Meningitis manifestations
Headache-excruciating
High fever
Nuchal rigidity
Positive Brudzinski’s sign
- Phenytoin need to knows (medication)/ IV use/ Anticonvulsant
Use for Seizures (anticonvulsant)
Very marrow therapeutic range; Monitor levels ()?
Can cause gingival hyperplasia; really good dental hygiene is important
Cause can thrombocytopenia; watch for any bruising/ nose bleeding; if so notify the provider
Monitor LFT for long term use
IV use: monitor IV site can cause irritation and watch for any infiltration
Anticonvulsant: they can decrease vitamin D which will affect calcium as well so we need to monitor electrolyte levels
- Levodopa need to know (medication)
Use for Parkinson’s
Protein can interfere with the absorption of levodopa. (Decrease protein intake); NO high protein diet
- Seizure nursing actions
Keep them safe; position them on their side
Good documentation: find out for any aura
Postictal Phase; period after the seizure, very often will be very sleepy (may be irritable or agitated at that time)
- Seizure classifications
Absence seizure: stares blankly, eyelids flutter, lack of prominent movement
Myoclonic seizure: sudden, brief jerking
Tonic-clonic seizure: muscle alternate between contraction and relaxation; jerking movement
- Post seizure nursing actions
Do you know what happened?
Did the nurse observe
What type of body movement?
Loss of consciousness
How long was the seizure
Was there an Aura?
Asses for postictal
Ask for any Automatisms: repetitive, none purposeful actions
- Parkinson’s manifestations
Muscle rigidity
-Tremors; pill rolling
- Bradykinesia- slow movement including slurred speech; masklike expression and decreased blinking
-Shufflinggait
- Guillan-Barre syndrome nursing considerations
Assess signs of respiratory distres
-spirometer
-skin care
-change position every 2 hours
-ROM exercises to prevent muscle atrophy
- Guillan-Barre syndrome manifestations
Weakness- that progresses
Tingling in the arms and legs
Paralysis
Incontinence
Other: Difficulty chewing, talking and swallowing
- ALS manifestations
Progressive muscle weakness; wasting of the arms
-legs and trunk develop-atrophy
-client experiences episode of muscle fasciculations (twitching)
If ALS affects the brain stem-difficulty speaking and swallowing,
-periods of inappropriate laughter and crying,
-respiratory failure
-total paralysis
- Encephalitis manifestations and diagnosis
Sudden fever,
severe headache,
-stiff neck,
-vomiting,
-drowsiness,
-tremors,
-seizures,
-spastic or flaccid paralysis,
-irritability,
-muscle weakness,
-lethargy,
-delirium,
-coma,
incontinence, visual disturbances
Ask for any recent bug bites?
- Baclofen need to knows
Is for Multiple Sclerosis and the therapeutic affect is to minimize symptoms like muscle spasticity and rigidity
- Brain tumor manifestations, focal
-headache (most common in the morning,
becoming increasingly severe and occurs more frequently as the
tumor grows),
-vomiting occurs without nausea or warning
-papilledema,
-seizures,
-speech difficulty,
-paralysis,
-double vision
other sensory loss,
-muscle weakness
Focal symptoms: specific on one part of the brain
Generalized symptoms: vomiting
- Brain tumor priority
Prevent increased intracranial pressure
- Huntington’s Disease manifestations
Choreiform movement (jerking movement/ rivaling)
-Mental apathy and emotional disturbances,
-grimacing
-Other: difficulty chewing and swallowing, speech difficulty, intellectual
decline, loss of bowel and bladder control; severe depression can lead
to suicide
- Valproic acid need to knows
Use for seizures (Anticonvulsant)
Watch for bruising, can cause thrombocytopenia
- Amantadine need to knows/ Selegiline
Use for Parkinson’s
Can cause insomnia and lightheadness
Selegiline: Avoid foods with high tyramine; cured meat, cheddar cheese
Client education with medication for Parkinson’s: A patient has symptoms of Parkinson’s for awhile but it took a while for the diagnosis and then get put on medication but instantly they get amazing results and decreased symptoms; usually after a couple of years the medication actually leans and is not as affect. Which can be honeymoon stage
