Adult test#1

ICU sections

(honestly first part is talking about what an ICU is and what an ICU nurse does...) common sense

Fostering Comfort and Communication

(refer back to communicating notecard earlier) -computer keyboards, magic boards, etc. -sedating patient and giving an analgesic until the ET isn't required anymore

ALS

-Amyotrophic lateral sclerosis (ALS) is a degenerative neurological disorder of the upper and lower motor neurons that result in deterioration and death of the motor neurons. This results in a progressive paralysis and muscle wasting that eventually causes respiratory paralysis and death. Cognitive function is not usually affected. -Death usually occurs within 3 to 5 years of the initial symptoms due to respiratory failure. The cause of ALS is unknown and there is no cure.

Nursing Diagnoses

-Impaired gas exchange r/t alveolar hypoventilation, intrapulmonary shunting, V/Q mismatch and diffusion impairment -Ineffective airway clearance r/t excessive secretions, decreased level of consciousness, presence of an artificial airway, neuromuscular dysfunction and pain -ineffective breathing pattern r/t neuromuscular impairment of respirations, pain, anxiety, decreased level of consciousness, respiratory muscle fatigue, and bronchospasm

Cystic Fibrosis Nursing Diagnoses

-Ineffective airway clearance related to abundant, thick bronchial mucus, weakness, and fatigue -ineffective breathing pattern R/T bronchoconstriction, anxiety, and airway obstruction -impaired gas exchange r/t recurring lung infections -imbalanced nutrition: less than body requirements r/t dietary intolerances, intestinal gas, and altered pancreatic enzyme production -ineffective coping r/t multiple life stressors such as decrease life expectancy, cost of treatment, and limitation on career choices

evaluation of brain tumors

-achieve control of pain, vomiting, and other discomforts -maintain ICP w/in normal limits -demonstrate maximal neurologic function given the location and extent of the tumor -maintain optimal nutritional status -accept the long-term consequences of the tumor and its treatment

Medications

-anticholinesterase agents: pyridostigmine and neogstigmine -immunosuppressants: prednison and azathioprine -immunoglobulins w/in 45 minutes should eat it before taking the medications (look at PP)

Nursing and collaborative

-assess/ control symptoms -maintain adequate nutrition: assess/ monitor swelling, small frequent meals, fluids (thicken as needed), small pieces -maintain mobility: physical therapy/ OT, exercise as much ass possible, assistive devices, ROM, stop periodically while walking, ADL support; make sure if you know one side is weaker get them out on their strong side of bed -safety: assess for mental status change, cognitive status change, safe environment, family support, social service referral, protect from complications, aspiration, altered cognition -medications: dopaminergic agents: Levodopa/ carbidopa, amy combine w/ domaminergic for better effect, anticholinergic, COMT, antivirals: watch out for orthostatic hypotension -surgical interventions

implementation for brain tumors

-assist in understanding what is happening/ support family (since pt might change personality) -protect from self-harm -pt might be disoriented or confused -make attempts to establish communication w/ patient since motor or sensory dysphagia may occur

Brain Tumor Nursing Assessment

-baseline data of pt's neurologic status -assess LOC, motor abilities, sensory perception, integrate function (including bowel and bladder), and balance and proprioception -determine the presence of seizures, syncope, n/v

Myasthenia Gravis diagnostic procedures

-electromyography -tensilon test: tensilon is administered; inhibits the breakdown of acetlycholine, making it available for use at the neuromuscular junction -positive test: noticeable improvement in muscle strength (very short lived, only about five minutes)

Evaluation for ICP

-maintain ICP and cerebral perfusion w/in normal parameters -Experience no serious increases in ICP during or after care activities -experience no complications of immobility

Maintaining Proper Cuff Inflation

-maintain cuff pressure at 20 to 24 cm H2O -measure on a routine basis (ever 8 hours) using the MOV (minimal occluding volume technique) or the MLT (minimal leak technique) -excess volume can damage the tracheal mucosa

Evaluation Head Injury

-maintain normal CPP -achieve maximal cognitive, motor, and sensory function -experience no infection or hyperthermia

planning for brain tumors

-maintain normal ICP -maximize neurologic functioning -achieve control of pain and discomfort -be aware of the long-term implications w/ respect to prognosis and cognitive and physical functioning

Evaluation for Acute Respiratory failure and ARDS

-maintain patentairway w/ effective removal of secretions -achieve normal or baseline respiratory rate and rhythm, and breath sounds -maintain adequate oxygenation as indicated by normal or baseline ABGS -experience normal hemodynamic status

Maintaining Correct tube placement

-maintain proper ET tube position by placing an "exit mark" on the tube -confirm that the mark remains constant while at rest and during patient care, repositioning, and transport -observe symmetric chest wall movement and auscultate to confirm bilateral breath sounds -if not positioned properly it is an EMERGENCY -ventilate w/ an Ambu bag and 100% 02: if dislodged tube is not repositioned it might place patient at risk for pneumothorax

Unplanned Extubation

-patient talking -acitvation of the low-pressure ventilator alarm -diminished or absent breath sounds -respiratory distress -gastic distention make sure tube is secured

Nursing Diagnoses for brain tumors

-risk for ineffective cerebral tissue perfusion r/t cerebral edema -acute pain (headache) r/t cerebral edema and increased ICP -anxiety r/t diagnosis and treatment -potential complication:increased ICP r/ tumor and failure of normal compensatory mechanism

Nursing Diagnosis Head Injury

-risk for ineffective cerebral tissue perfusionr/t interruption of CBF associated w/ cerebral hemorrhage, hematoma, and edema -hyperthermia r/t increased metabolism, infection, and hypothalamic injury -impaire physical mobility r/t decreased LOC -anxiety r/t abrupt change in health status, hospital environment, and uncertain future -potential complication: increased ICP r/t cerebral edema and hemorrhage

CF Nursing Implementation

-teach pt about delayed development of secondary sex characteristics such as breasts -self confidence in the young adult -teach about the issue of marrying and having children: genetic counseling is necessary -relief of bronchoconstriction, airway obstruction, and airflow limitation -aggressive chest physiotherapy, antibiotics, and O2 therapy -Good nutrition is VERY important

Nursing Diagnoses for Spinal Cord injury to follow

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Nursing Diagnoses for ICP to follow

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Nursing Diagnoses to follow

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Nursing Implementation for COPD

1. Health Promotion -STOP SMOKING -Those w/ AAT deficiency need to be aware of the genetic nature of the disease: should consult a pulmonologist about regular spirometry screening 2. Acute Intervention -for complications such as exacerbations of COPD, pneumonia, cor pulmonale, and acute respiratory failure 3. Ambulatory and Home Care -pulmonary rehabilitation: usually include exercise training, smoking cessation, nutrition counseling, and education -activity considerations: exercise training is very important b/c it an help to improve muscle function and help to reduce dyspnea; an occupational therapist can help you figure out how to save as much energy as you can while doing your ADLs -Sexuality and Sexual Activity: modify but do not abstain from sexual activities (ask your pt questions like "How does your SOB affect your desire for intimacy w/ your partner?") -Sleep: adequate sleep is extremely important to maintain quality of life and productivity; pts w/ COPD have an increased prevalence of sleep disorders (treat apnea) -Psychosocial considerations: remember that they have to deal w/ lifestyle changes such as decreased ability to care for themselves, decrease eery for social activities, and loss or change in job; let them know it can be managed but never cured

Assessing for Complications of ET

1. Unplanned Extubation 2. Aspiration

MOV

1. for the mechanically ventilated patient, place a stethoscope over the trachea and inflate the cuff to MOV by adding air until nor air leak is heard at peak inspiratory pressure (end of ventilator inspiration) 2. for the spontaneously breathing patient, inflate until no sound is heard after a deep breath or after inhalation with a BVM 3. use a manometer to verify that cuff pressure is between 20 to 25 cm H2O 4. record cuff pressure in the chart

Planning for ICP

1. maintain a patent airway 2. have ICP w/in normal limits 3. have normal fluid, electrolyte, and nutritional balance 5. prevent complications secondary to immobility and decreased LOC

Planning: pt w/ stroke

1. maintain a stable or improved LOC 2. attain maximum physical functioning 3. attain a maximum self-care abilities and skills 4. maintain stable body functions (e.g. bladder control) 5. maximize communication abilities 6. maintain adequate nutrition 7. avoid complications of stroke 8. maintain effective person and family coping

Planning Head Injury

1. maintain adequte cerebral oxygenation and perfusion 2. remain normothermic 3. achieve control of pain and discomfort 4. be free from infection 5. have adequate nutrition 6. attain maximal cognitive, motor, sensory function

planning SC

1. maintain an optimal level of neurologic functioning 2. have minimal or no complications of immobility 3. learn new skills, gain new knowledge and acquire new behaviors to be able to care for self or successfully direct other to do so 4. return to home and the community at an optimal level of functioning

Nursing Management Artificial airway

1. maintaining correct tube placement 2. Maintaining proper cuff inflammation 3. Monitoring oxygenation and ventilation 4. Maintaing tube patency 5. Assessing for complications 6. Providing oral care and maintaing skin integrity 7. fostering comfort and communication

Planning for Acute Respiratory Failure

1. normal ABG values or values w/in the patients baseline 2. normal breath sounds or breath sounds w/in the baseline 3. no dyspnea or breathing patterns w/ the patients baseline 4. independent maintenance of the airway 5. effective cough and ability to clear secretions

Endotracheal intubation indications

1. upper airway obstructions 2. Apnea 3. high risk of aspiration 4. ineffective clearance of secretions 5. respiratory distress

Under H category use AMPLE

A: allergiess to drug, food, latex, environment M: medication history P: Past health history (e.g., preexisting medical or psychiatric conditions, previous hospitalizations or surgeries, smoking history, recent use of drugs or alcohol, tetanus immunization, last menstrual period, baseline mental status) L: Last meal E: events or environmental factors leading to the illness or injury

Monitoring Oxygenation and Ventilation

ABGs, SpO2, if available ScvO2/SvO2 -assess for signs of hypoxemia (change in LOC, anxiety, dusky skin, dysrhythmias) -assess pt's respiratory rate, rhythm, and use of accessory muscles -PaCO2: indicator of alveolar hyperventilation (decreased PaCO2, increased pH indicated respiratory alkalosis) -PETCO2 monitoring (capnography) is done by analyzing exhaled gas directly at the patient ventilator circuit (mainstream sampling) or by transporting a sample of gas via a small-bore tubing to a bedside monitor (side stream sampling)

A

Airway With Cervical Spine Stabilization and/ or mobilization

Medications for MS

Azathioprine (Imuran) and cyclosporine (Sandimmune) ■ Immunosuppressive agents are used to reduce the frequency of relapses. ■ Nursing Considerations ☐ Monitor for long-term effects. ☐ Be alert for signs and symptoms of infection. ☐ Assess for hypertension. ☐ Assess for kidney dysfunction. ◯ Prednisone (Deltasone) ■ Corticosteroids are used to reduce inflammation in acute exacerbations. ■ Nursing Considerations ☐ Monitor for increased risk of infection, hypervolemia, hypernatremia, hypokalemia, hyperglycemia, gastrointestinal bleeding, and personality changes.multiple sclerosis and amyotrophic lateral sclerosis rn adult medical surgical nursing 107 ◯ Dantrolene (Dantrium), tizanidine (Zanaflex), baclofen (Lioresal), and diazepam (Valium) ■ Antispasmodics are used to treat muscle spasticity. ■ Intrathecal baclofen can be used for severe cases of MS. ■ Nursing Considerations ☐ Observe for increased weakness. ☐ Monitor for liver damage if on tizanidine or dantrolene. ■ Client Education ☐ Report increased weakness to provider. ☐ Report jaundice to provider. ☐ Avoid stopping baclofen abruptly. ◯ Interferon beta (Betaseron) ■ Immunomodulators are used to prevent or treat relapses. ◯ Carbamazepine (Tegretol) ■ Anticonvulsants are used for paresthesia. ◯ Docusate sodium (Colace) ■ Stool softeners are used for constipation. ◯ Propantheline (Pro-Banthine) ■ Anticholinergics are used for bladder dysfunction. ◯ Primidone (Mysoline) and clonazepam (Klonopin) ■ Beta-blockers are used for tremors.

B

Breathing

C

Circulation

Maintaining Tube patency

DO NOT ROUTINELY SUCTION PATIENT! Regularly assess the pt to determine if suctioning is needed 1.visible secretions in ET tube 2. sudden onset of respiratory distress 3. suspected aspiration of secretions 4. increase in peak airway pressures 5. auscultation of adventitious breath sounds over the trachea or bronchi 6. increase in respiratory rate 7. sudden or decrease in PaO2 or SpO2.

Collaborative care for ARDS/ planning

Diagnostic: ARDS: PaO2 <200, chest x-ray, pulmonary artery wedge pressure <18 mm HG or no clinical evidence of heart failure

D

Disability

Aspiration

ET passes through the epiglottis, splinting it in an open position, thus the intiubated patient cannot protect the airway from aspiration -keep HOB 30 to 45 degrees!!!

E

Exposure or Environmental Control

F

Full set of Vital signs, focused injunctions, facilitate family presence

G

Give comfort measures

Nursing Assessment Increased intracranial pressure

Glasgow coma scale Test the nerve functions! All of the nerves but especially the ocular nerves Test motor strength (push/pull strength test) -determine if there is spontaneous movement -record vital signs BE aware of cushiness triad

Implementation: Stroke

Health Promotion -know risk factors for stroke -uncontrolled or undiagnosed hypertension is the primary cause of stroke; therefore you need to be involved in BP screening and ensuring that patients adhere to the use of their antihypertensive medications Acute Intervention -Respiratory system: NURSING PRIORITY: risk for aspiration pneumonia is high b/c of impaired consciousness, keep pt on NPO until able to able to swallow, assess airway latency and function, providing oxygenation, suctioning, promoting patient mobility, positioning the pt to prevent aspiration, and encouraging deep breathing; oral care -Neurologic: use NIHHS (will be in following slide) -cardiovascular: 1. monitoring vital signs frequently 2. monitoring cardiac rhythms 3. calculating intake and output noting imbalances 4. regulating IV infucsions 5. adjusting fluid intake to individual patient needs 6. monitoring lung sounds for crackles and rhonchi indicating pulmonary congestion 7. monitoring heart sounds for murmur; watch for VTE -musculo skeletal system: maintain optimal function by preventing joint contrscture and muscular atrophy (tronchanter roll at the hip to prevent external rotation, hand cones to prevent hand contractors, arm supports w/ slings and lap boards to prevent shoulder displacement, avoidance of pulling the patient by the arm to avoid shoulder displacement, posterior leg splints, footboards, hand splints to reduce spasticity -integumentary: pressure relief by position change, special mattress, good hygienic, emollients applied to dry skin, early mobility -gastrointestinal: constipation issue: promote activity urinary system: AVOID indwelling catheter, retraining the bladder by: 1. adequate fluid intake w/ most of it given b/n 7am-7pm, scheduled toiling every 2 hours using bedpan, commode, or BRP, observation for signs of restlessness, and assess for bladder distention -Nutrition: SAFETY ALERT: the first oral feeding should be approached carefully b/c the gag reflex may be impaired due to dysphagia, help promote self-feeding -communication: 1. communicating frequently and meaningfully 2. allowing time for patient to comprehend and answer 3. using simple, short sentences 4. using visual cues 5. structuring conversation so that it permits simple answers by the pt 6. praising the patient honestly for improvements w/ speech -sensory perceptual alterations: homonymous hemianopsia (blindness in the same half of each visual field), double vision -coping Ambulatory and home care: rehab, musculoskeletal function, stroke survivorship and coping, sexual functioning

Nursing Implementation Head and Neck Cancer

Health Promotion: - QUIT smoking -Have good oral hygiene -safe sex practices to prevent HPV -QUIT drinking alcohol Acute Intervention: -Radiation Therapy -Surgical Therapy -Voice Rehabilitation (electrolarynx) -Stoma Care (nasal wash spray to keep stoma moist, remove it once a day to clean it) -Depression (allow pt to talk about feelings to help regain self-concept) -Sexuality Ambulatory and Home care: -most pts will need home care to make sure they are doing the proper self-care

Implementation Head Injury

Health Promotion: prevent car and motorcycle collisions & use car seats!! Driving safety Acute intervention: perform neurologic assessments, hyperthermia may occur, if CSF rhinorrhea or otorrhea occurs inform physician, ambulatory care: when you get home be aware of poor nutritional status, bowel and bladder management, spasticity, dysphagia, DVTs and hydrocephalus Pt teaching attached table

H

History and Head-to-Toe Assessment

Nursing Diagnoses (are the same as respiratory failure)

I will list the actual nursing care plans now, both pertain to BOTH ARDS and acute respiratory failure

I

Inspect Posterior Surfaces

Compliance

Is a measure of the ease of expansion of the lungs. This is a product of the elasticity of lungs and the elastic recoil of the chest wall. when complacence is decreased the lungs are more difficult to inflate. Examples include conditions that increase fluid in the lungs (pulmonary edema, ARDS, pneumonia), conditions that make lung tissue less elastic or distensible (pulmonary fibrosis), and conditions that restrict lung movement (pleural effusion)

Nursing care: Delirium

KEY: prevention, early recognition, and treatment; -recognition of high risk patients (factors that precipitate delirium notecard lists all): esp those w/ neurologic disorders (stroke, dementia, CNS infection, parkinsons disease), sensory impairment and advanced age -care focuses on eliminating the precipitating factors -correcting fluid/ electrolyte imbalances/ nutritional deficiences (if alcohol or drug related) -if r/t environmental (overstimulating environment) changes should be made -if r/t infection: give antibiotics -if r/t chronic illness: treat focused conditions PROTECT PATIENT AGAINST HARM -create calm/ safe environment -reorient to person, place, and time by using calendars, clocks, etc -touch and verbal communication: make eyeglasses/ hearing aid readily available -avoid use of restraints -relaxation techniques, music, massage -WATCH FOR SKIN BREAKDOWN -support family and caregivers during episode of delirium -Drug therapy is last resort: if so give low dose antipsychotic (such as Haldol, Risperdal, Zyprexa, Seroquel)

Nursing care ALS

Nursing Care ◯ Maintain a patent airway and suction and/or intubate as needed. ◯ Monitor ABGs and administer oxygen, intermittent positive pressure ventilation, bilevel positive airway pressure, or mechanical ventilation as needed. ◯ Keep the head of the bed at 45°; turn, cough, and deep breathe every 2 hr; conduct incentive spirometry/chest physiotherapy. ◯ Facilitate effective communication (dysarthria) with the use of a communication board or a speech language therapist referral. ◯ Assess coping and depression. ◯ Assess swallow reflex and ensure safety with oral intake. Thicken fluids as needed. ◯ Meet nutritional needs for calories, fiber, and fluids. When no longer able to swallow, provide enteral nutrition as prescribed. ◯ Utilize energy conservation measures. ◯ Address the client's interest in the establishment of advance directives/living wills.

common problems in ICU/ intervention to be made

Nutrition: determine who to feed, what to feed, when to feed, and how to feed (route of administration); either giving parenteral or enteral nutrition and determining what is best Anxiety: encourage patients and caregivers to express concerns, ask questions and state their needs: include in ALL conversations/ explain purpose; bring personal items; given anti anxiety drugs Pain: for critically ill: continuous IV sedation and an analgesic agent; (70% of ICU patients have moderate to serve unrelieved pain) Impaired Communication: explain every procedure, find alternative ways to communicate (magic slates, computer keyboards, notepads), translators, nonverbal is also key! if appropriate use touch to comfort Sensory Perceptual Problems: DELIRIUM! sensory overload is going to lead to ^ or anxiety/ stress; limit by muting phones, setting alarms based on pt condition, silencing anything you can Sleep Problems: schedule rest periods, dim lights, open curtains during day, limit noise, provide comfort measures (massage), and if necessary benzo to induce sleep

CF Planning

Overall goals 1. adequate airway clearance 2. reduce risk factors associated w/ respiratory infections 3. adequate nutritional support to maintain appropriate BMI 4. ability to perform ADLs 5. recognition and treatment of complications r/t CF 6. active participation in planning and implementing a therapeutic region

Assessment ALS

Risk Factors ◯ ALS affects more men than women, often developing between the ages of 40 to 70. ● Subjective Data ◯ Fatigue ◯ Twitching and cramping of muscles ● Objective Data ◯ Physical Assessment Findings ■ Muscle weakness - usually begins in one part of the body ■ Muscle atrophy ■ Dysphagia ■ Dysarthria ■ Hyperreflexia of deep tendon reflexes ◯ Laboratory Tests ■ Creatine kinase (CK-BB) level - Increased ◯ Diagnostic Procedures ■ Electromyogram (EMG) ☐ Reduction in number of functioning motor units of peripheral nervesmultiple sclerosis and amyotrophic lateral sclerosis rn adult medical surgical nursing 109 ■ Muscle biopsy ☐ Reduction in number of motor units of peripheral nerves and atrophic muscle fibers

ABGs

Used to determine oxgenation tatus and acid-base balance

Tracheostomy

a surgically created stoma (opening) in the trachea to establish an airway. Use for: 1. bypass an upper airway obstruction 2. facilitate removal of secretions 3. permit long rem mechanical ventilation

Implementation ICP

acute intervention: maintain patent airway! SAFETY ALERT: be alert to altered breathing patterns and snoring sounds indicate obstruction and require immediate intervention positioning of the head to 30 degrees suctioning and coughing -fluid and electrolyte balance: ESPECIALL important to monitor serum glucose, sodium, potassium, magenesium, and osmolaity -monitor I&Os to detect problems r.t diabetes insipidus and SIADH -monitor ICP -body positioning: head up postioning: make sure to turn pt slowly -protection from injury: confusion, agitation, and seizures -psychologic: anxiety/ assess family member's desire to assist in pt care

Head and neck cancer

arise from squamous cells that line the mucosal surfaces of the head and neck region. The cancer is identified according

MG nursing and collaborative care

assess maintain airway -high calorie meals -alternate rest/ activity -protect from complications -maintain nutrition -administer meds at regular intervals; plan activities around these intervals -referrals: PT/OT/ speech pathology -therapeutic procedures: plasmapheresis, thymectomy; spleenectomy allows better control of the symptoms

Nursing and Collaborative Care MS

assess status prevent UTI/ infections promote cognitive function promote effective communication support vision: eye patch promote mobility: promote exercising, stretching maintain safety medications team collaboration Encourage fluid intake and other measures to decrease the risk of developing a urinary tract infection. Assist the client with bladder elimination (intermittent selfcatheterization, bladder pacemaker, Credé [placing manual pressure on abdomen over the bladder to expel urine]). ◯ Monitor cognitive changes and take interventions to maintain function (reorient the client, place objects used daily in routine places). ◯ Facilitate effective communication (dysarthria) through the use of a communication board. ◯ Apply alternating eye patches to treat diplopia. Teach scanning techniques. ◯ Exercise and stretch involved muscles (avoid fatigue and overheating). ◯ Utilize energy conservation measures. ◯ Promote and maintain safe home and hospital environment to reduce the risk of

Clinical manifestations of increased ICP

change in LOC change in vital signs: cushings triad (systolic hypertension w/ widening pulse, bradycardia w/ a full bounding puse, & irregular breathing) decrease in motor function (flexor or extensor posutre) ocular signs: dilation of pupil on that side headache vomiting: NOT PRECEDED by nausea

nursing implementation

health promotion -seat belts, helmets, child safety seats, and tougher penalty for drunk driving offenses ; smoking cessation, recreation and exercise programs and alcohol treatment programs acute intervention -proper immobilization SAFETY ALET: use a hard cervical collar and a backboard to stabilize the neck to prevent lateral rotation of the spine, the body should always be aligned, perform turning so that the patient is moved as a unit to prevent movement of spine (log roll) respiratory dysfunction:above C4: REQUIRES VENTILATOR, might need assisted cough technique, pulmonary hygiene, respiratory distress may occur b/c of spinal cord edema; regularly asses: 1. breath sounds 2. ABGs 3. tidal volume 4. vital capacity 5. skin color 6. breathing patterns (especially the use of accessory muscles) 7. subjective comments about the ability to breathe 8. amount of color and sputum; probably need one if get distressed during first 48 hours; incentive spirometry, CPT -cardiovascular instability:: b/c of unopposed vagal response, the heart rate is slowed, often to less than 60 beats/ minute, chronic low BP, predispose the pt to DVT so SCD and lovenox, administer an anticholinergic drug such as atropine for low BP; for hypotension: vasopressors and fluids GIVE TWO TOGETHER; assess for hypovolemic shock BLEEDING/ h&h drop -fluid and nutritional maintenance: Gi tract stops functioning (paralytic ileus) and an NG tube must be instead; since cannot take oral intake monitor fluids and electrolyte a status, allow adequate time to eat (self-feed) -bladder and bowel management: urine is retained right after b/c of loss of autonomic and reflex control of the bladder and sphincter; UTIs are common; insert indwelling catheter; empty bladder -temperature control: no vasoconstriction, piloerection, or heat loss through perspiration below the level of injury, temperature control is largely external to the patient -stress ulcers: histamine receptor blockers (zantac, pepcid, prilosec) -sensory deprivation: conversation, music, and interesting foods can help -reflexes: spasms sometimes occur use Dantrium or Zanaflex -Autonomic dysreflxia: most common cause is distended bladder or rectum; a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system; recognize the symptoms: VERY hypertensive, throbbing headache, marked diaphoresis above the level of injury, bradycardia, piloerection (erection of body hair), flushing of the skin, blurred vision or spots, nasal congestion anxiety, and nausea; body trying to signal the brain that there is an irritant, but the SCI blocks the signal; assess and elimate the cause: bladder, bowel, skin, reproductive tract; treat HTN NTG paste; treat fam about causes and treatment; sit patient up REHABILITATION and HOME CARE -respiratory rehabilitation -neurogenic bladder: is any type of bladder dysfunction related to abnormal or absent bladder innervation; usually intermittent catheterization is done; urinary diversion surgery might be done it pt has related UTIs; teach patient -neurogenic bowel: suppositories, high fiber diet, and adequate fluid intake : be specific amount time and consistency; also includes upright positioning if possible/ rectal stimulation it is called "bowel program" -neurogenic skin: PROTECT SKIN!!!: prevention of ulcers and prevent avoidance of thermal injury; specialty beds/ positioning/ protect from extreme temperatures (people on steroids, immobile, moist skin, paper thin skin) -sexuality: less lubrication and harder to get erections in males; planned; woman remain fertile; -grief and depression: encourage family involvement, plan graded steps in rehab, avoid sympathy, provide honest information, use simple diagrams to explain injury, encourage patient to begin road to recovery

Triage

identifies and categorizes the patients so that the most critical are treated first. The emergency Severity Index is a five-level triage system that incorporates concepts of illness severity and resource utilization (ECG, lab work, radiological studiers, IV) to determine who should be treated first

MS stressors

infection, exposure to temp extremes, injury, stress and fatigue: SOME SORT OF STRESSOR

Ventilation

involves inspiration or inhalation (movement of air into the lungs) and expiration, or exhalation (movement of air out of the lungs). Air moves in and out of the lungs because intrathoracic pressure changes in relation to pressure at the airway opening. Contraction of the diaphragm and intercostal and scalene muscles increases chest dimensions, thereby decreasing intrathoracic pressure. Gas flows from an area of higher pressure (atmospheric) to one of lower pressure (intrathoracic)

Nursing Management Mechanical Ventilation

literally lists nothing but eNursing Care Plan 66-1 for patient receiving mechanical ventilation: found it! listed next are the different nursing diagnosis/ goals/interventions w/ rationale r/t mechanical ventilation!

Evaluation of SPI

maintain, adequate ventilation and have no signs of respiratory distress, maintain intact skin over bony prominences, establish a bowel management program based on neurologic, establish a bladder management program based on neurologic function, caregiver status, and lifestyle choices, experience no episodes on autonomic dysreflexia

For oral/nasal intubation

oral: place patient supine w/ head extended and the neck flexed (sniffing position): allows visualization of the goal cords nasal: nasal passages may be sprayed with local anesthetic and vasoconstrictor (lidocaine w/ epinephrine) to reduce trauma and bleeding -before intubation pre oxygenate pt using Ambu bag & 100% 02

ABGs normal values

pH 7.35-7.45 PaO2 80-100 SaO2 >95% PaCO2 35-45 mmHg HCO3 22-26 mEq/L

Critical care patient

patient at high risk for actual or potential life-threatening health problems who requires intensive vigilant care; 1. patient maybe physiologically unstable, requiring advanced clinical judgements by you and a physician 2. patient may be at risk for serious complications and require frequent assessments an often invasive interventions 3. the patient may require intensive and complicated nursing, support r/t the use of IV polypharmacy

Rapid sequence intubation

rapid, concurrent administration of both a sedative and paralytic agent during emergency airway management to descrease the risks of aspiration and injury to the patient. RSI is not indicated in patient who are in cardiac arrest or have a known difficult airway. -sedative hypnotic amensis (Versed) to induce unconsciousness -rapid onset opioid (Fentanyl) to blunt pain associated with procedure -paralytic drug (Anectine): produce skeletal muscle paralysis MONITOR PTS O2!!!

MLT

refere to MOV but w/ one exception -remove a small amount of air from the cuff until a slight of air leak is auscultated at peak inflation

Nursing and Collaborative Management Acute Respiratory Failure

specific care of the patient varies; this section discusses general assessment and collaborative care measures that apply to patients w/ acute respiratory failure. In acute care settings, collaboration b/n nursing and other health care team members (e.g. respiratory therapists) is essential

Elastic recoil

the tendency for the lungs to relax after being stretched or expanded. The elasticity of lung tissue is due to the elastin fibers found in the alveolar walls and surrounding the bronchioles and capillaries. The elastic recoil of the chest wall and lungs allows the chest to passively decrease in volume. Intrathoracic pressure rises, causing air to move out of the lungs

Prevention for Acute Respiratory Failure

thorough H&P teach pt about breathing and coughing, use of incentive spirometry, and ambulation -prevention of atelectasis, pneumonia, and complications of immobility, as well as optimization of hydration and nutrition

Nursing Diagnoes for COPD

to follow

ALS medications

◯ Riluzole (Rilutek) ■ Glutamate antagonist that can slow the deterioration of motor neurons by decreasing the release of glutamic acid. Must be taken early in disease process. Will add approximately 2 to 3 months of life to the client's overall lifespan. ■ Nursing Considerations ☐ Monitor liver function tests - hepatotoxic risk. ☐ Assess for dizziness, vertigo, and somnolence. ■ Client Education ☐ Avoid drinking alcohol. ☐ Take medication at evenly spaced regular intervals (e.g., every 12 hr). ☐ Store medication away from bright light. ◯ Baclofen (Lioresal), dantrolene sodium (Dantrium), diazepam (Valium) ■ Antispasmodics are used to decrease spasticity