HPA II - Exam 2

Seizure Clinical Manifestations

- Decreased LOC, loss, confusion. - involuntary movement: contractions, rigidity and rhytmic jerking, flaccidity - visual, auditory, olfactory stimuli (aura). amnesia afterwards - anxiety, depression, feeling of detachment. overwhelming fear, flood of ideas

generalized tonic-clonic seizure - phases

- Loss of consciousness or fainting (30sec-5min) - tonic phase 15-20 sec - clonic 1-2 minutes - biting cheek/tongue, clenched teeth/jaw. -incontinence - difficulty breathing or apnea, cyanosis

Intracerebral Hemorrhage

- Occurs into substance of brain. May be caused by trauma or non-trauma (high BP) - treatment: control of ICP, F+E, antihypertensives - craniotomy or craniectomy (flap removal) to remove clot and control hemorrhage because it's so deep in the brain.

carbamezepine (Tegretol)

- Treatment of tonic-clonic and focal seizures. - PO, extended release - monitor: serum levels, CBC, Na. - adverse: teratogenic, CNS depression, bone marrow suppression, hepatitis, stevens-johnson syndrome - interactions: warfarin, grapefruit juice, phenytoin and phenobarb

During a seizure

- oxygen tubing, oxygen suction apparatus available - 2-3 side rails up and padded - loosened clothing, patient side lying - bed in lowest position - privacy

A client has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the client may have developed liver metastases?

Abdominal pain and hepatomegaly - The early manifestations of malignancy of the liver include pain—a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation.

A client's health care provider has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.

Alanine aminotransferase (ALT) Gamma-glutamyl transferase (GGT) Aspartate aminotransferase (AST)

manifestations of brain injury

Altered LOC Pupillary abnormalities Sudden onset of neurologic deficits and neurologic changes; changes in sense, movement, reflexes Changes in vital signs Headache Seizures

Management of patient with head injury

Assume cervical spine injury until it is ruled out Therapy to preserve brain homeostasis and prevent secondary damage Treat cerebral edema Maintain cerebral perfusion; treat hypotension, hypovolemia, and bleeding; monitor and manage ICP Maintain oxygenation; cardiovascular and respiratory function Manage fluid and electrolyte balance

Chronic Kidney Disease (CKD)

Kidney damage or decrease in GFR for 3 or more months. - prolonged acute inflammation, not organ specific, not clearly understod. Manifestations: increased creatinine, anemia, fluid retention, and electrolyte imbalances.

Focal vs generalized seizures

Focal: seizure originating from one area of the cortex Generalized: seizures originating from both hemispheres simultaneously

nephrotic syndrome

Increased glomerular permeability (as result of glomerular damage). Leads to massive proteinuria - hypo-albuminemia, hyperlipidemia, hyper-coagulable state, edema - treatment: diuretics, ace-inhibitors, lipid-lowering agents, sodium restriction

seizure triggers

Increased physical activity, excessive stress, hyperventilation, overwhelming fatigue, acute alcohol ingestion, excessive caffeine intake, exposure to flashing lights, substances such as cocaine, aerosols, and inhaled glue products.

A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus (HAV). They ask the nurse how this could have happened. Which of the following explanations would the nurse correctly identify as possible causes?

Infection at school Suboptimal sanitary habits Consumption of sewage-contaminated water or shellfish Sexual activity

Epidural hematoma

Intracranial bleed, blood collection in the space between the skull and dura. Patient may have brief loss of consciousness with return of lucid states, then as hematoma expands increased ICP will often suddenly reduce LOC. Treatment: decrease ICP, removal of clot (craniotomy), stop the bleeding (decrease BP and burr holes) - monitor/support vital body functions; respiratory support

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?

Irritability and drowsiness

derealization

sensation of being in a dream-like state in which the environment seems foggy or unreal (client is not psychotic or out of contact with reality)

Grade 3 concussion

Loss of consciousness from seconds to minutes. Worsening headache, dizziness, seizure, slurred speech

Grade 2 concussion

No loss of consciousness. Transient confusion and mental status abnormalities resolve in greater than 15 minutes

Grade 1 concussion

No loss of consciousness. Transient confusion and mental status abnormalities resolve in less than 15 minutes

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding?

Octreotide - Acute hemorrhage from esophageal varices is life threatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide is started as soon as possible. Octreotide is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.

Chronic Subdural Hematoma

Old clot, develops over weeks to months, causative injury may be minor ad forgotten. - fluctuating S/S dull headache, alternating neuro changes that fluctuate (can be subtle), focal seizures, gradual confusion. - Treatment: evacuation of clot (skull stays on post-op if not worried about swelling)

end-stage kidney disease (ESKD)

Stage 5 CKD, Uremia develops (causes symptoms), RRT or replacement required, metabolic acidosis occurs (can't secrete). Complications: anemia, calcium-phosphorous imbalance, hyperkalemia, HTN, pericarditis, pericardial effusion, pericardial tamponade - nutrition: refer to dietician, protein increases workload on the kidney. restrict K and NA.

A patient is scheduled for a diagnostic paracentesis, but when coagulation studies were reviewed, the nurse observed they were abnormal. How does the nurse anticipate the physician will proceed with the paracentesis?

The physician will use an ultrasound guided paracentesis - Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions (Gordon, 2012). Ultrasound guidance may be indicated in some patients who are at high risk for bleeding because of an abnormal coagulation profile and in those who have had previous abdominal surgery and may have adhesions.

A nurse practitioner treating a patient who is diagnosed with hepatitis A should provide health care information. Which of the following statements are correct for this disorder? Select all that apply.

There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral-anal contact during sex. Typically there is a spontaneous recovery.

Focal seizures - complex partial seizures

WITH loss of consciousness - automatisms or repetitive non-purposeful activities (lip smacking, grimacing, patting, or rubbing clothing) - hallucinations and illusional experiences such as deja-vu - amnesia - spreads

Focal seizures - simple partial seizures

WITHOUT loss of consciousness - aura, involuntary movement, somatosensory disturbances (tingling, crawling sensations) - increased HR, flushing - sensory disturbances (visual, auditory, olfactory phenomena)

Diffuse axonal injury

Widespread axon damage in the brain seen with head trauma. Patient develops immediate coma.

pyelonephritis

a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. - causes: badder infection, BPH, bladder/prostate tumors, incompetent uretovesical valve or urinary tract obstruction, strictures, urinary stones, or systemic infections. - complicationL sepsis, dehydration, n&v. treat underlying cause, abx up to 6 weeks, and hydration

ventriculostomy

a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid

status epilepticus

a prolonged seizure lasting more than 5 minutes or repeated seizure activity within a 30-minutes time frame - biggest concerns: hypoxia, respiratory arrest, cerebral anoxia and edema. - diazepam or lorazepam IV, IV phenytoin, IV fluids with glucose.

Concussion

a temporary loss of consciousness with no apparent structural damage

Closed brain injury (blunt trauma)

acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue. coup contrecoup

seizures

an abrupt, abnormal, and uncontrollable electrical discharge of neurons within the brain that can cause alterations in LOC, motor function, sensory ability, and behavior.

tonic-clonic

bilateral symmetrical tonic contractions, then bilateral clonic contractions (1-2min); rigidity and rhythmic jerking. - aura as warning sign of impending seizure activity - respiratory issues, cyanosis, biting of cheek and tongue -postictal confusion and sleepiness

contusion

bruise, injury. longer period of unconsciousness with more symptoms of neuro deficits and changes in vital signs vs. concussion.

malingering

characterized by the intentional creation of false or grossly exaggerated physical or psychological symptoms

Epilepsy

chronic recurring abnormal brain electrical activity resulting in two or more seizures, 24 hours apart.

Acute Subdural Hematoma

collection of blood between the dura and the brain. symptoms develop over 24-48hrs. can require immediate craniotomy and control of ICP subacute: symptoms develop 48hrs-2 weeks

A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that most likely bring about hemostasis in the client are:

cryoprecipitate and fresh frozen plasma

atonic

flaccid muscle activity

absence seizures

generalized, non-convulsive epileptic events. typically children and cease in adulthood or evolved to generalized motor seizures. - blank stare, motionless. unresponsiveness - automatisms: lip smacking, mild clonic motion (usually eyelids), eye rolling - seen on EEG

pain disorder

has the primary physical symptom of pain, which is generally unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance.. pain primary symptom but unrelieved by analgesics

Scalp Wounds and Skull Fractures

manifestations depend on the severity and location of the injury scalp wounds: tend to bleed heavily and are portals for infection skull fractures: usually have localized, persistent pain fractures of the base of the skull bleeding from nose pharynx or ears battle sign-ecchymosis behind the ear. may indicate temporal bone fracture halo sign- ring of fluid around the blood stain from drainage. CSF leak

Chronic Pyelonephritis

multiple bouts of acute, causes scarred, contracted, nonfunctioning kidneys. cause of CKD - normally asymptomatic unless exacerbation... fatigue, headache, poor appetite, polyuria, excessive thirst, weight loss complication: ESKD, renal calculi, HTN

somatic symptom illness

multiple physical symptoms—combination of pain, GI, sexual, pseudoneurologic symptoms. no organic cause can be found

Open brain injury

object penetrates the brain or trauma is so severe that the scalp and skull are opened.

Concussion management

observe. report change in LOC or MS, difficult awakening, lethargy, dizziness, confusion irritability, anxiety, difficulty speaking or moving, severe headache, possible N/V. should be assessed frequently. Diagnostics: physical and neurological exam, skull and spinal radiography, CT scan, MRI

Depersonalization

persistent feeling of being detached from self of one's mental processes

illness anxiety disorder (hypochondriasis)

preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). It is thought that clients with this disorder misinterpret bodily sensations or functions.

clonic

repetitive, rhythmic myoclonus (twitching or jerking). bilateral, symmetrical - hyperventilation

la belle indifference

seeming lack of concern or distress about the functional loss.

tonic

sudden stiffening and sustained muscle contractions for seconds to minutes. limbs fixed in strained position - sudden loss of consciousness. sudden rigid, violent contraction of the muscles. - autonomic manifestations (arrhythmia, apnea, vomiting, incontinence, salivation)

myoclonic

sudden, involuntary contractions of muscles or muscle groups (specific muscle groups)

primary gains: internal motivators

the direct internal benefits that being sick provides, such as relief of anxiety, conflict, or distress.

secondary gains: external motivators

the external or personal benefits received from others because one is sick, such as attention from family members and comfort measures (e.g., being brought tea, receiving a back rub)

Conversion Disorder (Functional Neurological Symptom Disorder)

unexplained sensory or motor deficits associated with psychological factors; typically involves significant functional impairment (psuedoseizures, blindness, paralysis)

fugue experience

where the client suddenly moves to a new geographic location with no memory of past events and often the assumption of a new identity.

Phenytoin (Dilantin)

- Treatment of tonic-clonic seizures, prevention of status epilepticus -stabilizes neuronal membranes + prevents hyperexcitability caused by excessive stimulation. limits spread of seizure activity - adverse effects: CNS depression, gingival hyperplasia, liver toxicity, bone marrow suppression, teratogenic.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar skull fracture explanation: A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

Cerebral Perfusion Pressure (CPP)

CPP = MAP - ICP Means adequate oxygen is getting to the brain Want ICP <20, and CPP >60 . BP <150, MAP >60

A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk?

Central nervous system damage

Phenobarbital

- Treatment of tonic-clonic seizures and status epilepticus - produces sedation, anesthesia, and deep coma. alters cerebellar function, inhibits conduction in RAS - PO, IV, IM - adverse: bradycardia, hypoventilation, hypotension, dependence and withdrawal sundrome - toxicity: nystagmus, ataxia, respiratory depression, coma. pinpoint pupils. hypotension, death - interactions: interferes w/ metabolism of vitamin D and K - cns depressants - valproic acid (depakote) increases levels

ESKD pharmacology

- calcium and phosphate binders: sevelamer. given with meals, binds with phosphorous in food - antihypertensives: ace inhibitors, diuretics (pushing fluid out stimulates last working nephrons - cadiovascular agents: inotropics (digoxin po) -erythropoietin

Hemodialysis - complications and assessing graft/fistula.

- look for bleeding, hypotension, and fluid and electrolyte shifts. - get baseline vitals assessing graft/fistula: gently palpate, feel for a thrill. Listen for a bruit.

Post-ictal phase

- normal breathing, sleepiness (1hr or more), amnesia, headache, drowsiness, confusion (temporary and mild), weakness up to 24-48hrs following seizure (Todd's paralysis)

somatic symptom illnesses

- physical complaints suggest major medical illness but have no demonstrable organic basis. not under patient's conscious control - psychological factors/conflicts important in initiating, exacerbating, and maintaining symptoms.

Somatic symptom illnesses- nursing process application

- provide health teaching: improved health behaviors - help express emotions: journaling, time limit spent on physical complaints - teach coping strategy: emotion focused + problem focused - CBT - community groups, pain clinics, referrals

Suicide: Outcome identification examples

- safe from harming self and others - engagement in a therapeutic relationship - reporting suicidal ideation to staff - list of positive attributes - realistic plan to address underlying issues

Somatic symptom illnesses- treatment

- symptom management, improvement in quality of life - antidepressants for accompanying depression - pain clinic referral for disorder - involvement in therapy groups - coping, CBT

suicide - actions

- using an authoritative role - providing a safe enviroment - creating a support system list

Monroe-Kellie Hypothesis/Doctrine

-Cranial vault is a fixed space. -3 intracranial components -Blood -Brain -CSF -Any increase in once component requires a decrease in another. Compensated: Normal ICP, Decompensated: elevated ICP

Somatic symptom illnesses- outcome identification

-Identify relationship between stress and physical symptoms -Verbally express emotions/feelings -Establish and follow a daily routine -Demonstrate alternate ways to deal with stress, anxiety, and other feelings -Demonstrate healthy behaviors regarding rest, activity, and nutritional intake

acute nephritic syndrome

-Inflammation of glomerular capillaries -> glomerular nephritis -Post infectious cause: Group A beta-hemolytic streptococcus , acute viral infection -Manifestations:Hematuria, Edema, Azotemia (INCREASED nitrogen in the blood), Proteinuria, cola-colored urine, HTN Treatment: corticosteroids, manage HTN, ABX if infection still present, fluids, I&Os

Chronic Pyelonephritis - management

-meds: prophylactic antimicrobials, abx if bacteria in urine present - monitor for nephrotoxicity. - monitor I&O, vital signs Q4hrs, empty bladder completely, perineal hygiene. 3-4L/day fluid unless contraindicated

ESKD assessment findings

-neuro: altered MS, asterixis, restless legs, seizures, tremors, weakness, fatigue -integumentary: dry, flaky skin, ecchymosis, pruritis, thin, brittle nails - cardiovascular: JVD, hyperkalemia, HTN, edema - pulmonary: crackles, SOB, tachypnea -gastrointestinal: anorexia, nausea, vomiting, hiccups, cons/diarrhea hematologic: anemia, thrombocytopenia musculoskeletal: fractures, loss of strength, muscle cramps

Renal Replacement Therapy (RRT) - Dialysis

1. Artificial processes for removing waste and water from the body when the kidneys are no longer functioning 2. Hemodialysis uses an artificial membrane - arteriovenous fistula or graft. or HD catheter (double-lumen) ; PD uses the peritoneal membrane 3. Hemodialysis: extract toxic nitrogenous substances from the blood and remove excess fluid. need high-biologic protein (eggs, meat, fish) and fluid restriction ~ 1000ml/24hrs - The exact duration and number of sessions per week depend on the patient's individual status: renal function, weight, serum electrolyte, BUN/creatinine levels, and general health of the patient 4. Peritoneal dialysis is performed at home and rarely done in the hospital setting

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?

Octreotide (Sandostatin) - Octreotide (Sandostatin), a synthetic analogue of the hormone somatostatin, is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding.

Mannitol

Osmotic diuretic used to treat elevated ICP. Decreases through diuresis. Pulls fluid from brain cells Monitor VS, weight, I&O, renal function, serum Na and K.

Cushing's Triad

Signs of increased intracranial pressure: 1. hypertension 2. bradycardia 3. irregular respirations Medical emergency