NSG 2280 Exam 4

Components of the EOP: MCI planning

includes such issues as planning for mass fatalities and morgue readiness.

Ischemic Stroke nursing intervention: PREVENTING SHOULDER PAIN

-Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder. -Use proper patient movement and positioning (e.g., flaccid arm on a table or pillows when patient is seated, use of sling when ambulating) -Range-of-motion exercises are beneficial, but avoid over-strenuous arm movements. -Elevate patient's arm and hand to prevent dependent edema of the hand; administer analgesic agents as indicated.

Prioritize the order of care delivery for patients in the ED. (Primary Survey)

-anxiety reduction, a prerequisite to effective and appropriate coping; safety is of prime importance. The *primary survey* focuses on stabilizing life-threatening conditions. -follow the ABCDE (airway, breathing, circulation, disability, exposure) method: -Establish a patent airway. -Provide adequate ventilation, employing resuscitation measures when necessary. Patients who have experienced trauma must have the cervical spine protected and chest injuries assessed first, immediately after the airway is established. -Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or restoring effective circulation. This includes the prevention and management of hypothermia. In addition, peripheral pulses are examined, and any immediate closed reductions of fractures or dislocations are performed if an extremity is pulseless. -Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale (GCS). - Undress the patient quickly but gently so that any wounds or areas of injury are identified; this may entail cutting away articles of clothing

Carbon Monoxide Poisoning clinical manifestations and diagnostic findings,

-appear intoxicated (from cerebral hypoxia) -headache, -muscular weakness, -palpitation, -dizziness, -confusion, which can progress rapidly to coma. Skin color, which can range from pink or cherry-red to cyanotic and pale, is not a reliable sign. Pulse oximetry may reveal a high hemoglobin saturation, which may be deceiving, since the hemoglobin molecule is saturated with carbon monoxide rather than oxygen.

Treatment for Black Widow spider bites

-application of ice to the site to decrease swelling and discomfort, along with elevation and assessment of tetanus immunization status. -Analgesic agents and benzodiazepines may relieve muscle spasms. -Cardiopulmonary monitoring is essential. -Antivenin

medical management of heat-related injures (heat stroke)

-avoid hypothermia and to prevent hyperthermia, which may recur spontaneously within 3 to 4 hours. -The cooling process should stop at 38°C (100.4°F) in order to avoid iatrogenic hypothermia -Monitor vital signs, ECG findings (for possible myocardial ischemia, myocardial infarction, and dysrhythmias), central venous pressure (CVP), and level of responsiveness, all of which may change with rapid alterations in body temperature. A seizure may be followed by recurrence of hyperthermia. To meet tissue needs exaggerated by the hypermetabolic condition, 100% oxygen is given. Endotracheal intubation and mechanical ventilation to support failing cardiopulmonary systems may be required. IV infusion therapy of normal saline or lactated Ringer solution is initiated as directed to replace fluid losses and maintain adequate circulation. dialysis for AKI, anticonvulsant medications to control seizures, potassium for hypokalemia, and sodium bicarbonate to correct metabolic acidosis. Benzodiazepines such as diazepam (Valium) may be prescribed to suppress seizure activity, while a phenothiazine such as chlorpromazine (Thorazine) may be prescribed to suppress shivering

What will happen if you have brain swelling?

-edema -bleeding -pressure -herniation

Transsphenoidal Approach pre-op nursing management

-educated in deep breathing techniques before surgery -avoid vigorous coughing, blowing the nose, sucking through a straw, or sneezing, because these actions may place increased pressure at the surgical site and cause a CSF leak

Herniation and Cervical Intervertebral Disc Monitoring and Managing complications

-evaluated for bleeding and hematoma formation by assessing for swelling, excessive pressure in the neck, or severe pain in the incision area. -inspected the dressing for serosanguineous drainage, which suggests a dural leak. -Neurologic checks are made for swallowing deficits and upper and lower extremity weakness, because cord compression may produce rapid or delayed onset of paralysis -sudden return of radicular (spinal nerve root) pain, indicate instability of the spine -Report severe localized pain not relieved by analgesic agents -Monitor for signs of respiratory difficulty -Monitor blood pressure and pulse

Assess neurological functions using Glasgow Coma Scale (GCS)?

-eye opening, -verbal response, -motor response The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive

Herniation and Cervical Intervertebral Disc Promoting home and transitional care

-f/u with provider for assessment or range-of-motion and disappearance of old symptoms -Recurrent or persistent pain may occur; emotional support and understanding is needed -wear cervical collar for 6 weeks

Controlling ICP in Patients With Severe Brain Injury

Chart 68-5 Elevate the HOB as prescribed. Maintain the patient's head and neck in neutral alignment (no twisting or flexing the neck). Initiate measures to prevent the Valsalva maneuver (e.g., stool softeners). Maintain body temperature within normal limits; less than 38°C (100.4°F) Administer oxygen (O2) to maintain partial pressure of arterial oxygen (PaO2) >90 mm Hg. Maintain fluid balance with normal saline solution. Avoid noxious stimuli (e.g., excessive suctioning, painful procedures). Administer sedation to reduce agitation. Maintain cerebral perfusion pressure of 50-70 mm Hg.

Central Cord Syndrome

Chart 68-7 Characteristics: Motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved. Cause: Injury or edema of the central cord, usually of the cervical area. May be caused by hyperextension injuries.

What questions to ask for suspected food poisoning?

Chart 72-2 ---Not mentioned in lecture -How soon after eating did the symptoms occur? (Immediate onset suggests chemical, plant, or animal poisoning.) -What was eaten in the previous meal? Did the food have an unusual odor or taste? (Most foods causing bacterial poisoning do not have unusual odor or taste.) -Did anyone else become ill from eating the same food? -Did vomiting occur? What was the appearance of the vomitus? -Did diarrhea occur? (Diarrhea is usually absent with botulism and with shellfish or other fish poisoning.) -Are any neurologic symptoms present? (These occur in botulism and in chemical, plant, and animal poisoning.) -Does the patient have a fever? (Fever is characteristic in salmonella, ingestion of fava beans, and some fish poisoning.)

Anabolic Steroids overdose clinical manifestations "roids," "juice," methandrostenolone, stanozolol, nandrolone Synthetic testosterone

Table 72-1 -Increase in LDL, decrease in HDL -Alter carbohydrate metabolism -Hyponatremia, hypokalemia -Hypocalcemia/osteoporosis -Mood swings/violent behaviors -Invincibility, depression, potential for suicide attempts -Memory loss, cognitive disabilities -Immunosuppression -Used to bulk up muscles, so skeletal muscle hypertrophy is a common manifestation.

Inhalants overdose therapeutic management

Table 72-1 -Provide airway support, ventilation, and oxygen. -Treat cardiac dysrhythmias and hypotension. -Provide advanced cardiac life support as needed. -Monitor for profound hypotension when amyl nitrate is combined with MDMA and sildenafil or with anesthetic agents. -Monitor for hypertension when volatile solvents used.

Salicylate Poisoning clinical manifestations Aspirin (present in compound analgesic tablets) Toxic levels (150-200 mg/kg body weight) Chronic toxicity (occurs in older adults due to decreased kidney function) Long-term intoxication (>100 mg/kg/day for more than 2 days)

Table 72-1 -Restlessness -Tinnitus, deafness -Blurring of vision -Hyperpnea -Hyperpyrexia -Sweating -Epigastric pain, vomiting -Dehydration -Respiratory alkalosis and metabolic acidosis -Disorientation, coma -Cardiovascular collapse -Coagulopathy

Phases of Effects of Radiation Exposure: Prodromal phase (presenting symptoms)

Table 73-7 Time: 48-72 hours after exposure S&S: Nausea, vomiting, loss of appetite, diarrhea, fatigue High-dose radiation—fever, respiratory distress, and increased excitability

Phases of Effects of Radiation Exposure: Recovery phase OR

Table 73-7 Time: After manifest illness phase S&S: Can take weeks to months for full recovery

Phases of Effects of Radiation Exposure: Death

Table 73-7 Time: After manifest illness phase S&S: Increased intracranial pressure is a sign of impending death

Huntington's disease patho

a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. Onset usually occurs between 35 and 45 years of age Patients succumb in 10 to 20 years to heart failure, pneumonia, or infection, or as a result of a fall or choking. The basic pathology involves premature death of cells in the striatum (caudate and putamen) of the basal ganglia, the region deep within the brain that is involved in the control of movement. Cells also are lost in the cortex, the region of the brain associated with thinking, memory, perception, judgment, and behavior, and in the cerebellum, the area that coordinates voluntary muscle activity. One possible theory is that glutamine, a building block for protein, abnormally collects in the cell nucleus, causing cell death

pathophysiology alcohol overdose

a psychotropic drug that affects mood, judgment, behavior, concentration, and consciousness. Many people who drink heavily are young adults or those older than 60 years.

minimally conscious state

a state in which the patient demonstrates awareness but cannot communicate thoughts or feelings

Akinetic mutism

a state of unresponsiveness to the environment in which the patient makes no voluntary movement.

What is a concussion?

a temporary loss of neurologic function with no apparent structural damage to the brain

aneurysm

a weakening or bulge in an arterial wall

brain tumor medical management

craniotomy (incision into the skull), chemotherapy, and external-beam radiation therapy, are used alone or in combination -medications that suppress hormones -Corticosteroids such as dexamethasone (Decadron) are thought to reduce inflammation and edema around tumors; improves HA and LOC -Anticonvulsant medications to control seizures

PPE for CBRN Level C

protection requires the air-purified respirator, which uses filters or sorbent materials to remove harmful substances from the air. A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots.

PPE for CBRN Level B

protection requires the highest level of respiratory protection but a lesser level of skin and eye protection than with level A situations. This level of protection includes the SCBA and a chemical-resistant suit, but the suit is not vapor tight.

What question should you ask a severely depressed client suspected of suicidal ideation.

"Have you ever thought about taking your own life?" may be helpful. If the patient is seriously depressed, relatives should be notified. The patient should never be left alone, because suicide is usually committed in solitude.

Components of the EOP: Plan for people management and traffic flow

"People management" includes strategies to manage the patients, the public, the media, and personnel. Specific areas are assigned and a designated person is delegated to manage each of these groups

What is the snakebites treatment

-Give Fluids to treat hypotension.

What are the five P's neurovascular function assessment after a fracture?

-Pain, -Pallor, -Pulselessness, -Paresthesias, -Paralysis

Complete a neurological assessment using AVPU.

A quick neurologic assessment may be performed using the AVPU mnemonic: A—alert. Is the patient alert and responsive? V—verbal. Does the patient respond to verbal stimuli? P—pain. Does the patient respond only to painful stimuli? U—unresponsive. Is the patient unresponsive to all stimuli, including pain?

Blast Lung patho and S&S

Blast lung results from the blast wave as it passes through air-filled lungs. The result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli. -dyspnea, -hypoxia, -tachypnea or apnea (depending on severity), -cough, -chest pain, -hemodynamic instability

spinal cord tumor diagnostic findings

CT scans, MRI scans, biopsy Note: The MRI scan is the most commonly used and the most sensitive diagnostic tool, great at detecting epidural spinal cord compression and metastases

Patho of carbon monoxide poisoning

Carbon monoxide exerts its toxic effect by binding to circulating hemoglobin and thereby reducing the oxygen-carrying capacity of the blood. Hemoglobin absorbs carbon monoxide 200 times more readily than it absorbs oxygen. Carbon monoxide-bound hemoglobin, called carboxyhemoglobin, does not transport oxygen.

Ecchymosis/contusion

Chart 72-4 blood trapped under the surface of the skin

Abrasion

Chart 72-4 denuded skin

Stab

Chart 72-4 incision of the skin with well-defined edges, usually caused by a sharp instrument; a stab wound is typically deeper than long

Components of the EOP: Internal/external communication plan

Communication is critical for all parties involved, including communication to and from the prehospital arena.

Head Injuries S&S

Could be direct or indirect -Concussions -treatment for postconcussive syndrome is indicated

Components of the EOP: Demobilization response

Deactivation of the response is as important as activation; resources should not be unnecessarily exhausted. The person who decides when the facility resumes daily activities is clearly identified. Any possible residual effects of a disaster must be considered before this decision is made.

Skin Contamination Poisoning (Chemical Burns) medical/nursing interventions

Don appropriate PPE The skin should be drenched immediately with running water from a shower, hose, or faucet, *except in the case of lye and white phosphorus, which should be brushed off the skin dry* standard burn treatment (antimicrobial treatment, débridement, tetanus prophylaxis, antidote administration as prescribed, prophylaxis antibiotic) is instituted

What are some acute and chronic complications of fractures?

Early complications include shock, fat embolism, compartment syndrome, and VTE (deep vein thrombosis [DVT], pulmonary embolism [PE]). Delayed complications include delayed union, malunion, nonunion, AVN of bone, complex regional pain syndrome (CRPS, formerly called reflex sympathetic dystrophy), and heterotopic ossification.

Pulseless ventricular tachycardia (VT)

Initiate CPR Defibrillate Establish IV access Administer IV antidysrhythmic medications, such as epinephrine or vasopressin Consider the following medications: -Amiodarone -Lidocaine hydrochloride -Magnesium sulfate

Components of the EOP: After-action report or corrective plan

Facilities often see increased volumes of patients 3 months or more after an incident. Postincident response must include a critique and a debriefing for all parties involved, immediately and again at a later date.

Components of the EOP: Anticipated resources

Food and water must be available for staff, families, and others who may be at the facility for an extended period.

Ventricular fibrillation (VF)

Initiate CPR Defibrillate Establish IV access Administer IV antidysrhythmic medications, such as epinephrine or vasopressin Consider the following medications: -Amiodarone -Lidocaine hydrochloride -Magnesium sulfate

clinical manifestations and diagnostic findings of cold-related injuries (Frost Bite)

Frostbite ranges from first degree (redness and erythema) to fourth degree (full-depth tissue destruction). frozen extremity may be hard, cold, and insensitive to touch and may appear white or mottled blue-white

What is the GSC range for minor brain injury?

GCS 13-15

What is the GSC range for severe brain injury?

GCS 3-8; <7=comatose

What is the GSC range for moderate brain injury?

GCS 9-12

Pathophysiology of heat-related injures (heat stroke)

Heat stroke, whether the cause is exertional or nonexertional, causes thermal injury at the cellular level, resulting in coagulopathies and widespread damage to the heart, liver, and kidneys. heat stroke--prolonged exposure to an environmental temperature of greater than 39.2°C (102.5°F), although a heat index of greater than 35°C (95°F) is associated with increased mortality. Exertional heat stroke is caused by strenuous physical activity that occurs in a hot environment. Risk Factors People at risk for nonexertional heat stroke are those not acclimatized to heat, those who are older or very young, those unable to care for themselves, those with chronic and debilitating diseases, and those taking certain medications (e.g., major tranquilizers, anticholinergics, diuretics, beta blockers).

What is the most common form of shock secondary to hemorrhaging?

Hypovolemic shock

Medical management for heat exhaustion

IV fluids but may also take oral fluids, if they are tolerated.

S&S Stage II of Lyme disease

If no antibiotic Tx, then stage II will develop within 4-10 weeks. stage II Lyme disease S&S -Facial nerve palsy -joint pain, -memory loss, -poor motor coordination, -adenopathy, -cardiac abnormalities

What are the efforts taken to decrease ICP?

If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents.

Explain how triage is different in a disaster as compared to triage in the emergency department.

In nondisaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. However, in a disaster, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. Decisions are based on the likelihood of survival and consumption of available resources.

When is an Oropharyngeal/Nasopharyngeal airway contraindicated?

In the case of potential facial trauma or basal skull fracture, the nasopharyngeal airway should not be used because it could enter the brain cavity instead of the pharynx.

The cause of Hemorrhagic Stroke chart 67-1

Intracerebral hemorrhage Subarachnoid hemorrhage Cerebral aneurysm Arteriovenous malformation

increased intracranial pressure medical management

Medical Emergency immediate Tx -invasive monitoring -Decrease cerebral edema -Lowering the volume of CSF -Decreasing cerebral blood while maintaining cerebral perfusion Pharmacological Tx: -Mannitol -Fluid restriction -Antipyretic to control fever -Chlorpromazine to control shivering -Last resort (nothing else worked) high doses of barbiturates or paralyzing agents to decrease cellular metabolic demands

Concussion of the brain clinical manifestations

Monitoring includes observing the patient for: -decrease in LOC, -worsening headache, -dizziness, -seizures, -abnormal pupil response, -vomiting, -irritability, -slurred speech, -numbness or weakness in the arms or legs Repeated hits can lead to chronic traumatic encephalopathy with S&S of: -personality changes, -memory impairment, -speech and gait disturbances. Common injury in contact sports such as football or boxing. Presentation is similar to Alzheimer disease

What are the S&S of Acute radiation syndrome (ARS)?

Nausea and vomiting occur within 2 hours after exposure. Hemorrhagic complications including fever and sepsis are common. Sepsis, fluid and electrolyte imbalance, and opportunistic infections can occur as complications. An ominous sign is the presence of high fever and bloody diarrhea; these typically appear on day 10 after exposure CNS: cerebral edema; nausea; vomiting; headache; and increased intracranial pressure, which heralds a poor outcome and imminent death. Skin: erythema Airway, breathing, circulation, and fracture reduction require immediate attention.

neurogenic shock pathophysiology

Neurogenic shock develops as a result of the loss of autonomic nervous system function below the level of the lesion.

Clinical manifestation of a overactive patient

Patients who display disturbed, uncooperative, and paranoid behavior and those who feel anxious and panicky may be prone to assaultive and destructive impulses and abnormal social behavior. Intense nervousness, depression, and crying are evident in some patients.

How the the brain affected if CPP drops below 50 mm Hg?

Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.

Who is the first to ambulate recovering fracture patient?

Physical Therapy

Complication and treatment of Lumbar Puncture

Post-Lumbar Puncture Headache mild to severe that may occur a few hours to several days after the procedure. The headache is caused by CSF leakage at the puncture site. It is particularly severe on sitting or standing but lessens or disappears when the patient lies down. Tx: a blood patch The patient is positioned supine for 4 to 8 hours managed by bed rest, analgesic agents, and hydration. Prevention: Drinking liberal amounts of fluid for rehydration and replacement of CSF may decrease the incidence of post-lumbar puncture headache. see chart 65-4 pg. 1969

Components of the EOP: Identification of external resources

Resources outside of the facility are identified, including local, state, and federal resources and information about how to activate these resources.

What are some risk factors for ALS?

Risk factors that have been identified include -smoking, -viral infections, -autoimmune disease, -environmental exposures to toxins.

The functional recovery period from a Hemorrhagic Stroke Chart 67-1

Slower, usually plateaus at about 18 months

Phases of Blast Injury: Primary

Table 73-3 Results from pressure wave Common injuries: -Pulmonary barotraumas, including pulmonary contusions -Head injuries, including concussion, other severe brain injuries -Tympanic membrane rupture, middle ear injury -Abdominal hollow organ perforation, hemorrhage

Phase of Blast injury: Tertiary

Table 73-3 Results from pressure wave that causes the victim to be thrown Common injuries: -Head injuries -Fractures, including skull

How is CPP calculated?

The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). MAP-ICP= CPP

Components of the EOP: Activation response

The EOP activation response of a health care facility defines where, how, and when the response is initiated.

What is the Emergency Severity Index (ESI)?

The ESI assigns patients into five levels, from level 1 (most urgent) to level 5 (least urgent).

The functional Recovery period from Ischemic Stroke

Usually plateaus at 6 months

How does decreased CO2 affect circulation?

Vasoconstriction Decrease blood flow may also increase cerebral blood volume, thus raising ICP. Normal range for CO2 is 35-45

Expressive aphasia (non-fluent)

When the individual is having difficulty expressing what they want to say.

hemianopsia

blindness of half of the field of vision in one or both eyes

papilledema

edema of the optic nerve usually due to increased intracranial pressure (ICP)

What does a B wave indicate about ICP?

indicate intracranial hypertension and variations in the respiratory cycle

What does an A wave indicate about ICP?

indicates cerebral ischemia

Herniation and Lumbar Disc promoting home and transitional care

inpatient or outpatient rehabilitation The adequacy of pain management is assessed, and modifications are made to ensure adequate pain relief.

paresthesia

numbness, tingling, or a "pins and needles" sensation

Tetraplegia

paralysis of all four extremities; formerly called quadriplegia

chorea

rapid, jerky, involuntary, purposeless movements of the extremities or facial muscles, including facial grimacing

spasticity

sustained increase in tension of a muscle when it is passively lengthened or stretched

sentinel event

unanticipated events that result in patient harm an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

dysphonia

voice impairment or altered voice production

Deep tendon reflexes

Table 66-1 Tap patellar and biceps tendons

hemiplegia

(paralysis of one side of the body, or part of it) caused by a lesion of the opposite side of the brain.

Ischemic Stroke Modifiable Risk Factors chart 67-2

-*Hypertension (controlling hypertension, the major risk factor, is the key to preventing stroke)* -Asymptomatic carotid stenosis -Atrial fibrillation -Diabetes (associated with accelerated atherogenesis) -Dyslipidemia (Hyperlipidemia) -Excessive alcohol consumption -Hypercoagulable states -Migraine -Obesity -Sedentary lifestyle -Sleep apnea -Smoking -Sickle cell diseases -Periodontal disease -Chronic inflammatory conditions (e.g., systemic lupus erythematosus and rheumatoid arthritis) -Use of oral contraceptives -Atherosclerosis

Ischemic Stroke non-modifiable factors

-Advanced age (older than 55 years) -Gender (male) -Race (African American)

What are the stages of grief?

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Stroke diagnostic test: Lumbar puncture

is used to assess for the presence of blood in the cerebrospinal fluid. A positive finding is consistent with a cerebral hemorrhage or ruptured aneurysm.

How to splint an extremity?

A splint is applied before the patient is moved. To splint an extremity, one hand is placed distal to the fracture and some traction is applied while the other hand is placed beneath the fracture for support. The splints should extend beyond the joints adjacent to the fracture. Upper extremities must be splinted in a functional position. If the fracture is open, a moist, sterile dressing is applied. After splinting, assess vascular status -color, -temperature, -pulse, -blanching of the nail bed

What triage method is most ED care based on?

ABCDE method Airway Breathing Circulation Disability Exposure

What is the difference between an abdominal CT and abdominal ultrasound?

Abdominal CT scans permit detailed evaluation of abdominal contents and retroperitoneal examination. Abdominal ultrasounds can be used to rapidly assess patients who are hemodynamically unstable to detect intraperitoneal bleeding.

What is the antidote for snakebites?

Antivenin: Crotalidae polyvalent immune Fab antivenom (FabAV or CroFab) most effective if given within 4 hours and no greater than 12 hours after the snakebite Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is given as an IV infusion whenever possible, although intramuscular administration can be used. If the dose exceeds 10 vials, serum sickness will most likely occur. There is no limit to the number of antivenin vials that can be given.

What is the nursing action for sudden discharge of fluid from a cranial incision?

Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by CSF trickling down the throat.

Postoperative intracranial surgery Nursing Management

Assessing respiratory function; even a small degree of hypoxia can increase cerebral ischemia Fluctuations in vital signs are carefully monitored and documented Assess core temperature Neurologic checks A change in LOC or response to stimuli may be the first sign of increasing ICP. Inspect surgical dressing for signs of bleeding Monitor incision site for redness, tenderness, bulging, separation, or foul odor Sodium retention is common postoperatively; monitor serum and urine electrolytes, BUN, blood glucose, weight Monitor for seizures Monitor for restlessness which may be caused by pain, confusion, hypoxia, or other stimuli Vital signs and neurologic status (LOC and responsiveness, pupillary and motor responses) are assessed every 15 to 60 minutes. Extreme head rotation is avoided, because this raises ICP. monitor the patient's temperature and use the following measures to reduce body temperature: -removing blankets, -placing ice packs, -administering prescribed antipyretics to reduce fever Rewarming should occur slowly to prevent shivering, which increases cellular oxygen demands. -encourage yawning, sighing, deep breathing, incentive spirometry, and coughing (unless contraindicated)

Herniation and Lumbar Disc nursing pre-op/post-op care

Before surgery, the patient is also encouraged to take deep breaths, cough, and perform muscle setting exercises to maintain muscle tone. Health issues that may influence the postoperative course and quality of life (e.g., fatigue, mood, stress, patient expectations, smoking) are important to assess. Preoperatively the patient practices logrolling motion. Monitor for urinary retention especially in males. Have client void within 6-8 hrs.

Huntington's disease Medical management

Benzodiazepines, tetrabenazine (Xenazine), and neuroleptic drugs have also been reported to control chorea. Tricyclic antidepressants have been recommended for control of psychiatric symptoms. Akathisia (motor restlessness) in the patient who is overmedicated is dangerous because it may be mistaken for the restless fidgeting of the illness and consequently may be overlooked. rigidity is treated with Levodopa Psychotherapy aimed at allaying anxiety and reducing stress may be beneficial. Nurses must look beyond the disease to focus on the patient's needs and capabilities.

How will the nurse know if dobutamine (Dobutrex) and norepinephrine (Levophed) is effective at increasing cardiac output?

CPP is maintained greater than 70 mm Hg; indicating adequate cerebral perfusion.

What are some late indications of increased ICP?

Chart 66-1 LOC that continues to deteriorate until patient is comatose, bradycardia or erratic pulse rate and respiratory rate, increased systolic blood pressure and temperature, widened pulse pressure, rapidly fluctuating pulse; altered respiratory patterns (Cheyne-Stokes breathing and ataxic breathing); projectile vomiting; hemiplegia; decorticate or decerebrate posturing; loss of brain stem reflexes.

Helping Family Members Cope With Sudden Death part 1

Chart 72-2 -Take the family to a private place. -Talk to the family together so that they can grieve together and hear the information given together. Reassure the family that everything possible was done; inform them of the treatment rendered. -Avoid using euphemisms such as "passed on." Show the family that you care by touching, offering coffee, water, and the services of a chaplain. -Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief). -Avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression.

Laceration

Chart 72-4 skin tear with irregular edges and vein bridging

Avulsion

Chart 72-4 tearing away of tissue from supporting structures

Hematoma

Chart 72-4 tumor-like mass of blood trapped under the skin

Patterned

Chart 72-4 wound representing the outline of the object (e.g., steering wheel) causing the wound

Priority Management in Patients With Multiple Injuries

Chart 72-5 1. Establish airway and ventilation 2. Control hemorrhage 3. Prevent and treat hypovolemic shock 4. Assess for head and neck injuries 5. Evaluate for other injuries--expose and reassess head and neck, chest; assess abdomen, back and extremities 6. Splint fractures and then reassess pulses and neurovascular status 7. Perform a more thorough and ongoing examination and assessment; diagnostic studies

What are some clinical manifestations of fat emboli?

Classic Triad -hypoxemia (x-ray may show ARDS), -neurologic compromise, -petechial rash First manifestations: -pulmonary and include hypoxia, -tachypnea, -dyspnea accompanied by tachycardia, -substernal chest pain, -low-grade fever, -crackles, -respiratory failure Secondary manifestations: -Rash Neurological Deficits: -restlessness, -agitation, -seizures, -focal deficits, -encephalopathy

What is the rule for using restraints on an unconscious patient?

If the patient begins to emerge from unconsciousness, every measure that is available and appropriate for calming and quieting the patient should be used. Any form of restraint is likely to be countered with resistance, leading to self-injury or to a dangerous increase in ICP. Therefore, physical restraints are avoided, if possible; a written prescription must be obtained if their use is essential for the patient's well-being.

Herniation and Cervical Intervertebral Disc Relieving Pain Nursing care

Incisional pain is expected. Radicular pain improves over time as the nerve recovers. -monitoring the donor site for hematoma formation -administering the prescribed postoperative analgesic agent, -positioning for comfort, -reassuring the patient that the pain can be relieved. If the patient experiences a sudden increase in pain, extrusion of the graft may have occurred, requiring reoperation. A sudden increase in pain should be promptly reported to the surgeon.

Hemorrhagic Stroke Nursing management: Relieving Anxiety

Keep sensory stimulation to a minimum; reorient frequently help maintain orientation. Keep patient well informed of the plan of care; provide appropriate reassurances to help relieve fears and anxiety. Include family in discussions of care and support family members.

Hemiparesis Manifestations and Nursing Implications Table 67-2

Manifestations: -Weakness of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere) Nursing Implications/Education: -Place objects within the patient's reach on the nonaffected side. -Instruct the patient to exercise and increase the strength on the unaffected side.

Global (mixed) aphasia manifestations and nursing implications Table 67-2

Manifestations: -Combination of both receptive and expressive aphasia Nursing Implications/Education: -Speak clearly and in simple sentences; use gestures or pictures when able. -Establish alternative means of communication.

Dysarthria manifestations and nursing implications Table 67-2

Manifestations: -Difficulty in forming words Nursing Implications/Education: -Provide the patient with alternative methods of communicating. -Allow the patient sufficient time to respond to verbal communication. -Support patient and family to alleviate frustration related to difficulty in communicating.

Main Presenting Symptoms of Ischemic Stroke Chart 67-1

Numbness or weakness of the face, arm, or leg, especially on one side of the body

How does a SCI affect sexual and reproductive ablities?

Patient education may initially focus on the injury and its effects on mobility; dressing; and bowel, bladder, and sexual function. The nurse should reassure female patients with SCI that pregnancy is not contraindicated and fertility is relatively unaffected, but that pregnant women with acute or chronic SCI pose unique management challenges. The normal physiologic changes of pregnancy may predispose women with SCI to many potentially life-threatening complications, including autonomic dysreflexia, pyelonephritis, respiratory insufficiency, thrombophlebitis, PE, and unattended delivery. Preconception assessment and counseling are strongly recommended to ensure that the woman is in optimal health and to increase the likelihood of an uneventful pregnancy and healthy outcomes

Herniation and Cervical Intervertebral Disc Improving mobility

Post-op care: -a cervical collar (neck orthosis) may be worn, which contributes to limited neck motion and altered mobility. -instructed to turn the body instead of the neck when looking from side to side. -The neck should be kept in a neutral (midline) position, the nurse supports the patient's neck and shoulders when assisting to sitting. -The patient is assisted during position changes to make sure that the head, shoulders, and thorax are kept aligned. -To increase stability, wear shoes when ambulating. -Do not lift more than 10 pounds

Ischemic Stroke nursing management: Managing Complications

Post-Op Hemicraniectomy -Continuous hemodynamic monitoring -Neurologic assessment to determine whether stroke is evolving and whether other acute complications are developing. -Intubation with an endotracheal tube to maintain a patent airway -Supplemental oxygen -Monitor for urine tract infections, cardiac dysrhythmias, complications of immobility. -Monitor for hyperglycemia and treat if blood glucose is greater than 140 mg/dL.

What infections do ticks carry?

Rocky Mountain spotted fever West Nile virus Lyme disease

What is human trafficking.

defined as the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude; it may involve forced sex or labor or both.

Biologic Weapons: Anthrax clinical manifestation and diagnostics

Skin lesions (the most common infection) cause edema with pruritus and macule or papule formation, resulting in ulceration with 1- to 3-mm vesicles. A painless eschar develops, which falls off in 1 to 2 weeks Ingestion of anthrax results in fever, nausea and vomiting, abdominal pain, bloody diarrhea, and occasionally ascites. Inhalation: symptoms mimic those of the flu; cough, headache, fever, vomiting, chills, weakness, mild chest discomfort, dyspnea, and syncope, without rhinorrhea or nasal congestion. Most patients have a brief recovery period followed by the second stage within 1 to 3 days, characterized by fever, severe respiratory distress, stridor, hypoxia, cyanosis, diaphoresis, hypotension, and shock. hemorrhagic mediastinitis on a chest x-ray (a hallmark sign)

What level of injury in SCI results in respiratory dysfunction?

The muscles contributing to respiration are the diaphragm (C4). Injuries at C4 or above (causing paralysis of the diaphragm) often will require ventilator support, since acute respiratory failure is a leading cause of death

Nuclear radiation exposure clinical manifestation and diagnostics

The only way to detect radiation is through a device that determines the exposure per minute. Geiger counter (or Geiger-Mueller survey meter) can measure background radiation quickly through detection of gamma radiation and some beta radiation. Personal dosimeters are simple tools that identify radiation exposure and are worn by radiology personnel every day.

Herniation and Lumbar Disc Medical Management

The objectives of treatment are to relieve pain, slow disease progression, and increase the patient's functional ability -No bedrest -Muscle relaxants are given for acute pain -NSAIDs and systemic corticosteroids may be given to counter the inflammation and swelling that usually occurs in the supporting tissues and the affected nerve roots. -Moist heat and massage help relax muscles -weight reduction, physical therapy, and biofeedback -physical exercise to strengthen back muscles and decrease pain

Decompressive hemicraniectomy

The removal of a part of the skull allows the brain to expand without the pressure constraints exerted by the cranial vault. Complications of this procedure include infection and increased potential for injury to the unprotected underlying brain structures.

Signs of Human trafficking

The victim may have a history of being a chronic runaway, or of homelessness, and of self-mutilation. Common behaviors exhibited by these patients may include cowering or deferring to the person accompanying them, who may appear controlling, and appearing frightened or agitated. The patient may have a special mark/tattoo present, poor dentition, and multiple injuries in various stages of healing. complaints include injuries, poor healing or poorly healed old injuries, abdominal pain, dizziness, headaches, rashes or sores. Patients may demonstrate addiction, panic attacks, impulse control, hostility, and suicidal ideation. -offer an opportunity for the patient to speak, alone without an accompanying companion

How does increased CO2 affect circulation?

Vasodilation Increased blood flow Increase ICP Normal range for CO2 is 35-45

Treatment for Brown Recluse spider bites

Wound care consists of cleansing with soap and water, and hyperbaric oxygen treatments may be helpful.

biologic weapon

a biologic agent, such as anthrax, that is used to spread disease among the general population or the military

Epidural Hematoma

a collection of arterial blood in the space between the skull and dura mater FAST!!!

chemical weapon

agent that is used to cause disability and mortality in the general population or the military

Apraxia

an impairment in the ability to perform purposeful acts or to secure objects without any loss of strength, sensation, or coordination.

Diabetes insipidus

antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect Tx: Vassopressin and DDAVP

Stroke diagnostic test: Magnetic resonance angiography

are used to identify the presence of a cerebral hemorrhage, abnormal vessel structures (AV malformation, aneurysms), vessel ruptures, and regional perfusion of blood flow in the carotid arteries and brain.

agnosia

loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile

What could a TIA be warning of?

of impending stroke

penumbra region

penumbra region: area of low cerebral blood flow

Components of the EOP: Education plan

plan for all personnel regarding each step of the plan allows for improved readiness and additional input for fine-tuning of the EOP.

Nuclear radiation exposure medical/nursing interventions

potassium iodide, or KI is taken before or promptly after the intake of radioactive iodine to protect the thyroid gland.

Huntington's disease Assessment and diagnostic findings

presence of characteristic symptoms, a positive family history genetic marker CAG repeats in HTT; 50% chance of passing gene on to children CT or MRI scans show symmetrical striatal atrophy before motor symptoms appear

infarction

tissue necrosis in an area deprived of blood supply

Hemiparesis

weakness of one side of the body, or part of it, due to an injury in the motor area of the brain

weapons of mass destruction (WMD)

weapons used to cause widespread death and destruction

Aphasia

which can be expressive aphasia, receptive aphasia, or global (mixed) aphasia

The main presenting symptom of Hemorrhagic Stroke Chart 67-1

"Exploding headache" Decreased level of consciousness

Huntington's disease clinical manifestations

(1) motor dysfunction (the most prominent is chorea); (2) cognitive impairment (problems with attention and emotion recognition); and (3) behavioral features, such as apathy and blunted affect Facial movements produce tics and grimaces. Speech becomes slurred, hesitant, often explosive, and eventually unintelligible. Chewing and swallowing are difficult, and there is a constant danger of choking and aspiration. Choreiform movements persist during sleep but are diminished the gait becomes disorganized to the point that ambulation eventually is impossible. In the early stages, patients are particularly subject to uncontrollable fits of anger, profound and often suicidal depression, apathy, anxiety, psychosis, or euphoria. Judgment and memory are impaired, and dementia eventually ensues Hallucinations, delusions, and paranoid thinking may precede the appearance of disjointed movements.

spinal cord injury nursing interventions

*Airway: always #1, assess RR, breath sounds, ventilation support if high cord injury, assist with coughing/assess the strength of the cough *Diet: high protein, high calorie, prevent paralytic ileus, swallow studies -pt. more prone to diarrhea/c-diff -poor albumin, total protein levels *Urinary: indwelling catheter, strict asepsis, bladder/bowel program *Assist with ADL's *Prevent DVTS: SCD'S, Heparin, Lovenox, Passive ROM, sport bed, electrical stimulation, assess for s/s of DVT (redness, swelling) *Temperature control: problems with hypothermia, no vasoconstriction, can't maintain temp. below injury -add/remove covers to maintain temp. *Sex: sexual therapist, Viagra *Skin integrity: turn q2 hours, LOGROLL, speciality beds, air/egg-crate mattress

Triage Category: Expectant

*Black* Priority: 4 Injuries are extensive, and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. Patients who are unresponsive with penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomic sites and organs, 2nd/3rd-degree burns in excess of 60% of body surface area, seizures or vomiting within 24 hours after radiation exposure, profound shock with multiple injuries, agonal respirations; no pulse, no blood pressure, pupils fixed and dilated

What are the do nots for snakebite treatment?

*Do not leave patient unattended* *DO NOT apply Ice, incision and suction, or a tourniquet!!! In general, ice, tourniquets, heparin, and corticosteroids are not used during the acute stage. Corticosteroids are contraindicated in the first 6 to 8 hours after the bite. *discourage bringing the snake for identification—even a dead snake's venom is poisonous. Do not handle any snake brought to the ED.

Triage Category: Minimal

*Green* Priority: 3 Injuries are minor, and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances

Triage Category: Immediate

*Red* Priority: 1 Injuries are life threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and 2nd/3rd-degree burns of 15-40% total body surface area

Triage Category: Delayed

*Yellow* Priority: 2 Injuries are significant and require medical care but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, débridement, and external fixation; most eye and central nervous system injuries

Ischemic Stroke nursing intervention: ASSISTING WITH NUTRITION

-A swallow assessment should be performed as soon as possible after the patient's arrival the emergency department, prior to any oral intake. -Observe patient for paroxysms of coughing, food dribbling or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. -Consult with speech therapist to evaluate gag reflexes; assist in educating patient in alternate swallowing techniques, patient to take smaller bonuses of food, and inform patient of foods that are easier to swallow; provide thicker or pureed food as indicated. -Have patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated. -Prepare for enteral feedings through a tube if indicated; elevate the head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensure that cuff of tracheostomy tube is inflated (if applicable); monitor and report excessive retained or residual feeding.

Hemorrhagic Stroke Nursing management: Optimizing Cerebral Tissue Perfusion

-Adequate hydration (IV fluids) must be ensured to reduce blood viscosity and improve cerebral blood flow. -Monitor for changes in neurologic deterioration; record assessments via neurologic flow record. -Perform hourly checks of blood pressure, pulse, level of consciousness (an indicator of cerebral perfusion), pupillary responses, and motor function -Monitor respiratory status, because a reduction in oxygen in areas of the brain with impaired auto regulation increases the chance of a cerebral infarction. -Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. -Implement aneurysm precautions, including providing a mutating environment; plan care to prevent increases in ICP and minimize risk of further bleeding by providing relief and minimizing anxiety. -Increase HOB to 15 to 30 degrees to promote venous drainage and decrease ICP. -Maintain the systolic BP at 140 mm Hg -Avoid any straining or Valsalva maneuvers; any activity requiring exertion is contraindicated. -Dim lighting is helpful, because photophobia (visual intolerance of light) is common; external stimuli are kept to a minimum, including no television, no radio, and no reading. -Avoid caffeinated beverages. -Stool softeners and mild laxatives are prescribed to prevent constipation; no enemas are permitted. -Administer all personal care, including feeding and bathing to prevent any exertion that might increase the blood pressure.

Eligibility Criteria for Tissue Plasminogen Activator Administration Chart 67-3

-Age ≥18 years -Clinical diagnosis of ischemic stroke -Time of onset of stroke known and is less than 3 hours before treatment -Systolic blood pressure ≤185 mm Hg; diastolic ≤110 mm Hg -No minor stroke or rapidly resolving stroke -No seizure at onset of stroke -Prothrombin time ≤15 seconds or international normalized ratio ≤1.7 (if taking an anticoagulant, the same guidance is used) -Not received heparin during the past 48 hours with elevated partial thromboplastin time -Platelet count ≥100,000/mm3 -Glucose >50 mg/dL -No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm -No major surgical procedures or serious trauma within 14 days -No stroke, serious head injury, or intracranial surgery within 3 months -No gastrointestinal or urinary bleeding within 21 days -No pregnancy -Some of these are relative contraindications (the provider administering the medication needs to weigh the risks and benefits of the therapy). **There are more stringent criteria if t-PA is considered for those patients in the 3.0- to 4.5-hour time window. The goal is for intravenous (IV) t-PA to be given within 60 minutes of the patient arriving to the ED**

traumatic brain injury medical management

-All head injury presumed a cervical spine injury until proven otherwise. -Transport from the scene of the injury on a long spine board with the head and neck maintained in alignment with the axis of the body. -Cervical collar is applied and maintained until cervical spine x-rays have been obtained and the absence of cervical SCI documented. Common causes of secondary injury are: -cerebral edema, -hypotension, -respiratory depression that may lead to hypoxemia and electrolyte imbalance. Tx: -stabilization of cardiovascular and respiratory function to maintain adequate cerebral perfusion, control of hemorrhage and hypovolemia, and maintenance of optimal blood gas values. -If the patient is very agitated, benzodiazepines will calm client w/o affecting cerebral blood flow or ICP. -Lorazepam (Ativan) and midazolam (Versed) are frequently used but have active metabolites that may cause prolonged sedation, making it difficult to conduct a neurologic assessment -Propofol (Diprivan) is the preferred sedative Depressed skull fractures usually require surgery with elevation of the skull and débridement, usually within 24 hours of injury.

rape trauma syndrome phases

-An acute disorganization phase, which may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered or as a controlled state in which feelings are masked or hidden and the victim appears composed -A phase of denial and unwillingness to talk about the incident, followed by a phase of heightened anxiety, fear, flashbacks, sleep disturbances, hyperalertness, and psychosomatic reactions that is consistent with PTSD (see later discussion) -A phase of reorganization, in which the incident is put into perspective. Some victims never fully recover and go on to develop chronic stress disorders and phobias.

Ischemic Stroke nursing intervention: IMPROVING COMMUNICATION

-Anticipate communication disturbances in patients who are paralyzed on the right side. Broca area (area of brain responsible for speech) is so close to the left motor area that a disturbance in the motor area often affects the speech area. -Jointly establish goals, with patient taking an active part -Make the atmosphere conducive to communication, remaining sensitive to patient's reactions and needs and responding to them in an appropriate manner; treat patient as an adult. -Provide strong emotional support and understanding to allay anxiety; avoid completing patient's sentences. -Be consistent in schedule, routines, and repetitions. A written schedule, checklists, and audiotapes may help with memory and concentration; a communication board may be used. Computer-based communication software that runs on may be helpful. -Maintain patient's attention when talking to him or her, speak slowly, and give one instruction at a time; allow patient time to process. Use of gestures may enhance comprehension. -Talk to aphasic patients when providing care activities to provide social contact.

Ischemic Stroke nursing intervention: VISUAL-PERCEPTUAL DIFFICULTIES

-Approach patient with a decreased field of vision on the side where visual perception is intact; place all visual stimuli on this side. -Educate patient with a decreased field of vision on the side where visual perception is intact; place all visual stimuli on this side. -Increase natural or artificial lighting in the room; provide eyeglasses to improve vision. -Remind patient with hemianopsia about the other side of the body; place extremities so that patient can see them.

Postoperative intracranial surgery medical Management

-Arterial line -Central venous pressure -Monitor/manage B/P & CVP -Supplemental oxygen therapy through intubation tube -Reducing cerebral edema, relieving pain and preventing seizures, (Acetaminophen for temperatures exceeding 37.5°C (99.6°F) and mild pain) -Monitor ICP and neurologic status -phenytoin or levetiracetam prophylactically for client at high risk of seizures

The brain can maintain a steady perfusion pressure with what systolic blood pressure and ICP?

-Arterial systolic blood pressure is 50 to 150 mm Hg -ICP is less than 40 mm Hg.

What are the nursing interventions/Education for Cerebral angiography? (Pre-procedure)

-Assess the client for allergies to iodine and shellfish. -Assess renal function. -Assess for a medication history of anticoagulation therapy; withhold the anticoagulant medication prior to the procedure as prescribed. -Encourage hydration for 2 days before the test. -Maintain the client on NPO (nothing by mouth) status 4 to 6 hours before the test as prescribed. -Perform a neurological assessment, which will serve as a baseline for postprocedure assessments. -Mark the peripheral pulses. -Remove metal items from the hair. -Administer premedication as prescribed.

spinal cord injury clinical manifestations

-Bradycardia <60 bpm -Asystole complete spinal cord lesion signifies loss of both sensory and voluntary motor communication from the brain to the periphery, resulting in paraplegia or tetraplegia. Incomplete spinal cord lesion denotes that the ability of the spinal cord to relay messages to and from the brain is not completely absent. If conscious, the patient usually complains of acute pain in the back or neck, which may radiate along the involved nerve.

surviving a drowning incident nursing interventions

-CPR is the most important medical intervention to manage the hypoxia, acidosis, and hypothermia. adequate airway and respiration, thus improving ventilation (which helps correct respiratory acidosis) and oxygenation. Turn the client on their side once fluid is vomited out of the mouth to prevent aspiration. Have someone call 911 when CPR is initiated. -rewarming procedures (e.g., extracorporeal warming, warmed peritoneal dialysis, inhalation of warm aerosolized oxygen, torso warming) are started during resuscitation. -Serial vital signs and chest x-ray -Assess ICP -Monitor serum electrolyte levels -ECG monitoring is initiated, because dysrhythmias frequently occur. -An indwelling urinary catheter is inserted to measure urine output. Monitor I&O -Arterial blood gases are monitored to evaluate oxygen, carbon dioxide, bicarbonate levels, and pH. Monitor for metabolic acidosis due to decreased kidney function. -A rectal probe or other core measurement device monitoring hypothermia -Nasogastric intubation is used to decompress the stomach and to prevent the patient from aspirating gastric contents.

increased intracranial pressure diagnostic findings

-CT and MRI are the most common diagnostic tests. -Cerebral angiography, positron emission tomography (PET),and single photon emission tomography (SPECT) -ICP monitoring -transcranial Doppler to assess cerebral blood flow -Avoid lumbar puncture Complications: -Brain stem herniation -Diabetes insipidus -SIADH

Animal and human bites

-Cat and human bites have a high risk of infection -Report bites to authorities -Consider rabies vaccination -Cleanse wound -Tx with prophylactic ABX; consider rabies and tetanus vaccination

Pituitary Adenomas

-Common in older adults, but can occur at any age -Women are affected more often than men, particularly during the childbearing years. Pituitary tumors are rarely malignant but cause symptoms as a result of pressure on adjacent structures -optic nerves (CN II), optic chiasm, or optic tracts -hypothalamus or the third ventricle Hormonal hypersecretions: -prolactin (prolactinomas), -growth hormone (GH) producing acromegaly in adults, -adrenocorticotropic hormone (ACTH) resulting in Cushing syndrome -thyroid-stimulating hormone (TSH) Symptoms: -headache, -visual dysfunction, -hypothalamic disorders (disorders of sleep, appetite, temperature, and emotions), -increased ICP, -enlargement and erosion of the sella turcica -Males with prolactinomas have impotence and hypogonadism -Females with prolactinomas have amenorrhea or galactorrhea

Prioritize the order of care delivery for patients in the ED. (Secondary Survey)

-Complete health history, including the history of the current event -Head-to-toe assessment (includes a reassessment of airway and breathing parameters and vital signs) -Diagnostic and laboratory testing -Insertion or application of monitoring devices such as ECG electrodes, arterial lines, or urinary catheters -Splinting of suspected fractures -Cleansing, closure, and dressing of wounds -Performance of other necessary interventions based on the patient's condition

brain tumor diagnostic findings

-Computed tomography (CT) scans w/contrast (give specific information concerning the number, size, and density of the lesions, and the extent of secondary cerebral edema) -Magnetic resonance imaging (MRI) scan (detects brain tumors) -Positron emission tomography (PET) -Cytologic studies of the CSF -Computer-assisted stereotactic (three-dimensional) biopsy--used to Dx deep-seated brain tumors

Chronic subdural hematoma (SDH) clinical manifestations

-Develops over weeks to months (e.g., 3 weeks to months) -Causative injury may be minor and forgotten -Clinical S&S may fluctuate -Tx is evacuation of the clot through multiple burr holes or craniotomy Symptoms: severe headache, which tends to come and go; -alternating focal neurologic signs; -personality changes; -mental deterioration; -focal seizures

What is the treatment for hemorrhaging?

-Direct pressure -Pressure dressing -Immobilize extremity -Tourniquet The goals of emergency management are to control the bleeding, maintain adequate circulating blood volume for tissue oxygenation, and prevent shock. two large-gauge IV catheters are inserted, preferably in an uninjured extremity, to provide a means for fluid and blood replacement. Blood samples are obtained for analysis, typing, and cross-matching. Nursing Alert The infusion rate is determined by the severity of the blood loss and the clinical evidence of hypovolemia. Any blood replacement therapy should be given via warmer when possible, because administration of large amounts of blood that has been refrigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy.

neurogenic shock clinical manifestations

-Dry, warm skin -Bradycardia The vital organs are affected, causing decreases in blood pressure, heart rate, and cardiac output, as well as venous pooling in the extremities and peripheral vasodilation. patient does not perspire in the paralyzed portions of the body, because sympathetic activity is blocked cervical and upper thoracic spinal cord injury lost of accessory muscles of respiration= respiratory problems -decreased vital capacity, retention of secretions, -increased partial pressure of arterial carbon dioxide (PaCO2) levels and decreased oxygen levels, -respiratory failure, -pulmonary edema

neurogenic shock nursing interventions

-Elevate HOB 30º specially after stabilizing spinal injury or s/p spinal anesthesia -Immobilize client if spinal cord injury is suspected -Assess for lower-extremity pain, redness, tenderness, or warmth that may suggest formation of a venous thromboembolism -Provide passive ROM to promote circulation -Use pneumatic compression devices combined with antithrombotic (low-molecular-weight heparin). -Assess for signs of internal bleeding -Close observation is required for early detection of an abrupt onset of fever.

Ischemic Stroke nursing intervention: ENHANCING SELF-CARE

-Encourage personal hygiene activities as soon as the patient can sit up; select suitable self-care activities that can be out with one hand. -Help patient to set realistic goals; add a new task daily. -As a first step, encourage patient to carry out all self-care on the unaffected side. -Make sure patient does not neglect affected side; provide assistive devices as indicated. -Improve morale by making sure patient is fully dressed during ambulatory activities. -Assist with dressing activities (e.g., clothing with Velcro closures; put garment on the affected side first); keep environment uncluttered and organized -Provide emotional support and encouragement to prevent fatigue and discouragement.

What is the supportive care for hypothermia during rewarming?

-External cardiac compression (typically performed only as directed in patients with temperatures higher than 31°C [88°F]) -Defibrillation of ventricular fibrillation. A patient whose temperature is less than 32°C [90°F] experiences spontaneous ventricular fibrillation if moved or touched. -Defibrillation is ineffective in patients with temperatures lower than 31°C (88°F); therefore, the patient must be rewarmed first. -Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation -Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming, as described previously -Administration of sodium bicarbonate to correct metabolic acidosis if necessary -Administration of antiarrhythmic medications Insertion of an indwelling urinary catheter with a thermometer to monitor urinary output and kidney function

How to Communicating With the Patient With Aphasia; chart 67-5

-Face the patient and establish eye contact. -Speak in a clear, unhurried manner, and normal tone of voice. -Use short phrases, and pause between phrases to allow the patient time to understand what is being said. -Limit conversation to practical and concrete matters. -Use gestures, pictures, objects, and writing. -As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. -Be consistent in using the same words and gestures each time you give instructions or ask a question. -Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.

Food poisoning medical/nursing interventions

-Food, gastric contents, vomitus, serum, and feces are collected -Monitor patient's respirations, blood pressure, level of consciousness (LOC), CVP (if indicated), and muscular activity -Baseline weight and serum electrolyte levels are obtained for future comparisons. -antiemetic medication is given parenterally to Tx severe N/V -mild nausea patient is encouraged to take sips of weak tea, carbonated drinks, or tap water -As N/V subsides clear liquids are usually prescribed for 12 to 24 hours, and the diet is gradually progressed to a low-residue, bland diet.

Herniation and Lumbar Disc post-op assessment

-Frequent vitals signs -Assess for excessive saturation of serosanguineous drainage on dressing. If present, notify HCP. -Inspect for hemorrhaging -Assess sensation and motor strength of the lower extremities; notify HCP if new neuro changes occur -Assess color and temperature of the legs and sensation of the toes -Assess for urinary retention

Ischemic Stroke nursing intervention: MAINTAINING SKIN INTEGRITY

-Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts. -Employ pressure-relieving devices; continue regular turning and positioning (every 2 hours minimally); minimize shear and friction when positioning. -Keep skin clean and dry, gently massage healthy dry skin, and maintain adequate nutrition.

What are some alternative Gastric Emptying Tx for ingested poisons?

-Gastric lavage for the patient who is obtunded is only useful within 1 hour of ingestion, for sustained-release substances, or massive life-threatening amounts of a substance; however, complications of aspiration and stomach or esophageal perforation outweigh its usefulness. Gastric aspirate is saved and sent to the laboratory for testing (toxicology screens). -Activated charcoal administration if the poison is one that is absorbed by charcoal; given orally or by nasogastric tube, it is effective in small intermittent doses to decrease vomiting. It should be diluted as a slurry so that it is easier to drink or pass through the nasogastric tube. Activated charcoal absorbs most commonly ingested poisons except corrosives, heavy metals and hydrocarbons, iron, and lithium.

brain tumor clinical manifestations

-HA -Seizures (new onset); focal or generalized; occurs in 60% of clients -Vomiting with or without nausea -Visual disturbances -Impaired sensory and motor function -Impaired balance -Personality and mental changes Complications of Brain Tumors: -Increased ICP -Hydrocephalus

Hemorrhagic Stroke modifiable or treatable risk factors

-Hypertension -Excessive alcohol consumption -AVMs (younger patients), intracranial aneurysms, intracranial neoplasms -Certain medications (e.g., anticoagulant drugs, amphetamines) -Cocaine or use of illicit drugs

Inserting an Oropharyngeal Airway chart 72-3

-Measure the oral airway alongside the head. The airway should reach from lip to ear. -Extend the patient's head by placing one hand under the bony chin (only if the cervical spine is uninjured). With the other hand, tilt the head backward by applying pressure to the forehead while simultaneously lifting the chin forward. -Open the patient's mouth. A. Insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula. B. Rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway. An alternate method is to use a tongue blade to hold the tongue and insert the oropharyngeal airway directly without rotation. The distal end of the oropharyngeal airway is in the hypopharynx, and the flange is approximately at the patient's lips. Make sure that the tongue has not been pushed into the airway.

What are the nursing interventions/Education for Cerebral angiography? (Post-procedure)

-Monitor neurological status, vital signs, and neurovascular status of the affected extremity frequently until stable. -Monitor for swelling in the neck and for difficulty swallowing; notify a health care provider (HCP) if these symptoms occur. -Maintain bed rest for 12 hours as prescribed. -Elevate the head of the bed 15 to 30 degrees only if prescribed. -Keep the bed flat, as prescribed, if the femoral artery is used. -Assess peripheral pulses. -Apply sandbags or another device to immobilize the limb and a pressure dressing to the injection site to decrease bleeding as prescribed. -Place ice on the puncture site as prescribed. -Encourage fluid intake.

Anticipate abnormal findings which may be expected during a comprehensive health assessment of the patient with a spinal cord injury (SCI).

-Paralysis of the diaphragm, -Difficulty clearing of bronchial and pharyngeal secretions -decreased BP and HR -Edema of the spinal cord compromising spinal cord function -Spinal shock= complete loss of all reflex, motor, sensory, and autonomic activity below the level of the lesion that causes bladder paralysis and distention. -Urinary retention and overdistention of the bladder -Atonic bowel -Areflexia (the absence of DTR) -Poikilothermia -Compromised capillary circulation and venous return 2/2 spinal cord necrosis -Central Cord Syndrome -Anterior Cord Syndrome -Lateral Cord Syndrome (Brown-Séquard Syndrome)

Ischemic Stroke nursing intervention: ATTAINING BLADDER AND BOWEL CONTROL

-Perform intermittent sterile catheterization during period of loss of sphincter control, bladder atony, or spasticity. -Analyze voiding pattern and offer urinal or bedpan on patient's voiding schedule. -Assist the male patient to an upright posture for voiding. -Provide high-fiber diet and adequate fluid intake (2 to 3 L per day) to prevent constipation, unless contraindicated. -Establish a regular time (after breakfast) for toileting.

Ischemic Stroke nursing intervention: HELPING THE PATIENT COPE WITH SEXUAL DYSFUNCTION

-Perform sensitive, in-depth assessment to determine sexual history before and after the stroke. -Interventions for patient and partner focus on providing relevant information, education, reassurance, adjustment of medications, counseling regarding coping skills, suggestions for alternative sexual positions, and a means of sexual expression and satisfaction.

Ischemic Stroke nursing Interventions: IMPROVING MOBILITY AND PREVENTING JOINT DEFOAMITIES

-Position to prevent contractors; use measures to relieve pressure, assist in maintaining good body alignment, and prevent compressive neuropathies. -Apply a splint at night to prevent flexion of affected extremity. -Prevent adduction of the affected shoulder with a pillow in the axilla. -Elevate affected arm to prevent edema and fibrosis. -Position fingers so that they are barely flexed; place hand in slight supination. If upper extremity spasticity is noted, do not use a hand roll; a dorsal wrist splint may be used. -Change patient's position every 2 hours; place patient in a prone position for 15 to 30 minutes several times a day; use pillows between legs for lateral turns to maintain proper alignment.

dysphasia

-Process of expressing thoughts and ideas -Involves selection of words and formation of sentences -Can affect understanding also -impaired speech

Ischemic Stroke nursing intervention: FAMILY COPING

-Provide counseling and support to family. -Involve others in patient's care; provide education about stress management techniques and maintenance of personal health for family coping. -Give family information about the expected outcome of the stroke and counsel family members to avoid doing things for patient that he or she can do. -Develop attainable goals for patient at home by involving the total health care team, patient, and family. -Encourage everyone to approach patient with a supportive and optimistic attitude, focusing on abilities that remain; explain to family that emotional lability usually improves with time.

Ischemic Stroke nursing interventions: ESTABLISHING AN EXERCISE PROGRAM

-Provide full range of motion four or five times daily to maintain joint mobility, help patient regain motor control, pre-in the paralyzed extremity, prevent further deterioration of the neurormuscular system, and enhance circulation. If tightness occurs in any area, perform range of motion exercises more frequently. -Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus. -Observe for signs of pulmonary embolus or excessive cardiac workload during exercise period (e.g., shortness of breath, chest pain, cyanosis, and increasing pulse rate). -Supervise and support patient during exercises; plan frequent, short periods of exercise; encourage patient to exercise unaffected side at intervals throughout the day. -Quadriceps muscle setting and gluteal setting exercises are started early to improve the muscle strength needed for walking.

Ischemic Stroke nursing intervention: IMPROVING THOUGHT PROCESSES

-Reinforce structured training program using cognitive-perceptual retraining, visual imagery, reality orientation, and cueing procedures to compensate for losses. -Support patient: Observe performance and progress, give positive feedback, convey an attitude of confidence and hopefulness; provide other interventions as used for improving function after a head injury.

Ischemic Stroke nursing intervention: PREPARING FOR AMBULATION

-Start an active rehabilitation program when consciousness returns (and all evidence of bleeding is gone). -Educate patient to maintain balance in a sitting position then to balance while standing (use a tilt table if needed). -Begin patient walking as soon as standing balance is achieved; use parallel bars and have wheelchair available in anticipation of possible dizziness. -Keep periods for ambulation short and frequent. Note: Initiate a full rehabilitation program, even for older adult patients.

Hemorrhagic Stroke clinical manifestations

-Sudden severe headache (if conscious) -Vomiting -Early sudden changes in level of consciousness -Possibly focal seizures (due to frequent brain stem involvement) -Neurologic deficits including motor, sensory, cranial nerve, cognitive, and other functions similar to ischemic stroke -pain and rigidity of neck and spine, characteristic of an intracranial aneurysm rupture or AVM -Possibly visual disturbances (visual loss, diplopia, ptosis) if oculomotor nerve is involved -Tinnitus, dizziness or hemiparesis also possible -Severe bleeding, which may result in coma and death

Herniation and Lumbar Disc post-op position

-To position the patient, a pillow is placed under the head, and the knee rest is elevated slightly to relax the back muscles. -Avoid extreme knee flexion -*Logrolling* the patient, moving body as one unit -To get out of bed, the patient lies on one side while pushing up to a sitting position. At the same time, the nurse or family member eases the patient's legs over the side of the bed. -Ambulation to the bathroom the same day of surgery is encouraged.

brain tumor nursing intervention

-Upright positioning -Space nursing interventions to prevent rapid increase in ICP -Reorients the patient when necessary to person, time, and place -Monitor for adverse effects of corticosteroids -hyperglycemia, -electrolyte abnormalities, -muscle weakness Preoperatively: -Assess gag reflex and ability to swallow are evaluated. -Educate those with diminished gag response, to direct food and fluids toward the unaffected side, having the patient sit upright to eat, offering a semisoft diet, and having suction readily available. -Perform neurologic checks -Vital signs

Lab Specimens collected post rape

-Vaginal aspirate, examined for presence or absence of motile and nonmotile sperm. -Secretions (obtained with a sterile swab) from the vaginal pool for acid phosphatase, blood group antigen of semen, and precipitin test against human sperm and blood. -Separate smears from the oral, vaginal, and anal areas. -Culture of body orifices for gonorrhea. -Blood serum for syphilis and HIV testing and deoxyribonucleic acid (DNA) analysis. A sample of serum for syphilis may be frozen and saved for future testing. -Pregnancy test if there is a possibility that the female patient may be pregnant. -Any foreign material (leaves, grass, dirt), which is placed in a clean envelope. -Pubic hair samples obtained by combing or trimming. Several pubic hairs with follicles are placed in separate containers and identified as the patient's hair.

Hemorrhagic Stroke collaborative problems/potential complications

-Vasospasm -Seizures -Hydrocephalus -Rebleeding -Hyponatremia

Hemorrhagic Stroke Nursing management: Monitoring/Managing Complications

-Vasospasm: Assess for signs of vasospasm, including intensified headaches, a decrease in level of responsiveness (confusion, disorientation, lethargy), or evidence of aphasia or partial paralysis. Administer the calcium channel blocker (Nimodipine) for prevention of vasospasm; fluid volume expanders may also be prescribed. -Seizures: Should a seizure occur, maintaining the airway and preventing injury are the primary goals. Medication therapy is initiated at this time. -Hydrocephalus: Hydrocephalus can occur within the first 24 hours (acute) after subarachnoid hemorrhage or several (subacute) to several weeks (delayed) later. Symptoms vary according to the time of onset and may be nonspecific. Acute hydrocephalus is characterized by sudden onset of stupor or coma and is managed with a ventriculostomy drain to decrease ICP; symptoms of subacute and delayed hydrocephalus include gradual onset of drowsiness, behavioral changes, and ataxic gait. A ventriculoperitoneal (VP) shunt is placed for chronic hydrocephalus. -Rebleeding: Hypertension is the most serious and modifiable risk factor. Aneurysm rebreeding occurs most frequently during the first 2 weeks after the initial hemorrhage, is considered a major complication, and is confirmed by CT scan. Symptoms of rebreeding include sudden severe headache, nausea, vomiting, decreased level of consciousness, and neurologic deficit. -Hyponatremia: Hyponatremia occurs in 50% of patients with subarachnoid hemorrhage and must be identified as early as possible. The patient is then evaluated for syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. Treatment most often is with IV hypertonic 3 % saline.

increased intracranial pressure clinical manifestations

-changes in level of conscious -abnormal respiratory and vasomotor responses -Agitation, slowing of speech, and delay in response to verbal suggestions are early indicators. -Sudden change in condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. -Lethargy -Decreased cerebral perfusion pressure (CPP) can result in a Cushing response (increase in systolic blood pressure, widening of the pulse pressure, and reflex slowing of the heart rate) -Cushing triad (bradycardia/bounding pulse, bradypnea, and hypertension); widening pulse pressure is an ominous sign. -stuporous and may react only to loud auditory or painful stimuli (serious damage and surgical intervention required -Coma -Decorticate posturing -Decerebrate posturing -Flaccidity -When coma is profound, pupils are dilated and fixed, respirations are impaired, and death is usually inevitable. Long-term -headache, common in the mornings (deep, expanding, dull, but unrelenting) -nausea with or without vomiting, -papilledema

What are the three things that occur with brain death?

-coma, -the absence of brainstem reflexes, -apnea

What makes elders more susceptible to heat illnesses?

-decreased ability to perspire -decreased ability to vasodilate and vasoconstrict -less subcutaneous tissue, -decreased thirst mechanism, -diminished ability to concentrate urine to compensate for heat. -older adults do not drink adequate amounts of fluid, -they tend to keep windows closed despite high temperatures and humidity levels

What are the compensation mechanism for correcting increase ICP?

-decreased blood volume -CSF shift -increased absorption of CSF -decrease production

Dysarthria

-difficult, poorly articulated speech, -problems with physical ability to form words -affects how words are uttered -affects how clear the sounds are articulated patho: resulting from interference in the control and execution over the muscles of speech, usually caused by damage to a central or peripheral motor nerve. Interventions: strengthening the oral musculature and improving breathing patterns are often required. A referral to a speech-language pathologist.

What is the S&S of serum sickness from antivenin?

-fever, -arthralgias, -pruritus, -lymphadenopathy, -proteinuria and can progress to neuropathies -rash starting on the chest and spreading to the back; -GI disturbances [e.g., nausea, vomiting, diarrhea, abdominal pain], -headache The most common cause of allergic reaction to the antivenin is too-rapid infusion. Reactions may consist of a feeling of fullness in the face, urticaria, pruritus, malaise, and apprehension. These symptoms may be followed by -tachycardia, -shortness of breath, -hypotension, -shock *In this situation, the infusion should be stopped immediately and IV diphenhydramine given.* Vasopressors are used for patients in shock, and resuscitation equipment must be on standby while antivenin is infusing. that serum sickness (hypersensitivity) can occur within the first few weeks after discharge.

Decorticate posturing

-flexion of the upper extremities, -internal rotation of the lower extremities, -plantar flexion of the feet occurs when the brainstem is not inhibited by the motor function of the cerebral cortex.

Assessment of a snakebite

-having the person lie down, -removing constrictive items such as rings, -providing warmth, -cleansing the wound, -covering the wound with a light sterile dressing, -immobilizing the injured body part below the level of the heart. -Airway, breathing, and circulation are the priorities of care. -Where and when the bite occurred and the circumstances of the bite. -Sequence of events, signs, and symptoms (fang punctures, pain, edema, and erythema of the bite and nearby tissues). -Severity of poisonous effects. Call the local poison control phone number to gain access to information about an exotic snakebite presentation and management, as necessary. -Vital signs. -Circumference of the bitten extremity or area at several points. -Laboratory data (complete blood count, urinalysis, and coagulation studies).

spinal cord tumor medical management

-high-dose dexamethasone (Decadron) combined with radiation therapy is effective in relieving pain -Chemotherapy specific to the tumor type may be considered -Palliative care -Sudden decrease or loss of motor, sensory, and bowel and bladder function indicates the need for emergent surgery. The goal is to remove as much tumor as possible while sparing uninvolved portions of the spinal cord.

What are surviving drowning patients at risk for?

-hypoxic or ischemic cerebral injury, -ARDS, and -life-threatening cardiac arrest. -risk for aspiration; vomiting frequently occurs in patients requiring rescue breathing

spinal cord tumor clinical manifestations

-localized or shooting pains, -weakness and loss of reflexes below the tumor level to progressive loss of motor function and paralysis. -sharp pain occurs in the area innervated by the spinal roots -increasing sensory deficits develop below the level of the lesion. -loss of bowel and bladder function is common

Herniation of Lumbar Disc Clinical Manifestations

-low back pain with muscle spasm and sciatica (pain and tenderness that radiates along the sciatic nerve that runs through the thigh and leg) -Pain is aggravated by actions that increase intraspinal fluid pressure, such as bending, lifting, or straining (as in sneezing or coughing), and usually is relieved by bed rest. -If the patient lies on the back and attempts to raise a leg in a straight position, pain radiates into the leg due to stretches the sciatic nerve; straight-leg raising test. -muscle weakness, -alterations in tendon reflexes, -sensory loss.

Transsphenoidal Approach pre-op medical management

-nasopharyngeal secretions are cultured -Corticosteroids may be given before and after surgery -Antibiotic agents may or may not be given prophylactically.

Assess the patient on fibrinolytic therapy for potential adverse effects.

-no anticoagulant agents are given for the next 24 hours. -Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding (IV insertion sites, urinary catheter site, endotracheal tube, nasogastric tube, urine, stool, emesis, other secretions). -A 24-hour delay in placement of nasogastric tubes, urinary catheters, and intra-arterial pressure catheters is recommended.

Cushing syndrome S&S

-obesity with redistribution of fat to the facial, -supraclavicular, and abdominal areas; -hypertension; -purple striae and ecchymoses; -osteoporosis; -elevated blood glucose levels; -emotional disorders

altered level of consciousness medical management

-obtain and maintain a patent airway -intravenous (IV) catheter -feeding tube or a gastrostomy tube for unconscious client to maintain nutritional support

surviving a drowning incident clinical manifestations and diagnostic findings

-onset of hypoxia, hypercapnia, bradycardia, and dysrhythmias. -exercise-induced acidosis and tachypnea can result in aspiration with a violent struggle -acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis

Abdominal Injuries S&S

-pain, -guarding, -rebound tenderness, -rectal bleeding, -nausea, -vomiting

Decerebrate posturing

-upper extremities and lower extremities are extended -pronated arms (outward rotation of upper extremities) -the wrists are flexed -plantar flexion of the feet Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; implies brain pathology; poor prognostic sign

Discuss pathophysiology, clinical manifestations, diagnostic findings, medical management, and nursing interventions for the client with a head injury.

1) Brain suffers traumatic injury 2) Brain swelling or bleeding increases intracranial volume 3) Rigid cranium allows no room for expansion of contents so ICP increases 4) Pressure on blood vessels within the brain causes blood flow to the brain to slow 5) Cerebral hypoxia and ischemia occur 6) ICP continues to rise. Brain may herniate 7) Cerebral blood flow ceases

What type of physiologic changes places older adults at increased risk for hematomas?

1. brain weight decreases, the dura becomes more adherent to the skull, and reaction times slow with increasing age 2. many older adults take aspirin and anticoagulant agents as part of routine management of chronic conditions.

brain tumor pathophysiology

A brain tumor occupies space within the skull, growing as a spherical mass or diffusely infiltrating tissue. The effects of brain tumors are caused by: -inflammation, -compression, -infiltration of tissue A variety of physiologic changes result, causing any or all of the following pathophysiologic events: Increased intracranial pressure (ICP) and cerebral edema Seizure activity and focal neurologic signs Hydrocephalus Altered pituitary function Common at age 50-70 y/o. -Slight male predominance in the incidence of malignant brain tumors.

Herniation and Cervical Intervertebral Disc Surgical Management

A cervical discectomy, with or without fusion, may be performed to alleviate symptoms. An anterior surgical approach may be used through a transverse incision to remove disc material that has herniated into the spinal canal and foramina, or a posterior approach may be used at the appropriate level of the cervical spine. Potential complications with the anterior approach include carotid or vertebral artery injury, recurrent laryngeal nerve dysfunction, esophageal perforation, and airway obstruction.

Components of the EOP: Security plans

A coordinated security plan involving facility and community agencies is key to the control of an otherwise chaotic situation.

Components of the EOP: Data management strategy

A data management plan for every aspect of the disaster will save time at every step. A backup system for documenting, tracking, and staffing is developed if the facility utilizes an electronic health record.

Components of the EOP: Plan for coordinated patient care

A response is planned for organized patient care into and out of the facility, including transfers from within the hospital to other facilities. The site of the disaster can determine where the greater number of patients may self-refer.

Amyotrophic Lateral Sclerosis (ALS) Pahto

AKA Lou Gehrig disease a disease of unknown cause in which there is a loss of motor neurons (nerve cells controlling muscles) in the anterior horns of the spinal cord and the motor nuclei of the lower brainstem. As motor neuron cells die, the muscle fibers that they supply undergo atrophic changes. Neuronal degeneration may occur in both the upper and lower motor neuron systems ALS most commonly occurs between 40 and 60 years of age and affects all social, racial, and ethnic backgrounds, with men being affected at slightly higher rates than women.

ventriculostomy drain

AKA intraventricular catheter monitoring device is used for monitoring ICP, a fine-bore catheter is inserted into a lateral ventricle, preferably in the nondominant hemisphere of the brain removal of CSF to reduce ICP and restore CPP The "gold standard" for monitoring ICP HIGH RISK FOR INFECTION

Acute Subdural Hematoma (SDH) clinical manifestations

Acute: symptoms develop over 24 to 48 hrs Subacute: symptoms develop over 48 hrs to 2 wks --->both require immediate craniotomy and control of ICP

Ischemic Stroke nursing intervention: RELIEVING DISCOMFORT

Administer analgesic agents to help manage post stroke pain, including amitriptyline (Elavil); anticonvulsant medications Iamotrigine (Lamictal) and pregabalin (Lyrica) are good alternatives for patients who cannot tolerate amitriptyline.

Hemorrhagic Stroke non-modifiable risk factors

Advanced age (older than 55 years) Cerebral amyloid angiopathy Gender (male) Certain ethnicities (Latino, African American, and Japanese)

Preventing Head and Spinal Cord Injuries Chart 68-1

Advise drivers to obey traffic laws and to avoid speeding or driving when under the influence of drugs or alcohol. Advise all drivers and passengers to wear seat belts and shoulder harnesses. Children younger than 12 years should use an age/size-appropriate system in the back seat. Caution passengers against riding in the back of pickup trucks. Advise motorcyclists, scooter riders, bicyclists, skateboarders, and roller skaters to wear helmets. Promote educational programs that are directed toward violence and suicide prevention in the community. Provide water safety instruction. Educate patients about steps that can be taken to prevent falls, particularly in older adults. Advise athletes to use protective devices. Recommend that coaches be educated in proper coaching techniques. Advise owners of firearms to keep them locked in a secure area where children cannot access them.

Pathophysiology of altered level of consciousness

Altered LOC is not a disorder itself; rather, it is a result of multiple pathophysiologic phenomena. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic or kidney injury, diabetic ketoacidosis).

Hemorrhagic Stroke Nursing management: Assessment

Altered level of consciousness or responsiveness, ability to and orientation Sluggish pupillary reactions to light and ocular position Motor and sensory deficits Cranial nerve deficits (extra ocular eye movements, facial droop, presence of ptosis) Speech difficulties and visual disturbance Headache and nuchal rigidity or other neurologic deficits Ongoing assessments for any impairment in performance of daily activities

Herniation and Cervical Intervertebral Disc Pharmacologic Therapy

Analgesic agents (nonsteroidal anti-inflammatory agents [NSAIDs], acetaminophen/oxycodone [Tylox], or acetaminophen/hydrocodone [Vicodin]) are prescribed during the acute phase to relieve pain Muscle relaxants (cyclobenzaprine [Flexeril], methocarbamol [Robaxin], metaxalone [Skelaxin]) are given to interrupt muscle spasm and to promote comfort. NSAIDs (aspirin, ibuprofen [Motrin, Advil], naproxen [Naprosyn, Anaprox]) or corticosteroids are prescribed to treat the inflammation and swelling that usually occurs in the affected nerve roots and supporting tissues. corticosteroid is injected into the epidural space for relief of radicular (spinal nerve root) pain.

???Perform a neurological assessment of patients who are experiencing cerebrovascular disorder.

Assess eye response, verbal response, motor response

Ischemic Stroke nursing Assessment: Postacute Phase

Assess for: -Mental status (memory, attention span, perception, orientation, affect, speech and language) -Sensation and perception (patient's awareness of pain and temperature usually decreased) -Motor control (upper and lower extremity movement), swallowing ability, nutritional and hydration status, skin integrity, activity tolerance, and bowel and bladder function -Continued focus on impairment of function in patient's daily activities

increased intracranial pressure nursing management

Assess vital signs. Assess LOC (Glasgow Coma Scale), cranial nerve functions, reflexes, motor function Assess respirations, eye movements, corneal reflex, facial symmetry, presence of spontaneous swallowing or drooling, neck movement, response of extremity to noxious stimuli, reflexes, and abnormal posturing. -Maintain a Patent Airway -Achieve an Adequate breathing pattern -Optimize cerebral tissue perfusion -Maintain negative fluid balance -Prevent infection

altered level of consciousness nursing interventions

Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been given pharmacologic paralyzing agents (i.e., neuromuscular blocking agents) Glascow Coma scale If unconscious, establish an adequate airway and ensure ventilation. Do not speak negatively about the patient or condition in the presence of a coma patient. Monitor respiratory status, eye signs, and reflexes on an ongoing basis Protection of the patient, side rails are padded. Two rails are kept in the raised position during the day and three at night; however, raising all four side rails is considered a restraint by the Joint Commission if the intent is to limit the patient's mobility. Hydration status is assessed by examining tissue turgor and mucous membranes, assessing intake and output trends, and analyzing laboratory data. Fluid needs are met initially by administering the required IV fluids. Feed patients within 48 hrs of injury for best outcomes. Inspect mouth for dryness, inflammation, and crusting

traumatic brain injury clinical manifestations

Basal skull fractures signs An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Ears: CSF otorrhea Nose: CSF rhinorrhea Drainage of CSF is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura.

Management of Alcohol Withdrawal Syndrome/Delirium Tremens

Baseline B/P Give benzodiazepines to reduce anxiety Haloperidol (Haldol), esmolol (Brevibloc), or midazolam (Versed) may be given for severe acute alcohol withdrawal syndrome. patient is placed in a calm, nonstressful environment (usually a private room) and observed closely. Someone is designated to stay with the patient as much as possible. Restraints are used as prescribed, if necessary, if the patient is aggressive or violent, but only when other alternatives have been unsuccessful. Parenteral dextrose may be prescribed Orange juice, sports drinks, or other sources of carbohydrates are given to stabilize the blood glucose level and counteract tremulousness. Supplemental vitamin therapy and a high-protein diet Refer to rehab

What makeup your cranial vault?

Brain CSF Blood

Preoperative medical management of intracranial surgery?

CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. phenytoin (Dilantin), levetiracetam (Keppra), or a phenytoin metabolite fosphenytoin sodium (Cerebyx) before surgery to reduce the risk of postoperative seizures Fluids may be restricted. A hyperosmotic agent (mannitol) and a diuretic agent such as furosemide (Lasix) may be administered IV immediately before and sometimes during surgery if the patient tends to retain fluid. Antibiotic prophylaxis diazepam (Valium) or lorazepam (Ativan) may be prescribed before surgery to allay anxiety.

altered level of consciousness clinical manifestations

Changes are based on the client's severity of LOC. Changes occur in the pupillary response (PERRLA), eye opening response, verbal response, and motor response. However, initial alterations in LOC may be reflected by subtle behavioral changes, such as restlessness or increased anxiety.

What are some early indications of increased ICP?

Chart 66-1 disorientation, restlessness, increased respiratory effort, purposeless movements, mental confusion; pupillary changes impaired extra-ocular movements; weakness in one extremity or on one side of the body; headache that is constant, increasing in intensity, and aggravated by movement or straining.

What are some Assistive Devices to Enhance Self-Care After Stroke: Mobility Aids

Chart 67-4 Canes, walkers, wheelchairs Transfer devices such as transfer boards and belts

What are some Assistive Devices to Enhance Self-Care After Stroke: Dressing Aids

Chart 67-4 Elastic shoelaces Long-handled shoehorn Velcro closures

What are some Assistive Devices to Enhance Self-Care After Stroke: Bathing and Grooming Devices

Chart 67-4 Electric razors with head at 90 degrees to handle Grab bars, Nonskid mats, Handheld shower heads Long-handled bath sponge Shower and tub seats, stationary or on wheels

What are some Assistive Devices to Enhance Self-Care After Stroke: Toileting Aids

Chart 67-4 Grab bars next to toilet Raised toilet seat

What are some Assistive Devices to Enhance Self-Care After Stroke: Eating Devices

Chart 67-4 Nonskid mats to stabilize plates Plate guards to prevent food from being pushed off plate Wide-grip utensils to accommodate a weak grasp

The Patient Recovering From a Stroke At the completion of education, the patient and/or caregiver will be able to:

Chart 67-6 -State the impact of the stroke on physiologic functioning, ADLs, IADLs, roles, relationships, and spirituality. -State names, dose, side effects, frequency and schedule for all medications. -State how to contact all members of the treatment team (e.g., health care providers, home care professionals, rehabilitation team, and durable medical equipment and supply vendor). -State changes in lifestyle (e.g., diet, ADLs, IADLs, activity) necessary for recovery and health maintenance as applicable. -Demonstrate environmental modifications and adaptive techniques for accomplishing activities of daily living. -Demonstrate home exercises, the use of splints or orthotics, proper positioning, and frequent repositioning. -Identify safety measures to prevent falls. -Identify holistic interventions for pain management (e.g., positioning, distraction). -Describe procedures for maintaining skin integrity. -Demonstrate indwelling catheter care, if applicable. -Describe a bowel and bladder elimination program as appropriate. -Verbalize dietary adjustments (e.g., thickened liquids, pureed diet, small frequent meals) during recovery. -Demonstrate swallowing techniques or care of enteral feeding tube. -Identify psychosocial consequences of stroke (e.g., depression, emotional lability, frustration, fatigue) and appropriate interventions. -Discuss measures to prevent subsequent strokes. -Identify potential complications and discuss measures to prevent them (blood clots, aspiration, pneumonia, urinary tract infection, fecal impaction, skin breakdown, contracture). -Relate how to reach primary provider with questions or complications. -State time and date of follow-up medical appointments, therapy, and testing. -Identify resources and other sources of support (e.g., friends, relatives, faith community, stroke support groups, caregiver support). -Identify the need for health promotion, disease prevention, and screening activities -Identify appropriate recreational or diversional activities

Lateral Cord Syndrome (Brown-Séquard Syndrome)

Chart 68-7 Characteristics: Ipsilateral paralysis or paresis is noted, together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature. Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, fracture/dislocation of a unilateral articular process, or possibly an acute ruptured disc.

Anterior Cord Syndrome

Chart 68-7 Characteristics: Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact. Cause: The syndrome may be caused by acute disc herniation or hyperflexion injuries associated with fracture/dislocation of vertebra. It also may occur as a result of injury to the anterior spinal artery, which supplies the anterior two thirds of the spinal cord.

Helping Family Members Cope With Sudden Death part 2

Chart 72-2 -Encourage the family to view the body if they wish; this action helps to integrate the loss. Cover disfigured and injured areas before the family sees the body. Go with the family and do not leave them alone. Show acceptance by touching the body to give the family "permission" to touch. -Spend time with the family, listening to them and identifying any needs that they may have for which the nursing staff can be helpful. -Allow family members to talk about the deceased and what he or she meant to them; this permits ventilation of feelings of loss. Encourage the family to talk about events preceding admission to the emergency department. Do not challenge initial feelings of anger or denial. -Avoid volunteering unnecessary information (e.g., the patient was drinking).

How to apply restraints?

Choose the least restrictive type of device that allows the greatest possible degree of mobility. Pad bony prominences. Wrap the restraint around the extremity with the soft part in contact with the skin Secure in place with the Velcro straps or other mechanism, depending on specific restraint device Ensure that two fingers can be inserted between the restraint and patient's extremity Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint to the bed frame, not side rail Assess the patient at least every hour or according to facility policy. Assessment should include the placement of the restraint, neurovascular assessment of the affected extremity, and skin integrity. In addition, assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. Monitor the patient's vital signs. Remove the restraint at least every 2 hours, or according to facility policy and patient need. Perform range-of-motion (ROM) exercises. Keep the call bell within the patient's easy reach.

spinal cord tumor pathophysiology

Classification is based on the anatomical position on the spinal cord -The mass exerts pressure on the spinal cord

Huntington's disease home and transitional care

Consultation with a speech therapist may be indicated to assist in identifying alternative communication strategies if speech is affected. A PEG tube may be considered for nutritional support later in the disease Regular follow-up visits help allay the fear of abandonment. Home care assistance, day care centers, respite care, and eventually skilled long-term care can assist the patient and family in coping with the constant strain of the illness. Planning for end-of-life care should occur early in the disease when possible.

Ingested (Swallowed) Poisons nursing interventions

Control of the airway, ventilation, and oxygenation are essential. Monitor for Shock & Seizures (vital signs, CVP, and fluid and electrolyte imbalance) Indwelling urinary catheter is inserted to monitor kidney function. Blood specimens are obtained to determine the concentration of drug or poison. The local poison control center should be called if an unknown toxic agent has been taken or if it is necessary to identify an antidote for a known toxic agent. Give antidote ASAP If the patient complains of pain, analgesic agents are given cautiously. Give water or milk for ingestion of strong acid or base; contraindicated if acute airway edema or obstruction; potential for vomiting; or if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation.

What is the temperature range for severe hypothermia?

Core temperature less than 28ºC Tx: same as moderate hypothermia with active internal (core) rewarming Extracorporeal warming -extracorporeal membrane oxygenation (ECMO) -->ventricular assist device (VAD) combination is used for the patient whose heart cannot pump adequate blood through the lungs or the body. -Cardiopulmonary bypass -Peritoneal dialysis

S&S of Epidural Hematoma

EXTREME MEDICAL EMERGENCY Brief loss of consciousness with lucid intervals Rapid decline in neuro status (increased restlessness, agitation, and confusion) Headache Nausea and vomiting Seizures Hemiparesis Fixed dilated pupil on affected side Hemiplegia Seizures

Ischemic Stroke medical management

Early interventions in the ischemic process with medications such as tissue plasminogen activator (t-PA) and medications that protect the brain from secondary injury called neuroprotective agents can extend of secondary brain injury caused by a stroke. Pharmacology: Recombinant t-PA is given--contraindicated if actively bleeding Anticoagulation therapy (heparin or low-molecular-weight heparin) is initiated Manage increased ICP with ic diuretics, maintaining PaCO2 at 35 mm Hg, and positioning the patient's HOB elevated to avoid hypoxia Surgical: -Hemicraniectomy -The main surgical procedure for selected patients with TIAs and mild stroke is carotid endarterectomy (CEA); carotid stunting with or without angioplasty, is a less invasive procedure that is used for selected patients with severe stenosis

autonomic dysreflexia nursing interventions

Elevate the head of the bed to a high Fowler's position to assist with adequate ventilation and assist in the prevention of hypertensive stroke. -If autonomic dysreflexia occurs, immediately place the client in a high Fowler's position or sitting positon. -Rapid assessment is performed to identify and alleviate the cause. -The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. -The rectum is examined for a fecal mass. If one is present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed -The skin is examined for any areas of pressure, irritation, or broken skin. -Remove objects next to the skin or a draft of cold air -If these measures do not relieve the hypertension and excruciating headache, antihypertensive medications may be prescribed and given slowly by the IV route. -The patient is instructed about prevention and management measures. -Any patient with a lesion above the T6 segment is informed that such an episode is possible and may occur even many years after the initial injury

Preoperative nursing management of intracranial surgery?

For motor deficits or weakness or paralysis of the arms or legs, trochanter rolls are applied to the extremities, and the feet are positioned against a footboard or the ankles are supported in a neutral position with orthotic boots. A patient who can ambulate is encouraged to do so. If the patient is aphasic, writing materials or picture and word cards showing the bedpan, glass of water, blanket, and other frequently used items may help improve communication. The patient should plan to shower and wash their hair prior to surgery using the preferred cleansing solution. -Hair is removed with the use of clippers and the surgical site prepared immediately before surgery (usually in the operating room), -intravenous antibiotics are given 1 hour prior to the incision. -An indwelling urinary catheter is inserted in the operating room. -central and an arterial line placed

altered level of consciousness diagnostic findings

Glasgow Coma Scale: eye opening, verbal response, and motor response A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive For identifying cause of unconsciousness: computed tomography (CT) scanning, perfusion CT (PCT), magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), electroencephalography (EEG) EEG, MRI, and PET Lab: blood glucose, electrolytes, serum ammonia, and liver function tests; blood urea nitrogen (BUN) levels; serum osmolality; calcium level; and partial thromboplastin and prothrombin times.

Rape physical Assessment

Goal: provide support, to reduce the patient's emotional trauma, and to gather available evidence for possible legal proceedings. The patient should never be left alone. A written, witnessed informed consent must be obtained from the patient (or parent or guardian if the patient is a minor) for examination, for taking of photographs, and for release of findings to police. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. Urine drug test must be completed within 96 hours of the event to capture the presence of these drugs. Emesis can also be collected for testing Each item of clothing is placed in a separate paper bag External evidence of trauma (bruises, contusions, lacerations, stab wounds) Dried semen stains (appearing as crusted, flaking areas) on the patient's body or clothes Broken fingernails and body tissue and foreign materials under nails (if found, samples are taken) Oral examination, including a specimen of saliva and cultures of gum and tooth areas

Carbon Monoxide Poisoning medical management, and nursing interventions

Goals of management are to reverse cerebral and myocardial hypoxia and to hasten elimination of carbon monoxide. -Carry the patient to fresh air immediately; open all doors and windows. -Loosen all tight clothing. -Initiate traditional cardiopulmonary resuscitation. -Prevent chilling; wrap the patient in blankets. -Keep the patient as quiet as possible. Do not give alcohol in any form or permit the patient to smoke. -Assess skin turgor and LOC carboxyhemoglobin levels are analyzed on arrival at the ED and before treatment with oxygen if possible. To reverse hypoxia and accelerate the elimination of carbon monoxide, 100% oxygen is given at atmospheric or preferably hyperbaric pressures. -Oxygen is given until the carboxyhemoglobin level is less than 5%.

Cardiopulmonary resuscitation (CPR)

If no carotid pulse is detected and no defibrillator is yet available, chest compressions are initiated. Rescue breathing may be added by a health care provider in a ratio of 30 compressions to 2 ventilations. Compressions are performed with the patient on a firm surface such as the floor or a cardiac board. The provider, facing the patient's side, places one hand in the center of the chest on the lower half of the sternum and positions the other hand on top of the first hand (see Fig. 29-7). The chest is compressed 2 inches at a rate of 100 to 120 compressions per minute. Complete recoil of the chest is allowed between compressions. Interruptions in CPR to switch providers or check for a pulse are minimized. It is recommended that providers switch every 2 minutes due to the exertion of delivering effective compressions.

Prioritize the patients to recommend for hospital discharge in a disaster situation.

In descending order of priority from the most severe to the least severe type of client, the following clients should be selected for discharge and relocation during an external disaster when unexpected admissions of victims with varying degrees and severity of injury occur as a result of the massive casualty event in the community. 3rd- Unstable clients: Unstable clients are the most severe and, as such, are not candidates for discharge or transfer to another nursing care unit or relocation. 2nd- Stable clients: Stable clients who continue to need nursing and medical care and assistance are the second priority and, therefore, should not discharged until the lowest priority clients are discharged or transferred and there is a continued need for more reallocation of resources because higher acuity and higher priority clients need necessary care and services during the disaster. 1st- Ambulatory clients and self care clients: Ambulatory clients and self care clients who need little or no assistance are the first clients to be safely discharged, transferred or relocated.

Asystole

Initiate CPR Establish IV access Give epinephrine 1 mg IV push every 3 to 5 min Consider reversible causes Asystole is often the final rhythm as the electrical and mechanical activity of the heart has stopped. The provider should consider ceasing resuscitations is asystole persists.

Pulseless electrical activity (PEA)

Initiate the CPR If shockable rhythm, defibrillate Establish IV access Consider the most common causes Administer epinephrine 1 mg IV push every 3 to 5 min

What is a Cerebral angiography?

Injection of a contrast material usually through the femoral artery (or another artery) into the carotid arteries to visualize the cerebral arteries and assess for lesions

Therapeutic interventions for overactive patient

Introduce yourself by name. Tell the patient, "I am here to help you." Repeat the patient's name from time to time. Speak in one-thought sentences, and be consistent. Give the patient space and time to slow down. Show interest in, listen to, and encourage the patient to talk about personal thoughts and feelings. Offer appropriate and honest explanations. Tx: chlorpromazine and haloperidol

Differentiate between an ischemic and hemorrhagic cerebrovascular disorder.

Ischemic stroke is cerebral vascular blockage secondary to: -thrombotic- a blood clot on an atherosclerotic plaque that gradually shuts off the artery. Symptoms manifest over several hours to days. -embolic- caused by an embolus traveling from another part of the to a cerebral artery. The occlusion immediately shuts off blood flow distally and pt has instant LOC. THE Tx FOR ISCHEMIC STROKE IS tPA within 3 hrs of symptoms, but contraindicated if pt has an active bleed. Hemorrhagic stroke occur secondary to a ruptured artery or aneurysm. Often pt will present with a severe HA or experience a loss of consciousness. The CT will show bleeding in the subarachnoid space, ventricle of the brain, or the brain. A lumbar puncture can Dx bleeding into the subarachnoid space but contraindicated if ICP is elevated, so lumbar puncture not recommended.

Nuclear radiation exposure patho

It disperses radioactive material and may be called a radiologic weapon, but it is not a nuclear weapon, which uses a complex nuclear fission reaction that is thousands of times more devastating than the dirty bomb. When an element is radioactive, there is an imbalance in the nucleus, resulting from an excess of neutrons.

Causes of Ischemic Stroke Chart 67-1

Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolic Cryptogenic (no known cause)

Herniation of Lumbar Disc Assessment and Diagnostic Findings

MRI and CT scans as well as myelography.

cervical discectomy nursing interventions

Maintaining a patent airway is the priority. assessing for swelling, excessive pressure in the neck, or severe pain in the incision area; stridor is an emergency The dressing is inspected for serosanguineous drainage, which suggests a dural leak. Excessive seroganguineous drainage on dressing notify the Surgeon/Provider. Neurologic checks are made for swallowing deficits and upper and lower extremity weakness, because cord compression may produce rapid or delayed onset of paralysis. New onset neurologic changes need the Provider notified.

Dysphagia manifestations and nursing implications Table 67-2

Manifestations: -Difficulty in swallowing Nursing implications/Education: -Test the patient's pharyngeal reflexes before offering food or fluids. -Assist the patient with meals. -Place food on the unaffected side of the mouth. -Allow ample time to eat. -advised to take smaller boluses of food -Having the patient sit upright, preferably out of bed in a chair -instructing him or her to tuck the chin toward the chest as he or she swallows will help prevent aspiration -Use thicker to thicken thin liquids

Loss of peripheral vision Manifestations and Nursing Implications Table 67-2

Manifestations: -Difficulty seeing at night -Unaware of objects or the borders of objects Nursing Implications/Education -Place objects in center of patient's intact visual field. -Encourage the use of a cane or other object to identify objects in the periphery of the visual field. -Ensure that the patient's driving ability is evaluated.

Emotional Deficits manifestations and nursing implications Table 67-2

Manifestations: -Loss of self-control -Emotional lability -Decreased tolerance to stressful situations -Depression -Withdrawal -Fear, hostility, and anger -Feelings of isolation Nursing Implications/Education: -Support patient during uncontrollable outbursts. -Discuss with the patient and family that the outbursts are due to the disease process. -Encourage patient to participate in group activity. -Provide stimulation for the patient. -Control stressful situations, if possible. -Provide a safe environment. -Encourage patient to express feelings and frustrations related to disease process.

Hemiplegia manifestations and nursing implications Table 67-2

Manifestations: -Paralysis of the face, arm, and leg on the same side (due to a lesion in the opposite hemisphere) Nursing Implications/Education: -Encourage the patient to provide range-of-motion exercises to the affected side. -Provide immobilization as needed to the affected side. -Maintain body alignment in functional position. -Exercise unaffected limb to increase mobility, strength, and use.

Paresthesia manifestations and nursing implications Table 67-2

Manifestations: -Sensation of numbness, tingling, or a "pins and needles" sensation -Difficulty with proprioception Nursing Implications/Education: -Instruct patient that sensation may be altered. -Provide range of motion to affected areas and apply corrective devices as needed.

Cognitive Deficits manifestations and nursing implications Table 67-2

Manifestations: -Short- and long-term memory loss -Decreased attention span -Impaired ability to concentrate -Poor abstract reasoning -Altered judgment Nursing Implications/Education: -Reorient patient to time, place, and situation frequently. -Use verbal and auditory cues to orient patient. -Provide familiar objects (family photographs, favorite objects). -Use noncomplicated language. -Match visual tasks with a verbal cue; holding a toothbrush, simulate brushing of teeth while saying, "I would like you to brush your teeth now." -Minimize distracting noises and views when providing education to the patient. -Repeat and reinforce instructions frequently.

Ataxia Manifestations and Nursing Implications Table 67-2

Manifestations: -Staggering, unsteady gait -Unable to keep feet together; needs a broad base to stand Nursing Implications/Education: -Support patient during the initial ambulation phase. -Provide supportive device for ambulation (walker, cane). -Instruct the patient not to walk without assistance or supportive device.

Receptive aphasia manifestations and nursing implications Table 67-2

Manifestations: -Unable to comprehend the spoken word; can speak but may not make sense Nursing Implications/Education: -Speak clearly and in an unhurried manner to assist the patient in forming the sounds. -Explore the patient's ability to read as an alternative means of communication.

Expressive aphasia manifestations and nursing implications Table 67-2

Manifestations: -Unable to form words that are understandable; may be able to speak in single-word responses -often associated with damage to the left frontal lobe area Nursing Implications/Education: -Encourage patient to repeat sounds of the alphabet. -Explore the patient's ability to write as an alternative means of communication.

Homonymous hemianopsia Manifestations and Nursing Implications Table 67-2

Manifestations: -Unaware of persons or objects on side of visual loss -Neglect of one side of the body -Difficulty judging distances Nursing Implications/Education -Place objects within intact field of vision. -Approach the patient from side of intact field of vision. -Instruct/remind the patient to turn head in the direction of visual loss to compensate for loss of visual field. -Encourage the use of eyeglasses if available. -When educating the patient, do so within patient's intact visual field.

Diplopia Manifestations and Nursing Implications Table 67-2

Manifestations: Double vision Nursing Implications/Education -Explain to the patient the location of an object when placing it near the patient. -Consistently place patient care items in the same location.

Treatment for Epidural Hematoma

Medical emergency! • Airway and respiratory management • Decrease ICP and monitor cerebral perfusion • Frequent neuro assessments • Requires surgical intervention to drain the hematoma and stop the bleeding -- making openings through the skull (burr holes or craniotomy) to decrease ICP emergently, remove the clot, and control the bleeding.

Explain the roles of the nurse in emergency preparedness and response.

Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. For example, a critical care nurse may intubate a patient or even insert a chest tube. A nurse may perform wound débridement or suturing. A nurse may serve as the triage officer. In these situations, it is imperative that nurses strive to maximize patient safety and be aware of state regulations related to nursing practice

Care of the Patient With Huntington Disease: Nursing Interventions to prevent confusion Chart 70-5

Nursing Dx: Confusion and impaired social interaction Nursing Interventions -Reorient the patient after awakening. -Have clock, calendar, and wall posters in view to assist in orientation. -Use every opportunity for one-to-one contact. -Use music for relaxation. -Have the patient wear a medical identification bracelet. -Keep the patient in the social mainstream. -Recruit and train volunteers for social interaction. Role-model appropriate and creative interactions. -Do not abandon a patient because the disease is terminal. Patients are living until the end.

Care of the Patient With Huntington Disease: Nursing Interventions to prevent imbalanced nutrition Chart 70-5

Nursing Dx: Imbalanced nutrition: less than body requirements due to inadequate intake and dehydration resulting from swallowing or chewing disorders and danger of choking or aspirating food Nursing Interventions: -Administer phenothiazines (chlorpromazine) as prescribed before meals (calms some patients). -Talk to the patient before mealtime to promote relaxation; use mealtime for social interaction. Provide undivided attention and help the patient enjoy the mealtime experience. -Use a warming tray to keep food warm. -Learn the position that is best for this patient. Keep patient as close to upright as possible while feeding. Stabilize patient's head gently with one hand while feeding. -Show the food, explain what the foods are, and temperature (e.g., whether hot or cold). -Encircle the patient with one arm and get as close as possible to provide stability and support while feeding. Use pillows and wedges for additional support. -Do not interpret stiffness, turning away, or sudden turning of the head as rejection; these are uncontrollable choreiform movements. -For feeding, use a long-handled spoon (iced tea spoon). Place spoon on middle of tongue and exert slight pressure. -Place bite-sized food between patient's teeth. Serve stews, casseroles, and thick liquids. -Disregard messiness, and treat the person with dignity. -Wait for the patient to chew and swallow before introducing another spoonful. Make sure that bite-sized food is small. -Give between-meal feedings. Constant movement expends more calories. Patients often have voracious appetites, particularly for sweets. -Use blenderized meals if patient cannot chew; do not repeatedly give the same strained baby foods. Gradually introduce increased textures and consistencies to the diet. -For swallowing difficulties: -Apply gentle deep pressure around the patient's mouth. -Rub fingers in circles on the patient's cheeks and then down each side of the patient's throat. -Develop skill in the abdominal thrust (to be used in the event of choking).

Care of the Patient With Huntington Disease: Nursing Interventions for impaired communication Chart 70-5

Nursing Dx: Impaired communication from excessive grimacing and unintelligible speech Nursing Interventions: -Read to the patient. -Employ biofeedback and relaxation therapy to reduce stress. -Consult with speech therapist to help maintain and prolong communication abilities. -Try to devise a communication system, perhaps using cards with words or pictures of familiar objects, before verbal communication becomes too difficult. Patients can indicate correct card by hitting it with hand, grunting, or blinking the eyes. -Learn how this particular patient expresses needs and wants—particularly nonverbal messages (widening of eyes, responses). -Patients can understand even if unable to speak. Do not isolate patients by ceasing to communicate with them.

Care of the Patient With Huntington Disease: Nursing Interventions to prevent falls and skin breakdown Chart 70-5

Nursing Dx: Risk for injury from falls and possible skin breakdown (pressure ulcers, abrasions), resulting from constant movement Nursing Interventions: -Pad the sides and head of the bed; ensure that the patient can see over the sides of bed. -Use padded heel and elbow protectors. -Keep the skin meticulously clean. -Apply emollient cleansing agent and skin lotion as needed. -Use soft sheets and bedding. -Have patient wear football padding or other forms of padding. -Encourage ambulation with assistance to maintain muscle tone. -Secure the patient (only if necessary) in bed or chair with padded protective devices, making sure that they are loosened frequently.

Explain best practices to maintain staff and patient safety in the emergency department (ED).

Patients from prison and those who are under guard need to be handcuffed to the bed and appropriately assessed -For prisoners, the hand or ankle restraint (handcuff) is never released, and a guard is always present in the room. -A mask can be placed on the patient to prevent spitting or biting. -Non-restraint techniques should be tried when possible e.g., talking with the patient, minimizing environmental stimulation. -Physical restraints are used on any patient who is violent only as needed and, if used, should be humanely and professionally given; nonetheless, the staff should be cognizant that the patient could head-butt, even if restrained. -Distance should be maintained from the patient to avoid grabbing; staff should not wear items that can be grabbed by the patient, such as dangling jewelry and stethoscopes. Furthermore, distance should be maintained between the patient and the door so that an escape route for the staff member is preserved. -Objects should not be left within patient reach; even an intravenous (IV) line spike can become a tool of violence if the patient is determined. -Courses on safety (de-escalation and physical restraint techniques) assist the staff with preparing for various violent situations.

HIPPA (Health Insurance Portability and Accountability Act)

Patients have a moral and legal right to expect that the information contained in their patient health record will be kept private. All information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud. This includes patient names and all identifiers such as address, telephone and fax number, Social Security number, and any other personal information. It also includes the reason the patient is sick or in the hospital, office, or clinic, the assessments and treatments the patient receives, and information about past health conditions. Examples of breaches of confidentiality and security include the following: -Discussing patient information in any public area where those who have no need to know the information can overhear -Leaving patient medical information in a public area -Leaving a computer unattended in an accessible area with medical record information unsecured -Failing to log off a computer terminal -Sharing or exposing passwords -Copying or providing data, either on paper or in machine-readable form, for yourself, coworkers, or any other party, except as required to fulfill job responsibilities -Improperly accessing, reviewing, or releasing birth dates and addresses of friends or relatives, or requesting another person to do so -Improperly accessing, reviewing, or releasing the record of a patient out of concern or curiosity, or requesting another person to do so -Giving out information over the phone to unauthorized individuals

Hemorrhagic Stroke medical management

Pharm -Administering supplemental oxygen and maintaining the hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. -Seizures are treated with anti epileptic drugs such as phenytoin (Dilantin) -Hyperglycemia should also be treated. -Analgesic agents are given for head and neck pain. -Antihypertensive medications are given to control hypertension. -Calcium channel blocker (Nimodipine) to prevent vasospasms. Several days after the pt is stable, no bleeding, give Labetalol (Trandate), Nicardipine (Cardene), or hydralazine (Apresoline) IV if systolic BP >220 mm Hg -Mannitol may be given to reduce ICP Surgical Craniotomy -indicated if of worsening neurologic exam, increased ICP, or signs of brain stem compression. -goal prevent bleeding in an enraptured aneurysm or prevent further bleeding in an already ruptured aneurysm by isolating the aneurysm with a ligature or a clip across its neck. -Endovascular techniques may be used in selected patients to the blood flow from the artery that feeds the aneurysm with coils, or other techniques may be used to occlude aneurysm itself. Post-op Complications: (disorientation, amnesia, Korsakoff syndrome, personality changes); intraoperative embolization or artery rupture; post-operative artery occlusion; fluid and electrolyte disturbances (from dysfunction of the neurohypophyseal system); and gastrointestinal bleeding.

Post-op Spinal Cord Surgery Management

Post-op -Monitor for neurologic changes/deterioration -Assess movement, strength, and sensation of the upper and lower extremities. -Assessment of sensory function involves pinching the skin of the arms, legs, and trunk to determine if there is loss of feeling and, if so, at what level. -Monitor vital signs -Keep bed flat initially -Logroll client to keeping shoulders and hips aligned and the back straight -Placement of a pillow between the knees of the patient in a side-lying position helps to prevent extreme knee flexion. -educated about the dangers of heating devices (e.g., hot water bottles, heating pads, space heaters) as their sensory integration may be impaired

Components of the EOP: Plan for practice drills

Practice drills that include community participation allow for troubleshooting any issues before a real-life incident occurs.

Pre-op spinal cord surgery management

Pre-op -Assesses for weakness, muscle wasting, spasticity, sensory changes, bowel and bladder dysfunction, and potential respiratory problems - Evaluate for coagulation deficiency or anticoagulant home med. -Breathing exercises and pain management strategies

Discuss non-surgical management options for the patient who has had a cerebrovascular disorder.

Pt w/atrial fibrillation (or cardioembolic strokes) are treated with dose-adjusted warfarin (Coumadin) with a target international normalized ratio (INR) of 2 to 3. newer anticoagulants: -Dabigatran (Pradaxa), -apixaban (Eliquis), -edoxaban (Savaysa), or -rivaroxaban (Xarelto), unless they are contraindicated. If contraindicated use Platelet-inhibiting medications: -clopidogrel (Plavix) -aspirin, -extended-release dipyridamole plus aspirin (Aggrenox)

neurogenic shock diagnostic findings

Restore sympathetic tone; could be as simple as elevating HOB Tx depends on the cause of the shock

Guideline for physical restraints

Restraints should be used only as a last resort when alternative measures have failed and the patient is at increased risk for harming self or others. Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1 hour for children under 9 years of age. After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other licensed independent practitioner who is responsible for the care of the patient must see and assess the patient.

Amyotrophic Lateral Sclerosis Mangement

Riluzole (Rilutek), a glutamate antagonist, has been shown to prolong survival for persons with ALS for 3 to 6 months. Baclofen (Lioresal), dantrolene sodium (Dantrium), or diazepam (Valium) may be useful for patients troubled by spasticity, which causes pain and interferes with self-care. Modafinil (Provigil) may be used for fatigue, and additional medications may be added to manage the pain, depression, drooling, and constipation that often accompany the disease. Mechanical ventilation (using negative-pressure ventilators) is an option if alveolar hypoventilation develops. A patient experiencing aspiration and swallowing difficulties may require enteral feeding. The tube can be safely placed in patients who are using noninvasive positive-pressure ventilation for ventilatory support

Biologic Weapons: Anthrax patho

Route of transmission: Skin contact, GI ingestion, and inhalation Bacillus anthracis is a naturally occurring gram-positive, encapsulated rod that lives in the soil in the spore state throughout the world. The bacterium sporulates (i.e., is liberated) when exposed to air and is infective only in the spore form. Contact with infected animal products (raw meat) or inhalation of the spores results in infection. As an aerosol, anthrax is odorless and invisible and can travel a great distance before disseminating; hence, the site of release and the site of infection can be miles apart.

S&S Stage I of Lyme disease

Stage I may present with a classic "bull's-eye" rash (i.e., erythema migrans) that typically can be found in the axilla, groin, or thigh area and that appears within 4 weeks after the tick bite, with a peak manifestation time of 7 days after the bite. Classically, this rash is at least 5 cm in diameter with bright red borders. It is accompanied by flu-like signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. Without treatment, the rash subsides within 3 to 4 weeks. Tx: doxycycline [Vibramycin]

autonomic dysreflexia clinical manifestations and diagnostic findings

Sudden onset severe, throbbing/pounding headache Paroxysmal hypertension Severe, rapid hypertension Bradycardia Flushing above level of lesion (face, chest) Profuse Sweating (Diaphoresis) above the spinal level of the lesion (most often the forehead) Nausea Nasal congestion Pale extremities below the lesion due to vasoconstriction

Chemical Agent: Nerve Agents Sarin Soman

TABLE 73-6 Action: Inhibition of cholinesterase; causes hyperstimulation of nerve endings S&S: Increased secretions (salivation, lacrimation, emesis, urination), gastrointestinal motility, diarrhea, bronchospasm, sweating, twitching at the entry site Large doses causes systemic symptoms Decontamination and Treatment: Soap and water Supportive care Benzodiazepines Pralidoxime Atropine IV used up to 24 hrs; action decreased secretions, tachycardia, and decreased gastrointestinal motility -Another medication that may serve as an antidote is pralidoxime (Protopam); no effect on secretions Diazepam and valium used for seizure control

Swallowing reflex

Tabel 66-1 Drooling vs. spontaneous swallowing Absent in coma Paralysis of CN X and XII

Facial symmetry

Table 66-1 Asymmetry (sagging, decrease in wrinkles)

Pattern of respiration

Table 66-1 Cheyne-Stokes respiration Hyperventilation Ataxic respiration with irregularity in depth/rate

Eyes: PERRLA Pupils (size, equality, reaction to light)

Table 66-1 Equal, normally reactive pupils Equal or unequal diameter Progressive dilation Fixed dilated pupils

Level of responsiveness or consciousness Assessment

Table 66-1 Eye opening; verbal and motor responses; pupils (size, equality, reaction to light)

Response of extremity to noxious stimuli

Table 66-1 Firm pressure on a joint of the upper and lower extremity Observe spontaneous movements

Pathologic reflexes

Table 66-1 Firm pressure with blunt object on sole of foot, moving along lateral margin and crossing to the ball of foot

Eye movements

Table 66-1 Normally, eyes should move from side to side

Abnormal posture

Table 66-1 Observation for posturing (spontaneous or in response to noxious stimuli) Flaccidity with absence of motor response Decorticate posture (flexion and internal rotation of forearms and hands) Decerebrate posture (extension and external rotation)

Neck

Table 66-1 Stiff neck Absence of spontaneous neck movement

Corneal reflex

Table 66-1 When cornea is touched with a wisp of clean cotton, blink response is normal Tests CN V and VII

SSRI and other depressants overdose therapeutic management trazodone (Desyrel) fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) venlafaxine (Effexor) escitalopram (Lexapro) bupropion (Wellbutrin)

Table 72-1 -Administer activated charcoal with possibly whole bowel irrigation if a sustained-release medication was taken. -Use seizure precautions and administer benzodiazepines (e.g., diazepam) as prescribed.

SSRI and other depressants overdose clinical manifestations trazodone (Desyrel) fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) venlafaxine (Effexor) escitalopram (Lexapro) bupropion (Wellbutrin)

Table 72-1 -Decreased level of consciousness, confusion -Respiratory depression -Increased heart rate -Serotonin syndrome may occur if the SSRI was taken in conjunction with dextromethorphan or meperidine -Agitation, seizures -Hyperthermia, diaphoresis -Hypertension, headache, shivering, "goose flesh," cardiac dysrhythmias, loss of consciousness

Tricyclic Antidepressants overdose clinical manifestations amitriptyline (Elavil) doxepin (Sinequan) nortriptyline (Aventyl) imipramine (Tofranil)

Table 72-1 -Dysrhythmia: ventricular fibrillation/tachycardia, sinus tachycardia -Hypotension -Pulmonary edema, hypoxemia, acidosis -Confusion, agitation, coma -Visual hallucinations -Clonus, tremors, hyperactive reflexes, nystagmus, myoclonic jerking -Seizures -Blurred vision, flushing, hyperthermia

nonbarbiturate sedatives overdose therapeutic management

Table 72-1 -Endotracheal tube is inserted as a precaution; use assisted ventilation to stabilize and correct respiratory depression. Observe for sudden apnea and laryngeal spasm. -Assess for hypotension. -Insert indwelling urinary catheter for patient who is comatose; decreased urinary volume is an index of reduced renal flow associated with reduced intravascular volume or vascular collapse. -Start volume expansion with saline or dextrose as prescribed. -Evacuate stomach contents; lavage (if within 1 hour of ingestion); activated charcoal. -Start ECG monitoring. Observe for dysrhythmias. -Administer flumazenil (Romazicon), a benzodiazepine antagonist (reversal agent). -Refer patient for psychiatric evaluation (potential suicide intent).

Hallucinogens or Psychedelic-Type Drugs overdose therapeutic management

Table 72-1 -Evaluate and maintain patient's circulation, airway, and breathing. -Determine by urine or serum drug screen whether the patient has ingested hallucinogenic drug or has a toxic psychosis. -Try to communicate with and reassure the patient. "Talking down" involves understanding the process through which the patient is proceeding and helping the patient overcome fears while establishing contact with reality. -Remind the patient that fear is common with this problem. -Reassure the patient that he is not losing his mind but is experiencing the effect of drugs and that this will wear off. -Instruct the patient to keep the eyes open; this reduces the intensity of reaction. -Reduce sensory stimuli by minimizing noise, lights, movement, tactile stimulation. -Sedate the patient as prescribed if hyperactivity cannot be controlled; diazepam or a barbiturate may be prescribed. -Search for evidence of trauma; patients who use hallucinogens have a tendency to "act out" their hallucinations. -Manage seizures with benzodiazepines (e.g., diazepam) as necessary. -Observe patient closely; patient's behavior may become hazardous. Have safety officers stationed near the patient's room. -Monitor for hypertensive crisis if patient has prolonged psychosis due to drug ingestion. -Place patient in a protected environment under proper medical supervision to prevent self-inflicted bodily harm. -Management for Phencyclidine Abuse -Place patient in a calm, supportive environment to minimize stimuli; protect from self-injury. -Avoid talking down. -Do not leave patient unobserved. Treat symptoms as they occur. -Drug effects are unpredictable and prolonged. -Symptoms are likely to exacerbate; patient becomes out of control. -Refer all patients in this category for psychiatric and drug evaluation/rehabilitation.

Cocaine overdose Clinical manifestations

Table 72-1 -Increased heart rate and blood pressure -Hyperpyrexia -Seizures -Sluggish, dilated pupillary response -Muscle rigidity -Increased energy, agitation, aggression -Ventricular dysrhythmias -Intense euphoria, then anxiety, sadness, insomnia, and sexual indifference -Cocaine hallucinations with delusions -Psychosis with extreme paranoia and ideas of persecution -Hypervigilance -Chronic psychotic symptoms may persist. -Overall psychotic symptoms are short-lived compared to methamphetamines

Acetaminophen overdose clinical manifestations

Table 72-1 -Lethargy to encephalopathy and death -GI upset, diaphoresis -Right upper quadrant pain -Abnormal liver function tests, prolonged prothrombin time, increased bilirubin, disseminated intravascular coagulation -Hepatomegaly leading to liver failure -Metabolic acidosis -Hypoglycemia Stage I—within 24 hours; GI irritation, possible metabolic acidosis and coma if severe ingestion Stage II—24-48 hours; monitor liver and coagulation studies. Stage III—after 48 hours; hepatic encephalopathy/jaundice, vomiting, right upper quadrant pain, coagulopathy, hypoglycemia, acute kidney injury

Cocaine overdose Therapeutic Management

Table 72-1 -Maintain airway and provide respiratory support. -Control seizures. -Monitor cardiovascular effects; have antiarrhythmic drugs and defibrillator available. -Treat for hyperthermia. -If cocaine was ingested, evacuate stomach contents and use activated charcoal to treat. Whole bowel irrigation may be necessary to treat body packers ("mules"). -Refer for psychiatric evaluation and treatment in an inpatient unit that eliminates access to the drug. Include drug rehabilitation counseling.

Barbiturates overdose therapeutic management

Table 72-1 -Maintain airway and provide respiratory support. -Endotracheal intubation or tracheostomy is considered if there is any doubt about the adequacy of airway exchange. -Check airway frequently. -Perform suctioning as necessary. -Support cardiovascular and respiratory functions; most deaths result from respiratory depression or shock. -Start infusion through large-gauge needle or IV catheter to support blood pressure; coma and dehydration result in hypotension and respond to infusion of IV fluids with elevation of blood pressure. -Evacuate stomach contents or lavage if within 1 hour of ingestion to prevent absorption; repeated doses of activated charcoal may be given. -Assist with hemodialysis for patient with severe overdose. -Maintain neurologic and vital sign flow sheet.

Acetaminophen overdose therapeutic management

Table 72-1 -Maintain airway. -Obtain acetaminophen level. Levels ≥140 mg/kg are toxic. -Laboratory studies—liver function tests, prothrombin time/partial thromboplastin time, complete blood count, blood urea nitrogen, creatinine. -Lavage (if within 1 hour after ingestion); activated charcoal. -Prepare for possible hemodialysis, which clears acetaminophen but does not halt liver damage. -Administer N-acetylcysteine (Mucomyst) as soon as possible. N-acetylcysteine replenishes essential liver enzymes and requires a total of 18 doses every 4 hours. Charcoal absorbs N-acetylcysteine; do not administer together. Repeat N-acetylcysteine dose if patient vomits. -Refer patient for psychiatric evaluation (potential suicide intent).

Amphetamine-Type Drugs (pep pills, "uppers," "speed," "crystal meth") overdose clinical manifestations amphetamine (Benzedrine) dextroamphetamine (Dexedrine) methamphetamine (Desoxyn, "speed") 3,4-methylenedioxymethamphetamine (MDMA) ("Ecstasy," "Adam")a 3,4-methylenedioxy-N-ethylamphetamine (MDEA) ("Eve") 3,4-methylenedioxyamphetamine (MDA); methylphenidate (Ritalin) "ice," "rocks," "crystal meth" 3,4-methylenedioxypyrovalerone (MDPV) or 4-methylmethcathinone (mephedrone); "Bath salts" (synthetic stimulant)

Table 72-1 -Nausea, vomiting, anorexia -Palpitations, tachycardia -Increased blood pressure -Tachypnea, anxiety -Nervousness -Diaphoresis, mydriasis -Repetitive or stereotyped behavior -Irritability, insomnia, agitation -Visual misperceptions, auditory hallucinations -Fearfulness, anxiety, depression, hostility, paranoia -Hyperactivity, rapid speech, euphoria, hyperalertness -Decreased inhibition -Seizures, coma, hyperthermia -Cardiovascular collapse -Rhabdomyolysis -MDMA is both a hallucinogenic and stimulant. -MDPV and mephedrone effects last >24 hours.

Hallucinogens or Psychedelic-Type Drugs overdose clinical manifestations Lysergic acid diethylamide (LSD) Phencyclidine HCl (PCP, "angel dust") Mescaline, psilocybin Cannabinoids (marijuana) Ketamine ("special K") Synthetic cannabinoids ("spice," "incense," "K2") Butane honey oil (BHo)—"dabs," "shatter"

Table 72-1 -Nystagmus -Pupil dilation -Psychedelics -Sluggish pupillary response -Increased pulse and temperature -Muscle rigidity -Mild hypertension -Marked confusion bordering on panic -Incoherence, hyperactivity -Withdrawn -Combative behavior; delirium, mania, self-injury (lasts 6-12 hours) -Hallucinations, body image distortion -Hypertension, hyperthermia, acute kidney injury -Flashback—recurrence of LSD-like state without having taken the drug; may occur weeks or months after drug was taken -Ketamine—"out-of-body" experience; increased aggressiveness -Synthetic cannabinoids—euphoria, increased sensory experience, relaxation -Manufacturing can result in burns

Tricyclic Antidepressants overdose therapeutic management

Table 72-1 -Provide airway support, ventilation, cardiac monitoring; insert IV line with normal saline solution. -If within 1-2 hours after overdose, insert a nasogastric tube and instill activated charcoal every 4 hours × 3. -Administer a sodium bicarbonate drip to decrease dysrhythmias; the alkaline environment increases the protein binding of the metabolite. Synchronized cardioversion may be indicated with some dysrhythmias refractory to sodium bicarbonate. Torsades de pointes should be treated with IV magnesium sulfate. -Administer vasopressors. Manage seizure activity with benzodiazepines (e.g., diazepam) as necessary. Refer patient for psychiatric evaluation for potential suicide intent and evaluation of medication regimen for effectiveness.

Amphetamine-Type Drugs (pep pills, "uppers," "speed," "crystal meth") overdose therapeutic management

Table 72-1 -Provide airway support, ventilation, cardiac monitoring; insert IV line. -Use GI evacuation in cases of oral overdose; activated charcoal, gastric lavage if within 1 hour of ingestion. -Keep in calm, cool, quiet environment; elevated temperature potentiates amphetamine toxicity. Maintain normothermia, cooling the patient as necessary. -Administer small doses of diazepam (Valium) (IV) or haloperidol (Haldol) as prescribed for CNS and muscular hyperactivity. -Administer appropriate pharmacologic therapy as prescribed for severe hypertension and ventricular dysrhythmias. -Treat seizures with benzodiazepines (e.g., diazepam) as prescribed. -Treat sympathetic stimulation with beta-blocker agents as prescribed. -Try to communicate with patient if delusions or hallucinations are present. -Place in a protective environment (preferably psychiatric security room with video monitoring) to observe for suicide attempt. -Refer for psychiatric and drug rehabilitation evaluation.

Anabolic Steroids overdose therapeutic management

Table 72-1 -Provide supportive therapy appropriate to patient's emotional manifestations. -Protect the patient from self-harm/harming others. -Encourage the patient to stop use; refer patient for psychiatric evaluation.

Opioid overdose Therapeutic Management

Table 72-1 -Support respiratory and cardiovascular functions. -Establish IV lines; obtain blood for chemical and toxicologic analysis. Patient may be given bolus of glucose to eliminate possibility of hypoglycemia. -Administer narcotic antagonist (naloxone hydrochloride IV, IM [Narcan]) as prescribed to reverse severe respiratory depression and coma. -Continue to monitor level of responsiveness and respirations, pulse, and blood pressure. Duration of action of naloxone hydrochloride is shorter than that of heroin; repeated dosages may be necessary. -Send urine for analysis; opioids can be detected in urine. -Obtain an ECG. -Do not leave patient unattended; he or she may lapse back into coma rapidly. Clinical status may change from minute to minute. Hemodialysis may be indicated for severe drug intoxication. Activated charcoal may be considered if opioids were taken orally and if the patient is alert. -Monitor for pulmonary edema, which is frequently seen in patients who abuse/overdose on narcotics. -Refer patient for psychiatric and drug rehabilitation evaluation before discharge.

Salicylate Poisoning therapeutic management

Table 72-1 -Treat respiratory depression. -Induce gastric emptying by lavage (if within 1 hour after ingestion). -Give activated charcoal to adsorb aspirin. -Support patient with IV infusions as prescribed to establish hydration and correct electrolyte imbalances, including administration of sodium bicarbonate. -Enhance elimination of salicylates as directed by forced diuresis, alkalinization of urine, peritoneal dialysis, or hemodialysis, according to severity of intoxication. -Monitor serum salicylate level for efficacy of treatment. -Administer specific prescribed pharmacologic agent for bleeding and other problems. -Recognize that concretions formed in the gut may result in prolonged exposure as they are digested. -Refer patient for psychiatric evaluation (potential suicide intent). -Monitor thromboelastography for platelet function.

Barbiturates overdose clinical manifestations Pentobarbital (Nembutal), secobarbital (Seconal), amobarbital (Amytal), gamma-hydroxybutyrate (GHB, "liquid Ecstasy")

Table 72-1 Acute intoxication (may mimic alcohol intoxication): -Respiratory depression -Flushed face -Decreased pulse rate; decreased blood pressure -Increasing nystagmus (to vertical and horizontal gaze) -Sluggish pupils -Lack of convergence of eyes -Depressed deep tendon reflexes -Decreasing mental alertness -Difficulty in speaking -Poor motor coordination and flaccid muscles -Coma, death GHB: -Sexual disinhibition -Amnesia, myoclonus, agitation -Overdoses when mixed with alcohol

Opioid overdose Clinical Manifestations Heroin Opium or paregoric Morphine, codeine, semisynthetic derivatives: oxycodone (OxyContin), methadone, meperidine (Demerol), tramadol (Ultram), fentanyl (Sublimaze

Table 72-1 Acute intoxication (overdose) can result in: -Pinpoint pupils (may be dilated with severe hypoxia) -Decreased blood pressure -Marked respiratory depression/arrest -Pulmonary edema -Stupor → coma -Seizures -Fresh needle marks along course of any superficial vein -Skin abscesses (from "popping")

Inhalants overdose clinical manifestations Amyl nitrate Freon Propane Trichloroethylene Gasoline Perchloroethylene Toluene (metallic paint spray) Helium Canned air Hand sanitizer Routes may include: Sniffing/snorting—direct inhalation of fumes "Bagging"—sniff from a bag "Huffing"—sniff from a rag/cloth "Dusting"—direct spray into the nostrils

Table 72-1 Effects mimic those of alcohol, with dizziness and imbalance: -Euphoria, headache, disinhibition, altered level of consciousness to coma -Renal, hepatic, and cardiac toxicity -Aplastic anemia -Fetal growth retardation -Respiratory depression, arrest from CNS depression -Vasodilation -Nosebleeding -Vertical and horizontal nystagmus -Lack of convergence of eyes -Sluggish pupils -Temperature fluctuations -Circumoral red spots/rash -Air embolus

nonbarbiturate sedatives overdose clinical manifestations diazepam (Valium) chlordiazepoxide (Librium) oxazepam (Serax) lorazepam (Ativan) midazolam (Versed) flunitrazepam (Rohypnol, "roofies," "date rape drug")a

Table 72-1 Seizures, coma, circulatory collapse, death Acute intoxication: -Respiratory depression -Decreasing mental alertness -Confusion -Slurred speech, decreased blood pressure -Ataxia -Pulmonary edema -Coma, death Flunitrazepam: -Disinhibition with antegrade amnesia -Weakness and unsteadiness with impaired judgment -Powerlessness

Phase of Blast injury: Secondary

Table 73-3 Results from debris from the scene or shrapnel from the bomb Common injuries: -Penetrating trunk, skin, and soft tissue injuries -Fractures, traumatic amputations

Phase of Blast injury: Quaternary

Table 73-3 Results from pre-existing conditions exacerbated by the force of the blast or by postblast injury complications Common injuries: Severe injuries with complex injury patterns—burns, crush injuries, head injuries Common pre-existing conditions that become exacerbated—COPD, asthma, cardiac conditions, diabetes, and hypertension

Chemical Agent: Blood Agent Cyanide

Table 73-6 Action: Inhibition of aerobic metabolism; odor of bitter almonds, absorbed through mucous membranes and skin S&S: Inhalation—tachypnea, tachycardia, coma, seizures; bright red skin; can progress to respiratory arrest, respiratory muscle failure, cardiac arrest, death Decontamination and Treatment: Soap and water Sodium nitrite Sodium thiocyanate Amyl nitrate Hydroxocobalamin (Vitamin B12); can cause pink discoloration of mucous membranes, skin, and urine. High dose can cause tachycardia, HTN (self-resolving)

Chemical Agent: Vesicant Agents Lewisite Sulfur mustard Nitrogen mustard Phosgene

Table 73-6 Action: Blistering and burn agent S&S: Superficial to partial-thickness burn with vesicles that coalesce; conjunctivitis, nasal irritation, bronchitis, pneumonia, hematopoietic suppression, fluid filled bullae, pruritis, redness Decontamination and Treatment: Soap and water Blot; do not rub dry Respiratory exposure-mechanical ventilation and bronchoscopy

Chemical Agent: Pulmonary Agents Phosgene Chlorine

Table 73-6 Action: Separation of alveoli from capillary bed S&S: Pulmonary edema, bronchospasm, chest tightness, burning sensation, blurry vision; Phosgene can result in pain then blisters followed by partial to full-thickness burn Decontamination and Treatment: Copious flushing Move to fresh air—away from gases Airway management Ventilatory support Bronchoscopy most useful tool for identifying worsening symptoms is pulse oximeter

Phases of Effects of Radiation Exposure: Manifest Illness phase

Table 73-7 Time: After latent period phase S&S: Infection, fluid and electrolyte imbalance, bleeding, diarrhea, shock, and altered level of consciousness

Phases of Effects of Radiation Exposure: Latent phase (a symptom-free period)

Table 73-7 Time: After resolution of prodromal phase; can last up to 3 weeks With high-dose radiation, latent period is shorter S&S: Decreasing lymphocytes, leukocytes, thrombocytes, red blood cells

What are the pressure points for controlling bleeding?

Temporal Facial Carotid Subclavian Brachial Radial and Ulnar Femoral

medical management of cold-related injuries (Hypothermia)

The CABs of basic life support are a priority. patient's vital signs, CVP, urine output, arterial blood gas levels, blood chemistry determinations (blood urea nitrogen, creatinine, glucose, electrolytes), and chest x-rays are evaluated frequently. Core body temperature is monitored with an esophageal, bladder, or rectal thermistor. Continuous ECG monitoring is performed, because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. An arterial line is inserted and maintained to record blood pressure and to facilitate blood sampling.

What is the Canadian Triage and Acuity Scale (CTAS).

The CTAS system's five levels include time parameters that guide how frequently patients must be reassessed by either a nurse or provider. Patients assigned to the *resuscitation category* must receive continuous nursing surveillance, emergent category must be reassessed at least every 15 minutes, urgent category must be reassessed at least every 30 minutes, less urgent category must be reassessed at least every 60 minutes, nonurgent category must be reassessed at least every 120 minutes. The goal of all triage is rapid assessment and decision-making, preferably under 5 minutes

Explain the components of an emergency preparedness and response plan.

The Goal is the protect the community. -Activation response -Internal/external communication plan -Security plans -Identification of external resources -Plan for people management and traffic flow -Data management strategy -Demobilization response -After-action report or corrective plan -Plan for practice drills -Anticipated resources -MCI planning -Education plan for all the above

Where the preferred method of checking body temperature in an unconscious patient?

The body temperature of a patient who is unconscious is never taken by mouth. Rectal, tympanic (if not contraindicated), or core temperature measurement is preferred to the less accurate axillary temperature.

Herniation of Cervical Intervertebral Disc Clinical manifestations

The cervical spine is subjected to stresses that result from disc degeneration (due to aging, occupational stresses) and spondylosis (degenerative changes occurring in a disc and adjacent vertebral bodies). Cervical disc degeneration may lead to lesions that can cause damage to the spinal cord and its roots the disc herniates centrally onto the spinal cord, causing Lhermitte syndrome, an electric-like shock sensation in the extremities or spine with neck flexion or straining, and bilateral arm and leg weakness (myelopathy)

Amyotrophic Lateral Sclerosis Clinical Manifestations

The chief symptoms are fatigue, progressive muscle weakness, cramps, fasciculations (twitching), and lack of coordination. Loss of motor neurons in the anterior horns of the spinal cord results in progressive weakness and atrophy of the muscles of the arms, trunk, or legs. Spasticity Overactive and brisk DTR If bulbar muscles are impaired, speaking and swallowing are progressively difficult, and aspiration becomes a risk. Eventually, respiratory function is compromised. Death usually occurs as a result of infection, respiratory insufficiency, or aspiration.

medical management of cold-related injuries (Frost Bite)

The goal of management is to restore normal body temperature. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and not ruptured. Nonhemorrhagic blisters are débrided to decrease the inflammatory mediators found in the blister fluid. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for their anti-inflammatory effects and to control pain. Whirlpool bath for the affected body parts to aid circulation and débridement of necrotic tissue to help prevent infection Escharotomy (incision through the eschar) to prevent further tissue damage, to allow for normal circulation, and to permit joint motion Fasciotomy to treat compartment syndrome

What test are diagnostic of a Stroke?

The initial diagnostic test for a stroke is usually a non-contrast computed tomography (CT) scan. -*If ischemic, CT is normal the 1st 24hrs* Performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic as the type of stroke determines treatment. If ischemic, identify the source of the thrombi or emboli Additional Test: -A 12-lead electrocardiogram (ECG) and a carotid ultrasound (standard test). -CT angiography or CT perfusion; -magnetic resonance imaging (MRI) and magnetic resonance angiography of the brain and neck vessels; -transcranial Doppler flow studies; -transthoracic or transesophageal echocardiography; -xenon-enhanced CT scan; -single-photon emission CT scan

nursing management of heat-related injures (heat stroke)

The main goal is to reduce the high body temperature as quickly as possible simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) of basic life support After the patient's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour -Cool sheets and towels or continuous sponging with cool water -Ice applied to the neck, groin, chest, and axillae while spraying with tepid water -Cooling blankets -Immersion of the patient in a cold water bath is the optimal method for cooling (if available) an electric fan is positioned so that it blows on the patient to augment heat dissipation by convection and evaporation.

What is the normal range for CPP?

The normal CPP is 70 to 100 mm Hg

Preventing Heat-Induced Illnesses chart 72-6

The nurse provides the following advice for the patient treated for heat-induced illness: -Avoid immediate re-exposure to high temperatures; hypersensitivity to high temperatures may remain for a considerable time. -Maintain adequate fluid intake, wear loose clothing, and reduce activity in hot weather. -Monitor fluid losses and weight loss during workout activities or exercise and replace fluids and electrolytes. -Use a gradual approach to physical conditioning, allowing sufficient time for return to baseline temperature. -Plan outdoor activities to avoid the hottest part of the day (between 10 AM and 2 PM). -For older patients living in urban settings with high environmental temperatures: -The nurse directs these patients to places where air conditioning is available (e.g., shopping mall, library, church) and advises them that fans alone are not adequate to prevent heat-induced illness.

When is a consent needed in the ED?

The patient needs to give consent for invasive procedures (e.g., angiography, lumbar puncture) unless he or she is unconscious or in a critical condition and unable to make decisions. If the patient is unconscious and brought to the ED without family or friends, this fact must be documented.

Ischemic Stroke clinical manifestations

The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation. Motor Loss: -Hemiplegia -Hemiparesis -Flaccid paralysis or decreases DTR initially, d by reappearance (after 48 hours) of DTR and abnormally increased muscle tone (spasticity) -Disturbance of voluntary motor control on one side of the body Communication Loss: -Dysarthria -Dysphasia -Apraxia Perceptual Disturbances and Sensory Loss: -Homonymous hemianopia -Disturbances in visual-spatial relations (perceiving the relation of two or more objects in spatial areas), frequently seen in patients with right hemispheric damage -slight impairment of touch, or more severe loss of proprioception; difficulty in interrupting visual, and auditory stimuli; agnosia Cognitive Impairment and Psychological Effects: -Frontal lobe damage: limited attention span, difficulties in comprehension, forgetfulness, and tack of motivation.

Tympanic Membrane Rupture patho and S&S

There is an increased incidence of TM rupture when a blast occurs in close proximity to the patient and when it occurs in an enclosed space. -hearing loss, -tinnitus, -pain, -dizziness, -otorrhea

What is the Tx goals for poisonings?

Tx Goals -Removal or inactivation of the poison before it is absorbed -Provision of supportive care in maintaining vital organ function -Call poison control to help identify substance or the antidote -Administration of a specific antidote to neutralize a specific poison -Implementation of treatment that hastens the elimination of the absorbed poison

Biologic Weapons: Smallpox medical/nursing interventions

Tx: Isolations and clothes must be autoclaved before washing Nurses take standard precaution, contact, and airborne All people who have household or face-to-face contact with the patient after the fever begins should be vaccinated within 4 days to prevent infection and death. A patient with a temperature of 38°C (101°F) or higher within 17 days after exposure must be placed in isolation. Cremation is preferred for all deaths, because the virus can survive in scabs for up to 13 years

Biologic Weapons: Anthrax medical/nursing interventions

Tx: penicillin (Penicillin V), erythromycin (Erythrocin), gentamicin (Garamycin), or doxycycline (Vibramycin), Ciprofloxacin (Cipro)--begin within 24 hrs to prevent death If mass outbreak or client has not symptoms, use Cipro or Doxycycline b/c they can be given orally 60-day Tx is recommended Complications of inhaled anthrax Most patients have a brief recovery period followed by the second stage within 1 to 3 days, characterized by fever, severe respiratory distress, stridor, hypoxia, cyanosis, diaphoresis, hypotension, and shock. These patients require optimization of oxygenation, correction of electrolyte imbalances, and ventilatory and hemodynamic support. Nurses take standard precaution, contact, and airborne Cremation is recommended at death b/c spores can live for decades

How to remove a tick?

Use fine-tipped tweezers to grasp the tick as close to the skin's surface as possible. Pull upward with steady, even pressure. Don't twist or jerk the tick; this can cause the mouth-parts to break off and remain in the skin. If this happens, remove the mouth-parts with tweezers. If you are unable to remove the mouth easily with clean tweezers, leave it alone and let the skin heal. After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol or soap and water. Never crush a tick with your fingers. Dispose of a live tick by putting it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet.

What is the client education after a stroke?

Use the unaffected side of to exercise the affected side of the body. For edema of the extremities, massage by stroking from the fingertips or toes back toward the body to encourage fluid movement. Support the arm while in bed, the wheelchair, or during ambulation with an arm sling or strategically place pillows. If client has homonymous hemianopsia, instruct them to use a scanning technique when eating and ambulating.

Transsphenoidal Approach post-op nursing management

Vital signs are measured to monitor hemodynamic, cardiac, and ventilatory status. The head of the bed is raised to decrease pressure on the sella turcica and to promote normal drainage. The patient is cautioned against blowing the nose or engaging in any activity that raises ICP, such as bending over or straining during urination or defecation. fluid and electrolyte replacement and to assess for diabetes insipidus. Daily weight is monitored Oral care is provided every 4 hours or more frequently. Usually, the teeth are not brushed until the incision above the teeth has healed. Warm saline mouth rinses and the use of a cool mist vaporizer are helpful. The head of the bed is elevated at 30 degrees for at least 2 weeks after surgery. The patient is cautioned against blowing the nose or sneezing for at least 1 month

Ischemic Stroke nursing Assessment: During Acute Phase (1 to 3 days)

Weigh patient Assess for: -Change in level of consciousness or responsiveness, ability and orientation -Presence or absence of voluntary or involuntary movements of the extremities: muscle tone, body posture, and head position -Eye opening, comparative size of pupils and pupillary reactions to light, and ocular position -Color of face and extremities; temperature and moisture of skin -Quality and rates of pulse and respiration; arterial blood gas levels, body temperature, and arterial pressure -Volume of fluids ingested or administered and volume of urine excreted per 24 hours -Signs of bleeding -Blood pressure maintained within normal limits

nursing interventions of cold-related injuries (Frost Bite)

Wet clothing is removed as rapidly as possible. If the lower extremities are involved, the patient should not be allowed to ambulate. analgesic for pain is given as prescribed To avoid further mechanical injury, the body part is not handled. Massage is contraindicated. Sterile gauze or cotton is placed between affected fingers or toes to prevent maceration, and a bulky dressing is placed on the extremity. Problems such as hyperkalemia (e.g., from release of potassium in the damaged cells) and hypovolemia are corrected Monitor for infection; aseptic technique is used during dressing changes, and tetanus prophylaxis is given as indicated. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures. Avoid tobacco, alcohol, and caffeine because of their vasoconstrictive effects

spinal cord injury diagnostic findings

X-rays (lateral cervical spine x-rays) and CT scanning are usually performed initially. MRI scan may be ordered as a further workup if a ligamentous injury is suspected, because significant spinal cord damage may exist even in the absence of bony injury. If an MRI scan is contraindicated, a myelogram may be used to visualize the spinal axis. Continuous electrocardiographic monitoring may be indicated if an SCI is suspected, because -bradycardia (slow heart rate) -asystole (cardiac standstill) are common

Pathophysiology of cold-related injuries (Hypothermia)

a condition in which the core (internal) temperature is 35°C (95°F) or less as a result of exposure to cold or an inability to maintain body temperature in the absence of low ambient temperatures Contributing Factors: -Alcohol ingestion increases susceptibility because it causes systemic vasodilation. -Medications (e.g., phenothiazines) -Medical conditions (e.g., hypothyroidism, spinal cord injury) decrease the ability to shiver, hampering the body's innate ability to generate body heat. -Fatigue and sleep deprivation -Wet clothing accelerates heat loss, and immersion in cold water -Victims of trauma are also at risk for hypothermia resulting from treatment with cold fluids, unwarmed oxygen, and exposure during examination. -frostbite

incomplete spinal cord lesion

a condition in which there is preservation of the sensory or motor fibers, or both, below the lesion

complete spinal cord lesion

a condition that involves total loss of sensation and voluntary muscle control below the lesion

subarachnoid bolt

a hollow device that is inserted through the skull and dura mater into the cranial subarachnoid space Complications: high risk for infection

autonomic dysreflexia pathophysiology

a life-threatening emergency in patients with spinal cord injury that causes a hypertensive emergency; also called autonomic hyperreflexia

What is a transient ischemic attack (TIA)?

a neurologic deficit typically lasting 1 to 2 hours

Food Poisoning clinical manifestations and diagnostic findings,

a sudden illness that occurs after ingestion of contaminated food or drink. -severe vomiting (metabolic alkalosis) and diarrhea (metabolic acidosis) causes fluid and electrolyte imbalances, -lethargy, -rapid pulse rate, -fever, -oliguria, -anuria, -hypotension, -delirium -Hypovolemic shock

What are the manifestations of TIA?

a sudden loss of motor, sensory, or visual function. The symptoms result from temporary ischemia (impairment of blood flow) to a specific region of the brain; however, when brain imaging is performed, there is no evidence of ischemia.

Triage Tag

a tag containing key information that is attached to a patient during a multiple-casualty incident 3. Minor--Walking wounded 2. Delayed--Serious, non-life threatening 1. Immediate--Life threatening injury 4. Morgue--Pulseless, non-breathing

Transsphenoidal Approach post-op medical management

antimicrobial agents (which are continued until the nasal packing inserted at the time of surgery is removed), corticosteroids, analgesic agents for discomfort, and agents for the control of diabetes insipidus, if necessary

S&S of Alcohol Withdrawal Syndrome/Delirium Tremens

anxiety, uncontrollable fear, tremor, irritability, agitation, insomnia, and incontinence. talkative and preoccupied and experience visual, tactile, olfactory, and auditory hallucinations that often are terrifying. tachycardia, dilated pupils, and profuse perspiration, gastrointestinal losses (vomiting), and hyperventilation infections (e.g., pneumonia), trauma, hepatic failure, hypoglycemia, and cardiovascular problems

Pathophysiology swallowed or inhaled poisons, skin contamination, and food poisoning.

any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action.

How is a tourniquet applied?

applied just proximal to the wound and tied tightly enough to control arterial blood flow.

Alcohol intoxication medical/nursing interventions

approach the patient in a nonjudgmental manner, using a firm, consistent, accepting, and reasonable attitude. Speaking in a calm and slow manner is helpful because alcohol interferes with thought processes. R/o neurologic impairment Obtain blood specimen to analysis blood alcohol level maintenance of a patent airway observation for symptoms of CNS depression patient should be undressed and kept warm with blankets Monitor alcohol withdrawal delirium and for injuries and organic disease (such as head injury, seizures, pulmonary infections, hypoglycemia, and nutritional deficiencies) Assessed for head injury, hypoglycemia (which mimics intoxication) Monitor for Pulmonary infections Monitor for aspiration

What are patients who hemorrhage at risk for?

at risk for cardiac arrest caused by hypovolemia with secondary anoxia. Hypovolemic shock is the result of a cascade of events beginning with fluid loss -Hypertension -decreased intravascular volume -decreased venous return -decreased stroke volume -decreased cardiac output -decreased tissue perfusion Goal: restore intravascular volume, redistribute fluid volume, and correct underlining cause

S&S Stage III of Lyme disease

begin anywhere from weeks to more than a year after the bite and persist for over 10 years -arthritis, -neuropathy, -myalgia, -myocarditis.

neurogenic bladder

bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity

Hemorrhagic Stroke patho

bleeding into the brain tissue, the ventricles, or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension.

Intracerebral hemorrhage (ICH)

bleeding into the parenchyma of the brain. May result in: -Systemic hypertension, which causes degeneration and rupture of a vessel -Rupture of an aneurysm -Vascular anomalies -Intracranial tumors -Bleeding disorders such as leukemia, hemophilia, aplastic anemia, and thrombocytopenia -Complications of anticoagulant therapy

dementia

broad term for a syndrome characterized by a general decline in higher brain functioning, such as reasoning, with a pattern of eventual decline in ability to perform even basic activities of daily living, such as toileting and eating

radiologic weapon

by-products of radiation contamination that are used to cause morbidity and mortality in the general population or the military

Stroke diagnostic test: MRI

can be used to identify edema, ischemia, and necrosis.

increased intracranial pressure increased pathophysiology

cause decreases cerebral perfusion, stimulates further swelling (edema), and may shift brain tissue, resulting in herniation—a dire and frequently fatal event

What happens if ICP and MAP are the equal?

cerebral circulation ceases MAP=ICP; blood flow will stop Then MAP or ICP can be manipulated to increase or decrease blood flow, so it's easiest to fix ICP.

How to improve mobility and prevent joint deformities in a stroke pt?

change position every 2 hours To prevent adduction of the affected shoulder while the patient is in bed, a pillow is placed in the axilla when there is limited external rotation; this keeps the arm away from the chest. A pillow is placed under the arm, and the arm is placed in a neutral (slightly flexed) position, with distal joints positioned higher than the more proximal joints (i.e., the elbow is positioned higher than the shoulder and the wrist higher than the elbow). The fingers are positioned so that they are barely flexed. The hand is placed in slight supination (palm faces upward), which is its most functional position. If the upper extremity is flaccid, a splint can be used to support the wrist and hand in a functional position. If the upper extremity is spastic, a hand roll is not used, because it stimulates the grasp reflex. If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh

Biologic Weapons: Smallpox patho

classified as a deoxyribonucleic acid (DNA) virus. It has an incubation period of approximately 12 days. It is extremely contagious and is spread by direct contact, by contact with clothing or linens, or by droplets from person to person only after the fever has decreased and the rash phase has begun. Aerosolization of the virus would result in widespread dissemination.

Subdural Hematoma

collection of venous blood under the dura mater slowly

locked-in syndrome

condition resulting from a lesion in the pons in which the patient lacks all distal motor activity (paralysis) but cognition is intact inability to speak, but vertical eye movements and lid elevation remain intact and are used to indicate responsiveness

clinical manifestations and diagnostic findings of heat-related injures (heat stroke)

confusion, delirium, bizarre behavior, coma, seizures; elevated body temperature (40.6°C [105°F] or higher); hot, dry skin; and usually anhidrosis (absence of sweating), tachypnea, hypotension, and tachycardia.

Intracerebral hemorrhage (ICH) medical management

control of ICP; careful administration of fluids, electrolytes, and antihypertensive medications. Surgical intervention by craniotomy or craniectomy permits removal of the blood clot, if location permits, and control of hemorrhage

What are the S&S of hypovolemic shock?

cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, decreasing urine volume

What is the temperature range for moderate hypothermia?

core temperature 28-32ºC Tx: Active internal (core) rewarming -Warm IV fluid administration -Warm humidified oxygen -Warm peritoneal lavage -Pleural, bladder -extracorporeal membrane oxygenation (ECMO)

What is the temperature range for mild hypothermia?

core temperature 32-35ºC Tx: Passive external rewarming -Warm blankets -Warm water -Immersion -Forced air (Bair Hugger)

Post-op Care carotid endarterectomy (CEA)

cranial nerve injuries, infection or hematoma at the incision, and carotid artery disruption. It is important to maintain adequate blood pressure levels in the immediate postoperative period. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction. Difficulty in swallowing, hoarseness, or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body. The surgeon is notified immediately if a new neurologic deficit develops.

Contusion of the brain clinical manifestations

dependent upon size, location, and the extent of surrounding cerebral edema. -loss of consciousness associated with stupor and confusion. -hemorrhage and edema, peak after about 18 to 36 hours. These effects, which can cause secondary effects resulting in increased ICP and possible herniation syndromes, are most pronounced in temporal lobe contusions.

S&S of contemplating suicide

depression (e.g., loss of a loved one, loss of body integrity or status, poor self-image, weight loss, sleep disturbances, somatic complaints, suicidal preoccupation) and can be viewed as a cry for help and intervention.

Alcohol intoxication clinical manifestations

drowsiness, impaired coordination, slurring of speech, sudden mood changes, aggression, belligerence, grandiosity, and uninhibited behavior. In excess, it can also cause stupor and eventually coma and death (i.e., alcohol poisoning).

Acoustic Neuromas

encapsulated tumors that grow on CN VIII CN VIII--responsible for hearing and balance -grow slowly and attain considerable size before it is diagnosed Symptoms: -experiences loss of hearing, -tinnitus, -episodes of vertigo and staggering gait -painful sensations of the face may occur on the same side as a result of the tumor's compression of CN V Tx: -Surgical removal, open craniotomy -stereotactic radiotherapy

Who is at risk for suicide?

enduring unusual loss or stress; those who are unemployed, divorced, widowed, or living alone; those showing signs of significant depression previous suicide attempt, suicide in the family, or psychiatric illness Loss of a parent at an early age Specific plan for suicide A means to carry out the plan

personal protective equipment (PPE)

equipment beyond standard precautions; may include different levels of equipment to provide complete protection, depending on the nature of the suspected biologic, chemical or radiologic agent

Emergency Medical Treatment and Active Labor Act (EMTALA)

every ED with a Medicare provider agreement must perform a medical screening examination on all patients arriving with an emergency medical complaint if their acute signs and symptoms could result in serious injury or death if left untreated.

What is a secondary injury?

evolves over the ensuing hours and days after the initial injury and results from inadequate delivery of nutrients and oxygen to the cells. intracranial hemorrhage, cerebral edema, intracranial hypertension, hyperemia, seizures, and vasospasm Systemic Effects: hypotension, hyperthermia, hypoxia, hypercarbia, infection, electrolyte imbalances, and anemia can also be factors which add to the complex biochemical, metabolic, and inflammatory changes that further compromise an injured brain

craniectomy

excision of a portion of the skull

Monro-Kellie hypothesis AKA Monro-Kellie doctrine

explains the dynamic equilibrium of cranial contents. The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others. Because brain tissue has limited space to expand, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral blood volume. Without such changes, ICP begins to rise.

halo vest

external traction device that encircles the head like a halo and stabilizes the cervical spine

S&S of Black Widow spider bites

feel like pinpricks abdominal rigidity, nausea and vomiting, hypertension, tachycardia, and paresthesias within 30 minutes of bite Severe pain also develops within 60 minutes and increases over 1 to 2 days

What are the S&S of meningitis?

fever, chills, nuchal (neck) rigidity, and increasing or persistent headache

Improbable survivors after radiation exposure

have received more than 800 rad of total-body penetrating irradiation. People in this group demonstrate an acute onset of vomiting, bloody diarrhea, and shock. Any neurologic symptoms suggest a lethal dose of radiation. Personal protection is essential, because it is virtually impossible to fully decontaminate these patients; all of their internal organs have been irradiated. These patients would be triaged into the black category in a mass casualty. If it is not a mass casualty situation, aggressive fluid and electrolyte therapies are essential.

clinical manifestations and diagnostic findings of heat-related injures (heat exhaustion)

high body temperatures accompanied by headaches, anxiety, syncope, profuse diaphoresis, gooseflesh, and orthostasis. The cardinal manifestations of heat cramps include muscle cramps, particularly in the shoulders, abdomen, and lower extremities; profound diaphoresis; and profound thirst

Biologic Weapons: Smallpox clinical manifestations and diagnostics

high fever, malaise, headache, backache, prostration After 1 to 2 days, a maculopapular rash appears, evolving at the same rate, beginning on the face, mouth, pharynx, and forearms. Only then does the rash progress to the trunk and also become vesicular to pustular.

dyskinesia

impaired ability to execute voluntary movements

When is a cricothyroidotomy indicated?

in emergency situations in which endotracheal intubation is either not possible or contraindicated, as in airway obstruction from extensive maxillofacial trauma, cervical spine injuries, laryngospasm, laryngeal edema (after an allergic reaction or extubation), hemorrhage into neck tissue, or obstruction of the larynx. A cricothyroidotomy is replaced with a formal tracheostomy when the patient is able to tolerate this procedure.

receptive aphasia (fluent)

inability to understand what someone else is saying; often associated with damage to the temporal lobe area

When is endotracheal intubation indicated?

indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the patient to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions. Medications used to facilitate rapid sequence intubation include a sedative, an analgesic, and a neuromuscular blockade agent; these are usually given by the practitioner performing the intubation.

Gliomas

infiltrate any portion of the brain; most common type of brain tumor Oligodendroglial tumors, arising from oligodendroglial cells -->occur in adults ages 50 to 60, -->found in men more often than in women, -->are categorized as low or high grade (anaplastic) Tx: -a combination of surgery, radiation therapy, and chemotherapy -6 weeks of oral temozolomide (Temodar) during radiation therapy, followed by 6 to 12 months of oral temozolomide; one of few chemo drugs that cross the blood-brain barrier

Coma

is a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli, although nonpurposeful responses to painful stimuli and brainstem reflexes may be present.

Persistent vegetative state

is a condition in which the unresponsive patient resumes sleep-wake cycles after coma but is devoid of cognitive or affective mental function.

Ischemic Stroke patho

is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain. ischemic strokes are subdivided into five different types based on the cause: -large artery thrombotic strokes (20%), -small penetrating artery thrombotic strokes (25%), -cariogenic embolic strokes (20%), -cryptogenic strokes (30%), and other (5%). Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug use [cocaine], coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.

What is rape?

is forced sexual acts, especially if these acts involve vaginal or anal penetration. Attempted rape may include verbal threats of rape.

Assessment findings for stroke affecting left cerebral hemisphere?

is responsible for language, mathematic skills, and analytic thinking. -Expressive and receptive aphasia -Agnosia -Alexia (reading difficulty) -Agraphia (writing difficulty) -Right extremity hemiplegia or hemiparesis -Slow, cautious behavior -Depression, anger, and quick to become frustrated -Visual changes (hemianopsia)

Assessment findings for stroke affecting right cerebral hemisphere?

is responsible for visual and spatial awareness and proprioception -Altered perception of deficits (overestimation of abilities) -Unilateral neglect syndrome (ignore left side of the body: cannot see, feel, or move affected side, so client unaware of its existence). More common with right-hemispheric stroke, but can occur with left-hemispheric stroke -Loss of depth perception -Poor impulse control and judgment -Left hemiplegia or hemiparesis -visual changes (hemianopsia)

How does Cheyne-Stokes breathing affect the ABGs?

lowers the PaCO2 ventricular tachycardia

traumatic brain injury diagnostic findings

magnetic resonance imaging (MRI) scan provides better resolution and clearer pictures of the injured area computed tomography (CT) scan can be used to diagnose a skull fracture Positron emission tomography (PET)= assessing brain function.

What is the goal of wound care?

maintain and restore the physical integrity of the injured skin/tissue and function. Minimize scarring Treatment Aseptic technique Primary Closure: stapled or sutured, use steri strips or bond agents Delayed primary closure: appropriate when risk of infection is high Tetanus prophylaxis given if last booster is more than 5 years or vaccination status is unknown

Amyotrophic Lateral Sclerosis Assessment and diagnostic findings

no clinical or laboratory tests are specific to this disease Electromyography and muscle biopsy studies of the affected muscles indicate reduction in the number of functioning motor units. An MRI scan may show high signal intensity in the corticospinal tracts; this differentiates ALS from a multifocal motor neuropathy.

When should you suspect internal bleeding?

no external signs of bleeding but exhibits -tachycardia, -falling blood pressure, -thirst, -apprehension, cool and moist skin, -delayed capillary refill Treatment: packed red blood cells, plasma, and platelets are given at a rapid rate, and the patient is prepared for surgery arterial blood gas specimens are obtained patient is maintained in the supine position and monitored closely until hemodynamic or circulatory parameters improve

Probable survivors after radiation exposure

no initial symptoms or only minimal symptoms (e.g., nausea and vomiting), or these symptoms resolve within a few hours. These patients should have a complete blood count drawn and may be discharged with instructions to return if any symptoms recur.

Decompression Sickness

occurs secondary to diving, high-altitude flying, or flying in commercial aircraft within 24 hrs after diving Nitrogen bubbles form secondary to changes in atmospheric pressure Manifestations: -Joint pain -Numbness -Hypesthesia -Loss of ROM -Stroke like symptoms -Cardiopulmonary arrest -Air emboli causes stroke, paralysis, and death Management: -Patent airway -Rapid transfer to a hyperbaric chamber

What is traumatic brain injury, open (penetrating)?

occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain.

What is traumatic brain injury, closed (blunt)?

occurs when the head accelerates and then rapidly decelerates or collides with another object (e.g., a wall, the dashboard of a car) and brain tissue is damaged but there is no opening through the skull and dura.

craniotomy

opening the skull surgically to gain access to intracranial structures. This procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot, or control hemorrhage. The surgeon cuts the skull to create a bony flap, which can be repositioned after surgery and held in place by periosteal or wire sutures.

Medical management for heat cramps

oral sodium supplements and oral electrolyte solutions

Ingested (Swallowed) Poisons clinical manifestations

pain or burning sensations, any evidence of redness or burn in the mouth or throat, pain on swallowing or an inability to swallow, vomiting, or drooling; age and weight of the patient; and pertinent health history

S&S of Brown recluse spider bites

painless bite fever and chills, nausea and vomiting, malaise, and joint pain develop within 24 to 72 hours. The site of the bite may appear reddish to purple in color within 2 to 8 hours after the bite. Necrosis occurs in the next 2 to 4 days in approximately 10% of cases. The center of the bite may become necrotic, and surgical débridement may be necessary.

Paraplegia

paralysis of the lower body

spinal cord injury medical management

patient is resuscitated as necessary, and oxygenation and cardiovascular stability are maintained. Surgery is indicated in any of the following situations: -Compression of the cord is evident. -The injury results in a fragmented or unstable vertebral body. -The injury involves a wound that penetrates the cord. -Bony fragments are in the spinal canal. -The patient's neurologic status is deteriorating.

When is an Oropharyngeal/Nasopharyngeal Airway indicted?

patient who is breathing spontaneously but who is unconscious If breathing is ineffective or absent, bag-valve-mask ventilation is necessary.

Possible survivors after radiation exposure

present with nausea and vomiting that persist for 24 to 48 hours. They experience a latent period, during which leukopenia, thrombocytopenia, and lymphocytopenia occur. Barrier precautions and protective isolation are implemented if the patient's lymphocyte count is less than 1200/mm3. Supportive treatment includes administration of blood products, prevention of infection, and provision of enhanced nutrition.

surviving a drowning incident medical management

priority in resuscitation is to manage the hypoxia, acidosis, and hypothermia. endotracheal intubation with PEEP improves oxygenation, prevents aspiration, and corrects intrapulmonary shunting and ventilation-perfusion abnormalities (caused by aspiration of water); patient must be able to breath spontaneous for endotracheal intubation.

decontamination

process of removing, or rendering harmless, contaminants that have accumulated on personnel, patients, and equipment

Clinical manifestations and diagnostic findings of cold-related injuries (Hypothermia)

progressive deterioration, with apathy, poor judgment, ataxia, dysarthria, drowsiness, pulmonary edema, acid-base abnormalities, coagulopathy, and eventual coma. Shivering may be suppressed at a temperature of less than 32.2°C (90°F), because the body's self-warming mechanisms become ineffective. weak peripheral pulses Cardiac dysrhythmias hypoxemia and acidosis

Treatment post rape

prophylaxis against sexually transmitted infections (STIs) (also referred to as sexually transmitted disease [STDs]). Ceftriaxone (Rocephin), given intramuscularly with 1% lidocaine (Xylocaine), may be prescribed as prophylaxis for gonorrhea. In addition, a single oral dose of metronidazole (Flagyl) and either a single oral dose of azithromycin (Zithromax) or a 7-day oral regimen of doxycycline may be prescribed as prophylaxis for syphilis and chlamydia 21-day package of contraceptive medication should be given within 12 to 24 hours and no later than 72 hours after intercourse.

PPE for CBRN Level D

protection is the typical work uniform Levels C and D PPE are the levels most often used in hospital facilities.

PPE for CBRN Level A

protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. This includes a self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots.

material safety data sheet (MSDS)

provides information to employees and health care providers regarding specific chemical agents; includes chemical name, physical data, chemical ingredients, fire and explosive hazard data, health and reactive data, spill or leak procedures, special protection information, and special precautions; also known as the Worker's Right to Know

Blast Lung Management

providing respiratory support that includes administration of supplemental oxygen with nonrebreathing mask but may also require endotracheal intubation and mechanical ventilation If a hemothorax or pneumothorax is present, a chest tube must be inserted to re-expand the lung. In the event of an air embolus, the patient should be immediately placed in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber. Complications: respiratory failure as well as ARDS

spinal cord injury pathophysiology

ranges from transient concussion (from which the patient fully recovers) to contusion, laceration, and compression of the spinal cord tissue (either alone or in combination), to complete transection of the spinal cord (which renders the patient paralyzed below the level of the injury).

What does a C wave indicate about ICP?

relate to variations in systemic arterial pressure and respirations

nursing interventions of cold-related injuries (Hypothermia)

removal of wet clothing, continuous monitoring, rewarming, and supportive care. Active internal (core) rewarming methods are used for moderate to severe hypothermia (less than 28°C to 32.2°C [82.5°F to 90°F]) and include cardiopulmonary bypass, warm fluid administration, warmed humidified oxygen by ventilator, and warmed peritoneal lavage. Monitoring for ventricular fibrillation as the patient's temperature increases from 31°C to 32°C (88°F to 90°F) is essential. Passive external rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic, anaerobic extremities.

cranioplasty

repair of a cranial defect using a plastic or metal plate

Meningiomas

several classes of noncancerous tumors arising from the meninges; benign encapsulated tumors of arachnoid cells -slow growing, -occur most often in middle-aged adults, -more common in women Tx: Sx or radiation therapy

transection

severing of the spinal cord itself; transection can be complete (all the way through the cord) or incomplete (partially through)

mass casualty incident (MCI)

situation in which the number of casualties exceeds the number of available resources

When should the post wound care patient contact the provider?

sudden or persistent pain, fever or chills, bleeding, rapid swelling, foul odor, drainage, or redness surrounding the wound which indicate infection

surviving drowning incident pathophysiology

survival for at least 24 hours after submersion that caused a respiratory arrest. The most common consequence is hypoxemia. Children under 5 years of age and those over the age of 85 have the highest risk of drowning Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Salt-water aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. Prevention -avoiding rip currents offshore -surrounding the pool with fencing, use a self-latching/closing gate -taking swimming lessons -using a personal flotation device (PFD)

SIADH

syndrome of inappropriate antidiuretic hormone secretion

How is pulse pressure calculated?

systolic pressure - diastolic pressure Normally, the pulse pressure is 30 to 40 mm Hg. -Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. -Decreased or narrowing pulse pressure, an early indication of decreased stroke volume.

Contusion of the brain

the brain is bruised and damaged in a specific area because of severe acceleration-deceleration force or blunt trauma. The impact of the brain against the skull leads to a contusion. bruising of the brain surface can be characterized by loss of consciousness associated with stupor and confusion. The effects of injury, particularly hemorrhage and edema, peak after about 18 to 36 hours.

Cushing's response

the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure

What is a primary injury?

the consequence of direct contact to the head/brain during the instant of initial injury, causing extracranial focal injuries (e.g., contusions, lacerations, external hematomas, and skull fractures), as well as possible focal brain injuries from sudden movement of the brain within the cranial vault (e.g., subdural hematomas (SDHs), concussion, diffuse axonal injury [DAI]).

What therapeutic position are clients placed in after posterior fossa (infratentorial) Sx?

the patient is kept flat on one side (off the back) with the head on a small, firm pillow. The patient may be turned on either side, keeping the neck in a neutral position. When the patient is being turned, the body should be logrolled to prevent placing strain on the incision and possibly tearing the sutures. The head of the bed may be elevated slowly as tolerated by the patient.

What therapeutic position are clients placed in after supratentorial Sx?

the patient is placed on their back or side (on the unoperated side if a large lesion was removed) with one pillow under the head. The head of the bed may be elevated 30 degrees, depending on the level of the ICP and the neurosurgeon's preference.

transsphenoidal approach

through the mouth and nasal sinuses is often used to gain access to the pituitary gland

Transsphenoidal Approach complications

transient diabetes insipidus of several days' duration; Tx with vasopressin CSF leakage, visual disturbances, postoperative meningitis, pneumocephalus (air in the intracranial cavity), and SIADH

Discuss pathophysiology of cold-related injuries (Frost Bite)

trauma from exposure to freezing temperatures and freezing of the intracellular fluid and fluids in the intercellular spaces. It results in cellular and vascular damage. Frostbite can result in venous stasis and thrombosis. Commonly affected body areas are: -feet, -hands, -nose, -ears

terrorism

unlawful, systematic use of violence or threats of violence against people in order to coerce or intimidate

Stroke diagnostic test: Glasgow Coma Scale

used when the client has a decreased level of consciousness or orientation. The risk for increased intracranial pressure (ICP) exists related to the swelling of the brain that can occur secondary to ischemic insult.

snakebites Patho and Clinical Manifestations

venom consists primarily of proteins. It may affect multiple organ systems, especially the neurologic, cardiovascular, and respiratory systems. signs of envenomation are: -edema, -ecchymosis, -hemorrhagic bullae, leading to necrosis at the site of envenomation. Symptoms include: -lymph node tenderness, -nausea, -vomiting, -numbness, -metallic taste in the mouth. Without decisive treatment, these clinical manifestations may progress to include fasciculations, hypotension, paresthesias, seizures, and coma

cervical discectomy complications

with or without fusion, may be performed to alleviate symptoms. An anterior surgical approach may be used through a transverse incision to remove disc material that has herniated into the spinal canal and foramina, or a posterior approach may be used at the appropriate level of the cervical spine. Potential complications with the anterior approach: -carotid or vertebral artery injury, -recurrent laryngeal nerve dysfunction, -esophageal perforation, -airway obstruction (stridor) Swelling of the neck post-op is expected but stridor is an indication of narrowing airway.

What is the ICP normal range?

with the normal pressure being 0 to 10 mm Hg, and 15 mm Hg being the upper limit of normal