Capstone Exam 2 Nuro

A nurse is caring for a client who has a new chest tube in place to a closed-chest water-seal drainage and suction. The nurse should observe the client for which indication of a problem in the drainage system?

Continuous bubbling in water seal chamber Occasional or intermittent bubbling in the water-seal compartment is normal on expiration an indicates that air is being removed from the pleural space. Continuous bubbling in the water-seal chamber during both inspiration and expiration indicates air is leaking into the drainage system or pleural cavity.

Hypothalamus

Controls body temperature/autonomic nervous system

Diagnostic Head injuries

1. CT/CAT (may involve contrast dye) 2. MRI: pre screening, pacemakers, meta, pregnancy. 3. ICP monitoring: Infection risk, HOB 30

Head Injury Interventions

1. HOB over 30 degrees & Head midline neutral position 2. Avoid neck, hip, knee flexion or extension. (log roll with turning) 3. ICP goal= less than 15-20. Calculate CPP 4. PaCO2 around 35 mm Hg (to avoid vasodilation) 5. Seizure precautions, Suction= Hyperoxygenate with ambu bag.

Cerebral Edema

1. Vasogenic (Damage to BBB problem with blood vessel/damage)-- meningitis 2. Dilutional Hyponatremia: Cytotoxic edema (Concentration of sodium in blood very low causing cells to take on water and swell) Interventions Damage to BBB= Antibiotics/resolution of inflammation (SIADH) water retention Dilutional hyponatremia= Osmotic diuretics

Intracranial Bleeds

Aneurysms, hematomas, hemorrhages, AVMs. -Bleeding can occur quick (Increase ICP Decrease CPP) pre-existing aneurysm burst from sudden spike in BP or trauma -Hemorrhagic key symptom=HA Intervention=quick assessment and recognition pressure will need to be relieved asap

Cranial nerves responsible for six eye muscle that control eye movement

3) III 4) IV 6) VI

The high pressure alarm on a patient's ventilator rings and when the nurse goes into the room, the client is struggling to sit up. The oxygen saturation monitor reads 86%. What should the nurse do next?

Ask nurse to manually ventilate client while you assess the reason for high pressure alarm The information in the question does not give a clear reason for the high pressure alarm. You just know that alarm is sounding, the client appears in distress, and the O2 saturation is low. Manual ventilation should improve the patient's oxygenation status while you investigate to determine the specific problem.

A nurse monitoring a client who has sustained a head injury. Which vital sign trends over a nursing shift would indicate increased intracranial pressure (ICP)?

Bradycardia (Low HR) Hypertension (High BP) Bradypnea (low RR) Pyrexia (High Temp) Rationale: all signs of increased intracranial pressure. These are opposite from shock. Most types of shock (septic is an exception) involve decreased temperature d/t decreased peripheral blood flow.

Head injury interventions

Bed (head) ↑ to 30 degrees, head in midline neutral position Remember to avoid neck, hip / knee flexion or extension. Log roll with turning Report CSF leak / check for glucose Airway patency - Maintaining is PRIORITY; Monitor oxygen levels, Oxygen as needed; vital signs (hyperthermia) ICP - monitor (goal is to maintain at < 15 to 20 mmHg), calculate CPP. PaCO2 - keep around ___ mmHg. Immobility complications should be prevented. I & O need to be monitored to evaluate onset of diabetes insipidus or SIADH. Prevent and monitor for infection at site Neurological status - monitor (GCS, PERRLA, posturing changes) Safety- (side rails up), seizure precautions. ↓Stimulation, ↓Straining (avoid sneezing, coughing and blowing nose), before and after suctioning, hyperoxygenate with 100% oxyge

A client with a spinal cord injury has a post-void residual of 250 mL. The best response by the nurse would be to:

Catheterize immediately rationale: It is most important to catheterize the client first. Medications may be appropriate, but take time to begin working. With a spinal cord injury, a neurogenic bladder can occur and intermittent catheterization is required. Medications could assist in long-term management of this issue, but right now, the patient in front of us needs to be catheterized to aid in relief of the immediate problem.

Autonomic dysreflexia (T6 or higher)

Causes: some sort of stimulus like full bladder, fecal impaction, tight clothing, kinked catheter. Assessment: flushing, diaphoresis, headache, hypertension and bradycardia.

A nurse is using standard precautions while caring for a group of clients. Which of the following situations require that the nurse wear gloves? Select all that apply.

Changing ostomy pouch, providing oral care, Emptying urine from collection bag. (not placing oral med in clients hand) You do not need to wear gloves when delivering a try to a patient who has AIDS or when placing an oral medication into a client's hand. Emptying urine, a colostomy bag and oral care would require gloves.

Client is on a mechanical ventilator with a cuffed endotracheal tube. One of the alarms on the ventilator sounds. The nurse should immediately:

Check client for respiratory distress Rationale: When caring for a patient on a ventilator, if an alarm sounds - it is always important to check the patient first before attempting to troubleshoot the equipment or obtain an ABG.

Hydrocephalus

Congenital or acquired. +Increase in CSF production or decrease in drainage raise ICP Interventions -removal of excess CSF -VP shunt (post=immediate lie on nonoperative side, recognize signs of ICP returning)

Newborn exposed to drugs in utero interventions

Decreasing environmental stimuli, clustering care to minimize stimulation, swaddle the newborn to reduce self-stimulation and protect the skin from abrasion - tight swaddling vs. loose swaddling will help the newborn feel more secure, and small frequent feedings - not just frequent feedings - of high high-calorie formula are suggested.

ECG Management

Educate client regarding procedure. Deep breaths during EEG Understand the need to wash hair before procedure (no oils, sprays) Caffeine - not prior to EEG. A strobe light with flashes of light may be exposed to client The nurse should instruct the client / family members that procedure is not painful. Evaluate client / family's understanding of procedure / process. Sleep may be withheld prior to test. Sedatives or any medication that induces sleep or alters the brain waves should not be administered prior to this procedure if possible.

A client with a T2 spinal cord injury has been transferred from an assisted living facility to the hospital with an indwelling urinary catheter. The urine is cloudy and foul smelling. What nursing action would be most appropriate?

Encourage client to increase fluid intake Foul and cloudy urine would be signs of an infection. It would be most important from the choices given to increase fluid intake to keep the urine diluted and lessen the possibility of infection. A client with an injury at T4 would still have the ability to use their arms and hands normally but would have no sensation below nipple line and no trunk control.

Low pressure alarm

Evaluate cuff pressure at least q 8 hr. • Assess for air leaks, client being able to speak, air hiss, ↓ Sa O2; Fix the problem by correcting leak such as ↑ pressure to cuff. • K (C)olor of client, breath sounds, RR + rhythm. Maintain cuff pressure below 20 mm Hg to reduce risk of tracheal necrosis.

GCS Scale

Eye Opening (4) Spontaneous, opens to command, opens to pain, No response Verbal Response (5) Oriented conversation, Disoriented/confused but able to answer questions, Inappropriate responses, Incomprehensible speech, No response, Intubated=1T Motor Response (6) Obeys commands for movement, purposeful movement to painful stimulus, Withdraws from pain, Spastic (decorticate), Rigid Extensor (decerebrate), No response Best score - 15 Worst score - 3

The nurse is caring for a client who was just admitted with a T4 spinal cord injury. Which of the following clinical findings would indicate the client may be developing neurogenic shock?

HR was 67 now 50, BP was 145/78 now 102/58 Neurogenic shock is a common response of the spinal cord following injury. Symtoms include hypotension, bradycardia, flaccid paralysis, loss of reflex activity below the level of the injury.

A nurse is giving shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. When reporting about the client, what is included in the situation segment of SBAR?

History of current Injury In SBAR, the situation could include the history of the injury in a hand-off report. Pressure readings and Glasgow Coma Scale ratings would be assessment. Medication that is needed might be part of the recommendation or may not even be a necessary part of report depending on why it is being mentioned.

ICP monitoring

ICP sustained> 15 increased +Neuro assess Q1 +calculate cerebral perfusion pressure hourly by subtracting ICP from MAP (MAP-ICP) Normal Cerebral perfusion pressure= 70-100mmHg +adeguate CPP= 50-60, CPP< incompatible with cerebral life. +inspect site Q24 hours at least for red, swelling, drainage

Reportable disease

IMMEDIATE +Anthrax (Bacillus anthracis) +Botulism (Clostridium botulinum or Botulinum toxin) +Influenza (avian/novel strains) +Measles (Rubeola) +Meningococcal disease (N meningitidis) +Plague +Poliomyelitis +Rabies (Human) +Smallpox (Variola) +Viral hemorrhagic fevers (Ebola, Lassa, Marburg viruses) Urgently reportable 24 hours +Covid, Dengue, Animal bites, Diphtheria, Eastern encephalitis, H. Influenzae, HUS, Hepatitis acute, FLU death, Mumps, Pertussi, Rubella, Mpox, Q fever, VRSA, Syphillis, TB, Typhoid fever, vibrio, west nile. zika

Chest tube dislodge

If the chest tube accidentally falls out, instruct the patient to perform the Valsalva maneuver. At end-expiration immediately cover the insertion site with vaseline gauze (if indicated by your hospital), a dry sterile dressing, and occlusive tape (Pruitt, 2008). In the event of chest-tube disconnection with contamination, you can submerge the tube 1" to 2" (2 to 4 cm) below the surface of a 250-mL bottle of sterile water or saline solution until a new CDU is set up. This establishes a water seal, allows air to escape, and prevents air reentry (Bauman & Handley, 2011). The nurse should immediately call the physician and prepare for re-inserting of the chest tube. While informing the physician, place oxygen on the patient and sit patient in high-Fowlers.

A client with a complete spinal cord injury at the C5 level is complaining of a headache. The nurse should:

Immediately assess clients blood pressure rationale: Clients with a spinal injury T6 and above are at risk for autonomic dysreflexia, it would be most important to assess blood pressure first out of the given choices to check for hypertension.

High pressure alarm

Increased secretions, biting on tube, kinks, coughing, etc. If the problem is with secretions / coughing, then suction. If it is biting, then determine if sedation is necessary or if client is hypoxic (if client does not settle down with care, then notify HCP.) • G Give notice to fluid increase in the tubes and drain or notify resp. therapy. • H Hear changes in BS (moist, crackles), color of client, RR - rhythm and rate or RR, Monitor SaO2 ; Document and intervene as appropriate.

A nurse is performing a neurological assessment for a client who is receiving treatment for a head trauma. Which assessment will give the nurse information about the function of the third cranial nerve?

Instruct client to look up and down without moving the head Cranial nerve III is the oculomotor nerve. It is responsible for extraocular eye movement, elevation of eyelid and pupil constriction.

A nurse is planning care for a 6-year-old client who has bacterial meningitis. Which nursing intervention is unnecessary in the client's plan of care?

Measure Head circumference every shift Rationale: Bacterial meningitis is a medical emergency. The child or client with meningitis is at risk for potential complications such as septic chock, vasomotor collapse, seizures and increased ICP due to hydrocephalus, brain swelling and fluid overload. It would be important to place the client in semi-Fowler's position, implement seizure precautions and admit the patient to a private room. This client requires respiratory isolation. Measuring head circumference would not be required for a 6 year old.

Chest tube clamp rules

Never clamp the chest tube unless the physician orders it or when a nurse is changing the chest drainage unit. If the patient on water suction is going off the unit for a procedure/diagnostic test or being transferred, put the chest drainage unit to under water seal (UWS), which is a one-way valve which allows air to exit the chest and prevents air returning to the patient under normal conditions. When ambulating a patient, ensure that the drainage unit is carried at a level below the patient's chest. Ensure that the tube is functioning & the connections are secure. Also ensure that the UWS is at least 20cmH2O below the patient's fluid level.

A client returned from thoracic surgery three hours ago with bilateral chest tubes each set at 20 cm suction. Which finding would be considered abnormal?

No fluctuation in water seal chamber Rationale: Note the period of time is 3 hours after surgery. Fluid in the water-seal chamber should rise with inspiration and fall with expiration (tidaling or fluctuation). When tidaling occurs, the drainage tubes are patent and the system is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. Due to the period of time being only 3 hours after surgery, it is not likely that the lung has re-expanded already.

Normal ICP

Normal ICP values are 10-15mmHg. Rationale: Intracranial hypertension is defined as an ICP greater than 20-25 mmHg and can lead to a fatal herniation of the brain. Don't forget there are several things that can increase ICP temporarily like coughing, sneezing, positioning, etc. What we are looking for are sustained increases, not temporary. Of course we want to avoid the temporary increases, but sometimes they can't be helped.

A nurse in the intensive care unit is caring for a client who has a tracheostomy and is on a ventilator. The client also has an indwelling urinary catheter to gravity drainage, a central venous catheter and is on a heparin drip for a thromboembolism. The nurse can delegate which action to the unlicensed assistive personnel (UAP)?

Obtaining stool sample for occult blood testing Delegating to a UAP - no unstable patients, the other procedures would not be appropriate based on the task. Blood cultures and ABGs are not delegated to UAPs. A sputum culture for someone on a vent with a trach would also not be delegated to a UAP. Think very general, mostly ADLs and basic care

What would the nurse include in teaching the client about taking valproic acid (Depakene)?

Physical dependence may occur with long term use Rationale: Aspirin and Depakote should not be taken together as this increases the risk of bleeding. It is true that this medication can impair driving ability and it is not a PRN medication. It is a medication that requires a narrow therapeutic index and the timing of administration should be as strict as possible. Physical dependence NOT addiction may occur. It can not be stopped abruptly for this reason.

Chest tube indications

Pneumothorax (open and closed). • Tension pneumothorax. • Hemothorax. • Hemopneumothorax. • Pleural effusions. • Chylothorax (a type of pleural effusion that results from lymphatic fluid (chyle) accumulating in the pleural cavity). • Penetrating chest trauma. • Pleural empyema (collection of purulent material in the lungs).

Spinal injury

SCI above T12 have potential for impairment of respiratory function. Diaphragm receives innervation from the phrenic nerve which arises above C5. C4 or higher = paralysis of diaphragm.

Bacterial Meningitis

Severe HA, nuchal rigidity (stiff neck), Fever develop quick, Lumbar Puncture!!!! quick ABX crucial, prophylactic for persons in contact with PT, Vaccines available Systemic= WBC high, symptoms of increased ICP

tesnion pneumothorax

Severe respiratory distress • Tracheal deviation toward the unaffected side • Cyanosis • Muffled heart sounds • Cardiac arrest

Neurogenic shock

Spinal cord injuries (SCI) at T6 or above (Bradycardia, peripheral vasodilation below the level of injury, decreased systemic vascular resistance, and hypotension). Cardiac output is decreased resulting in decreased cardiac output.

A client who was previously healthy was involved in a motor vehicle accident. Four days after surgery, the client has the following results: O2 saturation 97% on 2L O2 via NC; WBC 19,000; Hgb 9g/dL, Hct 19%; PTT 30 sec. The nurse will expect to:

Start IV antibiotics and unit of packed RBC Rationale: O2 sat is within normal limits on small amount of oxygen, WBC count is elevated, Hgb and Hct are both low, PTT is normal. Elevated WBC count is typically a sign of infection and would need treatment with antibiotics. A low Hgb and Hct would require a blood transfusion. The need for oxygen to maintain acceptable saturation is likely contributed to by this severe, acute anemia, keeping in mind oxygen levels are more likely to suffer in acute, vs. chronic, anemia because of minimal time to compensate. This the best answer from the given choices.

A nurse monitors a client who has a traumatic brain injury. Which manifestation should the nurse report immediately to the provider?

Sudden Sleepiness The most important from the given answers is sudden sleepiness. The word sudden is a key word that is descriptive of change. This would denote a decreasing level of consciousness, lethargy which is an early sign of increasing ICP.

A client's cervical spinal cord injury has been immobilized with cervical tongs and traction to realign the vertebrae and facilitate healing of the bone. Which clinical finding requires immediate nursing intervention?

Traction weight resting on the floor With skeletal traction, it is important that the weights hang freely - that is what actually applies the traction. The weights must not touch the floor or there would be no traction.

A nurse is caring for a school-age child who sustained a closed head injury. Which finding is an early indicator of increased intracranial pressure?

irritability Irritability would be the only early sign of increased ICP from the given answers. Bradycardia and hypertension are late signs. Glasgow coma scale of 14 would not indicate increased ICP - remember 15 is normal. 4mm and reactive pupils would be normal findings and would not be related to increased ICP.

Seizure precautions

nothing placed inside the mouth - including padded tongue blade, IV equipment is needed for medication administration, oxygen and suction equipment, padded bedrails and fall risk precautions are also needed.

Chest tube not tidaling

the tubing could be kinked or clamped, or a dependent tubing section may have become clogged with fluid buildup. Examples of this are: the drainage color changed from serous to bloody or drainage output was greater than 100 ml in one hour when the Material Protected by Copyright output was normally 10 ml in 12 hours or there is increasing bloody drainage greater than 100 ml in one hour. If there is no drainage inform the physician and anticipate an order for a chest x-ray to see if the lung has re-expanded. If it has not re-expanded, the chest tube may be displaced or it may be clogged. The physician should be notified so that the patient can be reassessed. The physician may order a CT scan of the chest to check placement or may decide to place a new chest tube. Assessing for an air leak: Clamp off suction for one minute. An air leak is present if there is constant bubbling in the water-seal chamber. An air leak alerts the nurse that he or she must assess for the location of the leak by checking the connections from the chest drainage unit to the insertion site. If there is excessive, continuous bubbling in the water-seal chamber, there is most likely a large air leak. Starting from away from the patient and going towards the patient, check all connections. Lastly, change the dressing and make sure there is good seal with the dressing around the insertion site. If it is the pleural space that is leaking, intermittent bubbling with respiration is normal. This will resolve as the lung re-expands. Therefore, when a pneumothorax is the indication for the chest tube, an air leak is to be expected; yet, should decrease with patient improvement Keep all tubing patent and free of kinks or obstructions. Dependent loops with the chest tube tubing should be avoided since they obstruct chest drainage into the collection system and increase pressure within the lung. The tubing should also never dangle; coil it on the bed and anchor tubing when securing the chest tube.

Spinal cord GI

• Chronic Constipation : T12 or higher - Decreased intestinal peristalsis, absent rectal sensation, and an increase in anal sphincter tone = constipation. • Bowel incontinence: L1 or below - Will experience loss of tone throughout colon = bowel incontinence. • GI effects of spinal shock include gastroparesis, loss of intestinal peristalsis, and ileus. Resulting abdominal distention places client at risk for vomiting and aspiration and may interfere with respiratory function. • GI ulcers: High - level SCI may interfere with recognizing GI pain = risk for gastric stress ulceration which may lead to gastric hemorrhage.