Practical Assessment #1
A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make?
"They help prevent the development of contractures."
Symptoms of shock
(opposite of Cushing's Triad) Lower BP (hypotension) Rise in pulse (tachycardia) Increased RR
patient eligibility for tPA
(profused clot buster) 3hr window after observing first symptoms -after CT scan initiated; after CT results and labs assessed
Guillain-Barre Syndrome (GBS) symptoms
*reversible demyelination of vagus nerve and facial nerve SYMPTOMS: -quick (days or hours) -ascending, bilateral paralysis -begins in lower extremities: weakness, ataxia, bilateral paresthesia progressing to paralysis -No reflexes Problems with: respiration, talking, swallowing, bowel & bladder function
Myasthenia gravis (MG) symptoms
*symptoms escalate with activity (could be different between morning and evening) facial weakness and ptosis (eyelid droop); neck weakness, limb weakness Dysarthria - (muscles that form words in mouth) Dysphagia - difficulty swallowing Flat affect Difficulty chewing Weakness in extremities Chest weakness Ptosis - lid droop Diplopia - double vision Lid twitch
TBI RN interventions
-Assume cervical spine injury until it is ruled out -Prevent secondary damage (prevent hypoxia, support respirations, prevent edema) -Respiratory support (might need ventilator) -Seizure precautions and prevention -NG tube (nasal gastric tube - to prevent aspiration or decompress stomach) -Fluid and electrolyte maintenance - encourage oral hydration; monitor urine output; daily weights, input and output -Pain and anxiety management - begin with least invasive (ice, heat, turning, distraction, re-orienting, visitors, spiritual care, 1-1 care) then pharm intervention -Nutrition - high protein for healing -maintain body temp -HOB 30 degrees, no hip flexion, no neck rotation
Hemorrhagic stroke treatment
-Bedrest/sedation -BP management -Fever management (can increase injury from stroke) -Reverse anticoagulation effects -Seizure precautions (suction at the bedside, lay on side, maintain clear airway, padding on side rail, protect head, loose clothing), antiepileptic meds -Glycemic regulation (hyperglycemic state increases hypercoagulation) -DVT prevention (blood clot in deep vein) - ambulate, compression socks, -Bedside swallow evaluation by MD -Aneurysm repair (Surgical clipping, Endovascular coiling, Stenting (mesh tubes)
Types of TBI's
-Concussion (mild TBI) -Contusion (brain bruising, location determines symptoms) -Diffuse axonal injury (tearing of connective axons in brain) -ICH (Intracerebral brain hemorrhage) : Monroe-Kellie Hypothesis -Epidural hematoma -Subdural hematoma -Intracerebral hematoma
Increased Intracranial Pressure (ICP) - body compensations
-Monro-Kellie hypothesis -Compensation to maintain a normal ICP of 10 to 20 mm Hg is normally accomplished by shifting or displacing CSF -Increased ICP causes: ischemia, cell death, (further) edema -Herniation -Autoregulation
Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome?
3 hours
Cushing's Triad
3 signs that often indicate an icrease in ICP Rise in systolic BP (Hypertension) Lower pulse (Bradychardia) Lower/irregular respiration patterns (bradypnea)
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?
30-degree head elevation
Myasthenia gravis (MG) what is it
A weakness and rapid fatigue of muscles under voluntary control. The condition is caused by a breakdown in communication between nerves and muscles. ACh runs out too quickly and muscles fatigue/lose capacity affects voluntary muscles - swallowing, facial movement, limb movement, breathing (some of the muscles) (and NOT involuntary movement - heartbeat, GI peristalsis
AD - risk factors
AGE (older than 65) family history of disease inheriting genes existing mild cognitive impairment down syndrome unhealthy lifestyle previous head trauma isolation/shut off from a community
Seizures (what it is)
Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities
HD - nursing process
Activity intolerance: Involuntary movements (pad the bed, keep skin lubricated, give them space and leave the room); never restrain someone, just try to keep them safe Oral dysphagia Self care deficit Impaired cognition Alteration in thought process Altered nutrition; less than required Increased metabolic demand Grieving Hyperthermia (because of moving constantly - higher metabolic rate)
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?
Administer corticosteroids as ordered.
Tumors - medical & surgical management
After transsphenoidal surgery: looking out for CSF Surgery Craniotomy (skull) Transsphenoidal (up through nose into the brain) surgery Radiation therapy: External-beam radiation, Brachytherapy Chemotherapy Symptomatic Treatment (making Sx less bad): Corticosteroids - decrease swelling Antiepileptic medications - prevent seizures Diuretics - decrease edema Antiemetics - prevent vomiting (to decrease ICP)
Complications of MS
Altered Balance (when sitting too) Seizure disorders Bladder/bowel dysfunction - bowel retention usually the issue Sensory disturbances Spasticity/tremors Speech impairment Fatigue - hydration, temperature control, energy-saving activities are important Heat sensitivity Dysphagia Pain - mostly musculoskeletal, but some neuropathic Vision deficits Respiratory muscle weakness= PNA (pneumonia) Insomnia Obesity Depression/Suicide
Manifestations of TBI
Altered LOC Pupillary abnormalities Sudden onset of neurologic deficits and neurologic changes; changes in sense, movement, reflexes Changes in vital signs Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety Difficulty in speaking or movement Vomiting Headache Seizures Patient should be aroused and assessed frequently
Which is a late sign of increased intracranial pressure (ICP)?
Altered respiratory patterns
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?
An area of bruising over the mastoid bone
AD - diagnosis clues
Anomia (inability to remember names of things) Apraxia (misuses of common objects) Agnosia (inability to recognize familiar objects/sesnsations) Amnesia (memory loss) Aphasia (inability to express through speech) sundowning - symptoms appear later in the day
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
If warfarin is contraindicated as a treatment for stroke, which medication is the best option?
Aspirin
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
Seizure phases
Aura Ictus - tonic, clonic Postictal
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?
Autonomic dysreflexia
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?
Basilar skull fracture
Oncologic Brain Tumors
Benign - non-threatening, non-motile Malignant - motile Both cause pressure in brain; location of tumor affects symptoms Primary tumor: grew where it's at Secondary tumor: grew somewhere else and moved Types of primary tumors Gliomas Meningiomas Acoustic neuromas Pituitary adenomas
Epidural Hematoma (what it is, signs, treatment)
Blood collection in the space between the skull and the dura Brief LOC > return of lucid state>increased ICP/sudden LOC Uncal herniation (to relieve pressure) Reduce ICP via Burr holes, Craniotomy, Remove clot and stop bleeding, Drain insertion
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
Body temperature
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?
Body temperature
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.
Bradycardia Hypertension Bradypnea
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
Burr holes
At which of the following spinal cord injury levels does the patient have full head and neck control?
C5
Hemorrhagic stroke (what it is)
Caused by bleeding into the brain; 13% of stroke incidents; Monroe-Kellie Hypothesis (other materials have to go somewhere, leading to increased pressure, herniation, or loss of CSF); higher mortality rate, slower recovery rate Subarachnoid (SAH) - bleeding in the space that surrounds brain Intracerebral (ICH) - within tissue of the brain Intraventricular (IVH) - inside the ventricle; most fatal
MG crisis - cause and treatment
Causes of MG crisis: Aspiration Sepsis Surgery Tapering of medication Pregnancy Certain medications COVID-19 Treatment Mestinon - anticholinesterase Corticosteroids - suppress immune system Cytotoxic meds - suppress immune system Plasmaphoresis - take out plasma, clean it, then put it back in (takes 1-3 hrs every other day, only lasts a month or so) IVIG - IV immunoglobulins - crisis situation only Avoid BB (Beta blockers), CCB (calcium channel blockers), and statins No live vaccines Thymectomy - procedure to remove thymus gland (signals break down of ACh)
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment.
HD - symptoms
Cognitive decline (changes in behavior, apathy, anxiety, psychosis) , mood swings, involuntary movements, hallucinations, speech difficulties, behavioral & personality changes, "dance like" movements
Subdural Hematoma (what it is, signs, treatment)
Collection of blood between the dura and the brain; can happen over a long period of time (with small changes in symptoms) -Acute -Subacute (Requires immediate craniotomy and control of ICP) -Chronic (Older adults at risk)
Postictal phase symptoms/assessment
Confusion Sleepiness Weakness Muscle soreness H/A N/V (nausea / vomiting) Todd's Paralysis - temporary paralysis are seizure Evaluate motor strength Assess speech, memory and orientation
Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?
Controlling seizures and increased intracranial pressure
A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?
Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
Types of intracranial surgery
Craniotomy - incision into the skull Craniectomy - the surgical removal of a portion of the skull Burr holes - drill into the skull to relieve pressure or to remove hematomas EVD - external ventricular drain
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?
Damage to the optic nerve
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Decorticate
Intracranial surgery postoperative care (aims)
Detecting and reducing cerebral edema Relieving pain Preventing seizures Monitoring ICP and neurologic status Improve gas exchange Sensory deprivation Enhance Self-image Fall prevention
Multiple sclerosis (MS)
Diplopia, fatigue, muscle spasticity, numbness, walking problems (most frequent) also - bladder and bowel dysfunction, depression, vision problems, vertigo, cognitive symptoms, pain
A patient has been diagnosed with myasthenia gravis. The nurse documents the initial and most common manifestation of:
Diplopia.
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?
Drooping eyelids
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Elevating the head of the bed to 30 degrees
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? Oliguria and serum hyperosmolarity Oliguria and decreased urine osmolality Excessive urine output and decreased urine osmolality Excessive urine output and serum hypo-osmolarity
Excessive urine output and decreased urine osmolality
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.
Eye opening Verbal response Motor response
Hemorrhagic stroke manifestations
FOCAL DEFICITS ARE THE SAME AS ISCHEMIC STROKE AND MAY ALSO INCLUDE: RAPID DEVELOPMENT OF SX (MINUTES-HOURS) NO PRECEDING TIA SEVERE H/A (40%) N/V (45%) ALTERED MENTAL STATUS (50%) SEIZURES (7%) SENSITIVITY TO LIGHT NECK STIFFNESS STUPOR, RIGIDITY, AND COMA
ALS symptoms
Fatigue Progressive muscle weakness Cramps Twitching Lack of coordination Spasticity Restricted breathing, SOB Impaired Swallowing & Talking Urine and bowel control remain intact
Interventions for increased ICP
Frequent neurological assessments; Head in neutral position; Monitor fluid status; Aseptic technique; Monitor for CSF leak; Absolute bed rest; Elevate HOB 30 degrees; Avoid all activity that may increase ICP or BP; Valsalva maneuver Acute flexion or rotation of neck or head Exhale through mouth when voiding or defecating to decrease strain Nurse provides all personal care and hygiene Nonstimulating, nonstressful environment; dim lighting, no reading, no TV, no radio Prevent constipation Visitors are restricted
TBI Assessments
Glasgow Coma Scale - first injury assessment Rancho Los Amigos: rehab/recovery phase
While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?
Grade 3 concussion A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes
Traumatic Brain Injury (cause / prevention)
Head Injury: A broad classification that includes injury to the scalp, skull, or brain TBI is most common cause of death from trauma primary prevention: helmet Primary brain injury: (what caused the injury) gunshot wound, vehicle crash, ski accident Secondary injury: something that happens after, as a result of the injury/event (ie hypoxia) *care goal is to prevent secondary injury
Stroke diagnoses - nursing process
Impaired physical mobility impaired swallowing acute pain self-care defecits disturbed sensory perception impaired verbal communication disturbed thought processes urinary incontinence risk for impaired skin integrity interrupted family processes sexual dysfunction
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?
Increased ICP is 12 mm Hg.
Diagnosis for ICP: Nursing Process
Ineffective airway clearance Ineffective breathing pattern Ineffective cerebral perfusion Deficient fluid volume related to fluid restriction Risk for infection related to ICP monitoring
Infarct core vs. penumbra
Infarct core: where the infarct is happening; loss of brain cells Penumbra: area around the core that has the potential for being saved
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?
Insertion of a nasogastric (NG) tube
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Intracranial hemorrhage Age 18 years or older Ischemic stroke Systolic blood pressure less than or equal to 185 mm Hg
Intracranial hemorrhage
A patient is scheduled for a carotid endarterectomy. The nurse explains to the patient that this surgery.
Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?
It allows for stabilization of the cervical spine along with early ambulation.
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? Keep the head of the client's bed flat. Keep the client's neck in a neutral position (no flexing). Cluster all procedures together. Avoid sedation.
Keep the client's neck in a neutral position (no flexing).
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? Maintaining the client in a quiet environment Positioning the client to prevent airway obstruction Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess Keeping the client in one position to decrease bleeding
Keeping the client in one position to decrease bleeding
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
Lack of deep tendon reflexes
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume
A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?
Maintain a diet for the client that is high in protein, vitamins, and calories.
Nursing intervtions: decreased LOC
Maintain airway Safety Hydration Mouth Care Skin integrity Bowel & Bladder Sensory Stimuli
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?
Maintain cerebral perfusion pressure from 50 to 70 mm Hg
head injury manifestations
Manifestations depend on the severity/location of injury Scalp wounds usually just need suture Basilar fracture: Racoon eyes Bleeding from nose pharynx or ears CSF otorrhoea CSF rhinorrhea Halo sign (CSF ring around blood part) Battle's Sign (bruising behind the ear)
The most frequently administered hyperosmotic agent used to reduce cerebral edema before intracranial surgery is
Mannitol
Seizure treatment options
Medication Surgery Deep brain stimulation Dietary therapy
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
Midbrain
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Monitoring the patency of an indwelling urinary catheter Placing the client in Trendelenburg's position Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered
Monitoring the patency of an indwelling urinary catheter
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?
More than 200 mL/h
A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?
Neck flexion produces flexion of knees and hips
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
Neurologic examination
Hemorrhagic stoke risk factors
Non Modifiable older Age Gender-Male Race- African American, Asian, Hispanic Genetics Modifiable HTN (#1 risk factor for ischemic too) ETOH Oral anticoagulant use Illicit drug use Reperfusion syndrome (after lower oxygen to the brain, we reperfuse to the brain and then the body shuts down) Smoking Hypercholesterolemia
Ischemic stroke risk factors
Nonmodifiable risk factors: Age (older than 55 years) (Women: 35-44, after 85) Gender -Male Race -African American Family History Hypertension is the primary risk factor (for hemorrhagic stroke too) Cigarette/vape use DM - diabetes mellitus type 1 or 2; problem is hyperglycemia Dyslipidemia (high cholesterol) - more likely to get caught and cause obstruction A-fib CAD - coronary artery disease Postmenopausal hormone therapy (given estrogen); higher levels of estrogen combined with tobacco use creates hypercoagulative state Use of OC - oral contraceptives ^ same reason as above Diet - high fat/sodium diet Inactivity - risk factor for obesity Obesity - risk factor for stroke Migraine - people with migraines have higher rates of stroke (screening tactic)
ICP Assessment: Nursing process
Obtain history of events leading to illness Evaluate mental status, LOC Assessment of selected cranial nerves Assess cerebellar function, reflexes, motor and sensory function Glasgow Coma Scale, pupil checks Frequent vital signs Assessment of intracranial pressure
The most common cause of cholinergic crisis includes which of the following?
Overmedication
Paraplegia vs Tetraplegia
Paraplegia - full or partial paralysis of the lower half of the body; results from injuries lower on the spine Quadriplegia aka Tetraplegia - loss of function, can be a mix, doesn't mean total paralysis; paralysis of both legs and both arms, results from injuries higher on the spine
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
Paresthesia
PD - med treatment
Pharmacological Treatment Precursor, Sinemet (levadopa, carbadopa) to ensure dopamine metabolizes in brain Antiviral, Amantadine - increases dopamine production Dopamine agonist, Promipexole COMT Inhibitor, Comtan/Tasmar - prevents breakdown of dopamine MAOI, Selegilene - increases levels of dopamine and serotonin
Which of the following drugs may be used after a seizure to maintain a seizure-free state? Cerebyx Phenobarbital Valium Ativan
Phenobarbital
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? Positive Kernig's sign Negative Brudzinski's sign Positive Romberg sign Hyper-alertness
Positive Kernig's sign
autonomic dysreflexia
Possible restrictive factors: full bladder, tight clothing, trauma, skin integrity, full bowel, 85% of autonomy dysreflexia is from urinary retention (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
Ischemic stroke manifestations
Preceding TIA (15% of strokes)) transient ischemic attack (no permanent damage); can be subacute (slow onset); common symptoms: Contralateral weakness (blockage on one side of the brain, weakness felt on the other), sensory loss Change in LOC or mental status Visual changes Functional deficits (can't perform daily tasks)
chronic vs. acute subdural hematoma
Prior head trauma can lead to the development of a chronic subdural hematoma, which presents with symptoms such as severe headache, mental deterioration, focal neurologic changes, personality changes, and/or symptoms that the client is having a stroke. There is no indication that the client had follow-up imaging based on the prior head trauma, which should be included in protocol management of head injuries. Because the head trauma occurred a few months ago, an acute finding would have presented earlier, at the time of injury. The differential diagnosis of chronic subdural hematoma includes a stroke but there is insufficient clinical evidence to support this finding.
How does exercise help reduce hypertension?
Promotes vasodilation; promotes weight loss
A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time?
Propofol (Diprivan)
The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?
Psychosis, disorientation, delirium, insomnia, and hallucinations
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?
Raise the head of the bed and place the patient in a sitting position.
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?
Rebound hypotension
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?
Respiratory
Complications: decreased LOC
Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Deep vein thrombosis (DVT) Contractures
Early Manifestations of Increased ICP
Restlessness, confusion, drowsiness Pupillary changes and impaired ocular movements Weakness Headache
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Risk for injury related to neurologic deficit
ALS - nursing process
Risk for injury secondary to immobility impaired verbal communication alteration in comfort risk for altered skin integrity risk for dehydration secondary to dysphagia ineffective coping strategies impaired gas exchange secondary to ineffective airway clearance (impaired swallowing & gag reflex, absent cough)
Spinal cord injury complications
SPINAL SHOCK - Loss of reflexes; Transient; when they come back they're hyper reactive NEUROGENIC/VASOGENIC SHOCK - Loss of vascular tone (ability of blood vessels to constrict - when lost, means hypotension) Loss of nervous system response THROMBOEMBOLISM (blood clots) - DVT PE pulmonary embolism
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
Severe TBI.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity
The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke? Aphasia Altered intellectual ability Slow, cautious behavior Spatial-perceptual deficits
Spatial-perceptual deficits
Hemorrhagic stroke causes
Spontaneous rupture-HTN (anantomy-wise, everything is normal; but maybe high BP created rupture) Ruptured aneurysm - Amyloid angiopathy - deposits of proteins that happen in cerebral artery and makes it very fragile and likely to bleed AVMs - arteriovenous malformation Medications, anticoagulants
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
Suction the airway.
Brain tumor manifestations
Sx depend on location & size Increased ICP (seizures, HA Sx) Hydrocephalus (fluid swelling in brain ventricles) Pituitary dysfunction Frontal lobe - cognition, personality changes Parietal lobe - sensation changes contralaterally Temporal - more seizures Occipital - vision changes; hemionopsia, hallucinations Cerebellar - ataxia, gait disturbances, nystagmus Brain stem - all cranial nerves innervate here -very serious spot
Right hemisphere brain stroke
Symptoms: Possible paralysis on the left side of the body Vision problems Quick, overly curious behavior Poor decision making Facial weakness or problems swallowing Memory loss The Right Brain Controls: Movement on the left side of the body Art awareness Imagination Intuition Insight Holistic thought Music awareness Spatial recognition
Left hemisphere brain stroke
Symptoms: Possible paralysis on the right side of the body Speech/language problems Slow, cautious behavior Impairment of organizational abilities Facial weakness or problems with swallowing Memory loss Left brain controls: Movement on the right side of the body Critical thinking Logic & reasoning Language Science and math Writing
T/F: During assessment of an unconscious patient, the nurse notes "fixed, dilated pupils" and understands that brain injury is at the level of the midbrain.
TRUE
T/F: The earliest sign of increasing ICP is a change in LOC.
TRUE
T/F: The first treatment priority for a patient with an altered level of consciousness is to obtain and maintain a patent airway.
TRUE
Home instructions post seizure
Take medications correctly Get enough sleep Take care near water Wear a helmet Take showers instead of baths No driving Pad furniture Avoid stimulants
The neurologic functions that are affected by a stroke are primarily r/t (related to)? a. The amount of tissue area involved b. The rapidity of the onset of symptoms c. The brain area perfused by the effected artery d. The presence or absence of collateral circulation
The brain area perfused by the effected artery (important to know which artery it is)
Cushing's Triad
The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke
The Monro-Kellie hypothesis refers to which of the following? -A condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function -The dynamic equilibrium of cranial contents -The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure -Unresponsiveness to the environment
The dynamic equilibrium of cranial contents
Alzheimer's Disease (AD) - what it is
The most common cause of dementia; Progressive brain cell death in brain - shrinkage of cerebral cortex, shrinkage of hippocampus, enlarged ventricles, Tau neurofibrillary tangles Treatment Goals: (not curative) Slow progression Provide safe environment
A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?
The patient will be able to ambulate independently.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Traction with weights and pulleys
Huntington's Disease (HD) - what it is
Transmitted as an autosomal dominant trait Genetically linked disease; chromosomal defect Disease of the basal ganglia (which starts and stops movements, and regulates emotion) Onset 35-45 y/o Mortality 10-20 yrs after symptom onset
Guillain-Barre Syndrome (GBS) treatment / nursing process
Treatment: IV immunoglobulin (trying to stop the body from injuring itself further) with intensive monitoring - needs to happen quickly to stop symptoms and begin reversing them RN intervention: ineffective breathing patterns, may need ventilator; impaired urinary elimination; anxiety & risk for altered family roles; risk for altered skin integrity; impaired physical mobility that can lead to skin breakdown, pneumonia, contractions
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?
Vasopressin
A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?
Verapamil (Calan)
A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?
When symptoms cease, the client will return to presymptomatic state.
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure
Which are risk factors for spinal cord injury (SCI)? Select all that apply.
Young age Alcohol use Drug abuse
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:
a positive edrophonium (Tensilon) test.
hemianopsia
additional stroke deficit; loss of half of vision
amyotrophic lateral sclerosis (ALS)
aka Lou Gherig's disease degenerative disorder of motor neurons in the spinal cord and brainstem Loss of upper and lower motor neurons cause progressive weakness and atrophy of the muscles of the extremities and trunk
Acute treatment for ischemic stroke
allow induced HTN (to increase blood flow to brain, want to perfuse brain in the presence of clots) Statins - to lower cholesterol; platelet inhibitors - prevent other clots from forming (ASA, Plavix) Anticoagulants - blood thinners (Coumadin, xarelto) Thrombolytic therapy (tPA) - within 3 hours of symptoms Thrombectomy - removal of thrombus from large vessel (MCA, PCA, ACA) Craniectomy
Cheyne-Stokes respiration
an irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or apnea
Warfarin (Coumadin) - EPA
anticoagulant ; vitamin K antagonist - inhibit clotting factors can help prevent a blood clot from forming in blood vessels, or can help an existing clot from getting bigger / breaking off into circulation used for long-term anticoagulation ; preventing or treating blood clots (venous thromboembolism, DVT
ICP: signs and symptoms
changes in LOC, eyes (paapilledema, pupillary changed, impaired eye movement), posutring (decerebrate, decorticate, falccid), decreased motor function, headache, seizures, changes in vital signs (Cushing's tria), vomiting, changes in speech
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?
concussion
Types of spinal cord injuries
concussion, contusion, laceration, compression, severing hyperextension, penetration injury distraction (cord pulling away from spine)
Seizures signs and symptoms
confusion, aura, sudden falls, staring, uncontrollable jerking movements, strange sensations and meotions, loss of consciousness or awareness
AD - nursing process
consider quality of life; functional impairment; altered urinary/bowel elimination, disturbed sleep pattern, self-care deficit, impaired social interaction, imbalanced nutrition, risk for fall
Multiple sclerosis (MS) what's happening
degenerative disease that attacks the CNS; affects motor neuron pathway and the cortical track myelin sheath is stripped away (demyelinated) from CNS, leading to plaques & immunoglobulin clustering in patterns
dysarthria
difficulty forming words due to muscles; addityional stroke defecit
dysphagia
difficulty swallowing due to muscle control; additional stroke defecit
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
diplopia
double vision; additional stroke defecit
Ischemic injury: factors for progression
duration of ischemia period, rate of development, collateral circulation (more circulation, less injury), systemic circulation (blood pressure needs to be stabilized), coagulation, body temperature (elevated increases progression), glucose (hyper and hypo both increase progression)
Monro-Kellie hypothesis
dynamic equilibrium of brain/skull elements theory that states that due to limited space for expansion within the skull, an increase in any one of the cranial contents—brain tissue, blood, or cerebrospinal fluid—causes a change in the volume of the others; also referred to as Monro-Kellie doctrine
Types of MS spams
extensor spasms - hyperactive reflexes Clonus - consistent shakin in hand flexor spams - lifting knee up in seated positions stiffness in joints
Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:
famotidine (Pepcid).
Parkinson's disease - what it is
gradual loss of parts of basal ganglia - area that produces dopamine; a chemical transmitter that signals connections between different parts of brain to coordinate body movement
A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?
headache and hypertension related to spinal chord; injury above T6 is higher risk for autonomic dysreflexia
Multiple sclerosis (MS) risk factors
higher in women than men; no specific genetic link but there is a familial link; vitamin D deficiency, colder climates, smoking, caucasian, younger females between 20-40
Puritis
intense itching
Cryptogenic
ischemic stroke of unknown causes
Cardiogenic
ischemic stroke type ; clot came from the heart and travelled to the brain
Embolic stroke
ischemic stroke type; blood clot that started somewhere else and travelled up to the brain
thrombotic stroke
ischemic stroke; blood clot formed in the artery where it occurred
Most common sites for pressure ulcers
ischial tuberosity, greater trochanter, sacrum, occiput
sympathetic storming
low level glasgow scoring (below 8) is high risk for storming -- sympathetic nervous system is overreacting ; vasoconstriction everywhere, hyperthermia, tachycardia, tachypnea, sweating and agitation What can we do? scheduled beta blockers - lower HR and reduce hypertension morphine - relief during sympathetic storming antidiuretic (fluid conservation) cold washcloth/compress
PD - nursing management
medication therapy, deep brain stimulation (surgery, pacemaker like devise), rehabilitation, client & family education, warm baths and massage to relax muscles, bowel routine, self-help devices to help daily needs, exercise to loosen joint structure, range-of-motion exercises to prevent deformities
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise.
Warfarin (Coumadin) - RN monitoring
monitor for bleeding in unusual places (dark stool, blood oozing at gums, pink urine, bruising for no cause, nosebleeds, tachycardia and hypotension, severe headache) NOT for patients who have active bleeding, surgery, renal or liver failure *has a very narrow therapeutic range No OTC supplements without MD discussion (aspirin, NSAIDS) No alcohol
MI
myocardial infarction / heart attack
stenosis
narrowing (specifically for blood flow)
ALS treatment
no cure; focus on improving life expectancy via medication, noninvasive ventilation, percutaneous endoscopic gastronomy
Seizure precautions
oxygen and suction apparatus available; pillow under head; bed in lowest position; patient in side-lying position; loosened clothing; 2-3 side rails up and padded
Risk of hemorrhagic transformation (from ischemic event)
patient on blood thinner has higher risk for hemorrhagic transformation; Advancing age Stroke severity History of diabetes Hypertension History of hyperlipidemia (increased weight, high cholesterol) History of heart failure Increased weight
Trendelenburg
positioned with head down and feet elevated
GBS risk factors
possibly autoimmune related; association with immunizations; frequently preceded by mild respiratory or intestinal infection
Bleed precautions for patient on bloodthinners
prevent injury indoors (no toothpicks, caution using knives, fall risk), prevent injury outdoors: always wear shoes, gloves, etc.) Call doctor if: there is unexplained / spontaneous bruising, can't stop profuse blood in stools or dark stools; abnormal urine color, blood nose that doesn't stop
Coma signs
pupils fixed, no reflexes, non verbal, absent tracking, absent swallow reflex, flaccid
Depressed Neuro Status signs
pupils sluggish; restless/anxiety, slurred speech, extraocular movement, drooling, posturing
DECORTECATION
refers to abnormal flexion of the upper extremities and extension of the lower extremities as neurologic function deteriorates and the patient becomes comatose.
AUTOREGULATION
refers to the brain's ability to change the diameter of blood vessels to maintain cerebral blood flow.
PD - symptoms
resting tremors, pill rolling tremors, muscle rigidity, slowness of movement and difficulty initiating movement (bradykinesia or akinesia), jerky cog wheel movement, gait and postural disturbances, shuffling, dysarthria (slurred/slow speech), difficulty swallowing, micrographia, mask-like facial expression, 40% develop cognitive impairments
Which are characteristics of autonomic dysreflexia?
severe hypertension, slow heart rate, pounding headache, sweating
Autonomic Dysreflexia
spinal cord injury complication Symptoms: Severe headache, HTN, diaphoresis, nausea, nasal congestion, decreased HR When spinal cord is at T-6 or higher - and stimuli sustained at T-6 or below --> VASODILATION ABOVE (parasympathetic response) and VASOCONSTRICTION (sympathetic response) BELOW -- cool, pale, no sweating Example stimuli: restrictive clothing, pressure areas, full bladder or UTI, fecal impaction Intervention: sit up patient to lower BP, check for triggers/cause, give vasodilaters
apraxia
staggered coordinated movements; additional stroke defecit
Types of MS and symptom exacerbation factors
stress, changes in weather, alcohol use, smoking, physiological stress (sickness / infection) can all exacerbate symptoms
Stroke (what it is, types)
sudden loss of function/disruption of blood supply to the brain Types: Ischemic (87%) clot causing embolic stroke; plaque causing thrombotic stoke Hemorrhagic (13%) - aneurysm causing subarachnoid hemorrhage; torn artery causing intracerebral hemorrhage
agnosia
the inability to recognize familiar objects; additional stroke defecit
Spinal cord injury
the type of paralysis is determined by the level of the vertebra closest to the injury Risk factors are age (15-35), male (80%), alcohol use, drug use Immediate focus: Stabilize cervical spine - because it controls your respiratory muscles and keeps you alive; C4 and above are respiratory muscles
TIA
transient ischemic attack - will lead to ischemic stroke if not treated what to advise: reduce stress, no sharp movements, administer antihypertensives, provide supplemental oxygen is O2 levels are dropping
Small penetrating artery thrombosis
type of ischemic stroke (Lacunar)
Large vessel occlusion
type of ischemic stroke (MCA/PCA/ACA)
Systemic hypoperfusion
type of ischemic stroke; not enough oxygen to the brain, not from a clot (due to respiratory failure, hypotension,
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client
vomits