Final Exam (Units 13-14)
Two procedures to perform to diagnose Meningitis
Kernig's Sign: knee flex, knee cannot fully extend Brudzinski's Neck Sign: passive flexion of neck causes flexion of both legs and thighs
Treatment for Partial seizures
Neurotonin (Gabapentin), may cause CNS depression
What is a priority nursing assessment in the first 24 hours after admission of a client with a thrombotic stroke? 1. Cholesterol level 2. Pupil size and papillary response 3. Bowel sounds 4. Echocardiogram
Pupil size and papillary response
The nurse is teaching the family of a client with dysphagia from a CVA about decreasing the risk of aspiration while eating. Which of the following strategies is inappropriate? A. Maintaining an upright position B. Restricting the diet to liquids until swallowing improves C. Introducing foods on the unaffected side of the mouth D. Keep distractions to a minimum
Restricting the diet to liquids until swallowing improves
Joint Stiffness; atrophy
Will have to consider PT
Hemorrhagic Stroke (17%)
caused by a rupture of a cerebral blood vessel and is not related to a TIA Causes: HTN, aneurysm
The concern with a seizure lasting longer than 5 min?
life threatening and will require immediate medications to stop seizures
NIH Stroke Scale
low number is a good outcome
Loose Cast
not able to hold fracture securely, replace and reduce swelling before application of cast
Signs and Symptoms of a Fat Emboli
usually present 24 to 72 hours after initial injury, but it may be up to 2 weeks long for a long bone injury or pelvis or major trauma. respiratory changes, neurological abnormalities (mild confusion, drowsy), petechial rash: due to embolization of small dermal capillaries.
Febrile Seizures
very common, 3months to 5 years of age
Communicated Fracture
which the bone has splintered into several fragments
Mrs. Edna Cowan has had a CVA affecting the right side of her body. Before initiating oral feeding for the first time for Mrs. Cowan, which nursing action is most important? A. Position Mrs. Cowan in an upright position. B. Assess Mrs. Cowan for the presence of a gag reflex. C. Assess Mrs. Cowan's ability to swallow ice chips or water before offering food D. Suction Mrs. Cowan's oral cavity to prevent aspiration of secretions
Assess Mrs. Cowan for the presence of a gag reflex
What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably
Assess the client's breathing pattern
A client is experiencing mood swings after a stroke (brain cell injury related) and often has episodes of tearfulness, which are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? A. Sit quietly with the client until the episode is over B. Ignore the behavior C. Attempt to divert the client's attention D. Tell the client that this behavior is unacceptable
Attempt to divert the client's attention
Be Fast Test
Balance Eyes Face Arms Speech Time: to act
Treatment For Status Epilepticus
Benzodiazepines such as Valium or Lorazepam used IV, dilantin for long term control.
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature
Blood pressure
What can be used to diagnose CVA
CT head scan
Tight Cast can cause what?
Compartment Syndrome
What is the expected outcome of thrombolytic drug therapy (fibrinolytic therapy- tPA) for stroke? 1. Increased vascular permeability 2. Vasoconstriction 3. Dissolved emboli 4. Prevention of hemorrhage
Dissolved emboli
What can be used to diagnose seizures?
Electroencephalogram (EEG)
When communicating with a client who has aphasia following a stroke, which of the following nursing interventions is inappropriate? 1. Present one thought at a time 2. Encourage the client NOT to write messages 3. Speak with normal volume 4. Make use of gestures
Encourage the client not to write messages
A female client presents to the emergency department diagnosed with a stroke. Which of the client's current medication regimen is a risk factor for developing a stroke? A.Propranolol (lnderal) a beta blocker B.Furosemide (Lasix) a loop diuretic C. Estradiol/norgestimate (Ortho-Cyclen), acombination hormone of estrogen & progesteronecompounds D.Metformin (Glucophage) - a biguanide
Estradiol/norgestimate (Ortho-Cyclen), acombination hormone of estrogen & progesteronecompounds
An 87-year-old client is admitted with a stroke. During the admission interview and assessment, his speech is slow, non-fluent, and labored. How should the nurse document this finding? A. Receptive aphasia B. Wernicke's aphasia C. Expressive aphasia D. Global aphasia
Expressive Aphasia
FASTER
Face Arms Stability Talking Eyes React
A 79-year-old woman with a recent hip fracture is demonstrating signs of confusion, respiratory distress, and tachycardia. What complication might the nurse suspect? A. Infection B. Petechiae C. Fat emboli D. Deep vein thrombosis
Fat emboli
Hemorrhagic Stroke Signs and Symptoms
HA, vertigo, syncope, paresthesia, epistaxis, retinal hemorrhages
The nurse assesses a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity? A. Decreased distal pulse B. Inability to move C. Diminished capillary refill D. Coolness to the touch
Inability to move
The client's family asked the nurse, "What is the definition of a cerebrovascular accident?" How should the nurse describe this? A. It is a sudden change in the blood pressure, resulting in damage to the brain. B. It is a disruption in the normal blood supply to the brain, producing focal neurologic deficits. C. It is fluctuations in blood flow, leading to dizziness and subsequent falls. D. It is increased blood flow, resulting in hemorrhage and subsequent tissue damage.
It is a disruption in the normal blood supply to the brain, producing focal neurological deficits
Generalized/Both sides of brain Tonic-Clonic (grand mal) Seizures Signs and Symptoms
LOC changes, drop to the ground, stiffness, jerking
Which of the following might the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure (grand mal)? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abruptly ceasing all activity C. Facial Grimaces, patting motions, and lip smacking D. Loss of consciousness, body stiffening, and violent muscle contractions
Loss of consciousness, body stiffening, and violent muscle contractions
The nurse assesses the client who has suffered a CVA. The client speaks easily, but the phrases have little meaning. The nurse determines the client has: A. Expressive aphasia (Broca's) B. Receptive aphasia (Wernicke's) C. Dysarthria. D. Amnesic aphasia.
Receptive Aphasia (Wernicke's)
Wernicke's Aphasia
Receptive Aphasia, fluent, spontaneous speech, no comprehension, patient is unaware, no meaning to speech or written word, difficulty with choice of words
Absence Seizure Signs and Symptoms
Staring into space, blank stare, unresponsive, eyes may roll
When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: A. Physical dependency on the drug develops overtime B. Status epilepticus may develop C. A hypoglycemic reaction develops D. A heart block is likely to develop
Status epilepticus may develop
When a client is admitted to the hospital in an unconscious state following a subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm, the nurse anticipates the manifestations preceding the loss of consciousness were: A. Generalized weakness and fatigue accompanied by anorexia B. Gradual loss of speech or vision C. Sudden severe headache accompanied by vomiting D.Weakness, fever, nausea, and vomiting
Sudden severe headache accompanied by vomiting
Transient ischemic attacks are: A. Temporary episodes of neurologic dysfunction. B. Periods of alternating exacerbations and remissions of neurologic disease. C. Attacks that are caused by multiple small emboli. D. Ischemic attacks which result in progressive neurologic deterioration.
Temporary episodes of neurologic dysfunction
A client arrives in the emergency department with an ischemic stroke and receives recombinant tissue plasminogen activator alteplase (t-PA) administration. Which is the priority nursing assessment? A. Current medications B. Complete physical and history C. Time of onset of current stroke symptoms D. Upcoming surgical procedures
Time of onset of current stroke symptoms
General Cast Care
Turn the patient every 1-2 hours while cast is drying, may feel hot for 10-30 minutes, keep the limb elevated, ice as ordered, assess CMS (circulation-pulses, color, temp, cap refill Motion and weakness, Sensitivity (numbness, tingling) For itching: never put anything in the cast, try a blow dryer on cool air or ice to help, may lotion the skin around the cast but not in the cast, if at home call MD or go to the ER immediately for white, cold limb, or extreme unrelieved pain
RICE
Used to treat fractures, sprains, bruises, muscle strains, soreness, injuries, bleeding, etc. Rest Ice; first 24-48 then heat Compression; apply pressure Elevate: higher than heart to reduce swellling
Situation: Ms. Margaret Baird is a 78-year-old widow who has a brain tumor. Her history reveals headaches for the past several months.Her daughter reports she has also had personality changes. She was admitted to the hospital for further evaluation and surgical removal of the tumor. After surgery to remove the brain tumor, the nurse established a nursing diagnosis of potential complication for increased intracranial pressure. An appropriate intervention is to position Ms. Baird _____. A. Recumbent, with extremities restrained. B. With the head of the bed elevated 30 degrees. C. On her left side, with her neck flexed. D. On her right side, with her neck extended.
With the head of the bed elevated 30 degrees
What is used to treat absence seizures?
Zarontin (ethosuzimide)
If a patient has Allergic Dermatitis, what cast should they have?
a fiberglass cast
Open/Compound Fracture
a fracture in which damage also involves the skin or mucous membranes. Puts patients at a higher risk for osteomyelitis
Internal Fixation
a fracture treatment in which a plate or pins are placed directly into the bone to hold the broken pieces in place
External Fixation
a fracture treatment procedure in which pins are placed through the soft tissues and bone so that an external appliance can be used to hold the pieces of bone firmly in place during healing
Decerabrate Posturing
abnormal posture with the neck extended, the jaw clenched, arms pronated, extended and close to the sides, legs extended and feet plantar flexed with adduction and rigid extension of upper and lower extremities.
Decorticate Posturing
abnormal posture with the upper arms close to the sides, the elbows, wrists and fingers flexed, the legs are extended and internally rotated and the feet plantar with upper extremity flexion
Partial Simple- Focal Seizure
affects only a small region of the brain; speech affected here
Growing Pains
are normal, skeletal muscles attach to bones via tendons and pull with bone growth causing pain
Early Response to an altered ICP
bradycardia, bradypnea, hypertension, Cerebral Perfusion Pressure (CPP) which is the difference in MAP and the ICP
Transient Ischemic Attack (TIA)
can be referred to as a mini stroke or a warning stroke, symptoms will resolve within 24 hours to be classified in this category
Tonic Phase
consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20-30 seconds.
Common Triggers of Seizures
constipation, stress, flashing or bright lights, fatigue, alcohol, drugs, hormones, low blood sugar, fever/heat, early waking state, hyperventilation
Events that Briefly increase ICP
coughing, sneezing, vomiting, straining for BM, rectal digital stimulation, vagus nerve stimulation
Non-Healing Union
does not form a bone callous like needed
Daily Pin Care on External Fixation
done per facility protocol, may include cleaning around the pin site with normal saline, half-strength betadine, or alcohol, often an order to apply antibiotic ointment daily. THERE IS AN INCREASED RISK FOR INFECTIONS
Treatment for tonic-clonic
drug of choice is dilantin (phenytoin), not IV, most widely used Long Term: excessive growth of gum tissue, very common, don't take with dairy products, increase Vitamin D intake, shake if liquid form
Epileptic and One time Seizure
electrolytes, head injury, low blood sugar, etc.
Broca's Aphasia
expressive aphasia which is slow non-fluent, labored, difficulty with articulation of words, comprehends, obeys commands, aware of deficits, frustrated
Communicating with the Patient with Aphasia
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 the time to understand what is being said, limit conversation to practical and concrete matters, use gestures, pictures, object, and writing.
Signs and Symptoms of Meningitis
fever, HA, stiff neck, N/V, photophobia, AMS
In Status Epilepticus what should you give as an addition to a benzodiazepine?
give 50% dextrose to prevent hypoglycemia
What is the epiphyseal plate?
growth plate
What do you always want to have with a seizure patient?
have IV access always as a precaution
Late Response to an altered ICP
increase in systolic BP and a widened pulse pressure, bradycardia, irregular respirations
Meningitis
inflammation of the meninges.
Clonic Phase
involves repetitive movements and the seizure ends with confusion, drowsiness and resumption of respirations
Phenobarbital
is a CNS depressant, but is the safest form of long term anticonvulsant therapy. Tegretol (carbamazepine) use when other meds don't work
Recombinant Tissue Plasminogen Activator (tPA)
it is used to dissolve the clot formed in a thrombotic stoke/ischemic stroke. Dissolving the clot reestablishes the cerebral circulation. The treatment can only be used if the symptoms have occurred within the last 3 hours AE: bleeding
Non-Pharmacological Treatment of Seizures
ketogenic diet, high fat and moderate protein, low carb (renal calculi complication in 5%), brain surgery, vagus nerve stimulation.
Plaster Cast Care
leave uncovered and exposed to air to dry, it takes 24-72 hours to completely dry (depends on size and thickness), don't let it get wet after it dries.
What should be avoided to avoid aspiration?
liquids that are not thickened.
Airway Maintenance for someone having a Seizure
loosen clothing around the neck or chest, never force anything in the mouth, suction as needed, place in recovery position/side.
Driving Precautions with seizures
may not drive after a seizure for a certain period of time after (can be 6mo to a 1 year depending on state)
One or More TIA's
may precede a stroke, with the time between the attack and the stroke ranging from hours to months, the average time for one is 1-5 minutes that does not cause permanent damage.
Greenstick Fracture
more likely in kids because kids bones are bendy and it only breaks on one side.
Etiology of Seizures
most are idiopathic, no known cause, children may outgrow them.
Strategies for a patient with Epilepsy
never discontinue medications, keep a medication and seizure record, have medication serum levels checked regularly, avoid activities that require coordination until the effects of the mediation have been evaluated, report signs of toxicity, carry a medical alert bracelet, report signs of toxicity, avoid seizure triggers, take showers rather than tub, avoid excessive heat, minimize fatigue and insomnia
Partial Seizure
one half of the brain; can spread to other side
Pressure Sores
pad all bony prominences areas before applying the cast
Left Hemispheric Stroke
paralysis or weakness on right side of the body, right visual field deficit, aphasia (expressive, receptive, or global), altered intellectual ability, slow, cautious behavior
Right Hemispheric Stroke
paralysis or weakness on the left side of the body, left visual field deficit, spatial-perceptual deficits, increased distractibility, impulsive behavior and poor judgement, lack of awareness of deficits.
Protection during a Seizure
privacy, safety, never restrict movement, positioning for airway, reorient, reassure, comfort, give anticonvulsant meds (IV preferred), pad headboard, side rails if patient has a known seizure disorder.
Meninges
protective membranes covering the brain and spinal cord
Nursing Cares for ICP
reduce environmental stimulus, maintain cerebral oxygenation, monitor seizures, decrease ICP, promote circulation, maintain optimal neurological function, prevent complications, monitor VS, ICP, assess neurological function like PERLA, NIH Stroke Scale, and ready the client for rehabilitation
Simple Fracture
remains contained, with no disruption of the skin integrity
Altered ICP Signs and Symptoms
restlessness, irritable, confusion, N/V, HA, motor or sensory abnormalities, impulse may be slower, seizures, loss of reflexes, blurred vision, respiratory pattern change, speech change, hyperthermia
Stress Fracture
results from repeated loading of bone and muscle
Cheyne-Stokes Breathing
see it near death, the longer the apnea, the worse.
Nursing Management
stay with the client, call for assistance, and observe symptoms, LOC; recovery time to speak, movements, cognition, how long of sleep after, Timing, pattern, precipitating factors, aura, describe activity, observe symptoms, any injury
Positioning Protects Airway
stay with the client, call for assistance, note and observe symptoms, prolonged seizure or one right after another with no recovery in between (status epilepticus)
Warning Signs of a Stroke
sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance
Transverse Fracture
that is straight across a bone shaft
Left Cerebral Hemisphere is responsible for what?
the language center, calculation skills, and thinking/reasoning abilities.
Postictal Phase of Seizure
they should be drowsy to somnolenece because of exhaustion from abnormal and spontaneous neuron firing.
Ischemic Stroke
thrombotic (atherosclerosis) and embolic (MI, CHF, Valve Disease, A-FIB, TIA) stroke S/S: hemiparesis: weakness, paralysis, loss of speech, hemi sensory loss: numbness
What is the purpose of tPA?
to reestablish cerebral perfusion
What kind of onset is a stroke?
A sudden onset
