Pn3 EXAM 1

CVA/stroke/brain attack

Brain attack. Stroke that happens in the brain rather than the heart. Causes sudden loss of brain function accompanied by neurological deficit. Resulting from thrombus, embolus, severe vasospasm or cerebral hemorrhage.

Open head surgery complications

Hemorrhage from nose, pharynx, or ears. Discoloration of skin caused by bruising over mastoid area. Blood in conjunctiva. Raccoon eyes indicate basils fracture. Cerebrospinal fluid may leak from ears or nose. Catscan or m.r.I. determines injury.

Signs of impending death

Lungs unable to provide adequate gas diffusion. Heart and vessels unable to maintain adequate tissue perfusion. Brain ceases to regulate vital centers. Cheyne stoke respirations, quick breathing followed by apnea, also known as the death rattle.

Nursing education for internal radiation

Monitor for burning sensations, excessive perspiration, chills, fever, nausea, vomiting, or diarrhea.

Nursing care of post back surgery

Monitor neurological status and vitals. Encourage to cough, deep breathe, and use incentive spirometer hourly. Move legs as allowed, provide adequate fluids, check dressing for bleeding, check drainage and empty frequently. Use log roll.

Care for clients receiving I.V. chemo

Blood count must be monitored closely. Encourage client to eat for strength. Understand the drugs. Know possible side effects. I.V. leakage can cause extravasation, pain, swelling, burning, redness, blistering, necrosis. Basically when the chemo is leaking in places it shouldn't.

coordination

A function of the cerebellum.

Open Head Injury (OHI)

A penetrating head injury, or open head injury, is a head injury in which the dura mater, the outer layer of the meninges, is breached. Penetrating injury can be caused by high-velocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain. Assess blood pressure until within normal limits.

somatic nervous system

A subdivision of the peripheral nervous system. Enables voluntary actions to be undertaken due to its control of skeletal muscles

Chemo complications

Anaphylaxis is an allergy to the chemo

How to assess a clients coordination

Ask client to perform repetitious movements. Close eyes and repeatedly touch nose with alternated index fingers.

Lower extremity coordination

Ask client to run heel of foot down the opposite shin and repeat other side.

Process of assessing mental status

Requires observation of clients appearance, behavior, posture, mood, gestures, movements, and facial expressions. Compare these behaviors to expected behaviors of clients age, health status, education level, and social position. Assess mood by asking about feelings.

Aphasia

impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding). loss of ability to understand or express speech, caused by brain damage.

Lab values to monitor for chemotherapy

C.b.c.

Meniere's disease

Classic triad. Vertigo, tinnitus, and unilateral fluctuating hearing loss. Vertigo is often associated with nausea and vomiting. Tinnitus may be preceding aura or occur simultaneously with vertigo.

Closed Head Injury (CHI)

Closed-head injury is a type of traumatic brain injury in which the skull and dura mater remain intact. Closed-head injuries are the leading cause of death in children under 4 years old and the most common cause of physical disability and cognitive impairment in young people.

Hearing issues *Conductive hearing loss *Sensorineural hearing loss *Acoustic neuroma *Nursing education for hearing aids *Otitis media *Otosclerosis

Conductive hearing loss The inability of sound waves to reach inner ear. Caused by cerumen build up or blockage, a perforated tympanic membrane, or fixation of one or all of the ossicles. Sensorineural hearing loss Condition in which the inner ear or cochlear portion of cranial nerve 8 is abnormal or diseased. A tumor, infection, trauma, or exposure to loud noise may cause destruction of the nerve and result in sensor I neural hearing loss. Acoustic neuroma Dizziness, tinnitus, and hearing loss. Slow growing and usually benign tumor of the vestibular portion of the inner ear. Nursing education for hearing aids Ensure client knows how to properly put them in. Functional battery. Hearing aid is on comfortable level. Provide client and family with instructions. Mild soap and water to clean. Keep dry. Turn off to conserve battery. Avoid hairspray. Otitis media Ear pain, fever, redness of auricle and ear canal and sometimes enlarged lymph nodes over the mastoid process, parities, and upper neck. Occurs more in children than adults. Otosclerosis Secondary to pathological change of the bones in the middle ear. Common in adults, more in women. Signs and symptoms are changes in hearing and low pitched tinnitus. Difficult to distinguish a whisper or to hear and understand in crowded places.

Parasympathetic nervous system

Conserves energy as it slows the heart rate, increases intestinal and gland activity, and relaxes the sphincter muscles in the G.I. tract.

decerebrate, decorticate, and withdrawal

Decerebrate posture is an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain. Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of severe damage in the brain. The difference between the two... While decorticate posturing is still an ominous sign of severe brain damage, decerebrate posturing is usually indicative of more severe damage at the rubrospinal tract, and hence, the red nucleus is also involved, indicating a lesion lower in the brainstem. Withdrawal: Withdrawing from pain, or withdrawal, is where the patient typically flexes his arms toward the pain; however, he does not make a "purposeful" attempt to remove the pain or move his arms beyond chin level.

Glaucoma *Nursing interventions

Disorder characterized by an abnormally high pressure of fluid inside the eyeball. If pressure continues for long period of time it destroys neurons and brings blindness. Nursing interventions Administer ophthalmic agent. Monitor visual acuity before each instillation by asking if vision is clear or blurred and if client can read printed material in arms length. Notify physician of hypo tension, urine output of less than 240 mL in 8 hours and no pain relief 30 minutes after therapy.

Cataracts Nursing interventions

Disorder that causes the lens or its capsule to lose its transparency or become opaque, meaning unable to see. Nursing interventions Assess baseline visual acuity. Elicit functional description of what client can see or cannot see. Teach to slowly change positions and avoid reaching for objects to maintain stability when ambulating because depth perception is altered. Discuss clients ability to meet self care needs and activities of daily life. Evaluate how the clients current functional abilities are affected by activity restrictions and post operative care needs. Help client decide on realistic site for post operative needs.

Increased intracranial pressure *Early signs *Nursing care for client with increased intracranial pressure

Early signs Deterioration of level of consciousness. Confusion. Abnormal posturing. Headache, vomiting, hemiplegia, paraplegia, restlessness, change in pupil size. Nursing care for client with increased intracranial pressure Monitor neuro assessment, level of consciousness, vitals, glasgow scale, monitor I.c.p. device. Keep head at 30 to 40 degrees. Watch for arm and leg weakness, muscle twitching, nausea, vomiting, visual and hearing disturbances. Restrict fluids.

autonomic dysreflexia and nursing care for it

Emergency situation resulting in hypertensive crisis. Elevated systolic blood pressure of 260 to 300 m.m. h.g. possible stroke or seizure activity. Nursing care: Prevent bladder distension and fecal impactions implement a bladder and bowel training. Raise head of bed and lower legs to reduce blood pressure.

encephalitis, meningitis, and diagnostics for encephalitis and meningitis.

Encephalitis: Inflammation of the brain caused by viral infections. Meningitis: Inflammation of the meninges caused by virus, bacteria, and fungus. *Nursing interventions: Monitor changes in neurological status, and changes in level of consciousness and signs of intracranial pressure. Observe for seizure activity and protect from injury. Provide comfort measures, oral hygiene, tepid baths, and administer analgesics. Provide quiet environment. Diagnostics for encephalitis and meningitis: Lumbar puncture test which tests for c.s.f. causative agent. And c.b.c. identifies if it is viral or bacteria.

Risk factors for cancer

Environmental, asbestos, coal tar, radium, arsenic compounds, Lifestyle, tobacco, alcohol, sun exposure, diet, genetic, leukemia and cancer is the colon, stomach, prostate, lungs, and ovary may run in families, Viral factors, stomach, esophagus, colon. The earlier the detection, the more likely for successful treatment.

Assessment of client with spinal cord injury

Immobilization, evaluate for hemorrhage and other injuries. Monitor blood pressure and respiratory function. Treat systolic blood pressure less than 90 immediately to avoid shock.

Ataxia

Inability to perform coordination movements. In coordination of voluntary muscle action.

Stroke

Left side controls right side and right side controls left side... A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures). When that happens, part of the brain cannot get the blood (and oxygen) it needs, so it and brain cells die.

Consciousness *Level of consciousness *Indicators of level of consciousness change *Glasgow coma scale

Level of consciousness When assessing a clients level of consciousness check eye movement, pupil changes, vitals, intake and output, pulse, oximetry, and use Glasgow scale. Indicators of level of consciousness change Level of consciousness is assessed by determining the clients awareness and orientation and is the most important indicator of change in neurological status. Glasgow coma scale An objective tool for assessing consciousness in clients. Eye opening, verbal response, and motor response are scored using measurable criteria. 15 is the best score. 7 or less is considered a coma state. 3 is the worse score. The totaled scores indicate coma severity. The changes in glasgow scale indicate changes in the clients condition. If score dropping low, contact doctor immediately.

Multiple sclerosis *Nursing care and goals for clients with MS *Exacerbation causes for multiple sclerosis

Nursing care and goals for clients with MS Well balanced diet with roughage, plenty of fluids, dietician for weight loss or gain. Maintain high eat possible functioning, daily exercise, physical therapy, passive range of motion, and occupational therapy. Exacerbation causes for multiple sclerosis Exacerbation frequently brought on by emotional or physical stress. Hot baths or strenuous exercise can aggravate symptoms. Increases with disease progress. With progression client becomes bedridden and has difficulty handling saliva and develops emotional and intellectual disturbances.

Internal radiation *Nursing education for client receiving internal radiation *Nursing care for internal radiation

Nursing education for client receiving internal radiation While temporary implant is placed, stay in bed and rest quietly to avoid dislodging the implant. Avoid close contact with others until treatment is discontinued. Dispose of excretory materials in special container or toilets not used by others. Carry out the day but get extra rest when fatigue. Balanced diet, small meals as tolerated. Nursing care for internal radiation Place client in private room. Limit visits to 10 to 30 minutes standing 6 feet from client.

External radiation *Nursing education for external radiation *Nursing care for external radiation

Nursing education for external radiation Do not wash off skin markings used to designate reference points for treatment. Client is alone in room for treatment and must lie still. Treatment lasts 1 to 3 minutes and usually painless. Side effects may occur after treatment is completed. Nursing care for external radiation Relief from side effects. Avoid sunlight, use mild soap, wear loose clothing, assess GI discomfort, encourage nutrition due to loss of appetite and fatigue.

glaucoma

Nursing interventions Monitor blood pressure, pulse, and respirations every 4 hours if not receiving osmotic agent and every 2 hours if they are. Monitor intake and output while receiving osmotic agent. Remind client it may caused blurred vision 2 hours after. Adaption to darkness is hard due to pupil constriction. Monitor pain.

Medical staff for a quadriplegic and paraplegic patient Occupational therapist Physical Therapist Nurse (ABCDE) Physician

Occupational therapist: Helps client adjust to life and assist them in new ways to perform activities of daily life. Physical therapist: Rehabilitation, promotes strengthening for mobility and functioning. Nurse: Provides care such as neuro assessment, bowel and bladder function, psychosocial assessment, also monitors A,b,c,d,e (airway, breathing, circulation, disability, and exposure) Physician: Over sees clients care and writes orders

Parkinson's disease *Parkinson's disease interventions *Parkinson's disease safety *Importance of independence

Parkinson's disease interventions Encourage independence. Assist to establish regular bowel routine by encouraging client to drink at least 2 thousand milliliters daily and eat high fiber foods. Provide elevated toilet seat. Assist client and family to express feelings. Parkinson's disease safety Easy access bathroom and bedroom. Remove rubber soled shoes, throw rugs, and objects to trip on. Install handrails. No waxed floors. Provide assistance. Monitor for choking at meal times. Parkinson's, importance of independence improvements in motor and quality of life

Nursing goals when medicating clients with cancer pain

Prevent pain before is occurs. Analgesics work better when given regularly before pain becomes severe. Major nursing responsibility is to teach client to request medication before pain becomes severe.

pearla

Pupils that are equal, round, and reactive to light. Used only when pupils reaction is normal.

Quadriplegia, paraplegia, and the difference between quadriplegia and paraplegia

Quadriplegia: Injuries above C 5 affecting respiratory function. Complete upper body neuron injury. Paralysis is both arms, both legs, bowel and bladder. Paraplegia: Paralysis of the legs and lower body. Typically caused by spinal injury. Difference between quadriplegia and paraplegia: Quadriplegia affects all 4 extremities. Paraplegia affects lower extremities.

CVA *risks *Nursing interventions

Risks Hypertension, diabetes mellitus, atherosclerosis, aneurysm, cardiac disease, high blood cholesterol, obesity, sedentary lifestyle, smoking, stress, drug use, oral use of contraceptives. Nursing Interventions Monitor neurological status frequently. Monitor blood pressure, heart rate, respirations, pupils, vision. Jeep head elevated, quiet room, prevent strenuous bowels. Assess for twitching, and onset of seizure. Nursing education Blood pressure and cholesterol check ups. Low sodium and low fat diet. Exercise, no smoking, no alcohol, diabetes control, teach f.a.s.t.. Have doctor check for circulation problems and check for symptoms of atrial fibrillation.

Seizures , Aura, instructions for client taking anticonvulsant medications, tonic-clonic seizure.

Seizures: A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. If you have two or more seizures or a tendency to have recurrent seizures, you have epilepsy. There are many types of seizures, which range in severity. During seizures. Assess respiratory status. Observe muscular stiffness, position of eyes, sounds, incontinence, duration, and state of consciousness. After seizure. Assess signs of paralysis, inability to speak, difficulty awakening, confusion. This phase is called the poetical phase and can last from minutes to hours. Aura: When you have epilepsy, there's a chance you might have an aura before you have a seizure. An aura is a feeling, experience, or movement that just seems different. It can also be a warning that a seizure is going to happen Instructions and patient education for anticonvulsants: Anti-seizure or anticonvulsant medications can cause drowsiness, interfere with thinking, and interfere with other medications, so it is important that the primary care provider and pharmacist know all medications (prescription and over-the-counter), vitamins, herbs, or other supplements a patient may be taking. Status epilepticus: Instructions Anticonvulsants should not be discontinued abruptly because of the possibility of increasing seizure frequency; therapy should be withdrawn gradually to minimize the potential of increased seizure frequency, unless safety concerns require a more rapid withdrawal. Start one at a time and will increase doses gradually. Practice good oral hygiene. No alcohol. Take as directed, do not stop on own. Do not drive. Remove clutter. Tonic-clonic seizure. (Grandmal) A grand mal seizure is usually caused by epilepsy, but may have other triggers, such as very low blood sugar, high fever, or a stroke. The seizure has two stages. Loss of consciousness occurs first and lasts about 10 to 20 seconds, followed by muscle convulsions that usually last for less than two minutes. Many people will have only one such seizure in their lifetime. Others may need daily anti-seizure medications to prevent recurrence.

Chronic sensory deprivation contributing factors

Sensory deprivation can be caused by trauma, illness, or isolation. Brain damage decreases cognitive function such as reasoning, memory, attention and language. Blindness prohibits perception of stimuli.

How to assess a clients pupils

Shine penlight directly into eye by passing from the out edge to the center. Reaction is assessed by being brisk, sluggish or non reactive. Consensual reaction is the opposite pupil responding at the same time.

Sympathetic nervous system

Stimulates the body's fight or flight response. Regulates body's unconscious actions. Constantly active at a basic level to maintain hemostasis.

Difference between a TIA and CVA

T.I.a blockage is temporary, more accurately called a warning stroke. C.I.a. is a stroke.

T.I.a. - Mini stroke

Transient ischaemic attack. Mini strokes that frequently precede a stroke. Temporary or transient episodes of neurological dysfunction caused by temporary impairment of blood flow to the brain. Loss of motor sensory and lasts from seconds to 24 hours.

cachexia

Weakness and wasting of the body due to severe chronic illness. Nursing interventions Assess physical and psychosocial effects of weight loss. Support client and family. Assess appetite, oral intake, weight loss, level of fatigue. Evaluate secondary symptoms, dyspnea, depression, and discomfort. Help client manage weight loss and fatigue symptoms.

Complications and interventions of chemo

When extravasation occurs get the registered nurse immediately to stop the infusion.

Sympathetic and parasympathetic systems

When one system increases an action the other decreases the action.

Myasthenia gravis

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles