Adult Exam #3

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Interprofessional Care Acute Care for Ischemic Stroke

1st ABC!!!! assessment, VS, check pupils first, CT scan, difficulty keeping an open, clear airway bc of decr LOC or decr /absent gag, swallowing reflexes. O2 admin, artificial airway insertion, intubation, mechanical ventilation Baseline neurologic assessment = Monitor for s/s incr neurologic deficit, incr ICP incr BP = common immediately after stroke = reflect body attempt to maintain cerebral perfusion patients worsen in first 24-48 hrs = spacicidy drugs to decr BP = ONLY if BP is markedly incr (mean arterial pressure greater than 130 mm Hg or systolic pressure greater than 220 mm Hg). IV antihypertensives = metoprolol (Lopressor), nicardipine (Cardene) Control fluid/electrolyte balance = Promotes perfusion, decr further brain injury Manage ICP = Use interventions that improve venous drainage Overhydration = compromise perfusion by incr cerebral edema. secretion of (ADH) incr in response to stroke, urine output decr, fluid is retained. Low serum sodium (hyponatremia) may occur. IV solutions w/ glucose/water are avoided bc = hypotonic = cerebral edema, ICP. Glycemic control maintained = avoid extreme hypo- or hyperglycemia. Incr ICP is more likely to occur w/ hemorrhagic strokes but can occur w/ ischemic strokes, peaks in 72 hrs = may cause brain herniation. Management of incr ICP = improve venous drainage = elevating HOB, maintaining head/neck in alignment, avoiding hip flexion. incr ICP include management of hyperthermia (goal temp = 96.8 to 98.6° F [36° to 37° C ]), drugs = prevent seizures, pain, hypervolemia, c/

Head Injury and deaths

2x as common in males High potential for poor outcome Deaths occur at 3 points in time after injury majority of deaths = immediately after injury, direct head trauma or massive hemorrhage, shock. Deaths occurring within few hrs of trauma = progressive worsening of brain injury or internal bleeding. Deaths occurring 3 weeks or more after injury = multisystem failure. Expert nursing care in wks after injury is crucial in decr mortality risk, in optimizing pt outcomes.

GDC Coil

A, A hydrogel-coated platinum coil is used to occlude an aneurysm. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysms while posing little threat of rupture of the aneurysm. B, A catheter is inserted through an introducer (small tube) in an artery in the leg. The catheter is threaded up to the cerebral blood vessels. C, Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with coils. Packing the aneurysm with coils prevents the blood from circulating through the aneurysm, reducing the risk of rupture. Eventually, a thrombus forms within the aneurysm, and the aneurysm becomes sealed off from the parent vessel by the formation of an endothelialized layer of connective tissue.

Bone Healing Stages

A, Bleeding at fractured ends of the bone with subsequent hematoma formation. B, Organization of hematoma into fibrous network. C, Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium. D, Callus formation: new bone is built up as osteoclasts destroy dead bone. E, Remodeling is accomplished as excess callus is reabsorbed and trabecular bone is laid down.

Decorticate and Decerebrate Posturing

A, Decorticate response. Flexion of arms, wrists, fingers w/ adduction in upper extremities. Extension, internal rotation, plantar flexion in lower extremities. B, Decerebrate response. All 4 extremities in rigid extension, w/ hyperpronation of forearms, plantar flexion of feet. C, Decorticate response on right side of body, decerebrate response on left side of body D, Opisthotonic posturing.

Assistive Devices for Eating

A, The curved fork fits over the hand. The rounded plate helps keep food on the plate. Special grips and swivel handles are helpful for some persons. B, Knives with rounded blades are rocked back and forth to cut food. The person does not need a fork in one hand and a knife in the other. C, Plate guards help keep food on the plate. D, Cup with special handle. After the acute phase, a dietician can assist in determining the appropriate daily caloric intake based on the patient's size, weight, and activity level. Interventions to promote self-feeding include using the unaffected upper extremity to eat; employing assistive devices such as rocker knives, plate guards, and nonslip pads for dishes; removing unnecessary items from tray or table, reducing spills; providing a nondistracting environment to reduce sensory overload with distraction.

Classification According to Location

A, Transverse fracture is a fracture in which the line of the fracture extends across the bone shaft at a right angle to the longitudinal axis. B, Spiral fracture is a fracture in which the line of the fracture extends in a spiral direction along the shaft of the bone. C, Greenstick fracture is an incomplete fracture with one side splintered and the other side bent. D, Comminuted fracture is a fracture with more than two fragments. The smaller fragments appear to be floating. E, Oblique fracture is a fracture in which the line of the fracture extends in an oblique direction. F, Pathologic fracture is a spontaneous fracture at the site of a bone disease. G, Stress fracture is a fracture that occurs in normal or abnormal bone that is subject to repeated stress, such as from jogging or running.

Interprofessional Care Acute Care for Hemorrhagic Stroke

ABC Intracranial pressure Hyperdynamic therapy incr mean arterial pressure incr cerebral perfusion Vasospasms can be tx w/ CCB = nimodipine (Nimotop) After aneurysmal occlusion via clipping or coiling, hyperdynamic therapy (hemodilution-induced hypertension using vasoconstricting = phenylephrine or dopamine [Intropin] and hypervolemia) = incr mean arterial pressure, incr cerebral perfusion. Volume expansion is achieved via crystalloid or colloid solution. Nimodipine restricts influx of calcium into cells by decr # open calcium channels. Subarachnoid + intracerebral hemorrhage can involve bleeding into ventricles of brain = hydrocephalus = damages brain tissue from incr ICP = ventriculostomy for cerebrospinal fluid drainage

posterior pit hormones

ADH - incr resorption of water in kidneys oxytocin - uterus, breaks milk

Nursing Assessment Intracerebral Hematoma

Abnormal CT scan or MRI Abnormal EEG Positive toxicology screen or alcohol level ↑ or ↓Blood glucose level ↑ ICP Location and type of hematoma, edema, skull fracture, and/or foreign body on CT scan and/or MRI

Bacterial Meningitis

Acute inflammation of meningeal tissue surrounding brain, spinal cord Usually occurs in fall, winter, early spring Often secondary to viral respiratory disease Mandatory reporting to CDC Mortality rate near 100% if untreated Older adults, persons who are debilitated are more often affected than is general population. College students living in dormitories, institutions (e.g., prisoners) have high risk for contracting meningitis.

Pain Management

Acute pain = first few weeks of rehab Assess, evaluate, and treat routinely Analgesics Massage and repositioning Chronic pain May be result of overuse of muscles = for movement and repositioning Sleep may be disrupted = pain May refer to pain management specialist

Diabetic Ketoacidosis (DKA) first's

Add 5% to 10% dextrose when glucose approaches 250 mg/dL Continuous regular insulin drip 0.1 U/kg/hr glucose decr 36 to 54 mg/dL (2-3 mmol/L) per hr = avoid complications. Potassium replacement as needed Continuous telemetry Don't take action until you know the BS level!!! oxygen via nasal cannula or non-rebreather mask. bc fluid imbalance potentially life-threatening, initial goal of therapy is to establish IV access, begin fluid, electrolyte replacement. 0.45% or 0.9% NaCl at a rate to restore urine output to 30 to 60 mL/hr, to raise blood pressure. Overzealous rehydration, especially w/ hypotonic IV solutions, = cerebral edema. Monitor patients w/ renal or cardiac compromise for fluid overload. serum potassium level b/f starting insulin hypokalemic, insulin admin will further decr potassium levels, making early K replacement is essential. initial serum potassium value may be normal or high, levels can decr rapidly once therapy starts, insulin drives K into cells, leading to life-threatening hypokalemia. IV insulin admin is therapy directed toward correcting hyperglycemia and hyperketonemia. Insulin allows water and K to enter cell along w/ glucose and can lead to depletion of vascular volume, hypokalemia = monitor the patient's fluid balance and K levels.

Evaluation SCI

Adequate ventilation Adequate circulation and BP Intact skin Adequate nutrition Bowel management Bladder management No autonomic hyperreflexia

Respiratory Dysfunction SCI

Admin O2 ventilator support Chest physiotherapy Assisted (augmented) coughing Tracheal suctioning Incentive spirometry pain meds nasal stuffiness, bronchospasm. During first 48 hrs after injury, spinal cord edema may incr level of dysfunction = respiratory distress acute cervical SCI are initially managed in monitored unit or ICU. at or above C4 = phrenic nerve leading to diaphragm may be affected = breathing can stop exhausted from labored breathing or ABGs indicate inadequate O2 or ventilation = endotracheal intubation or tracheostomy + mechanical ventilation Pneumonia and atelectasis = bc decr vital capacity, loss of intercostal, abdominal muscle function = diaphragmatic breathing, pooled secretions, ineffective cough. PaO2 (partial pressure of oxygen in arterial blood) greater than 60 mm Hg + PaCO2 (partial pressure of carbon dioxide in arterial blood) less than 45 mm Hg = acceptable values in pt w/ uncomplicated tetraplegia. unable to count to 10 aloud w/o taking a breath needs immediate attention. experienced chest trauma or difficulty weaning from ventilator = need tracheostomy Chest physiotherapy = Place heels of both hands just below xiphoid process, exert firm upward pressure to area timed with patient's efforts to cough. tracheal suctioning if crackles or rhonchi older adult = difficulty responding to hypoxia + hypercapnia = aggressive chest physiotherapy, adequate O2, pain management = maximize respiratory function + gas exchange.

Interprofessional CareAcute Care

After stabilized, prevent further clots, pt w/ strokes caused by thrombi/emboli may be tx with anticoagulants and platelet inhibitors ASA, ticlopidine, clopidogel, dipyridamole Platelet inhibitors = aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine) statins = effective for the patient with an ischemic stroke. atrial fibrillation, oral anticoagulants = warfarin and direct factor Xa inhibitors: rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis). anticoagulants (e.g., heparin) = emergency phase following ischemic = not recommended bc risk intracranial hemorrhage. aspirin 325 mg = initiated w/I 24 to 48 hrs after onset of ischemic stroke. Complications of aspirin (with higher doses) include gi bleeding = hx of PUD

Interprofessional Care Rehabilitation stroke

After stroke stabilized for 12 to 24 hrs, care shifts from preserving life to lessening disability, attaining optimal functioning transferred to a rehabilitation unit, outpatient therapy, or home care-based rehabilitation

Risk FactorsNon-Modifiablestroke

Age = Stroke risk doubles each decade after 55 Gender = common in men; more women die Ethnicity/race = African Americans FMH 2/3 occur in individuals over age 65. More women die bc they tend to live longer higher incidence (x2) death rate from stroke among blacks r/t part to higher incidence of HNT, obesity, DM Genetic risk = vascular diseases, stroke, lipid metabolism, thrombosis, inflam 2 first-degree relatives w/ hx of subarachnoid hemorrhage or aneurysm = screened to rule out anomalies in their cerebral vasculature.

Nursing AssessmentIntracerebral HematomaObjective Datageneral

Altered mental status Lacerations, contusions, abrasions Hematoma Battle's sign Periorbital edema and ecchymosis Otorrhea Exposed brain Objective data = GCS = neuro status, determining CSF leak has occurred.

Ambulatory Care

Ambulation Reinforce physical therapist's instructions Mobility training Instruction in use of assistive aids Pain management patient with lower extremity dysfunction usually starts mobility training when able to sit in bed and dangle the feet over the side. administer analgesia before a physical therapy. degrees of weight-bearing ambulation: non-weight-bearing (no weight on the involved extremity) touch-down/toe-touch weight-bearing ambulation (contact with floor for balance but no weight borne) partial-weight-bearing ambulation (25% to 50% of patient's weight borne) weight bearing as tolerated (based on patient's pain and tolerance) full-weight-bearing ambulation (no limitations).

A patient has dysphagia. Before allowing him to eat, which action should you take first? Check the patient's gag reflex. Request a soft diet with no liquids. Place the patient in high-Fowler's position. Test the patient's ability to swallow with a small amount of water.

Answer: A Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow.

The nurse is caring for a patient with type 1 diabetes mellitus who is admitted for diabetic ketoacidosis. The nurse would expect which laboratory test result? Hypokalemia Fluid overload Hypoglycemia Hyperphosphatemia

Answer: A Rationale: Electrolytes are depleted in diabetic ketoacidosis. Osmotic diuresis occurs with depletion of sodium, potassium, chloride, magnesium, and phosphate levels. A patient with diabetic ketoacidosis will be dehydrated (fluid volume deficit), and blood glucose levels would be elevated (hyperglycemia).

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to breathe with respiratory support. drive a vehicle with hand controls. ambulate with long-leg braces and crutches. use a powered device to handle eating utensils.

Answer: B Rationale: A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; use wheelchair independently; and drive a car with powered hand controls (in some patients); attendant care 0 to 6 hours/day.

A patient has a severely sprained ankle from a sports injury. What should the nurse teach the patient prior to discharge from the urgent care center? Alternate cold and heat for 30 minutes each until symptoms are relieved. Apply cold for 20 to 30 minutes with breaks of 10 to 15 minutes during the first 2 days. Use continuous cold for the first 24 hours and then continuous heat until the symptoms are relieved. Apply continuous heat to the ankle for the first 24 hours and then continuous cold until the symptoms are relieved.

Answer: B Rationale: If an injury occurs, immediate care focuses on (1) stopping the activity and limiting movement, (2) applying ice compresses to the injured area, (3) compressing the involved extremity, (4) elevating the extremity, and (5) providing analgesia as necessary. These interventions will decrease local inflammation and pain for most musculoskeletal injuries. Cold (cryotherapy) in several forms can be used to produce hypothermia to the involved part. Physiologic changes that occur in soft tissue as a result of the use of cold include vasoconstriction and reduction in the transmission and perception of nerve pain impulses. These changes result in analgesia and anesthesia, reduction of muscle spasm without changes in muscular strength or endurance, reduction of local edema and inflammation, and reduction of local metabolic requirements. Cold is most useful when applied immediately after the injury has occurred. Ice applications should not exceed 20 to 30 minutes per application, and ice should not be applied directly to the skin. After the acute phase (usually 24 to 48 hours), warm, moist heat may be applied to the affected part to reduce swelling and provide comfort. Heat applications should not exceed 20 to 30 minutes, allowing a "cool-down" time between applications.

A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for return of reflexes. bradycardia with hypoxemia. effects of sensory deprivation. fluctuations in body temperature.

Answer: B Rationale: Neurogenic shock is due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia, which are important clinical clues. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. These effects are generally associated with a cervical or high thoracic injury (T6 or higher). Injury or fracture below the level of C4 results in diaphragmatic breathing if the phrenic nerve is functioning. Even if the injury is below C4, spinal cord edema and hemorrhage can affect the function of the phrenic nerve and cause respiratory insufficiency. Hypoventilation almost always occurs with diaphragmatic respirations because of the decrease in vital capacity and tidal volume, which occurs as a result of impairment of the intercostal muscles. Cervical and thoracic injuries cause paralysis of abdominal muscles and often intercostal muscles. Therefore the patient cannot cough effectively enough to remove secretions, leading to atelectasis and pneumonia. An artificial airway provides direct access for pathogens, making bronchial hygiene and chest physiotherapy extremely important to reduce infection. Neurogenic pulmonary edema may occur secondary to a dramatic increase in sympathetic nervous system activity at the time of injury, which shunts blood to the lungs. In addition, pulmonary edema may occur in response to fluid overload.

During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? A heart rate of 92 A reddened area over the patient's coccyx Marked perspiration on the patient's face and arms A light inspiratory wheeze on auscultation of the lungs

Answer: C Rationale: Autonomic dysreflexia is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It occurs in response to visceral stimulation once spinal shock is resolved in patients with spinal cord lesions. The condition is a life-threatening situation that requires immediate resolution. If resolution does not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/min), piloerection (erection of body hair) as a result of pilomotor spasm, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea.

As one of your clinical assignments, you are assisting an RN with health screening at a health fair. Which individual is at greatest risk for experiencing a stroke? A 46-year-old white female with hypertension and oral contraceptive use for 10 years A 58-year-old white male salesman who has a total cholesterol level of 285 mg/dl A 42-year-old African American female with diabetes mellitus who has smoked for 30 years A 62-year-old African American male with hypertension who is 35 pounds overweight

Answer: D Rationale: Option D: This individual has five risk factors: age, African American, male, hypertension, and overweight. Option A: This individual has two risk factors: hypertension and oral contraception use. Option B: This individual has two risk factors: male and increased cholesterol level. Option C: This individual has three risk factors: African American, diabetes mellitus, and smoking. Nonmodifiable risk factors include age, gender, ethnicity/race, and family history/heredity. Stroke risk increases with age, doubling each decade after 55 years of age. Two- thirds of all strokes occur in individuals >65 years. Strokes are more common in men, but more women die from stroke than men. Because women tend to live longer than men, they have more opportunity to suffer a stroke. African Americans have a higher incidence of stroke as well as a higher death rate from stroke than whites. A family history of stroke, a prior transient ischemic attack, or a prior stroke also increases the risk of stroke. Modifiable risk factors are those that can potentially be altered through lifestyle changes and medical treatment, thus reducing the risk of stroke. Modifiable risk factors include hypertension, increased cholesterol, elevated blood lipid levels, heart disease, smoking, excessive alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, and drug abuse. The early forms of birth control pills that contained high levels of progestin and estrogen increased a woman's chance of experiencing a stroke, especially if she also smoked heavily. Newer, low-dose oral contraceptives have lower risks for stroke except in those individuals who are hypertensive and smoke. Other conditions that may increase stroke risk include migraine headaches, inflammatory conditions, and hyperhomocystinemia. Sickle cell disease is another known risk factor for stroke.

A plaster splint is applied with an elastic bandage to the leg of a patient with a fractured tibia in preparation for open reduction and internal fixation. The patient complains of increasing pain in the affected leg and foot that is not relieved by loosening of the elastic bandage. The most appropriate action by the nurse is to elevate the leg on two pillows. apply ice over the fracture site. notify the health care provider. perform neurovascular assessment of the foot.

Answer: D Rationale: Prompt, accurate diagnosis of compartment syndrome is critical. Prevention or early recognition is the key. Regular neurovascular assessments should be performed and documented on all patients with fractures, but especially those with injury of the distal humerus or proximal tibia or soft tissue disruption in these areas. Early recognition and treatment of compartment syndrome is essential to avoid permanent damage to muscles and nerves. One or more of the following six Ps are characteristic of compartment syndrome: (1) paresthesia (numbness and tingling); (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle, traveling through the compartment; (3) pressure increases in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness or diminished/absent peripheral pulses. Carefully assess the location, quality, and intensity of the pain (see Chapter 10). Evaluate the patient's level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. After completion of the neurovascular assessment, the nurse should notify the health care provider immediately of a patient's changing condition.

The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed? Prone with the head turned to the right side High-Fowler's position with the legs elevated Supine position with the head on two pillows Side-lying with the head elevated 30 degrees

Answer: D Rationale: To prevent increased intracranial pressure, the nurse should maintain the patient in the head-up position (no more than 30 degrees). Head elevation over 30 degrees may decrease cerebral perfusion pressure. Extreme neck flexion (head on two pillows) and hip flexion (high-Fowlers position) should be avoided. Head should remain midline.

Neurogenic Bladdertx

Anticholinergic drugs α-Adrenergic blockers Antispasmodic drugs Bladder reflex training Indwelling, intermittent, external catheterization Urinary diversion surgery Anticholinergic = (oxybutynin [Ditropan], tolterodine [Detrol]) = suppress bladder contraction. α-Adrenergic blockers (e.g., terazosin [Hytrin], doxazosin [Cardura]) = relax urethral sphincter. Antispasmodic drugs (e.g., baclofen [Lioresal]) = decr spasticity of pelvic floor muscles. drainage methods = bladder reflex retraining if partial voiding control remains, indwelling catheter, intermittent cath, external catheter (condom catheter) long-term use of indwelling cath bc of associated high incidence of CAUTI, fistula formation, diverticula = some pt this may be best option. pt w/ indwelling cath need to have adequate fluid intake (3-4 L/day) Intermittent cath is most common Nursing assessment = selecting time interval b/w cath. cath is done Q4. If less 200 mL of urine is measured, time interval until cath extended. greater than 500 mL = time interval is shortened. Intermittent caths is usually done 4 or 6 times daily. Urinary diversion = for repeated UTIs w/ renal involvement or repeated stones or therapeutic interventions have been unsuccessful. Surgical tx of neurogenic bladder = bladder neck revision (sphincterotomy), bladder augmentation (augmentation cystoplasty), penile prosthesis, artificial sphincter, perineal ureterostomy, cystotomy, vesicotomy, anterior urethral transplantation

Interprofessional CareDrug Therapy for Hemorrhagic Stroke

Anticoagulants + platelet inhibitors are contraindicated Management of HNT is main focus = Oral + IV agents are used to maintain BP w/i a normal to high-normal range Seizure prophylaxis is situation-specific Systolic BP less than 160 mm Hg.

Brain AbscessPrimary treatment

Antimicrobial therapy Symptomatic tx for other manifestations Abscess may need to be drained or removed if drug therapy is not effective Nursing measures are similar to those for management of meningitis or incr ICP. surgical drainage or removal is tx, nursing care similar to that described under cranial surgery.

Interprofessional Care Preventive Drug Therapy

Antiplatelet drugs = pt who have had TIA r/t atherosclerosis Aspirin = most frequently used antiplatelet agent (81-325mg/day) ticlopidine (Ticlid) clopidogrel (Plavix) dipyridamole (Persantine) combined dipyridamole, aspirin (Aggrenox). atrial fibrillation, oral anticoag = warfarin (Coumadin), direct factor Xa inhibitors: rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis). no close monitoring or dosage adjustments. Statins (simvastatin [Zocor], lovastatin [Mevacor]) = prevention TIA

Clinical Manifestations Communication stroke

Aphasia = damages dominant hemisphere of brain, affects language Receptive - loss of comprehension Expressive - loss of production of language Global - total inability to communicate Language disorders = expression, comprehension of written, spoken words. Dysphasia = impaired ability to communicate Used interchangeably with aphasia Nonfluent = Minimal speech activity w/ slow speech Fluent = Speech is present but contains little meaningful communication (wrong word for object) Most types of aphasia are a mix of nonfluent and fluent, w/ impairment in both expression, understanding. dysarthria = Disturbance in muscular control of speech = Pronunciation, Articulation, Phonation Dysarthria does not affect meaning of communication or comprehension of language, but does affect mechanics of speech. Some pt = combo of aphasia and dysarthria.

Nursing AssessmentObjective Data

Apprehension Guarding Skin lacerations, color changes Hematoma, edema ↓ or absent pulse, ↓ skin temperature Delayed capillary refill physical assessment for clinical manifestations: General Apprehension, guarding of injured site Integumentary Skin lacerations, pallor and cool skin or bluish and warm skin distal to injury; ecchymosis, hematoma, edema at site of fracture Cardiovascular Reduced or absent pulse distal to injury, ↓ skin temperature, delayed capillary refill Objective Data Paresthesias Absent, ↓ or ↑ sensation Restricted or lost function Deformities; abnormal angulation Shortening, rotation, or crepitation Muscle weakness Imaging findings Perform a focused physical assessment for the following clinical manifestations: Neurovascular Paresthesias, absent or ↓ sensation, hypersensation Musculoskeletal Restricted or lost function of affected part; local bony deformities, abnormal angulation; shortening, rotation, or crepitation of affected part; muscle weakness Possible Diagnostic Findings Identification and extent of fracture on x-ray, bone scan, CT scan, or MRI

Neurogenic Bladder

Areflexic (flaccid), hyperreflexic (spastic), or dyssynergia Normal voiding requires nervous system coordination of urethral + pelvic floor relaxation w/ simultaneous contraction of detrusor muscle. Depending on injury, a neurogenic bladder may have: no reflex detrusor contractions (areflexic, flaccid) hyperactive reflex detrusor contractions (hyperreflexic, spastic) lack of coordination b/w detrusor contraction, urethral relaxation (dyssynergia). Common problems = urgency, frequency, incontinence, inability to void, high bladder pressures resulting in reflux of urine into the kidneys.

Cardiovascular DVTSCI

Assess for signs of DVT ROM and stretching low-molecular-weight heparins or low-dose heparin sequential compression devices (SCDs) graduated stockings Remove stockings Q8 = skin care. assess thighs, calves every shift for signs of DVT (e.g., deep reddish color, edema). Continue VTE prophylaxis for 3 months following injury.

Nursing Management: StrokeAcute CareCommunication

Assess pt for ability to speak, ability to understand alert pt usually anxious bc lack of understanding about what happened, bc difficulty w/ communicating, inability to communicate. stroke pt w/ aphasia = easily overwhelmed by verbal stimuli. frequent, meaningful communication allow time for patient to comprehend/answer using simple, short sentences using visual cues structuring conversation so that it permits simple answers by pt praising patient honestly for improvements w/ speech. picture board = communicating with stroke patient. Speech, comprehension, language deficits = most difficult problem for pt/family Speech therapists = plan to support communication teach the caregiver and family communication strategies.

neuro system assessment

AxO cranial nerves motor - gait, sensation, - romberg, muscles, hell-shin, finger to nose sensory - hot./cold, touch, position reflexes - bi, tri, patellar

Bacterial MeningitisInterprofessional Care

Bacterial meningitis = medical emergency Rapid dx based on hx, physical examination is crucial bc pt is usually in critical state when health care is sought. meningitis is suspected = antibiotic therapy is begun after collection of specimens for cultures, even before dx is confirmed (Table 56-17). Ampicillin, penicillin, vancomycin, cefuroxime (Ceftin), cefotaxime (Claforan), ceftriaxone (Rocephin), ceftizoxime (Cefizox), ceftazidime (Ceptaz) Dexamethasone (a corticosteroid) = before or w/ first dose of antibiotics. Collaborate w/ HCP to manage HA, fever, nuchal rigidity

Cardiovascular risks SCI

Because of unopposed vagal response = HR slowed = less than 60 beats/min. Any incr in vagal stimulation = turning/suctioning = can cause cardiac arrest. Loss of sympathetic nervous system tone in peripheral vessels = chronic low BP w/ potential postural hypotension lack of muscle tone to aid venous return = sluggish blood flow = DVT. Dysrhythmias may also occur.

Intracerebral Hematoma

Bleeding within brain tissue Usually within frontal and temporal lobes Size and location of hematoma determine patient outcome

Bacterial MeningitisDiagnostic Studies

Blood culture CT scan Diagnosis verified Lumbar puncture Analysis of CSF manifestations suggestive of bacterial meningitis, blood culture, CT scan should be done. dx is usually verified by doing lumbar puncture w/ analysis of CSF. lumbar puncture should be completed only after CT scan = ruled out an obstruction in foramen magnum in order to prevent fluid shift resulting in herniation. Specimens of CSF, sputum, nasopharyngeal secretions are taken for culture b/f start of antibiotic therapy to identify causative organism. A Gram stain = detect bacteria. predominant WBC type in CSF during bacterial meningitis is neutrophils. X-rays of skull = infected sinuses. CT scans and MRI = normal in uncomplicated meningitis CT scans may reveal evidence of incr ICP or hydrocephalus.

Vertebral Immobilization

Body jacket brace Immobilization and support for stable spine injuries injuries of thoracic or lumbar spine. brace around chest/ abdomen, extending from above nipple line to pubis. After application, assess for development of superior mesenteric artery syndrome (cast syndrome). occurs if brace applied too tight = compression of superior mesenteric artery against duodenum = abdominal pain, pressure, n/ v/ Assess decr bowel sounds (a window in brace may be left over umbilicus). tx = gastric decompression with (NG) tube/suction. Assessment = respiratory, bowel, bladder function, areas of pressure over bony prominences, especially iliac crest. brace may need to be adjusted/removed if any complications occur.

Clinical Manifestations Intellectual Function stroke

Both memory/judgment = FALL RISK!! some deficits are r/t hemisphere in which stroke occurred left-brain stroke = memory problems r/t language. pt w/ left-brain stroke = very cautious in making judgments, slowly and cautiously from wheelchair. Pt w/ right-brain stroke = impulsive, move quickly, right-brain stroke = try to rise quickly from wheelchair w/o locking wheels or raising footrests Patients with either type of stroke may have difficulty making generalizations, which interferes with their ability to learn.

Interprofessional CareAcute Care Additional assessmentSCI

Brain injury and/or vertebral artery injury hx of unconsciousness Signs of concussion Incr intracranial pressure bc patient has no muscle, bone, visceral sensations, only clue to internal trauma with hemorrhage = rapidly decr BP and incr pulse. Examine urine for hematuria = indicates internal injuries.

types of aphasia

Brocas - nonfluent, front lobe, short phrases that make sense, forget small words (is, and, the), can understand others Wernickes - fluent aphasia, temporal, long sensances, no meaning, unneed words, made up words, unaware of their mistakes global - nonfluent, damage to language area, decr ability to speak or comprehend

injury and results

C4 = tetraplegia C6 = T6 = nipple = paraplegia L1 = hips = paraplegia C1-3 = apnea, no cough C4 - poor cough, hypoventilation, diaphragmatic breathing C5-T6 = decr resp reserve T1-L2 = retention T5 = no BS, C/ T6 = bradycardia, hypotensive, + orthos

degree of paralysis

C4 = tetraplegia, everything below neck C6 = paralysis of hands, arms, lower body, keep shoulders T6 = paraplegia, below chest, get all hands/finger L1 = paraplegia, below waist others: C1-3 = apnea, inability to cough C4 = poor cough, diaphragmatic breathing, hypovent C5-T6 = decr resp reserve above T6 = bradycardia, hypotension above T5 = decr BS, paralytic ileus T1-L2 = retention of bladder

Diagnostic StudiesIntracerebral Hematoma

CT = best dx = head trauma = allows rapid dx, intervention in acute care setting. MRI, PET, evoked potential studies MRI scan = more sensitive than CT scan in detecting small lesions. Transcranial Doppler studies allow for measurement of cerebral blood flow (CBF) velocity. cervical spine x-ray series, CT scan, MRI of spine may also be indicated since cervical spine trauma often occurs at same time as head injury. dx studies = similar to those used for a patient with incr ICP.

Diagnostic StudiesOther studies stroke

CT angiography (CTA) = visualization of cerebral blood vessels, estimate of perfusion, detect filling defects in cerebral arteries. MRA can detect vascular lesions, blockages, similar to CTA. Angiography = cervical/cerebrovascular occlusion, atherosclerotic plaques, malformation of vessels. Intra-arterial digital subtraction angiography (DSA) = reduces dose of contrast material, uses smaller catheters, shortens length of procedure compared with conventional angiography. Transcranial Doppler (TCD) ultrasonography = noninvasive study, measures velocity of blood flow in major cerebral arteries. lumbar puncture = look for evidence of RBC in cerebrospinal fluid if subarachnoid hemorrhage is suspected but CT does not show hemorrhage. LICOX system = dx tool for evaluating progression of stroke. Cardiac imaging = recommended bc many strokes are caused by blood clots from heart.

Diagnostic StudiesSCI

CT scan = preferred = location, degree of injury, degree of spinal canal compromise. Cervical x-rays = when CT scan is not readily available. However, visualizing C7 and T1 on a cervical x-ray is often difficult, ability to fully evaluate cervical spine injury is compromised. MRI = soft tissue injury, neurologic changes, unexplained neurologic deficits, worsening of neurologic condition. comprehensive neurologic exam = assessment of head, chest, abdomen for additional injuries/trauma. pt w/ cervical injuries who demonstrate altered mental status = CT angiogram = rule out vertebral artery damage. Duplex Doppler ultrasound, impedance plethysmography, venous occlusion plethysmography, venography, clinical exam = dx DVT.

Causes of SIADH Drug Therapy

Carbamazepine (Tegretol) Chlorpropamide General anesthesia agents Opioids Oxytocin Thiazide diuretics SSRI Tricyclic antidepressants Chemotherapy drugs (vincristine, vinblastine, cyclophosphamide)

Diabetic Ketoacidosis (DKA)

Caused by profound deficiency of insulin Characterized by Hyperglycemia Ketosis Acidosis Dehydration Most likely to occur in type 1 diabetes body feels like it is starving bc no glucose to use as energy = produces glucose = but cant use it = still starving = makes more glucose severe illness or stress when pancreas cannot meet extra demand for insulin.

Cause SCI

Causes Spinal cord injuries are usually from trauma. 38% motor vehicle collisions 30% falls 14% violence 9% sports injuries 9% other miscellaneous cases

Types of Diabetes Insipidus (DI)

Central (neurogenic) DI: interference w/ ADH synthesis, transport, release Examples: Brain tumor, head injury, brain surgery, CNS infections Nephrogenic DI: inadequate renal response to ADH despite presence of adequate ADH kidney issue Examples: Drug therapy (especially lithium), renal damage, hereditary renal disease Primary DI: excessive water intake Examples: Structural lesion in thirst center, psychologic disorder

Bacterial Meningitis Etiology and PathophysiologyInflammatory response

Cerebral edema and increased ICP become problematic If process extends into parenchyma If concurrent encephalitis is present inflammatory response to infection tends to incr CSF production w/ mod incr in ICP. bacterial meningitis purulent secretions produced quickly spread to other areas of brain through CSF, cover cranial nerves, other intracranial structures. All patients w/ meningitis must be observed closely for s/s of incr ICP = result of swelling around dura, incr CSF volume.

Overall GoalsIntracerebral Hematoma

Cerebral oxygenation and perfusion Normothermic Control pain and discomfort Free of infection Adequate nutrition Maximal cognitive, motor, sensory function

Interprofessional CareAcute Care Initial careSCI

Cervical injury requires more intense support Obtain hx = emphasizing incident Assess extent of injury Initial assessment = Managing ABCs and vital signs Medical interventions and dx Complete neurologic using ASIA tool pt with SCI of thoracic/lumbar vertebrae require less intense support = respiratory not as severe, bradycardia ABCs, vital signs, airway, oxygenation, SBP is greater than 90 mm Hg.

Spinal Shock

Characterized by ↓ Reflexes Loss of sensation Absent thermoregulation Flaccid paralysis below level of injury lasts days-wks, may mask post-injury neurologic function.

Neurogenic Shock

Characterized by Hypotension Bradycardia Loss of SNS innervation Peripheral vasodilation Venous pooling ↓Cardiac output Neurogenic shock, in contrast to spinal shock, results from loss of vasomotor tone due to injury These effects are generally associated with a cervical or high thoracic injury (T6 or higher).

Fracture ReductionClosed reduction

Closed reduction = nonsurgical, manual realignment of bone fragments to their previous anatomic position. Traction and countertraction = manually applied to bone fragments to restore position, length, alignment. Closed reduction = while pt under local or general anesthesia. Traction, casting, external fixation, splints, orthoses (braces) = used after maintain alignment, immobilize injured part until healing occurs.

Clinical ManifestationsRespiratory System

Closely correspond to level of injury Above level of C4 = Total loss of respiratory muscle function Below level of C4 = Diaphragmatic breathing → respiratory insufficiency diaphragmatic breathing = phrenic nerve is functioning. Even if injury is below C4, spinal cord edema, hemorrhage can affect function of phrenic nerve = cause resp insufficiency. Hypoventilation, impairment of intercostal muscles leads to a decr in vital capacity, tidal volume. Paralysis of abdominal, intercostal muscles → ineffective cough → risk for aspiration, atelectasis, pneumonia Cervical and thoracic injuries cause paralysis of abdominal muscles and often intercostal muscles. Neurogenic pulmonary edema may occur secondary to a dramatic incr in sympathetic nervous system activity at time of injury, which shunts blood to lungs. pulmonary edema may occur in response to fluid overload.

Classification of fractures

Complete: break is completely through bone Incomplete: bone is still in one piece incomplete = bending or crushing forces applied to a bone. Based on direction of fracture line Linear Oblique Transverse Longitudinal Spiral spiral and greenstick = more peds = tugging = abuse displaced fracture = two ends of the broken bone are separated from one another and out of their normal positions. Displaced fractures are often comminuted (more than two fragments) or oblique nondisplaced fracture = periosteum is intact across the fracture, and the bone fragments are still in alignment. Nondisplaced fractures are usually transverse, spiral, or greenstick.

Compartment Syndrome

Compromises neurovascular function of tissues within that space Compartment syndrome is a condition in which swelling causes incr pressure within a limited space (muscle compartment). bc fascia surrounding muscle has limited ability to stretch, continued swelling = pressure that compromises function of blood vessels, nerves, tendons in the compartment. Capillary perfusion is decr below a level needed for tissue viability. Compartment syndromes usually involve the leg but can also occur in any muscle group (arm, shoulder, buttock, abdomen). Two basic types of compartment syndrome ↓ Compartment size = restrictive dressings, splints, casts, excessive traction, or premature closure of fascia ↑ Compartment contents = bleeding, inflammation, edema, or IV infiltration. Arterial flow compromised → ischemia → cell death → loss of function Edema = pressure to obstruct circulation, cause venous occlusion, which further incr edema. Arterial flow is eventually compromised, causing ischemia in extremity. ischemia continues, muscle, nerve cells are destroyed. Fibrotic tissue eventually replaces healthy tissue. Contracture, disability, loss of function Delays in dx and tx result in irreversible muscle, nerve ischemia. extremity may become functionally useless or severely impaired extremity. Compartment syndrome is usually associated with trauma, fractures (especially of long bones), extensive soft tissue damage, crush injury. Fractures of distal humerus, proximal tibia = most common

Types of Head InjuriesDiffuse Injury

Concussion May result in postconcussion syndrome Concussion (sudden transient mechanical head injury w/ disruption of neural activity, change in LOC) = minor diffuse head injury. may or may not lose total consciousness Typical s/s of concussion = brief disruption in LOC, amnesia regarding event (retrograde amnesia), headache = short duration. didnt lose consciousness, LOC less than 5 minutes, = discharged w/ instructions to notify HCP if s/s persist or behavioral changes

Interprofessional CareTreatment principlesIntracerebral Hematoma

Concussion and contusion = Observation and management of ICP prevent secondary injury by tx cerebral edema, managing incr ICP

Upper Extremity Immobilization sling

Contraindicated with proximal humerus fracture Ensures axillary area is well padded Encourage movement of fingers and nonimmobilized joints Support the extremity and reduce the effects of edema by maintaining elevation of the extremity with a sling. hanging arm cast = proximal humerus fracture, elevation or a supportive sling is contraindicated bc hanging provides traction, maintains fracture alignment. sling = ensure axillary area is well padded to prevent skin excoriation, maceration associated with direct skin-to-skin contact. Placement of sling should not put undue pressure on neck. movement of the fingers (unless contraindicated) to enhance pumping action of blood vessels to decr edema. actively move nonimmobilized joints of upper extremity to prevent stiffness, contractures.

Coup-Contrecoup Injury

Contusion = range from minor to severe. brain moves inside skull due to high-energy or high-impact injury. Contusions or lacerations occur both at site of direct impact of brain on skull (coup), secondary area of damage on opposite side away from injury (contrecoup) = multiple contused areas. Contrecoup = more severe, overall pt prognosis depends on amount of bleeding around contusion site.

Treatment for Diabetes Insipidus

Cornerstone Treatment: Fluid + Hormone Replacement IV Hypotonic or Dextrose 5% in water (D5W) Hormone Replacement DDAVP: Desmopressin (agent of choice) = Vasopressin IV glucose solutions are used = monitor serum glucose bc hyperglycemia, glycosuria = osmotic diuresis = incr fluid volume deficit. DDAVP = analog of ADH = hormone replacement of choice for central DI. Another ADH replacement drug is aqueous vasopressin. DDAVP = orally, IV, subQ, nasal spray. Assess response to DDAVP by pulse, BP, LOC, I&O, specific gravity. Chlorpropamide and carbamazepine (Tegretol) = decr thirst associated w/ Low Sodium diet no more than 3g/day Thiazide Diuretics NSAID = Indomethacin (Indocin) central DI.

Nursing Assessment Intracerebral Hematoma resp, gi, cardio

Cushing's triad = Impending herniation: systolic HNT w/ widening pulse pressure, bradycardia w/ full/bounding pulse, irregular resp Bowel and bladder incontinence Rhinorrhea, impaired gag, inability to maintain a patent airway, projectile v/

Incomplete SCICentral Cord Syndrome

Damage to central spinal cord Most commonly cervical cord region More common in older adults Motor weakness and sensory loss are present in upper extremities. Lower extremities are not usually affected Dysesthetic burning pain in upper extremities

Incomplete SCIBrown-Séquard Syndrome

Damage to one-half of cord Typically results from penetrating injury Ipsilateral (same side as injury): Loss of motor function and pressure, position, and vibratory sense. Contralteral (opposite side of injury): Loss of light tough, pain, temp sensation below level of injury.

PosturingIntracerebral Hematoma

Decerebrate posturing (extensor) = more serious damage Decorticate posturing (flexor) ICP continues incr = patient manifests changes in motor ability. contralateral (opposite side of mass lesion) hemiparesis or hemiplegia may develop, depending on location of source of the incr ICP. If painful stimuli are used to elicit motor response = pt may localize to stimuli or withdraw from it. Noxious stimuli may also elicit decorticate (flexor) or decerebrate (extensor) posturing Decorticate posture consists of internal rotation, adduction of arms w/ flexion of elbows, wrists, fingers as a result of interruption of voluntary motor tracts in cerebral cortex. Extension of legs may also be seen. decerebrate posture may indicate more serious damage, results from disruption of motor fibers in midbrain, brainstem = arms are stiffly extended, adducted, hyperpronated, hyperextension of legs w/ plantar flexion of feet.

Types of Head Injuries Diffuse Axonal Injury

Decortication, decerebration Global cerebral edema widespread axonal damage occurring after a mild, moderate, severe TBI. damage around axons in subcortical white matter of cerebral hem, basal ganglia, thalamus, brainstem. occur from tensile forces of trauma that sheared axon = axonal disconnection. Incr evidence that axonal damage is not preceded by immediate tearing of axon from traumatic impact = trauma changes function of axon = axon swelling, disconnection takes approximately 12-24 hrs to develop, may persist longer. s/s = decr LOC, incr ICP, decortication or decerebration, global cerebral edema. 90% of pt w/ DAI remain in persistent vegetative state. who survive initial event are rapidly triaged to ICU = watched s/s incr ICP and tx for incr ICP.

Clinical Manifestations Gastrointestinal System SCI

Decr GI motor activity: Gastric distention paralytic ileus Gastric emptying may be delayed (mainly higher level SCI) incr release of HCl = stress ulcers Dysphagia = mechanical ventilation, tracheostomy, anterior spine surgery. Intra Abdominal bleeding = difficult to diagnose = no pain or tenderness. Continued hypotension, decr h/h may indicate bleeding, Expanding girth of abdomen

Bacterial Meningitis Nursing Diagnoses

Decreased intracranial adaptive capacity Risk for ineffective cerebral tissue perfusion Hyperthermia Acute pain

Diabetes Insipidus

Deficiency of ADH (Antidiuretic hormone) from posterior lobe of pituitary Decr ADH decr kidney ability to concentrate urine = excessive diluted urination, excessive thirst, electrolyte imbalance, excessive fluid intake It can be transient or chronic

Diabetic Ketoacidosis (DKA) Clinical manifestations

Dehydration Poor skin turgor Dry mucous membranes Tachycardia Orthostatic hypotension Early symptoms may include lethargy and weakness. As patient becomes severely dehydrated, skin becomes dry, loose eyes become soft, sunken. Abdominal pain, weight loss, nausea/vomiting Kussmaul respirations Sweet, fruity breath odor Blood glucose level of ≥ 250 mg/dL (Lewis) or ≥ 300 (ATI) Blood pH lower than 7.30 Serum bicarbonate level < 16 mEq/L Moderate to high ketone levels in urine or serum Kussmaul respirations (rapid, deep breathing associated with dyspnea) are body's attempt to reverse metabolic acidosis through the exhalation of excess carbon dioxide. Acetone is noted on breath as a sweet, fruity odor.

Complications of Fracture Healing

Delayed union = healing progresses more slowly than expected. Healing eventually occurs. Nonunion = fails to heal despite tx. No x-ray evidence of callus formation. Malunion = heals in expected time but unsatisfactory position, possibly resulting in deformity or dysfunction. Angulation = heals in abnormal position r/t midline of structure (type of malunion). Pseudoarthrosis = Type of nonunion occurring at fracture site, false joint is formed w/ abnormal movement at site. Refracture = new fracture occurs at original fracture site. Myositis ossificans = Deposition of ca in muscle tissue at site of significant blunt muscle trauma or repeated muscle injury

Psychosocial problems fractures

Dependence in performing ADLs Family separation Finances Inability to work Potential disability Short-term rehabilitative goals = transition from dependence to independence in performing simple activities of daily living, preserving or incr strength, endurance. rehabilitative phase = adjust to any problems caused by injury (e.g., separation from family, financial impact of medical care, loss of income from inability to work, potential for lifetime disability).

Acute Complications

Diabetic ketoacidosis (DKA) - type 1, pediatrics Hyperosmolar hyperglycemic syndrome (HHS) - type 2, no acidosis bc little bit of insulin just not enough acute complications of DM arise from events associated w/ hyperglycemia and hypoglycemia. Hyperglycemia = not enough insulin working hypoglycemia = too much insulin working. It is important for HCP to distinguish b/w hyperglycemia and hypoglycemia bc hypoglycemia worsens rapidly and is a serious threat if action is not immediately taken.

Nursing Management: StrokeNursing Diagnoses

Diagnoses include but are not limited to Decreased intracranial adaptive capacity Risk for aspiration Impaired physical mobility Impaired verbal communication Nursing diagnoses for the person with a stroke may include, but are not limited to, the following: Decreased intracranial adaptive capacity related to decreased cerebral perfusion pressure of ≤50-60 mm Hg and sustained increase in ICP secondary to thrombus, embolus, or hemorrhage Risk for aspiration related to decreased level of consciousness and decreased or absent gag and swallowing reflexes Impaired physical mobility related to neuromuscular and cognitive impairment and decreased muscle strength and control Impaired verbal communication related to aphasia Diagnoses include but are not limited to Unilateral neglect Impaired swallowing Situational low self-esteem Unilateral neglect related to visual field cut and loss on one side of body (hemianopsia) and brain injury from cerebrovascular problems Impaired swallowing related to weakness or paralysis of affected muscles Situational low self-esteem related to actual or perceived loss of function and altered body image

Epidural and Subdural Hematomas

Different anatomical locations of epidural, subdural, and subarachnaoid hematomas.

Types of Head Injuries

Diffuse (generalized) Focal (localized) Minor (GCS 13-15) Moderate (GCS 9-12) Severe (GCS 3-8) LOW = MORE COMMATOSE Brain injuries = categorized as diffuse (generalized) or focal (localized). diffuse injury (concussion, diffuse axonal), damage to brain cannot be localized to one particular area of brain. focal injury ( contusion, hematoma), damage localized to specific area of brain.

Factors influencing healing:

Displacement and site of fracture Blood supply to area Immobilization Internal fixation devices = screws, pins Infection or poor nutrition Age Smoking ossification process may be slowed or even stopped by inadequate reduction, immobilization, excessive movement of the fracture fragments, infection, poor nutrition, systemic disease. Healing time for fractures incr w/ age. Smoking incr healing time. Fracture healing may not occur in expected time (delayed union) or may not occur at all (nonunion).

Nursing Management: Stroke Stroke Survivorship and Coping Interventions for atypical emotional response

Distract patient Explain to patient/family that emotional outbursts may occur Maintain a calm enviro Avoid shaming or scolding patient exhibit emotional responses that are not appropriate or typical for situation. apathetic, depressed, fearful, anxious, weepy, frustrated, angry. mood swings = mainly left side of the brain (right hemiplegia) unable to control emotions, burst into tears or laughter. behavior is out of context, often is unrelated to underlying emotional state of pt.

Ambulatory Care Cast Care DO

Do neurovascular assessments Apply ice for first 24 hours Elevate above heart for first 48 hours Exercise joints above and below Use hair dryer on cool setting for itching Check before getting wet Dry thoroughly after getting wet Report incr pain despite elevation, ice, analgesia Report swelling associated with pain, discoloration OR movement Report burning or tingling under cast Report sores or foul odor under cast Blot dry with towel. Regardless of type of cast material = cast can interfere with circulation, nerve function = too tightly, excessive edema elevating extremity above heart level to promote venous return, ice to control or prevent edema compartment syndrome = do not elevate the extremity above heart. Check with HCP before getting fiberglass cast wet.

Ambulatory Care Cast Care DONT

Do not Elevate if compartment syndrome Get plaster cast wet Remove padding Insert objects inside cast - skin breakdown and infection. Cover cast with plastic for prolonged period Do not bear weight on new cast for 48 hr. (Not all casts are made for weight bearing. Check with HCP when unsure.)

Brain AbscessSigns of increased ICP

Drowsiness Confusion Seizures CT and MRI used to diagnose Focal s/s = reflect local area of the abscess. example, visual field defects, psychomotor seizures = common w/ temporal lobe abscess occipital abscess = accompanied by visual impairment, hallucinations.

Nursing Goals DI

Early Detection Maintain adequate hydration Maintain fluid and electrolyte balance

Fracture ReductionOpen reduction

Early ROM of joint to prevent adhesions Facilitates early ambulation Open reduction = correction of bone alignment through surgical incision. internal fixation = use wires, screws, pins, plates, intramedullary rods, nails. risks = infection, complications with anesthesia, effect of preexisting medical conditions (DM). ORIF facilitates early ambulation that decr risk of complications r/t prolonged immobility.

Compartment Syndrome Clinical Manifestations

Early recognition and tx May occur initially or may be delayed several days Ischemia can occur within 4 to 8 hours after onset Six Ps Pain Pressure Paresthesia Pallor Paralysis Pulselessness pain out of proportion to injury, not managed by opioid, pain on passive stretch of muscle traveling through compartment

DKA/HHSNursing Management monitoring and assess

Electrolytes Renal status Cardiopulmonary status Level of consciousness monitor blood glucose, urine output, ketones, lab data IV fluids to correct dehydration insulin therapy = decr glucose, serum acetone electrolytes = correct electrolyte imbalance. Assess renal status, cardiopulmonary status r/t hydration, electrolyte levels. Assess s/s of K imbalance = hypoinsulinemia and osmotic diuresis. tx w/ insulin begins, serum K levels may decr rapidly as K moves into cells once insulin becomes available = movement of K into/out of extracellular fluid influences cardiac functioning. Cardiac monitoring = hyperkalemia, hypokalemia VS = fever, hypovolemic shock, tachycardia, Kussmaul respirations.

Hyperosmolar Hyperglycemic Syndrome (HHS) s/s

Enough circulating insulin to prevent ketoacidosis Fewer symptoms lead to higher glucose levels (>600 mg/dL) main difference b/w HHS and DKA = HHS usually has enough circulating insulin so that ketoacidosis does not occur. bc HHS has fewer s/s in early stages, blood glucose levels can climb high b/f problem is recognized. higher blood glucose levels incr serum osmolality = more severe neuro manifestations = somnolence, coma, seizures, hemiparesis, aphasia. bc manifestations resemble stroke, immediate determination of glucose level is critical for correct dx and tx. Laboratory values = blood glucose level greater than 600 mg/dL (33.33 mmol/L) = bc incr serum osmolality. Ketone bodies = absent or minimal in both blood and urine. as blood glucose rises = keeps getting worse

Nursing EvaluationIntracerebral Hematoma

Expected Outcomes Maintain normal cerebral perfusion pressure Achieve maximal cognitive, motor, and sensory function Experience no infection or hyperthermia

Nursing Management: StrokeAcute CareNeurologic system

Extension of stroke ↑ ICP Vasospasm Recovery from stroke symptoms primary clinical assessment tool neurological status in acute stroke = NIH Stroke Scale (NIHSS) = stroke severity, predictor of both short, long outcomes mental status, pupillary responses, extremity movement/strength, VS decr LOC = incr ICP = cerebral perfusion pressure =if ICU

Nursing Implementation Intracerebral Hematoma Acute Care = increased ICP

Eye problems = loss of corneal reflex, periorbital ecchymosis, edema, diplopia. Loss of corneal reflex = lubricating eye drops, taping eyes shut = abrasion. Periorbital ecchymosis = but cold -->warm compresses Diplopia = eye patch. Hyperthermia = injury to hypothalamus. = 36°to 37°C incr body temp = incr CBF, cerebral blood volume, ICP. Incr metabolism bc hyperthermia incr metabolic waste = cerebral vasodilation. decr temp w/ sedation = prevent shivering.

Nursing Management: Stroke Stroke Survivorship and Coping Family members

Family members = cope w/ 3 aspects of patient's behavior 1. Recognition of behavioral changes resulting from neurologic deficits that are not changeable 2. Responses to multiple losses both by patient and family Three aspects of the patient's behavior 3. Behaviors that may have been reinforced during the early stages of stroke as continued dependency

Bacterial Meningitis Clinical Manifestations

Fever, Severe HA, n/, v/, Nuchal rigidity Coma =poor prognosis photophobia, ↓ LOC s/s of ↑ ICP = Seizures, HA worsens , v/, irritability Meningococcus = skin = petechiae on trunk, lower extremities, mucous membranes. Tumbler test = pressing base of drinking glass against rash, no blanch, fade under pressure.

Events Leading to Second Injury

Figure 60-1 illustrates the cascade of events causing secondary injury following traumatic SCI. The resulting hypoxia reduces the oxygen levels below the metabolic needs of the spinal cord. Lactate metabolites and an increase in vasoactive substances, including norepinephrine, serotonin, and dopamine, occur. High levels of these vasoactive substances cause vasospasms and hypoxia with subsequent necrosis. Unfortunately, the spinal cord has minimal ability to adapt to vasospasm.

Syndromes Associated with Incomplete SCI

Five major syndromes are associated with incomplete injuries: central cord syndrome anterior cord syndrome Brown-Séquard syndrome cauda equina syndrome conus medullaris syndrome This figure shows areas of damage for four of the five syndromes.

Nursing Interventions DI

Fluid Replacement Monitor for Severe Dehydration Monitor Input and Output Monitor Vital signs Monitor LOC Daily Weights

Chronic SIADH Management

Fluid Restrictions (800 - 1000mL/day) Ice Chips Sugarless chewing gun or candies Daily Weight Dietary supp of Na + K Teach s/s electrolyte imbalance chronic SIADH in self-managing tx regimen. supplement diet w/ Na+K, especially if loop diuretics prescribed.

Types of Head InjuriesFocal Injury

Focal injury can be minor to severe and can be localized to an area of injury. Focal injury consists of lacerations, contusions, hematomas, and cranial nerve injuries.

Cardiovascular Instability SCI meds

Frequently assess VS Anticholinergic drug/pacemaker Fluid replacement, vasopressor agent blood loss = h/h, give blood = hypovolemic shock orthostatic BP = Abdominal binders/compression stockings symptomatic bradycardia = admin anticholinergic (atropine) Maintain SBP greater than 90 mm Hg at all times, keep MAP b/w 85-90 mm Hg for first 7 days following SCI. hypotension w/ fluid replacement + vasopressor = phenylephrine (Neo-Synephrine), norepinephrine (Levophed). Ortho hypo = with injury at T6 and above = light headedness, dizziness, n/, lose consciousness. Drugs = incr intravascular volume = salt tablets, fludrocortisone (Florinef). Midodrine (ProAmatine) = promote blood vessel contraction, incr venous return.

Nursing Management: Stroke Planning

Goals include that patient will: maintain stable/improved level of consciousness attain max physical functioning attain max self-care abilities/skills maintain stable body functions (e.g., bladder control) maximize communication abilities maintain nutrition avoid complications of stroke maintain effective personal and family coping. Goals include that patient will: Maximize communication abilities Maintain adequate nutrition Avoid complications of stroke Maintain effective personal and family coping

Interprofessional Care Acute Care for Ischemic Stroke

Goals: Preserving life Preventing further brain damage = decr disability Time of onset of symptoms is critical information

Hemorrhagic StrokeIntracerebral hemorrhage

HNT most common cause Hemorrhage occurs during activity Sudden onset w/ progression over min-hrs Extent of s/s varies, depends on amount, location, duration of bleeding Other causes = vascular malformations, coag disorders, anticoagulant, thrombolytic drugs, trauma, brain tumors, ruptured aneurysms. blood clot w/I closed skull = mass = pressure on brain tissue, displaces brain tissue, decr cerebral blood flow = ischemia/infarction. Manifestations: Neurologic deficits Headache --> n/v (incr pressure) Decr LOC HNT 1/2 of intracerebral hemorrhages occur in putamen, internal capsule, central white matter, thalamus, cerebellar hemispheres, pons. Hemorrhage in pons = most serious bc basic life functions (e.g., respiration) rapidly affected.

Nursing Assessment: SCI Subjective Data

Health history Functional health patterns Health perception-health management: alcohol or recreational drugs; risk-taking behaviors Activity-exercise: Loss of strength, movement, sensation below level of injury; dyspnea, inability to breathe adequately ("air hunger") Cognitive-perceptual: tenderness, pain at or above level of injury; numbness, tingling, burning, twitching of extremities Coping-stress tolerance: Fear, denial, anger, depression

Bacterial MeningitisComplications

Hemiparesis, dysphagia, hemianopsia (decr vision or blindness in half visual field) = resolve over time If they do not, a cerebral abscess, subdural empyema, subdural effusion, or persistent meningitis is suspected.

Infection - fractures

High incidence in open fractures and soft tissue injuries Devitalized and contaminated tissue is an ideal medium for many common pathogens, including gas-forming (anaerobic) bacilli = Clostridrium tetani. Delayed or ineffective tx = chronic osteomyelitis Wound may or may not be closed Closed suction drainage Skin grafting Antibiotics - irrigation, impregnated-beads, IV Open fractures require aggressive surgical debridement. The wound is initially cleaned by pulsating saline lavage in operating room. Gross contaminants are irrigated and mechanically removed. Contused, contaminated, devitalized tissue (muscle, subcutaneous fat, skin, bone fragments) = surgically excised (debridement). extent of the soft tissue damage determines if wound will be closed at time of surgery, if requires repeat debridement, closed suction drainage, skin grafting. Depending on location/extent of fracture = reduction may be maintained by external fixation or traction. During surgery the open wound may be irrigated with antibiotic solution. Antibiotic-impregnated beads = placed in surgical site. patient may have antibiotics administered IV for 3 to 7 days during postoperative phase.

Spinal Cord Injury (SCI)

Highest in men ages 16-30 temporary/permanent alteration in function of spinal cord. incr in # of older adults with SCIs = incr is r/t ppl with SCI living longer, older age at time of injury. ↓Mortality

Lower Extremity Immobilization

Hip spica cast Single spica Double spica extends from above nipple line to base of foot (single spica), may include opposite extremity up to an area above knee (spica and a half) or both extremities (double spica).

Risk FactorsModifiable

Hypertension Heart disease Serum cholesterol Smoking Obesity Sleep apnea Metabolic syndrome Waist to hip circumference Lack of physical exercise Poor diet Drug and alcohol abuse - birth control 90% result of modifiable risk factors. HNT = most important modifiable risk. Heart disease, MI, cardiomyopathy, cardiac valve abnormalities, cardiac congenital defects = risk factor for stroke. Atrial fibr = incr with age. Oral anticoagulants (dabigatran [Pradaxa]), adherence to these = prevention of stroke. risk for stroke = DM is 5x higher than in general pop Smoking 2x risk ischemic stroke, smokers Women who drink more than one alcoholic drink per day, men who drink more than two alcoholic drinks per day = risk for HNT = incr stroke. Illicit drug = cocaine = stroke risk. waist circumference to hip circumference ratio equal to or above mid-value for pop incr risk of ischemic x3, obesity = HNT, high blood glucose, elevated blood lipid levels, all of which incr risk. physical activity light to mod regular activity. American Stroke Association = 40 min of exercise 3 to 4 days per wk = reduce risk. diet high in fat, low in fruits /veggie = incr stroke risk. Women + migraine + aura = incr risk, American Heart Association = no smoking, alternatives to estrogen oral BC = decr risk stroke. Incr risk = inflammatory conditions (rheumatoid arthritis), sickle cell disease, lack of exercise, obesity.

Causes of SIADH Miscellaneous Conditions

Hypothyroidism Chronic obstructive pulmonary disease Positive pressure mechanical ventilation HIV Adrenal insufficiency SIADH, Syndrome of inappropriate antidiuretic hormone. Lung infection (pneumonia, tuberculosis, lung abscess)

Health Promotion SCI

Identify High-risk populations Counseling Teaching Support legislation to Prohibit texting while driving, use of seat belts in cars, helmets- motorcyclists/ bicyclists child safety seats tougher penalties for drunk-driving

Nursing Management: Stroke Ambulatory Care Musculoskeletal Function

If muscles are still flaccid several weeks after stroke, prognosis for regaining function is poor Focus = preventing additional loss Most patients show signs of spasticity with exaggerated reflexes within 48 hours following stroke small voluntary movements of hip/shoulder = involuntary movements in rest of extremity (synergy). final stage of recovery occurs when patient has voluntary control of isolated muscle groups. Balance training: Bobath = gain control over patterns of spasticity by inhibiting abnormal reflex patterns = normal muscle tone, normal movement, promotion of bilateral function of body. example = transfer into wheelchair using weak or paralyzed side, stronger side to facilitate more bilateral functioning. Constraint-induced movement therapy (CIMT) = weakened extremity by restricting movement of normal extremity. Supportive/assistive equipment = canes, walkers, leg braces = short/long-term Incorporate PT activities into daily routine

Nursing Management: Stroke Nursing Assessment

If stable: Hx of s/s previously experienced Current med Hx risk factors = HNT FMH of stroke, aneurysm, cardio disease 2nd assessment includes a comprehensive neurologic examination LOC = Include NIH Stroke Scale Cognition Motor abilities Cranial nerve function Sensation - dull, sharp Proprioception - gait, mobility Cerebellar function Deep tendon reflexes

Diabetic Ketoacidosis (DKA) Precipitating factors

Illness Infection Inadequate insulin dosage Undiagnosed type 1 diabetes Poor self-management Neglect

Interprofessional CarePrehospitalSCI

Immediate goals: Patent airway Adequate ventilation/breathing Adequate circulating blood volume (ABGs) Prevent extension of spinal cord damage (secondary injury) Immobilization: Rigid cervical collar supportive blocks on a backboard with straps Spinal immobilization with sandbags and tape is insufficient, and is not recommended with penetrating trauma not recommended Spinal immobilization in pt w/ penetrating trauma = not recommended bc of incr mortality. concern during initial management of pt w/ potential cervical spinal injuries is impairment of neurologic function due to movement of injured vertebrae. Systemic/neurogenic shock = tx to maintain systolic BP >90. Following cervical injury, all body systems must be maintained until the full extent of the damage can be evaluated.

Bladder Management

Immediately after injury, urine is retained bc of loss of autonomic, reflex control of bladder + sphincter (neurogenic bladder). bc no sensation of fullness, overdistention = reflux into kidney = renal failure. Bladder overdistention = rupture of bladder = indwelling catheter patency of catheter = inspection and irrigation = some institutions physician's order is required for this procedure. During period of indwelling cath = large fluid intake. Check catheter to prevent kinking, ensure free flow of urine. CAUTI = common problem = preventing UTIs = regular, complete bladder drainage. After pt stabilized = best means of managing long-term urinary function = Usually patient is started on intermittent cath program. Intermittent cath = 4-6 times daily = prevent bacterial overgrowth resulting from urinary stasis, Keep urine residuals under 500 mL to prevent bladder distention. If urine is cloudy, strong odor, chills, fever, malaise = send a specimen for culture.

Preoperative Care Patient Teaching fractures

Immobilization Assistive devices Expected activity limitations Pain medication Monitor vitals neurovascular assessments Monitor for bleeding or drainage Aseptic technique Blood salvage and reinfusion Closely monitor any limitations of movement or activity related to turning, positioning, and extremity support. Pain = minimized through proper alignment and positioning. blood salvage and reinfusion system = recovery and reinfusion of the patient's own blood may be used. blood is retrieved from a joint space or cavity, and patient receives this blood in form of an autotransfusion.

Upper Extremity Immobilization

Immobilization of an acute fracture or soft tissue injury of the upper extremity: Sugar-tong splint Posterior splint Short arm cast Long arm cast Sling to elevate and support arm Contraindicated with proximal humerus fracture sugar-tong splint = acute wrist injuries, injuries result in significant swelling. Splints = phalangeal joints of hand, extending up dorsal aspect of forearm around distal humerus and down volar aspect of the forearm to distal palmar crease. splinting material is wrapped with either elastic bandage or bias stockinette, accommodating early swelling in fractured extremity. short arm cast = stable wrist, metacarpal fractures. aluminum finger splint can be incorporated into short arm cast for concurrent tx of phalangeal injuries. provides wrist immobilization, permits unrestricted elbow motion. long arm cast = forearm or elbow fractures, unstable wrist fractures. similar to short arm cast but extends to proximal humerus, restricting motion at wrist and elbow.

Nursing Diagnoses - fractures

Impaired physical mobility Risk for peripheral neurovascular dysfunction Acute pain Readiness for enhanced health management Nursing diagnoses for the patient with a fracture may include, but are not limited to, the following: Impaired physical mobility related to loss of integrity of bone structures, movement of bone fragments, and prescribed movement restrictions Risk for peripheral neurovascular dysfunction related to vascular insufficiency and nerve compression secondary to edema and/or mechanical compression by traction, splints, or casts Acute pain related to edema, movement of bone fragments, and muscle spasms Readiness for enhanced health management

Nursing Management: StrokeAmbulatory Care Toileting interventions

Implement a bowel management program for prob with Bowel control Constipation Incontinence High-fiber diet and adequate fluid intake c/, responds to following dietary management: Fluid intake of 2500 to 3000 mL daily unless contraindicated Prune juice (120 mL) or stewed prunes daily Cooked fruit 3 times daily Cooked veggies 3 times daily Whole-grain cereal or bread 3-5 times daily

Carotid Endarterectomy

In a carotid endarterectomy (CEA), the atheromatous lesion is removed from the carotid artery to improve blood flow. Carotid endarterectomy is performed to prevent impending cerebral infarction. A, A tube is inserted above and below the blockage to reroute the blood flow. B, Atherosclerotic plaque in the common carotid artery is removed. C, Once the artery is stitched closed, the tube can be removed. A surgeon may also perform the technique without rerouting the blood flow.

Most obvious effect of stroke

Include impairment of Mobility Respiratory function Swallowing and speech Gag reflex Self-care abilities Symptoms are caused by the destruction of motor neurons in the pyramidal pathway (nerve fibers from the brain that pass through the spinal cord to the motor cells).

Electric Bone Growth Stimulation

Incr calcium uptake Activate intracellular calcium stores Incr bone growth factor production (e.g., bone morphogenic protein). Non-invasive, semi-invasive, invasive methods used to facilitate healing process for certain types of fractures, especially fracture nonunion or delayed union. Non-invasive stimulators = pulsed electromagnetic fields (PEMFs) to generate weak current, band over skin/cast worn 10 -12 hrs day, while sleeping. Semi-invasive or percutaneous = external power supply, electrodes inserted through skin, into bone. Invasive bone growth stimulators require surgical implantation of current generator in IM or subQ. electrode is implanted in bone fragments.

Bacterial Meningitis Nursing Assessment

Initial assessment should include Vital signs Neurologic assessment Fluid intake and output Evaluation of lungs and skin

Clinical ManifestationsCardiovascular System

Injury above T6 leads to dysfunction of sympathetic nervous system Leads to neurogenic shock: Bradycardia Peripheral vasodilation Hypotension Relative hypovolemia bc of ↑ in capacity of dilated veins Reduced venous return decreasing cardiac output Peripheral vasodilation--> hypovolemia bc incr capacity of dilated veins. reduces venous return of blood to heart = CO decr = hypotension. Other injuries can also cause hemorrhagic shock = further decr BP

Traction

Inspect exposed skin Monitor pin sites for infection Pin site care per policy Proper positioning Exercise as permitted Psychosocial needs slings are used with traction, regularly inspect exposed skin areas. skin pressure may impair blood flow = injury to peripheral neurovascular structures. skeletal traction or external fixation pin sites for signs of infection = chlorhexidine, rinsing pin sites sterile saline, drying of area with sterile gauze. External rotation of affected extremity is a classic assessment finding for patient with unrepaired hip fracture. If skin traction is ordered preoperatively, apply traction w/o attempting to reposition or realign extremity. Keep patient in center of bed in supine position = countertraction. prolonged immobility = simple exercise regimen based on activity restrictions. frequent position changes, ROM exercises of unaffected joints, deep-breathing exercises, isometric exercises, trapeze bar (if permitted) to raise body off bed for linen changes, bedpan.

Internal Fixation

Internal fixation devices (pins, plates, intramedullary rods, and metal and bioabsorbable screws) are surgically inserted to realign, maintain position of bony fragments. metal devices are biologically inert, made from stainless steel, vitallium, or titanium. Proper alignment, bone healing are evaluated regularly by x-rays.

Types of Head InjuriesLacerations

Intracerebral hemorrhage Subarachnoid hemorrhage Intraventricular hemorrhage actual tearing of brain tissue = occur in association w/ depressed, open fractures, penetrating injuries. Tissue damage is severe, surgical repair = impossible due to nature of brain tissue. antibiotics until meningitis is ruled out, preventing secondary injury r/t incr ICP. Intracerebral hemorrhage is generally associated w/ cerebral laceration. hemorrhage manifests as space-occupying lesion accompanied by unconsciousness hemiplegia on contralateral side, dilated pupil on ipsilateral side. hematoma expands, s/s incr ICP = more severe. Subarachnoid hemorrhage, intraventricular = secondary to head trauma.

Hemorrhagic StrokeSubarachnoid hemorrhage (SAH)

Intracranial bleeding into cerebrospinal fluid-filled space b/w arachnoid and pia mater Commonly caused by rupture of a cerebral aneurysm, trauma, drug abuse

Interprofessional Care Emergency Treatment Intracerebral Hematoma

Intubate if GCS <8/no gag Administer O2 via non-rebreather mask. IV access w/ 2 large-bore = NS or LR Control external bleeding = sterile pressure dressing. Remove clothing. Assume neck injury!!! Admin fluids cautiously = bc incr in intracranial pressure warmth using blankets, warm IV fluids, warming lights, warm humidified O2. VS, LOC, O2 saturation, cardiac rhythm, pupil size, reactivity. Assess for rhinorrhea, otorrhea, scalp wounds.

Stroke

Ischemia to part of brain Hemorrhage into brain = results in death of brain cells Also known as Brain attack Cerebrovascular accident brain requires continuous supply of blood to provide oxygen, glucose = neurons need to function. stroke occurs interruption, either from ischemia to part of brain or hemorrhage into brain, blood supply that results in death of brain cells. brain attack communicates urgency of recognizing warning signs of a stroke, tx it as a medical emergency, similar to heart attack. Severity of loss of function varies according to location and extent of brain damage = Physical, cognitive, and emotional impact on patient and family In a stroke, functions such as movement, sensation, thinking, talking, or emotions that were controlled by the affected area of the brain are lost or impaired. Common long-term disabilities include hemiparesis (partial paralysis on one side), inability to walk, complete or partial dependence for activities of daily living (ADLs), aphasia, depression. 5th most common cause of death in the United States Leading cause of serious, long-term disability Lifelong change for survivor and family aging population = incr incidence

Bacterial Meningitis Etiology and Pathophysiology

Leading causes of bacterial meningitis: Streptococcus pneumoniae Neisseria meningitidis Organisms enter CNS through upper respiratory tract or bloodstream, skull wounds or fractured sinuses Neisseria meningitides has at least 13 different subtypes (serogroups) w/ 5 of them (A, B, C, Y, W) causing most cases. Haemophilus influenzae = was most common cause. H. influenzae vaccine = significant decr in meningitis r/t this organism.

Diabetic Ketoacidosis (DKA) where to be tx

Less severe form tx on outpatient basis Hospitalize for severe fluid and electrolyte imbalance, fever, n/v,d, altered mental state Before advent of self-monitoring of blood glucose, pt w/ DKA required hospitalization for tx. Other considered: fever, n/v,d; altered mental status; nature of cause of ketoacidosis; availability of frequent communication with HCP (every few hours). Patients w/ DKA who have illness such as pneumonia or a UTI = admitted to the hospital.

Hyperosmolar Hyperglycemic Syndrome (HHS)

Life-threatening syndrome - creeping up BS over long time Occurs w/ type 2 diabetes Precipitating factors UTIs, pneumonia, sepsis Acute illness Newly diagnosed type 2 diabetes Impaired thirst sensation and/or inability to replace fluids patient w/ diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, extracellular fluid depletion. HHS is less common than DKA occurs in patients older than 60 years w/ type 2 diabetes. HHS r/t impaired thirst sensation, functional inability to replace fluids. usually a hx of inadequate fluid intake, incr mental depression, polyuria.

Clinical Manifestations of fractures

Localized pain Decreased function Inability to bear weight or use Guard against movement May or may not have deformity If fracture suspected, extremity is immobilized in position in which it is found. Unnecessary movement incr soft tissue damage, may convert a closed fracture to an open fracture or create further injury to adjacent nerves and blood vessels.

Lower Extremity Immobilization

Long leg cast Short leg cast Cylinder cast Robert Jones dressing lower extremity = immobilized by long leg cast, short leg cast, cylinder cast, prefabricated splint, immobilizer. long leg cast = unstable ankle fracture, soft tissue injuries, fractured tibia, knee injuries. cast usually extends from base of toes to groin and gluteal crease. short leg cast is used primarily used for stable ankle and foot injuries. cylinder cast = knee injuries or fractures, extends from groin to malleoli of ankle. A Robert Jones dressing = temporarily limit mobility of joint.soft padding materials (absorption dressing and cotton sheet wadding), splints, elastic wrap or bias-cut stockinette. Elevate extremity above heart Do not place in a dependent position Observe for signs of compartment syndrome, incr pressure After application of lower extremity cast or dressing = elevated on pillows above heart level for first 24 hours. After initial phase, casted extremity should not be placed in a dependent position bc possibility of excessive edema. After cast application = s/s compartment syndrome, incr pressure, especially in heel, anterior tibia, head of fibula, malleoli. incr pressure is manifested by pain or burning in areas. no pulse is late s/s necrosis in 4-6hrs

Traction - Skeletal traction

Long-term pull to maintain alignment Weights 5 to 45 lbs Risk for infection Complications of immobility treat joint contractures and congenital hip dysplasia. To apply skeletal traction, surgeon inserts a pin or wire into bone, weights are attached to align, immobilize injured body part. use of too much weight can result in delayed union or nonunion.

Clinical ManifestationsMotor Functionstroke

Loss of skilled voluntary movement = Akinesia Impairment of integration of movements Alterations in muscle tone, reflexes Changes from hyporeflexia to hyperreflexia Initial depressed reflexes progresses to hyperactive reflexes for most pt initial period of flaccidity = r/t nerve damage May last from days to several wks Spasticity of muscles follows flaccid stage = r/t interruptions of upper motor neuron influence bc pyramidal pathway crosses at level of medulla = lesion on one side of brain affects motor function on opposite side of body (contralateral).

Clinical Manifestations SIADH

Low Urine Output and Incr Body Weight Initial Findings: Thirst Dyspnea on Exertion Fatigue this weight gain will be w/o edema.

Interprofessional CareDrug TherapySCI

Low-molecular-weight heparin (e.g., enoxaparin [Lovenox]) = prevent VTE unless contraindicated = internal bleeding, abnormal kidney function, recent surgery. Vasopressor agents = phenylephrine (Neo-Synephrine), norepinephrine (Levophed), = acute phase as adjuvants to tx. maintain MAP at level greater than 85-90 mm Hg = incr perfusion to spinal cord. vasopressors = significant risk of complications = ventricular tachycardia, troponin elevation, metabolic acidosis, afib. drug metabolism altered in pt w/ SCI = drug interactions occur. correlate w/ level completeness of injury cervical cord injury than injury at lower spinal levels.

stroke dx

MRI/CT = edema, ischemia, necrosis MRA - hem, abnormal vessel structures, vessel rupture lumbar puncture - blood in spinal fluid + = hem or rupture gcs = decr LOC, incr ICP

Skeletal Traction

Maintain countertraction, typically patient's own body weight Elevate end of bed Maintain continuous traction Keep weights off the floor Fracture alignment depends on correct positioning, alignment of patient while traction forces remain constant. For extremity traction to be effective, forces must be pulling in opposite direction (countertraction). Countertraction is commonly supplied by the patient's body weight or by weights pulling in the opposite direction, may be augmented by elevating end of the bed.

Acute CareImmobilization SCI

Maintain neutral position Stabilize to prevent lateral rotation = Hard cervical collar or Backboard Keep body in correct alignment Proper immobilization of neck = maintain neutral position. hard cervical collar and backboard = stabilize neck = prevent lateral rotation of cervical spine. Turn the patient as a unit (i.e., logrolling) to prevent movement of the spine.

Hemorrhagic StrokeCerebral aneurysm

Majority are in Circle of Willis Incidence ↑ with age; incr in women Silent killer - no warning until ruptuered LOC may / not occur High mortality rate Aneurysms = saccular or berry aneurysms = few millimeters to 20 -30 mm in size, or fusiform atherosclerotic aneurysms. causes = trauma , illicit drug (cocaine) . warning s/s if ballooning artery applies pressure to brain tissue, minor warning s/s may result from leaking of aneurysm b/f major rupture. Other symptoms include focal neurologic deficits (including cranial nerve deficits), n/v, seizures, stiff neck. Complications of aneurysmal subarachnoid hemorrhage include rebleeding b/f surgery or other therapy is initiated, cerebral vasospasm (narrowing of blood vessels), can result in cerebral infarction. Despite better surgical techniques/management = pt w/SAH die. Some die immediately when rupture occurs. Others die from subsequent bleeding. Survivors = significant morbidity, cognitive difficulties.

Complications of Fractures

Majority heal without complication Complications of fracture or immobility Death after a fracture is usually the result of damage to underlying organs and vascular structures or from complications of the fracture or immobility. Complications of fractures may be direct or indirect. Direct complications = bone infection, bone union, avascular necrosis. Indirect complications of fractures are associated with blood vessel and nerve damage resulting = compartment syndrome, VTE, FES, breakdown of skeletal muscle (rhabdomyolysis), hypovolemic shock. Most musculoskeletal injuries are not life-threatening. open fractures or fractures accompanied by severe blood loss, fractures that damage vital organs (e.g., lung, heart) =medical emergencies

Fractures

Majority of fractures from traumatic injuries fracture is disruption or break in continuity of structure of bone traumatic injuries =majority of fractures some fractures are 2nd to disease process (pathologic fractures from cancer or osteoporosis).

Interprofessional Care for Stroke Health Promotion

Management of modifiable risk factors: Healthy diet Weight control Regular exercise No smoking Limiting alcohol consumption BP management Routine health assessments Primary prevention is priority for decr morbidity and mortality risk from stroke. goals of stroke prevention include health promotion for healthy lifestyle, management of modifiable risk factors to prevent a stroke. pt w/ known risk factors such as DM, HNT, obesity, high serum lipids, cardiac dysfunction require close management.

Manifestations of Right-Brain andLeft-Brain Stroke

Manifestations related to right- and left-brain damage differ somewhat. right side - hemiplegia, paralyzed left side, left side neglect, spatial perceptutal deficits, deny or minimize probs, rapid performance, short attention span, impulseive, saftey probs, impaired judgement, impaired time concepts left brain = paralyzes right side = hemiplegia, impaired speech/language aphasia, impaired r/l discrimination, slow performance, cautionous, aware of deficits - depression, anxiety, impaired comprehension r/t language, math

Mechanisms of Injury

Many situations may produce these injuries. This only shows some examples. A, Flexion injury of the cervical spine ruptures the posterior ligaments. B, Hyperextension injury of the cervical spine ruptures the anterior ligaments. C, Compression fractures crush the vertebrae and force bony fragments into the spinal canal. D, Flexion-rotation injury of the cervical spine often results in tearing of ligamentous structures that normally stabilize the spine.

ComplicationsSubacute Subdural Hematoma

May appear to enlarge over time Aoccurs within 2 to 14 days of the injury. After initial bleeding, may appear to enlarge over time, breakdown products of blood draw fluid into subdural space.

Nursing Management: StrokeAcute CareRespiratory system

May require endotracheal intubation, mechanical ventilation elders, immobility incr risk for atelectasis, pneumonia. aspiration pneumonia = impaired consciousness or dysphagia. kept NPO until dysphagia has been ruled out. frequent assessment of airway Oral care = Q2 for mechanical ventilation = decr ventilator-assisted pneumonia.

Hyperosmolar Hyperglycemic Syndrome (HHS) emergency

Medical emergency High mortality rate Therapy similar to that for DKA IV insulin and NaCl infusions More fluid replacement needed Monitor serum potassium and replace as needed Correct underlying precipitating cause management of DKA and that of HHS are similar immediate IV admin insulin and either 0.9% or 0.45% NaCl. HHS needs greater volumes of fluid replacement = slowly and carefully. pt w/ HHS = older, cardiac or renal compromise, necessitating hemodynamic monitoring to avoid fluid overload during fluid replacement. blood glucose levels fall to approximately 250 mg/dL (13.9 mmol/L), IV fluids containing dextrose are admin = prevent hypoglycemia. Electrolytes are monitored and replaced as needed. Hypokalemia is not as significant in HHS as it is in DKA, although fluid losses may result in milder potassium deficits that necessitate replacement. Assess VS, I&O, tissue turgor, lab values, cardiac monitoring = fluid and electrolyte replacement. includes monitoring of serum osmolality, frequent assessment of cardiac, renal, mental status. Once pt is stabilized, attempts to detect, correct underlying precipitating cause should be initiated.

External Fixation

Metal pins and rods Applies traction Compresses fracture fragments Immobilizes and holds fracture fragments in place external fixator = metallic device composed of metal pins that are inserted into bone and attached to external rods to stabilize fracture while it heals. used to apply traction or compress fracture fragments, immobilize reduced fragments when the use of a cast or other traction is not appropriate. external device holds fracture fragments in place similar to a surgically implanted internal device. A, Stabilization of hand injury. B, Stabilization of knee injury with pins in femur and tibia. external fixator is attached directly to bones by percutaneous transfixing pins or wires. Assess for pin loosening, infection Patient teaching Pin site care External fixation is often used in an attempt to salvage extremities that otherwise might require amputation. bc use of an external device is long-term process, ongoing assessment for pin loosening and infection is critical. Infection (indicated by exudate, erythema, tenderness, and pain) = removal of device. Instruct patient/caregiver about meticulous pin care. Although each physician has a protocol for pin care cleaning, chlorhexidine 2mg/ml is often used.

Clinical Manifestations SIADH Hyponatremia

Mild: Muscle cramping Irritable HA More Severe (120MEq/L [120mmol/L]): Cerebral edema Lethargy Confusion Seizures Coma

Inflammatory Brain Disorders

Most common inflammatory conditions of brain, spinal cord Brain abscesses, Meningitis, Encephalitis Inflammation = caused by bacteria, viruses, fungi, chemicals (e.g., contrast media used in dx tests, blood in subarachnoid space). CNS infections may occur via bloodstream, by extension from primary site, along cranial, spinal nerves. long-term neurologic deficits = hearing loss.

ComplicationsSubdural Hematoma

Most common source = Veins that drain brain surface into sagittal sinus Can also be arterial b/w dura mater and arachnoid hematoma may be slower to develop. = acute, subacute, chronic.

Risk Factors of stroke

Most effective way to decrease burden of stroke is prevention and teaching non-modifiable and modifiable risks risk increases with multiple risk factors Primary prevention of stroke, and reduction of these risk factors, can dramatically reduce the morbidity and mortality of stroke.

Nursing Implementation Intracerebral Hematoma Acute rehabilitation

Motor and sensory deficits Communication issues Memory and intellectual functioning chronic probs r/t motor, sensory deficits, communication, memory, intellectual functioning. poor nutritional status, bowel, bladder management, spasticity, dysphagia, DVT, hydrocephalus. outward physical appearance = not reflect what happened in brain.

Incomplete SCIAnterior Cord Syndrome

Motor paralysis, loss of pain, temp sensation below level of injury due to flexion injury. bc posterior cord tracts are not injured, sensations of touch, position, vibration, and motion remain intact.

Interprofessional CareAcute Care sci

Move patient in alignment as a unit (logroll) Monitor respiratory, cardiac, urinary, GI functions patient may go directly to surgery after initial immobilization or to ICU for monitoring/management.

Fracture Healing

Multistage healing process (union) Bone goes through a complex multistage healing process (union) that occurs in following stages: Fracture hematoma: bleeding creates a hematoma that surrounds ends of fragments. Occurs in first 72 hours after injury. Granulation tissue. Active phagocytosis absorbs products of local necrosis. hematoma converts to granulation tissue (consisting of new blood vessels, fibroblasts, osteoblasts), forms basis for new bone substance called osteoid during days 3 to 14 after injury. Callus formation: As minerals (ca, phosphorus, mg), new bone matrix are deposited in osteoid, an unorganized network of bone is formed, woven about fracture parts. Callus is primarily composed of cartilage, osteoblasts, calcium, phosphorus, usually appears by end of 2nd wk after injury. Callus formation can be verified by x-ray. Ossification: Occurs from 3 weeks to 6 months after fracture and continues until fracture has healed. Callus ossification is sufficient to prevent movement at fracture site when bones are gently stressed. fracture is still evident on x-ray. During this stage of clinical union, pt limited mobility or cast may be removed. Consolidation: callus continues to develop, distance b/w bone fragments decr, eventually closes. ossification continues, equated w/ radiologic union = when x-ray shows complete bony union. up to a year following injury. Remodeling: Excess bone tissue is reabsorbed in final stage of bone healing, union is completed. Gradual return of injured bone to its preinjury structural strength, shape occurs. Bone remodels in response to physical loading stress (Wolf's law). stress is provided through exercise. Weight bearing gradually introduced. New bone is deposited in sites subjected to stress, resorbed at areas of little stress.

Pain ManagementSCI

Musculoskeletal nociceptive pain = Antiinflammatory drugs, Opioids Visceral nociceptive pain = dx imaging to evaluate cause Musculoskeletal nociceptive = injuries to bones, muscles, ligaments. dull, aching pain is aggravated w/ movement or palpation. Antiinflammatory = ibuprofen (Motrin). Opioids = manage nociceptive pain. Visceral nociceptive pain = dull, tender, cramping in thorax, abdomen, pelvis, result from bladder/bowel. bowel, bladder function to avoid bladder distention, c/. Other causes of nociceptive pain include UTI, ureteral calculus. Neuropathic pain = initial phase = at level of SCI. one or both sides of body w/i affected dermatome, up to 3 levels below = hot, burning, tingling, shooting, electric pain. Gabapentin (Neurontin), pregabalin (Lyrica) = reduce pain. Neuropathic pain can occur months or yrs after SCI, become chronic, permanent. pt mood can affect pain, sudden noise, c/, infections. Tx - tricyclic antidepressants, intrathecal med, antiseizure drugs, epidural stimulation, destructive surgical intervention.

Compartment SyndromeInterprofessional Care

NO elevation above heart NO ice Surgical decompression (fasciotomy) application of cold compresses = vasoconstriction, exacerbate compartment syndrome. Infection = fasciotomy. compartment syndrome = amputation may be required.

Clinical Manifestations of Stroke

Neural tissue destruction is basis for neurologic dysfunction Affects many body functions r/t artery involved and area/half of brain it supplies Time of the onset of s/s /length of period of ischemia is important Neuro manifestations no differ b/w ischemic and hemorrhagic stroke. assessment + ask time of the onset of symptoms = effects tx effect motor, bladder, bowel, intellectual function, spatial-perceptual alterations, personality, affect, sensation, swallowing, communication.

Clinical ManifestationsUrinary System

Neurogenic bladder = Bladder dysfunction r/t abnormal/absent bladder innervation No reflex detrusor contractions (flaccid, hypotonic) Hyperactive reflex detrusor contractions (spastic) Lack of coordination b/w detrusor contraction, urethral relaxation (dyssynergia) Neurogenic bladder describes any type of bladder dysfunction r/t abnormal/absent bladder innervation. After spinal cord shock resolves, depending on completeness of SCI, pt usually have some degree of neurogenic bladder. Normal voiding requires nervous system coordination of urethral, pelvic floor relaxation, w/ simultaneous contraction of detrusor muscle. Common problems w/ neurogenic bladder = urgency, frequency, incontinence, inability to void, high bladder pressures =reflux of urine into kidneys. Acute phase = Urinary retention spinal shock, bladder is atonic, becomes overdistended, fails to empty = indwelling catheter postacute phase of SCI = bladder hyperirritable. A loss of inhibition from brain resulting in reflex emptying, failure to store urine, urinary incontinence.

Bowel ManagementSCI

Neurogenic bowel initially Adequate fluid and fiber intake Incr activity and exercise c/ during spinal shock bc no voluntary/involuntary (reflex) evacuation of bowels occurs (neurogenic bowel). bowel program should be started during acute care = choosing rectal stimulant (suppository or small-volume enema) inserted daily at regular time of day followed by gentle digital stimulation or manual evacuation until evacuation is complete. Initially program may be done in bed in side-lying position. as soon as patient resumed sitting = upright position on padded bedside commode chair. typically require 30-60 min c/ can be reduced w/ adequate fluid intake, a healthy diet of fiber and vegetables, and increased activity and exercise.

ComplicationsEpidural Hematoma

Neurologic emergency b/w dura, inner surface of skull. associated w/ linear fracture venous hematomas = w/ tear of dural venous sinus, develop slowly. arterial hematomas = middle meningeal artery lying under temporal bone torn. Classic signs = unconsciousness, w/ brief lucid interval, decr LOC. HA, n/v Rapid surgical intervention to evacuate hematoma, prevent cerebral herniation, medical management for incr ICP

Clinical ManifestationsPainSCI

Nociceptive pain = develop from musculoskeletal, visceral, other types of injury (e.g., skin ulceration, headache. describe musculoskeletal pain as dull or aching. starts or worsens w/ movement. Visceral pain is located in thorax, abdomen, pelvis, may be dull, tender, or cramping. Neuropathic pain in SCI occurs from damage to spinal cord or nerve roots. pain can be located at or below level of injury. extremely sensitive to stimuli = light touch = pain.

Interprofessional Care Nonoperative Stabilization SCI

Nonoperative tx = stabilization spinal segment, decompression, traction or realignment. Stabilization = eliminate damaging motion at injury site, prevent secondary spinal cord bc narrowing of spinal canal, continued contusion/compression of spinal cord at level of injury. Early realignment of unstable fracture-dislocation injury by closed reduction through craniocervical traction has been found to be effective and safe.

Nursing Management: Stroke Stroke Survivorship and Coping Community Integration

Nurse case managers, home health nurses, discharge planners, clinical nurse specialists National and local help is available community integration following stroke = difficult for pt bc persistent prob w/ cognition, coping, physical deficits, emotional changes Older patients who have had stroke often have more severe deficits, frequently experience multiple health problems. Community resources = National Stroke Association provides info, resources, referral services, quarterly newsletters on stroke. American Stroke Association = division of American Heart Association, has information regarding stroke, HNT, diet, exercise, assistive devices. Easter Seal Society = wheelchairs, assistive devices for stroke patients. Local groups = daily assistance such as meals, transportation.

Nursing DiagnosesIntracerebral Hematoma

Nursing diagnoses and a potential complication for the patient who has sustained a head injury may include, but are not limited to, the following: •Risk for ineffective cerebral tissue perfusion related to interruption of CBF associated w/ cerebral hemorrhage, hematoma, edema • Hyperthermia related to increased metabolism, infection, and hypothalamic injury • Impaired physical mobility related to decreased LOC • Anxiety related to abrupt change in health status, hospital environment, and uncertain future • Potential complication: increased ICP related to cerebral edema and hemorrhage

Fluid and Nutritional Maintenance sci

Nut started within 72 hours = Individualized solutions/additives Possible parenteral nutrition first 48 to 72 hrs after injury = GI tract may stop functioning (paralytic ileus) = need NGT = bc cannot have oral intake, monitor fluid/electrolyte Due to severe catabolism = high-protein, high-calorie =energy + tissue repair. parenteral nutrition = decr nitrogen losses that occur during hypermetabolic experience anorexia = depression, boredom w/ institutional food, discomfort at being fed (hurried nurse). refusal to eat is used as means of maintaining control over enviro bc of diminished or absent body control. make contract w/ patient w/ mutual goal setting for diet. This contract gives patient incr control of situation = improved nut intake. calorie count, record patient's daily weight = evaluating progress. Pt should participate in recording calorie intake. Dietary supplements incr dietary fiber = bowel function. Avoid allowing patient's nut intake to become basis for power struggle.

Ischemic StrokeThrombotic stroke

Occurs from injury to a blood vessel wall and form a blood clot = narrowing of blood vessel Most common cause of stroke (60%) associated w/ HTN and DM Many times they are preceded by TIA lumen of the blood vessel becomes narrowed, if becomes occluded = infarction. Thrombosis develops readily where atherosclerotic plaques have already narrowed blood vessels. Extent of stroke depends on Rapidity of onset Size of damaged area Presence of collateral circulation extent of stroke depends on rapidity of onset, size of damaged area, presence of collateral circulation. ischemic stroke do not have a decr LOC in first 24 hrs, unless brainstem stroke, seizures, incr ICP, hemorrhage. s/s progress in first 72 hrs as infarction and cerebral edema incr

Nursing Management: Stroke Acute Care Coping

Often a family disease Affects family Emotionally Socially Financially Changing roles and responsibilities usually a sudden, extremely stressful event for patient, caregiver, family, significant others. fear, apprehension, denial of severity of stroke, depression, anger, sorrow. During acute phase = stroke pt, caregiver, family, nursing interventions designed to facilitate coping involve providing info, emotional support Explanations to patient about what has happened, about diagnostic, therapeutic procedures should be clear, understandable Decision making/upholding patient's wishes during this challenging time are of upmost importance. Advance directives should be honored, family meetings/updates held daily about feeding tube placement or tracheostomy. Patient's family = careful, detailed explanation of what has happened to patient Family members usually have not had time to prepare for illness Social services referral is often helpful If family is extremely anxious, upset during acute phase, explanations may need to be repeated at later time.

Cranial nerves

Oh- Olfactory = smell Oh- Optic = snellen Oh- Oculomotor = follow the finger To - Trochlear = look down at nose Touch- Trigeminal = facial sensations/chewing And- Abducens = lateral eye movement Feel- Facial = smile, raise eye brows Virgin- Vestibulocochlear = tuning fork, balance, heal to shin Girls- Glossopharyngeal = gag Vaginas- Vagus = swallowing, say ahhh And- Accessory = shoulder shrug Hymens- Hypoglossal = stick out tongue

Health Promotion Health PromotionIntracerebral Hematoma

One of best ways to prevent head injuries is to prevent car, motorcycle accidents. helmets by cyclists has led to fewer TBIs. use of car seat belts, use of child car seats are also associated w/ reduced TBI mortality rates. Protective helmets should also be worn by lumberjacks, construction workers, athletes who play contact sports, miners, horseback riders, bicycle riders, snowboarders, skiers, skydivers. Additionally, ppl who are at risk for falls (e.g., older adults) should be evaluated for safety in home, as falls are 2 leading cause of head injuries.

Etiology and PathophysiologySecondary Injury

Ongoing, progressive damage that occurs after initial injury Several theories exist on what causes ongoing damage Free radical formation Lipid peroxidation Release of glutamate Uncontrolled influx K, Na, and Ca = neuronal cell death, decr spinal cord blood flow. Possible causes include vascular changes due to hemorrhage, vasospasm, thrombosis, loss of autoregulation, breakdown of the blood-brain barrier, and infiltration of inflammatory cells that cause ischemia, edema, and cellular necrosis. Apoptosis (programmed cell death) for wks after injury = post-injury demyelination. Lead to scar tissue formation, irreversible nerve damage, permanent neurolo deficit Within 24 hours or less = permanent damage bc of development edema Edema secondary to inflammatory = limited space for tissue expansion = compression of spinal cord occur Edema extends above/below injury = incr ischemic damage. Bc secondary injury progresses over time, extent of injury, prognosis for recovery are most accurately determined at least 72 hours or more after injury s/s of improvement muscular strength, pinprick sensation below level of injury greatest improvement occurs in first 3 to 6 months following injury, can continue over yrs in 20% of cases.

Overall Goals SCI

Optimal level of neurologic functioning Minimal to no complications of immobility learn new skills, gain new knowledge, and acquire new behaviors to be able to care for self or successfully direct others to do so Return to home at optimum level of functioning

Nursing Planning - fractures

Overall Goals Healing with no associated complications Satisfactory pain relief Maximal rehabilitation The overall goals are that the patient with a fracture will have healing with no associated complications obtain satisfactory pain relief, and achieve maximal rehabilitation potential.

Grief and Depression sci

Overwhelming sense of loss Loss of control Adjustment more than acceptance Wide fluctuation in emotions Allow mourning while encouraging hope Sympathy is not helpful. tx patient as adult, encourage participation in care planning. primary nurse relationship is helpful. Staff planning, sessions in which staff members can express their feelings help to provide consistency of care. patient needs continual support throughout rehab process in form of acceptance, affection, caring. Be attentive when patient needs to talk, sensitive to needs at various stages of grief process. depression during grief process usually lasts days to wks, some clinically depressed =tx for depression. Evaluate by psychiatric nurse or psychiatrist is recommended. tx = drugs and therapy. tx is max when patient's personal preferences are identified, care is tailored to individual needs. Pt's caregiver/family = counseling to avoid promoting dependency in patient through guilt/misplaced sympathy. family = experiences intense grieving. support group of family members/friends of pt with SCI = incr participation, knowledge of grieving process, physical difficulties, rehab plan, meaning of disability. Depression after SCI is common and disabling. Patients with SCIs may feel an overwhelming sense of loss. They may temporarily lose control over everyday life activities as they depend on others for ADLs and for life-sustaining measures. Patients may believe that they are useless and burdens to their families. At a life stage when independence is often of great importance, they may be totally dependent on others. With recent advances in rehabilitation, the patient is often independent physically and discharged from the rehabilitation center before completing the grief process. The goal of recovery is related more to adjustment than to acceptance. Adjustment implies the ability to go on with living with certain limitations. Although the patient who is cooperative and accepting is easier to treat, expect a wide fluctuation of emotions from a patient with SCI. Your role in grief work is to allow mourning as part of the rehabilitation process. Maintaining hope is important during the grieving process and should not be interpreted as denial.

Nursing Assessment - fractures Subjective Data

PMH of: Past health history: Traumatic injury; long-term repetitive forces (stress fracture); bone or systemic diseases, prolonged immobility, osteopenia, osteoporosis Medications: corticosteroids (osteoporotic fractures); analgesics Surgery or other tx: First aid treatment of fracture, previous musculoskeletal surgeries Subjective Data - Functional Health Patterns Estrogen replacement therapy Ca supplementation Loss of motion or weakness of affected part Muscle spasms Pain, numbness, tingling, loss of sensation Sudden and severe pain in affected area; numbness, tingling, loss of sensation distal to injury; chronic pain that increases with activity (stress fracture)

Nursing Implementation Acute Care

Patients with fractures can be treated in the emergency department or a physician's office Patients are released home, or they may require hospitalization Specific nursing measures depend on the setting and type of treatment.

Neurovascular Assessment

Peripheral vascular Color and temperature Capillary refill Pulses Edema no bump or finger prints when making the cast = pressure ulcers Place special emphasis on the region distal to the site of injury. Document clinical findings before fracture treatment is initiated to avoid doubts about whether a problem discovered later was missed during the original examination or was caused by the treatment. Neurovascular Assessment Musculoskeletal injuries have the potential for causing changes in the neurovascular status of an injured extremity. Application of a cast or constrictive dressing, poor positioning, and physiologic responses to the traumatic injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment should consist of peripheral vascular assessment (color, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic assessment (sensation, motor function, and pain). Peripheral vascular assessment Assess an extremity's color (pink, pale, cyanotic) and temperature (hot, warm, cool, cold) in the area of the affected extremity. Pallor or a cool/cold extremity below the injury could indicate arterial insufficiency. A warm, cyanotic extremity could indicate poor venous return. Assess capillary refill (blanching of the nail bed). A compressed nail bed should return to its original color is within 3 seconds. Compare pulses on both the unaffected and injured extremity to identify differences in rate or quality. This contralateral evaluation is critical. Pulses are described as strong, diminished, audible by Doppler, or absent. A diminished or absent pulse distal to the injury can indicate vascular dysfunction and insufficiency. Also assess peripheral edema. Pitting edema may be present with severe injury. Peripheral neurologic Motor function Upper and lower extremities Sensory function Paresthesia Peripheral neurologic assessment Assess ulnar, median, and radial nerve function to evaluate sensation and motor innervation in the upper extremity. Assess Motor function by asking the patient to abduct the fingers (ulnar nerve), oppose the thumb and small finger (median nerve), and flex and extend the wrist (or the fingers, if in a cast) (radial nerve). In the lower extremity, assess the patient's ability to perform dorsiflexion (peroneal nerve) and plantar flexion (tibial nerve). Evaluate sensory function of the peroneal nerve by touching the web space between the great and second toes. Stroke the plantar surface (sole) of the foot to assess sensory function of the tibial nerve. Paresthesia (abnormal sensation [e.g., numbness, tingling]) and hypersensation/hyperesthesia may be reported by the patient. Partial or full loss of sensation (paresis/paralysis) may be a late sign of neurovascular damage. Instruct patients to immediately report any changes in sensation or the ability to move the digits in the affected extremity.

Autonomic Dysreflexia  Manifestations

Piloerection Flushing of skin above level of injury Blurred vision or spots in visual field Nasal congestion Anxiety Nausea

Nursing Assessment Objective Data

Poikilothermism Warm, dry skin (neurogenic shock) Bradycardia, hypotension Respiratory Injury at C1-3: apnea, inability to cough Injury at C4: poor cough, diaphragmatic breathing, hypoventilation Injury at C5-T6: decr respiratory reserve Cardiovascular = above T5: bradycardia, hypotension, postural hypotension, absence of vasomotor tone GI = Decr/absent BS (paralytic ileus in injuries above T5), abdominal distention, c/, fecal incontinence, fecal impaction Urinary retention Flaccid or spastic bladder Hyperactive deep tendon reflexes Muscle atony, contractures Urinary = Retention (injuries b/w T1 and L2); flaccid bladder (acute stages); spasticity w/ reflex bladder emptying (later stages) Reproductive = Priapism, loss of sexual function Neurologic = Complete: Flaccid paralysis, anesthesia below level of injury resulting in tetraplegia (injuries above C8), paraplegia (injuries below C8) hyperactive deep tendon reflexes, bilaterally + Babinski test (after resolution of spinal shock) Incomplete: Mixed loss of voluntary motor activity, sensation Musculoskeletal = Muscle atony (in flaccid state), contractures (in spastic state)

Clinical Manifestations DI

Polyuria Polydipsia Hypotension Tachycardia Dehydration Hypernatremia CNS Manifestations: irritability mental dullness Coma Hypovolemic Shock primary characteristic of DI: excretion of large quantities of urine (2 to 20 L/day) w/ very low specific gravity (<1.005), urine osmolality of < 100 mOsm/kg (100 mmol/kg). Serum osmolality = incr to >295 mOsm/kg [295 mmol/kg]) bc hypernatremia (serum sodium >145 mg/dL) = pure water loss in kidneys

Types of Head Injuries Postconcussion Syndrome

Postconcussion syndrome = 2 wks to 2 mnths after injury. s/s = persistent HA, lethargy, personality, behavioral changes, shortened attention span, decr short-term memory, changes in intellectual ability. affect abilities to perform activities of daily living. concussion = generally considered benign, usually resolves spontaneously s/s beginning of a more serious, progressive problem, especially in pt w/ hx of prior concussion/head injury. d/c = instructions for observation, accurate reporting of s/s, changes in neurologic status.

Pin Site CareSCI

Potential for infection based on hospital protocol BID with half strength peroxide and normal saline solution applying antibiotic ointment = mechanical barrier

Knee Immobilizer

Prefabricated knee and ankle splints and immobilizers easy to apply/remove, which permits close observation of affected joint for signs of swelling and skin breakdown Depending on injury, removal of splint or immobilizer facilitates ROM of affected joint, faster return to function.

Neurogenic Skin

Pressure-relieving cushion or mattress Prevention of pressure ulcers = life-long treatment plan following SCI. comprehensive visual + tactile exam performed daily w/ special attention to bony prominences. carefully move patient to prevent injury, Q2 in bed, every 15 to 20 minutes when in a chair or wheelchair. adequate nutrition to skin condition. Protect skin = avoiding thermal injury = hot food, liquids, bath, shower, radiators, heating pads, uninsulated plumbing. Thermal injury = extreme cold (frostbite). noticed until severe damage has occurred..

Nursing Management: Stroke Nursing Assessment stroke

Primary assessment: Cardiac Respiratory Neurologic If patient is stable = description of current illness Pay special attention to symptom onset and duration, nature, changes Subjective/objective data from a person who has had a stroke are Pay special attention to initial s/s including whether they were intermittent or continuous. Obtain info from patient, caregiver, family members, significant others.

Compartment Syndrome Interprofessional Care

Prompt, accurate dx via regular neurovascular assessments Notify of pain unrelieved by drugs and out of proportion to injury Paresthesia is also an early sign Assess urine output and kidney function Carefully assess location, quality, intensity of the pain pressure is relieved (e.g., cast is cut [bivalve] or dressing loosened by order of the HCP), pain, paresthesia typically decr, compartment syndrome is avoided. Pulselessness and paralysis are later signs. muscle damage = assess urine output = Myoglobin released from damaged muscle cells precipitates = obstruction in renal tubules = acute tubular necrosis, acute kidney injury. Common signs are dark reddish brown urine = manifestations associated with acute kidney injury.

Venous Thromboembolism - fractures

Prophylactic anticoagulant drugs Veins of lower extremities, pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture. VTE = after total hip or total knee replacement surgery. limited mobility, venous stasis is aggravated by inactivity of muscles that normally assist in pumping action of venous blood from extremities to heart. high risk of VTE = prophylactic anticoagulant drugs warfarin (Coumadin), low-molecular-weight heparin (e.g., enoxaparin [Lovenox], fondaparinux [Arixtra], rivaroxaban [Xarelto])

Brain Abscess

Pus within brain tissue = Results from a local or systemic infection Primary infective organisms = Streptococci, Staphylococcus aureus Direct extension from an ear, tooth, mastoid, sinus infection = primary cause. Other causes for brain abscess formation include spread from distant site (e.g., pulmonary infection, bacterial endocarditis), skull fracture, prior brain trauma, surgery.

Immobilization  Skeletal tractionSCI

Realignment or reduction of injury = Crutchfield, Gardner-Wells, or halo or Rope, pulley, and weights Traction maintained at all times = Possible displacement of skull pins If displacement occurs = hold head in neutral position, get help = immobilize head while surgeon replaces tongs cervical injuries, closed reduction w/ skeletal traction = used for early realignment (reduction) after injury. Crutchfield or Gardner-Wells tongs or halo (halo ring) = type of traction, rope extends from center of device over pulley to weights attached at end. No specific recommendations available for max weight for traction. surgeon start w/ 10 pounds, add 5 pounds for each level to injury goal = spinal reduction Awake patients are monitored w/ x-ray + neuroc + pain assessment. Comatose pt = serial x-rays

Interprofessional CareDrug Therapy for Ischemic Stroke

Recombinant tissue plasminogen activator (tPA) Used to reestablish blood flow through a blocked artery to prevent cell death Must be administered within 3 to 4 ½ hours of onset of clinical signs of ischemic stroke pt are screened carefully b/f tPA can be given. Screening includes a noncontrast CT/ MRI scan to rule out hemorrhagic stroke, blood tests for coagu disorders, screening for recent hx of gi bleeding, stroke, head trauma w/i past 3 mnths; major surgery w/i 14 days, recent active internal bleeding w/i 22 days. During infusion of drug, pt vs. neuro status are monitored closely to assess for improvement or for potential deterioration r/t intracerebral hemorrhage. Control of BP (SBP less than 185) is critical during tx and for 24 hours following. Intra-arterial infusion of tPA may be used for pt w/ occlusions of middle cerebral artery who can be tx w/i 6 hours (if direct admin) of symptom onset. tPA produces localized fibrinolysis by binding to fibrin in thrombi. fibrinolytic action of tPA occurs as plasminogen is converted to plasmin, whose enzymatic action then digests fibrin and fibrinogen = breaking down clot. Other fibrinolytic agents cannot be substituted for tPA. thin, flexible catheter into artery (usually femoral artery), guides catheter (using angiogram) to area of clot. tPA is admin through catheter, immediately targets clot. Less tPA is needed when it is delivered directly to clot = reduce possibility of intracranial hemorrhage.

Rehabilitation and Home Care

Rehabilitation of person with an SCI is complex. w/ physical, psychologic care, intensive, specialized rehabilitation, pt w/ SCI can learn to function at highest level of wellness. All pt w/ new SCI should receive comprehensive inpatient rehabilitation in rehabilitation unit or center that specializes in spinal cord rehabilitation. Many of problems identified in acute period become chronic, continue throughout life. Rehabilitation focuses on retraining physiologic processes as well as extensive pt, caregiver, family teaching about how to manage physiologic, life changes resulting from injury. Organized around pt goals and needs Patient expected = To be involved in therapies, To learn self-care Can be very stressful = Frequent encouragement pt is expected to be involved in therapies, learn self-care for several hrs each day. Such intensive work at time when patient is dealing with sudden change in health, function can be very stressful. Progress may be slow. rehab nurse has pivotal role in providing encouragement, specialized nursing care, pt, caregiver teaching, helping to coordinate efforts of rehab team. Rehab is interprofessional team effort = rehab nurses, HCPs, PT, OT, speech therapists, vocational counselors, psychologists, therapeutic recreation specialists, prosthetists, orthotists, case managers, social workers, dietitians.

Clinical ManifestationsSCI

Related to level and degree of injury Incomplete → variable Sequelae more serious with higher injury The manifestations of SCI are generally related to direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection. patient with an incomplete injury may demonstrate a mixture of manifestations.

Other Measures - fractures

Renal calculi Cardiopulmonary deconditioning DVT/pulmonary emboli reduced mobility as a result of a fracture = c/ Renal calculi = from bone demineralization r/t reduced mobility. hypercalcemia from demineralization =incr urine pH = stone Unless contraindicated = incr fluids Rapid deconditioning of cardiopulmonary system = result of prolonged bed rest = ortho hypo, decr lung capacity. Unless contraindicated, sit on side of bed, allowing lower limbs to dangle over bedside, perform standing transfers. When allowed to incr activity, assess ortho hypo

Evaluation - fractures

Report satisfactory pain management Appropriate care of cast or immobilizer No peripheral neurovascular dysfunction Uncomplicated bone healing The expected outcomes are that the patient with a fracture will Report satisfactory pain management. Demonstrate appropriate care of cast or immobilizer. Experience no peripheral neurovascular dysfunction. Experience uncomplicated bone healing.

Interprofessional CareSurgical Therapy for Hemorrhagic Stroke

Resection Clipping of an aneurysm Evacuation of hematomas Procedure is chosen based on cause of stroke Surgical interventions for hemorrhagic stroke = immediate evacuation of aneurysm-induced hematomas or cerebellar hematomas larger than 3 cm. arteriovenous malformation (AVM) = hemorrhagic stroke if AVM ruptures. tx of AVM is surgical resection and/or radiosurgery (i.e., gamma knife). preceded by interventional neuroradiology to embolize blood vessels that supply AVM.

Cauda Equina Syndrome

Result from damage to cauda equine (lumbar and sacral nerve roots) Flaccid paralysis of lower extremities Areflexic (flaccid) bladder/bowel Severe, radicular, asymmetric pain Asymmetrical distal weakness, patchy sensation in lower extremities. Complete loss of sensation b/w legs, over buttocks, inner thighs, backs of legs (saddle area).

Degree of Injury Conus Medullaris Syndrome

Result from damage to conus medullaris (lowest portion of spinal cord) Motor function in legs may be preserved, weak, or flaccid Decr in or loss of sensation in perianal area Areflexic bladder/bowel Impotence Pain is uncommon.

Hemorrhagic Stroke

Results from bleeding into: Brain tissue = Intracerebral or intraparenchymal hemorrhage Subarachnoid space or ventricles = Subarachnoid or intraventricular hemorrhage Intracerebral hemorrhage = Bleeding w/i brain bc rupture of vessel Sudden onset of s/s min to hrs bc of ongoing bleeding Prognosis poor w/ 30-day mortality rate of 40%-80% Vessel ruptures in basal ganglia

Etiology and PathophysiologyPrimary Injury

SCI due to cord compression by: Bone displacement Interruption of blood supply Traction from pulling on cord spinal cord is wrapped in tough layers of dura, rarely torn/transected by direct trauma. Penetrating trauma, such as gunshot and stab wounds, can cause tearing and transection. initial mechanical disruption of axons as result of stretch or laceration is referred to as primary injury.

Classification of SCI

SCI is classified by Mechanism of injury Level of injury Degree of injury Major mechanisms of injury are Flexion Hyperextension Flexion-rotation Extension-rotation Compression flexion-rotation injury is most unstable bc ligaments that stabilize spine are torn = most often contributes to severe neurologic deficits.

Manifestations depend on level of spinal injury

SLIDE 21

Types of Head InjuriesScalp Lacerations

Scalp is highly vascular → Profuse bleeding Scalp lacerations = easily recognized type of external head trauma. bc scalp contains many blood vessels w/ poor constrictive abilities, most scalp lacerations = profuse bleeding. relatively small wounds can bleed significantly. major complications = blood loss and infection.

Nursing ImplementationIntracerebral HematomaAmbulatory Care

Seizure disorders = non penetrating head injury. Seizures = develop during 1 wk after head injury. Some may not develop seizure disorder until yrs after initial injury. Antiseizure drugs = prophylactically to manage posttraumatic seizure activity, but =controversial Mental, emotional sequelae of brain trauma are often most incapacitating problems. One of consequences of TBI = may not realize brain injury has occurred. pt w/ head injuries who have been comatose >6 hrs undergo some personality change. They suffer loss of concentration, memory, defective memory processing. Apathy = incr. Euphoria, mood swings, along w/ seeming lack of awareness of seriousness of injury behavior = loss of social restraint, judgment, tact, emotional control. Progressive recovery may continue for yrs. Specific nursing management in posttraumatic phase depends on specific residual deficits. Being able to return to work, maintaining employment is one of challenges during recovery period. decr awareness, ability to interpret enviro stimuli. Prepare family for patient's emergence from coma, explain process of awakening often takes several wks. Special "no" policies that may be appropriately suggested by neurosurgeon, neuropsychologist, nurse include no drinking of alcoholic beverages, no driving, no firearms, no working w/ hazardous implements, machinery, no unsupervised smoking.

Bacterial MeningitisComplicationsAcute cerebral edema may cause

Seizures CN III palsy Bradycardia Hypertensive coma Death HA - mnths after dx of meningitis until irritation, inflammation have completely resolved = pain management noncommunicating hydrocephalus = exudate causes adhesions that prevent normal flow of CSF from ventricles. CSF reabsorption by arachnoid villi may also be obstructed by exudate = surgical implantation of shunt is only tx. Waterhouse-Friderichsen syndrome = complication of meningococcal meningitis = petechiae, DIC, adrenal hemorrhage, circulatory collapse. DIC and shock, = most serious complications of meningitis = associated w/ meningococcemia.

SIADH Dx

Serum Sodium < 134mEq/L Serum osomolality < 280mmol/Kg Urine Specific Gravity >1.025 = concentrated urine blood diluted urine concentrated water is staying in body

Nursing Interventions SIADH

Serum Sodium >125 mEq/L (125mmol/L): Fluid Restriction 800 - 1000mL/day Loop Diuretic = Furosemide (Lasix) Possible need for electrolyte supplementation Seizure Precautions Fall Risk Precautions Maintain Skin Integrity loop diuretic = furosemide (Lasix) = promote diuresis = serum sodium must be at least 125 mEq/L (125 mmol/L) bc may promote further sodium loss. bc furosemide incr K, ca, and mg losses, supplements PRN Demeclocycline = blocks effect of ADH on renal tubules, resulting in more dilute urine. Initiate seizure and fall precautions if patient has an altered sensorium or is having seizures. HOB flat or elevated no more than 10 degrees = enhance venous return to heart, incr left atrial filling pressure = decr release of ADH. turning, positioning, ROM exercises = skin integrity, joint mobility. Severe Sodium loss <125mEq (125mmol/L): Hypertonic IV solutions (3% Saline) - slowly 8-12mEq/L in first 24hrs - if too quick = osmotic demyelination syndrome w/ permanent damage to nerve cells in brain Fluid Restriction 500mL/day Vasopressor receptor antagonists (drugs that block activity of ADH) Hypertonic IV solutions (3% Saline) = remove fluid from cell back into vascular system so urinated out (watch for causing fluid volume overload = give slowly = through central line per hospital protocol) Loop Diuretics & Hypertonic Solutions are usually order together. Incr of Na MUST BE done slowly, should not incr by more than 8 to 12 mEq/L in first 24 hrs. fluid restriction of 500 mL/day = severe hyponatremia. conivaptan (Vapriosol) and tolvaptan (Samsca). Conivaptan is given IV; tolvaptan is given orally. Neither w/ liver disease bc worsen liver function.

Sexuality

Sexuality is an important issue regardless of the patient's age or sex. To provide accurate, sensitive counseling, teaching about sexuality, be aware of your own sexuality, as well as understand human sexual responses. sexual potential = use scientific terminology rather than slang Injury level and completeness of injury impacts function Men normally have two types of erections: psychogenic and reflex. psychogenic erections begins in brain with sexual thoughts. Signals from brain are then sent through nerves of spinal cord to T10-L2 levels. signals are relayed to penis, trigger erection. Men w/ low-level incomplete injuries = more likely to have psychogenic erection than men w/ higher-level incomplete injuries. Men w/ complete injuries are less likely to experience psychogenic erection. reflex erection = direct physical contact to penis or other erotic areas. Involuntary, can occur w/o sexually stimulating thoughts, short-lived, uncontrolled, cannot be maintained, summoned at time of coitus. nerves that control man's ability to have reflex erection = located in sacral nerves (S2-S4) of spinal cord. Most men with SCI are able to have a reflex erection with physical stimulation regardless of extent of injury if S2-S4 nerve pathways are not damaged. Phosphodiesterase inhibitors = sildenafil (Viagra) = first line tx Sexual stimulation is required to get an erection after taking med. Penile injection of vasoactive substances (papaverine, prostaglandin E) = Risks = priapism (prolonged penile erection), scarring = only after failure of sildenafil. Vacuum suction devices use negative pressure to encourage blood flow into penis. Erection = maintained by constriction band placed at base of penis. main surgical option = implantation of a penile prosthesis. SCI affects male fertility = poor sperm quality, ejaculatory dysfunction. penile vibratory stimulation/electroejaculation. Combined with ovulation induction, intrauterine insemination of female effect of SCI on female sexual response is less clear. injury does not affect ability to become pregnant or deliver normally through birth canal. Menses may cease for as long as 6 months after injury. Sex resumed, protection against an unplanned prego normal pregnancy may be complicated by UTI, anemia, autonomic hyperreflexia. uterine contractions are not felt, a precipitous delivery is always a danger. Don't dislodge an indwelling catheter during sex, External cath = refrain from fluids, remove cath b/f sex. inform partner = incontinence is always possible woman = water-soluble lubricant = decr vaginal secretions, facilitate vaginal penetration.

Traction - Skin traction

Short-term (48-72 hours) Traction weights 5 to 10 pounds Skin assessment, prevention of breakdown imperative Tape, boots, or splints are applied directly to the skin to maintain alignment, primarily to help diminish muscle spasms in the injured extremity. Buck's traction boot = skin traction used preoperatively for patient with a hip fracture to reduce muscle spasms skin traction, regular assessment of skin is a priority bc pressure points, skin breakdown develop quickly. Assess key pressure points Q2-4

Manifestations Brain Abscess

Similar to meningitis and encephalitis HA Fever Nausea and vomiting

Level of Injury

Skeletal vs. neurologic level Level of injury may be Cervical Thoracic Lumbar Sacral Skeletal level of injury is the vertebral level with the most damage to vertebral bones and ligaments. Neurologic level is lowest segment of spinal cord w/ normal sensory, motor function on both sides of body. Cervical/lumbar injuries = most common bc levels are associated with greatest flexibility, movement. If cervical cord is involved, paralysis of all four extremities = tetraplegia (formerly quadriplegia). degree of impairment in arms following cervical injury depends on level of injury. lower level = more function is retained in arms. If thoracic, lumbar, or sacral spinal cord is damaged = result is paraplegia (paralysis, loss of sensation in legs). Figure 60-3 shows affected structures and functions at different levels of cord injury.

Causes of SIADH Malignant Tumors

Small cell lung cancer Pancreatic Lymphoid Thymus Prostate Colorectal (Hodgkin's lymphoma, non-Hodgkin's lymphoma, lymphocytic leukemia) more commonly = older adult most common cause cancer. self-limiting when caused by head trauma or drugs chronic when associated w/ tumors, metabolic diseases.

ReflexesSCI

Spasms = antispasmodic = baclofen (Lioresal), dantrolene (Dantrium), tizanidine (Zanaflex). Botulism toxin injections = tx severe spasticity. spinal cord shock is resolved, return of reflexes may complicate rehab Lacking control from higher brain centers, reflexes = hyperactive, produce exaggerated responses. Penile erections = from a variety of stimuli Spasms = mild twitches to convulsive movements below level of injury interpret this reflex activity as return of function = explain reason for activity. Inform patient of + use of these reflexes in sexual, bowel, bladder retraining.

Spasticity

Spasticity = beneficial + undesirable. aids w/ mobility = incomplete SCI. Spasticity improves circulation by promoting venous return, decr ortho hypo, DVT. marked spasticity, tone = difficulty w/ positioning, mobility secondary to spasms. Spasms = cause significant pain, (ADLs) difficult for patient. tx = ROM exercises to prevent muscle, joint tightness, reduce risk of contracture. Antispasmodic = baclofen or tizanidine. Botulinum toxin injection is useful for specific muscle involvement.

Homonymous Hemianopsia

Spatial and perceptual deficits in stroke. Perception of a patient with homonymous hemianopsia shows that food on the left side is not seen and thus is ignored.

Immobilization  Kinetic therapy SCI

Special beds used in management of pt with SCI. Kinetic therapy = continuous side-to-side rotation of a patient to 40 degrees or more to help prevent pulmonary complications, redistributes pressure = prevent pressure ulcers.

Interprofessional CareEndovascular Therapy

Stent retrievers (e.g., Solitaire FR) are a way of opening blocked arteries in brain by using a removable stent system. During procedure = catheter is used to guide small stent from femoral artery in groin area to affected artery in brain. stent is guided (using neuroimaging) into part of artery where a blood clot has formed. stent expands interior walls of artery, allows blood to get to patient's brain immediately to prevent as much brain damage as possible. clot seeps into mesh of stent. Then, after a few min stent and clot are removed together. Stent retrievers = most effective way of managing ischemic stroke. ENROUTE device accesses carotid arteries through neck, rather than groin, uses blood flow reversal system to capture pieces of blockage dislodged during stenting procedures, while also maintaining blood flow to brain.

Nursing Management: Stroke Acute Care Gastrointestinal system

Stress = catabolic state = interfere with recovery C/ = most common bowel problem Prophylactic stool softeners/fiber If no daily or every-other-day BM, check patient for impaction liquid stools = checked for stool impaction. fluid balance status, swallowing, fluid 1800 to 2000 mL/day fiber intake up to 25 g/day. Bowel retraining = training will continue into rehab phase. bowel management program = bedpan, commode, bathroom at reg time daily to reestablish bowel regularity. bowel program = 30 min after breakfast bc eating stimulates gastrocolic reflex, peristalsis =?adjusted as ppl bowel habits vary.

Causes of SIADH Central Nervous System Disorders

Stroke Brain tumors Cerebral atrophy Guillain-Barré syndrome Systemic lupus erythematosus Infection = encephalitis, meningitis Head injury = skull fracture, subdural hematoma, subarachnoid hemorrhage

Nursing Management: StrokeGerontologic Considerations

Stroke is a significant cause of death/disability 66% of strokes that require hospitalization = adults > 65 wondering if return to their "old self," loss of independence = major concern. limited family members (including adult children) living in close proximity to provide help. rehab phase, assisting older patient to deal with residual deficits of stroke, as well as aging Patients fearful/depressed bc = another attack or die = fear can become immobilizing, interfere with rehab. Changes may occur in patient-spouse relationship = dependency resulting from stroke may be threatening to relationship. Optimizing quality of life is the ultimate goal.

Types of Stroke

Strokes are classified based on underlying pathophysiologic findings Ischemic Thrombotic Embolic Hemorrhagic Intracerebral Subarachnoid - most in circle of willis

Nursing Management: Stroke Stroke Survivorship and Coping Assist coping process

Support communication between patient/family Discuss lifestyle changes from deficits Discuss changing roles/responsibilities within family Being an active listener to allow expression of fear, frustration, anxiety Include family in goal planning/patient care Support family conferences Identify support groups and referrals Maladjusted dependence with inadequate coping occurs when pt doesn't maintain optimal functioning for self-care, family responsibilities, decision making, socialization. resentment from both patient/family w/ a negative cycle of interpersonal dependency/control.

Interprofessional CareSurgical Therapy

Surgical interventions for pt with TIAs from carotid disease include: Carotid endarterectomy Transluminal angioplasty Stenting Evaluation must be done to confirm that s/s of TIA are not r/t other brain lesions = such as developing subdural hematoma or incr tumor mass. Transluminal angioplasty is insertion of balloon to open stenosed artery in brain, improve blood flow. balloon is threaded up to carotid artery via a catheter inserted in femoral artery. Postoperative care is important: Neurovascular assessment BP management Assessment for complications = Stent occlusion, Retroperitoneal hemorrhage decr complications at insertion site minimize complications at insertion site by keeping pt leg straight for prescribed amount of time.

Nursing Management: Stroke Acute Care Integumentary system

Susceptible to skin breakdown r/t: Loss of sensation Decr circulation Immobility age, poor nutrition, dehydration, edema, incontinence position changes, special mattresses, wheelchair cushions Position on weak/paralyzed side for 30 min skin hygiene Emollients applied to dry skin Early mobility position change schedule = Q2 for any position. If area redness, does not return to normal color w/i 15 min of pressure relief, epidermis/dermis are damaged. NO massage damaged area bc = additional damage.

Fat Embolism (FES)Clinical Manifestations

Symptoms 24 to 48 hours after injury Petechiae - neck, chest wall, axilla, buccal membrane, conjunctiva hemorrhagic interstitial pneumonitis w/ s/s = ARDS = chest pain, tachypnea, cyanosis, dyspnea, tachycardia, decr O2 Changes in mental status (hypoxemia) = classic triad memory loss, restlessness, confusion, incr temp, HA Fat cells in blood, urine, or sputum ↓ PaO2 < 60 mm Hg ST segment and T-wave changes ↓ Platelet count, hct levels incr ESR Chest x-ray →bilateral pulmonary infiltrates feeling of impending disaster.

Autonomic Dysreflexia SCI

T6 or higher distended bladder or rectum BP = SCI complains of a HA. HNT (up to 300 mm Hg systolic), throbbing HA, diaphoresis above level of injury, bradycardia (30 to 40 beats/minute). massive uncompensated cardiovascular reaction mediated by sympathetic nervous system. intact sympathetic nervous system below level of injury responds to stimulation w/ reflex arteriolar vasoconstriction = incr BP, but parasympathetic nervous system is unable to directly counteract these responses via injured spinal cord. Baroreceptors in carotid sinus, aorta sense hnt, stimulate parasympathetic system = decr HR, but visceral, peripheral vessels do not dilate bc injured spinal cord. bc sensory stimulation = stimulation of skin, stimulation of pain receptors.

Health Promotion - fracture

Teach safety precautions Advocate to decr injuries Encourage moderate exercise Safe enviro to reduce falls Calcium and vitamin D intake regularly using seat belts, speed limits, avoiding distracted driving, warming up muscles before exercise, using protective athletic equipment (helmets and knee, wrist, and elbow pads), using safety equipment at work. wear nonskid, hard-soled footwear, assess living enviro for safety risks.

Temperature ControlSCI

Temperature control is external no vasoconstriction, piloerection (erection of body hair), or heat loss through perspiration below level of injury Monitor enviro Do not use excessive covers or unduly expose pt (such as during bathing). If infection w/ high fever develops, more extensive methods for temp control may be needed (e.g., cooling blanket).

Drug Therapy fractures

Tetanus and diphtheria toxoid Bone-penetrating antibiotics muscle relaxants, pain associated with muscle spasms carisoprodol (Soma) cyclobenzaprine (Flexeril) methocarbamol (Robaxin) Bone-penetrating antibiotics cephalosporin (e.g., cefazolin [Kefzol, Ancef]) = prophylactically before surgery.

ASIA Impairment Scale

The American Spinal Injury Association (ASIA) Impairment Scale = classifying the severity of impairment resulting from spinal cord injury. combines assessments of motor, sensory function to determine neurologic level, completeness of injury. ASIA Impairment Scale = recording changes in neurologic status, identifying appropriate rehabilitation goals. Movement/rehabilitation potential r/t specific locations of SCI are described in Table 60-4 . general, sensory function closely parallels motor function at all levels.

Nursing Management: StrokeNursing Implementation

To help reduce the incidence of stroke Focus on stroke prevention Teach how to reduce modifiable risk factors = Cause of most strokes Nursing measures to reduce risk factors for stroke = similar to coronary artery disease. Uncontrolled/undiagnosed HNT = primary cause of stroke = blood pressure screening, antihypertensive med DM = stay well-controlled. atrial fibrillation = anticoagulant or aspirin = prevent the risk of stroke. Because smoking is a major risk factor for stroke, you need to be actively involved in helping patients to stop smoking Another very important aspect of health promotion is teaching patients and families about early symptoms associated with stroke or TIA. Table 57-1 presents information on when to seek health care for these symptoms.

Head Injury

Traumatic brain injury (TBI) Falls, MVA, Firearms, Assaults, Sports, Recreational, War -Related. Head injury = injury or trauma to the scalp, skull, or brain. serious form of head injury = traumatic brain injury (TBI). Statistics head injuries = incomplete bc many victims die at injury scene or bc condition is considered minor, health care services are not sought.

Disorders of Posterior Pituitary Gland

Two Primary Problems associated w/ ADH Secretions: Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Overproduction of ADH Diabetes Insipidus (DI) Underproduction of ADH antidiuretic = not gonna pee, holding onto fluid

Interprofessional CareIntracerebral Hematoma

Tx of skull fractures is usually conservative. For depressed fractures, fractures with loose fragments = craniotomy is necessary to elevate depressed bone, remove free fragments. large amounts of bone destroyed = bone may removed (craniectomy), cranioplasty will be needed at later time. large acute subdural, epidural hematomas, associated w/ significant neuro impairment, blood must be removed through surgery. craniotomy = visualize, allow control of bleeding vessels. Burr-hole openings = extreme emergency = rapid decompression ==> craniotomy. drain placed postoperatively for days to prevent reaccumulation of blood. extreme swelling = (e.g., DAI, hemorrhage) craniectomy = where piece of skull is removed to decr pressure inside cranial vault = decr risk herniation.

Nursing AssessmentObjective Data reprodructive, neuro, muscle

Uninhibited sexual expression Altered LOC Seizures Pupil dysfunction Cranial nerve deficit(s) Musculoskeletal weakness, palmar drift, paralysis, spasticity, D&D posturing, muscular rigidity/incr tone, flaccidity, ataxia Dx Findings: Location, type of hematoma, edema, skull fracture, foreign body on CT scan, MRI; abnormal EEG; + toxicology screen or alcohol level, ↓ or ↑ blood glucose level; ↑ ICP

Diagnostic Studies DI

Urine output > 200mL/hr Specific Gravity <1.005 Water Deprivation Test: before = body weight, urine osmo, gravity measured deprived water 8-12 hrs, give desmopressin (DDAVP) subQ or nasally. central DI = incr urine osmolality (100 ->600), decr urine volume. nephrogenic DI = not able to incr urine osmolality to > 300 mOsm/kg. ADH level after Desmopressin Given: measure level of ADH after an analog of ADH (e.g., desmopressin) given. central DI = kidneys respond hormone by concentrating urine. nephrogenic = kidneys do not respond

Assistive Devices

Use transfer belt for stability when teaching how to use Discourage from reaching for support Upper arm strength required cane (can relieve up to 40% of the weight normally borne by a lower limb) walker or crutches (may allow for complete non-weight-bearing ambulation) HCP decides = balancing need for max stability, safety vs maneuverability required in small spaces such as bathrooms. involved limb = advanced at same time or immediately after advance of device. uninvolved limb = advanced last. canes are held in the hand opposite the involved extremity. poor upper limb strength, poorly fitted crutches = weight at axilla rather than at hands, endangering neurovascular bundle that passes across axilla. Patients who must ambulate w/o weight bearing require sufficient upper limb strength to lift their own weight at each step. bc muscles of shoulder girdle/upper arm not accustomed to this work = vigorous and diligent training in preparation for this task. Push-ups, pull-ups using overhead trapeze bar, lifting weights develop triceps, biceps muscles. Straight-leg raises, quadriceps-setting exercises strengthen quadriceps muscles.

Ambulatory Care Cast Care

Validate understanding of cast care instructions Follow-up phone call Teach cast removal and possible alterations in appearance of extremity home care nursing visits are warranted, especially for the patient with a body jacket brace. cast is removed in the outpatient setting. Patients fear being cut by the oscillating blade of the cast saw. possible alterations in the appearance of the extremity (e.g., dry, wrinkled skin; atrophied muscle) that has been beneath cast.

Clinical ManifestationsPeripheral Vascular Problems

Venous thromboembolism (VTE) Deep vein thrombosis (DVT) = difficult to detect Pulmonary embolism = Leading cause of death Venous thromboembolism (VTE) is a common problem accompanying SCI during the first 3 months. Detecting a DVT may be difficult in a person with an SCI because the usual signs and symptoms, such as pain and tenderness, will not be present.

Fasciotomy for Compartment Syndrome

Volkmann's ischemic contracture of forearm following acute compartment syndrome secondary to a supracondylar fracture of humerus.

Neurogenic Bowel

Voluntary control may be lost High-fiber diet Adequate fluid intake Suppositories Small-volume enemas Digital stimulation = Mandatory for upper motor neuron injury bowel evacuation = bc voluntary control of this function may be lost. preventing c/ = high-fiber diet, fluid. suppositories = (bisacodyl [Dulcolax] or glycerin), small-volume enemas, digital stimulation (performed 20-30 min after suppository insertion) by nurse/patient Use of gastrocolic reflex Timing to not interrupt therapy stool softener = docusate sodium (Colace) = regulate stool consistency. Oral stimulant laxatives = only if absolutely necessary = not on regular basis. Valsalva maneuver, manual stimulation = lower motor neuron injuries. bc Valsalva maneuver requires intact abdominal muscles = with injuries below T12. bowel movement every other day is considered adequate. bowel evacuation for 30 to 60 min after first meal of day may enhance success by taking advantage of gastrocolic reflex induced by eating. Timing of the bowel program = discussed among interprofessional team = no interruptions when patient is doing therapy (e.g., swimming pool therapy).

Transient Ischemic Attack

Warning s/ of stroke!! - get anticoags bc at risk of stroke Hx of TIA = incr risk of stroke TIA = transient episode of neurologic dysfunction caused by focal brain, spinal cord, retinal ischemia, but w/o acute infarction of brain teach pt to seek tx for any stroke s/s = no way to predict if TIA will resolve/ new stroke. TIAs may be due to microemboli that temporarily block blood flow. TIAs = warning sign of progressive cerebrovascular disease. s/s of TIA depend on blood vessel involved, area of brain that is ischemic. TIA tx as medical emergency = precursor to ischemic stroke. Teach risk for TIAs to seek medical attention immediately w/ any stroke-like s/s, identify time of onset of symptoms. typically last < 1 hour no way to predict outcome 1/3 do not experience another event 1/3 have additional TIAs 1/3 progress to stroke

Halo Vest

When patient can begin to mobilize after stable injury (surgery is not needed), halo frame can be attached to a special vest (Halo vest). allows patient to mobilize, ambulate while cervical bones fuse. However, halo is not indicated if patient has ligament instability from injury = require surgery.

Balanced Suspension Traction

When traction is used to treat fractures, the forces are usually exerted on the distal fragment to obtain alignment with the proximal fragment. One of the more common types of skeletal traction is balanced suspension traction (Fig. 62-10).

Types of Subdural Hematomas

acute - 24-48hrs after severe trauma - immediate deterioration - tx is craniotomy, evacuation, decompression subacute - 48-2wk after trauma - alteration in mental status as hematoma develops, progression dependent on size, location of hematoma - tx is evacuation and decompression chronic - wks to months - over 20 days, often injury seemed trivial or wa forgotten by pt, nonspecific, nonlocalizing progression, progressive alteration in LOC - tx evacuation and decompression, membranectomy

Interprofessional CareSurgical Therapy SCI

acute SCI = fix instability, decompress spinal cord Surgery w/I first 24 hrs = improved neurologic outcome Posterior approach, Anterior approach, Fusion Surgical tx = acute SCI to fix instability, decompress spinal cord. type of surgery depends on severity/level of injury, mechanism of injury, location/degree of compression. back of spine (posterior) front of spine (anterior) both approaches may be needed Fusion = attaching metal screws, plates, other devices to bones of spine = keep aligned = when two or more vertebrae injured. Small pieces of bone may be attached to injured bones to help them fuse into one solid piece. bone used for this procedure = patient's spinal bone harvested during surgery, from bone in patient's body (autologous), from donor bone (allograft).

Nursing Management: Stroke Acute Care Urinary system

acute stage = poor bladder control = incontinence Avoid indwelling catheters Bladder retraining program Avoid bladder overdistention fluid intake w/ most given between 7:00 AM-7:00 PM scheduled toileting Q2 s/s of restlessness = need urination bladder distention = palpation. pants w/o drawstrings, buttons, zippers = difficult to manage if motor/sensory deficits exist. Assess postvoid residual volume If urine remains in bladder = incomplete emptying is prob = cause UTI.

HA

acute, chronic, temporary, life threatening primary - no identifiable cause, migraine, tension, cluster secondary - brain tumor, aneurysm triggers of migraines and cluster: alcohol enviro allergies intense odors, lights, meds tired, depression, stress, anxiety period, BC foods w/ tyramine, MSG, nitrates, milk

Gerontologic Considerations SCI

aging population = incr work, recreational activities among older adults = experiencing SCI. Falls = leading cause of SCI for people age 65 and older. Older adults w/ traumatic injuries = more complications than younger patients, hospitalized longer, higher mortality rates. Health promotion/screening in older patient with an SCI. = Daily skin and UTI prevention, Monthly breast examinations, regular prostate cancer Cardio disease = most common cause of morbidity, mortality lack of sensation = chest pain, = high-level injuries = mask acute MI. Altered autonomic nervous system function, decr physical activity can place pt at risk for cardio problems = HNT decr risk of injuries, instruct pt, caregivers on fall prevention strategies (using stepstool, long-handled reacher to access high shelves, install handrails on stairs). Rehabilitation = older person with SCI = longer bc preexisting conditions, poorer health status at the time of initial injury.

SIADH risks care

aka schwartz bartter syndrome excessive release of ADH aka vasopressin from pit gland excess ADH = renal reabsorption of water and suppression of renin angio = renal excretion of Na = water intoxication, cellular edema, dilutional hyponatremia tumors, incr intrathoracic pressure, head injury, meningitis, stroke, chemo, tcs, ssri, opioids, fluoroquinolone antibiotics restric fluids to 500-100ml/day flushes w/ 0.9% nacl NOT water = to replace Na monitor incr bp, tachycardia, hypothermia lung sounds = pul edema = emergency weigh gain 2.2lbs = 1L of fluid - REPORT incr envrio HF if loop diuretic

cerebral blood flow

amount of blood in ml passing through 100g of brain tissue in 1 min CCP = flow x resistance 60-100 less 50 = ischemia less 30 = incompatible w/ life cerebral pressure perfusion = CCP CCP = MAP-ICP MAP = DBP + 1/3 (SBP-DBP) bp = 112/84 = MAP = 97 = ICP = 12 = CPP = 85

fracture meds procedures

analgesics muscle relaxants stools softeners antibiotics

Overall goals of fracture tx

anatomic realignment of bone fragments through reduction immobilization to maintain realignment, and restoration of normal or near-normal function of the injured part.

stroke meds therapeutic complications

anticoag - hep na, enoxaparin, warfarin antiplatelets - aspirin, phenytoin, gabapentin = w.i 24-48hrs NO clopidogrel thrombolytic = w.i 4.5hr of s/s thrombolytic therapy = w/i 6hrs of s/s, not for hemorrhagic stroke = MRI first carotid artery angioplasty = cath in fem artery, catches clots carotid endarterectomy - open artery to remove = w/ TIAs extracranial intracranial bypass = improve cerebral perfusion dysphagia and aspiration - assess gag, NPO until SLP, initial feeding done by RN unilateral neglect - sling, footrest, dress effected side first

after seizure

assess: LOC VS pupil size position of eyes memory loss muscle soreness speech disorders weakness/paralysis sleep period duration of each s/s repo, suction, O2 don't need to call 911 if not first seizure, not prolonger, no injury

Brain Stent Used to Treat Blockages

balloon cath implant stent into artery of brain. balloon cath moved to blocked area of artery, then inflated stent expands due to inflation of balloon balloon deflated, withdrawn, leaving stent permanently in place holding artery open, improving flow of blood. Brain stent used to treat blockages in cerebral blood flow. A, A balloon catheter is used to implant the stent into an artery of the brain. B, The balloon catheter is moved to the blocked area of the artery and then inflated. The stent expands due to inflation of the balloon. C, The balloon is deflated and withdrawn, leaving the stent permanently in place holding the artery open and improving the flow of blood.

Raccoon Eyes and Battle's Sign

basilar skull fracture = linear fracture, fracture involves base of skull. Manifestations several hrs, vary w/ location, severity of fracture, may include cranial nerve deficits Battle's sign (postauricular ecchymosis), periorbital ecchymosis (raccoon eyes). fracture generally = tear in dura and subsequent leakage of CSF. Rhinorrhea (CSF leakage from the nose) or otorrhea (CSF leakage from the ear) = confirms that fracture has traversed the dura. significance of rhinorrhea may be overlooked unless pt is specifically assessed for this finding. risk of meningitis is high w/ a CSF leak, antibiotics should be admin Two methods of testing = fluid leaking from nose or ear is CSF. Dextrostix or Tes-Tape strip = glucose is present. CSF gives a + reading for glucose. blood is present in fluid = testing for presence of glucose is unreliable bc blood also contains glucose = look for halo or ring sign. allow leaking fluid to drip onto a white gauze pad (4 × 4) or towel, observe drainage. w/i few min, blood coalesces into center, yellowish ring encircles blood if CSF is present. Note the color, appearance, amount of leaking fluid bc both tests can give false-positive results.

Nursing Implementation Intracerebral Hematoma Measures for immobilized patients

bladder and bowel function, skin care, and infection n/v = antiemetic drugs. HA = acetaminophen or small doses of codeine. patient's condition deteriorates, intracranial surgery may be necessary burr-hole opening or craniotomy = depending on underlying injury causing prob emergency nature of surgery may hasten usual preoperative preparation. Consult w/ neurosurgeon = preoperative nursing measures. patient is often unconscious b/f surgery = family member sign consent form for surgery = difficult, frightening time for patient's caregiver, family, requires sensitive nursing management.

dual energy xray

bone mass hip or spine 2 beams of radiation osteoporosis, postmenopausal loss of height, bone pain, fractures

nuclear scans

bone scan = entire skeletal system, radioactive isotope injection 2-3hrs before scanning, see hair line, tumors, disease gallium and thillium scans - more sensitive, tissues of brain, liver, breasts to see organs, injection 4-6hr before, scan takes 30-60min indications: arthritis, osteomylitis, fractures, osteoporosis, bone cancer, bone pain allergy, prego, kindey

Buck's Traction

boot is a type of skin traction that is used to immobilize a fracture, prevent hip flexion contractures, and reduce muscle spasms.

generalize seizure

both sides of brain, LOC, sec-min tonic clonic - most common, aka grand mal, LOC, fall to ground, stiffening for 10-20 sec, jerking 30-40sec, blue, saliva, tongue, incontinence, after tired sleep for hrs absence - aka petit mal, kids and teens, daydreaming, less 10 sec, blinking, chewing, hand gesture, 100x/day, atypical - staring spell, blinking, jerking, moving lips, more 10 seconds, gradual begining myoclonic - jerk of muscles, forceful enough to drop/hurt the person atonic - drop attack, less 15 sec, wear helmets tonic - incr tone, stiffness, less 20 clonic - LOC, loss muscle ton, jerking, rare

findings in DKA and HHS

both: polyuria, polydipsia, polyphagia weight loss gi effect (n/v, pain) blurred vision/HA (dehydration) ortho hypo mental status changes (lack of glucose to brain) DKA: fruity odor of breath kussmaul resp (deep rapid, bc metabolic acidosis, don't want CO2) HHS: seizures (osmolarity over 350) reversible paralysis (osmolarity)

head injury complications

brain herniation: downward shift of brain tissue bc edema, through foramen magnum findings = dilated pupils, decr LOC, cheyne stokes, hemo unstable, abnormal posturing, tx = mannitol, debulking surgery severe neuro decr persists hematoma and intracranial hem = severe HA, decline in LOC, change ICP, herniation, tx osmotic diuretics Pulmonary edema = like pul edema w/o cardiac, survival is rare DI or SIADH cerebral salt wasting = bc ANF in hypothalamus, decr na retention in kidneys, prevent renin and aldosterone release decr osmolality, hyponatremia hypovolemia = incr extracellular fluid in clients with SIADH weight, i/o, fluid overload/dehydration, electro

craniotomy

burr holes drains stereotactic radiosurgery - computer guided, destroy tumor cell

muscles

cardiac - heart, spontaneous contractions smooth - walls of hollow structures, airway, arteries, gi, bladder, uterus, neural and hormonal skeletal - neural stim isometric - no contraction isotonic - shorten muscle cause movement

Fracture Immobilization

cast = temporary circumferential immobilization device. allows patient to perform many normal activities of daily living while providing sufficient immobilization to ensure stability. Cast materials = natural (plaster of Paris), synthetic acrylic, fiberglass-free, latex-free polymer, hybrid of materials. Immobilization above/below joint restricts tendon/ligament movement, assisting with joint stabilization while fracture heals. apply a cast = affected part first covered with stockinette cut longer than extremity, place cotton padding over stockinette with bony prominences given extra padding. plaster of Paris casting = immerse in warm water, wrap, mold around number of layers of plaster bandage, technique of application determine strength of cast. The plaster sets within 15 minutes not strong enough for weight bearing until 24 to 72 hrs after. fresh plaster cast should never be covered bc air cannot circulate. Heat then builds up in cast = burn = drying is delayed. Avoid direct pressure on cast during the drying period. Handle the cast gently = open palm =avoid denting cast. Once cast is thoroughly dry, rough edges = minimize skin irritation, prevent plaster of paris debris from falling into cast Several strips (petals) of tape = placed by health care provider over rough areas to ensure a smooth cast edge

immobilizing, casts, splints, tractions

casts, splints, traction, external/internal fixation casts - moleskin = if rough area, stockinette under plaster casts paster of paris = heavy, not water proof, 24-72hr to dry synthetic fiberglass = light, stronger, water resistant, dry very quick 30 min hander cast with palms not finger tips elevate for 24-48hjrs use cloth covered pillow traction: soft tissue injury, bone fragments, decr muscle spasms, correct or prevent further deformitites manual - pulling force by hands of provider for temporary immobilization, w/ sedation straight or running - counter traction applying pulling force in straight line = decr muscle spasm balanced suspension - counter traction such as slings or splints to support w/ ropes or weights, move w/o altering traction skeletal = screws in bone = halo, heavy weights pin care 1-2x a day

Respiratory Rehabilitation

cervical injury above C3 requires mechanical ventilation bc phrenic nerve is not stimulated = diaphragm is not functional. need round-the-clock caregivers = knowledgeable about respiratory hygiene, tracheostomy care. high cervical SCI may have greatly incr mobility w/ phrenic nerve stimulators or electronic diaphragmatic pacemakers. devices are not appropriate for all ventilator-dependent pt but may be helpful for those w/ intact phrenic nerve. successfully weaned from ventilator during hospitalization, down-sizing (gradual decr in size), removal of tracheostomy will be done during rehab. Teach assisted coughing, regular use of incentive spirometry, breathing exercises to pt w/ cervical injury who is not ventilator dependent. Limit exposure to persons w/ fever, cold, cough. Adhere to swallowing precautions (e.g., proper positioning of head, neck), diet = prevent aspiration.

pressure from compartment syndrome

check diastolic pressure = infection and pressure

HA triggers

chocolate, cheese oranges, tomatoes, monosodium glutamate, aspartame, alcohol, red wine, caffeine, fermented foods

Diabetic Ketoacidosis (DKA) explained

circulating supply of insulin is insufficient, glucose cannot be used for energy. body compensates by breaking down fat stores as a secondary source of fuel. Ketones are acidic by-products of fat metabolism that can cause serious problems when they become excessive in blood. Ketosis alters pH balance = metabolic acidosis Ketonuria = ketone bodies are excreted in urine = electrolytes become depleted as cations are eliminated along with anionic ketones in attempt to maintain electrical neutrality. Insulin deficiency impairs protein synthesis =excessive protein degradation = nitrogen losses from tissues. Insulin deficiency also stimulates production of glucose from amino acids (from proteins) in liver, leads to further hyperglycemia. bc there is a deficiency of insulin, the additional glucose cannot be used and the blood glucose level rises further, adding to the osmotic diuresis. If not treated, patient will develop severe depletion of Na, K, Cl, Mg, Ph. v/ = acidosis results in more fluid/electrolyte losses. hypovolemia --> shock. Renal failure = from hypovolemic shock = retention of ketones, glucose, and acidosis progresses. Untreated, patient comatose as result of dehydration, electrolyte imbalance, acidosis. condition not treated = death is inevitable. dehydrated = kidneys tries to flush out ketones and glucose = polyuria water and glucose follow each other

fractures

closed open = 1 min skin damage, 2 skin and muscle, 3 skin, muscle, nerves, blood complete incomplete simple - one line comminuted - multiple lines displaces nondisplaced stress pathological compression types: comminuted - fragmented oblique - angle across bone spiral - twisting impacted - wedged greenstick - one side, no through

types of fractures

colles = distal radius, common in adults, over 50 humeral = brachial artery, YA pelvic = life threatening, turn pt when told hip fracture = elders, fall femoral shaft = direct force, also injure soft tissues, incr blood loss tibial = no anterior muscle to protect, stress fracture stable vertebral = car, falls, not going to move or cause spinal cord damage facial = trach mandibular = face/jaw, ngt? straws?

Cast assessment

color temp cap refill peripheral pulses edema sensation motor pain pain, paresthesia, pressure, paresis, pallor, pulselessness

Loss of Postural Stability

common after stroke. nondominant hemisphere is involved, walking apraxia, loss of postural control are usually apparent. unable to sit upright tends to fall sideways. support with pillows or cushions

Sensory DeprivationSCI

compensate for absent sensations by stimulating patient above level of injury. Conversation, music, interesting foods = part of nursing care plan. HOB must remain flat = prism glasses to help patient read, watch tv. Help patient avoid withdrawing from enviro adequate rest/sleep, assess for changes in mood = Depression = common.

types of brain injury

concussion/mild trauma = change neuro, no brain damage, resolve w/i 72hrs contusion - brain bruised, unconsciousness w/ stupor or confusion diffuse axonal injury - widespread injury to brain = coma intracranial hemorrhage - epidural, subdural, intracerebral, delay or immediate open head injury = infection, profuse bleeding cervical spine injury - always suspected

status epilepticus

continuous seizure activity or recur in rapid cession w/o return to consciousness longer 5 min emergency neurons get tired = damage convulsive status epilepticus = most dangerous = decr breathing, hypoxemia, dysrhythmias, hyperthermia, acidosis subclinical seizure - sedated pt seizuse w/o external s/s bc sedative tx = lorazepam, diazepam then phenytoin, phenobarbital

structure of bones

cortical - compact and dense - units called osteons cancellous - spongy around each osteon are lamellae diaphysis = long shaft of bone periosteum - fibrous connective around bone

head injury procedures

craniotomy: removal of nonviable brain tissue so expansion or removal of epidural or subdural hematomas, or decr ICP, remove brain tumors drill burr hole, create bone flap 3 types: supratentorial = above tentorial infratentorial = below tentorial, brain stem transsphenoidal = through mouth and nasal passages infratenorial craniotomu = client flat on either side for 24-48hrs to prevent pressure on neck

Pathophysiology of DI

decr ADH --> decr water reabsorption in renal tubules --> decr intravascular fluid volume --> incr serum osmolality (hypernatremia) and excessive urine output

Nursing Management: StrokeAcute CareCardiovascular system

decr cardiac reserves from secondary dx of cardiac disease Cardiac efficiency may be compromised decr cardiac reserves secondary to cardiac disease, cardiac efficiency may be further compromised by fluid retention, overhydration, dehydration, bp variations. Central venous pressure, pulmonary artery pressure, hemodynamic monitoring = use to see fluid balance, cardiac function in ICU Monitoring VS frequently Monitoring cardiac rhythms intake and output IV infusions lung sounds = crackles/wheezes (pulmonary congestion) heart sounds = murmurs orthostatic hypotension = b/f ambulating 1st time Bedside monitors/telemetry may record cardiac rhythms. HNT = after stroke = body attempts to incr cerebral blood flow Neuro changes occur with a sudden decr in BP. Weak or paralyzed lower extremities are particularly vulnerable Teach = active ROM exercises if patient has voluntary movement in affected extremity. hemiplegia = passive ROM exercises should be done several times a day. VTE prophylaxis = low-molecular-weight heparin (e.g., enoxaparin [Lovenox]). measuring calf/ thigh daily, swelling lower extremities, unusual warmth, pain in calf.

Degree of Injury

degree of spinal cord involvement may be either complete or incomplete (partial). Complete = Total loss of sensory and motor function below level of injury Incomplete (partial) = Mixed loss of voluntary motor activity and sensation Some tracts intact degree of sensory, motor loss depends on level of injury, specific damaged nerve tracts.

Clinical Manifestations Affect stroke

difficulty controlling emotions = exaggerated or unpredictable Depression, Changes in body image, Loss of function pt may be frustrated by mobility and communication problems.

head trauma

diffuse - concussion, axonal injury focal - contusion, hematoma diffuse axonal injury - mild, mod, severe traumatic brain damage, , decr LOC, incr ICP, D&D, lacerations - tearing of brain tissue w/ depressed or open fractures, penetrating complications: epidural hematoma - bleeding b/w dura and inner surface of skull = emergency subdural hematoma - bleeding b/w dura mater and arachnoid intracerebral hematoma - bleeding w/i brain, frontal or temporal if comatose for over 6 hrs = personality changes

Nursing Management: Stroke Ambulatory Care

discharged from acute care setting to: Home Intermediate or long-term care facility Rehab facility Critical factor: independence in ADLs Ongoing rehab is essential to maximize patient's abilities discharge planning = starts early in hospitalization, promotes smooth transition from one care setting to another critical factor in discharge = level of independence in performing ADLs. prepare patient/family for discharge through: Teaching Demonstration/return demonstration Practice Evaluation of self-care skills Total care = med, nutrition, mobility, exercises, hygiene, toileting. Follow-up care = continuing nursing; PT, OT, speech therapy; medical care. Community resources should be identified to provide recreational activities, group support, spiritual assistance, respite care, adult day care, home assistance based on patient's needs.

extreme hyperglycemia

diuresis = fluid volume deficit = decr Na, K, Ph K = electrolyte imbalance = dehydration = hyperosmolarity = hypokalemia hypovolemua = decr renal perfusion, hypotension, hemoconcentration decr renal = oliguira = anuria = SHOCK hypotension = tissue anoxia = incr lactic acid = SHOCK hemoconcentration = hyperviscosity = thrombosis = SHOCK Shock, seizure, death, coma

hip replacement

do: elevate toliet, chair in tub pillow b/w knees for 6wks when on nonoperative side neutral, straight position don't flex hip greater 90 = like low chairs adduct hip = bring legs together at knees cross knees/ankles put on shoes/socks sit on chairs w/o arms

Diagnostic Studies stroke

dx studies are done to: Confirm that it is a stroke Identify likely cause of stroke MRI or noncontrast CT scan: rapid, very fast, rule out right away = CT first Indicate size, location Differentiate b/w ischemic or hemorrhagic stroke rule out the presence of different kind of brain lesion. Tests = guide decisions about therapy to prevent 2nd stroke. Serial CT scans =assess effectiveness of tx, evaluate recovery. MRI is more effective in identifying ischemic stroke than CT, but CT faster

SIADH findings and labs

early = HA, weak, anorexia, muscle cramps, weight gain w/o edema bc h20 not na na decr = hostility, slow DTR, n/v/d, oliguria, dark yellow concentrated urine confused, tired, cheyne strokes seizures, coma, death fluid volume excess = tachycardia, bounding pulses, hnt, crackles, distended neck veins, taut skin, weight gain w/o edema, intake > output labs: urine chem = think CONCENTRATED incr urine na incr urine osmolarity as volume decr = urine osmolarity incr blood chem = think dilute decr na = dilutional hyponatremia decr osmolarity = <270 volume incr = osmolarity decr

DKA Emergency Treatment

etiology - change in eating, insulin, exercise, malfunction of pump, infection, bad tx assessment findings - dry mouth, thirst, abd pain, n/v, fever, rapid weak pulse, incr restlessness, tired interventions - ABC, admin O2, IV, NaCl 0.9 1L until BP stable and urine is 30-60ml/hr, 0.1U/kg/hr insulin drip, hx of DM, last food, amount of last insulin injection monitoring - VS, LOC, cardiac rhythm, O2, urine output, breath sounds for fluid overload, serum glucose, serum potassium, admin K, admin Na bicard is pH < 7, add dextrose IV for glucose <250

head injury assessment, labs, dx

findings: alcohol/drugs amnesia LOC CSF leak - nose, ears - halo sign incr ICP - HA, LOC, pinpoint pupils, cheyne stokes, cushing triad, seizures labs: abgs, cbc, glucose, glucose, electro, serum.urine, ECG, anti seizure meds levels dx: ct, mri, icp monitoring

cluster headaches

findings: breif intense unilateral, non throbbing 30 min -2hrs, radiate to forehead, temple, cheek daily at the same time for 4-12 wks remission 9-12 months more during spring no warning less common than migraines men 20-50yo tearing of the eye w/ runny nose facial sweating drooping eyelid, eyelid edema miosis facial pallow/flushing bradycardia n/v pacing, walking, sitting, rocking meds: triptan ergotamine antiepiletpic ccb steriods OTC capsaicin melatonin glucosamine home O2 therapy 12L for 15-20 min @ onset of HA = relief in 15 min cool dark envro sitting when using O2 wear sunglasses, sleep, exersice avoid foods decr anger, anxiety, stress, fatigue

migraines

findings: photophobia phonophobia n/v stress, anxiety unilateral pain, behind ears or eye PMH or FMH of headaches alterations in ADLs for 4-72hrs categories: w/ aura = classic hrs to days b/f onset, irritable, craving, d/c/, urination 1st numbness, tingling of mouth lips, face, hands, visual disturbances = flashes, bright spots 2nd severe throbbing HA over hours, n/v/tired, vertido 3rd - 4 to 72hrs HA dull recovery = muscle pain, head and neck pain w/o aura - common migraine pain worsened by physical activity unilateral, pulsing pain one or more - photophobia, phonophobia, n/v 4-72hrs, early am, stress, pre-period, fluid retention atypical: status migrainosus = over 72hrs migrainous infraction = neuro over 7 days, ishemic unclassified - other dx = neuroimaging, cold dark quite enviro, HOB 30 meds: abortive therapy = alleviate pain during aura: NSAIDs, tylenol, antiemetics severe migraines: truptan = vasocontric ergotamine w/ caffeine = narrow blood vessles, decr inflam isometheptene preventative therapy: NSAIDs w/ BB = propranolol, CCB, beta adrenergic blocker check pulse w/ bb onabotulinumtocin A = injection in neck up to 5 times education: keep journal women over 50 - cardio and stroke riks meds that cause = ranitidine, estrogen, nutro, nifedipine

fracture healing

fracture hematoma granulation tissue callus formation ossification consolidation remodeling

seizure findings

generalized: both hemispheres, w/ aura TONIC CLONIC = stiff, LOC, 1-2min clonic, breathing can stop, biting cheek or tongue, incontinence, postictal = confusion, tired TONIC = LOC, incr muscle tone, apnea, v/, incontinence, salvation, 30 seconds - minutes, CONIC = several min, muscles contract then relax MYOCLONIC = jerking or stiffness, symetrical or not, seconds ATONIC or AKINETIC = few sec, muscle tone lost, confusion, falling partial or focal/local seizures: one cerebral hem COMPLEX PARTIAL = automatisms, behavior pt unaware, lip smacking, picking at clothes, LIC, blackout for few min, amnesia prior and after SIMPLE = conscious, dejavu, change HR, flshing, unilateral arm movements, pain, smell unclassified or idiopathic: half of all seizures

seizures risks and findings

genetic acute febrile state - infants head trauma cerebral edema abrupt cessation of antiepileptic drugs infection metabolic disorders exposure to toxins (CO2, lead) stroke heart disease brain tumor hypoxia acute substance withdrawl fluid and electro triggering factors: incr physical activity excessive stress hypervent tired acute alcohol ingestion caffeine flashing lights cocaine, aerosols, glue

spinal cord meds

glucocorticoids - adrenocortical steroids, methylprednisolone = decr edema in spinal cord = compression vasopressors = norepi and dopamine = tx hypotension during neuro shock antimuscarinic = atropine = tx bradycardia plasma expanders - dextran - volume expander, tx hypotension 2nd to spinal shock, a/e fluid overload muscle relaxants - baclofen/dantrolene - severe muscle spasticity, pressure ulcers = sitting hard, a/e tired, weakness cholinergic - bethanechol = decr spasticity of bladder, easier to train a/e retention analgesics - opioids, non opioids, nsaids = pain, muscle spasm pain anticoag - hep or low mole hep - DVT stool softeners and bulking lax - docusate Na or polycarbophil vasodilators - hydralazine, nitroglycerin - PRN for episodes of HNT, monitor bp

Nursing AssessmentIntracerebral Hematoma subjective Data

head injury = potential to develop incr ICP Meds - Anticoag? HA Mood/behavioral changes Mentation changes; impaired judgment Aphasia, dysphasia alcohol or drugs; risk-taking behaviors Fear, denial, anger, aggression, depression

long term disabilities in stroke

hemiparesis, inability to walk, ADLs, aphasia, depression

meningitis vaccines

hib = haemophilus flu type b = infants for bacterial, 4 doses, beginning at 2 months, final dose 12-15 months PPSV = pneumococcal polysaccharide vaccine -for immunocom, chronic disease, smoke, long term facility, over 65 MCV4 = meningococcal vaccine - neisseria meningitidis, teens b/f college, military, 11-12 then booster at 16

glasgow coma scale

higher score --> higher brain functioning E + V + M

stroke risks and findings

hnt, dm, smoking, fat, exercise risks: cerebral aneurysm arteriovenous malformation DM, fat, HNT atherosclerosis hyperlipidemia hypercoag a fib oral BC smoking cocaine findings: TIA - visual disturbance, dizzy, slurred speech, weak extremity = warning of oncoming stroke left cerebral hem - language, math, analytic thinking expressive/receptive aphasia = speak and understand agnosia - recognize familiar objects alexia - reading difficulty agraphia - writing difficulty right extrem hemiplegia/hemiparesis slow cautious behavior depression, anger, quick to be frustrated visual changes - hemianopsia right cerebral hem = visual and spatial awareness, proprioception overestimation unilateral negelect loss of depth perception poor impulse control/judgement left hemiplegia or hemiparesis visual changes = hemianopsia

Diagnostic for DKA and HHNS

hx and physical exam glucose, CBC, pH, ketones, electrolytes, BUN, ABGs UA - specific gravity, glucose, acetone fluids IV short acting electo replacement mental status I&O CVP glucose levels blood and urine for ketones ECG cardio and resp status

drugs for seizures

if not controlled = change timing or dosage tonic clonic and focal = phenytoin, carbamazepine, phenobarbital, divalproex, promodone myoclonic and absence - ethosuximide, divalproex, clonazepam other - gabapentin, topiramate, lamotrigine, tiagabine, zonisamide drugs have long half life A/E = diplopia, tired, ataxia, mental slowness phenytoin = gingival hyperplasia, hirsutism, BC, d/c by liver pregabalin - focal if not controlled

spinal cord procedures

immobilization: halo or cervical tongs - traction or immobilize spine, don't use halo device to turn client spinal surgery: donor bone from iliac crest, airway compromise if anterior approach, neuro Q4, rods usually not removed unless cause pain

Nursing Management: Stroke Stroke Survivorship and Coping Sexual function

impotence, occurrence of another stroke during sex Many patients = comfortable talking about their anxieties/ fears regarding sexual function if nurse is comfortable/open to topic Nursing interventions for sexual activity include teaching about: optional positioning of partners timing for peak energy periods patient/partner counseling.

Pathophysiology of SIADH

incr antidiuretic hormone --> incr water reabsorption in renal tubules --> incr intravascular fluid volume --> dilutional hyponatremia and decr serum osmolality SIADH = release of ADH despite normal/low plasma osmolarity. concentrated urine bc fluid staying in body ADH incr permeability of renal distal tubule, collecting duct = reabsorption of water into circulation. Extracellular fluid volume expands, plasma osmolality decr, GFR incr, Na decr (dilutional hyponatremia). Leads to reabsorption of water, suppression of Renin=angiotensin system = renal excretion of na = water intoxication, hyponatremia SIADH is characterized as: Fluid retention Serum hyperosmolality Dillutional hyponatremia Hypochloremia Concentrated urine in presence of normal or incr intravascular volume

Nursing DiagnosesSCI

ineffective breathing pattern related to respiratory muscle fatigue, neuromuscular paralysis, and/or retained secretions Imbalanced nutrition: less than body requirements related to paralytic ileus and metabolic demands of body Ineffective peripheral tissue perfusion related to hypotension and lack of mobility Impaired skin integrity related to immobility and/or poor tissue perfusion Impaired urinary elimination related to spinal injury and/or limited fluid intake Constipation related to neurogenic bowel, inadequate fluid intake, and/or immobility Risk for autonomic hyperreflexia (dysreflexia) related to reflex stimulation of sympathetic nervous system

bacterial meningitis

infalmmed meningeal tissues surrounding brain and spinal cord fall, winter, early spring, 2nd to resp disease dorms, prisons, military entry by resp, blood, wounds, fractures tx - antibiotics = dexamethasone, supportive, prevent incr ICP dx = ct, gram stain, smear, culture, PCR, tumbler test on rash pressure 200-500 WBC over 1000 - neutrophils protein over 500 glucose decr turbic and coudy s/s: fever, HA, n/v, nuchal rigidity photophobia, decr LOC, s/s ICP nut - high protein, high kcals stiff wks later must decr fever bc it incr edema/seizures complications = waterhouse friderichsen syndrome

Ischemic StrokeEmbolic stroke

infarction, edema of area supplied by involved vessel. Sudden onset with severe clinical manifestations Warning signs less common remains conscious Prognosis is related to amount of brain tissue deprived of blood supply Commonly recur affect any age Rheumatic HD = cause in young to middle-aged adults from atherosclerotic plaque = more common in elder effects of emboli characterized by severe neurologic deficits = temporary if clot breaks up /allows blood flow. Smaller emboli = obstruct smaller vessels = involve smaller portions of brain with fewer deficits noted.

ATI Meningitis

inflammation of meninges = membrane that protects the brain and spinal cord viral/aseptic = most common = no tx fungal = AIDs bacterial = most contagious, high mortality rate

Nursing ImplementationIntracerebral HematomaAcute Care - leaking CSF

inform HCP immediately. HOB may be raised to decr CSF pressure so that tear can seal. loose collection pad placed under nose or over ear. Do not place dressing in nasal or ear cavities Instruct patient not to sneeze, blow nose. NO nasogastric tubes. NO nasotracheal suctioning = high risk of meningitis and incr ICP Test CSF for glucose

Nursing Management: Stroke Acute Care Nutrition

initially receive IV infusions to maintain fluid and electrolyte balance nut needs in first 72 hours of admin Test swallowing, chewing, gag reflex, pocketing b/f beginning oral feeding Feedings --> scrupulous oral hygiene gag reflex = impaired bc dysphagia absent, defer feeding, exercises to stimulate swallowing speech therapist/OT = responsible for designing program. remain in high Fowler's position = in a chair with head flexed forward, for feeding and 30 minutes following Foods easy to swallow, enough texture, temp (warm or cold), flavor stimulate swallow reflex Crushed ice = stimulant Pureed foods = not best choice bc bland, too smooth. Thin liquids = difficult to swallow = promote coughing. Thin liquids = thickened = commercially available thickening agent (Thick-It). Avoid milk = incr viscosity of mucus, incr salivation. Place food on unaffected side of mouth. inability to feed oneself = frustrating = malnutrition, dehydration. self-feeding = unaffected upper extremity to eat; assistive devices = rocker knives, plate guards, nonslip pads for dishes; removing unnecessary items from tray/table = decr spills providing nondistracting, calm enviro = decr sensory overload/distraction. effectiveness of dietary program = evaluated in terms of maintain weight, hydration, patient satisfaction.

Nursing ImplementationIntracerebral HematomaAcute Care

injury scene = head-injured pt is to maintain cerebral O2, perfusion, prevent secondary cerebral ischemia. monitoring changes in neuro = deteriorate rapidly, necessitating emergency surgery. bc of close association b/w hemodynamic status, cerebral perfusion, be aware of any coexisting injuries or conditions. GCS = assessing LOC . Indications of deteriorating neurologic state, no matter how subtle = decr LOC, decr motor strength = reported to health care provider. Behavioral s/s w/ head injury = frightened, disoriented, combative Your approach should be calm, gentle. family member = stay w/ patient = decr anxiety, fear.

Types of Head InjuriesContusion

is bruising of brain tissue w/I a focal area. usually associated w/ a closed head injury. contusion may contain areas of hemorrhage, infarction, necrosis, edema, frequently occurs at fracture site. Monitor for seizures Contusions = continue to bleed or rebleed, appear to "blossom" on subsequent CT scans of brain. Bleeding worsens the neurologic outcome. Neuro assessment = demonstrate focal as well as generalized manifestation, depending on size/location of contusion. Seizures = bc brain contusion = frontal /temporal lobes. Older adults + falls = more severe = anticoagulants. Risk for falls = all patients taking anticoagulants.

meningitis nursing care and meds

isolation droplet until 24 hrs after antibiotics started and oral and nasal secretions not infectious decr fever = cooling blankets report to CDC decr enviro stimuli decr light HOB above 30, bed rest monitor incr ICP - no cough/sneezing seizure precautions meds: ceftriaxone or cefotaxime in combo with vanco - until sensitivity done, bacteria phenytoin - anticonvulsant if incr ICP tylenol/ibuprofen - HA, fever cipro, rifampin, ceftriaxone - prophylac for ppl in contact w/ pt no opioids bc masks altered LOC

joints and cartilage

joint - ends of 2 bones meet diarthrodial - synovial hyaline - most common, collagen, trachea, bronchi, nose, epiphyseal, bones elastic - collage, elastic fiber, most flexible, ear, epiglottis, larynx fibrous - collagen, tough, shock absorber, vertebral, knee, shoulder

seizures labs, dx, pt care, meds

labs - alcohol, drugs, HIV dx - EEG, MRI, CT, CAT< PET, CSF, xray during seizure: move furniture, oral suction, on side, loosen clothing, document NO padded tongue blade, opening jaw after seizure: side lying, vs, injuries, neuro, reorient, aura? trigger? meds: AEDs = antiepileptic drug = phenytoin therapeutic test to see blood levels same time every day oral gum growth decr BC effect no warfarin = decr absorption, incr metabolism

DKA risk factors

lack of insulin r/t undiagnoses o runtreated type 1 DM nonadherence to diabetic plan decr or missed dose of insulin condition that incr carb metabolism = stress, illness, infection, surgery, trauma incr hormone production (cortisol, glucagon, epi) stimulate liver to profuce glucose and decr effect of insulin

hyperglycemic hyperosmolar state risk factors

lack of insulin t/o undiagnosed DM, sufficent endogenous insulin to prevent ketosis but not neough to prevent hyperglycemia inadequate fluid intake poor kidney function 50-70yo MI, serecral vascular injury, sepsis meds (steriods, thiazide, phenytoin, BB, CCB) infection/stress

Autonomic Dysreflexia Nursing interventions

life-threatening situation If no resolution = status epilepticus, stroke, myocardial infarction, death. HOB 45 degrees or sitting upright, Stool impaction = digital rectal examination = after anesthetic ointment to decr rectal stimulation, prevent an incr of symptoms. Remove all skin stimuli, constrictive clothing, tight shoes. Monitor BP during episodes = nitroglycerine, nitroprusside, hydralazine.

Types of Head InjuriesSkull Fractures

linear or depressed; simple, comminuted, or compound; and closed or open. Linear fracture = break in continuity of bone w/o alteration of relationship of parts = low-velocity injuries depressed skull fracture = inward indentation of skull = powerful blow. simple linear or depressed skull fracture = w/o fragmentation or communicating lacerations = low to moderate impact. comminuted fracture = multiple linear fractures w/ fragmentation of bone into many pieces = direct, high-momentum impact. compound fracture = depressed skull fracture, scalp laceration w/ communicating pathway to intracranial cavity = severe head injury. Fractures = closed or open, depending on the presence of a scalp laceration or extension of fracture into air sinuses or dura. location of the fracture determines clinical manifestations. complications = intracranial infections, hematoma, and meningeal and brain tissue damage. basilar skull fracture = orogastric tube should be inserted rather than a nasogastric tube.

types of bones

long - diaphysis, epiphysis (2 wide ends) short - cancellous flat - compact, cancellous, compact irregular

Fracture Immobilization Cast Synthetic casting materials

made of synthetic materials are being used more than plaster bc lightweight, stronger, relatively waterproof, provide early weight bearing. synthetic casting materials (thermolabile plastic, thermoplastic resins, polyurethane, and fiberglass) are activated by submersion in cool or tepid water, molded to fit the torso or extremity.

spinal cord risk factors findings labs dx

male 16-30 alcohol or drug use disease - cancer, arthritis falls findings: report lack of sensation, neck or back pain, different touches absent DTR hypotension - worse when sitting upright shallow resp spinal shock - total but temp loss of all reflexes, below injury, days - wks labs - UA, hgb, abgs, cbc dx - xray, mri, ct, cat

head injury medication

mannitol - osmotic, tx edema, incr icp, fluid from brain into blood, need cath, do electro barbiturates - if want coma, decr metabolic demand until ICP decr, completely unresponsive, mechanical vent, cardiac and hem monitoring phenytoin - prophylactic for seizures, dose based on blood levels morphine - pain, restlessness, A/E = resp depression

Nursing Management: Stroke Ambulatory Care Rehabilitation

max patient's capabilities, resources to promote optimal functioning prevent deformity, maintain, improve function. Most recover in first 6 months, maximum benefit one year PT = mobility, progressive ambulation, transfer techniques, equipment needed for mobility. OT = cognitive and perceptual evaluation and training skills of daily living such as eating, dressing, hygiene, and cooking. Speech therapy = speech, communication, cognition, eating abilities.

Nursing Management: StrokeStroke Survivorship and Coping

may experience many losses = sensory, intellectual, communicative, functional, role behavior, emotional, social, vocational patient, caregiver, family process of grief, mourning associated with losses. long-term depression = anxiety, weight loss, fatigue, poor appetite, sleep disturbances. time/energy required to perform previously simple tasks = anger/frustration. Stroke support groups within rehab facilities and community are helpful Mutual sharing Teaching Coping Understanding Family therapy is a helpful adjunct to rehabilitation. Open communication, info regarding total effects of stroke, education regarding stroke treatment, therapy are helpful.

tension HA

most common type bilateral location, pressing, tight, frontal/occipital min to days episodic and chronic photophobia, phonophobia NO n/v no premonitory s/s physical activity does not aggravate tylenol, nsaids, sedative, muscle relax, tranquilizers antidepressants, NaSSS, antiseizures

cluster HA

most severe 20-45, men unilateral, eyes irregular melatonin and cortisol odors, weather, napping 3min - hrs swelling, tearing, flushing, pale, congesion, miosis every other day, up to 8x/day triptans, high flow 100% nonrebreather 6-8L for 10 min, can repeat after 5 min rest verapimil

SOMI Brace

need for surgery is determined after spine is reduced. After cervical fusion or other stabilization surgery, patient may wear a hard cervical collar or sternal-occipital-mandibular immobilizer brace.

focal seizures

one hem simple - remain conscious, alert, unusual feelings, sensation, joy, anger, n/, sad, hear, smell, taste see not real tho complex - lox, dreamlike, eye open, lip smacking, walk into traffic, remove clothes, 30 sec - 2 min

Classification According to External Environment

open (formerly called compound) or closed (formerly called simple) depending on communication or noncommunication with external enviro open fracture skin is broken, exposing bone, causing soft tissue injury. closed fracture the skin has not been ruptured, remains intact.

spinal cord complications

ortho hypo - change position and pooling in lower extrem, elastic wraps spinal shock - s/s = flaccid paralysis, loss of reflex activity below injury, paralytic ileus neuro shock - s/s bradycardia, hypotension, dependent edema, loss of temp regulation, autonomic dysreflexia - lesions below T6 dont get it bc parasympathetic able to neutralize, triggered by stimuli in lower part of body, s/s hnt, HA, pale, blurred vision, sweating, restless, n/ piloerection cause - full bladder, fecal impaction, clod stress, tight clothes, illness

fracture risks and findings dx

osteoporosis - weight loss, diet, no estrogen, falls, cars, substances, disease, abuse, lactose intolerance, age crepitus deformity muscle spasms edema ecchymosis ct, mri

The rehabilitation nurse assesses

patient's rehabilitation potential physical status of all body systems complications caused by stroke or other chronic conditions patient's cognitive status family resources/support expectations of patient/caregiver r/t rehabilitation program.

Teaching and counselingSCI

physical exams smoking cessation classes exercise programs alcohol treatment facilitate wheelchair-accessible examination rooms, adjustable-height examination tables, and appointment scheduling that allows extra time if needed.

DI findings and labs

polyuria - 4-30L a day output polydipsia - 2-20L a day nocturia tired dehydration sunken eyes tachycardia hypotension loss/absent skin turgor dry membranes weak, oor pulses decr cognition labs: electro = incr Na urine chem - think DILUTE decr urine specific gravity - <1.005 decr urine osmolality - <200 decr ph decr Na decr K as volume incr --> osmolality decr serum chem = think CONCENTRATED incr osmolality >300 incr Na incr K as volume decr --> osmolality incr

electromyography and nerve conduction

presence and cause of muscle weakness at bedside tin needles into muscles low currents neuro disorders, motor neuron disease

Skin CareSCI

pressure ulcers = sacrum. visual, tactile exam of skin at least once daily, special attention to areas over bony prominences. most vulnerable to breakdown = sacrum, ischia, trochanters, heels. Assess incisions, integrity of skin under collars, braces. reposition Q2, w/ gradual incr in times b/w turns if no redness over bony prominences is seen at time of turning Specialty mattresses = used to reduce incidence of pressure ulcers. moved to a chair or wheelchair, use pressure-relieving cushions Pressure relief = Q15 to 20 min when in chair, last 30-60 seconds nut status = weight loss and gain can contribute to skin breakdown. protein = skin health = prealbumin, total protein, albumin

viral meningitis

pressure under 250 WBC 25-500 = lymphocytes protein 50-500 glucose - normal to low clear or cloudy cause - HIV, HSV HA, fever, photophobia, stiff neck antibiotics after lumbar puncture

Traction

prevent or reduce pain, muscle spasm (e.g., whiplash, unrepaired hip fracture), immobilize a joint or part of the body reduce a fracture or dislocation treat a pathologic joint condition (e.g., tumor, infection). Pulling force to attain realignment - countertraction pulls in opposite direction 2 most common types of traction Skin traction Skeletal traction Traction apply a pulling force on fractured extremity to attain realignment countertraction pulls in opposite direction.

Nursing Management: Stroke Acute Care Musculoskeletal system

prevention joint contractures, muscular atrophy acute phase = ROM exercises, positioning Paralyzed or weak side needs special attention when positioned Passive ROM exercise is begun on 1stday of hospitalization. stroke is due to subarachnoid hemorrhage = movement limited to extremities. Position each joint higher than joint proximal = prevent dependent edema. Specific deformities on weak or paralyzed side that may be present in patients with stroke include internal rotation of shoulder; flexion contractures of hand, wrist, elbow; external rotation of hip; plantar flexion of foot. Trochanter roll at hip to prevent external rotation Hand cones to prevent hand contractures Arm supports with slings, lap boards to prevent shoulder displacement NO rolled washcloths NO pulling patient by arm = shoulder displacement Posterior leg splints, footboards, high-topped tennis shoes = foot drop Rather than preventing plantar flexion (footdrop), sensory stimulation of footboard against bottom of foot incr plantar flexion.

DI types risks

primary - lack ADH production or release bc hypothalamus or pit secondary - lack ADH production or release bc infection, tumors in or near hypothalamus or pit gland, head trauma, brain surgery nephrogenic - inherited, renal tubules dont react to ADH drug induced - lithium carbonate or demeclocycline can alter way kidnyes respond to ADH risks: head injury, tumor, lesion, surgery, irradiation near or around pit gland infection - meningitis, encephalitis taking lithium carbonate or demeclocycline elder - dehydration, decr thrist

bone growth nut

protein, B, C, D, calcium, phosphorus, mg, 2-3L fluid

Nursing Management: Stroke Acute Care Sensory-perceptual alterations

r/t hemisphere of brain in which stroke occurred Diplopia (double vision) --> use eye patch Loss of corneal reflex Ptosis (drooping eyelid) Homonymous hemianopsia stroke on right side of brain Respond best to directions given verbally left-brain stroke Nonverbal cues, instructions helpful for comprehension w/ pt One-sided neglect is common for people w/ right-brain stroke

DKA and HHS patient care

rapid infulsion of NS i/o, weight, kidney function, pul status, JVD, HF follow w/ hypotonic fluid = 0.45 NaCL when glucose @ 250 glucose to IV to decr risk cerebral edema bc rapid change in osmolarity reg insulin 0.1-0.15 u/kg IV bolus IV not subQ = immediate tx less 200 = goal monitor hourly monitor k levels = k will shift into cells bc insulin admin Na bicarb slow IV infusion = severe acidosis at home: if ill = bs Q1-4 no skipping insulin when sick maintain hydration change in mental status check urine for ketones = > 240 = bad notify if: illness lover 24hrs glucose over 250hrs inability to tolerate food and fluids ketones in urine for more than 24hrs temp over 101.5 for 24hrs

head injury care

resp status - injury death in 3-5 min w/o O2 GCS cranial nerves + pupil size bilateral sensory and motor response incr ICP - cath in burr hole into ventricle = 10-15 ICP can be incr by: hypercarbia = vasodilation enco or oral suctioning coughing neck or hip flexion less 30 HOB restrictive clothing valsalva maneuver actions to decr ICP: HOB atlest 30 avoid flex, extend, rotation head PaO2 over 60 stool sofeners decr stimuli hearing is last sense effected

spinal injury nursing care

resp status - involuntary resp affected bc lesion at or above phrenic nerve, or swelling from below C4, lesions in cervical or upper throacic area - impair voluntary movements or muscles tissue perfusion - neuro shocck = spinal trauma, loss of communication w/i sympathetic nervous system that keep muscle tone in blood vessels walls, w/i 24hrs of SCI = drop in CO, several days to wks, hypotension, i/o - NPO for days neuro - baseline then monitor for incr loss of neuor function muscle - above L1/L2 = spastic muscle tone, below L1/L2 = flaccid paralysis mobility - if incomplete can regain sensation - complete or incomplete, prevent breakdown bowel/bladder - spastic - condom cath, stimulation of micturition reflex by tugging on pubic hair, indwelling flaccid - lower motor neuron injuries, intermit cath, credes meth (downward pressure on bladder) gi - ileus, monitor BS skin - repo Q2, Q1 in wheelchair

Ischemic Stroke

result from: Inadequate blood flow to brain from partial or complete occlusion of an artery Ischemic strokes can be: Thrombotic Embolic

Clinical Manifestation Spatial-Perceptual Alterations stoke

right side = cause prob in spatial-perceptual orientation Incorrect perception of self /illness Unilateral neglect of affected side = Homonymous hemianopsia Spatial-perceptual orientation can also occur in ppl w/ left-brain stroke. Spatial-perceptual = 4 categories. 1ts = damage of parietal lobe, incorrect perception of self /illness = deny their illnesses or not recognize own body parts. 2nd category = pt neglects all input from affected side (erroneous perception of self in space) = worsened by homonymous hemianopsia, blindness occurs in same half of visual fields of both eyes. pt also has difficulty with spatial orientation = judging distances. 3rd = agnosia = inability to recognize object by sight, touch, hearing. 4th deficit = apraxia, inability to carry out learned sequential movements on command. Bt pt may or may not be aware of their spatial-perceptual alterations =assess for this potential prob as it will impact rehabilitation/recovery.

types of skull fractures

scalp lacerations skull fractures - linear, depressed, simple, communuted, compound, closed, open cranial nerve defects, battle's sign, preiorbital ecchymosis rhinorrhea or otorrhea = through dura test through Dextrostix or Tes Tape strip for glucose, can't do if has blood = look for halo ring

DKA and HHS labs

serum glucose: DKA >300 HHS >600 Na and K: DKA - na(l,n,h), k(depend on how long, then decr) HHS - na(n,l), k(n,h bc deyhydration, monitor for decr) BUN/creatine DKA - BUN > 30, Cr >1.5 = incr bc dehydration HHS - same serum and urine DKA - present HHS - absent serum osmolarity: DKA - high HHS - >320 pH - ABGs DKA - med acid w/ resp compensation = kussmals, pH <7.3 HHS - no acidosis, >7.4

Common Types of Casts

short arm long arm long leg short leg

Clinical ManifestationsIntegumentary System

skin breakdown over bony prominences in areas of decr/absent sensation is a major consequence of immobility r/t SCI. pressure ulcers = infection/sepsis. Poikilothermism = adjustment of body temp to room temp = bc interruption of sympathetic nervous system prevents peripheral temp sensations from reaching hypothalamus. decr ability to sweat or shiver below level of the injury = affects ability to regulate body temp degree of poikilothermism = level of injury. High cervical injuries = associated w/ greater loss of ability to regulate temp than are thoracic or lumbar injuries.

sprains vs strains

sprains = ligaments 1 - few fibers 2 - + swelling and tenderness 3 - complete tear strain = muscle stretching

ImmobilizationSCI

stable thoracic/lumbar spine injuries = immobilized w/ custom thoracolumbar orthosis (TLSO or body jacket) = inhibit spinal flexion, extension, rotation. Jewett brace = to restrict forward flexion. Unstable injuries may require surgical decompression/fusion in addition to TLSO or lumbosacral orthotic (LSO). Immobilization of neck of pt w/ SCI prevents further injury, but effects of immobility are profound. Meticulous skin care = bc decr sensation, circulation = more susceptible to skin breakdown Remove backboard ASAP, replace with other forms of immobilization = prevent skin breakdown in coccygeal, occipital areas. Fit cervical collars properly inspect areas under halo vest or jacket or under braces or orthoses to assess skin.

Interprofessional CareCore Measures for Stroke

stroke (STK) core measures were developed in partnership with the American Stroke Association (ASA) for use by primary stroke centers. These core measures are used by hospitals for accreditation and certification. Measures are implemented during the hospital admission and prior to discharge, and align with guidelines supported by the AHA Get With The Guidelines (GWTG)-Stroke patient management tool and the Centers for Disease Control and Prevention (CDC) National Acute Stroke Registry (PCNASR). VTE prophylazis antithrombilic therapy anticoag for afib thrombolyic therapy antiithrombotic therapy by end of hospital day 2 discharge on statin med stroke education assess for rehab

Clipping and Wrapping of Aneurysms

subarachnoid hemorrhage = bleeding from damaged vessel causes blood to accumulate b/w brain, skull. leaked blood can irritate, damage, destroy brain cells. blood enters subarachnoid space = mixes with cerebrospinal fluid (CSF). = block CSF circulation = incr ICP open spaces in brain (ventricles) may enlarge, resulting in hydrocephalus. further increases ICP (due to the large accumulation of blood) = brain injury. Insertion of ventriculostomy for CSF drainage = improve these situations by reducing ICP. Goals for managing ICP are the same for patients with SAH as they are for patients dealing with acute stroke. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm. Clipping of aneurysm = neurosurgeon placing metallic clip on neck of aneurysm to block blood flow, prevent rupture = clip remains in place for life.

Fat Embolism (FES)

systemic fat globules from fracture = distributed into tissues/organs = death Most common = long bones, ribs, tibia, pelvis FES = total joint replacement, spinal fusion, liposuction, crush injuries, bone marrow transplantation. mechanical theory = fat emboli may originate from fat that is released from marrow of injured bone. fat enters systemic circulation where it embolizes to other organs such as brain. fat droplets lodge in small blood vessels, local ischemia, inflammation occur. biochemical theory = hormonal changes caused by trauma/sepsis stimulate systemic release of free fatty acids (e.g., chylomicrons) = fat emboli.

ligaments and tendons

tendons - muscles to bone ligaments bone to bone bursae - sac of connective tissues w/ synovial fluid

SIADH meds therapy

tetracycline derivative - demeclocycline NOT if bad kidneys correct fluid/electro imbalances by stim urine flow dont take w/ ca, iron, mg, milk, aluminum yeast infection sunscreen, d/ vasopressin antagonists - tolvaptan, conivaptan promote water excretion w/o na loss monitor glucose, na, i/o, bowels loop diuretics - furosemide incr water excretion from the kidney careful - cause na excretion change positions slow hypertonic nacl IV fluid incr na levels = so no neuro s/s if severe admin 200-300ml hypertonic IV fluid check for fluid overload no alcohol

types of strokes

thrombotic - ischemic secondary to development of blood clot on atherosclerotic plaque in cerebral artery, causes ischemia distal to occlusion, hrs to days s/s embolic - ischemic by embolus traveling from another part of the body, neuro deficits or LOC instantly ischemic - thrombotic or embolic reversed by fibrinolytic therapy using alteplase aka tissue plasminogen activator (tPA) (unless active bleeding)

Major Types of Stroke

thrombotic stroke - process of clot formation (thrombosis) result in narrowing of lumen, which blocks the passage of blood through the artery embolc stroke - embolus is a blood clot or other debris circulating in blood, when it reaches an artery in brain that is too narrow to pass through, lodges there and blocks flow of blood hemorrhagic stroke - burst blood vessles may allow blood to seep into and damage brain tissue until clotting shuts off the leak

anterior pit hormones

thyroid stimulating hormone ACTH - adrenocorticotropic hormones LH - ovulation or stimulate testosterone FSH - growth follicle or sperm production prolactin GH - protein synthesis, muscle, bone

Fat Embolism (FES) tx

tx = prevention Management is supportive, related to s/s Repo patient as little as possible b/f fracture stabilization bc dislodging tx = fluid resuscitation = prevent hypovolemic shock, correct acidosis, replace blood loss. Coughing and deep breathing, O2 Intubation/ intermittent + pressure ventilation develop pulmonary edema, ARDS = leading to incr mortality rate. Most persons survive FES with few sequelae.

seizure

uncontrolled electrical discharge of neurons in brain interrupt normal function acidosis, hypoglycemia, electro imbalance, dehydration, withdrawal, water intoc, hypoxia gliosis - scar tissue where seizure was prodromal phase - w/ sensations or behaviors changs b/f aural phase - sensory warnings, similar everytime ictal phase - from first s/s to end seizure postictal phase - recovery after

migraine

unilateral throbbing light, sound, smell sensitive age 20-30, female risks: fam hx, low education, low socioeco, high workload, w/o aura most common = common migraine w/ aura - classic migraine 4-72hrs NSAIDs, spirin, caffine, triptan Botulinum toxin A - prophyatic injections around neck gabapentin

Clinical Manifestation Elimination stroke

urinary + bowel elimination occur initially + only temporary If affects 1 hemisphere of brain, prognosis for normal bladder function = excellent Initially, pt may experience frequency, urgency, incontinence. motor control of bowel is not a problem, pt frequently c/ = immobility, weak abdominal muscles, dehydration, decr response to defecation reflex. Urinary and bowel elimination prob also r/t inability to verbalize need to eliminate, difficulty w/ managing clothing = incontinence. Scheduled toileting , clothes are easily removed may encourage independence.

meningitis labs, dx, complications

urine, throat, nose, blood cultures and sensitivity CBC dx: CSF cloudy = bacterial clear = viral incr WBC, protein, pressure decr glucose (bacterial) CIE = counterimmunoelectrophoresis - done on CSF for infectious agent is viral or protozoa, indicated if antibiotics started b/f CSF CT/MRI - incr ICP or abscess complications incr ICP - brain herniation, LOC, pupil changes, mannitol SIADH - abd stimulation of hypothalamic, incr antidiuretic hormone = vasopressin, s/s = dilute blood, concentrated urine, admin demeclocucline, fluid restriction, weight septic emboli - hands and feet, gnagrene

other tx for seizures

vagal nerve stimulation: electrode in neck electrical impulse to agus nerve on left side magnet when senses seizure a/e = coughing, hoarseness, dyspnea, tingling in neck life 5-10 years ketogenic diet: high fat, low carbs, ketone pass into brain and replace glucose

seizures therapeutic procedures, complications

vagal nerve stimulator - tx of partial seizures, implanted into left chest wall, connected to electrode on left vagus nerve, hold magnet over head to stop/lessen seizure, no MRI, US, microwaves, radios conventional surgical procedures - partial or general seizures, AED d/c before surgery, WADA = see if speech/memory effected partial corpus callosotomy - resect corpus callosum = no discharges across hems complications: status epilepticus = repeat seizures w/i 30 min, or 1 seizure lasting more 5 min = caused by withdrawal, withdrawl from AEDs, head injury, cerebral edema, infection, metabolic disturbances give IV diazepam, lorazepam push then phenytoin or fosphenytoin

meningitis risk factors and findings

viral - mumps, measles, herpes, arbovirus, no vaccine fungal - infected sinuses from c. neoformans bacterial - otitis media, pneumonia, sinusitis, n. meningitidis, s. pneumoniae, h. influ immunosuppression direct contamination of spinal fluid invasive procedures skull fracture penetrating wound enviro - overcrowded living conditions findings: excruciating HA nuchal rigidity - stiff neck photophobia fever/chills n/v altered LOC + kernig's sign +brudzinski hyperactive DTR tachycardia seizures red macular rash restless

cerebral angiography

visualize blood vessles hides bones iodine based dye see aneurysms, tumors NPO, shellfish?, BUN/Creatinine, no jewelry, sedative

arthroscopy

visualize joints = knee or shoulder swelling, pain, infection, instability incr and elevate splint or sling

musculoskeletal system

vit C, D, protein lose weight ROM

stroke nursing care

vs Q1-2 180/110 = get help = ischemic stroke temp = fever = incr ICP HOB 30 tele mon no flex or extend neck, midline, neutral seizure precautions assess communication ability assist w/ feeding - unaffected side, suction, distraction free enviro passive ROM Q2, active Q2 elevate affected extreme = incr venous return scanning tech - turn head from unaffected to affected when eating/walking shoulder subluxation - if not supported

DI dx care meds complications

water deprivation = ADH stim test if lose more 2kg - stop test vasopressin subQ injection vaso = urine output with incr specific gravity differentiates from central and nephrogenic weight, reg diet no caffine bulk foods, laxative ADH replacement agents: desmopressin, aqueous vasopressin = nasal, PO, parental incr water reabsorption from kidney and decr urine output careful is CAD = vasocontriction water intoxication = HA, confusion gain over 2lb in 24hr = TELL DOC complications: hypovolemia, hyperosmolar, hypernatremia, seizures

SIADH complications

water intox, cerebral/pul edema, severe hyponatremia: crackles, distended neck veins, neuro, edema, decr urinary output do neuros, seizures central pontine myelinolysis: tx can result in this, destruction of myelin sheaths in brainstem = pons, can is rapid change in Na levels check na Q2-4hrs

Bacterial Meningitis Complicationsneuro

↑ ICP = Major cause of altered mental status Sequelae varies by cranial nerve residual neurologic dysfunction. Dysfunction involving many cranial nerves. Optic nerve (CN II) compressed by ↑ ICP = Papilledema with possible blindness Ocular movements = III, IV, VI = Ptosis, Unequal pupils, Diplopia CN V irritation = Sensory loss and loss of corneal reflex Inflammation CN VII = Facial paresis Irritation of CN VIII = Tinnitus, vertigo, deafness = permanent dysfunction = disappears within a few weeks.

Nutritional Therapyfracture

↑ Protein (1 g/kg of body weight) ↑ Vitamins (B, C, D) ↑ ca, ph, and mg ↑ Fluid (2000-3000 mL/day) ↑ Fiber Low serum protein and vitamin C deficiencies = decr tissue healing. Immobility and bone healing incr ca needs. immobilized in bed with skeletal traction or in a body jacket brace = eat 6 small meals so as not to overeating that can contribute to abdominal pressure, cramping.

ComplicationsChronic Subdural Hematoma

↑ Risk for misdiagnosis develops over wks or months after seemingly minor head injury. more common in elders = bc larger subdural space as result of brain atrophy. Atrophy = brain remains attached to supportive structures, tension is incr = subject to tearing. larger size of subdural space also accounts for presenting complaint to be focal symptoms (specific to certain area of brain), rather than s/s of incr ICP. Chronic alcoholics = prone to cerebral atrophy Delay in dx = mimic other prob iin elders = somnolence, confusion, lethargy, memory loss. misinterpreted as vascular disease (stroke, TIA), dementia.

Clinical ManifestationsMetabolic Needs

↑Nutritional needs caloric and nitrogen needs NGT suctioning = metabolic alkalosis = monitor Na, K Lean body mass is lost, muscles atrophy = weight loss. nut = prevent skin breakdown, decr infection, decr rate muscle atrophy.

Stress UlcersSCI

↑Risk secondary to severe trauma, physiologic stress Monitor stool, gastric contents, hematocrit physiologic response to severe trauma and psychologic stress. Peak incidence of stress ulcers is 6-14 days after injury. Histamine (H2)-receptor blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]) or PPI (e.g., pantoprazole [Protonix], omeprazole [Prilosec]) prophylactically to decr secretion of HCl acid

ComplicationsAcute Subdural Hematoma

↓ LOC, headache 24 to 48 hours of injury. s/s like brain tissue compression in incr ICP = decr LOC, HA. size of hematoma determines clinical presentation, prognosis. Pt appearance range from drowsy, confused, unconscious. ipsilateral pupil dilates, becomes fixed if ICP is significantly elevated. Blunt force injuries = acute subdural hematomas = cause significant underlying brain injury = cerebral edema. = incr ICP from cerebral edema = incr morbidity, mortality risk despite surgical intervention to evacuate hematoma.