NUR 419 Final Exam

What is ALS?

It is a rare nervous system disease that slowly weakens muscles and impacts physical function with no known cause.

Admission Assessment

Jaqui became angry with her aunt and states as an attempt to kill her aunt she lit pieces of paper on fire on her bed. This resulted in a massive house fire. All family members got out safely. Anger at her aunt is due to "her accusing me of being sexually active". Diagnoses: 1. Unspecified Depressive Disorder 2. Oppositional Defiant Disorder 3. THC Use Disorder- moderate 4. Borderline Intellectual Functioning 5. Prader- Willi Syndrome 6. Hypertension 7. Asthma 8. Enuresis 9. Morbid Obesity 10. Obstructive Sleep Apnea with BiPAP 11. H/O Precocious Puberty

Psychiatric and Mental health issues secondary to PWS

Jaqui has a host of issues apart from Prader Willi diagnosis. She experienced unstable family life from an early age, including the traumatic premature death of her mother. This, coupled with a family history of depression, places Jaqui at considerable psychiatric risk at a vulnerable time in her life. Her expressed auditory hallucinations, delusional conviction that she is persecuted by her aunt, and habitual lying, are symptoms typical of schizophrenia or some sort of schizo-affective mood disorder.

Ramifications of IQ

Jaqui has an IQ of 70, a sign of borderline mental retardation, is an unfortunate function of Prader-Willi. The consequences are widespread, and touch on many aspects of her life. Stunted intellectual capacity will make it difficult for Jaqui to become fully independent in the future. People with low IQ struggle to adapt to uncertain and disruptive conditions, the kind that Jacqui faces day to day. The intellectually disabled are subject to increased expenses throughout their life, a financial burden on their families.

Assessment of acute pain in children

Medical procedures like immunization Surgical and orthopedic procedures like tonsillectomy Medical treatments like chemotherapy induced mucositis Injury like falls Infection Exacerbation of disease related pain like sickle cell disease

Medications

Methimazole First choice for treating hyperthyroidism. Purpose: prevents the thyroid gland from producing too much thyroid hormone. Duration: Used for 12 to18 months. Propylthiouracil purpose: is used to treat an overactive thyroid gland by reducing the amount of thyroxine made by the gland. Duration: continue to take for as long as doctor advises to do so. Beta-blockers (ex. Propranolol) Purpose: it treats high blood pressure by making the heart beat slowly and with less force, thereby reducing blood pressure. Duration: continue to take unless doctor advises to stop. Purpose of radioactive iodine. Unlike anti-thyroid medications, radioactive iodine is a permanent and more reliable cure for hyperthyroidism. Used to treat hyperthyroidism by gradually shrinking the thyroid—ultimately destroying the gland. It can destroy all or part of the thyroid. Sometimes, the total destruction of the thyroid is most often necessary to alleviate your hyperthyroid symptoms, and this is referred to as radioactive iodine ablation. This intervention can interfere with other medications (anti-thyroid drugs) for hyperthyroidism. Anti-thyroid drugs would be stopped before the treatment can start. Taking iodine along with medications for an overactive thyroid might decrease the thyroid too much.

What is Hashimoto thyroiditis?

Hashimoto thyroiditis (hypothyroidism) is an autoimmune disorder in which immune cells mistakenly attack healthy thyroid tissue, causing inflammation of the thyroid.

Transcutaneous electrical nerve stimulation

(TENS) involves the placing of two pairs of flat electrodes on either side of the woman's thoracic and sacral spine. These electrodes provide continuous low-intensity electrical impulses or stimuli from a battery-operated device.

Hashimoto's thyroiditis

(hypothyroidism) is an autoimmune disorder in which immune cells mistakenly attack healthy thyroid tissue, causing inflammation of the thyroid. Goiter is hallmark of Hashimoto's thyroiditis Clinical manifestations of Hashimoto's thyroiditis • Fatigue and sluggishness • Increased sensitivity to cold • Constipation • Pale, dry skin • A puffy face • Hoarse voice • Unexplained weight gain • Muscle aches, tenderness and stiffness, especially in shoulders and hips • Pain and stiffness in joints • Muscle weakness, especially in lower extremities • Excessive or prolonged menstrual bleeding (menorrhagia) • Depression Treatment of Hashimoto's thyroiditis • If the thyroiditis is bacterial in origin, treatment may include specific antibiotics or surgical drainage • In the subacute and acute forms, NSAIDS (aspirin or naproxen (Aleve) are used to relieve symptoms • With more severe pain, corticosteroids (e.g., prednisone up to 40 mg/day) are used to relieve discomfort • Propranolol (Inderal) or atenolol (Tenormin) may be used to treat the cardiovascular symptoms related to hyperthyroid conditions

Grave's disease

- (hyperthyroidism) is an autoimmune condition in which autoantibodies are directed against the thyroid-stimulating hormone (TSH) receptor. As a result, the thyroid gland is inappropriately stimulated with ensuing gland enlargement and increase of thyroid hormone production. Classic finding in Grave's disease is exophthalmos, a protrusion of the eyeballs from the orbits that is usually bilateral Clinical manifestations of Graves' disease • Weight loss—despite increased appetite • Anxiety, restlessness, tremors, irritability, difficulty sleeping (insomnia) • Heat intolerance, sweating • Chest pain, palpitations • Shortness of breath, difficulty breathing • Increased stool frequency (with or without diarrhea) • Irregular menstrual periods • Muscle weakness • Difficulty controlling diabetes • Goiter • Prominent, bulging eyes • Vision problems (such as double vision) Treatment of Graves' disease • Radioactive iodine therapy • Anti-thyroid medications • Beta blockers • Surgery

Anticipated Physician Orders,

- O2 sats every 4 hours, wean O2 to keep sats greater than 92% -Abdominal binder - Schedule Gastrograffin Swallow (shows outline of the esophagus and stomach) for the AM (POD #1) rule out leak/obstruction. If negative for leaks • Post Bariatric Surgery Clear Liquid Diet Acetaminophen 650 mg po every 4 hours prn pain (crush) - May shower on POD #2

Ruptured cerebral aneurysm

- a weakness in a blood vessel in the brain that balloons and filled with blood Assessments for ruptured cerebral aneurysm (intracranial or brain) • Altered level of consciousness. • Sluggish pupillary reaction. • Motor and sensory dysfunction. • Cranial nerve deficits (extraocular eye movements, facial droop, presence of ptosis). • Speech difficulties and visual disturbance. • Headache and nuchal rigidity or other neurologic deficits. Nursing interventions for ruptured cerebral aneurysm (intracranial or brain) • All patients should be monitored in the intensive care unit after an intracerebral hemorrhage • Improving cerebral tissue perfusion • Relieving sensory deprivation • Monitoring and managing potential complications • Teaching patient's self-care

Anticipated Physician Orders, Mr. Jones is stable and considered to be doing well. What physician orders will you anticipate today?

-VS: every 1 hour for 1st 2 hours; then every 2 hours for the next 8 hours then every 4 hours. - Diet: NPO; may have 1 teaspoon ice every 4 hours. -Elevate head of bed 45 degrees. -OOB chair evening of surgery; majority of day on POD #1. - Ambulate four times daily -Consults: Physical Therapy & Dietary - Incentive spirometry every hour while awake; Deep Breathe and Cough every 1 hour while awake -Chest Percussion every 4 hours

NCLEX QUESTIONS #1: The most significant initial nursing observations that need to be made about a client with myasthenia include:

1. Ability to chew and speak distinctly, 2. Degree of anxiety about her diagnosis, 3. Ability to smile an to close her eyelids, 4. Respiratory exchange and ability to swallow and Answer 4. Respiratory exchange and ability to swallow Rationale: Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

NCLEX Question #3: A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:

1. Getting too little exercise 2. Taking excess medication 3. Omitting doses of medication 4. Increasing intake of fatty foods Answer 3. Omitting doses of medication Rationale---myasthenic crisis often is caused by undermedication. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

Intervention,

1. Inspect pacemaker insertion site for redness, edema, warmth, drainage, or tenderness. 2. Instruct patient to avoid wearing constrictive clothing until site has healed completely. 3. Instruct patient/family regarding pacemaker use, need for removal or replacement, and igns and symptoms to report to physician

Intervention,

1. Monitor ECG for changes in rhythm, rate, and presence of dysrhythmias. Treat as indicated. 2. Obtain and observe rhythm strip every 4 hours and prn. Notify physician of Abnormalities 3. Monitor patient for complains of dizziness, weakness, fatigue, syncope, edema, chest pain, palpitations, pulsations in neck veins, or dyspnea. Rational: 1. Observation for pacemaker malfunction promotes prompt treatment. Pacer electrodes may irritate ventricle and promote ventricular ectopy. 2. Identifies proper functioning of pacemakers, with appropriate capture and sensing. 3. During ventricular pacing, AV synchrony may cease and cause a sudden decrease in cardiac output. This may indicate "pacemaker syndrome" or failure of the pacer to function which results in decreased perfusion.

Intervention,

1. Monitor for presence of pulses at site, distal to pacer insertion. 2. Instruct patient in signs and symptoms, such as restlessness, syncope, chest pain, or dyspnea of which to notify nurse. 3. Instruct patient and/or family to notify physician for redness, swelling, or drainage at site of pacemaker battery insertion. Rationale: 1. Hemorrhage may promote tissue edema and compression to arterial blood flow resulting in diminished or absent pulses. 2. Provides prompt identification of potential complication and allows for timely treatment May indicate malposition of lead irritating heart muscle tissue, which can then be promptly treated. 3. Provides for potential identification of infection and allows for prompt treatment with antimicrobials to reduce possibility of sepsis.

Rationale,

1. Prompt detection of problems helps promote prompt treatment or nursing intervention. 2. May cause discomfort at incision site from pressure and rubbing against skin. 3. Pulse generators may require removal for battery replacement, fracture of lead wires, pacemaker failure, and so forth. Knowledge of potential problems can help facilitate timely identification, notification of physician and appropriate care.

Nutritional recommendations

1. Remove temptation - access to food should be controlled at all times, other than the food provided for meals and snacks. It is often necessary to lock cupboards, fridges and prevent access to garbage bins. Controlling the food environment is very important to ease the pressure Jacqui and will help her behaviour, reducing temptation, tantrums, guilt and sense of failure. 2. Behaviour - you will need to establish good eating routines, offer a wide variety of healthy food choices from an early age, and be consistent. Don't reward with food, and don't give in to tantrums. 3. Quantity - Jacqui will need to stay on a highly restricted diet 4. Quality - it is best to offer Jacqui high quality foods which are low in fat, but high in nutrients 5. Jacqui's grandmother should work with a dietitian to determine Jacqui's allowances from each of the core food groups to allow for satisfactory growth. These allowances need to be reviewed and adjusted at least once a year as your child grows. Plotting progress with height and weight on growth charts will help to determine the adequacy of the prescribed diet. 6. Exercise is also important in preventing weight gain

NCLEX Question #2: While reviewing a client's chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?

1. The client may be less sensitive to the effects of a neuromuscular blocking agent. 2. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. 3. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. 4. Pancuronium and succinylcholine both require cautious administration. Answer: 4. Pancuronium and succinylcholine both require cautious administration. Rationale: The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with MG.

Jacqui's Medications & Treatments

1. Zoloft 100mg po daily 2. Topamax 75mg po daily 3. Singulair 10mg po daily 4. Melatonin 6mg po QHS 5. Miralax 17g po BID 6. Lisinopril 30mg po daily 7. Amlodipine 10mg po daily 8. MVI one tab po daily 9. VitD3 1000 International Units po daily 10. Advair 115/21mcg 2 puffs Q12h 11. BiPAP 18/10 rate 15 QHS

Various stages of Bariatric Diet cont.

3rd stage - After a few weeks on pureed diet, Mr. Jones can add soft food to his diet which include: Ground or finely diced meats Canned or soft fresh fruit (without seeds or skin) Cooked vegetables (without skin) 4th stage - Around eight weeks, Mr. Jones can gradually return to solid foods and see what he can tolerate. He must avoid food such as Nuts and seeds, Popcorn, Dried fruits, Carbonated beverages, Granola, Stringy or fibrous vegetables, such as celery, broccoli, corn or cabbage, Tough meats or meats with gristle, Fried foods, and Breads 5th stage - around 3 to 4 months, Mr. Jones can return to a normal healthy diet with a focus on high proteins and low in carbs, and fats. He will be having about six smaller meals with a recommendation to take vitamin and mineral supplements.

The Situation:

44 year old male sitting in the exam room at the primary care office. When he moves to the table, he stumbles, laughs at himself, states "That happens all of the time."

Case Study

8 months later, Karen visits her neurologist. Her symptoms have improved with treatment. She is now planning on starting a family but has some concerns about becoming pregnant.....

NCLEX Question

: Which assessment data would make the nurse suspect the client has ALS? History of a cold or GI upset in the last month Complaints of double vision and drooping eyelids Fatigue, progressive muscle weakness, and twitching Loss of sensation below the level of the umbilicus

Is this a permanent or transient complication?

Hypoparathyroidism can be either permanent or transient. Permanent hypoparathyroidism is rare, but transient hypoparathyroidism affects approximately 7% of patients.

Bilevel Positive Airway Pressure (BiPAP)

A BiPAP machine uses two pressure settings, high and low, to deliver room air through a mask and into the airway to match an individual's natural breathing rhythm, the high pressure setting is used for inhaling, and the low pressure setting is used for exhaling. Sleep apnea is a serious sleep disorder that occurs when a person's breathing is interrupted during sleep. The pressure keeps the throat muscles from collapsing and reducing obstructions by acting as a splint. Jaqui has sleep apnea and the BiPAP machine allows her to breathe easily and regularly throughout the night

Spinal anesthesia

A block An anesthetic solution containing a local anesthetic alone or in combination with an opioid agonist analgesic is injected through the 3,4,or 5 lumbar interspace into the subarachnoid space where it mixes with the CSF Not suitable for vaginal birth but used for cesarean birth May see marked hypotension, impaired placental perfusion and an ineffective breathing pattern Before, assess maternal vital signs and 20 to 30 minutes of EFM as well as maternal fluid balance Advantage Absence of fetal hypoxia Maintenance of maternal blood pressure within a normal range Maternal consciousness is maintained Blood loss is not excessive Disadvantages Possible medication reactions like allergies Hypotension An ineffective breathing pattern After birth, bladder and uterine atony and postdural puncture headache, PDPH (due to leakage of CSF fluid) increases

Common Causes of Increased ICP

A blow to the head is the most common cause of increased ICP. Other possible causes of increased ICP include: infections tumors Stroke Aneurysm Epilepsy Seizures Hydrocephalus (an accumulation of spinal fluid in the brain cavities) hypertensive brain injury (when uncontrolled high blood pressure leads to bleeding in the brain) Hypoxemia (a deficiency of oxygen in the blood) Meningitis (inflammation of the protective membranes around the brain and spinal cord)

What is goiter?

A goiter is any enlargement of the thyroid gland. It is located at the base of the front side of the neck just below the Adam's apple. It may be a temporary problem that will remedy itself over time without medical intervention or A possibly severe, thyroid condition that requires medical attention.

Wound Healing,

A is primary intention wound healing that include surgical intention like bariatric surgery or papercut. It follows the normal three stages of healing. B is secondary intention that include trauma, infection or ulceration. Have large amount of exudate, irregular wound edges and tissue loss. Process of healing is the same as primary intention with differences being gaping wound edges and defects. C is tertiary intention also known as delayed primary intention. What happened is the delayed suturing due to a previous infection and it has been controlled and the the granulation tissues have been sutured together.

Lumbar puncture

A lumbar puncture can detect any blood in the fluid around the brain and spinal cord, which may be present in the case of a subarachnoid hemorrhage. • The procedure should be postponed until 12 hours after the initial onset of symptoms, to give the red blood cells enough time to break down to produce bilirubin - the actual substance for which the lumbar puncture checks. Nursing care for lumber puncture • Lumbar puncture is a strict aseptic technique requiring full sterile procedures • Encourage patients to drink well before and after the procedure • Positioned the patient carefully, laying on one side in a curled up position with the lumbar spine exposed (knees drawn up to the chest). Moving the patient's back closer to the edge of the bed will make access to the lumbar spine easier. Support the patient in this position throughout the procedure. • A small local sterile dressing is applied to the spinal site after removal of the needle. • Headache is a common complaint following lumbar puncture. The patient should lay flat for 6-12 hours afterwards, as sitting up may make any headache worse. Contradictions for lumber puncture • Skin infection near the site of the lumbar puncture • Suspicion of increased intracranial pressure due to a cerebral mass • Uncorrected coagulopathy • Acute spinal cord trauma

Main Complication of Thyroidectomy

A major complication is hypoparathyroidism, which is under functioning of the parathyroid glands. The function of the parathyroid glands is to control the body's calcium levels. If the parathyroids are damaged or nicked during surgery, this trauma can cause temporary or permanent shutdown, which results in a lowered calcium level, called hypocalcemia.

Pacemaker,

A pacemaker is an electronic device that provides electrical stimuli to the heart muscle. Pacemakers provide an electrical stimulus to depolarize the heart and cause a contraction to occur at a controlled rate. The function of the pacemaker (or pacer) is to maintain the heart rate when the patient's own intrinsic system is unable to do so. The stimulus of the pacer is produced by a pulse generator and delivered via electrodes or leads that are implanted in the epicardium or endocardium. The electrodes may be unipolar or bipolar, and the proximal end attaches to a pulse generator that is placed in the chest or abdomen.

Interpret this rhythm strip,

A pacer lead was placed on the atrium and the ventricle so it is conducting the atria or P wave (which tells the heart to fire, almost like a little spark) and the pacer in the ventricle causing the heart to contract and perfuse blood.

NCLEX Questions Which of the following values is considered normal for ICP?

A. 0-15 mmHg B. 25 mm Hg C. 35-45 mm Hg D. 120/80 mm Hg Answer: A. 0-15 mm Hg

NCLEX Questions A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident, Which of the following diagnosis takes highest priority over this client's plan of care?

A. Disturbed sensory perception B. Self care deficit; Dressing/grooming C. Impaired verbal communication D. Risk for injury Answer: D. Risk for injury

Medications used to treat pain in Children

Acetaminophen or NSAIDs (ibuprofen, naproxen) are used to manage pain that is mild or moderate. Opioid analgesics, often in combination w/ NSAIDS, are used for moderate-to-severe pain. Commonly prescribed opioids in children include: Morphine Oral, IM Injection, IV Fentanyl Oral, IV Codeine Oral Hydromorphone Oral, IV

Calculating BMI What is the patient's BMI?,

BMI is your weight (in kilograms) over your height squared (in centimeters). Mr. Jones height & weight is as follows: 385 lbs 5"10 (178 cm) BMI= 55.2 How would you classify him? Mr. Jones would be classified as morbidly obese which is includes any BMI >40+.

Pharmacological Interventions

Analgesics- Main choice for relieving pain 3 Categories- Non-Opioids, Opioids, and adjuvants Non-Opioid analgesics (acetaminophen, NSAIDS): Appropriate for mild to moderate pain Watch for hepatic effects of acetaminophen. Monitor for salicylism (tinnitus, vertigo, decreased hearing acuity) Prevent gastric upset by administering with food or antacids Monitor for bleeding with long-term NSAID use

Thyroid (Hashimoto) antibodies: Anti-thyroid Antibodies

Abnormal antibodies that attack your thyroid glands and by causing a decrease in the number of active thyroid glands (hypothyroidism). If Marla has hyperthyroidism, what lab values would you expect for these labs?

Pathophysiology,

Abnormal electrical discharges (1) may arise from central areas in the brain that affect consciousness; (2) may be restricted to one area of the cerebral cortex production manifestations characteristic of the particular anatomic cous or (3) may begin in a localized area of the cortex and spread to other portions of the brain and if sufficiently extensive produce generalized seizure activity. Seizure activity begins with a group of neurons in the CSN that because of excessive excitation and loss of inhibition amplify their discharge simultaneously

Lab Results: Interpret all lab results and discuss expected interventions.

According to ABG results, Mr. Jones is experiencing respiratory acidosis. Elevated K+, BUN, and glucose levels Low Hbg, RBC, and platelet count

Contraindications to Subarachnoid and epidural blocks

Active or anticipated serious maternal hemorrhage. Acute hypovolemia leads to increased sympathetic tone to maintain the blood pressure. Any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and fetus. Maternal hypotension. Coagulopathy. If a woman is receiving anticoagulant therapy (e.g., last dose of low-molecular-weight heparin within 12 hours) or has a bleeding disorder, injury to a blood vessel may cause the formation of a hematoma that may compress the cauda equina or the spinal cord and lead to serious CNS complications. Infection at the needle insertion site. Infection can be spread through the peridural or subarachnoid spaces if the needle traverses an infected area. Increased intracranial pressure caused by a mass lesion. Allergy to the anesthetic drug. Maternal refusal or inability to cooperate. Some types of maternal cardiac conditions. Epidural block effects on newborn: Has little or no lasting effect on the physiologic status of the newborn

Priorities of care for patient experiencing a stroke

Acute Care • Maintenance of airway • Fluid therapy • Treatment of cerebral edema • Prevention of second injury • Ischemic stroke - tissue plasminogen activator (tPA) IV or intraarterial, stent retrievers, MERCI retriever • Hemorrhagic stroke - surgical decompression if indicated, clipping or coiling of aneurysm Initial • Ensure patent airway • Call stroke code or stroke team • Remove dentures • Perform pulse Ox • Maintain adequate oxygenation with supplemental O2, if necessary • Establish IV access with normal saline • Maintain BP according to guidelines • Remove clothing • Obtain CT scan or MRI immediately • Perform baseline laboratory (including blood glucose) immediately, and treat if hypoglycemia • Position head in midline • Elevate head of bed 30 degrees if no symptoms of shock or injury • Institute seizure precautions • Anticipate thrombolytic therapy for ischemic stroke • Keep [patient NPO until swallow reflex evaluated Ongoing monitoring • Monitor vital signs and neurologic status, including level of consciousness, motor and sensory function, pupil size and reactivity, SaO2, and cardiac rhythm • Reassure patient and family

types of pain

Acute Pain: Usually of recent onset & commonly associated with a specific injury; Indicates that damage or injury has occurred.It can last anywhere from 6 secs to 6 months. However, most resolve within 6 weeks. Chronic Pain: Defined as pain that lasts longer than six months. May lead to disability. Nociceptive Pain: Usually arises from damage to or inflammation of tissue other than that of the peripheral and CNS. Usually throbbing, aching & localized. Neuropathic Pain Arises from abnormal or damaged pain nerves. Intense, shooting, burning or described as "pins and needles" Somatic Pain Occurs in ligaments, tendons, bones, blood vessels, and nerves. It is often poorly localized, may produce nausea, and may be associated with sweating and blood pressure changes. Somatic pain can be classified as either: 1) cutaneous, superficial or peripheral pain and 2) deep pain. Visceral Pain Originates from body organs

Types of Pain

Acute pain Short term and self-limiting Follows predictable trajectory Dissipates after an injury heals Incident pain - an acute type that happens predictably when certain movements take place Chronic or persistent pain Pain continues for 6 months or longer Divides into two categories Malignant Or cancer related Often parallels the pathology created by tumor cells Pain induced by tissue necrosis or stretching of an organ by the growing tumor Nonmalignant Often associated with musculoskeletal conditions such as arthritis or fibromyalgia Does not stop when injury heals and persists after the predicted trajectory Originates from abnormal processing of pain fibers from peripheral or central sites Breakthrough pain Transient spike in pain level in controlled pain syndrome

Epidural and intrathecal (spinal) opioids

Administered into the spinal Does not cause maternal hypotension or affect vital signs Feels contractions but not pain Side effects: nausea, vomiting, diminished peristalsis, pruritius (hives), urinary retention and delayed respiratory depression.

Recommendations

After two days in the hospital, Brian is to be discharged home. Because he continues to have intermittent headache and mild cognitive impairment, he is referred to a concussion clinic for ongoing management.

factors that affect the pain experience

Age Infants can't verbalize or understand their pain. Older adults may have multiple diseases that cause pain and limit function. Fatigue, which increases sensitivity Pain tolerance Anxiety & fear Culture Support systems Cognitive function Patients may not be able to report accurately.

Nursing Interventions -

Air way management , respiratory monitoring, Assess respiratory rate rhythm and depth. Rationale: respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. Assess patient ability to clear secretions. Rationale: an obstructed airway may cause a change in breathing pattern.

Potential Issues Related to Discharge

Alcohol and drug abuse Suicidal gestures Verbal and physical abuse by Jacqui's aunt Poor dietary habits Locate local or online PWS support groups for Jacqui, educate her and her family on beneficial nutritional practices. Notify Jacqui's school of her situation, schools can provide accommodation to PWS patients.

Arteriovenous malformation (AVM) repair,

An AVM is a tangle of faulty arteries and veins that can rupture within the brain Repair helps prevent further bleeding in the brain. Evacuation of hematomas > 3 cm Procedure is chosen based on the cause of the stroke

Opioid (Narcotic) Agonist - Antagonist Analgesics

An agonist is an agent that activates or stimulates a receptor to act; an antagonist is an agent that blocks a receptor or a medication designed to activate a receptor. Butorphanol (Stadol) and Nalbuphine (Nubain) are commonly used opioid agonist-antagonist analgesics. Provide adequate analegsia without causing respiratory depression in the mother or neonate. Higher doses does not produce additional respiratory depression and less likely cause nausea and vomiting

pain assessments in adults

An appropriate pain assessment includes: Identify the location Cause Quality Intensity Aggravating or relieving factors Acute vs. Chronic Pain Management measures used in the past including the success of those measures How does it affect function (ADL's)

Pulmonary Function Tests (PFT's),

Are non-invasive tests that shows the functional status of the lungs. The tests measure lung volume, capacity, rates of flow, and gas exchange. The information can help the PCP diagnose and decide the kind of treatment to be given.

Aromatherapy:

Aromatherapy uses oils distilled from plants, flowers, herbs, and trees to promote health and to treat and balance the mind, body, and spirit. tone the uterus, encourage contractions, reduce pain, relieve tension, diminish fear and anxiety, and enhance the feeling of well being.

Pain Assessment for Patient at Risk of Opioid Abuse

Assess patients for pain frequently, and intervene as appropriate. Sedation, repiratory depression and coma can occur as a result of overdosing. Sedation always comes before respiratory depression Identify high-risk patient (older adult clients, clients who are opioid-naive,teens looking for mind-altering effects) Carefully titrate doses while closely monitoring respiratory status. Stop the opioid and give antagonist (Naloxone-Narcan) if RR is below 8/min and shallow or the client is difficult to arouse. Use a sedation scale in addition to a pain rating scale Usage of the ORT

What is the Antidote?,

Atropine (a cholinergic antagonist), counteracts the effects of Tensilon. Atropine should always be ready during administration of Tensilon.

Management of Complete Heart Block,

Atropine and Transcutaneous/Transvenous Pacing. Transcutaneous pacing is the treatment of choice for any symptomatic patient. All patients who have complete heart block associated with repeated pauses, inadequate escape rhythm, or block below the AVN should be stabilized with temporary pacing.

Plan of care for Activity,

Based on these assessments, what will you include in your plan of care? Nursing Diagnosis: Activity Intolerance related to an imbalance of oxygen supply and demand as evidenced by the patient's drowsiness Outcome: Patient exhibits tolerance during physical activity as evidenced by rating of perceived exertion of 3 or less (on a scale of 0 to 10), HR less than or equal to 120 beats/min (or within 20 beats/min of resting HR), systolic BP within 20 mm HG increase resting systolic BP, respiratory rate less than 20 breaths/min, absence of chest pain or dyspnea Patient reports ability to perform required activities of daily living (ADLs). Intervention: Short term: establish guidelines and goals of activity with the patient and caregiver motivation is enhanced if the patient participates in goal setting. Depending on the etiological factors of the activity intolerance, some patients may be able to live independently and work outside the home. Other patients with chronic debilitating disease may remain homebound. Long term: Assist with ADLs as indicated; however, avoid patient dependency as much as possible assisting the patient with ADLs allows for conservation of energy. caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and self-esteem. Evaluation: Continue to monitor activity tolerance. Patient perform ADLs independently

Water Therapy (Hydrotherapy)

Bathing, showering, and jet hydrotherapy (whirlpool baths) with warm water (e.g., at or below body temperature) are nonpharmacologic measures that can promote comfort and relaxation during labor. The warm water stimulates the release of endorphins, relaxes fibers to close the gate on pain, promotes better circulation and oxygenation, and helps soften the perineal tissues. agency policy should be consulted to determine if the approval of the laboring woman's primary health care provider is required and if criteria need to be met in terms of the status of the maternal and fetal unit (e.g., stable vital signs and fetal heart rate [FHR] and pattern, and stage of labor). Intradermal Water Block: An intradermal water block involves the injection of small amounts of sterile water (e.g., 0.05 to 0.1 mL) by using a fine-gauge needle (e.g., 25 gauge) into four locations on the lower back to relieve low back pain. It helps because of the gate control theory

Pain Scales in Infants up to 36 months

Behavioral Indicators of Infant Pain (BIIP) Comfort Scale Crying, Requires increased oxygen, Increased vital signs, expression, sleeplessness (CRIES) pain scale Faces. Legs, Activity, Cry, and Consolability (FLACC) Scale Neonatal Facial Coding System (NFCS) Scale

Biofeedback

Biofeedback is based on the theory that if a person can recognize physical signals, certain internal physiologic events can be changed (i.e., whatever signs the woman has that are associated with her pain). For biofeedback to be effective, the woman must be educated during the prenatal period to become aware of her body and its responses and how to relax. The woman must learn how to use thinking and mental processes (e.g., focusing) to control body responses and functions.

Age at Assessment Features Sufficient to Prompt DNA Testing

Birth to 2 years old, 1. Hypotonia with poor suck. 2y-6 years old: 1. Hypotonia with history of poor suck. 2. Global developmental delay. 6y-12 years old: 1. History of hypotonia with poor suck (hypotonia often persists). 2. Global developmental delay. 3. Excessive eating (hyperphagia; preoccupation with food) with central obesity if uncontrolled. 13 years old through adulthood: 1. Cognitive disabilities; usually mild mental retardation. 2. Excessive eating (hyperphagia; preoccupation with food) with central obesity if uncontrolled. 3. Hypothalamic hypogonadism and/or typical behavior problems (including temper tantrums, perseverative and compulsive-like behaviors).

What is the therapeutic drug level for phenytoin?,

Blood levels 10-20mcg/mL (8-10mcg/mL in neonates)

Karen's clinical manifestations,

Blurry or "double" vision (diplopia), Right upper eyelid droops (ptosis), Altered speaking, Nods head forward intermittently, Difficulty chewing and swallowing food, Increased fatigue

Upper and Lower Motor Neurons

Both are Lost with ALS: Upper: Brain Lower: Spinal Cord and Brainstem Upper sends signals to lower which send signals to muscles Diagnosed between Ages 40 and 70 (AVG 55). 2:1 men to women ratio. 2-6 year period before palliative care and/or death depending on severity and care.

Meal Plan for One Day on a Ketogenic Diet,

Breakfast- Scrambled egg with cheese, tomatoes, berries, Lunch-Grilled chicken salad with avocado, Dinner-Salmon & spinach (or incorporate fave fish & veggie), Snack-apple and peanut butter

Treatment for Myasthenia Crisis

Breathing support: Endotracheal tube: This is also called an ET tube. It is put into your mouth or nose to keep your airway open. It may be attached to a ventilator to help you breathe, and you may get extra oxygen through your ET tube. You will not be able to talk while the ET tube is in place. Bilevel positive airway pressure: This is also called a BiPAP. It is a device that helps you breathe easier. Suctioning: This may help remove secretions from your airway so you can breathe easier.

Assessment

Brian is admitted to the pediatric unit of the local hospital. His VS are not significantly changed from those obtained by EMS personnel. The pediatric nurse inserts a peripheral IV catheter, which is capped. Brian complains of a headache and of being nauseous. The pediatrician diagnoses Brian with "MTBI".

Is Brian at risk for post-concussion syndrome or chronic traumatic encephalopathy (CTE)?

Brian would be more at risk for Post-concussion syndrome, based on the following S&S he already experiences from the list of diagnosing factors: Somatic symptoms: headache, sleep disturbance, dizziness, vertigo, nausea, fatigue, sensitivity to light or noise Cognitive: attention, concentration, memory problems Affective: irritability, depression, anxiety, emotional lability

Plan of Care

Brian's orders include: brain CAT scan, skull X-ray, regular diet, bedrest, acetaminophen 350 mg PRN pain. The nurse talks with Brian and Brian tells the nurse that he's actually been hit in the head "a couple of times" while playing soccer. He tells the nurse he didn't tell his parents because he was concerned that they would make him stop playing soccer. He also asks the nurse not to tell his parents.

Background

Brian's parents arrive at the hospital. During the intake process with the emergency department nurse, they state that last month Brian fell when playing soccer and complained of a headache later that evening; however, it resolved after Brian sat down and took Tylenol. Brian has a negative PMH and has no known allergies. Brian has a 10 yo sister and a 4 yo brother who are also in good health. Brian's parents report Brian has been "moody" and hasn't been doing well in school since shortly after soccer season started; his parents think he's been too busy with soccer and has not been focusing on his studies as much.

TBI/Concussion Situation

Brian, age 13 plays soccer for school and his community. Today he got hit in the left side of his head with the soccer ball. He fell to the ground. His coach called EMS because Brian was slow to respond verbally and appeared confused. EMS arrives and transports Brian to the local hospital. VS: 980F - 84 - 10 - 102/64. SpO2 94%.

Basilar skull fracture

CSF or brain otorrhea, bulging of tympanic membrane cause by blood or CSF, Battle's sign, tinnitus or hearing difficulty, rhinorrhea, facial paralysis, conjugate deviation of gaze, vertigo Assessments for basal skull fracture - same as everything else Nursing interventions for basal skull fracture - same as everything else

Differentiates between ischemic and hemorrhagic stroke,

CT is highly sensitive in detecting acute bleeding *Gold standard* Brain imaging is a crucial step in the evaluation of suspected hemorrhagic stroke and must be done ASAP. International guidelines consider neuro-imaging mandatory to prove or rule out intracranial hemorrhage. Brain imaging aids diagnosing hemorrhage, and it may identify complications such as intraventricular hemorrhage, brain edema, or hydrocephalus.

Combined Spinal-Epidural (CSE) analgesia

Called walking epidural Women can walk with it Women can be assisted to change positions and use upright positions during labor and birth

Imagery and visualization

Can produce a sense of wellbeing during pregnancy, assist with cervical dilation and decrease the experience of pain and tension during labor

Breathing techniques

Can promote relaxation of the abdominal muscles and increase the size of the abdominal cavity. It lessen discomfort. Paced Breathing Techniques Cleansing Breath Relaxed breath in through nose and out through mouth. Used at the beginning and end of each beginning and end of each contraction. Slow-Paced Breathing (Approximately 6 to 8 Breaths per Minute) Performed at approximately half the normal breathing rate (number of breaths per minute divided by 2) IN-2-3-4/OUT-2-3-4/IN-2-3-4/OUT-2-3-4 ... Modified-Paced Breathing (Approximately 32 to 40 Breaths per Minute) Performed at about twice the normal breathing rate (number of breaths per minute multiplied by 2) IN-OUT/IN-OUT/IN-OUT/IN-OUT ... For more flexibility and variety, the woman may combine the slow and modified breathing by using the slow breathing for beginnings and ends of contractions and modified breathing for more intense peaks. This technique conserves energy, lessens fatigue, and reduces risk for hyperventilation. Patterned-Paced or Pant-Blow Breathing (Same Rate as Modified) Enhances concentration 3 : 1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) 4 : 1 Patterned breathing IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction) Adapted from Nichols F: Paced breathing techniques. In Nichols FH, Humenick SS, editors: Childbirth education: practice, research, and theory, ed 2, Philadelphia, 2000, Saunders; Perinatal Education Associates: Breathing, 2008, www.birthsource.com/scripts/article.asp?articleid=

Immediate Post - Op assessment,

Careful assessments detailed head to toe with more focused on cardiovascular checking for normal heart sounds respiratory patient's airway breath sounds abdominal assess bowel sounds skin neurological PERRLA AAO X3 vital signs Pain level Safety

NCLEX question A patient presents to the ER with left hemiplegia. To determine whether the suspected stroke is ischemic or hemorrhagic, the nurse anticipates that the provider will request:

Cerebral arteriogram CT scan Lumbar puncture PET scan Answer is CT scan

Keep Area Clean

Change the diaper and inspect the circumcision at least every 4 hours. Wash the penis gently with warm water to remove urine and feces. Apply petrolatum to the glans with each diaper change (omit petrolatum if a PlastiBell was used). Do not use baby wipes because they can contain alcohol. Do not wash the penis with soap until the circumcision is healed (5 to 6 days). Apply the diaper loosely over the penis to prevent pressure on the circumcised area.

Observe for Urination

Check to see that the infant urinates after being circumcised. Infant should have a wet diaper 2 to 6 times per 24 hours the first 1 to 2 days after birth and then at least 6 to 8 times per 24 hours after 3 to 4 days.

NCLEX Question 2 On what chromosome are the key genes deleted that lead to Prader Willi syndrome?

Chromosome 15 Chromosome 22 Chromosome 21 Chromosome 4 Answer: Chromosome 15

Lisinopril 30 mg q AM,

Classification: ACE (Angiotensin Converting Enzyme) Inhibitor Purpose: Treats Hypertension & Congestive Heart Failure; Prevents Kidney & Eye Complications in Diabetics Drug Action: Prevents the conversion of Angiotensin I from being converted into Angiotensin II which causes a decrease in BP. Safe Dose Range: 20-40 mg daily with a max dosage of 80mg. --> Yes, it is safe & therapeutic. Adverse Effects: Dizziness, hypotension, hyperkalemia, increased blood urea nitrogen, and increased serum creatinine. Labs To Monitor: Potassium (K+), Creatinine, BUN, Hemoglobin & Hematocrit

Albuterol Inhaler PRN,

Classification: Bronchodilator, Purpose: treat or prevent bronchospasm in people with reversible obstructive airway disease; Also treat exercise-induced bronchospasm. Drug Action: Relaxes muscles in the airways and increases air-flow to the lungs. Safe Dose Range: 2 puffs every 4 to 6 hours as needed. --> Exact Dosage Not listed in Case Study. Adverse Effects: tremor, hypersensitivity reaction, & tachycardia. Labs To Monitor: Auscultate lungs after treatment for decrease in adventitious sounds, Monitor O2 level

Sitagliptin (Januvia) 100 mg OD in AM,

Classification: Dipeptidyl peptidase-4 (DPP-4) inhibitor Purpose: Treats Type 2 Diabetes. Drug Action: increases the amount of insulin released by the body & decreases the amount of sugar made by the body. Safe Dose Range: 100 mg orally once a day. --> Yes, it is safe & therapeutic. Adverse Effects: Body aches, cough, Dyspnea, Fever, Nasal congestion, Sore throat. Labs To Monitor/Contraindications: May enhance adverse effects of ACE inhibitors (Lisinopril), HbA1c

Acarbose 50 mg q AM, 100 mg at noon, 100 mg q PM,

Classification: Glucosidase inhibitorPurpose: Treats Type 2 Diabetes. Drug Action: Slows the digestion of carbohydrates in the body, which helps control blood sugar levels. Safe Dose Range: Weight greater than 60 kg(175 kg)= 100 mg orally 3 times a day; Normally 50mg-100mg. --> Yes, it is safe & therapeutic. Adverse Effects: Abdominal pain, diarrhea, & flatulence. Labs To Monitor: Blood glucose, HgA1C.

Simvastatin 35 mg q HS,

Classification: HMG CoA reductase inhibitors, or "statins." Purpose: Treats Hyperlipidemia while lowering risk of stroke & cardiac complications. Drug Action: Reduces levels of "bad" cholesterol (low-density lipoprotein, or LDL) and triglycerides in the blood, while increasing levels of "good" cholesterol (high-density lipoprotein, or HDL). Safe Dose Range: 5 to 40 mg orally once a day in the evening. --> Yes, it is safe & therapeutic. Adverse Effects: Dizziness, Fast or Irregular heartbeat, Fainting (syncope), Eczema, increased creatine phosphokinase Labs To Monitor/ Contraindications: Avoid Grapefruit juice, Creatinine, ALT, Lipid Panel (monthly)

Alli® (Used intermittently),

Classification: Lipase inhibitor, Purpose: Weight loss aid; help reduce the risk of regaining weight already lost, Drug Action: Blocks some of the fat ingested, keeping it from being absorbed by your body. Safe Dose Range: 1 capsule w/ each meal containing fat, Not to exceed 3 capsules per day. --Exact Dosage unknown. Adverse Effects: oily or fatty stools; gas and oily discharge;loose stools, or an urgent need to go to the bathroom, inability to control bowel movements; stomach pain, nausea, rectal pain. Labs To Monitor: Must be used with reduced-calorie diet, May need increase dosage of diabetes medications so monitor blood glucose & HgA1C

Roux-en Y (RYGB) Procedure,

Combination of restrictive and malabsorptive Consider the gold standard of bariatric surgery. an irreversible procedure that involved creating a small gastric pouch and attaching it directly to the small intestine using a Y-shaped limb of the small bowel, (Lewis, Dirksen, Heitkemper, and Bucher, 2014 p. 917)

ECG Interpretation,

Complete heart block or 3rd degree; no correlation between the P waves and the QRS. Third-degree atrioventricular block (AV block), also known as complete heart block, is a medical condition in which the impulse generated in the sinoatrial node (SA node) in the atrium of the heart does not propagate to the ventricles.

What is the purpose of concussion clinics?

Concussion Clinics is a free online tool provided by the Concussion Legacy Foundation that is designed to connect you with local medical providers and clinics that treat concussions. Finding the right doctor makes all the difference. For more information, the link below provides an interview with a doctor about concussion clinics: http://healthcare.utah.edu/the-scope/shows.php?shows=0_13rijqby

What is a MTBI?

MTBI stands for a Mild Traumatic Brain injury. Period of decreased LOC < 30 mins with a GCS of 13-15 after this LOC Amnesia to the event Alteration in mental status at the time of the event (dazed and confused)

Answer to NCLEX Question #3,

Correct answer: a Rationale: Fluids and foods high in carbohydrates tend to promote diarrhea and symptoms of dumping syndrome in patients with gastric bypass surgery. The diet generally should be high in protein and low in carbohydrates, fat, and roughage and consists of six small feedings a day because of the small stomach size. Liquid diets are likely to be used longer for the patient with a gastroplasty.

Answer to NCLEX Question #2,

Correct answer: b Rationale: The Roux-en-Y gastric bypass is a common combination of restrictive (limiting the size of the stomach) and malabsorptive (less food is absorbed) surgery. Lipectomy is used to remove unsightly flabby folds of adipose tissue. Adjustable gastric banding is the most common restrictive procedure. Vertical sleeve gastrectomy is a restrictive procedure that preserves stomach function.

Answer to NCLEX Question #1,

Correct answer: d Rationale: During the immediate postoperative period, water and sugar-free clear liquids are given (30 mL every 2 hours while the patient is awake).

Barriers to Pain Management in Adults

Cultural and societal attitudes Lack of Knowledge Fear of addiction Exaggerated fear of respiratory depression

Nursing Diagnosis #3

Decreased intracranial adaptive capacity Treatment: - Allow rest periods between nursing activities - Observe for signs of increasing ICP - Assess for CSF leak evidenced by otorhea or rhinorrhea Outcomes: patient will have decreased ICP

Medications: Tricyclic Antidepressants: Amitriptyline (Elavil)

Description: ● Block the reuptake of norepinephrine and serotonin at the presynaptic junction; used to treat depression. Also reduces seizure threshold. ● May reduce the effectiveness of antihypertensive agents. ● Use with alcohol can cause CNS depression. ● Do not give with MAOI's; can cause a hypertensive crisis ● Cardiac toxicity can occur; all clients should receive an ECG before treatment and periodically after ● Overdose is life threatening, necessitating immediate treatment. Side effects: ● Anticholinergic effects: dry mouth, difficulty voiding, dilated pupils and blurred vision, constipation ● Photosensitivity ● Tachycardia ● Orthostatic hypotension ● Sedation ● Weight gain Interventions: ● Monitor suicidal client during improved mood and increased energy levels ● Monitor bowel activity and for urinary retention ● Give dosage at bedtime due to sedative effect ● Avoid alcohol

Diagnostic tests for ALS

Difficult to diagnose early because it may mimic several other neurological diseases. Tests to rule out other conditions may include: • EMG studies of affected muscles indicate reduction in the number of functioning motor units • MRI may show high signal intensity in the corticospinal tracts

Assessment -

Difficulty chewing, dysphagia, difficulty breathing, weakness and fatigue, ptosis, diplopia, weak voice, limited facial expressions

Patient Education,

Discuss important patient education information r/t nutritional management and activity for this patient. Mr. Jones will be trying out food to see if he could tolerate it. His diet would be a high protein diets with low in carbs and fats. He must follow the dietitian's plan and to call his doctor if any issues. As mentioned in previous slides. As for activity: as soon as get home, start slow like a walk for 20 minutes to 30 minutes. Try to spread it out like 3 x a day. after 6 weeks post-op, with doctor's permission, can start a more intensive exercises like strengthening, flexibility and more aggressive endurance exercises.

Non- Pharmacological Pain Management

Distraction Ambulation, deep breathing, visitors, television, & music Relaxation Includes meditation, yoga, and relaxation of muscles Imagery Focus on a pleasant thoughts to take the focus off pain Requires an ability to concentrate Elevation of extremities w/ edema Promotes venous return and decreases swelling

Warfarin 5 mg OD,

Drug Class: Anticoagulant Purpose: Prophylaxis/tx of DVT, PE, Afib with embolization. Adverse Effects: GI: cramps, nausea Derm: dermal necrosis Hemat: bleeding Misc: fever *Frequent labs to monitor PT/INR. Prolonged If PT is 1.3-2x the control, or INR is 2-4.5

Amlodipine 7.5 mg OD,

Drug Class: Calcium Channel Blocker Purpose: HTN or angina Adverse Effects: CNS: dizziness, fatigue Derm: flushing CV: peripheral edema, angina, bradycardia, hypotension, palpitations *change positions slowly

Metoprolol 25 mg OD,

Drug Class: beta blocker Purpose: HTN, angina, MI prevention, HF Adverse Effects: CV: bradycardia, HF, Pulmonary edema CNS: fatigue, weakness, anxiety, dizziness Resp: bronchospasm, wheezing GI: diarrhea, constipation GU: erectile dysfunction *change positions slowly

Hydrochlorothiazide 25 mg OD,

Drug Class: thiazide diuretic Purpose: HTN, edema r/t HF or cirrhosis Adverse Effects: CNS: dizziness, drowsiness, lethargy, weakness CV: hypotension GI: anorexia, cramping, n/v Derm: Steven Johnson Syndrome, photosensitivity, rash ENT: glaucoma, myopia Endo: hyperglycemia F&E: hypokalemia, dehydration * discuss K supplementation with PCP

Nimodipine (Nimotop),

Drug class: calcium channel blocker, subarachnoid hemorrhage therapy agent. Purpose: Prevention of vascular spasm after subarachnoid hemorrhage, resulting in decreased neurologic impairment. The products of blood breakdown (which occurs when blood escapes) causes neighboring blood vessels to spasm & causes further damage and possible secondary stroke. How is it administered? PO only When given IV/parenterally, causes severe A/E including death If patient cannot swallow, extract contents of pill w/ sterile 18-gauge needle & empty into water or NG tube/gastric tube Dosage: 60 mg q4 hrs x21 consecutive days Therapy should be started within 96 hrs of hemorrhage If pulse is <60 bpm or systolic BP is <90 mmHg, hold medication & contact physician A/E: arrhythmia, HF, Steven-johnson Syndrome

Dopamine,

Drug class: inotropic, vasopressor, adrenergic Purpose: Increase BP, optimize cerebral perfusion How is it administered? IV Must be diluted: 200-800 mg in 250-500 mL solution Rate is based on weight: 5-15 mcg/kg/min Titrate to response Decrease rate gradually when d/c to prevent sudden drop in BP A/E: arrhythmia, hypotension

Schedule Categories

Drugs and other substances are classified into different categories under the Controlled Substances Act (CSA) into five schedules SCHEDULE 1 -Substances in this schedule have not currently been accepted for medical use in the United States Heroin, Acid (LSD), marijuana (cannabis), and more... SCHEDULE 2 -have a high potential for abuse which may lead to severe psychological or physical dependence Hydromorphone (Dilaudid), Demerol, oxycodone (OxyContin, Percocet), and fentanyl (Sublimaze, Duragesic). Morphine, and Codeine. SCHEDULE 3 -have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence Vicodin, Codeine (per dosage unit Tylenol with Codeine), and buprenorphine (Suboxone). -Other scheduled levels are not included as pain medications

What are the ongoing management concerns r/t this surgery?,

Dumping syndrome is a common side effect after Roux-en-Y Gastric Bypass (RNYGB) surgery with 85% of patients experiencing this symptom from poor food choices. There are two types of dumping: Early dumping which occurs 30-60 minutes after eating and can last up to 60 minutes. Symptoms include sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lie down, upper abdominal fullness, nausea, diarrhea, cramping, and active audible bowels sounds. Management= Dietary Compliance. Late dumping which occurs 1-3 hours after eating. Symptoms are related to reactive hypoglycemia (low blood sugar) which include sweating, shakiness, loss of concentration, hunger, and fainting or passing out. Management= small amount of sugar (such as one-half glass of orange juice) about one hour after a meal, which may prevent the attack.

Would you expect Mrs. Henry to undergo a lumbar puncture? Why or why not?,

Dx of subarachnoid hemorrhage (SAH) is based upon high clinical suspicion & CT scan w/out contrast. owever, CT scans are falsely negative in 10-15% of patients. Therefore, an LP may be done to look for presence of red blood cells in the CSF if a SAH is suspected but the CT does not show hemorrhage. So...YES; it is expected that she will undergo an LP to assist in the diagnosis of subarachnoid hemorrhage.

Discuss potential complications in the immediate period and long-term.

Early Complications: Deep venous thrombosis (DVT), Pulmonary embolism, Bleeding. Anastomotic leaks, Cardiovascular and/or pulmonary compromise. Late Complications: Adhesions, small bowel obstruction, marginal ulceration, stomal stenosis, cholelithiasis, pouch dilatation, depression, intolerance of sweet and/or fatty foods, dumping syndrome, nausea, vomiting, and diarrhea.

Effleurage and counterpressure

Effleurage is light massage, light stroking usually of the abdomen in rhythm with breathing during contractions Distraction the woman from contraction pain Counterpressure - steady pressure applied by a support person to the sacral area with a firm object or the fist or heel of the hand

NCLEX Question: Which diagnostic test is used to confirm ALS?

Electromyogram (EMG) Muscle Biopsy Serum Creatinine Kinase Enzyme (CK) Pulmonary Function Test

EMG What is it?

Electromyogram. Measures the signals, using a needle electrode, that run between the nerves and muscles and the electrical activity inside muscles to see if there is a pattern consistent with ALS.

Managing Jaqui's eating habits

Encourage having a daily schedule posted which includes all daily activities, including meal and snack times, exercise and leisure activities discuss any changes to the routine with your child beforehand teach the Jaqui about good food choices teach the concept that everyone has their own meal ie 'my plate', 'your plate'; • develop strategies to deal with constant food requests; Don't be afraid to get a specialist's help when needed do not offer second helpings at home as it may raise expectations in other situations avoid grocery shopping and eating out with Jacqui or have very clear rules about how these occasions are to be managed Inform all teachers and other caregivers of food rules and check to ensure they are following them praise good behaviours with immediate tangible rewards (stickers, cuddles) use non-food related rewards. ensure that the rest of the family enjoys food treats in private don't try and reason with Jaqui

Pharmacologic Pain Management

Epidural analgesia to relieve pain during labor and birth Sedatives May be given to a woman experiencing a prolonged latent phase of labor when there is a need to decrease anxiety or promote sleep May be given to augment analgesics and reduce nausea when an opioid is used Barbiturates should be avoided due to undesirable side effects involving respiratory and vasomotor depression affecting the woman and newborn. Phenothiazines such as promtehazine (Phenergan) do not relieve pain. It was believe that it potentiate the effects of an opioid but it actually impaired the analgesic efficacy of opioids. Metoclopramide (Reglan), an antiemetic is shown to potentiate the effects of analgesics. Benzodiazepines such as Valium or Ativan when given with opioid seem to enhance pain relief and reduce nausea and vomiting. Major side effect is significant maternal amnesia. Valium tend to disrupts thermoregulation in newborns. Flumazenil is a specific benzo antagonist which can reverse the effect. Analgesia and Anesthesia Goal is to develop methods that will provide adequate pain relief to woman without increasing maternal or fetal risk or the progress of labor Anesthesia - encompasses analgesia, amnesia, relaxation, and reflex activity. anesthesia abolishes pain perception by interrupting the nerve impulses to the brain. The loss of sensation may be partial or complete, sometimes with the loss of consciousness. Analgesia - alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness. `Systemic analgesia Like opioids Opioids provide sedation and euphoria, but their analgesic effect in labor is limited. The pain relief they provide is incomplete, temporary, and more effective in the early part of active labor. All opioids cause side effects, the most serious of which is respiratory depression. Other undesirable opioid side effects include sedation, nausea and vomiting, dizziness, altered mental status, euphoria, decreased gastric motility, delayed gastric emptying, and urinary retention. Prolonged gastric emptying time increases the risk for aspiration if general anesthesia becomes necessary in a woman who has received opioids Also opioid can cross the placenta causing an effect on the fetus and newborn

What is Epilepsy?,

Epilepsy is a brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness.

Evaluation,

Evaluating nursing diagnosis #1: The patient will demonstrate the use of breathing and coughing techniques, Will continue to monitor patient's ABGs levels, Evaluating nursing diagnosis #2: Will continue to monitor for signs of dehydration Will continue to monitor HR and BP Evaluating nursing diagnosis #3: will monitor electrolyte IV solutions will continue to assess for wound drainage and tissue injury Evaluating nursing diagnosis #4: will continue to monitor vital signs for infection will assess the patient in maintaining aseptic technique for wound care

Things to Remember

Every patient has the right to have his or her pain treated "Pain is what the patient says it is" Screen and assess all patients for pain Reassess your patient's pain BP, HR & RR can increase temporarily w/ acute pain. Administer effective pain control medications or treatments Address continued needs for pain control Always try non-pharmacological interventions first Educate your patients and families on proper pain management

Manifestations,

Eyes roll upward, immediate loss of consciousness, if standing fall to the floor, stiffness in generalized, symmetric tonic contraction of entire body musculature, arms usually flexed, legs head and neck extended, may utter or a peculiar piercing cry, may appear cyanotic, apneic, increased salivation and loss of swallowing reflex, Violent jerking movement as the trunk and extremities undergo rhythmic contraction and relaxation, may foam at the mouth, may be incontinent of urine and feces, As events movements less intense, occurring at longer intervals and then ceasing entirely

Troubleshooting, however, applies to both the demand mode and the asynchronous mode and includes the following:

Failure to pace is confirmed when there's no pacer spikes shown on your EKG or telemetry strip. Always check the batteries and replace them if necessary. (A good rule of thumb is to replace them every two to three days.) Then, check to make sure all connections are tight. If you're still not seeing pacer spikes it may mean the pacemaker is oversensing. A pacemaker will sense, or pick up and interpret, muscle movement and artifact as heart beats if the sensitivity threshold is set too high, or there are items in the vicinity of the pacemaker that interfere with its signals, or the lead wire is fractured. If oversensing is the likely cause of the failure to pace, lower the mV on the sensitivity dial, as it raises the sensitivity of the pacemaker, and remove items that could cause electromechanical interference such as electric razors, radios, or cautery devices. You'll need a chest X-ray to rule out a fractured lead wire. However, not seeing pacer spikes can be normal, such as when the patient's heart is beating faster than the rate set on the pacemaker. The next day the physician explains that Mrs. B will need a permanent pacemaker; her surgery is scheduled for the next morning.

S/S of Hypothyroidism

Fatigue Increased sensitivity to cold Constipation Dry skin Weight gain Puffy face Muscle weakness Elevated blood cholesterol level Muscle aches, tenderness and stiffness Pain, stiffness or swelling in your joints Heavier than normal or irregular menstrual periods Thinning hair Slowed heart rate Depression Impaired memory

S/S

Fatigue and sluggishness Increased sensitivity to cold Constipation Pale, dry skin A puffy face Hoarse voice Unexplained weight gain Muscle aches, tenderness and stiffness, especially in shoulders and hips Pain and stiffness in joints Muscle weakness, especially in lower extremities Excessive or prolonged menstrual bleeding (menorrhagia) Depression

Signs & Symptoms of Opioid Abuse

Fatigue, red or glazed eyes, and repeated health complaints Sudden mood changes, including irritability, negative attitude, personality changes and general lack of interest in hobbies/ activities Secretiveness and withdrawing from family Decreased or obsessive interest in school work Excessive sweating Low BP

Informed consent

First, the procedure and its advantages and disadvantages must be thoroughly explained. Second, the woman must agree with the plan of labor pain care as explained to her. Third, her consent must be given freely without coercion or manipulation from her health care provider.

Nutritional Interventions,

Food is now going to be bypassing about 90% of the stomach, duodenum and a small part of the jejunum. Complication is dumping syndrome which is when the gastric content empty or "dump" too quickly into the small intestine overwhelming the ability to digest the nutrient. Symptoms to include vomiting, nausea, weakness, sweating, faintness, and, on occasion, diarrhea.(Lewis, Dirksen, Heitkemper, and Bucher, 2014 p. 917). Recommend to avoid eating sugary food. Will be working with a dietitian to create a diet plan which include: measured amount of high protein liquid diet taught to eat slowly, stop eating when full and not to consume liquid with solid food vomiting is a common occurrence later, high in protein, low in carbohydrates and fat eat about six small meal a day fluid is restricted to less than 1000 mL a day. need to take multivitamin everyday due to risks of Iron deficiency anemia

Purpose of Medications:

Furosemide (Lasix): ● a potassium-wasting Loop Diuretic used to treat hypertension and edema in patients with congestive heart failure. ● Effectiveness is measured: ○ In the relief of dependent edema in the extremities as well as a reduction of fluid retention symptoms ○ If there is a decrease in the systolic blood pressure into normal limits. Simvastatin (Zocor): ● HMG CoA reductase inhibitors (also known as Statins) ● Decreases LDL cholesterol and triglyceride levels in the blood while increasing HDL cholesterol. ● Can lower risk of stroke, heart attack, and other heart problems in people with diabetes and CAD. ● Effectiveness is measured: ○ LDL Cholesterol will be <100mg/dL ○ HDL Cholesterol will be >40mg/dL ○ Triglyceride level will be <150mg/dL

Possible Adverse Effects:

Furosemide: ● Drowsiness, problems with memory or speech ● Jaundice (dark urine, yellowing of skin or eyes) ● Nausea, Vomiting, Anorexia ● Pale skin with easy bruising ● Hypokalemia, Hyponatremia ○ Patient should be monitored for any type of electrolyte imbalances. Symptoms include: dry mouth, increased thirst, little or no urination, rapid heart beat with dysrhythmias ○ Often, they are prescribed an increase in Potassium diet or Potassium supplements. ● Blurred vision Simvastatin: ● Dizziness ● Fainting ● Fast/irregular heartbeat ● Bladder pain ● Bloody/cloudy urine ● Blurred vision ● Cough ● Dry mouth ● Rhabdomyolysis ○ if patient is experiencing symptoms of muscle pain, weakness, or tenderness, HCP should be contacted right away and creatine kinase measured.

Possible Challenges and Interventions

GI - Imbalanced Nutrition. Loss of Appetite and Feeling Full Early. Choking easily, discouraged eating. Gastroparesis (Delayed Stomach Emptying). Weight Loss. Promote Family Meals and Concentrated Eating for the Patient. Respiratory - Breathing Difficulties Tracheotomy Improve breathing MS - Impaired Verbal Communication and Physical Mobility

Amlodipine 10mg po daily

Generic: Amlodipine Drug Class: Calcium channel blocker Uses: It can treat high blood pressure and chest pain (angina). Side Effects*:Swelling of the ankles or feet, Difficult or labored breathing, dizziness, fast, irregular, pounding, or racing heartbeat or pulse, redness of the face, neck, arms, and occasionally, upper chest, shortness of breath *see your doctor if any of these occur

Advair 115: 21 mcg 2 puffs Q12h

Generic: Fluticasone and Salmetrol Drug Class: Bronchodilator, Anti-Inflammatory Uses: Prevents asthma attacks, chronic bronchitis and/or emphysema Side effects: URTI, pneumonia, headache, dizziness, nausea. Call doctor immediately if sudden breathing problems occur after inhalation, indicates allergic reaction.

Melatonin 6mg P.O. QHS

Generic: Melatonin Drug Class: Hormone Uses: Insomnia, reset sleep-wake cycle, jet lag, shift work Side Effects*: confusion, depression, fast heart beat, hypothermia *see your doctor if any of these occur

Singulair 10mg P.O. Daily

Generic: Montelukast Drug Class: Anti-inflammatory Uses: Can treat allergies and prevent asthma attacks Side Effects*: skin rash, chest pain, irregular heartbeat, pain or swelling in sinuses, numbness or tingling, sudden stomach pain, unusual bleeding *see your doctor if any of these occur

Zoloft 100mg P.O. Daily

Generic: Sertraline Drug Class: Selective Serotonin Reuptake Inhibitor (SSRI) Uses: depression, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), premenstrual dysphoric disorder (PMDD), social anxiety disorder, and panic disorder. Side Effects*: Anxiety, vision changes, skin rash, tachycardia, unusual bleeding or bruising, suicidal thoughts, fever, sweating *see your doctor if any of these occur

Topamax 75 mg P.O. Daily

Generic: Topiramate Drug Class: Anticonvulsant Uses: Treat and prevent seizures, can prevent migraine headaches, weight loss (believed to inhibit the brain networks that cause food cravings), can also act as a mood stabilizer Side Effects*: bloody or cloudy urine, painful urination, sudden lower back or abdominal pain, numbness in fingers, labored breathing, changes in vision, weight loss *see your doctor if any of these occur

Miralax 17g po BID

Generic: polyethylene glycol 3350 Drug Class: laxative Uses: It can treat occasional constipation. Side Effects*: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); bleeding from the rectum or rectal pain; diarrhea; severe or persistent nausea, bloating, cramping, or stomach pain. *see your doctor if any of these occur

Prader Willi

Genetic disorder affecting appetite, growth, metabolism, cognitive function and behavior Associated with characteristics such as : Diminished fetal activity Obesity Hypotonia Mental Retardation Short Stature Hypogonadotropic hypogonadism Strabismus Small hands and feet Constant sense of hunger starting at age 2 years. Typically NOT inherited, can happen in any family No Cure for PWS

NCLEX Question 4 What are some treatment options for PWS? SELECT ALL THAT APPLY

Give child food with no restrictions A supervised diet C. Take child to a bakery as an incentive for losing weight D. Some symptoms can be treated with a growth hormone Answer: B. A supervised diet D. Some symptoms can be treated with a growth hormone

Check for Infection

Glans penis is dark red after circumcision and then becomes covered with yellow exudate in 24 hours, which is normal and will persist for 2 to 3 days. Do not attempt to remove it. Redness, swelling, discharge, or odor indicates infection. Notify the pediatric health care provider. if you think the circumcision area is infected. Provide Comfort Circumcision is painful. Handle the area gently. Provide comfort measures such as holding the baby skin-to-skin, cuddling, swaddling, or rocking.

What are priorities of care during the rehabilitative phase?,

Goals: lessen disability & attain optimal functioning ADLs Bathing, dressing, using the toilet, brushing teeth/hair, eating, transferring Preserve musculoskeletal & integumentary function Passive and active ROM strengthens stroke-impaired limbs Prevent contractures Hand splints to reduce spasticity Arm supports with slings and lap boards to prevent shoulder displacement Trochanter roll at hip to prevent external rotation Posterior leg splints, footboards, or high-topped tennis shoes to prevent foot drop High risk for skin breakdown Special mattress Apply skin emollients

What are the priorities of care during the acute phase?

Goals: preserving life, preventing further brain damage, reducing disability Manage airway, breathing & circulation: O2 administration, artificial airway insertion, intubation and mechanical ventilation may be required Continuous neurologic assessments: NIH Stroke Scale Continuous monitoring of vital signs: maintain blood pressure within a normal to high-normal range: <160 mmHg systolic Careful positioning to prevent aspiration Side lying position for unconscious pts

Types of Concussions

Grade I (confusion, no amnesia, no LOC) -Remove from activity (may return when asymptomatic) -3 concussions in 3 months: no activity that risks head trauma for 3 months Grade II (confusion and amnesia) -Remove from activity for day -Recheck in 24 hours -No activity for 1 week -Two grade II concussions in 3 months, no activity for 3 months Grade III (LOC)-To ED for CT -Symptom free for 2 weeks, then another 30 days -Two grade III concussions, no activity for 3 months

What is Grave's disease?

Graves Disease (hyperthyroidism) is an autoimmune condition in which autoantibodies are directed against the thyroid-stimulating hormone (TSH) receptor. As a result, the thyroid gland is inappropriately stimulated with ensuing gland enlargement and increase of thyroid hormone production.

Past Medical History:

H/O tracheostomy, currently treating wound until it heals. H/O increased prolactin and pancreatitis. Maximum weight was 460 pounds. She was admitted to a facility in Pittsburgh roughly one year ago to address this and her weight was brought down to 243 pounds. She follows a strict 1200 calories diet while hospitalized, however has gained 10 pounds back. Her labs are currently WNL except for a slightly elevated TSH.

Background,

Her PMH is significant mild obesity (BMI = 29); she also is diagnosed with hyperlipidemia and hypertension. Patient reports poor appetite and increasing shortness of breath. She had a hysterectomy at age 42. She reports having had shingles last year. She has no known allergies. Mrs. B's routine medications include: ● Furosemide, ● Simvastatin

Impact on the fetus -

Her baby may also faces significant risks, including neonatal MG, prematurity, severe malformation, and death. The fetus can be affected by transient neonatal MG (TNMG), which is self-limited and lasts approximately 3 weeks, and this is due to the transplacental transfer of antibodies. There can be fetal abnormalities such as pulmonary hypoplasia and arthrogryposis which refers to muscle weakness and joint deformities that are present at birth. Overall, the risk of pregnancy is high in Karen, so it is imperative that she discuss her plans of getting pregnant with her care giver.

What could have contributed to Mrs. Henry's stroke?,

Hypertension: High blood pressure can cause weakened arteries in the brain putting a person at an increased risk for stroke Stress and pressure can cause aneurysm to rupture Managing high blood pressure is critical to reduce your chance of having a stroke Atrial Fibrillation: Afib can cause blood to collect in the heart and potentially form a clot, which can travel to a person's brain and cause a stroke Cocaine Abuse: Habitual use can cause ongoing high blood pressure Warfarin: Given to prevent ischemic stroke but increases risk of developing a hemorrhagic stroke Increases risk of ICH 5-10x

Causes:

Hyperthyroidism Hypothyroidism Iodine deficiency Graves' disease Hashimoto's disease Multinodular goiter Thyroiditis

What Is Hyperthyroidism?

Hyperthyroidism is a condition in which the thyroid gland is overactive and makes excessive amounts of thyroid hormone. When the thyroid gland is overactive, the body's processes speed up and one may experience nervousness, anxiety, rapid heartbeat, hand tremor, excessive sweating, and weight loss, among other symptoms. The most common cause of hyperthyroidism is the autoimmune disorder Graves' disease.

NCLEX question A dx of ruptured cerebral aneurysm has been made in a patient with symptoms of stroke. The RN anticipates that treatment options for this patient include:

Hyperventilation therapy Surgical clipping of aneurysm Administration of hyperosmotic agents Administration of tPA answer is surgical clipping of aneurysm

Hypnosis

Hypnosis is a form of deep relaxation, similar to daydreaming or meditation (see www.hypnobirthing.com). While under hypnosis, women are in a state of focused concentration and the subconscious mind can be more easily accessed.

What is the danger if Mrs. Henry becomes hypotensive? Hypertensive?,

Hypotensive: Increased cerebral hypoperfusion Hypertensive: Increases the risk of bleeding May worsen hematoma or surrounding edema, which will increase ICP

Nursing Diagnosis #2

Imbalanced Nutrition More than body requirements Implementation: Encourage food tracking by consuming foods low in calories while maintaining nutritional intake A food diary provides the opportunity for the client to gain a realistic picture of the amount of food ingested and provides data on which to base the dietary program. Stress importance of exercise each day Outcome: Ability to maintain a normal weight and healthy diet

Treatment options are discussed with Marla, including both surgical intervention and pharmacologic management.

Immediate Treatment Goals for Marla Normalize serum TSH levels Reverse/correct clinical signs & symptoms and metabolic derangements. Lower the amount of thyroid hormones to establish a healthy balance. Block the adverse effects of excessive thyroid hormone. Prevent complications.

Various stages of Bariatric Diet,

Immediate post op diet - Liquid diet - Stage 1. Mr. Jones will try liquid to see if he tolerate liquid, about 30 mL every 2 hours when awake. It can include: Broth, Unsweetened juice, Decaffeinated tea or coffee, Milk (skim or 1 percent), Strained cream soup, Sugar-free gelatin or popsicles, skim or low fat milk, After a few days, Stage 2 Pureed Diet, Stained or mashed up food. Must be made into a smooth paste Include: Lean ground meats, Beans, Fish, Eggs, Soft fruits and cooked vegetables, Cottage cheese Can Blend solid foods with a liquid, such as: Water Skim milk Juice with no sugar added Broth

What are the risks for Karen and the fetus if she should become pregnant?

Impact in pregnancy - She may face risks of disease exacerbation, crisis, adverse drug response, or respiratory failure. Infections due to decreased immunity play a very important role in the exacerbation of MG during pregnancy. She is likely to have a cesarean section due to being fatigued during labor. Another complication she might have is premature rupture of the membranes holding the amniotic fluid. She may have a flare of her MG symptoms during the first trimester of pregnancy. Her MG symptoms, with the exception of general fatigue, may tend to decline during the second and third trimesters of pregnancy. Her breathing during sleep can be compromised as her pregnancy advances (sleep apnea).

Nursing Diagnoses,

Impaired physical mobility r/t neuromuscular and cognitive impairment, decreased muscle strength and control AEB limited mobility and ROM.

Nursing Diagnosis #3,

Impaired skin integrity may be related to: ● Insertion of pacemaker ● Alteration in activity ● Changes in mobility ● Loss of elasticity of the skin ● Aging Possibly evidenced by ● Disruption of skin tissue ● Insertion site ● Skin layer destruction

Nursing Diagnosis #3

Impaired social interaction related to trouble speaking and social adaptation difficulties Interventions: Help Jacqui identify personal strengths Encourage Jacqui to participate in activities with other family and friends Give positive reinforcement Outcome: Minimize disruption of social interaction

NCLEX Question # 1,

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in: A. African Americans, B. Women who smoke, C. Individuals with hypertension and diabetes, D. Those who are obese with high dietary fat intake. Answer: C, Rationale: The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.

Assessment:

In the ED, Mrs. B continues to deteriorate and has the following assessment findings: Cardiac/CV: VS: HR 56, BP 68/32, RR 26, SpO2 92% on RA, Temp 99.2 ● Pulmonary: clear to auscultation ● Distended neck veins Labs drawn include: CBC, CMP, PT/PTT, Troponin, and CK-MB. Peripheral IV catheters are inserted in her left hand and left antecubital veins. A right-sided EKG is also obtained and reveals: Interpretation: ST elevation in II, III, and aVF

Increased ICP

Increased intracranial pressure (ICP) is a rise in pressure around your brain. It may be due to an increase in the amount of fluid surrounding your brain. For example, there may be an increased amount of the cerebrospinal fluid that naturally cushions your brain or an increase in blood in the brain due to an injury or a ruptured tumor. Increased ICP can also mean that your brain tissue itself is swelling, either from injury or from an illness such as meningitis. Increased ICP can be the result of a brain injury. Alternately, it can cause a brain injury.

Nonverbal behaviors of pain

Influenced by a wide variety of factors including the nature of pain (acute versus chronic), age, and cultural and gender expectations Acute pain behaviors Involved autonomic responses Protective purpose Persistent (Chronic) pain behaviors Lives with the experience for months and years The person adapts over time with the pain Try to give little indication that they are in pain and are at a higher risk for under detection Sometimes people with chronic pain may exhibit behaviors such as exercise, prayer or inactivity that could indicate to the clinical staff that its comfort and fail to follow up

Early interventions/Special needs programs.

Individuals with PWS have varying degrees of intellectual difficulty and learning disabilities. Early intervention programs, including speech therapy for delays in acquiring language and for difficulties with pronunciation, should begin as early as possible and continue throughout childhood. Special education is necessary for Jacqui. Groups that offer training in social skills may also prove beneficial. An individual aide is often useful in helping PWS children focus on schoolwork.

Nursing Diagnoses

Ineffective Airway Clearance r/t respiratory muscle weakness. Impaired Physical Mobility r/t increase motor weakness caused by paralysis. Imbalanced Nutrition: Less Than Body Requirements r/t tongue atrophy or weakness.

Nursing Diagnoses #1,

Ineffective Cerebral Tissue Perfusion related to interruption of blood flow, as evidenced by altered level of consciousness.

Nursing Diagnoses,

Ineffective airway clearance r/t CNS depression and comatose state.

Nursing Diagnosis #1,

Ineffective cardiac perfusions, may be related to: ● Cardiac dysrhythmias ● Heart blocks ● Tachydysrhythmias ● Decreased blood pressure ● Decreased cardiac output Possibly evidenced by: ● Decreased blood pressure ● Decreased heart rate ● Decreased cardiac output, stroke volume ● Increased peripheral vascular resistance ● Changes in level of consciousness ● Mental changes ● Cold clammy skin ● Cardiopulmonary arrest ● Inappropriate pacing or sensing

Nursing Diagnoses,

Ineffective cerebral tissue perfusion r/t hemorrhage as evidenced by elevated BP, increasing NIHSS, and altered LOC.

Nursing Diagnosis #1

Ineffective tissue perfusion Implementation: Oxygen therapy Administer IV fluids to maintain hydration Outcome: pt will have improved cerebral perfusion

Tools for infants and children

Infants Pain assessment depends on behavioral and physiologic cues CRIES - postoperative pain in preterm and term neonates Measures physiologic and behavioral indicators on a three point scale FLACC - nonverbal assessment tool for infants and young children under 3 years Assesses five behaviors of pain: facial expression, leg movement, activity level, cry and consolubility Children 2 years Can report pain and point to its location. Cannot rate pain intensity 4 to 5 years Rating scales can be introduced such as the Faces Pain scale revised (FPS-R) and the oucher scales

How does an intracerebral hemorrhage differ from a subarachnoid hemorrhage?,

Intracerebral hemorrhage Most common type of hemorrhagic stroke Occurs when a blood vessel inside the brain ruptures and leaks blood into surrounding brain tissue Sudden onset of symptoms Progresses over minutes to hours because of ongoing bleeding Poor prognosis & high fatality rates

Why was it necessary to intubate Mrs. Henry? Mrs. Henry became comatose,

Intubation needs to be done for patients with a decreased level of consciousness and poor airway protection #1 priority is to protect airway

Past Psychiatric History

Jaqui has never had inpatient treatment before this time. She has had some outpatient treatment for ETOH and drug abuse, aggression and suicidal gestures. She has a history of self- injurious behavior. There is a documented history of past auditory hallucinations of her mother's voice telling her "to do good". She has used ETOH one time a week since the age of 13. She has used THC daily since the age of 9.

Situation

Jaqui is a 16 y/o African American female on an inpatient adolescent psych unit. Admitted on a 201.

Background

Jaqui is in her maternal grandmother's custody (legal and physical). She lives in a home with her grandmother, sister, nephew, aunt, and uncle. She is in 11th grade at a charter school and attends regular classes. Her IQ is 70. Mother died from an asthma related issue when Jaqui was 7 y/o. She has never known her father. There is a family history of depression. Jaqui has previously claimed both verbal and physical abuse by her aunt, although CYS investigated and the claims were unfounded. She identifies as a member of the Islamic faith.

The practitioner suspects hyperthyroidism and obtain lab tests.

Lab Values: T3: above 190 ng/dl T4: above 12 ug/dl The thyroid glands produce, thyroxine (T4) and triiodothyronine (T3) from iodine in the foods that we consume. The thyroid gland stores thyroid hormones and releases them into the bloodstream to control metabolism (conversion of oxygen and calories to energy).

NCLEX Question 3 Symptoms of PWS that occur around adolescence and early adulthood include: sELECT ALL THAT APPLY

Learning disabilities Obesity Infertility Weight loss Underdeveloped sex organs Answer: Learning disabilities Obesity Infertility Underdeveloped sex organs

Opioid (Narcotic) Antagonists

Like Naloxone (Narcan). Reverse the effects of CNS depressant esp. respiratory depression with the exception of Normeperidine. Counter the effects of stress induced levels of endorphins. More valuable to use if labor is more rapid than expected or birth occurs at opioid peaks effect. Tell the woman that pain relieved with opioid analgesic will return with opioid antagonist

Current Meds,

Lisinopril 30mg q AM Simvastatin 35 mg q HS Sitigliptin 100 mg OD in AM Acarbose 50 mg q AM, 100 mg at noon, 100 mg q PM Albuterol inhaler PRN Alli® (patient intermittently uses this medication)

Further/Ongoing Testing

Liver Function Test to watch for liver failure

acute care continued...

Manage increased intracranial pressure to avoid herniation, Elevated HOB, maintain head & neck in alignment, avoid hip flexion Manage seizures with medication (if noted) Management of GI problems Stool softeners for constipation Monitor of electrolyte status Monitor nutritional status Test swallowing before giving any oral feeding Monitor I&O may need intermittent cath for urinary retention

Treatment for ICP

Management of IICP • Sterile Technique o Dressing change o External drainage system o CSF sampling • Neurological Assessments • Maintain patent airway • Position to promote venous return o Head midline o HOB elevated 30 degrees • Hyperventilation o Risk of exacerbation cerebral ischemia • Osmotic Diuretics: Mannitol o Increases serum osmolality o Hold if serum osmolality > 320 mOsm/kg • Diuretics: Lasix o Dose 10-20 mg IV Q6H • Glucocorticoids: Decadron o May alternate with Mannitol • Fever o Increases the brain's metabolic rate and cerebral oxygen consumption o Treat with Tylenol • Prevent shivering • Therapeutic Hypothermia o Cooling body temperature to < 96.8 degrees Fahrenheit o Stabilizes blood-brain barrier o Prevents cell death o Decreases metabolic rate, o Decreases CO2 and lactate buildup • Sedatives o Decreases cerebral metabolic demands, facilitates ventilation and reduces ICP o Sedation vacation o Benzodiazepines Diazepam (Valium) Midazolam (Versed) Lorazepam (Ativan) o Propofol (Diprivan) • Neuromuscular Blocking Agents (NMBAs) o Facilitates ventilation o Prevents IICP from posturing, coughing o Unable to perform neuro assessment o Used in conjunction with sedation and analgesics o Monitor level of paralysis with Train of Four (TOF) • NMBAs o Vercuronium (Norcuron) o Cisatracurium (Nimbex) o Pancuronium (Pavulon) • Train of Four (TOF) o Assess paralysis: stimulus is applied to either the ulnar, facial, or posterior tibial nerve o The same site should be used consistently o Normal response: 1-2 twitches out of a possible total of 4 twitches (1-2/4) o Goal: 90% blockade = 1 twitch for every 4 electrical impulses o Absent response: patient is overparalyzed • Barbiturates o Pentobarbital o Decreases cerebral metabolism to limit swelling & cellular damage o Decreases cerebral oxygen needs o May improve blood flow to underperfused areas of the brain that have lost or reduced vasoreactivity o Hypotension common secondary to peripheral vasodilatation and mild myocardial depression

Case Study Situation,

Marla Jackson, a 32 yo female comes in to see her primary care practitioner for c/o fatigue poor sleeping for several weeks nervousness weight loss constantly hungry, but eating a lot of food lately Marla is accompanied by her husband who reports she's also irritable or "moody" and is developing "bug eyes". The two are concerned that Marla may have a brain tumor or a mental health problem because her mother's aunt was diagnosed as bipolar.

Background

Marla has no significant past medical history (PMH) They have a daughter who is 8y with an unremarkable pregnancy. Her current symptoms began about 6 weeks ago, and have progressed. Marla tells you she and her husband would like to have another child in the near future. Occupation: Accountant, but reports recent difficulty focusing on an account for more than a few minutes at a time. Marla also complains about also being hot lately and to having increased frequency of bowel movements.

Assessment

Marla is 5' 6" and weighs 148 pounds; patient reports she usually weighs 145 pounds. HEENT: ▪ Exophthalmos noted ▪ Neck with palpable thyroid gland ▪ Hair appears thin Cardio-respiratory ▪ Skin warm ▪ HR 124 GI: ▪ Hyperactive bowel sounds NEURO: ▪ Patient appears anxious, unable to sit in chair ▪ Fine tremors of hands noted bilaterally When interviewing Marla, you observe she is having difficulty sitting still and seems to be moving her gaze from one thing to another. Marla and her husband verbalize they are fearful about a "bad diagnosis" (of brain tumor or bipolar).

General anesthesia

May be used if spinal or epidural block is contraindicated or necessitate rapid birth like vaginal or emergent cesarean. If necessary, woman needs to be NPO and a wedge should be placed under one of the woman's hops to displace the uterus - prevent compression of aorta and vena cava. Need to be oxygenated with 100% oxygen for 2 to 3 minutes then intubated For recovery room: maintain open airway, and cardiopulmonary function and to prevent postpartum hemorrhage

Expected Outcomes -

Meals will be eaten around the time of anticholinesterase medication. Patient will have pureed food with a pudding like consistency. Patient will sit upright during meals, with neck slightly flexed. No aspiration will occur.

Nursing Interventions -

Mealtimes should coincide with the peak effects of anticholinesterase medication such as pyridostigmine. Rationale: Provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction.

What are the risk factors for a hemorrhagic stroke?,

Modifiable Risk Factors: High blood pressure #1 risk factor! Cigarette smoking Excessive alcohol intake Use of illegal drugs: cocaine Heart disease Obesity Poor diet Lack of physical exercise Serum cholesterol Some birth control pills Nonmodifiable risk factors: Age: risk doubles every decade after 55 yo Ethnicity: highest in African Americans Family history of stroke

What education and support do you anticipate Mrs. Henry's husband will need?,

Mr. Henry will need to gather all possible information regarding his wife's stroke What type of stroke did she have? What side of the brain was affected? What caused the stroke? How can another stroke be prevented? How can he properly care for his wife and her new disabilities?

Mr. Jones' Background,

Mr. Jones is an accountant and used to play golf but doesn't anymore because he gets too tired and the heat bothers him. He states he has tried "most diets" with only brief success. He adds he tried Alli® for a while but "had awful side effects" and stopped. He began considering surgical intervention about 2 years ago when he started to tire more easily and became short of breath with mild exertion. He adds that when the doctor told him he needed a second antidiabetic drug, he knew he had to do something.

Registered Dietician Meeting,

Mr. Jones is discharged today after meeting with a registered dietician. How has this surgery changed his need for specific supplements? Mr. Jones will need to be on a prescribed diet that include a reduce intake of supplement to prevent abdominal distention and dumping syndrome. His diet will be consisted of a high protein and low in carbohydrates, fat, roughage and consist of 6 small feedings a day. Fluid should not be ingested with meals and be reduced to 1000 mL per day.

Mr. Jones' Situation,

Mr. Jones states he has been "heavy" most of his life, but has steadily gained more weight over the past 6-8 years. At this time he has chosen to undergo bariatric surgery. Mr. Jones' pre-surgical weight is 385 pounds; Mr. Jones is 5'10" tall.

Recommendation,

Mrs. B has a temporary pacemaker inserted. Her monitor rhythm strip demonstrates the following rhythm:

Situation,

Mrs. B is a 62 year old female who presents to the Emergency Department with complaints of: ● increasing fatigue and mild shortness of breath; ● her skin is pale, cool and clammy

Background,

Mrs. Henry has HTN and atrial fibrillation. She was first diagnosed at age 30 after a 10-year history of cocaine abuse. Her husband tells the ED nurse that his wife is on Warfarin for her atrial fibrillation, and occasionally uses cocaine. He tells the nurse that he believes his wife always took her BP medication and Warfarin, however he adds that he knows she doesn't always follow up with appointments with her PCP. Mrs. Henry's current medications include: · Metoprolol 25 mg. OD · Amlodipine 7.5 mg OD · Hydrochlorothiazide mg OD · Warfarin 5 mg. OD

What type of stroke is Mrs. Henry most likely experiencing?,

Mrs. Henry is most likely experiencing a hemorrhagic stroke. She complained of the worst headache of her life. A headache (the most severe they've ever had) is an indicator of a hemorrhagic stroke. Progressive with intracerebral. Sudden and severe with subarachnoid. Her condition started to worsen after administering the Aspirin instead of improve like it would have if it was an ischemic stroke. Hemorrhagic stroke is less common than an ischemic stroke but more fatal

Hemorrhagic Stroke Situation,

Mrs. Henry, age 39, is a Caucasian female who has a history of atrial fibrillation and cocaine abuse. Today at breakfast she complained of a headache. She lives next door to you and her husband (knowing that you just graduated from a nursing program) texted you to come over and see his wife. When you arrive she says, "This is the worst headache of my life. Do you have any aspirin?" What should you do next?

Differentiates between upper and lower motor neurons and their reactions to stimulation

Muscle Biopsy Test: Confirms changes consistent with muscle atrophy and loss of muscle fibers

Music

Music, recorded or live, can provide a distraction, enhance relaxation, and lift spirits during labor, thereby reducing the woman's level of stress, anxiety, and perception of pain. It can be used to promote relaxation in early labor and to stimulate movement as labor progresses.

Barriers to Pain Management in Children

Myths Children, particularly infants, do not have the neurological physiology to experience pain in the same manner as adults. FALSE Inadequate Assessment/ Reassessment Concern that addressing pain in children requires excessive time and effort Imposing personal values Some clinicians who misplace the experience of pain in the development of the child "Pain builds character"

S/S

Nervousness Anxiety Increased perspiration Heat intolerance Hyperactivity Palpitations Warm, moist, smooth skin Hand tremor Muscle weakness Reduction in menstrual flow (oligomenorrhea) Tachycardia or atrial arrhythmia

What other members of the health care team need to be involved in Mrs. Henry's care?

Neurologist Physical therapist Occupational therapist Speech therapist Nutritionist Social worker

Neonatal pain

Newborn do experience pain Most common behavioral sign of pain is vocalization or crying Facial expressions Infant will flex and adduct the upper body and lower limbs in an attempt to withdraw from the painful stimulus How to assess for pain Need to consider the health of the neonate, type and duration of painful stimulus, environmental factors and infant's state of alertness Pain assessment tools include: Neonatal infant pain scale (NIPS) Premature infant pain profile (PIPP) Neonatal pain agitation and sedation scale (NPASS) Most commonly using NICU is CRIES. Management of Neonatal pain Minimize the intensity, duration and physiologic cost of the pain Maximize the neonate's ability to cope with and recover from the pain. Manifestations of Acute Pain in the Neonate Physiologic Responses Vital signs—Observe for variations. Increased heart rate Increased blood pressure Rapid, shallow respirations Oxygenation. Decreased transcutaneous oxygen saturation (tcPO2) Decreased arterial oxygen saturation (SaO2) Skin—Observe color and character. Pallor or flushing Diaphoresis Palmar sweating Laboratory evidence of metabolic or endocrine changes. Hyperglycemia Lowered pH Elevated corticosteroids Other observations. Increased muscle tone Dilated pupils Decreased vagal nerve tone Increased intracranial pressure Behavioral Responses Vocalizations—Observe quality, timing, and duration. Crying Whimpering Groaning Facial expression—Observe characteristics, timing, orientation of eyes and mouth. Grimaces Brow furrowed Chin quivering Eyes tightly closed Mouth open and squarish Body movements and posture—Observe type, quality, and amount of movement or lack of movement; relationship to other factors. Limb withdrawal Thrashing Rigidity Flaccidity Fist clenching Changes in state—Observe sleep, appetite, activity level. Changes in sleep-wake cycles. Changes in feeding behavior Changes in activity level Fussiness, irritability Listlessness

Nitrous Oxide for Analgesia

Nitrous oxide is mixed with oxygen can be inhaled in low concentration for 1st and 2nd stage of labor Gives the woman a sense of control, help to relax and reduces perception of pain Should be monitored for N and V, drowsiness, dizziness, and Loss of consciousness

Planning/Outcome -

No aspiration will occur

Culture and Genetics

No one clear genetic pain link but are genetic links to pain variability, susceptibility to painful diseases, development of nociceptors and neurotransmitters Pharmacogenetics is the effort to tailor pharmacologic agents to improve pain treatment based on genetic sequencing but not close to guiding individualized pain therapy Understanding the cultural background of how the patient would react to pain Ask the patient how would he or she behaves when in pain

You decide to give her 2 aspirin for her headache. She then complains of nausea, vomits, and becomes very drowsy. You and her husband then decide to drive her to the hospital Were your actions safe and appropriate?

No, anticoagulants and platelet inhibitors (ASA) are contraindicated in patients with hemorrhagic strokes. Since you are not sure yet whether she has a diagnosis of stroke (or what type of stroke), you should not administer ASA. The patient should have been transported via ambulance because the patient's condition may worsen en route. Note time of onset of symptoms! *TIME IS BRAIN*

What diagnostics would differentiate the types of stroke?,

Noncontrast CT scan or MRI Indicates the size and location of the lesion

Key Points

Nonpharmacologic pain and stress management strategies are valuable for managing labor discomfort alone or in combination with pharmacologic methods. The gate-control theory of pain and the stress response are the bases for many of the nonpharmacologic methods of pain relief. The type of analgesic or anesthetic to be used is determined by maternal and health care provider preference, the stage of labor, and the method of birth. Sedatives may be appropriate for women in prolonged early labor when there is a need to decrease anxiety or promote sleep or therapeutic rest. Naloxone (Narcan) is an opioid (narcotic) antagonist that can reverse narcotic effects, especially respiratory depression. Pharmacologic control of pain during labor requires collab-oration among the health care providers and the laboring woman. The nurse must understand medications, their expected effects, potential side effects, and methods of administration. Maintenance of maternal fluid balance is essential during spinal and epidural nerve blocks. Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response. The use of opioid agonist-antagonist analgesics in women with pre-existing opioid dependence may cause symptoms of abstinence syndrome (opioid withdrawal). Epidural anesthesia and analgesia is the most effective pharmacologic pain relief method for labor that is available. Therefore it is used by most women in the United States. General anesthesia is rarely used for vaginal birth but may be used for cesarean birth or whenever rapid anesthesia is needed in an emergency childbirth situation.

Pathophysiology

Normally, the secretion of thyroid hormone is controlled by a complex feedback mechanism involving the interaction of stimulatory and inhibitory factors Thyrotropin-releasing hormone (TRH) from the hypothalamus stimulates the pituitary to release TSH. Binding of TSH to receptors on the thyroid gland leads to the release of thyroid hormones—primarily T4 and to a lesser extent T3. In turn, elevated levels of these hormones act on the hypothalamus to decrease TRH secretion and thus the synthesis of TSH. Thyroid hormones diffuse into the peripheral circulation and more than 99.9% of T4 and T3 in the peripheral circulation is bound to plasma proteins and is inactive. In hyperthyroidism, serum T3 usually increases more than does T4, due to increased secretion of T3 as well as conversion of T4 to T3 in peripheral tissues.

Promoting parent infant interaction

Nurses assess attachment behaviors and provide support and education to parents as they become acquainted with the neonate. Teach parents to recognize infant cues and respond appropriately. Family-Centered Care: Helping Parents Recognize, Interpret, and Respond to Newborn Behaviors Learning to read a baby's body language can enable parents to be more effective in preventing and solving problems around the infant's sleeping, eating, and crying and enhances parent-infant interaction. Nurses can teach new parents the following: Identify three newborn "Zones," traditionally referred to as newborn states. "Resting Zone": also known as sleep states. Still/deep sleep: Baby is completely still. Breathing is regular. No spontaneous activity. No movement of eyes, and eyelids stay shut. No vocalizing. Muscles are totally relaxed. Active/light sleep: Baby may wiggle or vocalize. Eyes may flash open. Baby may make sucking movements—but still be asleep. "Ready Zone": alert state: Baby's eyes are bright. Baby can focus on an object or person. Baby reacts to stimulation. Motor activity is minimal. "Rebooting Zone": fussy/crying state: Baby's motor activity increases and is jerky. Baby is less responsive and moves from fussing to crying. Identify signs of stress. When babies are stressed or over-stimulated, they show changes in their body and behavior. These changes are called SOSs (Signs of Over-Stimulation), traditionally referred to as a baby's stress response. Body SOSs: changes in color (becoming more red or pale); changes in breathing (becoming more irregular or choppy); changes in movement (becoming jerky or having more tremors). Behavioral SOSs: "spacing out" (going from an alert state to a drowsy state); "switching off" (gaze aversion, or looking away from parent); "shutting. down" (going from drowsy to a sleep state) When baby shows an SOS, parents should decrease stimulation and increase support by doing one or several of the following: Quiet one's voice Glance away from baby Encourage baby to suck a finger or mother's breast Swaddle baby Place baby skin to skin Help baby sleep well. Distinguish active/light sleep from still/deep sleep. Parent's care: Prepare baby to sleep: swaddling may help; feed in quiet, dark room at night and active, light environment during day. Get baby to sleep: put baby down for sleep while he or she is still awake. Help baby stay asleep: don't pick up during active/light sleep. After breastfeeding is well established, notice when sleeping baby moves into active/light sleep. Wait and see if baby will transition from active/light sleep back to deep/still sleep—and sleep a bit longer. Help baby eat well. Recognize early signs of hunger during the first few weeks: wiggling, making sucking movements, bringing hand to mouth. Notice if a fragile baby "spaces out" or "shuts down" when trying to eat. Bring this baby skin to skin and decrease stimulation before resuming feeding. If a parent needs to wake a fragile or small baby to eat, do so from active/light sleep, not from still/deep sleep. Help crying baby: Consider what "TO DO." T: Talk quietly to baby in sing-song voice. O: Observe to see if baby takes self-calming actions: brings his or her hand to his or her mouth, making sucking movements, or moves into the fencing reflex position. DO: Bring baby's hands to his or her chest; encourage sucking; make gentle "shooshing" sounds; swaddle baby; and/or bring baby skin to skin. Play with baby so he or she can learn and grow. Demonstrate baby's ability to look at a parent's face, watch a toy move, or turn to parent's voice. Watch for an SOS during play. If an SOS occurs, decrease stimulation and increase support as described earlier in box. Observe baby's developing process of interaction: first, getting quiet and still; second, turning toward parent; third, turning toward and looking at parent. Reinforce benefits of sensitive, face-to-face parent interaction with baby.

Obesity,

Obesity is an exaggeration of normal adipose tissue. Adipocytes is the cellular basis for obesity which may be increased in size or number Obesity is the underlying cause of Diabetes, hypertension, Hyperlipidemia, Atherosclerosis, Heart Disease and more

TBI/Concussion Assessments for TBI •

Objective data is obtained by applying the GCS, assessing and monitoring neurologic status and determining whether a CSF leak has occurred

Therapies

Occupational Therapy Speech Therapy Physical Therapy GU - Urinary Incontinence Urinary Retention Intermittent Catheterization Both Flaccid and Spastic Bladders Issues Dependent on Patient Measure INput/OUTput

Subarachnoid hemorrhage,

Occur when an aneurysm (a blood-filled pouch that balloons out from an artery) on or near the surface of the brain ruptures and bleeds into the space between the brain and the skull. Bleeding in between meningeal layers

Opioid Agonist Analgesics.

Opioid (narcotic) agonist analgesics commonly used in obstetrics are meperidine (Demerol) and fentanyl (Sublimaze). Create feelings of euphoria and enhance rest. However can inhibit uterine contractions. Should be administered after labor is well established. Demerol is widely used for labor pain. However has undesirable side effects on newborn. Can cross placenta and prolonged neonatal sedation and neurobehavioral changes. Cannot be reversed with naloxone because have long half-life. It can persist for the first 2 to 3 days of life. Sublimaze: Short acting. Rapid crossing the placenta. Fewer neonatal effects and less maternal sedation and nausea. Disadvantage is more frequent dosing is required due to short action. Most commonly administered as a PCA.

Pharmacological Interventions: OPIOIDS

Opioid analgesics Morphine sulfate, fentanyl, and codeine Treats moderate to severe pain w/ short term (24 to 48 hr) around-the-clock administration of opioids is preferred over a PRN schedule

Nursing Diagnosis #2,

Outcome: Patient is normovolemic as evidenced by systolic BP greater than or equal to 90 mm HG (or patient's baseline), absence of orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr and normal skin turgor. Intervention: Short term:Assess skin turgor and oral mucous membranes for signs of dehydration rationale: loss of interstitial fluid causes loss of skin turgor. Assessment of skin turgor in older adults is less accurate because the skin normally loses its elasticity. Therefore skin turgor assessed over the sternum or the forehead is best. Several longitudinal furrows and coating may be noted along the tongue. long term: monitor and document the patient's HR and BP rationale: a reduction in circulating blood volume can cause hypotension and tachycardia. This change in HR is a compensatory mechanism to maintain cardiac output. Usually the pulse is weak and may be irregular if electrolyte imbalances also occurs. Hypotension is evident in hypovolemia

Nursing Diagnosis #3,

Outcome: Patient will maintain normal serum electrolyte balance as evidenced by sodium level of 136 to 145 mEq/L; potassium level of 3.5 to 5.1 mEq/L; chloride level of 98 to 107 mEq/l; total calcium level of 9 to 10.5 mg/dl; ionized calcium of 4.6 to 5.1 mg/dl; and magnesium level of 1.8 to 3 mg/dl. Intervention: Short term: Administer balanced electrolyte IV solutions as prescribed: rationale: Lactated Ringer's solution has an electrolyte concentration equivalent to that of extracellular fluid. Isotonic saline (0.9% sodium chloride) may contribute to hypernatremeia if used for an extended time. Excessive use of sodium free IV solutions (e.g. D5W) puts the patient at risk for hyponatremia. Long term: assess for wound drainage and extensive tissue injury associated with risk for electrolyte imbalances. rationale: patients with draining wounds, especially gastrointestinal fistulas, are at risk for loss of sodium and magnesium. Extensive tissue injury as may occur with trauma or burns may cause hyperkalemia, initially. Later, the patient may be at risk for hypokalemia and hyponatremia.

Nursing Diagnosis #1,

Outcome: patient maintain optimal gas exchange as evidenced by ABGs within the patient's usual range, alert responsive mentation or no further reduction in level of consciousness, relaxed breathing and baseline HR for patient Intervention: Short term: teach the patient appropriate breathing and coughing techniques Rationale: These techniques facilitate adequate air exchange and secretion clearance. Long term: Monitor ABGs and note changes. Rationale: Increasing PaCO2 and decreasing PaO2 are signs of respiratory acidosis and hypoxemia. As the patient's condition deteriorates, the respiratory rate will decrease and Paco2 will begin to increase. Some patients such as those with COPD have a significant decrease in pulmonary reserves, and additional physiological stress may result in acute respiratory failure.

Nursing Diagnosis #4,

Outcome: patient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions and tubes. Intervention: short term: For patient at risk, monitor elevated temperature for signs of actual infection: rationale: Temperature of up to 38°C (100.4°F) for 48 hours after surgery is related to surgical stress after 48 hours, temperature greater than 37.7°C (99.8°F) suggests infection; fever spikes that occur and subside are indicative of wound infections; very high temperature accompanied by sweating and chills may indicate septicemia. long term: Maintain or teach asepsis for dressing changes and wound care, catheter care and handling and peripheral IV and central venous access management use of aseptic technique decreases the chances of transmitting or spreading pathogens to the patient. A basic tenet of any infection prevention - related intervention is to interrupt the transmission of infection along the various steps that compromise the chain of infection

Pathophysiology

PWS is caused by the loss of a function of genes in a particular region of Chromosome 15. One copy of the chromosome is typically inherited from each parent. Some genes are turned on (active) only on the copy that is inherited from a person's father (the paternal copy). This parent-specific gene activation is caused by a phenomenon called genomic imprinting. About 70% of PWS cases occur when a segment of the paternal chromosome 15 is deleted in each cell. About 25% of cases a person has two copies of chromosome 15 inherited from the mother In very rare cases, PWS can be caused by a translocation or mutation on chromosome 15. Characteristic features of PWS result from the loss of function of several genes on Chromosome 15 that control appetite. Flaw in hypothalamus that controls feelings of hunger and satiety.

Hospice and Its Benefit for the Patient

Pain Control and Comfort Symptom Control Care for Patients Wherever They May Be with Reduced Rehospitalization Coordinated Care at Every Severity Level with Security of Consistent Care Emotional and Spiritual Assistance Respite Care Bereavement Services

Use of opioid

Pain Relief: -Acute pain after surgery -Injury of trauma -Cancer pain -Pain arising from a disease or other source Anesthesia: 3 Main Aspects - pain relief or analgesia, loss of memory of the surgery and muscle relaxation to facilitate surgery and manipulation. De-Addiction: -Some opioids such as Methadone and Suboxone are used to help wean patients off some of the more potent opioids such as Heroin. Cough Suppressant: - Such as Codeine, Hydrocodone, and Hydromorphone Diarrhea Suppressant: -Used to treat irritable bowel syndrome and some other organic causes of diarrhea

Why is pain management in children important?

Pain is a common complaint in children, w/ 50-83% of children report having experienced pain over a 3-month period & 25% experiencing recurrent pain (Velleman et. al, 2010). It can impact energy levels, functional ability & normal development. It can lead to psychological depression and put them at higher risk for suicide. Pain can also affect a child's appetite and quality of sleep so pain control can optimize healing.

Background

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. -Most common reason for seeking health care→ 5th Vital Sign Since nurses spend the most time with patients in pain, it is important that we understand the pathophysiology of pain, physiological/ psychological effects of acute & chronic pain and the methods used to treat pain. Pain management sometimes includes the usage of opioids which creates a need for possible assessment of patients at risk for opioid abuse.

Subjective data

Pain is defined as unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Always subjective Self-report is the gold standard of pain assessment (what the patient say) Can use the PQRST method. P - provocation/palliation Q - quality/quantity R - Region/Radiation S - Severity scale ( like 0 to 10) T - Timing

Factors influencing pain response

Pain is influenced by a variety of physiologic, psychologic, emotional, social, cultural and environmental factors

Epidural anesthesia or analgesia (block)

Pain relief is provided into the epidural (peridual) space Injection is made between the fourth and fifth lumbar vertebrae Most effective pharmacologic pain relief method for labor Effectively relieves pain caused by uterine contractions but not completely remove the pressure sensations that occurs as the fetus descends in the pelvis. Advantages: The woman remains alert and is more comfortable and able to participate. Good relaxation is achieved. Airway reflexes remain intact. Only partial motor paralysis develops. Gastric emptying is not delayed. Blood loss is not excessive Fetal complication are rare Disadvantages: Ability to move freely are limited Hypotension Weakness of legs.

Expression of pain

Pain results in physiologic effects and sensory and emotional (affective) responses. Increase in blood pressure and heart rate Maternal respiratory patterns change in response to an increase in oxygen consumption Hyperventilation sometimes accompanied by respiratory alkalosis can occur as the pain intensifies and more rapid, shallowing breathing are used Increasing anxiety with lessened perceptual field

Gate control theory of pain

Pain sensations travel along sensory nerve pathways to brain but only a limited number of sensations or messages can travel through these nerve pathways at one time. Utilizing distraction such as music can block or reduces the hypothetic gate in the spinal cord thus preventing pain signals from reaching the brain.

Structure and Function

Pathologic pain develops by two main processes: Nociceptive - develops when functioning and intact nerve fibers in the periphery and the CNS are stimulated Four phases: Transduction Noxious stimulus takes place in the periphery Transmission Pulse impulse or the message moving along the spinal cord to the brain Perception Conscious awareness of painful sensation Interpretation Modulation Slow down and then stopping the pain stimulus Neuropathic Abnormal processing of the pain message from an injury to the nerve fibers Often perceived long after the site of injury heals Evolves into chronic condition

Cardiogenic Shock Assessments for cardiogenic shock

Patient Monitoring • Continuously monitor oxygenation status with pulse oximetry. • Monitor for desaturation in response to nursing intervention. • Monitor ECG for dysrhythmias caused by hypoxemia, electrolyte imbalances, or ventricular dysfunction. • Monitor fluid volume status. Patient Assessment • Obtain HR, RR, and BP every 15 minutes to evaluate the patient's response to therapy and detect cardiopulmonary deterioration. • Assess the patient's respiratory status. The use of accessory muscles and inability to speak suggest worsening pulmonary congestion. • Assess for excess fluid volume, which can further compromise myocardial function. Diagnostic Assessment • Review ABGs for decreasing trend in Pao2 (hypoxemia) or pH (acidosis). These conditions can adversely affect myocardial contractility. • Review serial chest radiographs to evaluate the patient's progress or a worsening lung condition. Treatment of cardiogenic shock • Oxygenation - provide supplemental O2 (e.g., nasal cannula, non-rebreather mask), intubation and mechanical ventilation, if necessary, monitor ScvO2/SvO2 • Circulation - restore blood flow with thrombolytic, angioplasty with stenting, emergent coronary revascularization, reduce workload of the heart with circulatory assist devices: IABP, VAD • Drugs - Nitrates (e.g., nitroglycerin), Inotropes (e.g., dobutamine), Diuretics (e.g., furosemide), B-Adrenergic blockers (contraindicated with decreased EF) • Supportive - treat dysrhythmias Assessments for organ failure • Vigilant assessment and ongoing monitoring to detect early signs of deterioration or organ dysfunction • Collaborative care for patients with SIRS and MODS focuses on: o Prevention and treatment of infection o Maintenance of tissue oxygenation o Nutritional and metabolic support o Appropriate support of individual failing organs

Background

Patient reports good health with no major illnesses. He is happily married with four kids. Works in the maintenance department at the local school district. Patient states, "His wife encourages him to have a physical exam because he hasn't had one in a long time." Patient also states, "His wife is concerned because he drops things more frequently"; where patients responds that he is just in a hurry.

Nursing Interventions -

Patients food will have a pudding-like consistency. Rationale: This type of consistency can be swallowed more easily. Aids in swallowing effort. Patient's HOB will be elevated to semi-fowler's position. Rationale: Upper airway patency is facilitated by upright position.

Seizure Medications for tonic/clonic seizures

Pharmacologic Management • Tonic-clonic and focal seizures o Phenytoin o Carbamazepine o Phenobarbital Phenytoin: Pediatric Dosing • Therapeutic level: 10 - 20 mcg/mL • Initially: 5 mg/kg/day (BID or TID); max 300 mg/day • Children > 6y: Maintenance: 4 to 8 mg/kg with minimum dose 300 mg/d • Complications o Suicidal ideation o Stevens Johnson Syndrome (SJS) o Toxic epidermal necrolysis o Decreased bone density o Hepatotoxicity o Pancytopenia ±BMD Other Seizure Drugs • Carbamazepine o OK for pediatric patients o Obtain baseline labs before beginning Rx Monitor for renal problems Monitor LFTs o Other uses Diabetic neuropathy Trigeminal neuralgia Bipolar disorder o Contact prescriber if rash, fever, bleeding, or weakness • Phenobarbital o 60 - 120 hours' half-life o Can take up to 2-3 weeks to be fully effective o Withdrawal gradually o 15-50 mg 2 or 3 times daily for general seizure management o 3-4 mg/kg daily for febrile seizures

Non-pharmacologic interventions

Physical therapy. Muscle weakness is a serious problem among individuals with PWS. For children younger than age 3, physical therapy may increase muscular strength and help such children achieve developmental milestones. For older children, daily exercise will help build lean body mass. Behavioral therapy. People with PWS have difficulty controlling their emotions. Using behavioral therapy can help. Stubbornness, anger, and obsessive-compulsive behavior, including obsession with food, should be handled with behavioral management programs using firm limit-setting strategies. Structure and routines also are advised

What are these conditions and how do they differ?

Post concussion syndrome ● Medical problem that persists for a period of time after the head injury has occurred. Can last for weeks to months ● Symptoms can be vague and attributable to other reasons ● Can be worse in people who have had previous concussions or head trauma ● Commonly reported symptoms: headache, dizziness, sleep problems, psychological problems, cognitive problems

Recommendation

Practitioner orders: Lumbar puncture Why a Lumbar Puncture? Used to test the Spinal Fluid to determine if there are any infections or any other problems. MRI

Nursing care of bariatric surgery

Pre-op Surgical Care Needs • Bariatric bed • Skin preparation • Transport • Infection prevention • Pulmonary o Teach IS o CPAP? Post-op Surgical Care Interventions • Bariatric bed • NGT and IVF o Move to sugar-free clear liquids • Assess for complications o Vomiting o Wound dehiscence o Staples "pop" • Manage pain • Provide wound care • Frequent skin care • Pulmonary hygiene • Teach patient to eat slowly Bariatric Surgery Concerns • Anemia • Infection • Vitamin deficiency • Failure to lose weight • Peptic ulcer • Dumping syndrome (With Roux-en-Y) • Small bowel obstruction • Excess flabby skinfolds • Metabolic syndrome Dumping Syndrome • Occurs with significant amount of stomach removal • Symptom onset within 15 - 30 minutes after food intake o Weakness o Sweating o Palpitations o Dizzy o Abdominal cramps → urge to defecate Post-op Care: Ambulatory and Home Care • Nutrition o Dramatic decrease in oral intake o Substantial weight loss first 6 - 12 m • No fluids with meals • Multivitamin, iron, calcium and cobalamin supplements • Psychological support • Be alert for complications

Precocious Puberty

Precocious puberty is defined as earlier than expected maturation of a child's body, including the early development of secondary sex characteristics. There is a significant association between PWS and precocious puberty, and early development may give a cause for Jaqui's illicit behavior, such as EtOH use, at such a young age. Early puberty also accelerates hormonal process, and may be a potential cause for some of her difficulties in judgment and affect, although these are multi-factorial issues.

Acupressure and Acupuncture

Pressure, heat, or cold is applied to acupuncture points called tsubos. These points have an increased density of neuroreceptors and increased electrical conductivity. Acupressure is said to promote circulation of blood, the harmony of yin and yang, and the secretion of neurotransmitters, thus maintaining normal body functions and enhancing well-being. Acupuncture is the insertion of fine needles into specific areas of the body to restore the flow of qi (energy) and to decrease pain, which is thought to be obstructing the flow of energy. Effectiveness may be attributed to the alteration of chemical neurotransmitter levels in the body or to the release of endorphins as a result of hypothalamic activation.

Suggested measures for supporting a woman in labor

Provide companionship and reassurance. Offer positive reinforcement and praise for her efforts. Encourage participation in distracting activities and nonpharmacologic measures for comfort. Give nourishment (if allowed by primary health care provider). Assist with personal hygiene. Offer information and advice. Involve the woman in decision making regarding her care. Interpret the woman's wishes to other health care providers and to her support group. Create a relaxing environment. Use a calm and confident approach. Support and encourage the woman's family members by role modeling labor support measures and providing time for breaks.

Nonpharmacologic pain management

Provide the woman with a sense of control Enhancing relaxation like music, meditation, massage, or warm bath Should be encourage to try a variety of method

Multivitamins

Purpose of medication: treat or prevent vitamin deficiency Potential side effects: tooth staining, stomach bleeding, muscle weakness, and confusion.

Assessing Pain in Children "QUESTT"

Q: Question the Child U: Use the Pain Rating Scales E: Evaluate Behavioural and Physiological changes S: Secure the parents' involvement T: Take the cause of pain into accountT: Take action and evaluate results

What other diagnostic procedures might Marla undergo?

Radioactive Iodine Uptake Test Radio Iodine Uptake Test will help determine why Marla's thyroid is overactive. If the uptake of radioiodine is high that indicates that her thyroid gland is producing too much thyroxine. If the uptake of radioiodine is low that indicates that the thyroxine stored in the gland is leaking into the bloodstream and may have inflammation of the thyroid.

Support,

Reach out to family and friends Build a network/join a support group with other stroke survivors and caregivers Take time for himself Consider seeking help from mental health professionals (can teach coping skills)

Nerve block analgesia and anesthesia.

Regional analgesia (some pain relief and motor block). Regional anesthesia (complete pain relief and motor block). Local anesthetics is temporary interruption of conduction of nerve impulses like pain. Examples: bupivacaine (Marcaine), chloroprocaine (Nesacaine), and lidocaine (Xylocaine). Reaction may include respiratory depression, hypotension and other severe adverse effects. To reverse the effects, give epinephrine, antihistamines, oxygen and supportive measures. Local Perineal Infiltration anesthesia May be used when an episiotomy is to be performed or lacerations must be sutured after birth Usually lidocaine Pudendal nerve block Administered late in the second stage of labor Like an episiotomy is to be performed or forceps or vacuum extractor is used Can be used during third stage of labor if an episiotomy or lacerations must be repaired Does not relieve pain from uterine contractions but relieve pain in the lower vagina, vulva and the perineum Does not change maternal hemodynamic or respiratory functions, vital signs or FHR However, bearing down reflex is lessened or lost

Relaxation and Breathing techniques

Relaxation Reduction of body tension Ideally combined with activity such as walking, slow dancing, rocking and position changes that help the baby rotate though the pelvis. Rhythmic motion stimulates mechanoreceptors in the brain which decreases pain perception.

Interventions,

Remain alert for critical changes in patient's respiratory, CNS and cardiovascular functions. Maintain adequate hydration. Maintain patent airway and provide humidification if acidosis requires mechanical ventilation. Institute safety measures and assist patient with positioning. -Continuously monitor arterial blood gases Compare labs related to perfusion to baseline to determine if there was a higher blood loss than expected or need for transfusion if hgb drops below 7 and hematocrit below 20. Notify provider of results

After 24 hours Mrs. Henry's BP approaches acceptable range. She continues to have significant neurological deficits with an NIHSS of 25. The next day Mrs. Henry is transferred to the progressive care unit. She improves slightly and is scheduled to have a PEG tube inserted. She is extubated but her left side remains flaccid. She has global aphasia: total inability to communicate. In considering that Mrs. Henry had a SAH and a right-brain stroke, what are specific complications that can persist based on this type of stroke damage which can impact patient safety?

Right Brain Damage: Paralyzed left side: "hemiplegia" Left-sided neglect Tends to deny or minimize problems Rapid performance, short attention span Impulsive, safety problems Impaired judgment/time concepts Complications: Fall r/t the above, rebleeding before surgery, or cerebral vasospasm (which can result in infarction)

Nursing Diagnosis #2

Risk for Injury Implementation: -Assess neuro and respiratory status for signs of ICP and respiratory distress - monitor VS Outcome: Pt will remain free from injury

Diagnosis -

Risk for aspiration r/t difficulty swallowing, weakness of bulbar muscles

Nursing diagnosis #2,

Risk for injury may be related to: ● Pacemaker failure ● Puncture of perforation of heart tissues, ● Lead migration ● Skin erosion Possibly evidenced by: ● Decreased cardiac output ● Decreased stroke volume ● Increased peripheral vascular resistance ● Increased systemic vascular resistance ● Hemorrhage ● Diaphoresis ● Hypotension ● Chest pain ● Muscle twitching ● Pneumothorax ● Decreased breath sound

Nursing Diagnosis #1

Risk for self inflicted, life threatening injury related to past hx of suicide Interventions: Ask patient directly if she has thoughts of harming self and plans to carry out. Maintain close observation of client. Encourage client to express angry feelings within appropriate limits. Provide safe method of hostility release. Outcome: patient will remain free from self harm

Medications and Lab Test

Role of Riluzole use in ALS? Benzothiazole, Glutamate Inhibitor Normal dose is 50 mg every 12 hours Prolongs survival and/or delay the need for tracheostomy. Exact reason why it works is not known. Prevents further damage to motor neurons responsible for controlling muscle function. There are no significant side effects to the use of this medication. Common side effects of other medications may persist but not specifically related to the drug itself. For example: diarrhea, muscle weakness, N/V, SOB, trouble breathing, cough

Pain intensity

Self-report are not sufficiently valid for children below the age of 3 years

Bariatric Unit,

Shortly after arrival to the Bariatric unit, the lab reports his results. His SpO2 continues to be 89-91% on 2 L NC. ABG: pH 7.32, pCO2 48, pO2 91, HCO3 20. CMP: Na 145 K 5.8 (HIGH) Cl 105 BUN 28 (HIGH) Creatinine 1.2 Glucose 164 (HIGH) CBC: WBC: 11,000 Hgb 9 (LOW) Hct 32 RBC 3.4 (LOW) Platelets 142,000 (LOW)

Environment

Should be safe, homelike and private allowing for the woman to be herself as she tries different comfort measures

Six months after discharge...

Six months after discharge, Mr. Jones' is in for another follow-up appointment. He has been following his diet and activity plans and has already experienced significant weight loss. He asks what he can do about "the flabby skin I'm starting to develop". How will you advise him? There are cosmetic surgeries to reduce the flabby skin such as: Lipectomy which is (adipectomy) is performed to remove unsightly flabby folds of adipose tissue (Lewis, Dirksen, Heitkemper, and Bucher, 2014 p. 917). Another cosmetic surgical procedure is liposuction, or suction-assisted lipectomy. It is used for cosmetic purposes and not for weight reduction. This surgical intervention helps improve facial appearance or body contours. (Lewis, Dirksen, Heitkemper, and Bucher, 2014 p. 917).

Medications for Prader-Willi Syndrome

Somatropin: Medication classification: Growth Hormone Purpose of medication: it is indicated for the treatment of pediatric patients who have a growth failure due to Prader-Willi Syndrome Potential side effects: upper respiratory tract infection, arthropathy, headache, reduced sensation, increased serum glucose, limb pain, myalgia, paresthesia, and peripheral edema.

Signs & Symptoms

The diagnosis of cardiogenic shock can sometimes be made at the bedside by observing the following: ● Hypotension ● Absence of hypovolemia ● Clinical signs of poor tissue perfusion ● Rapid breathing ● Severe shortness of breath ● Sudden, rapid heartbeat (tachycardia) ● Loss of consciousness ● Weak pulse ● Sweating ● Pale skin ● Cold hands or feet ● Urinating less than normal or not at all

Assessment,

Subjective: Difficulty chewing and swallowing food, Diet changed to soft-textured foods because of the difficulty in chewing and swallowing food. Head seems to nod forward at times. Increased fatigue by the end of the day. Objective: Voice becomes softer as she speaks, UE muscle strength test is "4" Nods head intermittently Palpation during swallowing indicates effort is required to effectively swallow.

NCLEX Question 1 What usually causes death in Prader-Willi patients?

Suicidal tendencies Obesity Complications Malnutrition Respiratory distress Answer : B. Obesity complications

Developmental competence

The aging adult Pain is not part of the normal process of aging It indicate pathology or injury People with dementia do feel pain - somatosensory cortex is generally unaffected by dementia Assess body language instead of verbal communication Patient with Dementia - use the PAINAD scale Pain Assessment in Advanced Dementia scale Evaluates five common behaviors: breathing, vocalization, facial expression, body language and consolubility Gender differences Influenced by societal expectations, hormones and genetic makeup Men may be more stoic Women may displayed more affect or emotion for pain Hormonal changes have strong influences on pain sensitivity

Comfort

Support: Emotional support Supportive presence of person like doula, childbirth educator, family member, friend, nurse or a partner

Mrs. Henry becomes comatose and is immediately intubated and taken to the OR. What type of surgery do you anticipate Mrs. Henry having?,

Surgical interventions used to treat hemorrhagic strokes include Resection of area that's bleeding Clipping of an aneurysm Done to block off the aneurysm from the blood vessels in the brain Prevents further leaking of blood from the aneurysm Coil embolization Catheter inserted into artery and coil is pushed into the aneurysm that will cause a blood clot to form, which will block blood flow through the aneurysm and prevent it from bursting again

Nonpharmacologic method

Swaddling or snugly wrapping the infant with a blanket Facilitated tucking - hand swaddling technique Nonutritive sucking (NNS) Sometimes with oral sucrose

Further Med Instruction

Take med 1-2 hours before eating and at the same time each day. If medication is missed, skip it and continue regimen the following day at the same time Do not take other medications that may harm liver such as: Theophylline, HIV Drugs, Tylenol, and Diuretics.

Pain Assessment Tools

Teach patient on how to use each pain assessment tools Printed language should be translated to the patient's native language Should be free of medical jargon, direct and at 6th grade reading level Ask the patient to rate and evaluate all of the pain sites Use pain tool consistently before and after treatment to see if treatment has been effective Reassessment of pain following intervention is necessary Overall pain assessment tools More useful for chronic pain conditions or problematic acute pain problems Examples - initial pain assessment, brief pain inventory and McGill Pain Questionnaire Initial pain assessment Asks the pain to answer 8 questions concerning location, duration, quality, intensity and aggravating/relieving factors Brief pain inventory Ask the patient to rate the pain within the past 24 hours using graduated scales ( 0 to 10) with respect to its impact on areas such as mood, walking ability and sleep McGill Pain Questionnaire Ask the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain Pain rating scales are intended to reflect pain intensity Numeric rating scales ask the patient to choose a number that rates the level of pain for each painful site, 0 being no pain and 10 being worse pain ever Verbal descriptor scale Uses words to describe the patients feelings and meaning of pain Visual Analogue scale Let's the patient make a mark along a 10 cm horizontal line from no pain to worst pain imaginable Descriptor scale Lists words that describe different levels of pain intensity such as no pain, mild pain, moderate pain and severe pain

Thyroid Scan

Test requires an injection of radioactive isotope into the veins of the hand or elbow. Can be used in combination with the Radio Iodine Uptake Test using the same radioactive iodine to get an image of the thyroid gland. Disadvantage of this test is that it exposes an individual to a small amount of radiation and the individual can experience some neck discomfort.

VS in the ED: BP 185/100, T 98.4 F, HR 122, RR 14,

The ED nurse inserts a peripheral IV in her right hand, has the lab tech draw ordered labs and then Mrs. Henry is transferred to the Neuro ICU with a diagnosis of acute stroke.

Mr. Jones' case study cont.

The PACU nurse reports that the patient tolerated the surgery well, and his time in PACU was uneventful; he is ready for transfer to the Bariatric unit. Currently, the patient's vital signs are stable: T 99.30F, AR 112, BP 120/82, RR 8. Mr. Jones is drowsy but arousable. The patient has a hemovac drain, NGT to low intermittent suctioning (LIS), and indwelling catheter in place. The patient's wife is in the surgical waiting room and the PACU nurse will talk with her just before he transfers the patient out of PACU, and tell her to head up to her husband's room. An ABG, CMP and CBC were sent just prior to discharge from PACU.

Plan of Care,

The PCP performs an edrophonium chloride (Tensilon) test and orders the following additional tests: EMG, Head CT/MRI and PFT's.

How does thyrotoxicosis differ from myxedema crisis?

Thyrotoxicosis Is excess of thyroid hormones in the body by many causes such as hyperthyroidism and inflammation of the thyroid glands. Myxedema Is severe life-threatening complication of hypothyroidism that is caused by possible infection or the discontinuation of thyroid supplements.

Cardiogenic Shock

The clinical definition of cardiogenic shock is decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. Cardiogenic shock is the leading cause of death in acute myocardial infarction (MI), with mortality rates as high as 70-90% in the absence of aggressive, highly experienced technical care.

Mrs. B is transferred to the cardiac ICU for ongoing monitoring and management for a diagnosis of RVI. Because she now reports jaw pain and chest pain, a decision is made to send her for emergent PCI.

The lab calls back results: · WBC 10.1, Hgb 12.1, BUN 12, Creatinine 1.6, Troponin 1 and Troponin T elevated, Glucose 122, Na 136, K+ 3.3

Expected Outcome -

The patient will maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth. Absence of dyspnea. Priority care for a patient with myasthenia gravis.

Activity tolerance assessment,

The physical therapist meets with the patient and his wife and gets Mr. Jones up for his first walk in the hall. Important assessment: pain level: recommend to give pain meds before activity assess vital signs: monitor bp due to medications like pain meds may cause an unsafe drop in blood pressure and oxygen saturation levels assess levels of consciousness: Assess environmental safety: no clutter, easy to maneuver around and supports for the patient like assistive device

Recommendation

The practitioner confirms Marla has hyperthyroidism after reviewing her laboratory tests. What is Thyrotoxicosis? Thyrotoxicosis (hyperthyroidism) is excess of thyroid hormones in the body, causing a low level of thyroid stimulating hormones (TSH) in the bloodstream. This occurs because body senses there is an excess amount of circulating thyroid hormone.

Clinical Manifestations,

The primary feature of MG is fluctuating weakness of skeletal muscle. The muscles involved are those used for moving the eyes and eyelids, chewing, swallowing, speaking, and breathing. These muscles are generally the strongest in the morning and become exhausted with continued activity, so a period of rest usually restores strength. The eyelid muscles or extraocular muscles are involved in 90% of cases. Facial mobility and expression can be impaired, so the patient may have difficulty chewing and swallowing food. Speech is affected, and the voice often fades after a long conversation. The muscles of the trunk and limbs are less often affected. Of these, the proximal muscles of the neck, shoulder, and hip are more affected than the distal muscles.

Negative feedback loop

The production and release of thyroid hormones, T4 and T3, is controlled by a feedback loop system which involves the hypothalamus in the brain, the pituitary and thyroid glands. The hypothalamus secretes thyrotropin-releasing hormone which, in turn, stimulates the pituitary gland to produce thyroid stimulating hormone. Thyroid stimulating hormone (TSH) stimulates the production of the thyroid hormones, T4 and T3 by the thyroid gland. This hormone production system is regulated by a negative feedback loop so that when the levels of the thyroid hormones, T4 and T3 increase, they prevent the release of both thyrotropin-releasing hormone and TSH. So, negative feedback loop allows the body to maintain a constant level of thyroid hormones in the body.

If permanent, how would the resultant condition be managed?

This condition can be managed or treated with calcium and vitamin D for life. Treatment Options If Marla Becomes Pregnant The preferred treatment for pregnant women with hyperthyroidism is anti-thyroid medication. In the first trimester of pregnancy, the preferred drug to treat hyperthyroidism is propylthiouracil (PTU). Methimazole may cause birth defects if taken early during pregnancy. She may need to take methimazole in the first three months of pregnancy if she cannot tolerate PTU. After the first trimester, doctors recommend switching from PTU to methimazole, this is because in rare cases PTU can cause severe liver injury. And she should not receive treatment with radioactive iodine as this usually destroy the patient's thyroid gland to stop it from being overactive, and also can harm the unborn baby's thyroid.

Head CT/MRI,

This is done to help rule out other diagnoses. It is important to have a CT or MRI of the chest to makes sure a tumor of the thymus is not present.

Upon return from pacemaker insertion surgery, the nurse observes the following ECG on Mrs. B's monitor:

This last strip appears that Mrs. B has had a dual chamber AV pacemaker inserted. It's pacing the atrium and the ventricle hence why you see two spikes prior to every beat.

opioid risk tool

This tool should be administered to patients upon an initial visit prior to beginning opioid therapy for pain management. A score of 3 or lower indicates low risk for future opioid abuse, a score of 4 to 7indicates moderate risk for opioid abuse, and a score of 8 or higher indicates a high risk for opioid abuse

Embolic Stroke,

This type of stroke is also caused by a blood clot; however, the clot is formed somewhere else in the body. It then travels through the bloodstream to an artery in the brain and lodges there blocking blood flow.

Wound Healing cont.

Three stages of primary intention: initial granulation maturation and scar contraction For bariatric surgery: continually assessing the skin for an complications such as infections or dermatitis Frequent monitoring of drainage, condition of the incision and signs of infection like monitor vital signs such as fever Picture A is dehiscence and picture B is infection after surgery

TSH: levels below 0.5

Thyroid Stimulating Hormone (TSH) stimulates the thyroid gland to produce more hormones. It signals the thyroid gland to manufacture and secrete T3 and T4 thereby raising their blood levels.

What type of seizure was Janelle most likely experiencing?,

Tonic Clonic formerly grand mal (generalized seizure), Most common, occurs without warning, tonic phase lasts approximately 10-20 seconds, Patho of a generalized seizure develops when neuronal excitation from the epileptogenic focus spreads to the brainstem particularly the midbrain and reticular formation. Hallmark early systemic clinical changes during a generalized seizure include tachycardia, hypertension, hyperglycemia and hypoxemia.

Touch and massage

Touch can be as simple as holding the woman's hand, stroking her body and embracing her. Important to find out the woman's preference for touch and responses to touch Therapeutic touch (not even going to get into it) Head, hand, back and foot massage may reduce tension and enhance comfort May improve management of labor pain

Pathophysiology of Acute Pain

Transduction: the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (Nociceptors). Transmission: the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it. Perception: occurs in various areas of the brain, with influences from thought and emotional processes. Modulation: Occurs in spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli.

causes of acute and chronic pain

Trauma Surgery Cancer (tumor invasion, nerve compression, bone metastases, immobility) Arthritis Fibromyalgia Neuropathy Diagnostic or treatment procedures (injection, intubation, radiation)

What can trigger it? -

Unintended overdose of treatment drugs. Exposure to nerve agents. Post-surgical overdosing of cholinesterase inhibitors intended to reverse residual muscle paralysis.

How do we manage pain in children?

Use of pharmacologic interventions Non-pharmacologic measures Relaxation exercises Controlled breathing Distraction during painful procedures (Age-appropriate toys, electronic devices, or other items) Massage of the painful area Emotional support (Include family members in pain management) Most measures are usually non-invasive, although occasionally invasive procedures (use of injectable local anesthetics to prevent pain

Pharmacologic management

Used to alleviate pain in neonates associated with procedures Local anesthesia used for circumcision and chest tube insertion Topical anesthesia used for circumcision, lumbar puncture, venipuncture, and heelsticks

Diagnosis

Usually made based on clinical symptoms. Should be suspected in any infant with significant hypotonia Confirmed by blood test Methylation analysis: detects >99% of cases including PWS subtypes from deletion, uniparental disomy, or imprinting mutation (Preferred method) FISH (fluorescent in-situ hybridization) can detect PWS due to deletion but not by uniparental disomy or imprinting error

Pain during labor and birth

Visceral pain during the first stages of labor is due to stretching of cervical tissue, and distention of lower uterine segment Referred pain - pain originates in the uterus then radiates to the abdominal wall, lumbosacral area, iliac crests, gluteal area, thighs and lower back First stage of labor Discomfort only during contractions and is free of pain between contractions Sometimes especially if the fetus is in a posterior position, experience continuous contraction related low back pain even in the interval Second stage of labor Somatic pain - intense, sharp, burning and localized Due to distention and traction on the peritoneum and uterocervical supports during contractions Pressure against the bladder and rectum Stretching of perineal tissues and pelvic floor Lacerations of soft tissue Pain impulses are transmitted via pudendal nerve through S2 to S4 spinal nerve Third stage of labor Pain during and afterpains are uterine similar to first stage of labor Perception of Pain Pain threshold - person's perception of and behavioral responses to pain Meaning of pain and verbal and nonverbal expressions given to pain are apparently learned from interactions within the primary social group. Pain tolerance refers to the level of pain a laboring woman is willing to endure. hen this level is exceeded, she will seek measures to relieve the pain

Sources of pain

Visceral pain: large internal organs Dull, deep, squeezing or cramping Transmitted by ascending nerve fibers along with nerve fibers of ANS (autonomic nervous system) Present with autonomic responses such as vomiting, nausea, pallor and diaphoresis Somatic pain: Deep somatic pain Sources such as blood vessels, joints, tendons, muscle and bone Describe as aching or throbbing Cutaneous pain Skin surface and subcutaneous tissues Describe as superficial, sharp or burning Usually well localized and easy to pinpoint Can be accompany by nausea, sweating, tachycardia and hypertension caused by ANS response Referred pain Pain felt at a particular site but originate from another location Why? Both sites are innervated by the same spinal nerve and difficult or brain to differentiate the point of origin

Bariatric Unit Assessment,

Vital signs pain assessment PQRST Method P = Provocation/Palliation Q - Quality/Quantity R - Region/Radiation S - Severity Scale T - Timing infection risks Head to toe assessment cardiovascular: checking for normal heart sound and pulses present respiratory: checking for normal lung sounds neurological and muscular: AAOX3 and LOC, pupils - PERRLA (Pupil Equal and Responsive Reactive to Light and Accommodation), and motility and transferring abdominal: Bowel obstruction, and dumping syndrome, wounds for drainage, condition of incision and signs of infection, and monitor for patency and correct placement Skin: fluid status. Monitor I/O with the indwelling catheter

Interpretation of Results,

WBC 10.1- within normal limits 5.2-12.4. Hgb 12.1- within normal limits 12.0-16.0. BUN 12- within normal limits 9-23. Creatinine 1.6- high/elevated 0.5-1.1 mg/dL Troponin 1 and Troponin T elevated Glucose 122 high/elevated 74-106 mg/dl Na 136 within normal limits 132-146 mEq/L K+ 3.3 low 3.5-5.5 Hypokalemia attributes to the coronary issues the patient is facing which is representative in the elevated troponin levels

Application of heat and cold

Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Heat relieves muscle ischemia and increase blood flow to the area of discomfort. Cold application may be effective in increasing comfort when the woman feels warm. Relieves pain by reducing the muscle temperature and relieving muscle spasms

Patient Teaching: Care of the Circumcised Newborn at Home

Wash hands before touching the newly circumcised penis. Check for Bleeding. Check circumcision for bleeding with each diaper change. If bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure, notify primary health care provider.

S/S

Weight loss—despite increased appetite Anxiety, restlessness, tremors, irritability, difficulty sleeping (insomnia) Heat intolerance, sweating Chest pain, palpitations Shortness of breath, difficulty breathing Increased stool frequency (with or without diarrhea) Irregular menstrual periods Muscle weakness Difficulty controlling diabetes Goiter Prominent, bulging eyes Vision problems (such as double vision)

Severe vs mild TBI

What determines the severity of a TBI? Mild Traumatic Brain Injury: Concussion: brief change in mental status with axonal swelling. Moderate to Severe Brain Injury: Contusion: "bruising" Fractures: linear, comminuted, depressed, basilar Bleeds: epidural, subdural, intracerebral

Pain in Children: Management

What do we do? A treatment plan for pain management of a child is necessary before the pain can be controlled or alleviated. However, prior to implementing a plan of care, an appropriate pain assessment must be performed, which includes use of an acceptable pain assessment tool (Wong-Baker FACES Chart).

Upon arrival to the neurologic unit, Mrs. Henry is started on dopamine and nimodipine,

What is the classification and purpose of these drugs? How are they administered?

Pre-Op Teaching,

What pre-op teaching should have been discussed with Mr. Jones? Preoperative assessment to get a "snapshot" of the patient's lifestyle. Included are questions about medical, surgical, and psychological history, food intake and eating habits, activities of daily living, mobility, and activity tolerance. Evaluate Readiness to change: Review Pre-op medications & insure patient understanding about procedure explianed by physcian. → Include consult from dietician on necessary diet changes

Assessment

When performing patient interview, the patient was asked what encouraged him to come in? The patient stated, "I was out fishing a few weeks ago and noticed I couldn't hold into the pole as tightly as I needed to. Since then he noticed weakness in his legs, arms, and hands, but was putting in a new HVAC where he was doing a lot of bending." Patient mentions that his jaw feels "funny" lately, so he thought that he should get it checked out; also thought that he may have heartburn. BMI is 23, VS WNL, Skin warm and dry. Respiratory: clear to auscultation. AAOx3, with difficulty swallowing, patients states that it has been occurring. DTRs WNL except for plantar reflexes, +Babinski. Patient has resistance in lower and upper extremities, but not full resistance; and complains of arms and legs feeling "heavy" at times. No abnormalities in GU/GI

Prompt Questions for Pain Management

Where does it hurt? How bad does the pain hurt (use a measurement tool appropriate for your patient, such as 1 to 10 scale or Wong-Baker face scale)? How long does the pain last? Is it constant or does it come and go? How does the pain affect your ability to function? Can you describe the pain (Throbbing, sharp, radiating, etc)? What makes the pain worse? What makes the pain better? What do you normally use at home to treat your pain?

NCLEX QUESTION 2,

Which of the following is the priority nursing intervention when a child is unconscious after a fall? Establish adequate airway. Perform neurologic assessment. Monitor intracranial pressure. Determine whether a neck injury is present. ANS: A, Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishment of an adequate airway is always the first priority.

Childbirth preparation methods

Women are assisted to develop their birth philosophy and inner knowledge and then choose from a variety of skills to use for coping with the labor process. Methods developed from Birthing from Within, Birth works, Association of Labor Assistants, and Childbirth educators (ALACE), childbirth and postpartum professional association, (CAPPA) and hypnobirthing

Pain Scales for Children: Age 3 to 7

Wong- Baker FACES Scale Oucher Pain Scale (Use the picture scale) Children 7+ Oucher Pain Scale Visual Analog Scale

Other interventions,

Wound care for prevention of infections. Ted stockings or an air massager compression machine for prevention of DVT. Incentive spirometry to prevent pulmonary complication such as atelectasis and pneumonia. Cough using a pillow to splint the abdomen. Emphasize follow up cares to prevent complications. Educate the patient on body changes such as possibly reconstructive surgeries. Educate the patient on the importance of the diet plan and exercise. Assess the color and amount of urine. Report urine output less than 30 mL/hr for 2 consecutive hours: concentrated urine denotes fluid deficit. Assess the skin, nail beds and mucous membranes for pallor or cyanosis: Cool, pale skin may be secondary to a compensatory vasoconstrictive response to hypoxemia. as oxygenation and perfusion become impaired, peripheral tissues become cyanotic.

Box 30-1, Developmental Characteristics of Children's Responses to Pain

Young Infant: • Generalized body response of rigidity or thrashing, possibly with local reflex withdrawal of stimulated area. • Loud crying • Facial expression of pain (brows lowered and drawn together, eyes tightly closed, and mouth open and squarish). • No association demonstrated between approaching stimulus and subsequent pain Older Infant: • Localized body response with deliberate withdrawal of stimulated area • Loud crying • Facial expression of pain or anger • Physical resistance, especially pushing stimulus away after it is applied. Young Child: • Loud crying, screaming • Verbal expressions such as "Ow," "Ouch," "It hurts" • Thrashing of arms and legs • Attempts to push stimulus away before it is applied • Lack of cooperation; need for physical restraint • Requests termination of procedure • Clings to parent, nurse, or other significant person • Requests emotional support such as hugs or other forms of physical comfort • May become restless and irritable with continuing pain • Behaviors occurring in anticipation of actual painful procedure School-Age Child: • May see all behaviors of young child, especially during actual painful procedure, but less in anticipatory period • Stalling behavior such as, "Wait a minute" or "I'm not ready" • Muscular rigidity such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead. Adolescent: • Less vocal protest • Less motor activity • More verbal expressions such as, "It hurts" or "You're hurting me" • Increased muscle tension and body control

NCLEX Question #2: In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

a- Heart rate, blood pressure, and pulse rate may be normal while the client is experiencing pain.b- Opioid-based analgesics may have little if any effect on reducing the quality of chronic pain.c- The client may have adapted so successfully to the presence of chronic pain that measures for relief are unnecessary.d- The actual intensity of chronic pain is difficult to assess because the client may complain constantly. ANS: AAdaptation to the presence of chronic pain is physiologic. Thus, the usual alterations in physiologic parameters when acute pain is present do not accompany chronic pain.

NCLEX Question #1: The nurse caring for a client with suspected appendicitis knows that the pain associated with appendicitis is

a- cutaneous pain.b- visceral pain.c- superficial pain.d-somatic pain. ANS: BVisceral pain originates from body organs, or viscera, and often includes pain caused by acute appendicitis, cholecystitis, inflammation of the biliary and hepatic tract, gastroduodenal disease, cardiovascular disease, pleurisy, and renal and ureteral colic. Somatic pain is from ligaments, tendons, bones, blood vessels, and nerves. It is often poorly localized, may produce nausea, and may be associated with sweating and blood pressure changes. Cutaneous pain would arise from the skin structures. "Superficial" pain is not a defining designation.

NCLEX Questions, A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication?

a. 5% human albumin b. Furosemide (Lasix) IV c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef) Answer ANS: B The PAWP indicates that the patient's preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock

NCLEX Question #3 What information should be included in the dietary teaching for the patient following a Roux-en-Y gastric bypass?,

a. Avoid sugary foods and limit fluids to prevent dumping syndrome. b. Gradually increase the amount of food ingested to preoperative levels. c. Maintain a long-term liquid diet to prevent damage to the surgical site. d. Consume foods high in complex carbohydrates, protein, and fiber to add bulk to contents.

NCLEX Questions Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?,

a. Check temperature every 2 hours. b. Monitor breath sounds frequently. C. Maintain patient in supine position. d. Assess skin for flushing and itching. Answers: ANS: B Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock

NCLEX Questions, An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next?,

a. Increase the rate for the dopamine (Intropin) infusion. b. Decrease the rate for the nitroglycerin (Tridil) infusion. c. Increase the rate for the sodium nitroprusside (Nipride) infusion. d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion. Answer ANS: C Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

NCLEX Question #2, A 40-year-old severely obese female patient with type 2 diabetes wants to lose weight. After learning about the surgical procedures, she thinks a combination of restrictive and malabsorptive surgery would be best. Which procedure should the nurse teach her about?,

a. Lipectomy b. Roux-en-Y gastric bypass c. Adjustable gastric banding d. Vertical sleeve gastrectomy

NCLEX Question #1, A severely obese patient has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient,

a. may have severe diarrhea early in the postoperative period. b. will not be allowed to ambulate for 1 to 2 days postoperatively. c. will require nasogastric suction until the incision heals. d. may have only liquids orally, and in very limited amounts, during the early postoperative period.

NCLEX Question The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?

a.) Assess neurological status b.) Monitor pulse, respiration, and BP c.) initiate an intravenous access d.) Maintain adequate airway Answer: D.) The most important nursing action would be to maintain adequate airway. We have all been in nursing school for 4 semesters now, whenever it says "priority" in the question and "airway" in the answer, we all know what to do.

NCLEX Question The client diagnosed with a mild concussion is being discharged from the ED. Which discharge instruction should the nurse teach the client's significant other?

a.) Wake the client every 2 hours. b.) monitor for ICP d.). Observe frequently for hypervigilance e.) Offer the client food every 3-4 hours Answer: A.) Awakening the client every 2 hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety, which are all signs of post concussion syndrome and would warrant a return to the emergency department.

Thyrotoxic crisis

acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation. Considered a life-threatening emergency Clinical manifestations of thyrotoxic crisis • All the symptoms of hyperthyroidism are prominent and severe • Severe tachycardia, heart failure, shock, hyperthermia, restlessness, irritability, seizures, abdominal pain, vomiting, diarrhea, delirium and coma Treatment of thyrotoxic crisis • Reducing circulating thyroid hormone levels and the clinical manifestations with appropriate drug therapy • Supportive therapy is directed at managing respiratory distress, reducing fever, replacing fluids, and eliminating or managing the initiating stressors

If any part of the assessment indicate that the patient is becoming unstable: Provide immediate interventions for:

cardiopulmonary complications pulmonary clot be cautious with transferring the patient, airway must be maintained at 30 to 45 degree angle risk for re-sedation because the body stored anesthetics in adipose tissue. if this should happen, perform a modified jaw thrust maneuver or head tilt and keep the airway open also monitor how the patient's breathing. Obesity can cause rapid shallow breathing due to excess adipose tissue compressing the diaphragmatic, thoracic and abdominal structures. thrombus formation DVT anastomosis leaks breakdown between the anastomosis (connections between organs) and caused fluid to leak out patient will be in an egregious amount of pain. Not resolved with pain meds. electrolyte imbalance fluid deficit or excess

Goiter

enlarged thyroid gland. In a person with a goiter the thyroid cells are stimulated to grow, which may result in an overactive thyroid (hyperthyroidism) or an underactive thyroid (hypothyroidism). The most common cause of goiter worldwide is a lack of iodine in the diet Clinical manifestations of goiter • A visible swelling at the base of your neck that may be particularly obvious when you shave or put on makeup • A tight feeling in your throat • Coughing • Hoarseness • Difficulty swallowing • Difficulty breathing Treatment of goiter • With thyroid hormone may prevent further thyroid enlargement • Surgery is used to remove large goiters

Phenobarbital adverse effects,

hangover, delirium, depression drowsiness, excitation, lethargy, vertigo, respiratory depression, nausea vomiting constipation, phlebitis at iv site

Types of Shock

● Cardiogenic ● Hypovolemic ● Distributive ○ Septic ○ Anaphylactic ○ Neurogenic ● Combined

Typical S&S: The signs of increased ICP

include: ◦ Headache ◦ Nausea ◦ Vomiting ◦ Increased blood pressure ◦ Decreased mental abilities ◦ Confusion about time, and then location and people as the pressure worsens ◦ Double vision ◦ Pupils that don't respond to changes in light ◦ Shallow breathing ◦ Seizures ◦ Loss of consciousness ◦ Coma

Peripheral neuropathy (PN)

is symmetric damage to peripheral nerves (feet or hands) resulting in pain without stimulation of the nerves. This is a common neuropathic pain characterized by numbness and tingling, with interspersed shooting or lancinating pain that is not attributed to a specific nociceptive source.14 Diabetic neuropathy is a common complication of diabetes and may relate to demyelination of the larger peripheral nerves, with an increase in smaller myelinated nerves. Other etiologies may include ischemic damage to nerves or hyperglycemia, causing changes in nerve microenvironment.9 Patients experience burning pain in feet bilaterally, which is often worse at night.

A key feature

is that a typically innocuous stimulus (e.g., a light brush of a cotton ball or clothing) can create a severe, intense painful response. Other subjective data include burning pain often disproportionate to the degree of injury and joint pain during movement. Objective data include swelling, disappearance of skin wrinkles, cool skin temperature, discoloration, brittle nails, and finally atrophic changes (pale, dry, shiny skin and muscle atrophy). Treatment includes high doses of drugs (e.g., prednisone, amitriptyline, pregabalin, clonidine) to decrease symptoms and physical therapy to regain limb function.

Chemotherapy-induced PN (CIPN)

occurs after chemotherapy treatment for cancer. The risk increases with the number of agents used in the course of treatment, higher cumulative doses of neurotoxic agents, preexisting neuropathy from diabetes or other causes, and older age.12,14 A symptom is numbness or burning, shooting pain in a glove-and-stocking distribution. Note: With any cancer survivor, you must address new onset of pain promptly to rule out pathologic recurrence of the cancer because this is what survivors most fear.12

Complex Regional Pain Syndrome (CRPS)

or Reflexive Sympathetic Dystrophy (RSD)A key feature is that a typically innocuous stimulus (e.g., a light brush of a cotton ball or clothing) can create a severe, intense painful response. Other subjective data include burning pain often disproportionate to the degree of injury and joint pain during movement. Objective data include swelling, disappearance of skin wrinkles, cool skin temperature, discoloration, brittle nails, and finally atrophic changes (pale, dry, shiny skin and muscle atrophy). Treatment includes high doses of drugs (e.g., prednisone, amitriptyline, pregabalin, clonidine) to decrease symptoms and physical therapy to regain limb function.RSD/CRPS is a chronic progressive nerve condition, characterized by burning pain, swelling, stiffness, and discoloration of the affected extremity. It affects both men and women, usually around 40 to 60 years old, and occurs weeks to months after a nerve injury (e.g., carpal tunnel syndrome, broken leg, cerebral lesions). Pathophysiology involves a complex interaction of sensory, motor, and autonomic nerves and the immune system. The nerve injury may modify the usual pain pathway, causing a neuropathic "wind-up" or "short-circuit" mechanism.

Phenytoin adverse effects,

suicidal thoughts, ataxia, agitation, confusion, dizziness, drowsiness, dysarthria, dyskinesia, extrapyramidal syndrome, headache insomnia, weakness, hypotension, nausea, vomiting, constipation, steven-johnson syndrome

Patient with an acute anterolateral myocardial infarction

who developed cardiogenic shock. Coronary angiography images showed severe stenosis of the left anterior descending coronary artery, which was dilated by percutaneous transluminal coronary angioplasty.

Assessment for MG

• Assess fatigue (severity, what body part is affected) • Assess coping abilities and strategies and understanding the disorder • Respiratory rate, depth, oxygen saturation, ABGs, pulmonary function tests, and evidence of respiratory distress in patients with acute myasthenic crisis • Assess muscle strength of all face and limb muscles, swallowing speech (volume and clarity), and cough and gag reflexes

Nursing Assessment: Post seizure

• Assess for o Bitten tongue, soft tissue damage, cyanosis o Abnormal respiratory rate o Apnea (ictal) o Absent or abnormal breath sounds o Airway occlusion • Hypertension, tachy/bradycardia • Bowel/urinary incontinence, excessive salivation • Weakness, paralysis, ataxia (postictal)

Clinical manifestations of hypothyroidism

• Cardiovascular system - increased capillary fragility, decreased force of contractions, varied changes in blood pressure, cardiac hypertrophy, distant heart sounds, anemia, tendency to develop heart failure, angina, myocardial infarction • Respiratory system - dyspnea, decreased breathing capacity • Gastrointestinal system - decreased appetite, N/V, weight gain, constipation, distended abdomen, enlarged scaly tongue, celiac disease • Integumentary system - dry, thick, inelastic, cold skin, thick, brittle nails, dry, sparse, coarse hair, poor turgor of mucosa, generalized interstitial edema, puffy face, decreased sweating, pallor • Musculoskeletal system - fatigue, weakness, muscular aches and pains, slow movements, arthralgia • Nervous system - apathy, lethargy, fatigue, forgetfulness, slowed mental processes, hoarseness, slow, slurred speech, prolonged relaxation of DTR, stupor, coma, paresthesia, anxiety, depression • Reproductive system - prolonged menstrual periods or amenorrhea, decreased libido, infertility • Other - increased susceptibility to infection, increased sensitivity to opioids, barbiturates, anesthesia, intolerance to cold, decreased hearing, sleepiness, goiter

Hyperthyroidism Clinical manifestations of hyperthyroidism

• Cardiovascular system - systolic hypertension, increased force and rate of cardiac contractions, bounding, rapid pulse, increased cardiac output, cardiac hypertrophy, systolic murmurs, dysrhythmias, palpitations, atrial fibrillation, angina • Respiratory system - increased respiratory rate, dyspnea on mild exertion • Gastrointestinal system - increased appetite, thirst, weight loss, increased peristalsis, diarrhea, frequent defecation, increased bowel sounds, splenomegaly, heptomegaly • Integumentary system - warm, smooth, moist skin, thin, brittle nails, detached from nail bed (onycholysis), hair loss (may be patchy), clubbing of fingers (thyroid acropachy), palmar erythema, fine silky hair, premature graying, diaphoresis, vitiligo, pretibial myxedema (infiltrative dermopathy) • Musculoskeletal system - fatigue, muscle weakness, proximal muscle wasting, dependent edema, osteoporosis • Nervous system - difficulty focusing eyes, nervousness, fine tremor) of fingers and toes, insomnia, lability of mood, delirium, restlessness, personality changes of irritability, agitation, exhaustion, hyperactive DTRs, depression, fatigue, apathy, lack of ability to concentrate, stupor, coma • Reproductive system - menstrual irregularities, amenorrhea, decreased libido, impotence in men, gynecomastia in mean, decreased fertility • Other - intolerance to hear, elevated basal temperature, lid lag, stare, eyelid retraction, exophthalmos, goiter, rapid speech

Assessment for ALS

• Clinical manifestations - fatigue, progressive muscle weakness, cramps, twitching, and incoordination • Assess strength: progressive weakness, muscle atrophy (arms, trunk, legs), spasticity, brisk or overreactive muscle reflexes • Assess cranial nerves: muscle weakness, difficulty talking, difficulty swallowing, difficulty breathing, soft palate and upper esophageal weakness and weakness on the posterior tongue • Assess bulbar muscle: progressive difficulty in speaking, difficulty in swallowing, articulation and speech effects and compromised respiratory function

Priority assessments for thyroidectomy

• Complications include hypothyroidism, damage to or inadvertent removal of parathyroid glands causing hypoparathyroidism and hypocalcemia, hemorrhage, injury to the recurrent or superior laryngeal nerve, thyrotoxicosis, and infection • Recurrent laryngeal nerve damage leads to vocal cord paralysis. If both cords are paralyzed, spastic airway obstruction will occur, requiring an immediate tracheostomy • Airway obstruction after thyroid surgery is an emergency situation. Oxygen, suction equipment, and a tracheostomy tray should be readily available in the patient's room • Respirations may become difficult because of excess swelling on the neck tissues, hemorrhage and hematoma formation • Laryngeal strider (harsh, vibratory sound) may occur during inspiration and expiration as a result of edema of the laryngeal nerve. May also be related to tetany, which occurs if the parathyroid glands are removed or damaged during surgery, leading to hypocalcemia. To treat tetany, IV calcium salts should be available o Assess patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression o Place patient in semi-fowler's position and support the patient's head with pillows. o Monitor vitals and calcium levels. Complete the initial assessment by checking for signs of tetany secondary to hypoparathyroidism and by evaluating difficulty in speaking and hoarseness. o Monitor for Trousseau's sign (carpal spasm when bp cuffed is applied) and Chvostek's sign (twitching facial muscles when tapping anterior to the ear) Calcium - (8.6-10.2)

Bariatric Surgery Types of bariatric surgery

• Currently the ONLY successful, long-lasting option • Criteria o BMI ≥ 40 kg/m2 o ≥1 obesity-caused health condition • Problematic underlying histories or conditions o Depression o Eating disorder o Psychosis o Substance abuse • Restrictive o Adjustable gastric banding o Vertical sleeve gastrectomy • Malabsorptive o Biliopancreatic diversion o Biliopancreatic diversion with duodenal switch • Combination o Roux-en-Y gastric bypass Surgery to Reduce Excess Fatty Tissue • Performed for cosmetic purposes o Lipectomy o Liposuction • Many associated risks o Long anesthesia time o Poor wound healing • Obesity can recur

Nursing diagnoses for stroke

• Decreased intracranaial adaptive capacity • Risk for aspiration • Impaired physical mobility • Impaired verbal communication • Unilateral neglect • Impaired urinary elimination • Impaired swallowing • Situational low self-esteem

Treatment of hyperthyroidism

• Drug therapy - antithyroid drugs: methimazole (Tapazole), propythiouracil (PTU), Iodine (Lugol's solution, SSK), B-Adrenergic receptor blockers: prioranolol (Inderal), atenolol (Tenormin or metoprolol (Toprol) • Radiation therapy - radioactive iodine • Surgical therapy - subtotal thyroidectomy • Nutritional therapy - high-calorie, high protein diet, frequent meals

Clinical manifestations of hypocalcemia

• Easy fatigability, depression, anxiety, confusion, numbness and tingling in extremities and region around mouth, hyperreflexia, muscle cramps, Chvostek's sign, Trousseau's sign, laryngeal spasm, tetany, seizures Treatment of hypocalcemia • Treat underlying cause • When severe, IV preparations of calcium (e.g., calcium gluconate, calcium chloride) are given • Mild, involves a diet high in calcium-rich foods along with vitamin D supplementation. Oral calcium supplements, such as calcium carbonate, can be used when patients are unable to consume enough dietary calcium • Measures to promote CO2 retention, such as breathing into a paper bag or sedating the patient, can control muscle spasm and other symptoms of tetany until calcium levels can be corrected • Adequately treat pain and anxiety because hyperventilation-induced respiratory alkalosis can precipitate hypocalcemic symptoms • Closely observe any patient who has had thyroid or neck surgery in the immediate preop period for manifestations of hypocalcemia because of proximity of the surgery to the parathyroid glands Clinical manifestations of hypercalcemia • Lethargy, weakness, depressed reflexes, decreased memory, confusion, personality changes, psychosis, anorexia, N/V, bone pain, fractures, polyuria, dehydration, nephrolithiasis, stupor, coma Treatment of hypercalcemic • Promoting urinary excretion of calcium by administering loop diuretic (e.g., furosemide (Lasix)) and hydrating the patient with isotonic saline infusion • Patient must drink 3000-4000 mL of fluid daily to promote the renal excretion of calcium and decrease possibility of kidney stone formation • Bisphosphonates (e.g., pamidronate (Acredia), zoledronic acid (Zometa)) are most effective agents in treating hypercalcemia cause by malignancy.

Nursing interventions for ALS

• Facilitating communication • Reducing risk of aspiration • Facilitating early identification of respiratory insufficiency • Decreasing pain secondary to muscle weakness • Decreasing risk of injury related to falls • Providing diversional activities such as reading and companionship

How BP managed for stroke* Assessments for stroke

• Focus on cardiac and respiratory status and neurologic assessment. Typical findings include: • Altered LOC • Weakness, numbness, or paralysis of portion of body • Speech or visual disturbances • Severe headache • Increased or decreased heart rate • Respiratory distress • Unequal pupils • Hypertension • Facial drooping on affected side • Difficulty swallowing • Seizures • Bladder or bowel incontinence • N/V • Vertigo

Clinical manifestations for ICP

• Headache • Nausea • Vomiting • Increased blood pressure • Decreased mental abilities • Confusion about time, and then location and people as the pressure worsens • Double vision • Pupils that don't respond to changes in light • Shallow breathing • Seizures • Loss of consciousness • Coma

Hemorrhagic stroke (headache) (poor prognosis0

• Hemorrhage - Occurs when a blood vessel inside the brain ruptures and leaks blood into surrounding brain tissue. Bleeding in between meningeal layers. o Usually sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding. o Manifestations include neurologic deficits, headache, N/V, decreased LOC, and hypertension. o Putaminal and internal capsule bleeding manifestations include weakness on one side, slurred speech, and deviation of eyes o Progression of symptoms include hemiplegia, fixed and dilated pupils, abnormal body posturing and coma o Thalamic hemorrhage results in hemiplegia with more sensory than motor loss o Blood into the subthalamic areas of the brain leads to problems with vision and eye movement o Celebrallar hemorrhages are characterized by severe headaches, vomiting, loss of ability to walk, dysphagia, dysarthria, and eye movement disturbance o Hemorrhage in the pons is the most serious because of basic life functions (respirations) Characterized by hemiplegia leading to complete paralysis, coma, abnormal body posturing, fixed pupils, hyperthermia, and death • Subarachnoid - Occur when an aneurysm (a blood-filled pouch that balloons out from an artery) on or near the surface of the brain ruptures and bleeds into the space between the brain and the skull o Worst headache of the one's life is a characteristic symptom of ruptured aneurysm o Loss of consciousness o Other manifestations include focal neurologic deficits, N/V, seizures and stiff neck

Side effects of epidural and spinal anesthesia

• Hypotension • Local anesthetic toxicity • Lightheadedness • Dizziness • Tinnitus (ringing in the ears) • Metallic taste • Numbness of the tongue and mouth • Bizarre behavior • Slurred speech • Convulsions • Loss of consciousness • High or total spinal anesthesia • Fever • Urinary retention • Pruritus (itching) • Limited movement • Longer second-stage labor • Increased use of oxytocin • Increased likelihood of forceps- or vacuum-assisted birth

Review mannitol Osmotic Diuretics: Mannitol (Osmitrol)

• Increase osmotic pressure of the glomerular filtrate, inhibiting reabsorption of water and electrolytes. • Used to decrease intracranial pressure in clients with an increased ICP from head trauma. • Side effects: • Fluid/electrolyte imbalances • Pulmonary edema from the rapid shifts of fluids • Nausea and vomiting • Headache • Tachycardia from rapid fluid loss • Hyponatremia and dehydration. Interventions: • Monitor • Vital signs • Weight • Urine output • Electrolytes • Assess lungs for crackles indicating pulmonary edema • Change client's position slowly to prevent orthostatic hypotension • *Monitor for crystallization in the vial of mannitol before administering the medication; if crystals are noted, do not administer the medication from that vial. Review ventriculostomy - a neurosurgical procedure that involves creating a hole ("stomy") within a cerebral ventricle for drainage. It is done by surgically penetrating the skull, dura mater, and brain such that the ventricle of the brain is accessed.

Nursing interventions for TBI

• Initial - ensure patent airway, stabilize cervical spine, administer O2 via non-rebreather mask, establish IV access with two large bore catheters to infuse normal saline or lactated Ringer's solution, intubate if GCS score <8, control external bleeding with sterile pressure dressing, remove patient's clothing • Ongoing monitoring - maintain patient warmth using blankets, warm IV fluids, overhead warming lights, warm humidified O2, monitor vital signs, LOC, O2 saturation, cardiac rhythm, GCS score, pupil size and reactivity, anticipate need for intubation if gag reflex is impaired or absent, assume neck injury with head injury, assess for rhinorrhea, otorrhea, scalp wounds, administer fluids cautiously to prevent fluid overload and increasing ICP

What activities can you delegate to an LPN/LVN

• LPN - administer scheduled anticoagulant and antiplatelet medications • UAP - obtain VS and report to RN, measure and record urine output, assist with positioning patient and turning patient at least ever 2 hr, perform passive and active ROM exercises, place equipment needed for seizure precautions in patient room

Nursing intervention for MG

• Maintaining adequate ventilation, continuing drug therapy, and watching side effects of therapy • Be able to distinguish cholinergic from mysthenic crisis because the causes and treatment of the two conditions differ greatly • Focus care on neurologic deficits and their impact on daily living • Teach patients about a balanced diet that can be easily chewed and swallowed - semi liquid foods may be easier to eat than solids or liquids • Schedule doses of drugs so that peak action is reached at mealtime ma make eating less difficult • Arrange diversional activities that require little physical effort and match the patient's interests. • Help the patient plan activities of daily living to avoid fatigue • Teaching should focus on the importance of following the medical regimen, complications of the disease, potential adverse reactions to specific drugs, and complications of therapy (crisis condition) and what to do about them

Management,

● Correct hypotension: ○ Fluid resuscitation to correct hypovolemia, ○ Inotropic or Vasopressor support: ■ Dobutamine ■ Milrinone ■ Norepinephrine ■ Dopamine ■ Epinephrine ● Oxygenation ● If MI - ASA, Heparin, and Revascularization ● If arrhythmia - correct arrhythmia ● If extracardiac abnormality - reverse or treat cause.

Risk factors for stroke

• Modifiable Risk Factors: o High blood pressure o Cigarette smoking o Excessive alcohol intake o Use of illegal drugs: cocaine o Heart disease o Obesity o Poor diet o Lack of physical exercise o Serum cholesterol o Some birth control pills • Nonmodifiable risk factors: o Age: o Risk doubles every decade after 55 yo o Ethnicity: o Highest in African Americans o Family history of stroke

Care for seizure Collaborative Care

• Most seizures do not require emergency medical care because they are self-limiting and rarely cause bodily injury. • Immediate medical care if o Status epilepticus occurs o Significant bodily harm occurs o The event is a first-time seizure • Seizure disorders are primarily treated with antiseizure drugs. o The goal of therapy is preventing seizures with minimum toxic side effects from drugs. o Medications control seizures in about 70% of patients. • Drugs act by stabilizing nerve cell membranes and preventing spread of the epileptic discharge. o About 1/3 of patients require a combination regimen for adequate control. o Therapeutic drug ranges are guides. o Serum drugs levels can be helpful. • Surgical intervention to remove the epileptic focus or prevent spread of epileptic activity in brain • Benefits of surgery o Cessation of seizures o Reduction in frequency of seizures • Anterior temporal lobe resection is the most common surgical intervention. o About 70% of patients are essentially seizure free after this procedure. • Not all types of epilepsy benefit from surgery. Alternative Interventions • Ketogenic diet has been effective in controlling seizures in some. o High-fat, low carbohydrate diet o Ketones pass into the brain and replace glucose as an energy source. • Biofeedback to control seizures teaches patient to maintain a certain brain wave frequency.

Clinical manifestations of ischemic vs. hemorrhagic stroke

• Neuro manifestations do not significantly differ between the two because destruction of neural tissue is the basis for neurologic dysfunction caused by both types of stroke • Clinical manifestations are related to the location of the stroke • Stroke can affect many body functions, including o Motor activity o Bladder and bowel elimination o Intellectual function o Spatial-perceptual alterations Homonymous hemianopsia- blindness occurs in the same half of the visual fields of both eyes Agnosia - inability to recognize an object by sight, touch, or hearing Apraxia - inability to carry out learned sequential movements on command o Personality o Affect o Sensation o Swallowing o Communication Aphasia: reception (loss of comprehension), expressive (inability to produce language), global (total inability to communicate) Dysphais - inability to communicate (aphasia also used interchangeably) Dysarthria - disturbance in the muscular control of speech • These functions are directly related to the artery involved and area of the brain is supplies

Nursing Implementation: Acute Intervention

• Observe, treat, and document seizure. o Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor. o Do not restrain patient or place any objects in their mouth. o May require positioning, suctioning, or oxygen after seizure.

Planning

• Overall goals are that patient will o Be free from injury during seizure. o Have optimal mental and physical functioning while taking antiseizure medications. o Have satisfactory psychosocial functioning.

Etiology of Prader Willie

• PWS is caused by the loss of a function of genes in a particular region of Chromosome 15. One copy of the chromosome is typically inherited from each parent. Some genes are turned on (active) only on the copy that is inherited from a person's father (the paternal copy). This parent-specific gene activation is caused by a phenomenon called genomic imprinting. o About 70% of PWS cases occur when a segment of the paternal chromosome 15 is deleted in each cell. o About 25% of cases a person has two copies of chromosome 15 inherited from the mother o In very rare cases, PWS can be caused by a translocation or mutation on chromosome 15 o Characteristic features of PWS result from the loss of function of several genes on Chromosome 15 that control appetite o Flaw in hypothalamus that controls feelings of hunger and satiety.

Stroke Clinical manifestations for right sided stroke

• Paralyzed left side: hemiplegia • Left-sided neglect • Spatial-perceptual deficits • Tends to deny or minimize problems • Rapid performance, short attention span • Impulsive, safety problems • Impaired judgement • Impaired time concepts

Clinical manifestations for left sided stroke

• Paralyzed right-side: hemiplegia • Impaited speech/language discrimination • Slow performance, cautious • Are of deficits: depression, anxiety • Impaired comprehension related to language and math

Nursing Implementation: Ambulatory and Home Care

• Prevention of recurring seizures is the major goal in treatment. o Instruct on importance of adherence to medication, not to adjust dose without physician. Medi-alert bracelets o Keep regular appointments. o Teach family members emergency management.

Nursing Implementation: Health Promotion

• Promote safety measures. o Wear helmet if risk for head injury. o General health habits (diet, exercise) o Assist to identify events or situations precipitating seizures and avoid if possible. o Instruct to avoid, fatigue, loss of sleep, and excessive alcohol.

Nursing diagnoses for TBI

• Risk for ineffective cerebral tissue perfusion related to interruption of CBF associated with cerebral hemorrhage, hematoma, and 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

Features of dobutamine are as follows:

● Dobutamine may be preferable to dopamine if the systolic blood pressure is, higher than 80 mm Hg, ● Compared with dopamine, dobutamine has less effect on myocardial oxygen demand, ● Tachycardia from dobutamine may preclude its use in some patients

Diet instructions for bariatric surgery

• Set realistic goals • Include basic food group options • Distinguish low-calorie from very low-calorie • Prevent nutritional deficiency • Be cautious with fad diets • Stages o Immediate post op diet - Liquid diet - Stage 1(about 30 mL every 2 hours when awake). It can include: broth, unsweetened juice, decaffeinated tea or coffee, milk (skim or 1 percent), strained cream soup, sugar-free gelatin or popsicles, skim or low fat milk o After a few days, Stage 2 Pureed Diet - stained or mashed up food. Must be made into a smooth paste can include: lean ground meats, beans, fish, eggs, soft fruits and cooked vegetables, cottage cheese. Can Blend solid foods with a liquid, such as: water, skim milk, juice with no sugar added, broth o 3rd stage - After a few weeks on pureed diet, can add soft food to his diet which include: ground or finely diced meats, canned or soft fresh fruit (without seeds or skin), cooked vegetables (without skin) o 4th stage - Around eight weeks, can gradually return to solid foods and see what they can tolerate. Must avoid food such as nuts and seeds, popcorn, dried fruits, carbonated beverages, Granola, Stringy or fibrous vegetables, such as celery, broccoli, corn or cabbage, tough meats or meats with gristle, fried foods, and breads o 5th stage - around 3 to 4 months, can return to a normal healthy diet with a focus on high proteins and low in carbs, and fats. Will be having about six smaller meals with a recommendation to take vitamin and mineral supplements.

Myasthenia Gravis Drugs for MG

• Tensilon test in a patient with MG reveals improved muscle contractility after IV injection of the anticholinesterase agent edrophonium chloride (Tensilon). (Anticholinesterase blocks the enzyme acetylcholinesterase) • This test also aides in the diagnosis of cholinergic crisis (secondary to overdose of anticholinerase inhibition. Tensilon will not improve muscle weakness but may increase it • Atropine, a cholinergic antagonist, should be readily available to counteract effects of Tensilon when it is used diagnostically • Anticholinesterase drugs are aimed at enhancing function of the neuromuscular junction. Pyridostigmine (Mestinon) is the most successful drug • Corticosteriods (Prednisone) are used to suppress the immune response • Drugs such as azathioprine (Imuran), mycophenolate (CellCept), and cyclosporine (Sandimmune) may be used for immunesuppression

Ischemic stroke (TIA) - ask time of onset!

• Thrombotic - the process of clot formation (thrombosis) results in a narrowing of the lumen, which blocks the passage of the blood through an artery. o Most common cause of stroke and usually preceded by a TIA. • Embolic - an embolus is a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and bloods the flow of blood. o Second most common cause and clinical symptoms occur suddenly.

Treatment of hypothyroidism

• Thyroid hormone replacement therapy (e.g., levothyroxine) • Monitor thyroid hormone levels and adjust dosage • Nutritional therapy to promote weight loss • Patient and caregiver teacher

Factors influencing the expression of genetic disorders (Prader Willie)

• What are factors that can increase expression of gene defects? • Chemicals (alcohol, tobacco, drugs, hormones), maternal/paternal age, health, altitude

● Barbiturates

○ Used for tonic-clonic seizures, acute episodes of seizures caused by status epilepticus. ○ Side effects: ■ Sedation, ataxia, dizziness ■ Mood changes ■ Hypotension ■ Respiratory depression

Additional orders include:

● 1 L .45 NSS +20 KCl at 100 mL/hr, ● Furosemide 40 mg IVP Mrs. B is stable upon return from her emergent PCI. However, that night, the nurse reassesses her and finds: ● VS: HR 32, RR 28, BP 74/? by Doppler ● Decreased mentation ● Lungs clear ● Increased jugular venous pressures

Why would the physician want a Right Sided ECG?,

● A complete set of right-sided leads is obtained by placing leads V1-6 in a mirror-image position on the right side of the chest (see diagram, below). ● It may be simpler to leave V1 and V2 in their usual positions and just transfer leads V3-6 to the right side of the chest (i.e. V3R to V6R). ● The most useful lead is V4R, which is obtained by placing the V4 electrode in the 5th right intercostal space in the midclavicular line. ● ST elevation in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI.

Single-chamber vs. Dual-chamber pacemaker,

● A pacemaker consists of a small, battery-powered generator and one or more leads. ● In a single-chamber system, one lead is used, most commonly pacing the right ventricle. ● Dual-chamber pacemakers have two leads, placed in the right atrium and right ventricle.

Managing RVI,

● A sign that your patient is experiencing a right ventricular myocardial infarction is a rapid and profound decrease in blood pressure after the administration of nitroglycerin. ● If this occurs, one should immediately suspect right ventricular infarct, and treat as such. ● However, the right ventricle is less susceptible to infarcts because it functions at lower pressure and volume and has thinner walls, which require less oxygen to function. ● In addition, the right ventricle is perfused during both systole and diastole, giving it a larger supply of blood and enabling it to extract oxygen during periods of increased stress.

Temporary vs. Permanent dual-chamber pacemaker,

● A temporary pacemaker to treat a bradydysrhythmia is used when the condition is temporary and when a permanent pacemaker is either not necessary or is not immediately available. ● Complications are common and include infection, local trauma, pneumothorax, arrhythmias and cardiac perforation. ● Dual-chamber pacemaker - With this device, 2 pacing leads are implanted (1 in the right ventricle and 1 in the right atrium); this is the most common type of implanted pacemaker How would you determine if a temporary pacemaker was working if you did not observe any pacemaker spikes? Checking the stimulation and sensitivity thresholds should be done at least daily if the pacemaker is in demand mode.

Diagnosis/ Laboratory studies

● Biochemical profile ● CBC ● Cardiac enzymes (eg, creatine kinase and CK-MB, troponins, myoglobin, LDH) ● Arterial blood gases ● Lactate ● Brain natriuretic peptide

Features of dopamine are as follows:

● Dopamine is the drug of choice to improve cardiac contractility in patients with hypotension, ● Dopamine may increase myocardial oxygen demand ● Dopamine is usually initiated at a rate of 5-10 mcg/kg/min IV ● The infusion rate is adjusted according to the blood pressure and other hemodynamic parameters ● Often, patients may require doses as high as 20 mcg/kg/min

Should the nurse honor Brian's request to not discuss previous injuries with his parents?

● Due to the fact that Brian is a minor and this information is vital to his treatment, as the nurse, this should be explained to Brian. He needs to educated about his condition in terms he understands as well as explaining to him the importance of notifying his parents to any type of injury to the head. ● By keeping this information from his parents in fear of not being able to play sports, he now will have to sit out from all sports until he's recovered.

Diagnosis/ Imaging studies

● Echocardiography should be performed early to establish the cause of cardiogenic shock ● Chest radiographic findings are useful for excluding other causes of shock or chest pain (eg, aortic dissection, tension pneumothorax, pneumomediastinum) ● Ultrasonography can be used to guide fluid management ● Coronary angiography is urgently indicated in patients with myocardial ischemia or MI who also develop cardiogenic shock

Cardiogenic shock is an emergency requiring the following:

● Fluid resuscitation to correct hypovolemia and hypotension, unless pulmonary edema is present, ● Prompt initiation of pharmacologic therapy to maintain blood pressure and cardiac output, ● Admission to an intensive care setting (eg, cardiac catheterization suite or ICU or critical care transport to a tertiary care center), ● Early and definitive restoration of coronary blood flow; at present, this represents standard therapy for patients with cardiogenic shock due to myocardial ischemia ● Correction of electrolyte and acid-base abnormalities (eg, hypokalemia, hypomagnesemia, acidosis)

S&S of MTBI/Concussion

● Headache ● Dizziness ● Nausea ● Blurred vision ● Mental changes ● Irritability ● Syncope ● Unconsciousness- usually brief ● Sleeping problems, insomnia ● Anxiety ● Depressive symptoms ● Anger, aggression ● Inattention, difficulty concentrating ● Fatigue

Osmotic Diuretics: Mannitol (Osmitrol)

● Increase osmotic pressure of the glomerular filtrate, inhibiting reabsorption of water and electrolytes. ● Used to decrease intracranial pressure in clients with an increased ICP from head trauma. ● Side effects: ○ Fluid/electrolyte imbalances ○ Pulmonary edema from the rapid shifts of fluids ○ Nausea and vomiting ○ Headache ○ Tachycardia from rapid fluid loss ○ Hyponatremia and dehydration. ● Interventions: ○ Monitor ■ vital signs ■ Weight ■ urine output ■ Electrolytes ○ Assess lungs for crackles indicating pulmonary edema ○ Change client's position slowly to prevent orthostatic hypotension ○ *Monitor for crystallization in the vial of mannitol before administering the medication; if crystals are noted, do not administer the medication from that vial.

S&S of Increased ICP in Infants

● Increased ICP in infants can be the result of child abuse, especially shaken baby syndrome (a condition in which a small child has been roughly handled to the point of brain injury) ● Symptoms of increased ICP in infants include those for adults, as well as some additional signs unique to babies less than 12 months old. ● Because the bony plates that form the skull are softer in babies than in older children and adults, they may spread apart in an infant with increased ICP. ● This is called separated sutures of the skull. Increased ICP can also cause the fontanel (the soft spot on the top of a baby's head) to bulge outward.

Discharge instructions for Brian and his Parents?

● Most mild traumatic brain injuries require no treatment other than rest and OTC pain relievers to treat headache ● Brian would need to be closely monitored at home for persistent, worsening, or new symptoms ● May have follow up appointments

Brian is ordered acetaminophen for pain. Why is Brian not ordered Ibuprofen or a narcotic analgesic?

● NSAIDS can have an effect on the clotting process; in someone with a MTBI, they may increase the risk of bleeding in the damaged vessels of the brain. ● Narcotics can cause respiratory depression and decreased level of consciousness.

Managing LVI,

● Nearly 70% of all AMIs involve some or part of the left ventricle. ● This happens, in part, because the left ventricle is larger, has the most muscle mass, requires more oxygen to function, and therefore is most sensitive to oxygen supply and demand. ● The left ventricle also shows more resistance to subendocardial perfusion than the right ventricle, and it receives most of its blood supply only during diastole. ● Depending on which area of myocardium is affected, AMIs of the left ventricle are classified as anterior, lateral, posterior, or inferior wall infarcts (or a combination of those areas).

"Spike" and "Capture",

● Pacemaker rhythms are identified by the presence of a conspicuous vertical mark known as a "spike". ● If the spike precedes the P wave, it is referred to as an Atrial Pacemaker rhythm. ● If the spike precedes the ventricular depolarization, it is referred to as a Ventricular Pacemaker rhythm. ● If there is a spike prior to the P wave and the ventricular depolarization, it is referred to as an AV (atrioventricular sequential) Pacemaker rhythm. ● Capture refers to when the device delivers an electrical impulse of sufficient strength to result in depolarization. The waveform immediately follows the pacing spike. ● Loss or Failure to Capture may occur for a number of reasons, but commonly occurs when the generator is unable to deliver a sufficient amount of energy to cause depolarization. This may be due to the age of the batteries. This will result in a spike with no corresponding depolarization or a delayed depolarization of unusual morphology. Capture - notice the waveform immediately following the pacing spike. Loss of Capture - notice the 4th and 7th complex morphology is different and the waveform does not immediately follow the pacing spike.

How is it Managed?

● The most urgent goal of treatment is to reduce the pressure inside your skull. The next goal is to address any underlying conditions. ● Effective treatments to reduce pressure include draining the fluid through a shunt, or small hole, in the skull or via the spinal cord. ● The medications mannitol and hypertonic saline can also lower pressure. ○ They work by removing fluids from your body. Because anxiety can make increased ICP worse by raising your blood pressure, you may receive a sedative as well.

Mrs. B does well and is scheduled for discharge home. Discharge Teaching,

● Patient instructed to restrict vigorous activity or lifting heavy objects for a week or two. The incision site is usually completely healed after two or three weeks. ● During this initial period you should watch for signs of bleeding or infection, such as swelling, increased redness or worsening pain, and let your doctor know if any of these signs occur. You will need to have your pacemaker checked periodically to see whether it is functioning normally and to make sure its battery has plenty of energy. ● Usually, these pacemaker checks are done by telephone every month or two (using a special device your doctor will give you for telephone follow-up), and by visits to your doctor's office once or twice a year. ● The patient was instructed in implantable cardioverter defibrillator the moods and feelings when the device delivers a countershock, a blow, thump, or kick in the chest. ● The patient was advised that someone touching the patient will not feel the shock or will feel only a tingle. ● The patient was taught not to wear close-fitting, restrictive clothing like belts and girdles. The patient was reviewed to evade strong magnets and magnetic fields as a radio or TV transmitting towers, spark plugs or running motor like lawn mower or car, handheld airport detectors, microwave ovens, hair dryers. ● Prior to travel, depending on the pacer and the type of scanner check with Doctor when traveling and airports

Desired Outcome,

● Patient will be free of dysrhythmias with an adequate cardiac output to perfuse all body organs. ● Patient will be free of dysrhythmias and be able to maintain cardiac output within normal limits. ● Patient will be able to recall accurately all instructions given. ● Patient will be able to adhere to all activity restrictions. ● Permanent pacemaker function will be without complications, with no lead dislodgement or competitive rhythms noted.

Desired Outcomes,

● Patient will be free of life-threatening complications that may be associated with pacemaker insertion.

Desired Outcomes,

● Patient will have healed wound sites without signs or symptoms of infection. ● Patient will have well-healed incision with no signs or symptoms of infection. ● Patient will be able to recall instructions given. ● Patient will be able to demonstrate appropriate wound care prior to discharge.

Pharmacologic therapy:

● Patients with MI or acute coronary syndrome are given aspirin and heparin ● Inotropic and/or vasopressor drug therapy may be necessary in patients with inadequate tissue perfusion and adequate intravascular volume, so as to maintain mean arterial pressure (MAP) of 60 or 65 mm Hg ● Diuretics are used to decrease plasma volume and peripheral edema

Diagnosis/Electrocardiography

● Perform electrocardiography immediately to help diagnose MI and/or myocardial ischemia ● A normal ECG, however, does not rule out the possibility of acute MI

Invasive procedures include the following:

● Placement of a central line may facilitate volume resuscitation, provide vascular access for multiple infusions, and allow invasive monitoring of central venous pressure ● An arterial line may be placed to provide continuous blood pressure monitoring ● An intra-aortic balloon pump may be placed as a bridge to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)

Right Sided ECG,

● Right ventricular infarction complicates up to 40% of inferior STEMIs. Isolated RV infarction is extremely uncommon. ● Patients with RV infarction are very preload sensitive (due to poor RV contractility) and can develop severe hypotension in response to nitrates or other preload-reducing agents. ● Hypotension in right ventricular infarction is treated with fluid loading, and nitrates are contraindicated.

Cardiogenic Shock

● Shock caused as a result of cardiac pump failure ○ Results in a decrease in CO ○ SVR is increased in an effort to compensate to maintain organ perfusion ○ Causes: ■ Myocardial Infarction ■ Arrhythmias (Atrial fibrillation, ventricular tachycardias, bradycardias, etc) ■ Mechanical abnormalities (valvular defects) ■ Extracardiac abnormalities (PE, pulm HTN, tension pneumothorax)

Cardiogenic Shock What is shock?

● Shock is the "physiologic state characterized by significant reduction of systemic tissue perfusion, resulting in decreased tissue oxygen delivery." -Tissue perfusion is dependent on SVR (systemic vascular resistance) and CO (cardiac output) -Imbalance between oxygen delivery and oxygen consumption which leads to cell death, end organ damage, multi-system organ failure, and death

Physical Exam Findings on physical examination include the following:

● Skin is usually ashen or cyanotic and cool; extremities are mottled ● Peripheral pulses are rapid and faint and may be rregular if arrhythmias are present ● Jugular venous distention and crackles in the lungs are usually (but not always) present; peripheral edema also may be present ● Heart sounds are usually distant, and third and fourth heart sounds may be present ● The pulse pressure may be low, and patients are usually tachycardic ● Patients show signs of hypoperfusion, such as altered mental status and decreased urine Output ● Ultimately, patients develop systemic hypotension (ie, systolic blood pressure below 90 mm Hg or a decrease in mean blood pressure by 30 mm Hg)

Dangers of Increased ICP

● The brain is confined in the rigid skull ● Increased ICP obstructs cerebral flow ● Destroys brain cells and displaces tissues ○ Normal ICP- 5-15 mm Hg ○ Sustained pressure >20 mm Hg requires treatment ● Cerebral flow decreases; which can cause altered mental state, stroke ● Cerebral perfusion pressure decreases ● Cerebral ischemia ● Cerebral edema ● Coma ● Brain death

Chronic Traumatic Encephalopathy

● The gradual degeneration in brain function due to repeated head injuries ● Occurs once symptoms of concussion have faded, months to years later and new symptoms occur. ● Symptoms include: concentration and memory problems, episodes of disorientation, confusion dizziness, and headache. ● As if the concussion symptoms are returning without a new head injury ● As it progresses the pt becomes more aggressive and psychotic

Diagnosis/Invasive hemodynamic monitoring

● The hemodynamic measurements of cardiogenic shock are a pulmonary capillary wedge pressure (PCWP) greater than 15 mm Hg and a cardiac index less than 2.2 L/min/m 2 ● The presence of large V waves on the PCWP tracing suggests severe mitral regurgitation ● A step-up in oxygen saturation between the right atrium and the right ventricle is diagnostic of ventricular septal rupture ● High right-sided filling pressures in the absence of an elevated PCWP, when accompanied by ECG criteria, indicate right ventricular infarction

Diagnostic tests- CT scan & Skull X-ray

● There is no single test to definitively confirm dx of TBI● H&P, S&S, and additional tests are used. ● CT scan: most commonly used ○ Fast and widely available ○ Highly effective at detecting bleeding, and edema of the brain ● Skull X-ray will be able to detect skull fractures ○ Simple linear, depressed, or basilar fractures

Medications: Anticonvulsant Barbiturates: Phenobarbital (Luminal)

● Used to depress abnormal neuronal discharges and prevent the spread of seizures to adjacent neurons. ● Interventions ○ Initiate seizure precautions ■ Make sure room has suction equipment available at the bedside ■ Make sure the room has safety precautions ○ Monitor urinary output ○ Monitor for S/S of medication toxicity (CNS depression, ataxia, nausea/vomiting, drowsiness, dizziness, restlessness, visual disturbances.

Less Common Treatments for Increased ICP

● removing part of the skull ● taking medicines to induce coma ● deliberately chilling the body, or induced hypothermic "Mechanism of Injury" of Concussion

Assessment -

Difficulty breathing or speaking, fever, cold, headaches, feeling tired during the daytime, weak cough with increased secretions such as mucus or saliva, trouble swallowing or chewing, weight loss.

What is Dronabinol?,

Dronabinol is a man-made form of cannabis (also known as marijuana). Despite availability of many different kinds of seizure drugs, 30% of people with epilepsy continue to have seizures. Safety and side effects of antiseizure drugs has improved, but side effects affect the quality of life. Patients need new treatments that control seizures and have fewer side effects. This treatment gap has led patients and families to seek alternative treatments. Cannabis based treatment has been in social media and in response many states have legalized cannabis for treatment of epilepsy in children and adults. The pharmacologic and biochemical features of cannabinoids make them candidates for anti-seizure medications. Dronabinol has a pure isomer of THC which is the main isomer in cannabis.

Benazepril, 40 mg OD

Drug Classification: Ace Inhibitor, Purpose: use to treat high blood pressure, Adverse Reactions: Headache, weakness, dizziness, somnolence, postural dizziness, *Inform patient that this drug may cause them to develop a persistent non-productive cough

Amlodipine, 7.5 mg OD,

Drug Classification: Calcium Channel Blocker, Purpose: used to treat chest pain (angina), also used to treat high blood pressure, Adverse Reactions: Headache, edema, rash, fatigue, dizziness

Hydrochlorothiazide (?) mg OD,

Drug Classification: Diuretic, Purpose: helps prevent your body from absorbing too much salt, also used to treat high blood pressure, Adverse Reactions: Eye pain, vision problems, dry mouth, nausea, vomiting, dizziness, lightheadedness, *give in the morning or early evening to avoid nocturia, *monitor serum electrolyte levels, BUN, and serum creatinine levels

Nitroprusside,

Drug Classification: Hypertensive Emergency Agents, Purpose: Immediate reduction of blood pressure of patients in hypertensive crises, Adverse Reactions: Dyspnea, hypotension, palpitations, dizziness, headache, diaphoresis, flushing, rash, abdominal pain, nausea, rapid/shallow breathing, fatigue, nausea, blurred vision, and cold, clammy skin. *Continuously monitor blood pressure

Recommendations,

The PCP suspects that Karen has MG and refers her to a neurologist. The neurologist orders a CT of the chest to evaluate the thymus and prescribes the following medications - Pyridostigmine, Azathioprine, IV immunoglobulin G

Mechanical ventilation

-If respiration becomes difficult or if the patient stops breathing then such a patient will require mechanical ventilation support via endotracheal intubation as a support to help the breathing until the crisis resolves on its own. The damage in the respiratory system due to cholinergic crisis unfortunately still has no therapy or pharmacologic solution.

Thrombotic Stroke,

A blood clot (thrombus) forms inside of the brain's arteries. The clot blocks blood flow to a part of the brain causing brain cells in that area to stop functioning and die quickly.The blood clot that triggers a thrombotic stroke usually forms inside an artery that already has been narrowed by atherosclerosis. This is a condition in which fatty deposits (plaques) build up inside blood vessels.

NCLEX QUESTION 3,

A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is which of the following? "Epilepsy is easily treated." "Very few children have actual epilepsy." "The seizure may or may not mean that your child has epilepsy." "Your child has had only one convulsion; it probably won't happen again." ANS: C Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a chronic seizure disorder with recurrent and unprovoked seizures.

Lumbar Puncture:

A lumbar puncture can detect any blood in the fluid around the brain and spinal cord, which may be present in the case of a subarachnoid hemorrhage. The procedure should be postponed until 12 hours after the initial onset of symptoms, to give the red blood cells enough time to break down to produce bilirubin - the actual substance for which the lumbar puncture checks. So in Mr. Watson's case he would not receive a lumbar puncture.

NCLEX Question # 2,

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because: A. the patient has probably experienced an asymptomatic lacunar stroke, B. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours, C. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off, D. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease. Answer: D: Rationale: A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

Considering that Mr. Watson had a left-sided stroke, what are specific complications that can persist based on this type of stroke damage which can impact patient safety?,

A stroke in the left hemisphere of the brain can cause right-sided paralysis of the body which would place Mr. Watson at an increased risk for falls. Considering that the nitroprusside also could cause hypotension, this makes the fall risk all the more serious. Mr. Watson may also have memory issues due to the stroke which places him at risk for injuries at home, for example, leaving the stove on. Mr. Watson's verbal and written language may be affected as well as his reasoning which could possibly lead Mr. Watson to make decisions that are unsafe due to his inability to understand why he should avoid these actions.

Postictal state,

Appears to relax, may remain semiconscious and difficult to arouse, may awaken in a few minutes, poor coordination, mild impairment of fine motor movements, may have visual and speech difficulties, may vomit or complain of severe headache, when left alone usually sleeps for several hours, on awakening is fully conscious and usually feels tired and complains of sore muscles and headache no recollection of entire event

Etiology,

Acute, Febrile episodes, Intracranial infection, Intracranial hemorrhage, Tumor, Cerebral Edema, Anozia, Toxin, Drugs, Metabolic alterations, Chronic Epilepsy, Hypoglycemic states, Uremia, Allergy, Cardiovascular dysfunction, Migraine

Tacrolimus -

Advise patient to check with provider before taking other drugs during therapy. Instruct patient to report adverse reactions promptly. Advise patient taking extended-release capsules that if a dose is missed, the dose may be taken up to 14 hours after the scheduled time. Beyond the 14-hour time frame, patient should wait until the usual scheduled time to take the next regular daily dose.

Stroke Risk Factors,

African Americans: African-Americans have a much higher risk of death from a stroke than Caucasians do. This is partly because African Americans have higher risks of high blood pressure, diabetes and obesity. Patients Age: The chance of having a stroke approximately doubles for each decade of life after age 55. While stroke is common among the elderly, a lot of people under 65 also have strokes. Family History: Your stroke risk may be greater if a parent, grandparent, sister or brother has had a stroke. Some strokes may be symptoms of genetic disorders like CADASIL (Cerebral Autosomal Dominant Arteriopathy with Sub-cortical Infarcts and Leukoencephalopathy), which is caused by a gene mutation that leads to damage of blood vessel walls in the brain, blocking blood flow. Most individuals with CADASIL have a family history of the disorder — each child of a CADASIL parent has a 50% chance of inheriting the disease. Gender (women): Each year, women have more strokes than men, and stroke kills more women than men. Use of birth control pills, pregnancy, history of preeclampsia/eclampsia or gestational diabetes, oral contraceptive use, and smoking, and post-menopausal hormone therapy may pose special stroke risks for women. Be sure to discuss your specific risks with your doctor. Prior Stroke, Heart Attack and/or TIA: The risk of stroke for someone who has already had one is many times that of a person who has not. Transient ischemic attacks (TIAs) are "warning strokes" that produce stroke-like symptoms but no lasting damage. TIAs are strong predictors of stroke. A person who's had one or more TIAs is almost 10 times more likely to have a stroke than someone of the same age and sex who hasn't. Recognizing and treating TIAs can reduce your risk of a major stroke. TIA should be considered a medical emergency and followed up immediately with a healthcare professional. If you've had a heart attack, you're at higher risk of having a stroke, too.

Recommendation,

After two more months during which Janelle had almost daily seizures, she was re-admitted to the hospital for additional diagnostics. Janelle underwent a 24-hour continuous EEG which confirmed she has frequent seizures. Janelle's parents are concerned because Janelle is missing school and her playtime with friends is restricted because of her seizures. At this time, it is decided Janelle will try to be managed with meds and a ketogenic diet.

Anticholinesterase Drugs,

Anticholinesterase drugs are aimed at enhancing function of the neuromuscular junction. These drugs blocks the enzyme (Acetylcholinesterase) that breaks down ACh, thereby prolonging the action of ACh and facilitating transmission of impulses at the neuromuscular junction.

Medicines:

Anticholinesterase drugs: This medicine helps improve energy and strength. Immunosuppressants: This medicine is used to slow down your immune system and slow the progression of myasthenia gravis. Immune globulins: This is given as a shot or an IV infusion to help your immune system. Each infusion can take 2 to 5 hours. IV fluids: These may be given to prevent your blood pressure from becoming too low. IV fluids may also help replace any lost fluids and electrolytes (salts) from your body. Plasma exchange: This is a procedure that removes plasma from your blood and replaces it with plasma from a donor.

Nursing Diagnosis #3,

Anxiety parent related to child having life-threatening and incapacitation seizure activity, Expected outcomes: Parent will cope with child's condition and receive adequate support, Nursing intervention ---Rationale, Allow parent to remain with child during seizure--- decrease fear of unknown and allow parent to see measures taken to protect child, Instruct parent on proper intervention---- promote parent participation and foster sense of control over situation, Provide information regarding nature of seizure therapeutic intervention ad lifestyle modifications--- to promote knowledge of condition parental intervention and sense of control

Cholinergic Crisis,

Cholinergic crisis - Is an over-stimulation at a neuromuscular junction due to an excess of acetylcholine resulting to inactivity or the decrease of the AChE enzyme, which usually breaks down acetylcholine. This crisis is seen in individuals who suffer from MG with an inconsistent weakening of the medications and uses a high dose of anticholinesterase drugs. When cholinergic crisis takes place, the muscles can no longer react to the inflow of acetylcholine, so the symptoms usually follow.

Treatment for Cholinergic Crisis

Cholinergic crisis is a medical emergency and treatment involves the use of: Atropine - Atropine will reverse the muscarinic side effects including bradycardia but will have no effect on the nicotinic side effects of paralysis and respiratory arrest. So atropine will not improve the muscle strength and ability to breathe in someone with cholinergic crisis.

Edrophonium Chloride (Tensilon),

Classification - Cholinergic muscle stimulant, Mode of action - Edrophonium works by prolonging the action acetylcholine, which is found naturally in the body. It does this by inhibiting the action of the enzyme acetylcholinesterase. Admin Route - IV, IM injection, Adverse effects - muscle twitches that are visible under the skin, seizures, slurred speech, trouble breathing, trouble speaking, unusual tiredness, irregular heartbeat.

Pyridostigmine (Mestinon),

Classification - Cholinesterase inhibitor, Mode of action - It inhibits acetylcholinesterase in the synaptic cleft by competing with acetylcholine for attachment to acetylcholinesterase, thus slowing down the hydrolysis of acetylcholine, and thereby increases efficiency of cholinergic transmission in the neuromuscular junction and prolong the effects of acetylcholine. Admin Route - Orally (syrup & tablets), Injection (IM) or IV (given slowly). Adverse effects- nausea, vomiting, abdominal cramps, increased peristalsis, increased salivation, diaphoresis, increased bronchial secretion, muscle cramps, pupil constriction (miosis), and muscle weakness.

Neostigmine (Prostigmin),

Classification - Cholinesterase inhibitor, Mode of action - It works by improving the transmission of nerve impulses in muscles so that the muscles can work better. Admin Route - IM, SC or IV (given slowly) injection. Adverse effects—abdominal cramps, diarrhea, difficulty speaking, vision problems, dizziness, muscle twitching , difficulty breathing, fast or slow heart rate and extreme muscle weakness.

Teaching Needs for (Anticholinesterase drugs)

Edrophonium chloride, Neostigmine, Pyridostigmine Edrophonium chloride - Patient should be informed that adverse effects of drug will be transient because of its short duration of effect (30 mins). Neostigmine - Instruct patient to take medication exactly as directed. Do not skip or double up on missed doses. Taking the dose late may result in myasthenic crisis. Taking the dose early may result in cholinergic crisis. Patients with MG must continue this regimen as lifelong therapy. Instruct patient with myasthenia gravis to space activities to avoid fatigue. Advise patient to carry identification describing disease and medication regimen at all times. Pyridostigmine - The importance of taking drug exactly as prescribed, on time, and in evenly spaced doses should be emphasized. Extended-release tablets should be taken at same time each day, at least 6 hours apart. Patient should be advised not to crush or chew extended-release tablets. Explain that patient may have to take drug for life. Advise patient to wear or carry medical identification that identifies his/her myasthenia gravis.

What are the symptoms? -

Excessive salivation, Failure of the respiratory system due to the insufficient gas exchange, Flaccid paralysis wherein the muscle tone is decreased by paralysis or enfeeblement that might be caused by a disease or trauma. Too much sweating. Bronchial secretions together with miosis

Discharge Teaching Plan,

Explain tonic clonic seizures to parents. Inform parents if having a seizure place on their side to prevent aspiration, airway occlusion. Review with parents the child's medication and give instructions and inform them of doctors info. Advise DO NOT stop giving your child seizure medicines without talking with your child's doctor. Advise DO NOT stop giving your child seizure medicines just because the seizures have stopped. Go over safety in the home and outside the home. For example, bed in lowest position with a separate mattress on the floor. Child should shower instead of bathe. Child should carry or wear medical bracelet. To explain info to Janelle I would use photos, explain things slowly, ask questions and have her ask as many questions as needed. Put pads on sharp corners of furniture. Place a screen in front of the fireplace. Use nonslip flooring or cushioned floor covers. DO NOT use freestanding heaters. Avoid letting a child with epilepsy sleep on the top bunk. Replace all glass doors and any windows near the ground with either safety glass or plastic. Plastic cups should be used instead of glassware. The use of knives and scissors should be supervised. Supervise your child in the kitchen. Safe activities include jogging, aerobics, moderate cross-country skiing, dancing, tennis, golf, hiking, and bowling. Games and playing in gym class or on the playground are generally OK. Supervise your child when swimming. To prevent head injury, your child should wear a helmet during bike riding, skateboarding, and similar activities. Children should have someone to help them climb on a jungle gym or perform gymnastics. Ask your child's doctor about your child participating in contact sports.

Stroke Signs and Symptoms,

F.A.S.T: F- Face, Facial drooping. Ask the person to smile, and see if one side is drooping. The smile may be uneven. A- Arm, Arm weakness. Ask the person to raise both arms. Is there weakness or numbness on one side? One arm drifting downward is a sign of one-sided arm weakness. S- Speech, Speech Difficulty. People having a stroke may slur their speech or have trouble speaking at all. Speech may be incomprehensible. T- Time, Time to call 911. If a person shows any of the symptoms above, even if the symptoms went away, call 911 and get the person to the hospital immediately.

Is the ordered dose of phenytoin safe and therapeutic?,

First we convert to kilograms the patients weight, 2.2lb/1kg=49lb/x , 2.2x/2.2=49lbs/2.2, x=22.2kg, 22.2lb x 7.5mg/kg/day=167mg (would be lower range), 22.9lb x 9 mg/kg/day= 200 mg (would be higher range), Patient should be getting medication within 167-200 mg, The patient is prescribed 70mg BID which is 140 mg a day so this is not a proper dose. The minimum dose is 167 mg

Differentiate generalized and focal seizures.

Focal (Partial)- seizures which have a local onset and involve a relatively small location in the brain. Types: Simple partial seizures with motor signs, Simple partial seizures with sensory signs and Complex partial seizures. Generalized Seizures-involve both hemispheres of the brain and are without local onset. Types: tonic colonic, Absence, Atonic and akientc seizures also known as drop attack, and Infantile spasms

Management,

Home: Many of the same rules apply. The child should have rails on the bed that are padded and parents should do all that nurses do. Also child should shower vs bath the child should not swim alone the child should wear a helmet with activities. The child should carry or wear medical bracelet. The family, teachers, caregivers must understand the importance of drug therapy. A child with chronic seizures does not need to be sent home from school after a seizure. Emergency: During seizure, Remain calm, Time seizure if child is standing or seated ease down to the floor. Place pillow or folded blanket under child's head, loosen restrictive clothing, remove eyeglasses, clear areas of any hazards or hard objects, allow seizure to end without interference, if vomiting occurs turn child to one side, DO Not attempt to restrain child or use force, DO Not Put anything in child's mouth. After: Time postictal period, Check breathing check position of head and tongue, Reposition head, If child is not breathing give rescue breaths, Keep child on side, Remain with child, No food or drink, Call ems when necessary, Check for injuries ** inside mouth tongue lips cheeks can be bitten. When Janelle first experienced a seizure, she was emergently admitted to the PICU where both phenytoin and phenobarbital were prescribed.

How would you promote safety in someone actively experiencing a seizure?,

Hospital: Important nursing care includes safety, accurate documentation of events. The child must be protected from injury. Side rails raised, side rails and other hard surfaces padded. It is impossible to halt a seizure and a nurse should never attempt to it is important for the nurse to remain calm and make accurate ssessments. The nurse must stay with the child and prevent them from sustaining any harm. The child should be in isolation close doors or curtain. If the nurse can reach the child in time the child should be placed to the floor including child in wheel chair. During a tonic-clonic seizure the child should be placed on their side to prevent aspiration and airway occlusion. Suctioning of the oral cavity may be necessary. Do not forcefully restrain the child or place solid object between the teeth.

Other therapies recommended are,

Immunosuppressants: Prednisone, Cyclosporine, Mycophenolate mofetil, Tacrolimus, Thymectomy and Plasmapheresis

Nursing Diagnoses #3,

Impaired physical mobility related to hemiparesis as evidenced by poor muscles tone on the right side due to left sided stroke.

Nursing Diagnoses #2,

Impaired verbal communication related to loss of facial or oral muscles tone control.

Planning/Outcomes -

Improvement in breathing pattern at the end of hospital stay. Patient's compliance with medication use such as Anticholinesterase drugs.

Signs/Symptoms,

In more than 50% of people who develop MG, their first signs and symptoms involve eye problems, such as: Ptosis - Drooping of one or both eyelids, Diplopia - Double vision, which may be horizontal or vertical and improves when one eye is closed In about 15% of people with MG, the first symptoms involve face and throat muscles, which can cause: Altered speaking, Difficulty swallowing, Problems chewing, Limited facial expressions. Neck and Limb muscles - MG usually affects arms more often than legs. However, if it affects the legs, you may waddle when you walk. If the neck is weak, it may be hard to hold up one's head. Increased fatigue.

Diagnosis -

Ineffective breathing pattern r/t neuromuscular weakness of the respiratory muscles and throat. Risk for lung failure resulting from severe breathing problem.

Electromyography (EMG),

Is a test that measures the electrical activity of muscles when at rest and when being used. It is a procedure used to assess the health of muscles and the nerve cells that control them (motor neurons). It is used to help detect neuromuscular abnormalities.

Assessment,

Janelle was discharged home after 4 days; she had no other seizures while in the hospital. However, three weeks after being home, Janelle again began experiencing seizures and was readmitted to the hospital. At this time, Janelle is diagnosed with epilepsy. Janelle is ordered 70 mg phenytoin BID; she weighs 49 pounds. Literature states "4-7 years: Usual range, 7.5-9 mg/kg/day IV/PO divided two to three times daily."

Background,

Karen has not seen her PCP for 3 years Her last physical exam did not reveal any health problems and Karen considers herself "healthy". Karen has been stressed at work and tires easily. She is also planning to be married in 4 months. At first Karen thought her "double vision" was due to the stress of work, planning a wedding and the late hours spent reading in preparation for work the next day.

Case Study Situation,

Karen, age 28, has recently been experiencing blurry or "double" vision. She also notices that her upper eyelid droops by the end of the day. She makes an appointment to see her optometrist for an eye exam. The optometrist notes the right eye ptosis and also notes that Karen's voice seems to get softer as she speaks. The optometrist tells Karen to make an appointment with her primary care practitioner because the optometrist is concerned about the ptosis and voice changes.

Pediatric Seizures Seizure Disorders,

Most common cause of pediatric neurological disorders. Seizures are caused by excessive and disorderly neuronal discharges in the brain. Manifestation of seizures depends on the region of the brain in which they originate and may include unconsciousness or altered conscious; involuntary movements and changes in perception behaviors sensations and posture. Seizures are a symptoms of underlying disease process. Causes may be infectious, neurologic, metabolic, traumatic or related to ingestion of toxins. Epilepsy is a condition characterized by two or more unprovoked seizures and can be caused by a variety of pathologic process in the brain

Mr. Watson's PMH,

Mr. Watson has HTN; he was first diagnosed at age 38y. His wife tells the ED nurse that her husband is a bank VP and was hoping to take early retirement when he turned 62; she is tearful and clearly distressed with his current situation. She tells the nurse that she believes her husband always took his medication, however she adds that she knows he doesn't follow his low-sodium diet very well when he's not home. Mrs. Watson also adds that she knows work has been stressful for him for the past few months. Upon further discussions, Mrs. Watson tells the nurse that she recalls that a few weeks ago her husband appeared to "just stare" for a few and didn't respond when she spoke to him, however, this event only lasted a few minutes and she thought maybe he was actually sleeping with his eyes open.

Ischemic Stroke,

Mr. Watson is most likely experiencing Ischemic stroke. This type of stroke occurs as a result of an obstruction of a blood vessel in the brain. There are two types of Ischemic Stroke: Thrombotic and Embolic

After 24 hours on Nitroprusside,

Mr. Watson's BP approaches acceptable range and his nitroprusside is discontinued. The next day Mr. Watson is transferred to the progressive care unit and then discharged to inpatient rehab the following day to provide ongoing speech and physical therapy. The nurse reviews the discharge plan with Mr. and Mrs. Watson.

Stroke Situation,

Mr. Watson, age 61, is an African-American male who has a history of HTN. Today at breakfast his wife noticed his speech appeared slurred and he appeared to have trouble holding his fork; Mrs. Watson drove her husband to the emergency department. In the ED, Mr. Watson's right side became weaker and he developed expressive aphasia. Mr. Watson denies having a headache. VS in the ED: BP 194/102, T 98.40 F, HR 122, RR 14. The ED nurse inserts a peripheral IV in his right hand, has the lab tech draw ordered labs and then Mr. Watson is transferred to the acute neurologic unit with a diagnosis of acute left brain stroke.

Myasthenia Gravis (MG) Some facts...,

Myasthenia Gravis (MG) is an autoimmune disease of the neuromuscular junction characterized by the fluctuating weakness of certain skeletal muscle groups. MG affects the voluntary muscles of the body, especially those that control the eyes, mouth, throat and limbs. The disease can strike anyone at any age, but is more frequently seen in young women (age 20 and 30) and men aged 50 and older. The prevalence rate is about 20 per 100,000 and currently, about 60,000 people have MG in the United States. It is estimated to affect more than 700,000 people worldwide. A myasthenia gravis crisis can involve difficulty in swallowing or breathing. MG has no cure, but early detection and prompt medical management can help people live longer, more functional lives.

Pathophysiology,

Myasthenia Gravis (MG) is caused by an autoimmune process in which antibodies attack acetylcholine (Ach) receptors, resulting in a decreased number of ACh receptor (ACh R) sites at the neuromuscular junction. This prevents ACh molecules from attaching and stimulating muscle contraction. These antibodies act by blocking the binding of ACh to ACh R, and this increases the degradation rate of ACh R. A nerve cell, stimulated by a nerve impulse would release acetylcholine, which crosses the neuromuscular junction and binds to receptors on the muscle cell, and then triggers a muscular contraction in a normal situation. In MG, the antibodies bind to the receptors, preventing acetylcholine from binding to them and thus preventing the muscle from responding to the nerve signal.

Myasthenic Crisis,

Myasthenic crisis - A myasthenic crisis is a severe form of myasthenia gravis. The major complications of MG result from muscle weakness in areas that affect swallowing and breathing. It is a life-threatening condition that happens if the muscles you use for breathing become very weak. It can cause severe breathing problems and lead to lung failure. This respiratory failure may require intubation and mechanical ventilation.

Cholinergic crisis is also sub-divided into:

Nicotinic crisis - The muscle weakens and twitches involuntarily, dysphagia or the difficulty of swallowing, and cramping. Muscarinic crisis - Vision becomes blurry, pain in the abdomen can be felt, vomiting, diarrhea, nausea, discharge and secretion of tears, and too much secretion of the bronchial passages.

Nitroprusside,

Nitroprusside is a vasodilator. It works by relaxing the muscles in the blood vessels to help them dilate. This drug lowers blood pressure and allows blood to flow more easily through veins and arteries. It is used to treat life threatening hypertension and can also be used to treat heart failure. Nitroprusside is a short term drug that is administered intravenously. Nitroprusside is usually given for as long as needed until your body responds to the medication. The patient's breathing, blood pressure, oxygen levels, and other vital signs will be watched closely while receiving nitroprusside. Blood and urine may also need to be tested during treatment.

Hypertensive Emergency,

Occur when blood pressure levels exceed 180 systolic OR 120 diastolic. Blood pressure MUST be lowered SLOWLY. The consequences of uncontrolled blood pressure in this range can be severe and include: Stroke, Loss of consciousness, Memory loss, Heart attack, Damage to the eyes and kidneys, Loss of kidney function, Aortic dissection, Angina (unstable chest pain), Pulmonary edema (fluid backup in the lungs), Eclampsia, If you get a blood pressure reading of 180 or higher on top or 110 or higher on the bottom, AND are experiencing signs of possible organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision, difficulty speaking, do not wait to see if your pressure comes down on its own. Call 9-1-1!

What complications might occur during Tensilon test?,

Patient may experience side effects such as, nausea, abdominal discomfort, dizziness, blurred vision, sweating, fainting, breathing difficulties, and rapid frequent blinking of the eyelids. More serious complications are - respiratory failure and abnormal heart rhythms. Emergency resuscitation equipment should be available in such cases.

Mycophenolate mofetil -

Patient should not open or crush capsules nor to cut, crush, or chew extended-release tablets, but to swallow them whole on an empty stomach 1 hour before or 2 hours after meal. Stress the importance of following treatment as prescribed. Inform patient of the importance of follow-up visits and ongoing laboratory tests during therapy.

How do these two drugs differ in duration of action?,

Phenytoin action- Po onset 2-24 hr peak 1.5-3 hr duration 6-12hr .... Iv peak rapid duration 12-24 hrs ***one week onset without loading dose. Phenobarbital- Po onset 30-60 min peak unknown duration >6 hours Iv onset 5 minutes peak 30 minutes duration 4-6 hours

Diagnostics,

Physical Exam: Onset of Signs & Symptoms, Vital Signs, PMH, Family History. Blood Tests: Chemistry Panel, Complete Blood Count, & PTT/PT-INR. Brain Imaging: CT Scan and MRI * Imaging allows us to see the area of the brain affected by the stroke, as well as to confirm the type of stroke (ischemic or hemorrhagic). Carotid Ultrasound. CT Angiogram: * Catheter must be inserted through a blood vessel in the groin and threaded up to the blood vessels of the neck, where dye is injected to highlight any areas of blockage. Heart Testing: Echocardiogram * The heart or the aorta is the source of the blood clot that led to the stroke. Atrial fibrillation is a high-risk heart rhythm condition for blood clot formation and ischemic stroke. Patients are put on a continuous cardiac monitor to look for atrial fibrillation and/or other heart rhythm problems for the first day or two in the hospital. Electrocardiogram (ECG): * Many people with ischemic strokes also have coronary artery disease, there may be a lack of blood flow (called "ischemia") in the heart during the stroke. The ECG will help the clinician to diagnose and treat any heart problems as quickly as possible.

Teaching Needs (Immunosuppressants)

Prednisone, Azathioprine, Cyclosporine, Mycophenolatae mofetil, Tacrolimus. Prednisone - Patient should not stop drug abruptly or without prescriber's consent. Drug should be taken with food or milk. Teach patient signs and symptoms of early adrenal insufficiency such as fatigue, muscle weakness etc. Advise patient receiving long-term therapy to have periodic eye examinations. Advise patient to report to provider any sudden weight gain or swelling. Instruct patient to avoid exposure to infections and to contact provider if exposure occurs. Azathioprine - Patient should report to provider mild infections such as colds, fever, sore throat etc. Warn patient that some hair thinning is possible. Advise patient to report unusual bleeding or bruising. Advise patient to use soft toothbrush and perform oral care cautiously. Cyclosporine - Encourage patient to take drug at same time each day and to be consistent with relation to meals. Instruct patient not to take drug with grapefruit juice. Explain to patient the importance of frequent laboratory monitoring while receiving therapy. Advise patient to see dentist regularly because drug can cause gum disease. Warn patient to wear protection in the sun and to avoid excessive sun exposure.

What is Stevens - Johnson syndrome and why is this syndrome a concern for this patient?,

Rare disorder of skin and mucous membranes often begins with flu like symptoms and is followed by purple red blistery rash this is medical emergency it is a reaction to medication like phenytoin

Nursing Diagnosis #2,

Risk for aspiration and ineffective breathing pattern related to impaired motor activity LOC and loss of airway protection, Expected outcomes: Child's airway will remain patent child will have effective ventilation, Nursing intervention----rationale, Place child in side lying position----prevent aspiration and choking, Remain with patient---- protect airway, Administer oxygen when necessary—to prevent hypoxia

Nursing Diagnosis #1,

Risk for injury related to CNS dysfunction and inability to control self, Expected outcomes, Child will not experience physical injury as a result of seizure activity, Nursing interventions---rationale, Administer AEDs ----- to prevent seizure activity, Teach family and child the purpose of AEDs ---- to promote understanding of condition, Initiate seizure precautions (pad side rails, set up suction and oxygen)---prevent physical harm

Case study,

Situation & Background: Janelle, age 5y had her first seizures just after turning 4 years old. Her mother described her first seizure pattern as "suddenly she fell to the floor and had jerky-type movements of her arms and legs. She didn't respond when I called her name. I called 911 and they came and she stayed in the hospital for four days. She slept the whole way into the hospital and most of that first day."

What is the purpose of ordering the Tensilon Test?,

The edrophonium (Tensilon) test is a first-line test for diagnosis of MG. IV injection of edrophonium chloride (Tensilon) may result in a sudden, although temporary, improvement in muscle strength. Tensilon, an anticholinesterase inhibitor injection, prevents the breaking down of acetylcholine (ACh), which then helps stimulate the muscles. A person tests positive for MG if the muscles get stronger after being injected with Tensilon. It is also used to differentiate between myasthenia gravis and cholinergic crisis, so that doctors can select the proper treatment.

What can trigger it?,

The following may trigger or increase your risk for a myasthenic crisis:, Fevers, coughs, colds, and lung infections, such as pneumonia, A tumor in the thymus, Aspiration pneumonitis caused by breathing in stomach acid, Thyroid disease, Drug overdose/Inadequate drugs, Stress from trauma, surgery, or emotional upset, Some contrast dyes used in imaging tests, such as CT scan or MRI

NCLEX Question # 3,

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of: A. furosemide (Lasix), B. lovastatin (Mevacor), C. daily low dose aspirin. D. nimodipine (Nimotop), Answer: C: Rationale:The administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

What is a ketogenic diet?,

The ketogenic diet is a high-fat, adequate-protein, low-carbohydrate diet that in medicine is used primarily to treat difficult-to-control (refractory) epilepsy in children. The diet forces the body to burn fats rather than carbohydrates.

What could have occurred in the situation Mrs. Watson described wherein her husband didn't respond or a brief period of time?,

The symptoms that Mrs. Watson described are indicative of Transient Ischemic Attack (TIA), also known as a "mini-stroke". This is a brief interruption of blood flow to the brain that can mimic stroke symptoms but resolves itself by dissolving the clot within a few minutes and does not usually leave any lasting effects. This type of event should be taken seriously and as a warning to seek medical attention in order to avoid the occurrence of an actual stroke.

NCLEX Question # 4,

The priority intervention in the emergency department for the patient with a stroke is: a. intravenous fluid replacement, b. administration of osmotic diuretics to reduce cerebral edema, c. initiation of hypothermia to decrease the oxygen needs of the brain, d. maintenance of respiratory function with a patent airway and oxygen administration. Answer: D: Rationale: The first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

Phenytoin,

Treatment/ prevention of tonic-clonic seizures and complex partial seizures, Action: limits seizure propagation by altering ion transport, May also decrease synaptic transmission, Notes: fosphenyton is often used to treat seizures instead of iv phenytoin because of possible complication and drug interactions associated with iv phenytoin if iv phenytoin is used it should be administered via slow iv push at a rate that does not exceed 50mg/min because phenytoin precipitates when mixed with glucose only normal saline is used to flush the tubing fosphenytonin may be given in saline or glucose solution at a rate of up to 150 mg phenytoin equivalent (PE)/ min it may be given IM if necessary

Assessment,

Upon arrival to the neurologic unit, Mr. Watson is started on nitroprusside for continued for BP 194/106.

What are the symptoms?,

Visual problems, including drooping eyelids (ptosis) and double vision (diplopia), Severe muscle weakness and fatigue in the neck or limbs, Difficulty breathing or speaking. Weak tongue, trouble swallowing or chewing, and weight loss, The skin between your ribs, around your neck, or on your abdomen pulls in when breathing. Morning headaches, or feeling tired during the daytime. Waking up frequently at night or feeling like you are not sleeping well. Weak cough with increased secretions (mucus or saliva) or an inability to clear secretions.

How is it determined if Karen has a myasthenia vs. a cholinergic crisis?

We can determine that she has myasthenia and not a cholinergic crisis as evidenced by the symptoms she present with such as: blurry or "double" vision (diplopia), right eye ptosis, voice getting softer as she speaks, nodding head forward intermittently (indicate severe muscle weakness and fatigue in the neck), difficulty chewing and swallowing food her increased fatigue.

NCLEX QUESTION 1,

When a child is experiencing a generalized tonic-clonic seizure, an appropriate nursing action would be to: a. guide the child to the floor if the child is standing, and then go for help. b. move objects out of the child's immediate area. c. stick a padded tongue blade between the child's teeth. d. manually restrain the child. ANS: B, During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.

Phenobarbital,

anticonvulsant in tonic-clonic partial and febrile seizures in children **** don't confuse phenobarbital with pentobarbital ***, Action- produces all level of CNS depression depresses the sensory cortex, decreases motor activity and alters cerebellar function, Inhibits transmission in the nervous system and raises the seizure threshold, Capable of inducing enzymes in the liver that metabolize drugs, bilirubin and other compounds