Exam4 review for advanced PDF

Preview

Summary

keiser university 3rd semester exam 4 for advanced adult health care...

Description

Neuro diagnostics: Cerebral angiography, visualization of cerebral blood vessels. Contrast dye injected into artery during procedure. Assess for allergies. Head will be immobilized during, and void before procedure Electroencephalography- assess electrical activity of the brain, performed to determine seizure activity. Stay awake prior to test. GCS- A score less than 8 indicates severe head injury/coma. 9-12, moderate head injury. -

E: 4, eyes open spontaneously. 3, eyes open secondary to voice/sound. 2, eye opens secondary to pain. 1, does not occur. V: 5, coherent and oriented. 4, incoherent and disoriented. 3, words spoken but inappropriate. 2, sounds are made but no words. 1, does not occur. M: 6, commands followed. 5, local reaction to pain. 4, general withdrawal from pain. 3 decorticate posturing (Adduction of arms). 2, decerebrate posturing (head arched back, abduction of arms) 1, motor response does not occur.

Lumbar puncture: small amount of CSF is withdrawn from spinal canal and analyzed, determines diseases like meningitis, MS, syphilis and can be used to reduce CSF. Brain herniation is a complication. “cannonball position”. Patient remain lying for several hours to reduce post lumbar headache caused by CSF leakage. Chap 66 Neuro dysfunction/seizures: -

-

-

-

-

Locked in syndrome: lesion affecting the pons and results in paralysis and inability to speak, can only move eyes. Persistent vegetative state, devoid of cognitive function but has sleep-wake cycles, does not require ventilator support unless they have another disorder. Interventions: Using frequent turning schedule, maintaining thermoregulation- if temp is elevated, use minimum bedding, hypothermia blanket, giving a cooling sponge bath and prevent shivering. Calm environment. Risk factors for seizures: genetic predisposition, acute febrile state, head trauma, cerebral edema, infection, cardiovascular disease, stroke, exposure to toxins, brain tumor, hypoxia substance withdrawal, hypertension. Generalized seizures: tonic clonic, tonic (stiffening of muscles, breathing can stop) clonic (jerking of the extremities) Postical phase, period of confusion and sleepiness following a seizure. Maintain in a side lying position. Status epilepticus, occurs with repeated seizure activity within 30 minutes or a single prolonged seizure more than 5 minutes. Meds, administer diazepam/lorazepam IV push followed by IV phenytoin/fosphenytoin. Meds: phenytoin- antiepileptic medication. Take meds at the same time every day to enhance effectiveness. Avoid oral contraceptives and anticoagulant meds while taking phenytoin.

Increased intracranial pressure: Surgical aseptic technique for monitoring. Normal ICP 10-15. Limit monitoring to 3 to 5 days. Normal CPP, 70-100. Less than 50, irreversible brain damage. CPP=MAP-ICP. Mannitol is used in ICP (osmotic diuretic) for cerebral edema. LATE SIGN:::

-

Cushings triad: seen where cerebral blood flow decreases significantly. Increase in systolic blood pressure, widening of the pulse pressure and a slowing of the heart rate. Requires immediate attention. (severe hypertension, widened pulse pressure and bradycardia.)

3 assessments: - intraventricular catheter (fluid filled catheter inserted into lateral ventricles most often the right side through a burr hole. – Subarachnoid screw or bolt (hollow, threaded screw or bolt is placed into the subarachnoid space through a twist drill burr hole in the front of the school behind hairline.) – Epidural/subdural sensor (a fiber optic sensor inserted into the epidural space through a burr hole) -

S/S: headache, altered LOC, restlessness, irritability, dilated or pinpoint pupils, slowness to react, Cheyne stokes respirations. Oculocephalic, “Doll eyes” turn head, eyes stay center = pons and medulla affected. Oculovestibular, “Caloric reflex” cold water injected into ears, eyes should move towards stimulus, brain stem intact.

Chap 68 Neuro trauma: Group highest risk, males 15-24. Everyone with head injury is assumed to have spine injury until ruled out. XRAY. Place cervical collar and align spine at all times. Most common death from trauma MVA (motor vehicle accident) -

-

-

-

Primary injury, due to initial damage, like contusions, lacerations, foreign object penetration, damage to blood vessels. (edema) inflammation cascade bring cytokines to help heal. Secondary injury, damage evolves after initial insult. Cerebral edema, ischemia, or chemical change associated with trauma. Scalp wounds tend to bleed heavily and are also portals for infection. Skull fractures open or closed, usually have localized, persistent pain. Skull fracture, Linear, break in bone.- bed rest and observation Comminuted, splintered or multiple fracture line. Depressed, skull bones displaced downward. / surgical intervention within 24 hours, elevation of the skull and debridement. Basilar, fracture at base of the skull. Bleeding from nose pharynx and ears. Battles sign, ecchymosis behind the ear, seen on the mastoid process. CSF leak- halo sign- ring of fluid around the blood stain from drainage, big chance of infection. Meds: dexamethasone, antibiotics. Instruct patient not to blow nose, cough, inhibit sneeze and sneeze through open mouth. Call for help if change of LOC, vomiting, blurred vision, slurred speech, stiff neck or seizures. Neuro assessments frequently Brain Injury, Closed head injury, blunt trauma. Open, object penetrates the brain or trauma is so severe that the scalp and skull are open. Contusion, more severe injury with possible surface hemorrhage. Concussion, temporary loss of consciousness with no apparent structural damage, patient should be aroused and assessed frequently. Intracerebral hemorrhage is the worst, bleeding into the brain tissue. S/S, ipsilateral pupil dilation, herniation. Subdural hemorrhage, blood between dura and arachnoid-pia mater. S/S confusion, drowsiness.

-

Epidural hemorrhage, blood between skull and dura. Tear in meningeal artery, rapid deterioration to herniation. S/S altered LOC and will return to lucid state than hematoma expands and increased ICP and sudden lost of LOC.

Spinal cord injury- Risk factors include alcohol and drug use. Classified by complete or incomplete injury, cause of injury and level of injury. PROM four times a day. Maintain proper body alignments. Meds: Steroids to prevent secondary cord injury from edema and ischemia, vasopressors, antispasmodics such as dantrolyne or baclofen. analgesics, TCA’s. -

-

-

-

Spinal shock, sudden depression of reflex activity, causes edema. S/S flaccid paralysis, loss of reflex activity below injury, keep MAP at least 85. TX: IV steroids. Dextran, volume expander, treat hypotension secondary to spinal shock. Neurogenic shock, loss of function of the ANS. Causes: SCI, spinal anesthesia, medications. S/S: bradycardia, hypotension, dependent edema, loss of temp regulation. TX: ABC, atropine 0.5mg IV, Keep MAP greater than 70. Methylprednisolone IV. Vasopressor (noepinephrine & dopamine) used to treat hypotension. Autonomic dysreflexia, ACUTE EMERGENCY! Occurs in person with a spinal cord lesion above T6. S/S, severe hypertension, severe pounding headache, sudden increase in BP, bradycardia. – remove stimulus- Most common is bladder distension, constipation, tight clothing. Sit patient up to decrease BP secondary to postural hypotension, determine cause of stimulus, notify provider. Paraplegia, paralysis of lower portion of body, below the level of T1. Quadriplegia, paralysis of both arms and legs, bladder and bowel dysfunction. Interventions: NG tube to alleviate gastric distention, high calorie, high protein, high fiber diet. Traction pin care, temporary indwelling catherization or intermittent catherization.

Chapter 70 Neuro oncology or degenerative neuro: Akathisis, restlessness, urgent need to move around and agitation. Risk factors, increase ICP, seizures, hydrocephalus and altered pituitary function. Oncologic tumors, neoplasm. Primary tumors, gliomas (within brain tissue) Meningiomas (covering the brain) acoustic neuromas (8th cranial nerve) angiomas (masses of abnormal blood vessels (cerebellum). Physcial findings: positive Babinski and Romberg sign. -

-

Secondary class, supratentorial tumors occur in the cerebral hemispheres above the tentorium cerebelli. Below that are infratentorial tumors that occur on the brainstem and cerebellum, which show hearing loss or ringing of ears, visual changes, facial drooping, nystagmus. Manifestations of supratentorial brain tumors, severe headache, worse upon awakening but improve, worsen by cough or straining. Visual changes (blurred or visual field deficit) Meds: Nonopioid to treat headaches. Corticosteroids to reduce cerebral edema. Osmotic diuretics (mannitol- to decrease fluid content in brain.) Anticonvulsants, H2 antagonist and antiemetics.

Care of a patient with Parkinson’s: decreased levels of dopamine and to much acetocolyine . four primary findings: tremor, muscle rigidity, bradykinesia, (slow movement) and postural instability and masklike expression. More common in males. EMG takes sample of the brain. -

Document clients weight weekly. High calorie, high protein supplements. Encourage ROM and exercise. Safety precautions, no throw rugs and using an electric razor, well lits rooms and

-

uncluttered spaces. Encourage to eat slowly and chew thoroughly before swallowing to prevent aspiration pneumonia. Monitor swallowing and food intake : thicken food and sit upright to eat. Suction available in case of aspiration. Meds: levodopa, increases dopamine levels in the basal ganglia. Monitor for wearing off and dyskinesia (problems with movement) which can indicate a need for medication adjustment. Dopamine agonists: bromocriptine and anticholingerics: benztropine to bring acetocolyne down.

Huntingtons: chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. Transmitted by autosomal dominant trait. Premature death of cells in the striatum (caudate and putamen). Progression of less than 2 years from diagnosis. Family history is assessed with diagnosing, as well as the presence of the genetic marker CAG. -

3 triad symptoms. 1, motor movement (chorea) rapid, jerky, involuntary purposeless movement. 2, cognitive impairment, problems with attention and emotion recognition. 3, behavioral features such as apathy and blunted affect. Only med to treat the symptoms of chorea, is tetrabenazine (Xenazine) and haloperidol (antipsychotics)

ALS, also known as Lou Gehrig disease: degenerative disease of upper and lower Loss of motor neurons (nerve cells controlling muscles) in the anterior horns of the spinal cord and the motor nuclei of the lower brainstem. Can cause progressive paralysis and atrophy of the muscles of the extremities and the trunk. Respiratory paralysis and swallowing impaired. Common between ages 40-60. Death 3-5 years. -

S/S: chief symptoms, fatigue, progressive muscle weakness, cramps, fasciculations (twitching) and lack of coordination, muscle atrophy. DX: based on S&S and (CK-BB) creatinine kinase. Increased EMG: Maintain patent airway, suction as needed. Monitor for pneumonia and respiratory failure. Meds: Riluzole : slow deterioration of the motor neurons, and can extend patients life to 2-3 months and Baclofen is another med. Nursing measures, Patent airway, intubate, suction, HOB 45 degrees, monitor for pneumonia and respiratory failure, provide communication.

Care of patient undergoing a craniotomy, pre-op, post op and complications: -

Preop: education, stop any anticoagulants at least 72 hours before procedure. Inform of all OTC use, review living will, POA and anti anxiety meds. Diazepam Postop: ABC, VS, neuro assessments, GCS, HOB to 30 degrees as ordered in neutral position. Control pain, no straining activities, monitor I&O, bleeding. Complications: When the hypothalamus is damaged, SIADH can occur where fluid is retained. Treatment consists of fluid restriction, oral conivaptan and treatment of hyponatremia with 3% hypertonic saline solution for severe cases. DI, diabetes insipidus: can also occur after supratentorial surgery, where large amounts of urine are excreted as a result of deficiency of ADH. Treatment consists of massive fluid replacement, administration of synthetic vasopressin.

chapter 13 Neurocognitive disorders:

Delirium: disturbance in level of awareness and change in cognition. Develops rapidly, abruptly and over a short period of time. S/S: shifting attention, extreme distractibility, disorganized thinking, speech that is rambling, irrelevant, disorientation to time and place. Vital signs unstable. Is reversible if underlying cause is treated. -

Autonomic symptoms, tachycardia, sweating, flushed face, dilated pupils and elevated BP, Staff to remain with patient at all times to monitor behavior and reorientation. Room with low stimulus level. Low dose antipsychotic agents to relieve agitation and aggression. Benzodiazepines are commonly used when etiology is substance withdrawal.

Dementia: multiple cognitive deficits that impair memory and can affect language. Donepezil is used to improve cognition in patients diagnosed with mild to moderate dementia associated with AD. Vital signs stable. Memory loss is an example. Gradual onset and progressive and irreversible. Alzheimer dementia: Primary NCD. Non-reversible dementia. Risk factors: exposure to metal waste, head injury/trauma and history of herpes infection. Onset is slow and insidious, generally progressive and deteriorating. Memory loss and changes in personality. -

-

Offer snacks and finger food, provide frequent walks to prevent wandering. Keep a structured environment and introduce change gradually. Avoid overstimulation, noise and clutter to a minimum. Single day calender, reorientation and maintain toileting schedule. Remove scatter rugs. Install door locks at home, good lighting. 7 stages,

Stage 1: no symptoms Stage 2: forgetfulness, no memory problems, Stage 3: mild cognitive deficits, mild memory loss, noticeable to family members. Stage 4: personality changes, obvious memory loss Stage 5: assistance with ADL is necessary Stage 6: incontinence and wander, safety risk Stage 7: impaired swallowing, no ability to speak ataxia. -

Confabulation, during the fourth stage a patient can present this behavior, memory loss in which the patient fills in memory gaps with information about events that have not occurred. Meds: Donepezil: prevent breakdown of acetocolyne: administer daily at bedtime. memantine/rivastigmine and cholinesterase are used in AD. Observe for frequent stools and upset stomach. Monitor for dizziness or headache and use caution with patients with asthma or COPD.

Chapter 14 shock/MODS: Stages of shock: -

1st : Compensatory: increased HR. SNS causes vasoconstriction. Maintains BP, CO. Body shunts blood from skin, kidneys, GI tract, resulting in cool, clammy skin, hypoactive bowel sounds, decreased urine output. Tissue perfusion is inadequate. Metabolic acidosis/anaerobic

-

-

-

-

metabolism = LACTIC ACID (LIVER). RR decreased (respiratory alkalosis), confusion may occur. REVERSIBLE. Normal serum lactate...