MDC4 Notes PDF

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Complete notes from black board, covering all topics from modules 1-11...

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Module 02 Increased Intracranial Pressure (IICP) https://rasmussen.webex.com/recordingservice/s ites/rasmussen/recording/ebcb39d1056b47d784 9754ca9c9695a4/playback Module 02 Increased Intracranial Pressure (IICP) 

Increased Intracranial Pressure (IICP) Increased Intracranial Pressure (IICP) is a risk that occurs during the first 72 hours after onset of the stroke. Assessment should occur at a minimum of every 4 hours, and more often for an unstable client.

Assessing IICP o o

o o o

The best indicator for change in the client’s condition is level of consciousness. Checking for signs of increased intracranial pressure would include a change in the client’s behavior, which would include restlessness, irritability, and confusion. Pressure centers located in the medulla oblongata induce nausea and projectile vomiting. The client may experience changes in speech, such as aphasia. A later sign will be pupillary changes such as dilated and non-reactive pupils (blown pupils), or constricted and non-reactive pupils.

As the pressure increases, a change in cranial nerve function occurs. The client that is at risk for increased ICP should be placed on seizure precautions, particularly the first 24 hours after the onset after a stroke. Abnormal posturing may occur with severe injury to the brain. When injury to the cerebral hemisphere occurs, the client will display the abnormal posturing known as decorticate. Decerebrate posturing indicates that there is damage to the brain stem and is the worst, most ominous signs, of the two posturing.

Module 02 Managing Clients with Increased Intracranial Pressure (IICP) 

Managing Clients with Increased Intracranial Pressure (IICP) A client with increased intracranial pressure (IICP) is in an intensive care unit. There are many interventions in caring for a client that is recovering from a hemorrhagic stroke.

Nursing Care o o o o o o o o

Keep the HOB elevated to allow for full-lung expansion, decreased chance of aspiration, as well as improved perfusion in the brain. Do not hyperextend or over use pillows, but maintain the head in a midline, neutral position. Maintain the head in the midline position promotes cerebral venous drainage. Oxygenation is important because there are two things that the brain does not store and one is oxygen, the other being glucose. Keep the oxygen saturation at or above 94% to facilitate oxygenation and perfusion of brain tissue. The positioning of the rest of the body is also important. Remember to maintain body alignment in caring for a client with IICP. No extremes in hip flexion which can increase intrathoracic pressure which then increases ICP.

In other courses you may have learned it is best to cluster nursing activities together. For the client with IICP, too much activity at one time is dangerous and can raise pressures in the brain. o o o o

Closely monitor the client’s environment and adjust as needed. Monitor the number of visitors and watch the client’s response. Keep the lighting in the room low and environmental stimulation, such as noise, to a minimum. Vital signs may be monitored as frequently as every 5 to 15 minutes.

Airway is always the nurse’s top priority, and it is no different in this situation. The client with such a severe brain injury may be placed in a medically-induced coma and on mechanical ventilation to protect the brain as well as manage IICP. Suctioning is necessary to maintain a patent airway in such cases. However,

frequent suctioning is not recommended. The cough reflex and gag reflex produced with suctioning greatly increase ICP.

Brain Death Determination of brain death occurs by establishing the following criteria by a neurologist and critical care intensivists:    

Coma – client must be observed for a period of time to determine that the client will not recover Normal or near-normal core body temperature Normal systolic blood pressure higher than or equal to 100 mm Hg At least one neurological examination (some states require two examinations)

Module 03 The Peripheral Nervous System Module 03 The Peripheral Nervous System https://rasmussen.webex.com/rec ordingservice/sites/rasmussen/rec ording/playback/2931b21ef2664d 5797baaf58bfe9a9e6 

The Peripheral Nervous System The Peripheral Nervous System is composed of the spinal nerves and cranial nerves. Take a moment to review the anatomy and function of the peripheral nervous system.

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Diseases of the Peripheral Nervous System Guillain-Barre Syndrome Gullain-Barre Syndrome (GBS) is a result of overactive immunity. It is rare and affects men more than women. The myelin sheath is attacked by circulating antibodies resulting from an immune response. There are various triggers from bacterial to viral. The most common presentation is a viral-like illness one to

three weeks prior to GBS symptoms. The result of the overactive immunity results in destruction of the myelin sheath which slows the transmission of impulse from node-to-node. The slowing of impulses produces the symptoms of GBS. The hallmark of the disease is ascending weakness.

Stages of GBS o o

Acute Stage – Onset of symptoms Plateau – Symptoms remain for a few days to a few weeks

Recovery o

May take up to 2 years

Diagnostics

o o

Lumbar puncture to evaluate cerebral spinal fluid (CSF) for increase in protein--results are non-conclusive Electrophysiologic studies (EPSs)--demonstrates demyelinating neuropathy Treatment Options

o o o o o o o

Plasmapheresis – Remove circulating antibodies Start within several days of onset of illness 3 to 4 treatments – 1-to-2 days apart Weigh the client before and after procedure IV immunoglobulin (IVIG) Is as effective as Plasmapheresis Infuse slowly observing for any side and adverse effects

o

Nursing Care o o o o o o o o o o o

Frequent monitoring of the respiratory and cardiovascular system Inability to maintain airway--potentially fatal with ascending paralysis Aspiration precautions Suction equipment at the bedside HOB elevated 45 degrees Change position every 2 hours Breathing exercises, cough and deep breathing Incentive spirometer Oxygen Report change in HR and BP to primary healthcare provider Interdisciplinary – Respiratory therapy

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o Chest physiotherapy o Managing airway if compromise occurs o Oxygen o During the recovering period involve other disciplines o PT/OT o Speech therapy o Nutritionist Myasthenia Gravis

Myasthenia Gravis is a progressive-acquired autoimmune disease. It is a breakdown in the relaying of signals from the nerves to the muscles. This breakdown in communication at the synapses causes muscle weakness. The typical area where symptoms are first noticed is visual disturbances. Other symptoms can include drooping of the eyelids and difficulty swallowing. Death can result from a rapid development of muscle weakness which can induce respiratory failure.

Signs and Symptoms o o o o o o o o

Ptosis Diplopia Dysphagia Fatigue Respiratory compromise Progressive muscle weakness that worsens with repetitive use - improves with rest Decreased sense of smell and taste Paresthesias

Diagnostics o o

Repetitive nerve stimulation (RNS) Imaging for Thymoma

Treatment o o o o

Anticholinesterases or cholinergic drugs Immunosuppressive drugs or corticosteroids Plasmapheresis Thymectomy

Nursing Care o o o o o

Administer meds 45 minutes to 1 hour after taking ChE inhibitors to avoid aspiration Cholinergic crisis Side effect of medication used for treatment Manifested by nausea, vomiting, diarrhea Can cause life-threatening symptoms such as bronchospasm and bradycardia

Myasthenic Crisis Myasthenic Crisis can occur for a number of reasons. The client may need an adjustment in their medication, or the client may be suffering from a stressor such as an infection. The result of the crisis is muscles of the respiratory system become so weak that the client may need mechanical ventilation.

Cholinergic Crisis Think of an overdose; Cholinergic Crisis is caused by taking too much of the anticholinesterase drugs. It causes an over-stimulation at a neuromuscular junctions. The causes the following symptoms:    

Salivation Lacrimation Urination Defecation

Similar to Myasthenic Crisis, muscle weakness occurs in which the client may need mechanical ventilation. 

Trigeminal Neuralgia

Cranial Nerve Disorders Trigeminal Neuralgia is a disorder of cranial nerve V that causes severe facial pain. A client that experiences Trigeminal Neuralgia literally stops in their tracks due to the severity of the pain. The client may actually cry out in pain, cradle their face, and then become silent. The client may also experience facial twitching or tics, hence the secondary name of tic douloureux. The pain is unilateral and may have a precipitating factor such as dental work or may have a sudden, unprovoked onset.

The priority of care for the client is pain management with drug management being the first choice. Carbamazepine (Tegretol) or gabapentin (Neurontin) may be used. There are other options for treatment which include peripheral chemical nerve block with ropivacaine or stereotactic radiation treatments. The utilization of a gamma knife is a surgical approach that disrupts trigeminal neuralgia to provide pain relief. The client may avoid facial movement in fear of aggravating the pain cycle. When caring for the patient, they may seem withdrawn, depressed, or uninterested in conversation. This is simply a self-protecting mechanism to avoid the sudden onset of Trigeminal Neuralgia. 

Bell’s Palsy (Facial Paralysis)

Bell’s Palsy will scare a client into thinking that they have had a stroke (CVA). This is because the symptoms are just like those of a stroke, such as facial paralysis, drooping eyelid, and drooping mouth. The symptoms are occurring not because of brain injury, but because of a virus such as herpes simplex virus type 1 affecting the 7th cranial nerve. approximately 2 to 5 days. The client will not be able to close the affected eye, wrinkle the forehead, smile, whistle, or grimace. The client may experience tinnitus, pain behind the affected ear, and change in taste.

Treatment is administration of corticosteroids, 30 to 60 mg daily and acyclovir (Zovirax). Nursing care revolves around the psychological care and reassurance that this is not a stroke, and the symptoms will resolve. Since the eyelid will not close, the eye has to be protected. Teach the client to manually close the eyelid at intervals and apply artificial tears during the day. Since the eye doesn’t close on its own, there is no natural lubricant. At night wear an eye patch or tape the eye shut and use an ophthalmic ointment to supply moisture to the eye.

Fluids may be challenging as the weak side of the mouth will droop and drool. Encourage the client to drink, chew, and swallow on the unaffected side. For a short period of time, a soft diet may be beneficial. Monitor the client’s hydration status.

Anticipate that the client suffering from Bell’s Palsy will benefit from physical therapy. The therapist will teach muscle strengthening exercises that can be done at home with great benefit. In rare cases a permanent sense of pain may linger which can be treated with gabapentin (Neurontin).

Module 04 Perioperative 

https://rasmussen.webex.com/recordingservice/sites/rasmussen/recording/pla yback/2931b21ef2664d5797baaf58bfe9a9e6

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Overview The words “you need surgery” may cause anxiety in clients. The surgical client has known risks that occur which the surgical team works to prevent. Complications and errors that have occurred in the surgical suite have influenced how we practice today. Progression through this module will center around three areas; perioperative, intraoperative, and postoperative. Let’s begin with perioperative.

Perioperative The perioperative period begins when the client is placed on the surgical schedule and ends when the client is transferred to the surgical suite. There are specific reasons for surgery, such as: diagnostic, curative, transplant, restorative, palliative, or even cosmetic. There are also different levels of urgency. For example, a total joint replacement is an elective surgery and is a planned procedure. A displaced bone fracture is urgent and intervention should not be delayed more than 24-48 hours. As compared to a gunshot wound, which is emergent due to the life-threatening nature of the injury, the client would immediately go to the surgical suite. The next consideration in surgery is the surgical approach.

Simple, Minimally-Invasive, and Radical Surgical Approaches The simple surgical approach only applies to the areas involved in the surgery. An example of this surgery would be simple/partial mastectomy. Another surgical approach is minimally-invasive surgery. Most of the surgeries fall within this category. Examples include: lung lobectomy, arthroscopy, and cholecystectomy. The last surgical approach is termed radical which involves removing surrounding structures as well as lymph nodes. Examples of the procedures are radical prostatectomy and hysterectomy.

Surgical Checklist No matter where surgery takes place, either as an inclient or outpatient, client safety is a priority. It is standard practice for facilities to have a comprehensive surgical checklist to complete. Lists of this nature are only as good as the person completing them. The RN completes the pre-operative checklist, the anesthesiologist also completes a checklist, interviews the patient, and assesses the airway preparing for safe administration of anesthetics. One of the most important steps that is now standard practice is the Time-Out. This occurs right before the skin incision is made. The designated team member calls for a TimeOut to review and confirm that the correct procedure is going to be performed on the correct client at the correct site. Other verifications include that a signed informed consent by the client or designated health care surrogate is within the records. Is the site marked clear and is it the correct site verified with consent? In other words, is the team operating on the correct limb? Any other concerns are raised by the team at that time. Remember, this step prevents errors.

The Older Adult and Surgery At-Risk for Complications The older adult is at risk for complications related to surgery as well as anesthesia. As the health history is taken, questions will revolve around lifestyle and life choices. Encourage the client to answer truthfully. Concerns would focus on the following:        

Comorbidities Age-related changes in the kidneys and liver Drugs and substance use Tobacco use Alcohol use Prescription medications Over-the-counter medications Herbal supplement use

Completeness It is essential that the client has a complete history and physical. Have the client or family bring in every medication that the client takes. Prepping a client for surgery can increase both stress levels and induce anxiety. Many healthcare workers are asking lots of questions, and some are repetitive. Reassure the client that every question is asked to ensure a safe journey through the surgical experience. The client may be asked many times:      

State your name and date of birth? What are your allergies? Have you had any previous anesthesia? If the answer is yes, how did you react to the anesthesia? Do you have any loose teeth, dentures, partial plates, etc.? What surgeries have you had in the past?

When able, and if you sense frustration, give the client a mental break for a moment. The perioperative period can feel overwhelming to the older adult.

Allergies A part of the medical history is client allergies. Here are some relational allergies that may impact decisions for the OR team.    

Allergy to povidone-iodine (Betadine) is the same allergens found in shellfish. Allergy to avocados, bananas, strawberries--alerts the team to a possible latex allergy. Allergy to egg, peanut, or soy should be an alert for the anesthesiologist. The client may adversely react to propofol (Diprivan). Allergy to metal. Joint replacements are made from metal. Clients with a known nickel allergy will receive an implant that is made from titanium to prevent a systemic allergic response to the implanted item.

Age-Related Changes in the Older Adult (over 65 Years of Age) As the person ages, there are changes that occur in all body systems. During the surgical journey, the client will endure the gathering of their medical history and multiple physical exams from several providers as well as the RN. Each body system is reviewed and evaluated. Let’s looks at changes that occur simply due to aging by body system:

Cardiovascular System  Decreased cardiac output  Increased blood pressure  Decreased peripheral circulation Respiratory System  Reduced vital capacity  Loss of lung elasticity  Decreased oxygenation of blood Renal/Urinary System  Decreased blood flow to kidneys  Reduced ability to excrete waste  Decline in glomerular filtration rate  Nocturia common Neurological System  Sensory deficits  Slower reaction time  Cognitive impairment Musculoskeletal System    Skin 

Osteoporosis Arthritis Decreased mobility Dry skin

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Less subcutaneous fat Greater risk for injury

Blood Loss In preparation for blood loss during surgery, the client has the option to donate their own blood. This is called an autologous blood transfusion and is preferred if there is time prior to an elective surgery to do so. This must occur several weeks prior to the scheduled surgery. The client should alert the perioperative personnel that they have donated their own blood prior to the surgery. The client will provide documentation from the donation center.

A client may refuse the administration of blood products because of religious beliefs. There are processes in place to respect those beliefs and have positive surgical outcomes. If the surgery is elective, there is time to prep the client by administering epoetin alpha (Epogen, Procrit) to stimulate red blood cell production. The client can also take supplements such as iron, folic acid, vitamin b12, and vitamin C also for red blood cell formation. During surgery, the use of a cell saver machine can collect, wash, and return blood loss during surgery. There is an increased use of minimally-invasive surgery among surgeons which minimizes blood loss during surgery (Ignativacius,D., et. al., 2018).

It is a better option for the client to receive their own blood than from a donor’s blood that could carry diseases .

Module 04 Laboratory and Imaging Studies 

The laboratory tests and radiology imaging is ordered before surgery depends on the client’s age, medical history, and type of anesthesia planned. It is important to report abnormal results to the surgeon.

The most common tests include: o o o o o o o o o o o

Urinalysis Blood type and screen Complete blood count or hemoglobin & hematocrit Clotting studies Prothrombin time (PT) International ratio (INR) Activated partial thromboplastin time (aPTT) Platelet count Electrolyte levels Serum creatinine Blood urea nitrogen levels

o Pregnancy test o Arterial Blood Gas Imaging Assessment o o o Other o

Chest x-ray CT Scan MRI Diagnostics ECG

Module 04 Informed Consent 

An informed consent is a process to educate the client of the planned invasive procedure. The client should be informed of the following: o The name of t...