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109 Cards in this Set

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  • Back
What should the nurse assess initially in a patient with spinal cord injury?
*Assess respiratory pattern
*Ensure adequate airway
*Assess for intra-abdominal hemorrhage or bleeding around fracture site (hypotension, tachycardia & weak thready pulse can also indicate hemorrhage)
*Determine Glasgow Coma Scale
*Detailed assessment of motor and sensory status
What level of spinal cord injury is at high risk for respiratory compromise?
Cervical (C3 - C5)
Why are C3 - C5 injuries at increased risk for respiratory problems?
Because the cervical spinal nerves innervate the phrenic nerve, which controls the diaphragm
What is often needed to prevent respiratory arrest in C3 - C5 injury patients?
Endotracheal intubation
What does the Glasgow Coma Scale determine?
The patient's level of consciousness (LOC)
What is the significance of a detailed assessment of motor and sensory status (for patients with SCI)?
*Assists in determining the level of injury
*Serves as baseline data for future comparison
What is "the level of injury?"
The lowest neurologic segment with intact or normal motor/sensory function
What dermatome level is the top of the foot and the calf of the leg?
What dermatome level is the umbilicus?
What dermatome level is the clavicle?
*C3 or C4
Finger sensation is considered to be which dermatome level?
*C7 and C8
What is meant by the term hypoesthesia?
Decreased sensation
What is meant by the term hyperesthesia?
Increased sensation
How would a nurse assess for C4-C5 injury?
Apply downward pressure while the patient shrugs shoulders upward
How would a nurse assess for C5-C6 injury?
Apply resistance while the client pulls up his or her arms
How would a nurse assess for C7 injury?
Apply resistance while the patient straightens his or her flexed arms
How would a nurse assess for C8 injury?
Assess the patient's ability to grasp an object and form a fist
How would a nurse assess for L2-L4 injury?
Apply resistance while the patient lifts his or her legs from the bed
How would a nurse assess for L5 injury?
Apply resistance while the client dorsiflexes his or her feet
How would a nurse assess for S1 injury?
Apply resistance while the client plantar flexes his or her feet
What are the signs/symptoms of autonomic dysreflexia?
*Severe, rapidly occurring hypertension
*Flushing above the level of the lesion
*Severe, throbbing headache
*Nasal stuffiness
*Blurred vision
What is included in emergency care of autonomic dysreflexia?
*Raise the HOB to high Fowler's
*Call the physician to notify him/her of the emergency
*Loosen tight clothing on patient
*Check the Foley catheter tubing (if present) for kinks or obstruction
*If a Foley is not present, check for bladder distention and catheterize immediately
*Check the client for fecal impaction; if present, disimpact immediately using anesthetic ointment
*Check the room temperature to ensure that it is not too cool or drafty
*Monitor blood pressures every 10-15 minutes
*Give nitrates, hydralazine (apresoline), or Procardia as ordered
What is the cause of autonomic dysreflexia?
Noxious stimulus, most often a distended bladder or constipation
What will likely happen if autonomic dysreflexia is not treated promptly?
Hypertensive stroke
What are the signs/symptoms of spinal shock?
*Absent deep tendon reflexes
*Absence of all motor function
*Absence of all sensation
*Decreased peristalsis
*Absent bowel sounds
*Gastric distention
What are the effects of an upper motor nueron (UMN) lesion on the bladder?
Bladder spasms/difficulty in urination
What might a nurse teach a client with UMN lesion to do to stimulate urination?
*Stroke the inner thigh
*Pull on pubic hair and hair of the upper thigh
*Pour warm water over the perineum
*Tap the bladder area to stimulate the detrusor muscle
What effect does a lower motor neuron (LMN) injury have on bowel elimination?
The resulting flaccid large bowel may require the client to perform or undergo manual disimpaction
What effect does an upper motor neuron injury have on bowel elimination?
Spasms: difficulty in eliminating
What is usually included in a bowel retraining program?
*Consistent time for bowel elimination
*High fluid intake (at least 2000 mL/day), unless fluid intake is restricted
*High fiber diet
*Rectal stimulation with or without suppositories
*Stool softeners, if needed
How long does spinal shock usually last?
72 hours to several months
What happens after spinal shock subsides?
Hyperreflexia of muscles and deep tendon reflexes
What is an appropriate intervention for paralytic ileus as a result of spinal shock?
NG tube with low suction
What is an appropriate intervention for hemodynamic instability as a result of spinal shock?
*Monitor vital signs closely
*Change positions slowly to avoid orthostatic hypotension
What is hemodynamic instability?
Decrease in blood pressure and pulse
What is a key nursing intervention for spinal shock patients with regards to skin care?
*Monitor pressure areas (poor blood perfusion to the skin)
*Blanching test
With what type of SCI does autonomic dysreflexia most often occur?
Injuries at or above T6
What are some potential long-term SCI complications?
*Renal calculi (non weight-bearing)
*UTI's if urinary tract care not stringent
*Possible contractures and/or dislocations
Why do SCI patients have an increased risk for pneumonia?
Due to compromised respiratory function and decreased activity of supporting muscles
What is the leading cause of death in SCI patients, in long-term management of this condition?
What drugs might help to control severe muscle spasticity in patients with UMN injuries?
*Dantrolene (Dantrium)
*Baclofen (Lioresal)
20 - 30% of spinal cord tumors are secondary mets from what?
*Lung cancer
*Breast cancer
*Colon cancer
*Prostate cancer
*Uterine cancer
List some clinical manifestations of spinal cord tumor:
*Pain from cord compression/infiltration of cancer cells
*Motor deficit: weakness, clumsiness, ataxia, hyperreflexia
*Spastic paralysis
*Flaccid paralysis
*Sensory loss: numbness, tingling, temperature loss, loss of touch
*Gradual loss of bladder control, and then loss of bowel control
What tests are usually done to diagnose a spinal cord tumor?
*CT Scan
What are the signs/symptoms of spinal cord compression?
*Back pain (usually occurs before any neurologic deficits occur)
*Loss of urethral, vaginal, rectal sensation
*Muscle weakness
*Sometimes paralysis occurs
If spinal cord compression causes paralysis, can this be reversed?
No; if paralysis occurs due to spinal cord compression, it is usually permanent
What is the nurse's responsibility in regards to skeletal traction?
*Maintaining the correct balance between traction pull and counteraction force
*Make sure weights are not removed, unless ordered
*Make sure the weights are freely hanging at all times
*Inspect skin at least Q 8hrs. for signs of irritation/inflammation
*Remove the boot or belt when possible to inspect skin under it
*Perform pin care every day
*Observe pin sites at least every 8 hours for drainage, color, odor, and severe redness
*Check traction equipment to ensure proper functioning
*Inspect all ropes, knots and pulleys at least every 8 hours for loosening, fraying and positioning
*Check weight for consistency with health care provider's order
*Assess the neurovascular status of the affected body part to detect circulatory compromise and subsequent tissue damage
What is included in the assessment of neurovascular status for a client in traction?
*Skin color
*Skin temperature
*Capillary refill
Decreased dopamine levels cause Parkinson's patients to lose what ability?
The ability to refine voluntary movement, (result=jerky movements)
A decrease in epinephrine levels cause what to occur in Parkinson's patients?
Orthostatic hypotension
What causes Parkinson's disease?
*Depigmentation/degeneration of Substantia Nigra
*Depletion of dopamine
Parkinson's can possibly be associated with what conditions?
*Head trauma
*Basal ganglia infarct
What muscles are affected by Parkinson's?
All skeletal muscle
What are the cardinal symptoms of Parkinson's?
*Muscle rigidity
*Bradykinesia (slow movement)
*Poor posture
What is must be present in order to diagnose Parkinson's?
At least 2 of the cardinal symptoms
List some other signs/symptoms of Parkinson's:
*Resting tremor
*Muscular weakness with rigidity
*Inability to maintain balance
*Mask-like face
*Slowed, monotonous speech
*Shuffling gait
*Cognitive function impairment
*Emotional lability
What is the purpose of "drug holidays" from Parkinson's medications?
After 3-5 years of taking the medicine, there is a loss of response to the med. Drug holidays attempt to improve effectiveness of the drugs.
What type of medications are used for Parkinson's patients?
Dopaminergics (precursor to dopamine)
What specific drugs are used most often for Parkinson's?
*Carbidopa/Levodopa (Sinemet)
What is the goal of drug treatment for Parkinson's?
To achieve a balance between dopamine and acetylcholine in the basal ganglia
What should Parkinson's patients know about the side-effects of Sinemet?
The following can result from long-term use:
*Dyskinesia/tardive dyskinesia
*Orthostatic hypotension: change positions slowly
*Fasciculations of tongue
What is significant of Levodopa?
Converts to dopamine in the CNS
Patients taking dopaminergics should be instructed to take medication with what to avoid interactions with vit. B6 in food?
Juice and a low-protein snack
What should be included in patient teaching for a patient who is taking anticholinergic drugs?
*Take drug with meals to decrease GI distress
*Change positions slowly
*Effectiveness of drug is evaluated by decreased muscle rigidity/ tremors
What type of drug is selegiline (Eldepryl)?
MAO inhibitor
What condition should patients beware of when taking selegiline (Eldepryl)?
What foods should patients taking selegiline (Eldepryl) avoid?
*Red wine
What is COMT?
An enzyme that inactivates dopamine
What does a COMT inhibitor do?
Increases the effect of Levodopa
What is the end result of a Pallidotomy?
Stops tremors, but causes permanent motor loss
What are some signs of levodopa toxicity?
*Mental status changes
*Personality changes
*Increased twitching
*Tongue protrusion
What is included in the management of an acute exacerbation of MS?
*Solu-Medrol (methylprednisolone): administer 1 g IV for 3-14 days, depending on provider and pts symptoms
*Prednisone (PO) 60 mg may be given after Solu-Medrol for 5-7 days
*Adrenocorticotropic (ACTH) 25-60 international Units IV or IM may be given instead of Solu-Medrol and tapered gradually over 2-4 weeks
What is the purpose of giving corticosteroids / ACTH in an acute exacerbation of MS?
To reduce edema and inflammatory response
What are the major types of MS?
*Relapsing-remitting type
*Primary progressive type
What is involved in relapsing-remitting MS?
characterized by relapses that develop over 1-2 wks and resolve over 4-8 months. Pt returns to baseline.
What is significant of Primary Progressive MS?
Involves a steady and gradual neurologic deterioration w/out remission of symptoms
What is the diagnosis method for MS?
Usually diagnosed by obtaining a thorough history from the patient
What are some bladder control options for older children with myelomeningocele?
*Clean intermittent catherization taught to older children
*Medication (Ditropan or Detrol) used to improve bladder storage & continence
*Vesicotomy (stoma on abdominal wall for urinary drainage)
*Regular bladder emptying
What is the most common cause of neuropathic bladder dysfunction?
What should be included in parent teaching upon discharge of a myelomeningocele patient?
*Passive range-of-motion exercises, positioning, & stretching exercises may help prevent muscle contractures
*Watch for skin breakdown since decrease sensitivity in lower extremities
*Bladder training
*Catherization, medicines
*Bowel control with diet modification reg. toilet habits, prevention of constipation & impaction
*Prone position
*Infants held to promote bonding or touch, stroke, talked to
What is used to diagnose myelomeningocele (antepartum)?
*Elevated alpha-fetoprotein (AFP): AFP performed between 16-18 wks
*If positive diagnosis, C-section will be done
What can women of child-bearing age take to prevent myelomeningocele?
Folic Acid 0.4 mg/day
What is included in care of a myelomeningocele patient prior to surgery?
*Prevention of myelomeningocele from drying out by applying sterile, moist nonadherent dressing (changed q 2-4 hr)
*Inspect sac for leaks, abrasions, irritation or signs of infection
*Keep infant in prone position
*No rectal temps
*Measure head circumference & examine fontanels (ICP)
What type of allergies are very common in Cerebral Palsy patients?
Latex allergies
What should a nurse consider in regards to latex allergies?
*Allergic reaction- urticaria, wheezing, watery eyes, rashes, anaphylactic shock
*Most severe reaction occurs when latex comes in contact with mucous membranes, wet skin, bloodstream or airway
*Food cross-reactions: banana, avocado, kiwi, chestnuts, milk
What are the signs/symptoms of Cerebral Palsy?
*Increased muscle tone
*Increased DTR and clonus
*Difficulty with fine and gross motor skills
*Heelcord contracture (most common)
*Visual deficits
*Feeding problems
*Language deficits
*Intellectual impairments
What should a nurse assess in a cerebral palsy patient, in relation to association with hydrocephalus?
*Measure head circumference daily (predominant sign of hydrocephalus)
*Bulging fontanels (esp. anterior) that are tense & nonpulsatile
What are the signs/symptoms of hydrocephalus?
*Increased head circumference
*Bulging fontanels
*High-pitched cry
*Pupils sluggish
*Depressed eyes
What interventions can be done to promote communication with a cerebral palsy patient?
*Enlist speech therapist to promote good habits of communication
*Talk to child slowly to give child time to understand speech
*Use articles and pictures to reinforce speech and encourage understanding
*Use feeding techniques that help facilitate speech, such as using lips, teeth, and various tongue movements
*Teach and use of nonverbal communication methods for children with severe dysarthria
*Help family acquire electronic equipment to facilitate nonverbal communication (computer with voice synthesizer)
What is Dorsal Rhizomoty?
A procedure that involves selectively cutting the dorsal column sensory rootlets that have an abnormal response to electrical stimulation
What is the expected outcome of Dorsal Rhizomoty?
*Flaccid muscles
*Improve function rather than for cosmetic purposes
What should parents be taught about Dorsal Rhizomoty?
*Surgery done when child doesn’t respond to more conservative measures
*Child needs intensive PT, they must be retaught to sit, stand, and walk
What should parents be taught regarding feeding a child with cerebral palsy?
*Feed in normal eating position (flexed sitting position with arms brought forward to decrease the tendency toward back and neck extension)
*Manual jaw control to help with stability of jaw
*Provide extra calories to meet energy demands
*Provide vitamin, mineral, and protein supplements to meet caloric requirements
*Feeding techniques- place food at side of tongue, make them use lips to get food off spoon
What should be included in discharge teaching for a patient with Myasthenia Gravis?
*Explain signs and symptoms of myasthenic and cholinergic crises and need to contact Dr. when in crises
*Teach family to use resuscititation equipment
*Keep medication and water at bedside so can take med. Even when too weak to get out of bed
*Take meds on time
*Plan strenuous activities when meds peaks
*Don’t take OTC meds without checking with Dr.
*Factors that predispose client to exacerbation are infection, stress, surgery, hard physical exercise, sedatives, enemas
*Lifestyle adaptation- avoid heat, crowds, overeating, erratic changes in sleep habits, stress
What is significant of the activity level of a Myasthenia Gravis patient?
*Generalized weakness that increases as the day progresses
*Weakness increases with activity, improves with rest
*Limb weakness is more often proximal. Client may have difficulty climbing stairs, lifting heavy objects, or raising arms overhead
What should the nurse do to avoid complications of a thyectomy?
*Observe for signs of pneumothorax or hemothorax, such as chest pain & sudden SOB
*Maintain adequate respiratory function
What is a myasthenic crisis?
An exacerbation of MG symptoms caused by undermedication with anticholenesterase drugs
What are the signs/symptoms of myasthenic crisis?
*Increased pulse and respiration
*Increase BP
*Bowel and bladder incontinence
*Decreased urine output
*Absence of cough and swallow reflex
What is involved in treatment of myasthenic crisis?
*Maintain ventilatory function
*Tensilon test: if muscle activity returns (+ tensilon test) give Tensilon
What is a cholinergic crisis?
An acute exacerbation of muscle weakness caused by overmedication with cholinergic drugs (Tensilon)
What are the symptoms of a cholinergic crisis?
*Nausea, vomiting, diarrhea
*Abdominal cramps
*Blurred vision
*Facial muscle twitching
What is involved in treatment of cholinergic crisis?
Hold anticholinergic drugs (Tensilon) and give Atropine (which will thicken secretions so watch airway)
What is the antidote for Tensilon?
What should a nurse teach a patient regarding the drug Mestinon?
*Take with milk/crackers 30-60 min a.c.
*Maintain steady blood levels (Take same time each day)
*Take drugs before any activity
*Avoid muscle relaxants, aminoglyocides, magnesium (these increase muscle weakness)
What is important to know regarding nutrition/feeding with clients who have myasthenia gravis?
*Small, frequent meals and high calorie snacks
*Record client’s calorie counts, serum albumin levels, daily weights, I & O
*Assess client’s gag reflex and ability to chew and swallow
*Frequent oral hygiene
*Keep head of bed elevated during and after meals (30-60 min)
*Avoid liquids
*Administer anticholinesterase drugs (Tensilon or Prostigmin) 45-60 min prior to meals
What is involved in Tensilon testing?
Tensilon is injected IV and within 30 -60 seconds, most MG clients show a marked improvement in muscle tone that last 4-5 mins. (+ Test)
What are the dangers of Tensilon testing?
*Ventricular fibrillatino
*Cardiac arrest
What is Guillain Barre Syndrome?
*Cell-mediated immunologic reaction
*Patients have history of acute illness, surgery, immunization, trauma, respiratory infection, Epstein-Barr virus, CMV (which causes T-cells to attack myelin)
*Acute autoimmune disorder
*Mortality is usually from complications of resp. compromise-emboli or respiratory arrest
*Immune system destroy the myelin sheath around axons resulting in slow conduction of impulses
*Self limiting disease, paralysis temporary
*Ascending GBS is most common form
What is important to know regarding the care of a patient with Guillain Barre Syndrome?
*Assess respiratory function
*Pain control
*ROM and change position q 2 hr
*Plasmopheresis: removal of antibody
*Put on cardiac monitor
*Hypertension: treat with beta blockers or nitroprusside
*Hypotension: treat with IV fluids and pt is supine
*Atropine for bradycardia
*If urinary retention: insert foley and strict I & O’s