Cindy Exam 1

Front 1

What three things do we look at with the Glasgow coma scale?

Back 1

Eyes, Verbal and Motor

Front 2

What's the highest score you can get on the Glasgow coma scale? Lowest?

Back 2

15 (Best)
3 (Worst)

Front 3

How are the eyes classified on the Glasgow coma scale?

Back 3

Does not open eyes (1)
Opens to painful stimuli (2)
Opens in response to voice (3)
Opens spontaneously (4)

Front 4

What are the verbal classifications on the Glasgow coma scale?

Back 4

Makes no sounds (1)
Incomprehensible sounds (2)
Utters inappropriate words (3)
Confused, disoriented (4)
Oriented, converses normally (5)

Front 5

What are the motor classifications on the Glasgow coma scale?

Back 5

Makes no movements (1)
Extension (decerebrate) to painful stimuli (2)
Abnormal flexion (decorticate) to painful stimuli (3)
Flexion/withdrawal to painful stimuli (4)
Localizes painful stimuli (5)
Obeys commands (6)

Front 6

Nursing interventions for increased ICP

Back 6

Maintain patent airway
Head elevated 35-40 deg. neck non-flexed
Monitor ABG's
Cool environment
Neuro checks Q15min
Position Q2hrs (Passive ROM)
Space out client care activities
Prevent constipation (no valsalva)
Minimize stress
Limit suctioning

Front 7

Drugs for ICP

Back 7

Mannitol (diuretic)
Decadron (steroid)

Front 8

Assessments for ICP

Back 8

Pulillary functions (same side as lesion remains dilated)
Visual disturbances
Motor function changes (progressive weakness on side opposite lesion)
Headache (cough, strain, stoop, progressive)
Widened pulse pressure (systolic up, diastolic down or same)
Bradycardia (vagal stimulation)
CUSHING'S RESPONSE: Widening pulse pressure, systolic up, slow pulse
Respirations (r/t level of stem compression)
Temp: rises (hypothalmic pressure)usually late

Vomiting (early)

Front 9

Early signs of ICP

Back 9

Restless, disoriented, lethargic
Vague headache
Contralateral hemiparesis (weakness)
Stable VS
Ipsilateral pupil dilation
Vision: blurring, decreased acuit, diplopia
Usually no vomiting
Normal temp
No papilledema (optic disk swelling)
Brain herniation absent or just beginning

Front 10

Late signs of ICP

Back 10

Coma
Increasing headache pain
Decorticate, decerebrate, then flaccid posturing
Cushing's response
Irregular respirations
Pupils dilated bilaterally and fixed
Projectile vomiting
Eleveted temp
Maybe papilledema
Brain herniation

Front 11

What to check for a PT on direct ICP monitoring

Back 11

Inscision for s/s of infection

Front 12

Nursing interventions for the unconsious client

Back 12

AIRWAY: position, side 30-45deg.; suction; ascultate; vent tube patency/settings; oral care; ABGs
FLUID/NUTRITION BAL.: I&O; Slow IV admin; TPN?NG feeds
MAINTAIN MEMBRANES: saline rinse; lip lube
SKIN INTEGRITY: T&P Q2; alignment; passive ROM; foot board; bony prom. pads; trocanter rolls
CORNEAL INTEGRITY: risk for ulcers; art. tears Q2; eye patch
THERMOREGULATION: hypothalamus; rectal temps; temp determined by condition
URINARY RETENTION: palpate; catheterize; assess for UTI
BOWEL FNCTN.: sounds; girth; impaction exam; softeners; monitor BMs
FAMILY: allow to vent; support; allow involvement

Front 13

What's a seizure?

Back 13

A paroxysmal and abnormal electric firing of brain neurons (GRAY MATTER)

Front 14

What's epilepsy?

Back 14

Recurring seizures without a metabolic or systemic cause

Front 15

What's a tonic-clonic seizure?

Back 15

AKA grand mal - abrupt loss of consiousness

Front 16

What does a tonic-clonic (grand mal) seizure look like?

Back 16

Abrupt loss of consiousness
Body stiffens (5-30 sec.)
Shrill cry
Apnea
Pupillary changes
Inc. HR, BP, saliva
Clonic Phase (10-30 sec.) (jerking)
Sphincter relaxation
Consiousness returns (10- 30 min.)
Awakens w/ headache, exhaustion, no memory

Front 17

What are precipitating factors of a tonic-clonic (grand mal) seizure?

Back 17

Emotional stress
Fatigue
Loss of sleep
Menstrual periods
Fever/Ilness
Specific sensory stimuli/activities
Med non-compliance

Front 18

Nursing interventions for seizures

Back 18

Bed in low position
Call light in resch
Oral airway, suction & O2 at bedside
Pad siderails
**During Seizure: Stay w/ PT; maintain airway; pupport/potect head; turn on side; ease to floor/pad rails; loosen clothing; NOTE: freq. time, length and type
**After Seizure: maintain airway; suction if necess.;check VS; O2 if necess.; reorient; oral hygene; Document: what preceeded; type, time, duration, interventions
ADDRESS ANXIETY: theraptc. comm.; ID coping mech. & alternatives; health teaching; refer to profs.; increase social support

Front 19

Effects of cervical tumors - C4 and above

Back 19

Sensory: Vertigo
Motor: Quadriparesis; sternoclmstd. atrophy; dysphagia (diff. swallow); dysarthria (motor speech diff.); tongue deviation; resp. insuff.;
Other: occipital headaches; nuchal rigidity; nystagmus; papilledema

Front 20

Effects of tumors - C4 and below

Back 20

Sensory: Paresthesia; Horner's sundrome
Motor: Weakness; muscle atrophy
Other: shoulder and arm pain

Front 21

Effects of thoracic tumors

Back 21

Sensory: hyperesthesia band above level of lesion
Motor: spastic paresis of lower extremeties; positive Babinski; lower motor neuron deficits
Other: sphincter impairment

Front 22

Effects of lumbar tumors

Back 22

Sensory: localized loss in legs & saddle area
Motor: footdrop, decreased or absent patellar & achilles ref.
Other: severe low back pain with radiation down legs; perianal and bladder discomfort; decreased libido; impotence; bladder disturbances

Front 23

What's a laminectomy?

Back 23

Surgery to relieve compression of the spinal cord, usually lumbar or cervical, midline incision - laminae and ligaments removed.

Front 24

What to do after lumbar spinal surgery

Back 24

Bedrest first 24h
Ambulate 2nd post-op day
HOB flat or 5-10 deg.
Log roll to reposition
Avoid sitting first 2 days (except to defecate)
TEDS
Assess dressing, remove third day

Front 25

What to do after cervical spinal surgery

Back 25

Bedrest first 24hrs.
Ambulate 2nd post-op day
HOB flat or 5-10 deg.
Cervical collar
TEDS

Front 26

Neuro assessment for cervical laminectomy/disectomy

Back 26

Weakness of upper extremities and shoulders
Increase sensory loss (upper)
Decreased reflexes
Horner's syndrome: ipsilateral pupil smaller, sunken, ptosis; lack of ipsilateral perspiration (w/ ant. cerv. discectomy)
Dysphagia/vocal cord paralysis

Front 27

Neuro assessment for lumbar laminectomy/disectomy

Back 27

Weakness/Increased sensory loss of lower extremities
Decreased reflexes

Front 28

Potential problems seen with a tumor in the Frontal Lobe

Back 28

PERSONALITY DISORDERS (untidiness, obscenities)
parts of speech
movement
emotions
problem solving
reasoning
planning

Front 29

Potential problems seen with a tumor in the Parietal Lobe

Back 29

movement
orientation
recognition
perception of stimuli
writing/math

Front 30

Potential problems seen with a tumor in the Occipital Lobe

Back 30

visual processing

Front 31

Potential problems seen with a tumor in the Temporal Lobe

Back 31

perception and recognition of auditory stimuli
memory
speech
spatial perception disturbances

Front 32

Potential problems seen with a tumor in the cerebellum

Back 32

dizziness
ataxia
staggering gait
nystagmus

Front 33

Nursing diagnoses for a client with a brain tumor

Back 33

Fluid Vol. Deficit (r/t chemo & radiation)
** I&O, turgor, BP/HR, Admin oral & IV intake, antiemetics
Body Image Disturbance (r/t hair loss, change in body structure/function)
** theraputic relationship, assess perceptions, encourage venting, promote social inter.
Impaired Skin Integrity (r/t chemo & radiation)
** assess, clean & dry, egg crate, T&P Q2, encourage fluid/nutrition
Anticipatory Grieving (r/t actual/perceived death)
** anticipate anger twds. nurse, encourage discussion of fear, help with planning, emotional support, refer to groups & hospice counseling

Front 34

What's normal specific gravity?

Back 34

1.010 - 1.030

*1.005 = diabetes insipidus

Front 35

Nursing management for a client with a craniotomy

Back 35

Altered cerebral tissue perfusion (r/t cerebral edema - peaks 24-72 hrs. post-op)
Neuro checks Q1H w/ vitals
Check for s/s of increasing cerebral edema (pupils, pulse press, brady, etc)
Supratentorial: HOB 30-45
Fratentorial: HOB 0-20
Health teaching: avoid hip flex, iso. exercize, coughing, straining)
Maint. normothermia
Maintain O2 (low increases ICP)
Seizure prec.
Planning to minimize ex. stim.
Corticosteriods/Osmotic diuretics

Front 36

Signs of increased ICP

Back 36

Change in LOC
Pupil size
Widening pulse pressure
Bradycardia
Decreased resp. rate

Front 37

Nursing diagnoses for a client with a craniotomy

Back 37

Pain (r/t headache/incisional discomfort)
** Assess Q2, analgesics, comfort measures
Potential for infection (r/t surgery, immunosupp.) ** Brudinski/Kernig's signs? (raise neck, knees come up)
Fluid Vol. Deficit (r/t diuretics {Mannitol}, DI)
** Specific gravity, I&O, Vasopressin
Impaired gas exchange
Body Image

Front 38

Nursing diagnoses for a client after transphenoidal surgery

Back 38

Altered mucous membranes
** I&0, no toothbrush for 10 days,
Alt. Visual Perception
Fluid Vol. Deficit
INFECTION: PN drip? Excessive Swallowing? Glucose test, no nose blowing/cough, Nuchal rigidity, Brudinski/Kernig's signs? (raise neck, knees come up)

Front 39

Nursing care for a client after an endarterectomy

Back 39

Potential Altered Cerebral Tissue Perf.
** Monitor temporal artery pulses, assess for swallowing difficulties, hoarseness, neuro checks
Potential decreased CO
*BP, pulses (incl. peripheral)
Potential Ineffective Breathing Pattern
** Assess recp. QH, tracheal position, ABG's, secretions, spirometer

Front 40

What's a cerebral aneurism?

Back 40

Localized dilation that develops secondary to a weakness of the arterial wall

Front 41

What are some compilcations of subarachnoid hemorrage from aneurysm rupture?

Back 41

REBLEEDING - first 24-48 hrs., and again 7-10 days after first episode
DIABETES INSIPIDUS
VASOSPASMS: 4-10 days after hemorrage
ICP

Front 42

Aneurysm precautions

Back 42

Bedrest/Quiet Environment
Darken Room
Restrict Visitors
Mild Sedatives/Analgesics
Soft, High-Fiber Diet
Stool Softeners, No Enemas
Perform ADL's

Front 43

Clinical manifestations of aneurysms

Back 43

Usually asymptomatic till they rupture
Some experience headache, photophobia, nuchal rigidity, neuro deficits depend on locn., BRUIT

Front 44

What's a stroke?

Back 44

Ischemia of brain tissue normally perfused by a damaged vessel
Occurs either via occlusion (thrombus/embolus) or hemorrage

Front 45

What's a TIA? Clinical manifestations?

Back 45

Temp. episode of sudden loss of motor, sensory or visual function. LASTS: few seconds - 24hrs. (often caused by temp. impairment of blood flow to brain)

Clinical Manifestations:
Carotid - sudden painless loss of vision in one eye
Bacillary - vertigo, diplopia, dec. LOC, numbness/weakness, aphasias

Front 46

What's Anosognosia?

Back 46

Physiological denial of current condition & resulting deficits

*Unable to realize something has happened to them

Front 47

What's Agnosia?

Back 47

Unable to recognize the meaning of perceptual stimuli

Loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective

Front 48

What's Apraxia?

Back 48

Unable to carry out a motor act despite intact motor and sensory systems, good comprehension, and full cooperation

Front 49

What's Broca's Aphasia?

Back 49

Verbal, motor or expressive aphasia

Restricted vocabulary, poorly articulated words, grammar restrictions

Front 50

What's Wernicke's Aphasia?

Back 50

Sensory, acoustic or receptive aphasia

Impaired auditory comprehension, speech fluent but lacks meaningful content

Front 51

Side effects of t-PA

Back 51

BLEEDING
intercranial - VS & Neuro checks
IV insertion site
Urinary catheter
ET tube
NG tube
Urine
Stool
Emesis

Front 52

t-PA interventions

Back 52

Give within 3hrs of diagnosis, IF not on anticoagulants, no recent surgeries, head injuries, seizures

Monitor for bleeding, hold NG tubes, catheters, art. lines for 24 hrs. monitor BP (<180/105)

VS Q15 - 2hrs; Q30 - next 6; Qhr - till 24 hrs.

Front 53

General guidelines for antineoplastics

Back 53

Particularly susceptable areas: Bone marrow, GI mucosa, Hair follicles

Withold chemotherapy if WBC count <2000; Platelets <100,000

GI tract toxicity - oral ulcers, intestinal bleeding, nausea, vomiting, loss of app., diarrhea

Front 54

Side effects of antineoplastics

Back 54

Bone marrow depression (leukopenia, thrombocytopenia) maybe irreversible
Agranulocytosis (Anemia)
GI disturbances
Hepatic toxicity
Dermatosis
Immunosupression
CNS - depression, lethargy, etc.
GU - acute renal failure, reproductive abnormalities

Front 55

Nursing considerations with antineoplastics

Back 55

Avoid preparation if pregnant
Prepare under a laminar flow hood
Latex, not vinyl gloves
Good handwashing
Prevent contact with skin or mucosa
Disposable non-permeable gown
Goggles

Front 56

Nursing assessment with antineoplastics

Back 56

Check infusion sites
Monitor CBC, Renal andLFT's
Assess I&O, VS, skin
Assess client/family understanding, coping, living will

Front 57

Antineoplastics interventions

Back 57

Monitor VS, I&O
Report pain, redness, edema at injection site
For Extravasation: stop & follow protocol, aspirate, antidote, apply ice (heat if vinca alkyloid)

Front 58

Decadron

Back 58

Corticosteriod (to decrease ICP)

Front 59

Dilantin (Phenytoin)
Tx:
Contraindications:

Back 59

Tx: Tonic-clonic epilepsy, parenteral: status epilepticus & to control seizures during neuro surgery

Contraindications: Liver/renal impairment, Pregnancy, Lactation

*Check Ca levels - bone demineralization (osteomalacia in adults, rickets in children)

*Check for rashes, gingival hyperplasia, hematopoetic, aranulocytosis, aplastic/hemolytic anemias

Front 60

Depakene (Valproic acid)
Tx:
Contraindications:

Back 60

Tx: Simple and complex absence seizures (petit mal), multiple seizure patterns, complex patrial seizures
Contraindications: Liver disease//dysfunction, urea cycle disorders, lactation, pregnancy

*Administer at bedtime
*Do not consume w/ CNS depressants
*Do not chew tablets
*Monitor CBC, bleeding times, LFT's
*Check for pancreatitis, rashes, visual dis., bleeding/bruising

Front 61

Tegretol (Carbamazepine)
Tx:
Contraindications:

Back 61

Tx: partial seizures with complex symptoms, tonic-clonic seizures, children under 6
Contraindications:Hx of bone marrow supression, Geriatric patients may experience confusion, agitation, AV heart block, Diabetes Insipidus, bradycardia

Front 62

Carmustine (BCNU)

Back 62

Wafers

NSG Implications:
Bone marrow depression (monitor CBC's) Take only Q 6 weeks.
Thrombocytopenia/leukopenia -bleeding/infections
Pulmonary toxicity (hx of lung disease?) pulmonary fibrosis years after treatment (may be fatal)

*Give antiemetic first, expect severe flushing, contraception, no BF

Front 63

Lomustine (CCNU)

Back 63

Bone marrow supression (CBC's)
High incidence of n/v (3-6hr. post-admin. lasting 24hrs.)
Renal/pulmonary toxicity
Comes in capsules of 3 strengths (combine for right dose)
Take antiemetics first - n/v up to 36 hrs. post, the 2-3 days of anorexia
Avois all OTC agents

Front 64

Matulane (Procarbazine)

Back 64

KIDS: Tremors, seisures, coma

Caution with kidney or liver problems
N/V
Eye problems
Liver problems
CNS (many)
Resp. problems (pleural effusion
Blood Problems
GU problems (frequency)

*Boy breast enlargement, hearing loss, pain, myalgia, malignant myleosclerosis

NO TYRAMINE, SUN, ALCOHOL, PREGNANCY

Front 65

Vincristine (Oncovin)

Back 65

Leakage into surroundong tissue = severe irritation (intrathecal = death)

IV only
Neurotoxicity, gait, constipation, paralytic ileus (family should report)
Bronchospasm (family should report dysp., cough, fatigue)
Renal
Eye

*Assess for s/s of gout
*Birth control
*Prevent constipation

Front 66

Pregnant woman taking an anticonvulsant?

Back 66

Take Vit. K one month pre-delivery

Front 67

S/s of liver toxicity when taking an antoconvulsant

Back 67

Jaundice
Dark Urine
Appetite loss
Abdominal pain

Front 68

What to do about megaloblastic anemia when taking an anticonvulsant

Back 68

Take Folic Acid

Front 69

Anticonvulsant NSG implications

Back 69

IV - monitor for resp. depression/cereb. vasc. collapse
CNS side effects (blurring, slurring, nystagmus, confusion)
Watch for muscle twitch/bizzare behavior
No driving
Take with large amts. of fluid/food to avoid GI distress
Vit. D prevents hypocalcemia
Avoid alcohol/ CNS depressants
Oral Hygene
Increased chance of seizures w/ low sugar, sodium, fever
Hypersensitivity
Hematologic toxicity (sore throat, nosebleed)
Liver Toxicity
Vit. K for pregnant women
Folic acid prevents anemia