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106 Cards in this Set
- Front
- Back
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ICP |
-intracranial pressure (pressure that occurs within the cranium) |
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Head injury |
-any traumatic damage to the head resulting from blunt or penetrating trauma of the skull -blood vessels, nerves, and meninges can be torn -bleeding, edema, and ischemia may result |
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Brain Tumour |
-an invasive neoplasm of the intracranial portion of the CNS |
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spinal cord injury |
-any one of the traumatic disruptions of the spinal cord, often associated with extensive musculoskeletal involvement -common injuries are vertebral fractures and dislocations such as those suffered in car accidents, airplane crashes, or other violent impacts |
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cerebral angiography |
-a radiographic procedure used to visualize the vascular system of the brain after injection of a radiopaque contrast medium |
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magnetic resonance imaging (MRI) |
- is a technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues within your body -pt's are placed in large, tube-shaped magnets; the magnetic field temporarily realigns hydrogen atoms in the pt's body |
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cerebral edema |
-an accumulation of fluid in the brain tissues-caused from infection, trauma, or exposure to certain toxins -early symptoms would be change in LOC, sluggishness, dilation in one or both pupils, gradual loss of consciousness -can be fatal if not treated ASAP! |
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Coma |
-a state of profound unconsciousness, characterized by the absence of spontaneous eye openings, response to painful stimuli, and vocalization |
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unconsciousness |
a state of complete or partial unawareness or lack of response to sensory stimuli -a result of hypoxia caused by resp. insufficiency or shock; from metabolic or chemical brain depressants such as drugs, poisons, ketones, electrolyte imbalance, trauma, seizures, CVA, brain tumour, infection |
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concussion |
damage of the brain caused by a violent jarring or shaking, such as a blow or an explosion |
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epidural hematoma |
- think of Epi as Emergency! -accumulation of blood in the epidural space, caused by damage to and leakage of blood from the middle meningeal artery, producing compression of the dura mater and thus the brain -if not rectified, may cause death |
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subdural hematoma |
- think of Sub as Slow bleed - accumulation of blood in the subdural space, usually caused by an injury or fall |
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aneurysm |
-a localized dilation of the wall of a blood vessel -may be caused by atherosclerosis and hypertension, trauma, infection, congenital weakness in vessel wall |
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stereotactic surgery |
Is a minimally invasive form of surgical intervention which makes use of a three-dimensional coordinate system to locate small targets inside the body and to perform on them some action such as ablation, biopsy, lesion, injection, stimulation, implantation, radiosurgery (SRS), etc. |
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seizure |
a hyperexcitation of neurons in the brain, leading to abnormal electric activity that causes a sudden, violent involuntary series of contractions of a group of muscles -may be tonic or clonic, unilateral or bilateral, generalized or partial-also called a convulsion |
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persistent vegetative state |
a state of wakefulness accompanied by an apparent complete lack of cognitive function, experienced by some pt's in an irreversible coma -brainstem functions are intact, but the cortex is permanently damaged |
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Ateleotasis |
-an abnormal condition characterized by the collapse of alveoli, preventing the respiratory exchange of carbon dioxide and O2 in a part of the lungs -S/S: diminished breath sounds; crackles; fever; dyspnea, but SAT O2 may be normal. |
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Hypothalamus |
-portion of the diencephalon of the brain -activates, controls and integrates the PNS (autonomic), endrocrine processes, and many somatic functions such as body temp, sleep, and appetite |
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Cushings Triad |
-a physiological nervous system response to increased intracranial pressure (ICP) that results in increased blood pressure, irregular breathing, and a reduction of the heart rate -a clinical triad variably defined as having irregular resp's (caused by impaired brainstem function), bradycardia& systolic hypertension (Widening Pulse Pressure) |
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decorticate posture |
-the position of a comatose pt in which the upper extremities are rigidly flexed at the elbows and wrists -suggestive of severe brain injury |
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Decerebrate posture |
-the position of a comatose pt in which the arms are extended and internally rotated, and legs are extended with feet in a forced plantar flexion -indicates compression of the brainstem at a low level (brainstem damage) |
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What is the Glasgow Coma Scale? |
-a quick, practical standardized system for assessing the degree of consciousness (or LOC) -involves eye opening, verbal response, motor response: these 3 things are numerically scored -GCS of 13-15: indicates mild brain injury (concussion) -GCS of 9-12: indicates moderate brain injury -GCS of 3-8: indicates severe brain injury (ICU, intubation, neuromonitoring, ICP monitoring, surgery) -GCS of 3 or below: compatible with brain death |
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What are the 3 components within the skull? |
1) Blood 2) Brain tissue 3) CSF |
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How does the blood in the brain compensate for increases in ICP? |
vasodilation/constriction of vessels of the brain to increase or decrease blood flow |
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How does the brain tissue compensate for increases in ICP? |
there could be tissue compression - but not much movement with this REMEMBER: THERE ISN'T MUCH ROOM FOR COMPENSATION IN THE SKULL: "THE BRAIN IN THE BOX" |
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How does the CSF compensate for increases in ICP? |
displacement of fluid into the brain stem and spine, or decreased production |
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What happens with the blood, CSF and brain tissue fail to compensate for increased ICP and there is no medical intervention?? |
-ICP continues to increase -brain stem compression -herniation of brain through the foramen magnum -neuronal compression -ischemia of brain tissue -DEATH!! |
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A patient is admitted with a BP of 130/90 and HR of 75. Which one of the following subsequent sets of vital signs would be most indicative of dangerously increased ICP? a) 90/50, HR 100 b) 70/48, HR 40 c) 110/40, HR 125 d) 148/93, HR 58 |
Think of Cushing’s Triad: 2 of the 3 elements of this triad involve widening pulse pressure (primarily by way of rising systemic BP), and a drop in HR. The only thing missing in this case is abnormal breathing patterns. So, option d) best reflects these signs |
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Which one of the following head trauma patients is most likely to receive a CT scan?
a) a pt with a GCS of 15 b) a pt with a GCS of 1 c) a pt with a GCS of 12 d) a pt who lost consciousness for 2 minutes |
Option c) is correct – a score of 12 or less will require a CT scan |
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It is 2330 and the nurse notices that the patient’s GCS score has fallen from 15 to 14. Which one of the following nursing interventions is the most appropriate? a) after ensuring patient safety,call the physician immediately b) ensure patient safety and call the physician in the morning c) continue to monitor and call the physician if the score falls below 14 d) continue to monitor and call the physician if the score falls below 13 |
Regardless of the patient’s baseline GCS scoring, a drop of 1 point at anytime requires the immediate attention of the physician, so option A is the best option |
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What is CPP? |
Cerebral Profusion Pressure |
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What is MAP? |
Mean Arterial Pressure |
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Does MAP & BP mean the same thing? |
YES! MAP is just a fancy way of stating the blood pressure. |
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Genitourinary System |
referring to the genital and urinary system of the body: the organ structures, functions or both. |
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Acute renal failure |
-characterized by oliguria and the rapid accumulation of nitrogenous wastes in the blood -many forms of ARF are reversible after the underlying cause has been identified |
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pyelonephritis |
-infection of the pelvis of the kidney -usually results from an infection that ascends from the lower urinary tract to the kidney -U&A reveals the presence of bacteria and WBCs -S/S include: fever, chills, pain in flank area, nausea, and urinary frequency |
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What physiological sign happens to one or both of the pupils when the occular-motor nerve is being compressed?
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-dilation of one or both pupils and sluggish response to light (on the same side as the injury)
-increased pressure could also constrict muscle movement, so the pt may not be able to move eye up or down and may have droopy eyelids |
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What is the assumed "normal range" of ICP? |
0-15 mm/Hg |
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What happens when there is an increase in ICP or a drop in MAP? |
This will decrease cerebral perfusion (CPP will drop) |
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What should the medical team do if a pt's CPP is too low and ICP is normal? |
Give IV fluids to add to blood volume (to increase MAP). |
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What should the medical team do if a pt's CPP is too low and ICP is too high? |
They should seek to bring down the ICP to therapeutic levels (0-15 mm/Hg)
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If a pt's CPP is too high, what should the medical team seek to do? |
They need to lower blood pressure to avoid increases in ICP and/or cerebral hemorrhage (lower MAP to lower CPP) |
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What happens with changes to a pt's vital signs in the late stages of increased ICP? |
-Cushings Triad -when the brain doesn't have anywhere to go but down (through the foreman magnum, which presses the brain on the hypothalamus), a pt's breathing could be abnormal (Cheyne stokes) or irregular breathing rate, their HR could be really low, and they could have a spike in BP. |
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What are some types of medications used to decrease ICP? |
-corticosteroids: thought to reduce intracranial pressure -Mannitol: (is an osmotic diuretic): It works by increasing the amount of fluid excreted by the kidneys and helps the body to decrease pressure in the brain and eyes, but if used long term, will have the opposite reaction -Barbiturate or benzodiazipine therapy: can cause a fall in BP, but will also decrease level of CNS, cause depression, sedation |
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What is another way to decrease ICP without medications? |
surgically drill burr holes to relieve pressure, or perform a craniotomy (removal of a part of the skull) until the pressure decreases |
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Why can't a pt with a T6 (or higher) spinal cord inury be taughter DB/C exercises? |
this injury will affect the intercostal muscles d/t the paralysis of the abdomen, leading to the inability to do DB/C exercises |
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If a pt has an injury above C4, will they need to be on a ventilator to assist in breathing? |
YES! Above C4 (phrenic nerve), movement of the diaphram is impaired. |
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What is spinal shock? |
-a loss of sensation and movement (below the injury site) that may last for days to months -it masks future functioning as some of these functions may return once the shock passes |
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What is neurogenic shock? |
-a form of shock that results from peripheral vascular dilation -for injuries above T6, the influence of the sympathetic NS is decreased, yielding bradycardia & vasodilation (drop in BP) -may last up to 6wks |
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How might a SCI influence the GU system? |
cause pt to have neurogenic bladder or incontinence |
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Why would a pt with a SCI at T3 (Vagus Nerve) be on metoclopramide? |
Metoclopramide: increases motility and emptying |
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What is autonomic dysreflexia? |
- is a reaction of the autonomic NS to overstimulation -S/S: sudden onset of severe high BP associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, decreased HR, anxiety, and sometimes by cognitive impairment -believed to be triggered by afferent stimuli (nerve signals that send messages back to the spinal cord and brain) which originate below the level of the spinal cord lesion |
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You have just found a pt who has suffered an unwitnessed fall. What do you do?
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1) assess for cervical spine injury (examine head/neck for abnormal positioning) 2) if suspected cervical spine injury, immobilize head/neck until emergency help arrives 3) Assess LOC(assessing for increased ICP), ABC's 4) work through questions on the GCS, examine pupils to rule out fast bleeding that would be an emergency
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How does the medication Methylprednisolone help with a SCI within the first 8hours post injury? |
-restores extracellular calcium (needed for nerve conduction) -decreases release of fatty acids from spinal cord tissues (less chance of metabolic acidosis) -decreases inflammation and edema (keeping adequate blood flow to spine, avoiding ischemia) -improves nerve impulse conduction |
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Nursing interventions for pt with SCI
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-assist with grief, depression, anxiety (counselling and medications)
-stimulation above the level of SCI (ROM and conversation) -monitor temp (warm blankets applied, fan to cool) -stabilization of spine (log roll in bed) -watch for S/S of autonomic dysreflexia, N/V (NG Tube), constipation -increase in fluid & fibre intake
-ABGs, intubation, repositioning q2hr, suctioning, chest physio, trachia care, skin care
-V/S and medications -peri-care, catheter care, total care may be required -compression stockings, assessment for DVT
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glomerulonephritis |
an inflammation of the glomerulus of the kidney, characterized by proteinuria, hematuria, decreased urine production, and edema
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urolithiasis |
-the presence of calculi in the urinary tract -Causes include: chronic dehydration, over heating, diet high in protein, family Hx, increase/decrease in pH over a longer period of time |
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Kidney cancer |
-also called renal cancer -is a disease in which kidney cells become malignant and grow out of control, forming a tumor -usually tumors appear in the tubules in the kidney (renal cell carcinoma) |
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bladder cancer |
-the most common malignancy of the urinary tract -risk increases with smoking and carcinogen exposure -S/S: hematuria, frequent urination, dysuria (painful or difficult urination) |
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nephrectomy |
-surgical removal of a kidney (d/t tumor or disease) -post op recovery is painful, DB/C exercises are difficult d/t incision being so close to diaphram -SOB needs to be dealt with immediately, as the pleura may have been accidentally nicked during surgery, causing spontaneous pneuomothorax |
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nephrostomy |
surgical procedure in which a flank incision is made so that a catheter can be inserted into the kidney pelvis to drain the kidney, often done to relieve obstruction |
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cystectomy |
surgical procedure in which all or part of the urinary bladder is removed, as may be required in treating bladder cancer |
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ureterolithiasis |
Formation or presence of calculi in one or both ureters |
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urinary diversion (ileal conduit) |
-a method of urinary diversion using intestinal tissue, where the ureters are implanted in a section of dissected ileum that is drawn through the abdominal wall (RLQ) to create a stoma -pt wears a pouch to collect urine |
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lithotripsy |
a treatment, typically using ultrasound shock waves, by which a kidney stone or other calculus is broken into small particles that can be passed out by the body |
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renal angiogram |
an imaging test to look at the blood vessels in your kidneys |
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renal biopsy |
-a medical procedure in which a small piece of kidney is removed from the body for examination, usually under a microscope -microscopic examination of the tissue can provide information needed to diagnose, monitor or treat problems of the kidney |
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end stage renal failure (ESRF) |
-inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolyes -may result from many other dx's -Tx usually includes restricted water and protein intake, and the use of diuretics; long-term hemodialysis or peritoneal dialysis is often begun and kidney transplantation is considered |
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hemodialysis |
-a cleansing of the blood of waste buildup
-usually run through a central venous catheter (CVC) or a Fistula (port-a-cath) -hooked up to a dializer (cleansing of blood outside body) -pt needs to restrict diet and fluids
-tx is usually 3 to 4 hrs, 3 X's/wk at a clinic/hosp
-takes a toll on body, increased risk of infection
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peritoneal dialysis |
-fluid instilled in the perineum and is perfused through a port in the abdomen
-30 min's 4X's/day, or hooked up at night
-waste fluid is collected in drainage bag; cleansing/exchange of fluid is done within the body
-most common occurring problem is peritonitis, by a failure to use aseptic technique!
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What is pre-renal failure? |
anything that is going to decrease GFR (ex: dehydration, blood loss, shock, sepsis) |
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How would we treat pre-renal failure?
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Treat the cause (ex: hypovolemia, decreased cardiac output, decreased peripheral vascular resistance, decreased renovascular blood flow): GIVE A BOLUS!
-this is treated within 2-3 days; should resolve quickly; if not treated, will lead to intra-renal failure |
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What is intra-renal failure? |
you have direct damage to renal tissue (ex: really bad infection or long term decrease in GFR) |
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What is post-renal failure? |
anything that will block urine flow from kidneys -most common reason: occlusion/obstruction of the ureters, bladder, urethra -could also be neuromuscular disorders (stroke, spinal damage) |
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How would we treat post-renal failure? |
1. Surgery (to remove stones) 2. Lithotripsy (Soundwaves) to break up stones to resolve occlusion issue -should resolve relatively quickly -if not treated, will lead to intra-renal failure |
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what happens when there is a decrease in GFR? |
-results in oliguria (little urine output) or anuria (not urine output) -these conditions lead to other issues like: 1. anemia 2. uremia (raised level of urea and other nitrogenous waste compounds) 3. altered WBC count 4. increased edema 5. metabolic acidosis (increase in H in urine) 6. decrease in erythropoietin (hormone which helps with RBC production) |
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What are the phases of ARF?
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1. Onset Phase (decrease in GFR) 2. Diuretic Phase (beginning to resolve, kidneys started to recover, starting to excrete waste, have NOT yet recovered ability to control urine concentration) 3. Recovery Phase (GFR back up) - most who recover from ARF achieve clinically normal kidney function again |
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Glomerulonephritis |
-an inflammation of the glomerulus of the kidney (usually affecting both kidneys) characterized by proteinuria, hematuria, decreased urine production and edema -caused by infection or autoimmune disorder -Nsg Interventions include: +++rest, restrict Na and fluids, diuretics & anti-HTN meds, corticosteroids & immuno-suppressants in some cases |
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acute pyelonephritis |
-infection of the pelvis of kidney (usually with intra-renal failure) -usually results from infection in the lower urinary tract to the kidney -nursing interventions include: reduce fever, relieve pain, promote rest/comfort, encourage increase in fluid intake, monitor in's/out's closely,U&A (looking for casts and WBCs), C&S urine and blood test to rule out infection, treat with Ax for UTI |
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Urolithiasis (urinary tract calculi) Collaborative Care |
1. Manage pain with narcotics 2. Increase fluids to flush out minerals (at least 2L/day) 3. Monitor GFR, urea, creatinine *4. Catheter care (minimize bacteria) 5. Cystoscopy to investigate/remove stones *6. Nephrostomy if ureter is obstructed 7. surgery to remove stones if needed 8. lithotripsy (sound waves) to break stones |
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What is the course of action with someone who is diagnosed with kidney cancer? |
Nephrostomy (tube directly into renal pelvis) |
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What takes place with someone who has bladder cancer? |
-transurethral removal of lesions -+++hydration for clot removal (possibly continuous bladder irrigation) -ileal conduit (stoma located in RLQ) -Body image changes (from having ileostomy) -empty collection bag when about 1/2 full |
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uremia |
build up of urea and other nitrogenous waste products in the blood that occur with renal failure |
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oliguria
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a diminished capacity to form and pass urine -less than 500 ml of urine every 24 hrs -usually caused by electrolyte imbalances, renal lesions, or urinary tract obstruction |
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anemia |
inadequate tissue oxygenation, d/t several possible causes -in ARF (d/t decrease in GFR) the hormone erythrompoetin isn't being released, therefore the production of RBCs are being affected |
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AIDS |
-acquired immunodeficiency syndrome -characterized by profound immunosuppression that leads to opportunistic infections and malignancies not commonly found in clients with functioning immune defences |
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HIV |
-the human immunodeficiency virus, a virus that weakens your immune system (which is your body’s built-in defense mechanism) against disease and illness
-this virus is able to construct DNA from the host body RNA using reverse transcriptase, a unique metabolic function -this type of synthesis with this type of virus is called retrovirus, due to the "backwards" synthesis from RNA to DNA
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antiretroviral |
drugs that are used to treat retrovirus' such as HIV
-HAART (highly active antiretroviral therapy) |
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opportunistic infections |
-infections caused by normally nonpathogenic organisms in a host whose resistance has been decreased by disorders such as DM, HIV, cancer, or by immunosuppressant drugs. |
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retrovirus |
-RNA viruses containing the enzyme reverse transcriptase in the virion -genetic information is stored in a molecule of RNA; after entering the target cell, the virus uses reverse transcriptase to direct the cell to make viral DNA -the DNA then become integrated into the DNA of the host cell |
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immunity |
-being insusceptible to or unaffected by a particular disease or condition |
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Health-Care Associated infections |
-are infections that patients get while receiving treatment for medical or surgical conditions -sometimes called "nosocomial" or "hospital-acquired" infections (ex: pneumonia, incision site infections, UTI, bloodstream infections) |
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Neoplasm |
any abnormal growth of new tissue, benign or malignant -also called tumour |
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Karposis Sarcoma |
-is a cancer that causes lesions to grow in the skin -affecting the mucous membranes lining the mouth, nose, and throat; lymph nodes; or other organs -the lesions are usually purple and are made of cancer cells, new blood vessels, red blood cells, and white blood cells |
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cryptosporidium virus |
-is a diarrheal disease caused by microscopic parasites, Cryptosporidium, that can live in the intestine of humans and is passed in the stool of an infected person -both the disease and the parasite are commonly known as "Crypto." |
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What are the 3 variable factors that impact HIV transmission? |
1. How much contact with body fluids 2. How high is the virulence (viral load level) 3. How is the host immune system |
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What is the window period if you were exposed to HIV? |
3 weeks to 3 months -you should be tested after 3 wks, and then again after 3 months |
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What is meant by CD4 count? |
-CD4 T-cells are the cells that HIV mostly target, as they have more sites to bind to than other WBC cells -it is the loss of T-cells that most disrupts the immune response |
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If someone has a CD4 count of 600, what does that tell you? |
-immune system is compromised -usual count for unaffected individual is a CD4 count of 800-1200/microlitre -anything below a CD4 count of 200 is considered having AIDS |
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Basic pathological process of an HIV infection
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1. HIV binds to CD4 receptors on T-cells 2. HIV enters the host cell 3. Viral DNA is incorporated into the host cell DNA 4. All "daughter cells" of the infected cell will also be affected 5. The host cell is eventually destroyed through this process
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How long does a normal CD4-T cell last compared with an infected CD4-T cell?
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Normally: lifespan is 100 days Infected with HIV: lifespan of only 2 days |
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How many CD4-T cells does HIV destroy per day? |
approximately 1 Billion CD4-T cells!!! |
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Where do CD4-T cells get made in the body? |
Bone marrow and thymus -they replace CD4-T cells for many years before the numbers get too low, thereby decreasing the immune capability -this is where AIDS and opportunistic infections and diseases come into play |
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Nursing interventions when supporting a client with HIV |
1. Teach about health-enhancing activities, such as adequate rest/sleep, proper nutrition, H2O intake, monitor of blood glucose, support groups, properly administration of ARV's, avoid sharing needles, do not donate blood, use barrier protection during sexual activity 2. Monitor for fever, infection S/S, CD4 count, liver function, kidney function, CBC, blood glucose, serum amylase & triglyceride levels (to determine effectiveness & toxicity of drug) 3. Provide emotional support to the patient!!! |
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Why might drug regime compliance be challenging for some clients? |
-many side effects can dramatically influence the ADL -some drugs cause dizziness or insomnia, fever, abdominal pain, N/V, numbness, burning of feet or hands, joint pain, chills, rash. -instruct patient to report these symptoms to their health provider |
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What to do when a needle stick happens?? |
1. Wash hands with soap and water. 2. Let the area bleed freely - do not press on area. 3. Notify charge nurse. 4. Notify security (usually they are First Aid) to fill out paper work for WCB 5. Visit Emerg. Dept ASAP. Tell them you are a health care worker...they will put you to the front of the line, especially with a needle stick injury |
