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21 Cards in this Set
- Front
- Back
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Ataxia
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Impaired coordination of movements.
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Spasticity
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muscle hypertonicity
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S/S of MS
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Ataxia, spasms, tremors, tinnitus, vertigo, dysphasia, blurred vision, diplopia, nystagmus, bowel and bladder dysfunction, fatigue, depression, weakness, limb numbness, pain.
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What is autonomic dysreflexia characterized by?
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Severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing.
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What usually causes autonomic dysreflexia?
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Most often caused by a distended bladder or constipation.
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What are immediate nursing actions for autonomic dysreflexia?
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Contact a HCP, sit pt. up in high Fowler's, remove noxious stimulus, loosen tight clothing, check for bladder distention, if pt. has a foley check for kinks in tubing, check for fecal impaction & disimpact if necessary, assess environment, & monitor vitals.
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What is angina almost always associated with?
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Obstruction of a major coronary artery.
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S/S of angina
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Pain that may radiate to the shoulders, arms, jaw, neck, or back; dyspnea; pallor; sweating; palpitations and tachycardia; dizziness and syncope; hypertension; digestive disturbances.
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Management of angina
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Nitrates, beta blockers, calcium channel blockers, antiplatelets and anticoagulants, and oxygen administration.
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Nitroglycerin nurse administration
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Administer sublingually; Assess pt's response (relief of CP & effect on HR/BP); If CP is unchanged or lessened but still present, nitroglycerin SL administration is repeated up to 3 doses; If pain is significant & continues, pt. is evaluated for MI. *Always check expiration dates.*
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Self-Administration of Nitroglycerin
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Make sure mouth is moist, tongue is still, & not to swallow until tab dissolves; Carry med at all times & keep secure in original container; Med is volatile & inactivated by heat, moisture, air, light, & time; Renew every 6 months; Med should be taken in anticipation of any activity thay may produce pain; Recommend pt. to note how long it takes to relieve discomfort; If pain persists after taking 3 SL tabs at 5min intervals, seek emergency medical services.
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Side effects of Nitroglycerin
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Flushing, throbbing headache, ↓BP, and ↑HR. Sit down for a few minutes when taking to avoid hypotension & syncope.
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Patient education for angina
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Nitroglycerin administration, diet modification, exercise program, and smoking cessation.
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Interventions for AAA
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Vital signs; Recording I&O's; B/L comparison of upper arm BP; Peripheral pulses; Motor & sensory function; Temperature & color of extremities; Capillary refill.
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What are indications of a rupturing AAA?
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Constant, intense back pain; falling blood pressure; decreasing hematocrit; ↑HR.
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What are risk factors for developing an AAA?
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Age (>50), male sex, tobacco use, family history, & hypertension.
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Risk factors for pericarditis
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MI & following a respiratory virus.
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S/S of Pericarditis
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SOB, friction rub, pain relieved when sitting forward, fever/chills, malaise, fatigue, & chest pain.
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Risk factors for endocarditis
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Valvular dysfunction, body piercing, degenerative valve disease, hx infective endocarditis, IV drug use, mitral regurgitation.
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Interventions for endocarditis
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Monitor the patient closely; Watch for complications; Dyspnea, ↑HR, crackles, and edema may be present.
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S/S of endocarditis
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Chills, fever, painful lesions, fatigue, murmur, petechiae, weight loss, anorexia, night sweats, & back/joint pain.
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