• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/53

Click to flip

53 Cards in this Set

  • Front
  • Back
Remember when you have an unconscious ER pt
CHECK YOUR ABC's Always check oxygenation first
Trained Assistive personnel
who are trained, can check capillary blood glucose levels as ordered
Cushings triad
systolic hypertension with widening pulse pressure, bradycardia with a full and bounding pulse, and irregular resp. Medical emergancy. Sign of brainstem compression and impending death
Widening pulse pressure
Bp 120/80--> 130/64--> 144/22
Decorticate (toward the core)
Internal rotation, adduction and flexion of the arms in an unconscious patient.
Measurment of ICP
Intravascular catheters increase the risk for infection, Monitor patient's oral temp. Could need abx or removal or monitor
The Vestriculostomy System
Helps show whether blood flow to the brain is adequate. Keep explanations short and sweet to the family members (IE monitors blood flow)
Medications for ICP
Given IV Mannitol (Osmitrole) goal to decrease ICP
Glasgow Coma Scale
Opens eyes to verbal commands, speech or shout, 3pts
Inappropriate respones, words discernible: 3 pts
Purposeful movement to painful stimulus: 5 pts = 11pts
A dilated or non responsice pupil may indicate
an intreacerebral hemorrhage and IICP
When managing pts with increased ICP
Keep HOB at 30 degrees or higher to help reduce IICP
Head Injury/ Family waiting
Allow family to stay with the pt, and briefly explain procedures to them. The need for information is very high in family members, putting them in the waiting room will increase there anxiety
Head trama includes
an alteration in consciousness, no matter how brief. If LOC changes, pt more difficult to arouse suspect IICP.
In head trama pts, if urine output greater than 30 mL per hour
suspect diabetes insipidus may be developing, Report to health care provider immediatly.
Following a head injury
pt should avoid operating heavy machinery including driving
Battle sign in Skull Fractures
Appears 7-10 days after injury (Brusing behind the ear indicating bleeding happened) Use Tes-Tape strips for glucose readings
Skull Fractures Rhinorreha or Otorrhea
indicates that a fracture has traversd the dura. Leaking fluid should be tested to determine if fluid is CSF.
Minor Head Trama (Concussion)
Provide discharge instructions about monitoring neurologic status and the need to return if neurologic status deteriorates
Coup-Contercoup Injury
If pt is taking Coumadin report to health care provider immediately. Increases risk for intracranial hemorrage.
Epidural Hematoma
Results from bleeding between the dura and the inner surface of the skull- Rapid surgery they remove the hematoma and prevent herniation.
Crainotomy/Suctioning
Suctioning increases ICP and is done only when the pt's respiratory condition indicates it is needed
Head Trauma Nursing Care
Impaired physical mobility- perform range of motion exercises every 4 hours to prevent the complication of immobility
Major focus of nursing care related to increased ICP
Post Suctioning
after suctioning you note the intracranial pressure has increased from 14 to 16 mm Hg. Check to be sure the patient's neck is not is a flexed position. It is normal for the ICP to increase after suctioning.
Pts leaking CSF
Raise the head of bed and do NOT pack the nose or ears.
Bacterial Meningitis
Organisms enter CNS from respiratory tract or bloodstream.- wear a mask- maintain respiratory isolation as well as standard precautions.
Meningitis Immunization
This is often secondary to a viral respiratory disease- Immunizing adolescents and college freshman against Neisseria meningitides will decrease the incidence.
Bacterial Meningitis and family
If pt disoriented and anxious encourage family members to remain at the bedside
Bacterial Meningitis Vitals
Vital signs- Shock is a serious complication of menigitis, watch for low BP
Brain Tumors-Frontal lobe tumors
Cognitive dysfuncion including mood problems and modd or personality changes-come from frontal lobe tumors (changes in judgment)
Sterotactic Surgery
Bolted in for surgery
Neurogenic Shock
Characterized by hypotension and bradycardia and warm extremities due to vasodilation
Spinal Injuries
Paralysis of all four extremities occurs (Tetraplegia {Quadriplegia})
Spinal Injuries: Injury to T1
Will retain full motor and sensory function of the arm
Spinal Injuries: Injury to T10
Will result in neurogenic bladder. Teach the patient how to self-catheterize
Methylprednisolone (MP)
When administered early and in large doses, recovery of neurologic function greater, eval leg strength and sensation.
Nursing Diagnoses for tetra or paraplegic
Risk for automonic dysreflexia- Teach the purpose of a prescribed bowel program. Fecal impaction is a common stimulus
Ineffective coping- Pt will grieve. Allow pt to verbalize feelings, Ask for the patient's input into the plan of care.
Brown-Sequard Syndrome (Result of damage to one half of the spinal cord)
Vasomotor paralysis on the same side as lesion- If turning pt. to the right, position the patient's right leg when turning the patient.
Respiratory Dysfunction in the Halo Vest
Respiratory distress may occur, assessing respiratory function is the 1st priority
Autonomic Dysreflexia
Massive uncomensated cardio reaction mediated by sympathetic nervous system: Throbbing headache: CHECK BP
Rehab and Home Care after spinal injuries
To learn self-care- Family members who will be assisting with the pt's ongoing care need to feel that their input is important. Develop a plan to increase the pt's independence in consultation with the patient and spouse.
A pt with a C6 injury
should be able to push a manual wheelchair on flat, smooth surfaces.
Cervical level injury pts not on a ventilator need to learn:
Assisted coughing- Place the hands on the epigastric area and push upward when the pt coughs
Pts with a T3 injury will have:
sexuality changed, but there are options for expression of sexuality and for fertility
Spinal Cord Tumors
Sensory and motor problems-
Pt has a new onset of weakness in both legs requires immediate action. Indicates cord compression may be able to preserve function.
Guillian-Barre Syndrome
An acute, rapidly progressing and potentially fatal form of polyneuritis
Guillian-Barre Syndrome: Watch for
Respiratory paralysis- observe respiratory rate and effort. Respiratory failure is the most serious complication of Guillian-Barre Syndrome.
Guillian-Barre Syndrome: Pain
May be tx with high-dose immunoglobulin to reduce the extent and length of sx.
Guillian-Barre Syndrome: Respiratory
If pt starts drooling-requires immediate action, monitor airway patency
Questions to ask to get pts to discribe pain
How would you descride your pain? Because pain in a multidimensional experience, asking a quetion that addresses the pt's experience with the pain is likely to elicit more information.
Dimensions of Pain: Cognitive
Imagery and hypnosis are cognative therapies. They impact the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.
Cognative questions about pain
asking if the pain keeps the person from doing things they enjoy assesses the pts function and quality of life
Amitriptyline (Elavil)-
Trycyclic antidepresants are effection for treating neuropathic pain.
Pt states they feel depressed because they ache too much to play golf
HIGHEST nursing priority for the nurse when developing the nursing treatment plan is that the patient will be able to play 1 to 2 rounds of golf.