Med/surg #1 Semester 6

Front 1

Remember when you have an unconscious ER pt

Back 1

CHECK YOUR ABC's Always check oxygenation first

Front 2

Trained Assistive personnel

Back 2

who are trained, can check capillary blood glucose levels as ordered

Front 3

Cushings triad

Back 3

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

Front 4

Widening pulse pressure

Back 4

Bp 120/80--> 130/64--> 144/22

Front 5

Decorticate (toward the core)

Back 5

Internal rotation, adduction and flexion of the arms in an unconscious patient.

Front 6

Measurment of ICP

Back 6

Intravascular catheters increase the risk for infection, Monitor patient's oral temp. Could need abx or removal or monitor

Front 7

The Vestriculostomy System

Back 7

Helps show whether blood flow to the brain is adequate. Keep explanations short and sweet to the family members (IE monitors blood flow)

Front 8

Medications for ICP

Back 8

Given IV Mannitol (Osmitrole) goal to decrease ICP

Front 9

Glasgow Coma Scale

Back 9

Opens eyes to verbal commands, speech or shout, 3pts
Inappropriate respones, words discernible: 3 pts
Purposeful movement to painful stimulus: 5 pts = 11pts

Front 10

A dilated or non responsice pupil may indicate

Back 10

an intreacerebral hemorrhage and IICP

Front 11

When managing pts with increased ICP

Back 11

Keep HOB at 30 degrees or higher to help reduce IICP

Front 12

Head Injury/ Family waiting

Back 12

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

Front 13

Head trama includes

Back 13

an alteration in consciousness, no matter how brief. If LOC changes, pt more difficult to arouse suspect IICP.

Front 14

In head trama pts, if urine output greater than 30 mL per hour

Back 14

suspect diabetes insipidus may be developing, Report to health care provider immediatly.

Front 15

Following a head injury

Back 15

pt should avoid operating heavy machinery including driving

Front 16

Battle sign in Skull Fractures

Back 16

Appears 7-10 days after injury (Brusing behind the ear indicating bleeding happened) Use Tes-Tape strips for glucose readings

Front 17

Skull Fractures Rhinorreha or Otorrhea

Back 17

indicates that a fracture has traversd the dura. Leaking fluid should be tested to determine if fluid is CSF.

Front 18

Minor Head Trama (Concussion)

Back 18

Provide discharge instructions about monitoring neurologic status and the need to return if neurologic status deteriorates

Front 19

Coup-Contercoup Injury

Back 19

If pt is taking Coumadin report to health care provider immediately. Increases risk for intracranial hemorrage.

Front 20

Epidural Hematoma

Back 20

Results from bleeding between the dura and the inner surface of the skull- Rapid surgery they remove the hematoma and prevent herniation.

Front 21

Crainotomy/Suctioning

Back 21

Suctioning increases ICP and is done only when the pt's respiratory condition indicates it is needed

Front 22

Head Trauma Nursing Care

Back 22

Impaired physical mobility- perform range of motion exercises every 4 hours to prevent the complication of immobility

Front 23

Major focus of nursing care related to increased ICP
Post Suctioning

Back 23

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.

Front 24

Pts leaking CSF

Back 24

Raise the head of bed and do NOT pack the nose or ears.

Front 25

Bacterial Meningitis

Back 25

Organisms enter CNS from respiratory tract or bloodstream.- wear a mask- maintain respiratory isolation as well as standard precautions.

Front 26

Meningitis Immunization

Back 26

This is often secondary to a viral respiratory disease- Immunizing adolescents and college freshman against Neisseria meningitides will decrease the incidence.

Front 27

Bacterial Meningitis and family

Back 27

If pt disoriented and anxious encourage family members to remain at the bedside

Front 28

Bacterial Meningitis Vitals

Back 28

Vital signs- Shock is a serious complication of menigitis, watch for low BP

Front 29

Brain Tumors-Frontal lobe tumors

Back 29

Cognitive dysfuncion including mood problems and modd or personality changes-come from frontal lobe tumors (changes in judgment)

Front 30

Sterotactic Surgery

Back 30

Bolted in for surgery

Front 31

Neurogenic Shock

Back 31

Characterized by hypotension and bradycardia and warm extremities due to vasodilation

Front 32

Spinal Injuries

Back 32

Paralysis of all four extremities occurs (Tetraplegia {Quadriplegia})

Front 33

Spinal Injuries: Injury to T1

Back 33

Will retain full motor and sensory function of the arm

Front 34

Spinal Injuries: Injury to T10

Back 34

Will result in neurogenic bladder. Teach the patient how to self-catheterize

Front 35

Methylprednisolone (MP)

Back 35

When administered early and in large doses, recovery of neurologic function greater, eval leg strength and sensation.

Front 36

Nursing Diagnoses for tetra or paraplegic

Back 36

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.

Front 37

Brown-Sequard Syndrome (Result of damage to one half of the spinal cord)

Back 37

Vasomotor paralysis on the same side as lesion- If turning pt. to the right, position the patient's right leg when turning the patient.

Front 38

Respiratory Dysfunction in the Halo Vest

Back 38

Respiratory distress may occur, assessing respiratory function is the 1st priority

Front 39

Autonomic Dysreflexia

Back 39

Massive uncomensated cardio reaction mediated by sympathetic nervous system: Throbbing headache: CHECK BP

Front 40

Rehab and Home Care after spinal injuries

Back 40

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.

Front 41

A pt with a C6 injury

Back 41

should be able to push a manual wheelchair on flat, smooth surfaces.

Front 42

Cervical level injury pts not on a ventilator need to learn:

Back 42

Assisted coughing- Place the hands on the epigastric area and push upward when the pt coughs

Front 43

Pts with a T3 injury will have:

Back 43

sexuality changed, but there are options for expression of sexuality and for fertility

Front 44

Spinal Cord Tumors
Sensory and motor problems-

Back 44

Pt has a new onset of weakness in both legs requires immediate action. Indicates cord compression may be able to preserve function.

Front 45

Guillian-Barre Syndrome

Back 45

An acute, rapidly progressing and potentially fatal form of polyneuritis

Front 46

Guillian-Barre Syndrome: Watch for

Back 46

Respiratory paralysis- observe respiratory rate and effort. Respiratory failure is the most serious complication of Guillian-Barre Syndrome.

Front 47

Guillian-Barre Syndrome: Pain

Back 47

May be tx with high-dose immunoglobulin to reduce the extent and length of sx.

Front 48

Guillian-Barre Syndrome: Respiratory

Back 48

If pt starts drooling-requires immediate action, monitor airway patency

Front 49

Questions to ask to get pts to discribe pain

Back 49

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.

Front 50

Dimensions of Pain: Cognitive

Back 50

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.

Front 51

Cognative questions about pain

Back 51

asking if the pain keeps the person from doing things they enjoy assesses the pts function and quality of life

Front 52

Amitriptyline (Elavil)-

Back 52

Trycyclic antidepresants are effection for treating neuropathic pain.

Front 53

Pt states they feel depressed because they ache too much to play golf

Back 53

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.