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48 Cards in this Set
- Front
- Back
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what are the different types of cerbral hematomas?
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Epidural, Subdural, Intracerebral
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where is the location and s/s of Epideral Hematoma?
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Location: Arterial blood collects between the skull and the dura
S/S: Client may e alert after initial unconsciousness, but then becomes increasingly lethargic before lapsing into coma. Common symptoms: headache, ipsilateral(same side as injury) hemiparesis( weakness or paralysis) |
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where is the location and s/s of subderal hematoma?
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venous blood collects between the dura and the subarchnoid layers.
S/S: deteriation of LOC is progressive. There are ipsilater pupil changes, deccreased extraocular muscle movement, and contralateral hemiparesis, with periodic episodes of memory lapse, confusion, drowsiness, and personality changes. |
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where is the location and S/S of intracerebral hematoma?
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blood collects within the brain
S/S: clinet shows classics signs of IICP: headache, vomiting, ,seizures, posturing, hyperthermia, irregular breathing. |
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what are L- sided epidural hematoma symptoms?
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paralysis/ or weakness of the right side of body. headache , may be alert after initial unconsciousness then becomes lethargic before slipping into coma.
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what is autonomic dysreflexia?
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an exaggerated sympathetic nervous system response amoung those with spinal cord injuries above T6.
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What triggers autonomic dysreflexia?
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Full bladder, abdominal distension, impacted feces, skin pressure or breakdown, overstretched muscles, sex, labor and delivery, sunburn below the cord injury, infected ingrown toenail, hot or cold environments over the counter decongestants
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characteristics of autonomic dysreflexia?
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severe hypertension, slow heart rate, pounding headache, nausea, blurred visioin, flushed skin, sweating, goosebumps nasal stiffness
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Guillian-Barre syndrome
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Acute post infectious polyneuropathy, ployradiculoneuritis. Affects the peripheral nerves and the spinal nerve roots
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Assessment finding of Guillin-Barre syndrome
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they vary : weakness, numbness, and tingling in the ars and legs that the client may perceive as painful often are the first symptoms. weakness is progressive and moves to upper areas of the body and affects the muscles of respiration. paralysis may follow muscle weakness. chewing talking and swallowing may become difficault.
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Nurse management of Guillian - Barre
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monitor for respirtory distress, encourage use of spiramator. check llung sounds for s/s of pneumonia
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what is Reye syndrome?
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occurs mostly in children . affects all organs but mostly the brain and liver. causes an acute increase in pressure in the brain. Normally occurs in conjunction with a viral infection such as chicken pox or the flu.
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what is Reye syndrome linked to ?
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Aspirin and viral infections
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what is an endarteretomy?
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Surgical removal of artherosclertotic plaque.
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What assessments should be performed on patient after an endarterectomy?
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Frequent neurologic checks to detect paralysis, confusion, facial asymmetry or aphasia Monitors heart rythm because of dysrhythmias can aler the flow to the brain. Monitor for swelling of the neck or difficaulty breathing or swallowing or hoarseness. the nurse places airway at bedside and is prepared for intuation if airway obstructed.
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Coumadin has what contrainications with foods?
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foods high in vitamin K (asparagus, beans broccoli, brussel sprouts, cabbage, cauliflower, collards, green tea, kale, milk, spinach, seiss chard, turnups, yogurt
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Multiple Sclerosis
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Chronic progressive disease of the peripheral nerves. normally between 20-40 yr olds.
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what is the cause of MS?
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unknown
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what is demyelinating disease?
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it causes permanent degeneration and destruction of myelin.
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What is myelin?
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Myelin acts as an insulator, enabling nerve implulsess to pass along a nerve fiber.
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what happens with the loss of myelin?
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the loss of myelin interrupts transmission of impulses along nerve axons.
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cerebral hematoma
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bleeding into the cerebrum, the largest section of the brain resulting in an expanding mass of blood that damages surrounding tissues by compressing and cutting off it's blood supply
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S/S of cerebral hematoma
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sudden loss of consciousness, sudden headaceh, following by nausea and vomitting, weaknes or paralysis on one side, aphasia, and pronounced confusion.
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Causes of cerebral hematoma
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most result from head trauma or cerebral ascular disorders which include obesity, high cholesterol, hypertension, sedentary lifestyle and chronic use of tobacco
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review visitor interaction with a paatient that has a head injury
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keep stimulation to a minimum.
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What are the different levels of consciousness?
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1. Conscious
2. Somnolent or lethargic 3. Stuporous 4. Semicomatose 5. Comatose |
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Conscious?
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responds immediately, fully, an appropriately to visual, auditory and other stimulation.
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Somnolent or lethargic?
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drowsy/ sleep at inappropriate times but can be aroused, only to fall asleep again. Delayed responses or inappropriate. speech is incoherent. Responds to painful stimuli
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Stuporous?
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aroused only by vigorous and continuous stimulation. One or two word answers. behavior towards avoiding further stimulation
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Semicomatose?
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unresponsive except to superficial, relatively mild painful stimuli to which mild movement to evade stimulation.
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Comatose?
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responds only to very painful stimuli by fragmentary, delaye reflex withdrawl: in deeper stages they lose all responsiveness. resp rate irregular.
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How to confirm CSF presence?
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use a dextrostick or testape strip with drainage from nose or ear. if positive. collect drainage on white absorbent pad. observe wet area after few minutes for a halo sign. if yellow ring encircles red ring, the yellow suggest CSF
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what instructions would you give a client on seizure medication?
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Take meds as prescribed
recognize adverse effects of the meds. keep routine follow up and lab appointments do not operate vehichle until 6 months after control of seizure. wear a medic alert bracet. Avoid situations known to trigger seiers |
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what are early signs of ICP?
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drowsy, difficault to awake
restless, confused, irritable, glasgow coma scale less than 13 personality changes sluggish/unequal pupil respons. weakness in arms/ legs slow slurred speech sull headache, vomit w/out nausea |
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what are late signs of ICP?
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unresponsive, glasgow coma scale less than 12.
decreased response to painful stimuli increased weakness/ hemiparesis. dilted pupils/ seizures/ cushing's triad, loss of gag |
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Cushings Triad?
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bradycardia, elevated systolic BP w/ wide pulse pressure. irregular breathing
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what is the medication Requip used for/
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Management of s/s of idiopathic parkinsons disease. decreases tremors and rigidity in parkinsons.
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What is the action of the drug Mestinon?
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pyriostigmine bromide- generic prolong the action of acetylcholine, which sustains muscle contraction.
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what is mestinon used for/
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Myasthenia gravis( a neuromusclar disorder characterized by severe weakness of one or more groups of skelaatal muscles.
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what is ptosis?
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drooping of the eyelids /( Is a manifestation of myasthenia gravis.)
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what are some nursing interventions for a client with bacterial menegitis?
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VS, performm a neuro exam and continue w/ a flow sheet for comparison. Observe rate and characteristics of respirations and ausculatates the lungs q 4- 8 hours.
Evaluates client ability to swallow and clear the airway of secretions. Records bowel elimination to assess for constipation assess severity of headache . if seizure, then document duration and where it affected ( one side or both) |
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parkison results from what?
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a deficiency of neurotransmitter dopamine. so the globus pallidus becomes overactive. the imbalance results in a movement disorder.
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s/s of parkinsons
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early: stiffness (rigidity) and tremors of one or both hands. bradykinesia ( performing spontaneous movements slowly), hypophonia(low volume of speech) a shuffling
late stages: slurred speech, difficault chew and swallow. contractures. droooling |
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What are the different types of seizures?
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Partial (focal)
complex Partial Generalized Unclassified |
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Partial (focal ) seizure
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no loss of consciousness
Motor symptom special sensory symptoms autonomic symptoms Psychic symptoms |
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Complex Partial (focal ) seizures
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1. begin as a partial seizure and progresses to complex partial with loss of consciousness.
2. Loss of consciousness at onset of seizure |
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Generalized seizure
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a. absence seizures
b. myolclonic seizures c. clonic seizures d. tonic seizures e. tonic-clonic seizure f. atonic seizures |
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Unclassified seizures
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all seizures that do not fit into other classifications.
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