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66 Cards in this Set
- Front
- Back
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Expressive aphasia
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Cannot formulate language/thought processes
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Receptive aphasia
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Cannot understand language
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Dysarthria
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A speech problem involving the motor ability to form words, impairment of muscles involved in the production of speech
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Decorticate posturing
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An extension of the legs straight out and clt will have arms adducted and flexed
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Decerebrate posturing
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Extension of all extremities, rotation of the hand palms outwards (more serious than decorticate; brain stem involvement - impaired breathing); both are very serious conditions
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Glasgow Coma Scale
What the scores indicate and what three areas are being assessed? |
Quick way to assess clt's neuro impairment
Highest score is 15 8 and below - clt is comatose Lowest score is 3 (cannot be 0) Assessment areas: 1. Best eye opening response (1-4) 2. Best verbal response (1-5) 3. Best motor response (1-6) |
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Cheyne-Stokes respiratory pattern
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Hyperventilation with alternating periods of apnea
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Central Neurogenic Hyperventilation respiratory pattern
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Constant hyperventilation; RR is 25 or greater and may fluctuate but always hyperventilating
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Apneustic respiratory pattern
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Prolonged inspiration followed by few seconds of pause/no breathing; pons of brain stem is being affected since rate is affected
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Ataxic respiratory pattern
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Completely irregular breathing pattern, erratic; not going to be able to come up with definitive breathing rate
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IICP (increased intra-cranial pressure)
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A complication that can result from a head injury; pressure greater than 50 mmHg, potentially life threatening; anything greater than 15 mmHg is considered ICP; can result from hematoma, brain tumor, aneurysm
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S/S of IICP
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Earliest indications are very subtle; LOC change, irritability, anxiety, mental status continues to deteriorate, pupils may be PERRLA and then may have difference shortly after, restlessness, dec LOC; HA – sensitive to light, noise, BP and pulse changes; clt can go into coma and eventually die
Late Manifestation: Cushing’s Triad – increase in systolic BP, change in HR, widened pulse pressure (difference between systolic and diastolic)/change in body temperature |
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NI for IICP
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Relieve the cause of pressure; Meds - osmotic diuretics (mannitol), Corticosteriods (decadron) with stool softeners, Zantac, anti-emetics, prophylactic anticonvulsant meds (Phenobarbital); NG tube to prevent paralytic ileus and gas buildup; foley - monitor I&Os; antipyretics for fever, antibiotics (prophylactic); elevate HOB 30 deg; avoid straining, suction only if needed, decrease stimuli in the area, IV fluids NS or LR - monitor for fluid overload; mechanical hyperventilation - to blow off CO2 (lowered CO2 causes vasoconstriction to slow bleeding and to decrease ICP); surgery, craniotomy, pain control
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CVA generalized s/s
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HA, NV, confusion
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CVA focal s/s
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Related to side of infarction, hemoplegia (one sided paralysis), aphasia, visual disturbances (homonymous hemianopsia)
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NI for acute stage CVA
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Tx: monitor for IICP - admin decadron, mannitol, stool softeners, and anticonvulsants as ordered; heparin drip for blood clot
NI in acute stage: Maintain patent airway, maintain VS and neuro checks, observe for s/s of ICP, bed rest, maintain F&E balance, adequate nutrition (TPN for first 24-48 hrs) then poss PEG tube, IV therapy (usually 75ml/hr to avoid fluid overload), turn and reposition q 2 hr, maintain skin integrity, provide quiet, provide means of communication |
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NI for rehabilitation stage CVA - hemoplegia (one sided paralysis)
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Turn q2hrs, proper positioning to avoid foot drop, support paralyzed arm on pillows, active and passive ROM exercises q4hr, safety measures,
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NI for rehabilitation stage CVA dysphagia
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Make sure gag reflex is intact, elevate HOB, mouth care before and after meals and meds
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NI for rehabilitation stage CVA aphasia
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Give slow simple instructions, change topic very gradually, allow clt time to respond, anticipate what the clt is trying to say
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NI for rehabilitation stage CVA apraxia (loss of ability to form purposeful mvmts)
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Guide clt through movements, give clt ample time to do it
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NI for Homonymous Hemianopsia r/t CVA
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visual disturbance that can happen; loss of visual field to one side; when clt eating food they may only eat what they can see, let them know where things are and that they may have to turn their head to see, when walking have them take a few steps and then do a scan to avoid falls
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Cerebral aneurysm
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Caused by weakness of a blood vessel, resulting in dilation; can cause TIA, IICP; dissected aneurysm - when blood vessel breaks causing stroke and IICP
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S/S for cerebral aneurysm
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Severe HA with eye pain, diplopia, LOC changes, NV, seizures
Focal s/s - depend on location of aneurysm |
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TX for cerebral aneurysm
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Same NI as IICP and CVA; surgery if location accessible, bypass, stent
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Risk factors for seizures
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Drugs, CVA, tumors, IICP, fatigue, sleep deprivation, fever, emotional stress, hypoglycemia, water intoxication; can be from sounds, strobe lights
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Tonic-Clonic (grand mal) seizure: Pre-ichtal (predromal) phase manifestations
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Aura, irritability, anxiety
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Tonic-Clonic (grand mal) seizure: Ichtal (dromal) phase
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Tonic Phase: severe muscle contraction, diaphragm may stiffen, pt may scream, pt falls on floor, loss of consciousness
Clonic Phase: actual seizure, salivation, sweating, eyes roll back into the head, incontinence of bowel/bladder or both |
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Tonic-Clonic (grand mal) seizure: Post-Ichtal (post-dromal) phase
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Suction, pt may be unconscious for minutes to hours after seizure, monitor clt, when clt awakens may feel embarrassed, provide emotional support
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Status epilepticus
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Clt never goes into true post-ichtal phase and recovers from last seizure; continuous period of tonic-clonic seizures in which the clt does not regain consciousness; very dangerous/damaging and can be fatal - can result in brain damage, IICP
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Tx for seizures
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Goal is to prevent seizures, anticonvulsive medications (depakote, triliptil, neurontin), if therapeutic levels are not kept, seizures can still occur, meds may cause swollen gums, GI problems, decrease in WBC’s (klonopin)
Educate pt on medications and therapeutic levels, do not suddenly stop taking medications (especially dilantin) can have rebound effect. |
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Meningitis
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Disorder involving inflammation of the meningial membranes; causes can be viral/bacterial - bacterial form is highly contagious and seen mostly with school age clts; cerebral edema may occur, clt may develop seizures, coma
s/s: severe HA, NV, photophobia, nuchal rigidity (stiff neck), LOC changes, tachycardia |
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Positive Brudzinski's sign
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When head is pushed forward to touch chest the clt's knees will come up and back will arch
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Positive Kernig's sign
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When leg is bent, then straightened, clt will bow up and leg will not straighten
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Diagnostic tests for meningitis
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Lumbar puncture (LP)
Bacterial meningitis - CSF will be cloudy, dec in glucose, WBCs; protein may be present Viral meningitis - CSF usually clear, glucose may be normal CT or MRI of brain |
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TX for meningitis
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Culture and sensitivity of CSF, antibiotics, isolation for bacterial type, Tylenol for fever, mild analgesics for H/A, anti-seizure medications prophylactically, monitor I/O’s, baseline labs, monitor for IICP.
Monitor for: DIC (disseminated intravascular coagulation) may develop with severe meningitis, petechial rash all over body, bleeding from gums and nose SIADH—syndrome of inappropriate anti-diuretic hormone—ADH keeps your fluid balance, with SIADH, you will retain fluids |
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Encephalitis
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Acute inflammatory disease of the brain that can be caused by many different viruses (West Nile); can be bacterial or fungal but is mainly viral
s/s: HA, NV, nuchal rigidity, viral symptoms; focal symptoms due to area of brain affected most |
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Diagnostic tests for encephalitis
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CT, MRI, EEG, slow wave forms in EEG, history, presentation, LP (due to presentation similar to meningitis)
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Tx for encephalitis
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Antiviral medications (if viral), supportive, bed rest, monitor for IICP, prevent seizures, may be some neuro deficits
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Alzheimer's characteristics
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Delirium may be present and is characterized by "fluctuating levels of consciousness"; delirium tends to be abrupt in its onset and tends to involve mental confusion, excitement, hallucinations, and illusions; dementia tends to progress in stages over a long period of time
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The 4 As of Alzheimers - Amnesia
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Inability to learn new information or recall previously learned information
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The 4 As of Alzheimers - Agnosia
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Inability to recognize familiar objects
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The 4 As of Alzheimers - Aphasia
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Language disturbances both expressive and receptive
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The 4 As of Alzheimers - Apraxia
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Inability to carry out motor activities despite intact motor function (ability to grasp door knob but not knowing what to do with it)
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Stage 1 (Early) Alzheimers
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Lasts 2-4 years/memory loss present/difficulty with abstract thinking and math problems/loss of sense of humor/subtle personality changes/lack of energy/disorientation of time
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Stage 2 (Middle) Alzheimers
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May last several years/impaired cognition and abstract thinking/restlessness and agitation/Wandering "sundowners"/inability to carry out ADL’s/impaired judgement/impaired impulse control/inappropriate social behavior/repetitive behavior/appetite for junk food increases/depression may be present
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Stage 3 (Late) Alzheimers
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Agnosia- inability to recognize familiar objects or family/needs repeated instructions for simple tasks/outbursts of anger, hostility, or paranoia/usually lasts 1-2 yrs but can last up to 10/emaciation/indifference to food/unable to speak or ambulate/bedridden, fetal position/echolalia-parroting/Palilalia- certain words or phrases repeated frequently with increasing rapidity
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Tx and NI for Alzheimers
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No cure for disorder, focus is on the symptoms and maintaining quality of life, NI safety measures: SR up, bed in low position, frequent clt checks and help with ambulation, never leave anything at bedside that could harm clt, approach clt in friendly/relaxed manner - clts tend to mock those around them; speak in clear low-pitched voice, use simple words and sentences, ask one question at a time, orient clt to person, place, and time, label items, maintain mobility and exercise, avoid isolating the clt, promote bowel and bladder continence, prevent constipation - high fiber and exercise; encourage clt to take frequent rest breaks, but don't let sleep all day; avoid overstimulation at bed time by scheduling activities and tests for morning and early afternoon
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Multiple Sclerosis Drug Therapy
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No cure, goals aimed at decreasing symptoms, preventing complications, and providing emotional support
Drug therapy: corticosteriods to decrease inflammation, Dantrium - reduces muscle rigidity and spasticity, antibiotics, Ditropan - for urinary incontinence, antidepressants; immune system regulators - beta interferon, glatiramer, novantrone help decrease the number of exacerbations |
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Symptomatic mgmt of Multiple Sclerosis
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Physical therapy, proper nutrition high in fiber and protein, adequate fluid intake, limiting evening fluid intake may aid in reducing nocturia
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Therapeutic mgmt of Multiple Sclerosis
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-Plasmapheresis (plasma exchange) removes T lymphocytes that cause inflammation. Some success in causing remission.
-Avoid large amounts of caffeine -Indwelling or suprapubic catheters -Manage bowel dysfunction by setting an elimination schedule. -Regular position changes help maintain skin integrity. -Continued emotional support -Avoid extreme changes in climate, temperatures, stress |
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Initial s/s of Parkinson's
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Pill rolling motion, resting tremor, tremors increase with purposeful movement, tremors absent during sleep
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2nd Group of s/s of Parkinson's
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Bradykinesia (slowness of movement), produces poor body balance, shuffling gait
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3rd Group of s/s of Parkinson's
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Rigidity, stooped posture, difficulty rising from sitting position, masklike face with decreased blinking of eyes, little or no expression. Quiet, monotone speech, depression. Increased salivation or drooling may be present, cramped small hand writing, decreased sexual activity, excessive sweating, constipation, heat intolerance
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Myasthenia Gravis
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-Believed to be autoimmune disorder, characterized by fatiguability of voluntary muscles as a result of a defect in neurotransmission.
-Defect is located at neuromuscular junction – transmission of impulses from nerve to muscle occur here. |
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S/S of Myasthenia Gravis
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-Abnormal fatigue of voluntary muscles limbs.
-Weakness of ocular muscles – ptosis (drooping) of eyelids, diplopia, and blurred vision. -Bulbar muscle weakness – speech and swallowing abnormalities. -Facial muscle weakness – difficulty smiling -Respiratory muscle weakness – respiratory distress |
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Medications to tx Myasthenia Gravis
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• Anticholinestrase drugs – Tensilon, Mestinan, Prostigmin, and Mytelase. No fixed dosages, dose and schedule should be the minimal amount needed to provide maximum improvement in the muscles of swallowing and breathing. Common S/E – GI distress, N/V, increased salivation, twitching and spasm.
• Corticosteroids – prednisone |
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Tx for Myasthenia Gravis
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• Thymectomy – removal of the thymus gland accomplished by median sternotomy approach. Post-op: chest tube, prn meds, ventilator depending on the extent of respiratory muscle weakness
• Plasma exchange – used if patient does not respond to treatment regimen or if relapse occurs during the treatment regimen. Usually shows improvement within 24 hours however some MG patients show no improvement |
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Myasthenic Crisis
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Abrupt onset, generalized muscle weakness with inability to swallow, speak or maintain respirations. Causes: undermedication, physical or emotional stress, or infection. Symptoms improve with Tensilon test. (Tensilon is a short acting anticholinestrease medication)
Result from not enough medication |
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Cholinergic Crisis
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Symptoms similar to Myasthenic crisis. May have excessive salivation, sweating, abdominal cramps. Causes: overmedication with anticholinestrease medication. Symptoms worsen with Tensilon test. Have atropine sulfate available.
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Nsg Care in Crisis - Myasthenic/Cholinergic
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• Maintain tracheostomy or intubation equipment
• Monitor ABG’s • Administer meds: Myasthenic crisis increase the dose of anticholinestrease. Cholinegic crisis, D/C anticholinetrease meds. |
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Huntington's Disease
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Genetic disorder characterized by increased involuntary movements, progressive intellectual decline, and personality and mood changes
Think Parkinson's and Alzheimer's together; Tx is primarily supportive |
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Guillan-Barre Syndrome S/S and progression
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-Progressive muscle weakness that develops over a matter of hours up to 10 days. Lower extremities affected first.
It is an acquired inflammatory disease that results in the demyelinization of the peripheral nerves. -Patient has progressive ascending paralysis (paralysis starts low and it works its way up the body) that is reversible. – clt has good prognosis, very rarely does it reoccur -Patient may be unable to walk, may fall -Over time, upper extremities become involved, flaccid paralysis. -Facial nerves almost always involved, bilateral facial weakness present -Dysphagia, dysathria -Respiratory muscles usually affected last, ventilator support needed. |
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Guillan-Barre Diagnostic Tests and Therapeutic Mgmt
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-LP – CSF has increased protein and pressure/clinical presentationo Plasma exchange--After plasma exchange, treatment is supportive.
-Anticipate respiratory failure -Low dose heparin to prevent thrombophlebitis -Antacids to prevent GI bleed -High top sneakers, ROM, prevention of contractures -Heel and elbow protectors -Artificial tears to prevent eye from drying due to lack of automatic blinking. |
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Spinal Cord Injury
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Symptoms depend on the location of the injury; immobilize the head, neck, and back
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Autonomic Dysreflexia r/t spinal cord injury
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Exaggerated symptoms, injury is usually T6 or above. Precipitated by bladder or abdominal distention, fecal impaction. Severe hypertension, tachycardia, pounding HA, nausea, blurred vision, anxiety, flushed skin above the level of T-6. If left uncontrolled can lead to seizures, stroke, and death. Relieving the precipitating cause is important once it starts. Raising the HOB, remove noxious stimuli, and call MD to get antihypertensive medications to relieve the HTN. Below level of T-6 can be cool, diaphoretic, pale
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Therapeutic mgmt for spinal cord injury
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-Immobilize the head, neck, and back.
-Maintain airway, intubation may be necessary. -ABG’s -IV, treat hypotension -Assessment – document baseline motor movement, strength, and sensory level. -Neutral position with head and neck in proper alignment. -Traction, Halo -Drug therapy – Corticosteriods, antibiotics -Monitor for respiratory complications, UTI, skin break down. -Nutrition – may be on TPN, when able to have |
