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285 Cards in this Set
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What two respiratory related conditions can ^ ICP?
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hypercapnia & hypoxia
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What’s priority NI for ^ ICP?
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patent airway
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What HOB for ICP?
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30-45 degrees
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What position do you put client in with ^ ICP?
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head elevated, no neck flexion
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What temp do you keep the environment for pt w/ ^ ICP?
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cool
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How often neuro check for ^ ICP?
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Q15 minutes
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How often T&P for ^ ICP?
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Q2 hours
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What do you provide when T&P ^ ICP pt?
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passive ROM
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What can you do r/t pt care activities to prevent ^ in B/P?
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space them out
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Avoid what r/t GI sys in pt w/ ^ ICP?
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Valsalva’s
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What do you want to limit r/t patent airway maintenance?
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suctioning (induces Valsalva’s)
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What are the immediate medical Rx for ICP?
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1. Hyperosmolar agents
2. Steroids 3. Hypothermia blanket 4. Barbiturate Coma 5. Respiratory Tx |
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What are the "hyperosmolar agents" used to Rx ICP?
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Mannitol,
Lasix |
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What is the steroid of choice for ICP?
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Decadron
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What type of Resp Tx do you admin to ICP pt?
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controlled positive-negative pressure,
high flow, 12L, via mask, humidified |
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What are 4 causes of ICP?
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1. trauma
2. vascular dysfunction 3. mechanical obstruction 4. ^ CSF production |
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What are the 10 areas to look for signs of ^ ICP?
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Pupils, papilledema
ROM (motor function) o Headache i Brain Herniation i Temp i Visual disturbance, vs, vomiting e LOC y |
"PROHIBITIVELY"
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What are the early signs of ^ ICP r/t LOC?
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restlessness,
disorientation, lethargy |
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What are the late signs of ^ ICP r/t LOC?
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late signal,
coma, hard to arouse |
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What are the early signs of ^ ICP r/t HEADACHE?
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vague complaint
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What are the late signs of ^ ICP r/t HEADACHE?
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increasing pain
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What are the early signs of ^ ICP r/t MOTOR FUNCTION?
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contralateral hemiparesis
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What are the late signs of ^ ICP r/t MOTOR FUNCTION?
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decorticate & decerebrate posturing,
flaccid muscles |
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With decorticate posturing, hands in or out?
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hands in
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With decerebrate posturing, hands in or out?
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hands out
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What are the early signs of ^ ICP r/t PUPILS?
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dilated ipsilaterally
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What are the late signs of ^ ICP r/t PUPILS?
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dilated bilaterally, and
fixed |
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What are the early signs of ^ ICP r/t VISUAL DISTURBANCES?
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blurring,
v visual acuity, diplopia |
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What are the late signs of ^ ICP r/t VISUAL DISTURBANCES?
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n/a
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What are the early signs of ^ ICP r/t VOMITING?
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usu. none
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What are the late signs of ^ ICP r/t VOMITING?
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projectile
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What are the early signs of ^ ICP r/t TEMPERATURE?
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normal
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What are the late signs of ^ ICP r/t TEMPERATURE?
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elevated
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What are the early signs of ^ ICP r/t PAPILLEDEMA?
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none
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What are the late signs of ^ ICP r/t PAPILLEDEMA?
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may be present
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What is papilledema?
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bulging red fundus of eye
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What are the early signs of ^ ICP r/t BRAIN HERNIATION?
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absent or
just beginning |
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What are the late signs of ^ ICP r/t BRAIN HERNIATION?
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present
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What are the early signs of ^ ICP r/t VITAL SIGNS?
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stable
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What are the late signs of ^ ICP r/t VITAL SIGNS?
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Cushing's response,
irregular resp |
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What is CUSHING'S RESPONSE?
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^ sys,
^ pulse pressure, v P |
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What's worse DECEREBRATE or DECORTICATE POSTURING?
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decerebrate
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What's normal ICP in mm Hg?
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0-15
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What are the 4 elements of NURSING MANAGEMENT of client in ICP MONITORING?
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1. complications
2. resp sys 3. cardiac monitoring 4. lab studies |
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What is the main complication of ICP MONITORING?
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infection
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What are 4 things to check r/t CARDIAC MONITORING of client in ICP monitoring?
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b/p, cardiac dysrhythmias, bradycardia, hemodynamic monitoring
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What are 6 LAB STUDIES to manage for client in ICP monitoring?
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ABGs, serum electrolytes, CBC, platelets, serum/urine osmolarity, anticonvulsant levels
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What are the four categories of drugs Tx for client on ICP monitoring?
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1. Fluid balance
2. CNS 3. GI sys 4. Anti-infective (systemic) |
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For pt on ICP monitoring, what are the drug classes used r/t fluid balance?
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Steroids,
Diuretics |
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For pt on ICP monitoring, what's the steroid of choice?
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Decadron
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For pt on ICP monitoring, what are the diuretics of choice?
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mannitol, Lasix, Diamox
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For pt on ICP monitoring, what are the drugs used r/t the CNS?
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barbiturates,
muscle relaxants, anticonvulsants |
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For pt on ICP monitoring, what is the anticonvulsant of choice?
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Dilantin
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For pt on ICP monitoring, what are the drugs used r/t GI sys?
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H2 histamine blockers,
antacids, laxatives |
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For pt on ICP monitoring, what are the H2 histamine blockers of choice?
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Tagament,
Zantac |
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For pt on ICP monitoring, what is the antacid of choice?
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Maalox
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For pt on ICP monitoring, what is the laxative of choice?
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colace
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For pt on ICP monitoring, what is barbiturate tx used for?
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uncontrolled ICP
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For pt on ICP monitoring, when do you use muscle relaxants?
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when pt intubated
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What are the five levels of the CNS affected by ICP?
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thalamus,
midbrain, pons, medulla, spinal cord |
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What type of breathing might you see when THALAMUS is affected by ICP?
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normal or
Cheyne-Stokes |
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What type of breathing might you see when MIDBRAIN is affected by ICP?
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neurogenic hyperventilation
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What type of breathing might you see when PONS is affected by ICP?
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Biot's
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What type of breathing might you see when MEDULLA is affected by ICP?
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apneustic
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What two things might you see along with Cheynes-Stokes in ^ ICP ?
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v pain response,
v corneal reflexes |
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What two things might you see along with NEUROGENIC HYPERVENTILATION in ^ ICP?
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not responsive to O2,
"patterned" resp |
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What two things might you see along with Biot's resp in ^ ICP ?
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regular periods of hypervent,
irregular periods of apnea |
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What two things might you see along with APNEUSTIC RESP in ^ ICP ?
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ataxia,
gasping, shallow pattern |
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What's the LOC with THALAMUS affected r/t ICP if normal resp?
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stupor
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What's the LOC with THALAMUS affected r/t ICP if Cheynes-Stokes?
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semi-coma
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What's the LOC with MIDBRAIN affected r/t ICP?
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coma
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What's the LOC with PONS affected r/t ICP?
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coma
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What's the LOC with MEDULLA affected r/t ICP?
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coma
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What condition are pupils in with THALAMUS affected r/t ICP?
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small,
reactive |
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What's condition are pupils in with MIDBRAIN affected r/t ICP?
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mid-position,
nonreactive |
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What's condition are pupils in with PONS affected r/t ICP?
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mid-position,
nonreactive |
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What's condition are pupils in with MEDULLA affected r/t ICP?
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mid-position,
nonreactive |
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What posture might you see if THALAMUS affected r/t ICP?
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decorticate
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What posture might you see if MIDBRAIN affected r/t ICP?
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decerebrate
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What posture might you see if PONS affected r/t ICP?
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flaccid
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What posture might you see if MEDULLA affected r/t ICP?
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flaccid
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What level of CNS is affected if pt is neg for Doll's eye?
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Thalamus
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When level of CNS is affected if pt is pos for Doll's eye?
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midbrain, pons, medulla
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If CNS affected by ICP, at what level might pt be arousable?
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Thalamus
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What level of CNS affected if pt is pos for Babinski reflex?
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definitely if: pons or medulla
maybe if: midbrain |
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What level of CNS is affected if pt needs vent?
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definitely if: pons or medulla
maybe if: midbrain |
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What are the 3 parts of the GLASGOW COMA SCALE?
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eye open,
best verbal response, best motor response |
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What score on GCS indicates coma?
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<7
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What does GCS score of 15 indicate?
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pt is A&O
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What are the 9 NI for the UNCONSCIOUS CLIENT?
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Airway patent
Corneal integrity Thermoregulation Integrity of skin Oral hygiene Nutritional/Fluid balance Bowel function Urinary retention Support family in crisis |
"ACTION BUS"
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What are two risks r/t patent airway of the unconscious client?
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choke on tongue/epiglottis,
aspirate puke or phlegm |
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W/ the unconscious client, if not on vent, what do you do r/t patent airway?
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position on side, HOB 30-45 deg;
suction prn; auscultate chest |
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W/ the unconscious client, if on vent, what 4 things do you do?
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trach / ET tube patency,
oral care, ABGs, maintain vent settings |
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W/ the unconscious client, how do attain fluid / nutr balance?
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strict I&O,
admin IV, TPN / NG feedings |
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W/ the unconscious client, what should you NEVER do r/t positioning?
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never let pt lie totally flat
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W/ the unconscious client, how do you maintain oral mucous membranes?
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saline rinse,
lubricate lips |
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W/ the unconscious client, what do you need to keep in mind r/t lubricating lips?
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no jelly,
balm only |
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W/ the unconscious client, what are 6 ways to maintain skin integrity?
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reposition Q2 hrs,
maintain alignment, passive ROM, foot board / stiff sneaks, bony prominence pads, trochanter rolls |
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W/ the unconscious client, what do you do r/t corneal integrity?
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artificial tears Q2 hrs,
eye patch, alternating |
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W/ the unconscious client, how do you take temp?
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rectal
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W/ the unconscious client, according to what do you determine best temp?
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client's condition
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W/ the unconscious client, what do you do r/t preventing urinary retention?
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palpate bladder for distention,
catheterize PRN, assess s/s UTI |
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W/ the unconscious client, how often do you check for voiding to prevent skin breakdown?
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Q1 hr
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What is first sign of bowel obstruction?
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high-pitched BS
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How often should you hear bowel sounds?
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5-15 sec
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W/ the unconscious client, what 5 things do you do to promote bowel function?
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assess bowel sounds,
measure abd girth (chk distention), rectal exam, stool softeners, monitor BMs |
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What's the source of seizures?
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gray matter
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What's epilepsy?
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recurring seizures without metabolic or systemic cause
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What's a generalized seizure?
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symmetrical,
w/o local onset |
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What's a tonic seizure?
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contracting muscle w/ excessive muscle tone
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What's a clonic seizure?
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alternating contraction and relaxation of muscles
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In a tonic-clonic seizure, how long does tonic phase last?
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5-30 sec
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In a tonic-clonic seizure, what happens first?
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abrupt loss of consciousness
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In a tonic-clonic seizure, what happens in the tonic phase?
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body stiffens, shrill cry then apnea, may bite tongue, autonomic pupillary changes, ^ HR, ^ B/P, profuse salivation
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In a tonic-clonic seizure, how long does the clonic phase last?
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10-30 sec
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In a tonic-clonic seizure, what happens during clonic phase?
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clonic jerking,
then gradual v freq & v intensity |
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In a tonic-clonic seizure, how does it wind up?
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incontinence, slow return of consciousness over 10-30 min
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In a tonic-clonic seizure, what state is person in after it's all over?
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h/a, exhausted, no memory of seizure
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What are the precipitating factors of a seizure?
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Cycle of menstruation
Only certain activities Non-compliance w/ meds Very tired (fatigue) Under the weather (fever/illness) Loss of sleep Specific sensory stim Emotional stress |
CONVULSE
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What are two nsg dx for client w/ seizures?
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potential for injury,
anxiety |
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What could anxiety be r/t for client w/ seizures?
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fear of seizures,
embarrassment, threatening to self-concept, change in economic status |
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For client w/ seizures, what do you keep ready at bedside?
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oral airway,
suction equipment, O2 |
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For client w/ seizures, what particular that you do for pt environment?
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pad side rails
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For client w/ seizures, what do you do during seizure?
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support and protect head,
ease pt to floor if erect, turn pt on side, place pillows, loosen tight clothing, stay w/ pt |
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For client w/ seizures, what do you document after episode?
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preceding events,
type of seizure, time and duration, (& freq if >1) nursing interventions |
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For client w/ seizures, what do you do after seizure?
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patent airway,
vs and neuro checks, O2 PRN, reorient pt, oral hygiene, |
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W/ anticonvulsant meds, what do you monitor for with IV admin?
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resp depression,
CV collapse |
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W/ anticonvulsant meds, what do you take to prevent megaoblastic anemia?
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folic acid
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W/ anticonvulsant meds, what do you give one month before childbirth?
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Vit K
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W/ anticonvulsant meds, what do you give to prevent hypocalcemia?
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Vit D
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W/ anticonvulsant meds, what are four categories of adverse effects?
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CNS,
Hematologic, Hepatic, GI sys |
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W/ anticonvulsant meds, what can you do to lessen GI effects?
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large amounts of fluids w/ med,
small freq meals, ^ bulk |
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W/ anticonvulsant meds, what are s/s of liver toxicity? x4
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jaundice,
dark urine, appetite loss, abd pain |
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W/ anticonvulsant meds, what CNS s/e might you see r/t the eyes?
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blurred vision,
nystagmus |
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W/ anticonvulsant meds, what CNS s/e might you see r/t the mentation?
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confusion,
bizarre behavior, amnesia |
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W/ anticonvulsant meds, what CNS s/e might you see r/t the muscles (in face and body)?
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slurred speech,
muscle twitching, v muscle tone |
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W/ anticonvulsant meds, what areas might you see CNS s/e?
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eyes, muscles (face/body), mental status
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w/ anticonvulsant meds, what might you have to do if pt under physical or emotional stress?
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adjust dosage
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w/ anticonvulsant meds what are the s/s of hematologic toxicity?
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sore throat,
bruising, bleeding |
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w/ anticonvulsant meds what bleeding is pt prone to?
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nose bleeds,
gum bleeding |
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w/ anticonvulsant meds, what's a NI r/t gum bleeding?
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oral hygiene,
floss and soft toothbrush, dental exams, |
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w/ anticonvulsant meds, what conditions should pt avoid? (besides stress)
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fever,
low sugar, low sodium |
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w/ anticonvulsant meds, what could fever, low sugar, or low sodium cause?
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lower seizure threshold
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When is Tegretol contraindicated?
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hx bone marrow depression,
syndrome of inappropriate antidiuretic hormone |
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Tegretol - generic name?
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carbamazepine
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Depakene - generic name?
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valproic acid
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What are the indicated conditions for Tegretol?
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partial seizures w/ complex symtoms,
tonic-clonic seizures, kids under 6 y/o |
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What are the indications for Dilantin?
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tonic-clonic epilepsy,
status epilepticus, during neurosurgery to control seizures |
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What are the 2-ish contraindications for Dilantin?
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liver/renal impairment,
pregnancy or lactation |
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What adverse effect can Dilantin cause?
What two things can that lead to? |
bone demineralization;
adults: osteomalacia kids: rickets |
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What are the seizure indications for Depakene?
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as combo tx,
absence seizures (complex/simple), multi seizure patterns, partial seizures (complex) |
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What are the contraindications for Depakene?
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liver issues (urea cycle disorder),
lactation and pregnancy |
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When do you take Depakene and why?
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hs to v CNS depression
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What are the two types of strokes?
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occlusion,
hemorrhage |
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What are the two things that can get stuck in a stroke from an occlusion?
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thrombus,
emboli |
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What's TIA stand for?
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transient ischemic attack
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What's a TIA defined?
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sudden temporary loss of motor sensory, or visual function
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How long does a TIA last?
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a few seconds up to 24 hours
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What are the two areas of clinical manifestation for TIA?
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carotid artery,
bacillary artery |
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What is the main symptoms of TIA with carotid artery involvement?
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sudden, painless loss of vision in one eye
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What are the main symptoms of TIA with bacillary artery involvement?
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Diplopia
Extremity paresthesia LOC v Vertigo Expressive/receptive aphasia |
"DELVE"
delve into the bacillary artery involvement of a TIA |
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What's AVMs stand for?
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Arteriovenous Malformations
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What are AVMs?
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No separation between arterial and venous sys
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What's the pt missing if they have AVMs?
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vascular bed
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What cannot happen r/t lack of vascular bed in AVMs?
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perfusion of brain tissue,
exchange of metabolites |
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What are AVMs known to cause?
In who? |
Infarctions in kids
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What are the 5 s/s of AVMs?
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headaches, seizures, subarachnoid hemorrhage, ICP, CVA
"HEAD SEIZURES SUBstitute INTer-Change" |
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What are the 5 Tx for AVMs?
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Control b/p
Record & document Aneurysm precaution Prevent bleeding Prevent arterial vasospasm Identify ICP Encourage rest |
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What drug could you use to control bleeding in AVMs?
|
Amicar
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How is arterial vasospasm prevented?
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by ^ perfusion, and
v vascular resistance |
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What side of the body is motor paralysis/paresis r/t CVA?
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contralateral
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hemianopsia - define
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blindness of one half of the visual field of one or both eyes
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anosognosia - define
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denial of CVA
(neurological, not psychological) |
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Agnosia - define
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unable to recognize meaning of perceptual stim
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apraxia - define
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unable to carry out motor action despite intact motor and sensory systems
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aphasia - define
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inability to express or understand language
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dysarthria - define
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difficulty controlling muscles, organs, articulation, phonation, or respiration
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denial of CVA
(neurological, not psychological), what's the term? |
anosognosia
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blindness of one half of the visual field of one or both eyes,
what's the term? |
hemianopsia
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unable to recognize meaning of perceptual stim,
what's the term? |
agnosia
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unable to carry out motor action despite intact motor and sensory systems,
what's the term? |
apraxia
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inability to express or understand language,
what's the term? |
aphasia
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difficulty controlling muscles, organs, articulation, phonation, or respiration,
what's the term? |
dysarthria
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NSG ASS of CVA, what are five areas of assessment r/t body parts?
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EYES,
MOUTH/EARS, BODY/SKIN, MIND/BRAIN, PELVIS/ELIMINATION |
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NSG ASS of CVA, what are 4 assessments r/t EYES?
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*agnosia
inability to revisualize spatial perception deficits visual alterations |
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NSG ASS of CVA, what are 4 assessments r/t MOUTH/EARS?
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*agnosia
aphasia dysarthria dysphagia |
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NSG ASS of CVA, what are 6 assessments r/t BODY/SKIN?
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*agnosia
anosognosia apraxia motor paralysis/paresis sensory alterations unilateral neglect |
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NSG ASS of CVA, what are 5 assessments r/t MIND/BRAIN?
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*agnosia
anosognosia emotional lability impaired judgment short-term memory deficits |
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NSG ASS of CVA, what are 2 assessments r/t PELVIS/ELIMINATION?
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bladder functioning
bowel functioning |
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Broca's aphasia,
1. also called? 2. what's it sound like when pt speaks? 3. what's unique about communication? |
expressive aphasia,
may use only single words, easier to listen and read than speak and write |
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Wernicke's aphasia,
1. also called? 2. what's it sound like when pt speaks? |
receptive aphasia,
word salad |
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Nsg interventions for CVA, neuro checks how often?
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q 15-60 min prn
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Nsg interventions for CVA, HOB?
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30-45 deg
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Nsg interventions for CVA, avoid what r/t ^ ICP? x4
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hip flexion, (no sex)
neck flexion, (no blowjob) isometric exercises, (no workout) straining at stool (no pooping) |
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Nsg interventions for CVA, what's particular ABGs?
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PaCO2 at 25-30 mm Hg
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Nsg interventions for CVA, what drugs? x5
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steroids, diuretics, barbiturates, muscle relaxants, sedatives
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Nsg interventions for CVA, what about bed rails?
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rails up on paralyzed side
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Nsg interventions for CVA, should you finish sentences?
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no
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Nsg interventions for CVA, should you repeat yourself?
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yes
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Nsg interventions for CVA, should you encourage gestures from client?
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yes
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Nsg interventions for CVA, should you speak loudly?
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no
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Nsg interventions for CVA, should you encourage use of communication board?
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1st encourage talking
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What are the contraindications for t-PA? x5
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onset p >3 hrs,
taking anticoagulants, recent MI, intracranial pathology, NIHSS score > 22 |
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Main s/e of t-PA?
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bleeding
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With t-PA, where should you look out for bleeding? x8
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G/I sys
Emesis N/G tube Intracranial Urinary catheter Stool |
"GENIUS"
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What are two complications of subarachnoid hemorrhage from aneurysm rupture?
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rebleeding,
diabetes insipidus |
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What's the principle complication of subarachnoid hemorrhage from aneurysm rupture?
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rebleeding
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What are the two time periods to worry about REBLEEDING in subarachnoid hemorrhage from aneurysm rupture?
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24-48 hrs,
7 to 10 days |
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What's lacking that causes DI in subarachnoid hemorrhage from aneurysm rupture?
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Deficient ADH/vasopressin
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What are the aneurysm precautions?
h |
A/DLs performed by nurse (not pt)
Neuro checks q 15 Easy does it (bedrest) Unlit room Restricted visitors You be quiet! (quiet room) Soft, high fiber diet; stool softeners (no ememas) Mild sedatives & analgesics |
"ANEURYSM"
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What are the usual symptoms of aneurysm before rupture?
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asymptomatic
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What are the sym of aneurysm in not asymptomatic?
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h/a, photophobia, lethargy, nuchal rigidity, neuro deficits
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What are the two expected outcomes from Decadron r/t brain tumors?
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relieve h/a,
v edema around tumor |
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What three tissue types are particularly susceptible to antineoplastic agents?
x3 |
GI mucosal epithemlium,
bone marrow, hair follicles |
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If WBC count falls below what amount do you withhold chemo?
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2,000/mm3
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If platelet count falls below what count do you withhold chemo?
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100,000/mm3
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When might the cumulative effects on bone marrow cause depression of WBCs and platelets?
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week or months after tx start
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How does GI tract toxicity manifest from chemo? (x6 s/e)
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oral ulcers, intestinal bleeding, nausea, vomiting, loss of appetite, diarrhea
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When is chemo tx contraindicated?
x3 |
hypersensitivity,
up to 4 weeks after radiation or other chemo tx, 1st trimester of prergnancy |
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What are 3 contraindicated conditions r/t chemo tx?
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1. preexisting bone marrow depression
2. malignant infiltration of bone or kidney 3. liver dysfunction |
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What chemo drug class is particulalry teratogenic?
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alkylating agents
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What type of gloves to you use to prepare cytotoxic agents?
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latex
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If extravasation of chemo tx drug occurs, what are the five steps of NI?
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1. document and report
2. aspirate drug thru cannula w/ tb syringe 3. admin antidote 4. remove catheter/needle 5. apply ice or heat |
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What chemo tx drug to you apply heat, not ice, if extravasation occurs?
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vinca alkaloids
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Carmustine, what's the unique adverse effect?
When can it occur? Who is particularly susceptible? |
pulmonary fibrosis,
years after tx, those treated in childhood [it's like unrighteous delayed 'karma'] |
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Lomustine, what's a particular s/e?
How long does it last? |
n/v 3-6 hr after admin,
can last 24 hours [it's 'lame' how you think you're in the clear, then you puke after a few hours] |
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What's particular about the level of toxicity of Matulane?
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more toxic than the rest
[it'll 'mutilate' you] |
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Who do you have to monitor closely with Matulane?
What could happen to them? x3 |
children,
r/t tremors, convulsions, coma |
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What is particular bad if it happens with Oncovin?
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extravasation
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What is the first sign of neurotoxicity r/t ONCOVIN?
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constipation
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What are the three notable dangers to assoc w/ ONCOVIN?
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extravasation, neurotoxicity, bronchospasm
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What is a less life-threatening s/e of ONCOVIN?
What should you have on hand for it? |
gout,
allopurinol |
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What s/e is of particular note r/t anticonvusants?
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liver toxicity
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What's the function of theOCCIPITAL LOBE?
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sight
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What's the function of the CEREBELLUM?
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balance
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What's the function of the
FRONTAL LOBE? |
thought
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What's the function of the
TEMPORAL LOBE? |
motor sensory
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What's the function of the
PARIETAL LOBE? |
touch sensory
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What's the function of
WERNICKE'S AREA? |
word comprehension
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What's the function of
BROCA'S AREA? |
word expression
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What neurosurgery involves structuresincluding frontal, temporal, parietal, occipital lobes?
Where's the incision made? |
supratentorial,
behind hairline |
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What neurosurgery involves the cerebellum?
Where' the incision? |
infratentorial,
slightly above neck |
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How often neuro checks for craniotomy?
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q 1 hour
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What's the HOB for supratentorial craniotomy?
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30-45 deg
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What's the HOB for intratentorial craniotomy?
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0-20 deg
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How often do you assess pain for craniotomy?
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q 2 hours
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How often do you monitor wound site for craniotomy?
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q 2 hours
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positive Kernig's and Brudzinski's sign may mean what?
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meningitis
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What range of SPG of urine may indicate DI?
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<1.005
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What range of SPG of urine may indicate volume deficit?
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<1.025
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Equate ADH with ...
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vasopressin
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Admin what if DI occurs?
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vasopressin
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Serum osmolarity that may indicate DI?
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<295 mOsm/kg
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Urine osmolarity that may indicate DI?
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<300 mOsm/kg
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Serum sodium that may indicate DI?
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145 mEq/L
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How often auscultate breath sounds r/t craniotomy?
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q 2 hours
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What brain surgery goes thru mouth?
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transsphenoidal surgery
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After transsphenoidal surgery, oral hygiene:
1. cleanse mouth w/ what? 2. how often? 3. Instruct not to use what? 4. for how long? |
1/2 strength H2O2, q 2 hours;
no toothbrush for 10 days |
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What do you assess unique to post transsphenoidal surgery?
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visual acuity
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When do you call MD post transsphenoidal surgery besides vision problems?
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excessive post nasal drip and excessive swallowing
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After carotid endartectomy, what three NI?
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monitor for temporal pulses,
monitor for hoarseness, control B/P |
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After carotid endartectomy, assess resp how often?
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q 1 hour
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R/t spinal cord tumors, where's the tumor if there's resp insufficiency?
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C4 or up
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R/t spinal cord tumors, what might you see if tumor at C4 or above?
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resp insufficiency
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R/t spinal cord tumors, where's the tumor if there's paresthesia?
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C4 or below
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R/t spinal cord tumors, where's the tumor if there's Horner's Synd?
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C4 or below
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R/t spinal cord tumors, where's the tumor if there's weakness or muscle atrophy?
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C4 or below
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R/t spinal cord tumors, where's the tumor if there's shoulder or arm pain?
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C4 or below
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R/t spinal cord tumors, where's the tumor if there's issues with lower half?
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thoracic or lumbar
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R/t spinal cord tumors, where's the tumor if there's spastic lower extremities?
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thoracic
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R/t spinal cord tumors, where's the tumor if there's positive Babinski's?
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thoracic
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R/t spinal cord tumors, where's the tumor if there's sensory loss in legs or saddle area?
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lumbar
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R/t spinal cord tumors, where's the tumor if there's footdrop?
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lumbar
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R/t spinal cord tumors, where's the tumor if there's loss of DTR in legs?
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lumbar
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R/t spinal cord tumors, where's the tumor if there's sciatica-like pain?
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lumbar
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R/t spinal cord tumors, where's the tumor if there's lower GU issues?
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lumbar
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How long are you on bedrest after spinal cord surgery?
When do you ambulate? |
24 hrs,
ambu 2nd day post-op |
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What's HOB for post spinal cord surgery?
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flat or 5-10 deg
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What position do you avoid post lumbar surgery?
For how long? |
sitting for 2 days
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When might you see Horner's synd? (after what surgery?)
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post Cervical surgery
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ipsilateral pupil smaller, sunken eyes, ptosis, lack of perspiration on ipsilat side of face,
what's the term? |
Horner's syndrome
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Client with spinal tumor, nursing diagnosis of impaired mobility:
What are the NI? x6 h |
Teds stocking
Reposition q 2 hours Assess motor strength, sensation, proprioception q 2 hours Cough & DB q 2 hours Thrombophlebitis... ...Observation ROM, passive |
"TRACTOR"
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What are 2 Nsg Dx for spinal tumor?
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1. impaired mobility r/t spinal cord compressioni
2. potential alteration in urinary elimination r/t sphincter disturbance |
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What are the complications of Carotid Endarterectomy? x7
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Cardiac dysrhythmias
Hyper-/hypotension Infarct of... ...Cerebrum Damage to cranial nerves VII, X-XII Infection Vocal cord paralysis Airway obstruction |
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Post carotid end. surg., how often do you check B/P?
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q 15 min until stable,
then q 1 hour |
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