Test 1

Card Set Information

Test 1
2010-03-22 13:33:36

Adult Care, Trauma, Peds
Show Answers:

  1. Altered LOC
    not a disorder but a result of other problems
  2. Most common cause of LOC
    CVA, head injury, brain tumor, drug overdose
  3. Three components of Glascow Coma Scale
    • eye
    • verbal
    • motor
  4. Glascow Coma Scale scoring
    can never have less than 3 or greater than 15
  5. Basic principles for nurses with altered LOC pts
    • always assume person can hear, even when no response
    • aways address pt by name, tell them what you are going to do prior to nursing intervention
    • refrain from conversations about their conditions around them
  6. Basic principles for care of pt with altered LOC
    • if unconscious take rectal temps if possible
    • report changes in vital signs
    • note changes in response to stimuli
    • note return of protective reflexes
    • keep the room comfortable, feel their skin temp, adjust as needed
  7. assessment pt with altered LOC
    • complete head to to - focus on neuro (PERRLA - size, asymmetry in mouth/face/smile, Babinski abnormal in adult)
    • if localized signs; assumed neurologic disease till ruled out
  8. Dx test for altered LOC
    CT scan, MRI, less common PET
  9. Labs ran for altered LOC
    blood glucose, electrolytes, CBC, BUN, Creatinine, PT, PTT, Ca, toxicology screens, ABG's
  10. Nursing consideration for pt undergoing MRI
    • On patient - NO: pacemakers, metal plates, prosthetic joints, aneurysm clips, artificial heart valves, intrauterine devices, cochlear implants or other metallic implants
    • In room - NO: credit cards, O2 tanks, traditional ventilators, stethoscopes
  11. Complications with Altered LOC
    respiratory failure, pneumonia, aspiration, pressure ulcers, contractures, DVT
  12. Medical treatment with altered LOC pt
    • Maintain patent airway - first priority
    • position, suction (be sure equip works), NO verbal restraint order, must be written
    • May require ventilation, should be monitored
    • IV access
    • Nutritional support (NGT, PEG) asap to maintain GI function
    • weight is most objective sign of nutrition, provide mouth care a minimum of Q 4 hrs - ESPECIALLY if on on vent
  13. Nursing goals of care with altered LOC
    • maintenance of clear airway
    • protect from injury
    • attainment of fluid volume balance
    • achievement of intact skin integrity
    • absence of corneal abrasions/irritation
    • effective thermoregulation
    • effective urinary/bowel elimination
    • maintains family support
    • absence of complications
  14. Nursing intervention for maintaining airway
    • Position - lateral recumbent position (coma position)
    • Suction - at the bedside, with equipment working, catheters at bed side
    • Reposition - side to side
    • Administer O2; assess cannula sites for skin breakdown, pulse oximeter
  15. Maintaining Airway in a pt that emerges from unconsciousness
    • should be available to calm, quiet the pt.
    • DO NOT restrain - will lead to self injury or dangerous increase in ICP
    • Physical restraints should be avoided if possible - a WRITTEN order must be obtained Q24 hrs
  16. Protection the pt with altered LOC
    • Side rails padded, 2 rails are up during day, 3 at night (never 4 - this is restraint)
    • Assess any tight dressing, damp bedding, dressings, monitor tubes, drains
    • Protect dignity by privacy, speaking to patient while caring for, do not speak negatively about the pt's condition
  17. Nutritional Care for pt with altered LOC
    • assess tissue turgo, mucous membranes, assess I/O, analyze lab values
    • fluid initially by IV route (slowly administered - too rapid can cause ICP)
    • may need PEG/NGT
  18. Mouth care for pt with altered LOC
    • inspect dryness, inflammation, crusting
    • care Q4 hrs
    • petrolatum on lips prevent dryness, crusting
    • Move ET tube side to side to prevent ulcer in corner of mouth daily
  19. Preventing skin breakdown in pt with altered LOC
    • regular turning schedule
    • special beds
    • do not drag, pull up in bed/creates shearing forces and friction - instead lift
    • maintain correct body position - passive ROM all extremeties, use splints foam boots to prevent foot drop, trachanter rolls support hip joint, arms abducted with fingers flexed, hands slight supination, assess heels for pressure
  20. Care for High fever in altered LOC pt
    • adjust environment
    • few covers, drapes, sheets
    • if elderly and no temp room should be warm
  21. strategies for redcution of temp
    • remove bedding as possible
    • admin acetaminophen as prescribed
    • cool sponge bath, electric fan to blow
    • use hypothermia blanket
    • frequent monitor temp, PREVENT shivering and excessive drop in temp
  22. Nursing care for corneal integrity in altered LOC
    • clean with cotton balls moistened with sterile NS
    • artificial tears per protocol
    • for periorbital edema post craniotomy - cold compress
    • if eye patch is ever used must be sure no contact with cornea
  23. Preventing urinary retention with altered LOC
    • often incontinent/retention
    • palpate bladder, bladder scan to determine if present
    • can have overflow voiding - may insert foley if not voiding to BSD, and acute phase injury; inspect urinary meatus for drainage; left in place as short time as possible; monitor if voiding with bladder scan US device; may use external condom cath for males; conscious bladder training program started; incontinent pt, assess skin breakdown, implement prevention strategies
  24. Bowel Function with altered LOC
    • risk for diarrhea constipation
    • monitor bowel movements
  25. provide sensory stimulation
    • ICP not an issue
    • help sensory deprivation - goal to restore daily rhythm of day and nights, touch important, talking with pt, orient x3, family can read to pt, when pt arouse from coma may be agitated, positive clinical sign, may need to minimize stimulation in these cases
  26. Meeting family needs with altered LOC
    • state of crisis
    • reinforce, clarify info
    • involve family
  27. Brain dead
    • irreversible loss of all function of entrie brain, including brain stem
    • - pt appears to be alive (HR, breathing)
    • - must provide accurate, timely, understandable, consistent info to family
  28. Monitor/Managing Complications
    - Pneumonia
    - Impaired Skin integrity
    - DVT
    • assess respiratory, v/s, labs, SaO2
    • assess around every peice of med equip used on pt; place on special mattress, turn, skin care, prevent shearing forces
    • s/s, can progress to PE, thigh high stockings, pneumatic compression devices
  29. 3 components of skull (cranial vault)
    • brain tissue (1400g)
    • blood (75mL)
    • CSF (75mL)
  30. equilibrium normal pressure
  31. Normal ICP values
    older child and adult
    • 2-6
    • 3-7
    • 0-10
  32. elevated ICP
    > 20 for more than five minutes (lower number used for infant and child)
  33. If increased in any one component, and due to limited space for expansion brain will first

    excessive increase when
    shift CSF to spinal canal, increase absorption of CSF, or decrease crebral blood flow

    mechanism fails causes braint issue to herniated down through the opening in base of the skull
  34. ICP
    - primary brain injury
    - secondary " "
    immediate/irreversible - can be traumatic, or nontraumatic (stroke, tomor, infection)

    consequences of primary injury or of such processes as hypoxia, hypotension, hypercapnia, acidosis, reduced oxygen delivery
  35. ICP
    - an increase in any component; blood, CSF, brain tissue or tumor means...
    - CSF is most commonly misplaced; if ICP remain high after CSF has been displaced....
    • that the volume of the others is reduced by equal amounts (Monroe-Kellie doctrine)
    • cerebral blood volume is altered; when maximal volume is shifted, further increase in intracranial volume will markedly increase ICP
  36. ICP
    - inflammation and edema are
    part of the healing process so they occur
  37. Crebral edema
    can be localized or generalized and can lead to loss of auto regulation, compensatory change in diameter or intracranial blood vessels that maintains constant blood flow despite change in CPP (this loos causes increased blood for to the brain causing fluid to shift from the intravascular to the interstitial space)
  38. Change in BP can affect ICP
    - hypertension
    - hypotension
    - low leves of PACO2 from hyperventilation can cause
    - crebral edema can damage
    • can increase blood flow and increase edema
    • can cause ischemic injury, hypoxia and incnrease PACO2 levels causing vasodilation thus edema
    • vasoconstriction, which diminishes blood flow to and from the brain and increases risk of secondary brain injury
    • hypthalamus; triggers hyperthermia, leads to more vasodilation, increased metabolic rate, increased O2 demands
  39. Cerebral blood flow
    - CPP =
    - cerebral perfusion pressure is...
    - Normal CPP
    • MAP-ICP
    • pressure at which cells perfuse and is important indicator if cerebral blood flow
    • >70
    • >50-60
    • >40-50
  40. Early signs of ICP; report immediately
    - late early signs (chances are you missed something)
    • disorientation, restlessness, increased respiratory effort, puposeless movement, mental confusion
    • pupil changes, impaired extraoccular movements, weakness on one side or in one extremity, constant HA increased in intensity and aggravated by movement or straining
  41. Late signs of ICP
    Cushing's triad, decreasing LOC till comatose, projectile vomitting, hemiplegic, decorticate or decerebrate posturing
  42. cushing's triad
    irregular resp pattern, widening pulse pattern, bradycardia
  43. ICP Care of Pt
    - notify MD of
    • electrolytes, O2 sat, carbon dioxide level
    • s/s infection, sustained elevation of ICP, CPP>100 or less than 70 and any change in CSF drainage, amount, color, clarity
  44. ICP monitoring - device types
    - inctracranial bolt
    - intraventricular catheter
    - intraparenchymal fiber optic option
    • subdural or subarachnoid space; no direct CSF access
    • insterted into ventricle, more invasive; direct access to drain CSF; infection risk
    • cant be zeroed once in and over time become inaccurate
  45. ICP monitoring
    - all monitors should be....
    - fluid filled systems leveled to...
    • zeroed once a shift, per protocols; when taking report review, verify orders concerning monitoring parameters, leveling, drainage parameters with the off going nurse
    • the foramen of Monro to ensure measurement is accurate
  46. ICP monitoring
    - after leveling/zeroing...
    - if fluid leak from nose or ears...
    • obtain your reading, inspect the system for leaks, kinks; check insertion site for bleeding, infections, CSF leakage, if using drain device for CSF check output; color, amount and clarity hourly
    • test for glucose with strip, report to MD immediately, glucose in CSF is about 2/3 serum value (use of strips can cause false postitive and negatives) are followed up with more precise lab test
  47. Nursing Care for ICP
    • monitor LOC (GCS)
    • assess motor responses bilaterally
    • check for positvie babinski sign
    • assess sensory response (emphasis on side on opposite side of injury)
    • assess pupils
    • monitor VS, notify MD of deviation from set parameters
    • provide resp care measures
    • position to maintain venous outflow from brain
    • admin meds
    • control noise stimuli
    • provide rest/activity balance (stagger tasks)
    • eye, skin, oral mucosa care
    • education/emotions support to family
    • be sure to zero monitor
    • always sedate prior to using a paralytic
    • should have a negative fluid balance
  48. what to include when assessing pupils (ICP)
    • compare size, shape, equal
    • check with direct light reflex (each eye separately)
    • PERRLA
    • assess 6 cardinal fields of gaze (cranial nerves III, IV, VI)
    • assess for doll's eye phenomenon in unconscious (indicated brain stem damage)
  49. resp care measures for ICP
    • PaO2 >60
    • Spo2>90%
    • suctioning (may give lidocain down EET prior to suctioning need MD order)
    • ABG's; provide O2
    • monitor O2 sat
    • monitor vent settings
  50. maintaing venous outflow from brain (ICP)
    • elevate HOB 30 degrees (except dural tear)
    • no pillow under head
    • turn, log roll q 2 hrs
  51. Intracranial surgery types
    • craniotomy
    • trassphenoidal
    • craniectomy
    • cranieplasty
  52. preop care for intracranial surgery
    • baseline preop assessment
    • assess pt and fmly understanding
    • teach re: compression stockings, SCD
    • assure consent forms are signed after MD obtain informed consent
  53. Post Op Intracranial surgery Nursing dx
    • inneffective cerebral tissue perfusion
    • risk for imbalance body temp
    • potential impaired gas exchange
    • disturbed sensory perception
    • body image disturbance
  54. Goal with Intracranial surgery
    neurologic homeostasis to increase cerebral perfusion
  55. Potentional problems/complications with intracranial surgery
    increased ICP, bleed, hypovolemic shock, fluid electrolyte imbalance, infection, seizures
  56. Post Op care for intracranial surgery
    • maintain cerebral tissue perfusion
    • position
    • regulate temp
    • treat and monitor for hypothermia
    • improve gas exchange
    • manage sensory deprivation
    • enchance self image
  57. maintaining cerebral tissue perfusion for post op ICS
    • assess resp status
    • monitor for s/s of cerebral edema
    • avoid head rotation/flexion
  58. positioning
    - supratentorial surgery
    - posterior fossa ( infratentorial)
    place on back or side (unoperated side if a large lesion was removed) with one pillow under the head; HOB elevated 30 degree if ok with MD

    patient kep flat on one side (off the back) with head on a small, firm pillow; may turn side to side with head in neutral position; may eleveate HOB as tolerated; when turning, turn body as a unit as not to strain incision Q 2 hrs and assess skin frequently
  59. regulating temp with ICS
    expect moderate temp elevation, treat high temp; monitor; to decrease temp remove blankeys, apply ice bags to axilla and groin areas, use a hypothermia blanket as prescribed, and admin meds;

    also treat and monitor for hypothermia - frequent rectal temp if not contraindicated; rewarm pt, prevent shivering
  60. improving gas exchange post op ICS
    • monitor for s/s of resp infection - high temp, increased pulse, and change in resp (decrease breath sounds)
    • reposition q2hrs
    • when conscious instruct to deep breath, no coughing unless MD ok
    • cautiosly suction if needed
    • consult resp therapy
  61. managing sensory deprivation with ICS
    periorbital edema is common; hematoma may form under scalp and spread down to the orbit producing an area of ecchymosis (black eye); place pt in head up and apply cold compressess; notify MD if edema worsens, indicates postoperative clot is developing or that there is increasing ICP and poor venous drainage; announce yourself when entering pt room
  62. enhancing self image
    • encourage to tlk about feelings, frustrations
    • " " image, use turban/wig
    • " " support groups, social interaction
  63. monitor manage complications with ICS
    • increased ICP bleeding
    • F&E
    • prevent infection
    • seizures
    • DVT's, PE, Pulmonary or UTI's, pressure ulcers
  64. Increased ICP, bleeding
    • life threatening
    • increased blood pressure with decrease in pulse and resp failure = increased ICP
    • clot under bone flap may be life threatening - s/s: pt who does not waken as expected, new post op deficits (dilated pupil on side of op site)
  65. in the event of blood clot symptoms
    pt is returned to OR immediately for evacuation of clot
  66. cerebral edema, infarction, metabolic disturbances, hydrocephalus all mimic
    clinical manifestations of a clot
  67. to decrease ICP
    alignment of head in a neutral position without flexion to promot venous drainage, elevate HOB to 30 degrees, admin mannitol (osmotic diuretic) and possible admin of paralytic
  68. Post Op ICS mgt of F&E
    regimen depends on type of procedure and determined on individual basis; if cerebral edema occurs MD may restric fluids; Oral fluids are started after the first 24 hrs when gag, swalling reflex are present; then increase DAT;
  69. pt on corticosteroids at increase risk of
    infection (main) and developing hyperglycemia
  70. any surgery near pituitary/hypothalmus may develop
    diabetes insipidus
  71. diabetes insipidus s/s
    increase serum osmolality; decerased urine osmolality; hypernatremia; decreased urine specific gravity
  72. preventing infection
    • monitor incision/invasive lines
    • monitor for CSF leak
    • instruct no to blow nose, cough, sneeze
  73. s/s CSF leak
    post nasal drip, trickle back of throat, frequent swallowing, salty taste
  74. seizure monitoring
    assess for, document, medicate
  75. complications of transsphenoidal surgery
    • trasient diabetes insipidus
    • CSF leak
    • visual disturbances
    • post op meningitis
    • pneumocephalus
  76. Pre op transsphenoidal surgery care
    • teach deep breathe, DO NOT: cough, blow nose, sneeze, suck through a straw
    • usual pre op craniotomy but will not have head shaved
  77. post op transsphenoidal surgery care
    • monitor VS; neuro status (visual acuity fields)
    • HOB elevated
    • no blowing nose coughing, sneezing, straws
    • I/O, weights
    • specific gravity hourly/ each voiding
    • check nasal packing, change nasal mustache dressing but DO NOT remove pakcing
    • oral care frequent, room, O2 humidified
    • no brush teeth - rinse mouth with saline wash
    • HOB elevated for 2 wks post op/at home humidifier
  78. serum osmolality
    - norm
    - panic
    urine osmolality
    - norm
    - average
    - norm
    Urine specific gravity
    - norm
    • 280-300mOsm/kg
    • <240 or >320mOsm/kg

    • 50-1200mOsm/kg/h2o
    • 200-800Osm/kg/kwater


  79. decreased serum osmolality s/s
    over hydration or water toxicity (ha, confusion irritability) super dilute intravascular fluids
  80. decreased urine osmolity s/s
    excessive intake of fluids or IV, s/s water toxicity (increased dehydration will cause increased levels, hyperosmolar due to SIADH, correct self in day or two)
  81. gerontologic consideration with epilepsy
    increased risk of new onset d/t stroke, head injury, dementia, infection, alcoholism, and aging

    monitor age group closely for s/s of toxicity, drug/drug interaction
  82. seizure
    abnormal motor, sensory, autonomic or psychic activity or combination
  83. partial seizure
    beginning locally
  84. simple partical sezures
    - with elementary symptoms, generally without impairment of consciousness
    • with motor symptoms
    • with special senosry or somatosensory symptoms
    • with autonomic symptoms
    • compound forms
  85. complex partial seizures
    - with complex symptoms, generally with impairment of consciousness
    • with impairment of consciousness only
    • with cognitive symptoms
    • with affective symptoms
    • with psychosensory symptoms
    • with psychomotor symptoms (automatisms)
    • compound forms
  86. generalized seizures
    - convulsive or nonconvulsive, bilaterally symmetric, without local onset
    • tonic-clonic seizures
    • tonic seizures
    • clonic seizures
    • ansence seizures
    • atonic seizures
    • myoclonic seizures (bilaterally massive epileptic)
  87. causes of seizures

    acquired - have it b/c of another d/o
  88. major antiseizure medications
    • carbamazepine (tegretol)
    • clonazepam (klonopin)
    • ethosuximide (zarontin)
    • felbamate (felbatol)
    • gabapentin (neurontin)
    • lamotrigine (lamictal)
    • levetiracetam (keppra)
    • oxacarbazepine(trileptal)
    • phenobarbital (luminal)
    • phenytoin (dilantin)
    • primidone (mysoline)
    • tiagabine (gabitril)
    • topiramate (topamax)
    • valproate (depakote, depakene)
    • zonisamide (zonegran, excegran)
  89. carbamazepine (tegretol)
    - SE - dose related
    - toxic effects
    dizziness, drowsy, unsteady, N/V, diplopia, mild leukopenia

    severe skin rash, blood dyscrasias, hepatitis
  90. clonazepam (klonopin)
    - dose related SE
    - toxic effects
    drowsy, behavior changes, HA, hirsutism, alopecia, palpitations

    hepatoxicity, thombocytopenia, bone marrow failure, ataxia
  91. ethosuximide (zarontin)
    - dose related SE
    - toxic effects
    N/V, HA gastric distress

    skin rash, blood dyscrasias, hepatitis, lupus erythematosus
  92. felbamate (felbatol)
    - dose related side effects
    - toxic effects
    cog. impair, insomnia, N, HA, fatigue

    aplastic anemia, hepatotoxicity
  93. gabapentin (neurontin)
    - dose related Se
    - toxic effects
    dizzy, drowsy, somnolence, fatigue, ataxia, weight gain

    severe rash (stevens-johnson syndrome)
  94. levetiracetam (keppra)
    - dose related SE
    - toxic effects
    somnolence, dizzy, fatigue
  95. unknown
  96. oxacarbazepine (trileptal)
    - dose related Se
    - toxic effects
    dizzy, somnolence, double vision, fatigue, N/V, loss of coordination, abnormal vision, abdominal pain, tremor, abnormal gait

  97. phenobarbital (luminal)
    - dose related SE
    - toxic effects
    sedation, irritability, diplopia, ataxia

    skin rash, anemia
  98. phenytoin (dilantin)
    - dose related SE
    - toxic effects
    visual probs, hirsutism, gingival hyperplasia, dysrhythmias, dyarthria, nystagmus

    severe skin reaction, peripheral neuropathy, ataxia, drowsiness, blood dyscrasias
  99. hirsutism
    abnormal facial hair growth on females
  100. gingival hyperplasia
    overgrowth of gums
  101. dysarthria
    motor speech disorder
  102. nystagmus
    involuntary eye movement
  103. ataxia
    lack of muscle coordination
  104. somnolence
    near sleep
  105. primidone (mysoline)
    - dose related side effects
    - toxic effects
    lethargy, irritability, diplopia, ataxia, impotence

    skin rash
  106. tiagabine (gabitril)
    - dose related se
    - toxic effects
    dizzy, fatigue, nervous, tremor, diff concentrating, dysarthria, weak or buckling knees, abdominal pain
  107. unknown
  108. topiramate (tompamax)
    - dose related SE
    - toxic effects
    fatigue, somnolence, confusion, ataxia, anorexia, deppression, weight loss

  109. nephrolithiasis
    kidney stones
  110. valproate (depakote, depakene)
    - dose related SE
    - toxic effects
    N/V, weight gain, hair loss, tremor, menstrual irreg.

    hepatoxicity, skin rash, blood dyscrasias, nephritis
  111. zonisamide (zonegran, excegran)
    - dose related SE
    - toxic effects
    somnolence, dizzy, anorexia, HA, N, agitation, rash

    leukpenia, hepatotoxicity
  112. Epilepsy
    - def
    - affects who
    - dx
    group of seizure activity characterized by unprovoked recurring seizures; classifed by specific features; onset, fam hx, seizure type;

    3% of population - most occur in childhood

    detailed developmental hx; PE; MRI; will do EEG w/ 24 hr monitoring; LAB's to make sure no other cause;

    anti seizure meds make BCP less effective
  113. Seziure documentation
    time (start and stop); characteristics, conscious or not, bowel and bladder fx, LOC
  114. Pharmacologic Tx of Seizures
    - start
    - if not controlled
    - DO NOT
    start with a single antiseizure med, start slow and draw labs for therpeutic levels

    may change med or use a combo of meds

    suddenly withdraw/ can cause seizures to occur
  115. Major seizure medications
    tegretol, klonopin, neurontin, lamictal, triliptal, lunimal, dilantin, mysoline, depakote
  116. Major SE of anti seizure medications
    idosyncratic/ allergic disorders; acute toxicity when starting meds; chronic toxicity - over time, later;
  117. long term dilantin use can cause
    gengival hyperplasia
  118. Epilepsy in women
    increased number of seizures with onset menses; effects of contraceptives is decreased due to antiseizure meds; address bone loss r/t long term use of antiseizure meds - risk for osteoporosis
  119. Nursing Care DURING seizure
    • provide privacy
    • ease to floor, if in bed pull up all padded rails
    • protect head with pad to prevent injury
    • loosen constrictive clothing
    • push aside any furniture that may injure the pt
    • remove all pillows
    • if an aura preceds the seizure, insert an oral airway to reduce possiblity of the tongue or cheek being bitten
    • DO NOT attempt to pry open mouth or jaw when seizure is happening - browken teeth and injury to lips and tongue may result
    • DO NOT restrain; if possible place on side with head flexed forward
    • document sequence of signs
  120. Nursing Care POST seizure
    • keep on their side
    • may have short apneic time during or immediately after a generalize seizure
    • when awake reorient
    • if become agitated after seizure, use calm persuasion and gentle restraint of you physically not physical restraints
  121. Nursing Care for seizure
    • assess major complications; status epileptics and medication toxicity
    • major goal is prevention of injury, control seizures
    • reduce fear of seizures through teaching
    • improve coping
    • monitor and manage complications
  122. reduce frear of seizure through teaching by
    • medications, SE, Monitoring
    • will not be addicted to meds
    • need to ID any preciptating events to seizure
    • reg diet avoid stimulants
    • avoid phobic stimuli (flashing lights, TV)
    • avoid alcohol
    • carry emergency ID med info
  123. improve coping with seizures by
    support groups, counseling referrals
  124. moitor and managing seizure complications
    - satus epileptics major complication
    - state of
    - precipitating factors
    - goal
    - draw labs to
    - contstant monitoring of
    - if not successful may use
    • prolonged seizure activity occurs without full revocery of consciousness between attacks, last at least 30 min;
    • medical emergency
    • withdrawal from meds; fever with infections
    • stop seizures; airway may need ETT, give IV valium, ativan until seizures stop
    • check medication levels, check for hypoglycemia
    • VS
    • general anesthesia, short acting barbituate
  125. Home care checklist for pt with epilepsy
    - medication therapy
    - documentation
    - notify MD when
    - antizeizure serum levels checked
    - things to avoid
    - report signs of toxicity such as
    - medical alert bracelet
    - take showers rather than tub bath why?
    - excerise
    - sleep pattern
    - special services
    • take meds daily as prescribed to keep the drug level constant to prevent seizures; pt should never d/c meds even when no seizures
    • keep medication and seizure chart, noting when meds are taken and any seizure activity
    • if pt cannot take meds d/t illness
    • regularly; when testing is prescrived pt should report to lab for blood sample before taking morning meds
    • activities that require alterness and coordination (driving, operating machinery) until after the effects of the meds have been evaluated; OTC meds unless approved by pt MD; seizure triggers i.e. ETOH, electrical shocks, stress caffeine, constipation, fever, hyperventilation, hypoglycemia
    • drowsiness, lethargy, dizzy, diff walking, hyperactivity, confusion, inapp sleep and visual disturbances
    • specify name of pt anitseizure meds and MD
    • to avoid drowning if seizure occurs, never swim alone
    • exercise on moderation in a temp controlled environment to avoid excessive heat
    • develop reg sleep patter to minimize fatigue and insomnia
    • epilepsy foundation - help in getting meds, voc rehab, and coping
  126. prevention of seizures
    - nonmodifiable risk factors
    - modifiable risk factors
    age (over 55), male gender, African American, low birth weight infants, genetics

    HTN (primary risk factor), smoking, elevated choleterol or elevated hematocrit, obesity, diabetes, atrial fibrillation, BCP use, drug and ETOH abuse
  127. Headache
    - primary (types)
    - secondary
    migraine, tension, cluster, cranial arteritis

    associated with organic cause
  128. headache assessment
    Hx, PE, meds, exposure to toxic substances, Dx test are specific to r/o the HA are not organic in nature
  129. headache prevention
    avoid triggers, take meds as prescribed, avoid ETOH, nitrates, vasodilators if cluster headaches
  130. Stroke
    - def
    - types
    "brain attack" - sudden loss of function resulting from a disruption of the blood supply to a part of the brain

    ischemic (87%); hemorrhagic (15 to 20%)
  131. ischemic stroke
    - def
    - causes
    disruption of the blood supply d/t an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue

    • large atery thrombosis
    • small pentrating artery thrombosis
    • cardiogenic embolism
    • cryptogenic (no known cause)
    • other
  132. causes of hemorrhagic stroke
    intracerebral hemorrhage, subarachnoid hemorrhage, cerebral aneurysm, arteriovenous malformation
  133. AHA 7 d's of stroke care
    detection, dispatch, delivery, door, data, decision, drug
  134. cerebrovascular disorders
    - def
    - primary
    - costs
    functional abnormality of the CNS that occurs when the blood supply is disrupted

    stroke - the third lead cause of death in US and the leading cause of serioud long-term disability in the US

    direct and indirect are billions
  135. ischemic stroke
    - sx
    - precipitated by
    - occur when
    - three types
    develop over a few minustes or can worsen over hours

    a warning sighn (loss of strenght in extremity; one side of the body may be different; speech can be affected; language; can complain of change in their vision or balance)

    more often at night or early in the morning - not sure why

    throbotic, embolic, system hypoperfusion
  136. LAB studies (rationales)
    -PT and PTT
    -Cardiac enzyme
    - ABG
    • need data on coagulation status; elevated INR, no thrombolytics
    • may experience AMI with stroke
    • r/o suspected hypoxia, acid-base disturbances; avoided if potention for thombolytics
  137. Dx for stroke
    - to determine whether ischemic or hemorrhagic
    - if ischemic then
    - other tests
    • non contrast CT scan
    • EKG, carotid ultrasound
    • transcranial doppler flow studies, transhoracic or transesphageal achocardiogram, MRI, SPECT
  138. Manifestations of Ischemic Stroke
    - sx depend on
    - common sx
    location and size of affected area

    numbness or weakness of face, arm or leg especially on one side; sudden confusion or change in mental status; trouble seeing in one or both eyes; trouble speaking or understanding speech; difficulty walking, dizziness, or loss of balance or coordination; sudden sever HA
  139. LAB studies with stroke
    - glucose, electrolytes to indicate?
    - CBC (focus on?)
    hypogylcemia, hyperglycemia, uremia

    provides info regarding H/H, Plt counts
  140. Mgt goals with stroke
    - miminmize?
    - stroke chain of survival
    brain injury and maximize pt recovery

    rapid recognition and reaction to stroke warning signs; rapid EMS dispatch; rapid EMS system transport and hospital prenotification; rapid dx and tmt in hospital
  141. recommened stroke eval timeline
    - door to doctor
    - access to neurologic expertise
    - door to CT scan completion
    - door to CT scan interpretation
    - door to tmt
    - admission to monitored bed
    • 10 min
    • 15min
    • 25 min
    • 45 min
    • 60min
    • 3hrs
  142. fibrinolytic checklist
    - Inclusion criteria
    - age
    - dx
    - time
    • 18 or older
    • clinic dx of ischemic stroke w/ measurable neuro deficits
    • time of symptom onset well established <180 min before treatment would begin
  143. fibrinolytic checklist
    exclusion criteria
    - evidence of ______ on CT
    - clinical presentation of _____ with normal CT
    - hx of
    - uncontrolled ?
    - known?
    - acute bleeding plt count?
    - received heparin w/in?
    - current use of
    - w/in 3 mos of?
    - w/in 7 days of?
    • intracranial hemorrhage on pretreatment CT
    • suggestive of subarachnoid hemorrhage with normal CT
    • intracranial hemorrhage
    • HTN at time of tmt; S>185 or D>110 with tmt
    • AVM, brain tumor, aneurysm
    • 48 hrs with elevated PTT
    • Coumadin with >INR
    • intracranial or intraspinal surgery, serious head trauma, previous stroke
    • arterial puncture at a noncompressible site
  144. immediate assessment of stroke pt in ED
    • assess ABC's/ VS
    • provide o2 if hypoxemic
    • obtain IV access, draw blood, limit attempts
    • check glucose; treat if needed
    • neurologic screening
    • activate stroke team (stroke centers)
    • MD order emergent CT scan of brain
    • obtain 12 lead EEG
    • immediate neurologic assessment including: pt hx (timeline), sx onset, neuro exam (NIH stroke scale)
  145. stroke meds
    - fibrinolytic agents
    - adult dose
    - IV not to exceed
    - infuse over; with % bolus
    - assess how often
    - s/s toxicity; give?
    • alteplase (activase)
    • 0.9mg/kg
    • 90mg/dose
    • 60 min with 10% total dose admin initial IV bolus over 1 minute
    • q 15 min during 1st hr
    • local bleeding, monitor IV sites; blood, platelets
  146. If CT shows NO hemorrhage (with stroke)
    - probable
    - consider
    - repeat
    - pt still candidate
    - give
    - NO
    • probable acute ischemic stroke
    • thrombolytic
    • neuro exam; are defictis rapidly improving to norm
    • review risks and benefits w/ fam if acceptable
    • tPA
    • anticoagulants or antiplatelet tmt for 24 hrs
  147. If CT scan DOES show hemorrhage (stroke)
    - consult
    - admit to
    - monitor
    - initiate
    • neurologist or neurosurgeon
    • to stroke unit if available
    • BP and treat; neuro deficit, emergent CT if worsen; blood glucose
    • supportive therapy
  148. Transient Ischemic Attack (TIA)
    - def
    - warning of
    - dx
    • temporary neurologic deficit resulting from a temporary impairment of blood flow
    • impending stroke
    • work-up is required to treat and prevent irreversible deficits
  149. Nursing care of pt recovering from ischemic stroke
    - acute phase
    • ongoing/frequent monitoring of all system including VS and neuro assessment: LOC and motor, speech and eye sx
    • monitor for potential comp including muskuloskeletal probs, swalling difficulties, resp probs, and s/s of increase ICP and meningeal irritation
  150. nursing care after stroke is complete
    - focus on pt function
    - indicated for pt with s/s of
    - primary complications
    - maintain adequate
    - neuro flowsheet
    • self care ability, coping and teaching needs to facilitate rehab
    • TIa or mild stroke found to be caused by sever (70-90%) carotid artery stenosis or moderate (50-68%) stenosis or other significant risk factors
    • stroke, cranial nerve injuries, infection, or hematoma at incision site, and carotid artery disruption
    • BP - avoid hypotension - Nipride used to reduce BP to previous levels, close cardiac monitoring
    • notify MD if neurologic deficit occurs
  151. Nursing Dx for stroke
    • impaired physical mobility
    • acute pain
    • self care deficits
    • disturbed sensory perception
    • impaired swallowing
    • urinary incontinence
    • disturbed thought process
    • impaired verbal communication
    • risk for impaired skin integrity
    • interrupted family process
    • sexual dysfunction
  152. Major goals for pt recovering from ischemic stroke
    • improved mobility
    • avoidance of shoulder pain
    • achievement of self care
    • relief of sensory and perceptual deprivation
    • prevention of aspiration
    • continence
    • improved thought process
    • achievement of form of communication
    • maintenance of skin integrity
    • resoration of fam fx
    • improved sex
    • absence of comp
  153. nursing interventions for Potential complications with ischemic stroke
    - incision hematoma
    - HTN
    - post op hypotn
    - hyperperfusion syndrome
    - intracerebral hemorrhage
    • monitor neck discomfort and wound expansion; report swlling, subjective feelings of pressure of theneck, diff breathing
    • risk is highest in first 48 hrs after surgery; check BP freq and rept devi from base; observe and report new onset of neuro defi
    • moitor BP and observe for s/s
    • ovserve for sever unilateral HA improved by sitting upright or standing
    • monitor neuro status and report any changes in MS or neuru funct
  154. improving mobility and prevent joint deformities in stroke recovery
    • turn and position in correct alignment q2hrs
    • use splints
    • practices passive or active ROM 4 to 5 times/day
    • position hands and fingers
    • prevent flexion contractures
    • prevent shoulder abduction
    • do not lift by flaccid shoulder
    • implement measures to prevent and treat shoulder probs
    • encourage pt to exercise unaffected side
    • establish routine
    • assist pt OOB asap; assess and help pt achieve blance and move slowly
    • use quadriceps setting and gluteal exercises
    • implement ambulation training
  155. Interventions for stroke recovery
    • ehance self care: realistic goals, encourage person hygiene, ensure pt does not neglect affected side, assistive devices and mod of clothing
    • support and encouragement
    • enhance communication
    • encourage pt with visual field loss to turn his head and look side to side
    • nutrition: consult speech therapist or nutritionist, sit upright to eat, use chin tuck or swallowing method, feed thickened liquids or pureed diet
    • Bowel and bladder control: asses and schedule voiding; prevent constipation; provide retraining
  156. strategies to enhance communication with stroke pt
    • face pt and establish eye contact
    • speak normal
    • use short phrases and pause to allow pt to understand
    • limit conversation to practical and concrete matters
    • use gestures, pics, and obj
    • as pt uses and handles obj, say what it is
    • be consistent
    • keep noises to minimum
  157. with pt not recieving tPA
    - med
    - maintainence of cerebral hemodynamics
    - manage complications
    • anticoagulant (heparin)
    • inc ICP from brain edema and associated comp after large ischemic stroke: elevate HOB unless contrain, osmotic diuresis, maintin PaCO2, provide continuous hemodynamic monitoring and neuro assessment
    • beside pulmonary and cardiac; UTI, dysrythmias, and immobility
  158. hemorrhagic stroke
    - cause by
    - may be d/t
    - brain metabolism
    - ICP
    - compression or secondary ischemia from
    • bleeding into brain tissue, the ventricles or subarachnoid space
    • spontaneous rupture of small vessels primarily related to HTN; subarachnoid hem d/t ruptured aneurysm; or intracerebral hem r/t amyloid angiopath, arterial venous mlform (AVM's), intracranial aneurysms, or meds such as anticoagulants
    • disrupted by exposure to blood
    • increases d/t blood in subarachnoid space
    • reduced perfusion and vasoconstriction injures brain tissue
  159. assessment and dx of hemorrhagic stroke
    • similar to ischemic stroke
    • severe HA
    • early and sudden changes in LOC
    • vomitting
    • syncope
    • neck stiffness
    • markedly elevated BP
  160. Dx of hemorrhagic stroke
    • CT scan to determine type, size and location of hematoma and presence of ventricular blood
    • any pt with neuro defi - careful hx and PE
    • initial assessment focuses on airway patency, cardiovascular status and gross neuro def
    • may present with temp neuro sx - transient ischemic attack
  161. Tx of hemorrhagic stroke
    • currently no standard
    • Goal: stop or decrease bleeding, remove extra vascular blood
    • Admit to ICU: airway - >95%; glucose wnl; BP wnil; IV fluids to meet specific pt needs; Cardiac monitor; antiseizure meds
  162. Nursing focus for hemorrhagic stroke
    Monitor For:
    - airway
    - dysphagia
    - warning signs
    - test
    - NPO until
    - supplement oxygen
    - Temp
    - Cardiac Monitoring
    - HTN
    - Blood Glucose
    - Increased ICP
    patency may need ETT with vent support

    • leads to aspiration, pneumonia, more common in those with breathing issues; can occur with normal or near normal LOC:
    • difficulty speaking, weak voluntary cough, drooling
    • watch pt attempt to swallow 3 oz of water if their voice is wet there is a risk of aspiration
    • until swallowing is assessed and ok'd

    keep pulse ox at >95%, treat and report hypoxia

    treat with antipyretics, assess for infection

    stroke is associated with atrial fib, CAD; cleared cardiac in the ED, must monitor for arrythmias, AMI; notify MD if arrythmia's occur

    treat HTN in hemorrhagic stroke cautiously; monitor BP trends and report; general - lower BP gradually in 1st 24 hrs to keep S<108/ D<105

    goal keep <140 - use sliding scale reg insuling; test routinely

    tend to suffer increased ICP = deteriorate quickly; know ICP care
  163. right hemispheric stroke
    • paralysis or weakness on right side of body
    • right visual field deficit
    • aphasia (expressive, receptive, or global)
    • altered intellectual ability
    • slow, cautious behavior
  164. Left hemispheric stroke
    • paralysis or wearkness on left side of body
    • left visual field deficit
    • spatial-perceptual deficits
    • increased distractibility
    • impulsive behavior and poor judgment
    • lack of awareness of deficits
  165. visual field deficits with hemorrhagic stroke
    - homonymous hemianopsia
    - loss of peripheral vision
    - diplopia
    loss of half of the visual field; place objects within field of vision; approach from unaffected side; instruct to turn head side to side

    • place objects in center of vision
    • evaluate driving ability

    explain location of objects; place pt care items in same place
  166. Motor deficits with hemorrhagic stroke
    - hemiplegia
    - hemiparesis
    - ataxia
    - dysarthria
    - dysphagia
    ROM to affected side; provide immobilization to affected side; maintain body alignment; exercise unaffected side - strength, mobility, use

    place objects w/in reach of unaffected side; exercise and increase strenght on unaffected side

    support pt during ambulation; provide supportive device for ambulation

    alternative communication methods; allow pt time to respond verbally; support pt/fam to alleviate frustration

    test pharyngeal reflex prior to eating or taking liquids; assist with meals; place food on unaffected side of mouth; allow ample time to eat
  167. sensory deficits with hemorrhagic stroke
    - paresthesia
    instruct pt that sensation may be altered; provide ROM to affected area; apply corrective devices if needed
  168. verbal deficits of hemorrhagic stroke
    - expressive aphasia
    - receptive aphasia
    - global (mixed) aphasia
    pt to repeat sounds of alphabet; explore pt ability to write

    speak slowly/clearly to assist in forming words; explore pt ability to read

    speak clearly and in simple sentences; use gestures or pics when able; establish alternative means of communication
  169. cognitive deficits of hemorrhagic stroke
    • reorient pt to time, place and situation
    • use verbal and auditory cues to orient
    • provide familiar objects
    • match visual tasks with a verbl cue
    • minimize distraction noises and views when teaching
    • repeat and reinforce
  170. emotional deficits with hemorrhagic stroke
    • support pt during uncontrollable outbursts
    • discuss with pt/familty that outbursts are d/t disease process
    • encourge pt to participate in group activity
    • provide stimulation
    • control stressors
    • provide safe env
    • encourage pt to express feelings
  171. Vasospasm
    - def
    - morbidity
    - leads to increased....
    - s/s
    - occurs when
    - Tx
    • narrowing of the lumen of the involved cranial blood vessel; serious complication
    • 40-50 %
    • vascular resistance which impedes cerebral blood flow and causes brain ischemia and infarction
    • worsening HA, decrease LOC, new focal neuro def
    • 4-14 days after initial hemorrhage
    • Ca channel blockers, fluid volume expanders, indcued arterial hypertension and hemodilution
  172. Intracranial Aneurysms
    - def
    - precautions
    - activity
    - HOB
    - to decrease strain...
    - personal care
    - environment
    result of weakness in the arterial wall; cause unknown

    absolute bed rest; avoid all activity that may increase ICP or BP; implement valsalva maneuver, acute flexion and rotation of the neck or head

    30 degrees to promote venous drainage or keep the bed flat to increase cerbral perfusion

    exhale through mouth when voiding or defacting; prevent constipation

    nurse provides all

    provide nonstimulating, nonstressful environment: dim lighting, no reading, no TV and no radio, restrict visitors
  173. Interventions for intracranial aneurysm
    relieve sensory deprivation and anxiety; keep sensory stimulation to minimum for aneurys precautions, implement reality orientation, provide pt and fam teaching, support and reassurance, seizure precautions, strategies to regain and promote self care and rehab
  174. Home Care and Teaching for pt recovering from stroke
    • prevention of subsequent strokes, health promo, and implementation of follow up care
    • prevention of and s/s of comp
    • medication teaching
    • safety measures
    • adaptive strategies and use of assistive devices for ADL's
    • nutrition: diet, swallowing techs, and tube feeding admin
    • elimination: bowel and bladder programs and catheter use
    • exercise and activities: recreation and diversion
    • socialization, support groups, and community resource