Test4 Nursing 122
Card Set Information
Test4 Nursing 122
Test4 Nursing 122epine
Stroke (Brain Attack)
Ishemic = Thrombotic/Embolic
Hemorrhagic = bleeding-severe HA
CVA- Who are the high risk Patients?
Age older then 55, Male, African American, And HTN.
: DM, obesity, smoking, heat disease, hyperch olesterolemia and periodontal diease.
CVA- Primary Assessments
History, complete physical and neurlogical examination.
: CT, MRI, Ultrasound.
CVA- Clinical Manifestations
Confusion, changes in mental status, Slurred speech, paralysis, visual disturbances, dizziness, loss of balance, difficulty walking and sudden severe HA.
CVA- Nursing interventions
Elevate head of the bed 35-40 degrees. Airway patency, frequent neuro assestments, bowel ad bladder trainging, self care, skin integrity, Rehab and sensory perception.
Decrease blood flow, cerebral hypoxia, vasospasma, Increase ICP and HNT.
: Monitor inter cranial pressure.
Maintain airway, o2,UTI monitoring, TPA, anticoagulation therapy, neuro assessment and vital signs.
: Half vision field is gone.
Partial and generalized.
MORE interventions airway, aspiration risk and ABC.
Privacy, safety , side lying position , clear area , padding and not bite tongue or check.
Auto immune DI9SEASE THAT ATTACKS MYELINSHEATH.
MULTIPLE SCLEROSIS- Pathophysiology
Brain and spinal canal are effected. The immune system destroys the myelin sheath, plaques develop and slows transmission of impulses.
MULTIPLE SCLEROSIS- Clinical Manifestations
Numbness, weakness, loss of coordination, fatigue, dizziness, blurred vision and diplopia (double vision)
MULTIPLE SCLEROSIS- Patient Teaching
Avoid triggers, heat sun and stress.
: Exercise and rest, assistive devices, Rest in cool environment, bladder and bowel training.
Muscle weakness from activity, autoimmune.
MYASTHENIA GRAVIS- Assessment data
History, muscle weakness, difficulty breathing and talking, fatigue, ptosis (dropping) and diplopia (doube vision).
MYASTHENIA GRAVIS- Test to r/o
Tensilon (eproponium chloride) given IV to see if muscle strength increases after 0 - 40 seconds.
If not have MG you will get muscle twitches in < then 5 minutes.
Tensilon side effects are bradycardia, have Atropein to counter -act it.
Pain in 5th cranial nerve.
TRIGEMINAL NEURALGIA- What precipitates attacks
washing face, shaving, brushing teeth, eating, drinking , cold air and direct pressure.
Inflammation of the 7th cranial nerve.
BELL'S PALSY- Clinical Manifestations
Facial, paralysis, inability to close eye, increase tearing, painful sensations in face, drooping and speech difficulty.
BELL'S PALSY- Nursing Interventions
Protect eye from injury with eye shield and eye drops (so eyes don't dry out and maintain muscle tone).
ALS - ( Lou Gehrig's Disease)
Loss of motor neurons in brain stem and spinal chord. (so neurone can't send messages to muscles).
ALS(LOU GEHRIG'S DISEASE)
: Baclofen, Valium, Dantrium, Rilutek and CPAP.
Baclofen decrease muscle spams.
Emotional support and prevent aspiration and aspiration pheumonoa.
Hereditary disease of nervous system of involuntary movement and dementia ONSET ABOUT 40-50 YRS OLD.
HUNTINTONS DISEASE- Clinical Manifestations
Chorea ( abnormal involuntary movement) slurred speech, dysphagia, impaired memory, dementia, personality changes and hallucinations.
Post - polio
Complications in Patients years after the initial infection.
Physical therapy, occupational therapy, speech therapy and respiratory therapy.
Severe head ache.
MIGRANES- Effects of alcohol
Acts as a trigger and set off migraines.
Incurable neuro disease where these is progressive weakening and wasting of muscles.
MUSCULAR DYSTROPHY- Medical Management
Physical therapy, corticosteroids, braces, orthotic jacket and assistive devices.
Relation to infectious diseases?
Stress decreases immune system and makes us more prone to infections and disease.
What has the greatest impact?
Stress is a stimulus for disease.
Prevention is # 1 intervention.
Blood and body fluids!!!
HIV/AIDS- Clinical Manifestation of encephalopathy
Is Characterized by a progressive decline in cognitive, behavioral, and motor function.
HIV/AIDS- Common infection
pneumocystis pneumonia, mycocaterium repitory infection, TB, oral candidiasis, wasting syndrome, kaposi's sarcoma, B- cell lymphomas, prephrial neuropathy, HIV encephalopy, cryptococcus neoformans, progressive multifocal leukoencephalopathy and depression.
HIV/AIDS- Common tx for diarrhea
Give ocreotide ( Sandostain) Increase absorption of fluids and electrolytes from GI and increases transit time.
HIV/AIDS- Common Tx for weight gain
Give Megestrol ( megace) = increase appetite and weight.
God nutrition and balanced diet with oral supplements.
( idea is to maintain weight and gain when necessary).
Abstinence, stop Iv drug use, stop homosexual relationships and correct use of condom ad standard precautions.
Disease when an abnormal cell is transformed by the genetic mutation of cellular DNA.
CANCER- Primary prevention
Avoid carcinogens, dietary and life style changes, ware sun screen, stop smoking and decrease processed food take.
CANCER- Secondary prevention
Screening and early detection.
Breast, testicular, pap and mammogram.
Use beams of high x-rays to destroy cancer cells.
RADIATION- Common side effects
mouth sores, hair loss, anorexia, N/V, fatigue, malaise, anemia, leukopenia and thrombocytopenia.
Chemo= Antineoplasitc Agents
Common side effects
N/V/D Anemia, Leukopenia, Thrombocytopenia, anorexia, HF, RF, sterility, fatigue, weakness, numbness, hematuria, stomatitis, etc.
Chemo= Antineoplasitc Agents
Disposal of meds
Hazardous waste, thick gloves, long sleeved protective gown and double bag.
Bone Marrow Transplant
Replace bone marrow in bones that makes RBC, WBC and platelets.
Bone Morrow Transplant- 100 day concern
monitor for infection, restrictive abnormality in pulmonary system and recurrent pneumonia.
Prevention Strategies: 2 yearly breast exams, yearly mammogram, MRI, self breast exam monthly, avoid carcinogens and dietary and life style changes.
When they would be used?
Before the cancer disease takes effect.
phenytoin (dilantin) Anticonvulsant
side effetcts- pruritus, rash, N/V, dizziness (Ataxia), slurred speech, nervousness, coordination problems, HA and insomnia.
caramazepine (Tegretol) Anti convulsant.
Side effects N/V, hypertension, hypotension, lightheadedness, dizziness, confusion, clumsiness and diplopia (double vision).
lioressel ( Baclofen) - Skeletal muscle relaxant.
purpose of drug- is a CNS depressant and , decreases muscle spasms..
Thrombolytic - TPA ( Tissue Plasminagen Activator)
Time frame - 24 hr after embolus or thrombus.
Contraindications - Dissolves ay clots, so can not have resent surgery.
Imitrex (Sumatriptan)- AntiMigrane
Not given to who - Uncontrolled HTN CVA or perpheral vascular syndromes.
Don't give to uncontrolled HTN, angina, MI stroke, or cardiac issues.