NUR 122 test 4
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. What would you like to do?
What is the priority nursing intervention for unconscious patient?
What is a side effect of Sumatriptain (Imitrex)?
- Chest pain.
- Can cause cardiac disorder
- *Do not give to pt.s with heart disorders
Why does alcohol cause migraine/headache?
It’s a vasodilator
Postictal stage of seizure
- Last stage of seizure
- Lasts 5-30 minutes or more
- s/s Drowsiness, confusion, nausea, HTN, headache, migraine
- *Nurse assess for signs of injury, paralysis, difficulty awakening from sleep
4 stages of seizure
- -Prodromal- mood change, irritability, insomnia
- -Aura- sensation warning pt. of impending seizure
- -Loss of motor activity of bladder/bowel control, Loss of consciousness
- -Postictal- lasts 5-30 min.drowsiness/ confusion/ nausea/ HTN/ headache
What is a side effect of Dilantin for long-term tx. of seizure?
- Gingival hyperplasia
- Provide really good oral care
Non-modifiable risk for stroke:
Modifiable risk for stroke:
Hypertension is primary risk factor
tPA in tx of stroke
- Continuous monitoring of cardiac after admission of tPA
- Must be given within 3 hrs of stroke
- Not for hemorrhagic strokes!
Risks for using thrombolic agent
- Contraindicated of already on anticoagulants
Nursing intervention after stenting/carodid endarterectomy
Raise HOB to reduce intracranial pressure
#1 risks for stroke
- Increasing age (non-modifiable)
- HTN (modifiable)
During assessment, what could facial droop be indicative of?
What is the primary focus of assessment for ischemic and hemorrhagic stroke?
Cardiac and respiratory function
During a hemorrhagic stroke why should nurse raise HOB?
Decrease intracranial pressure in subarachnoid space
How is hemorrhagic stroke diagnosed?
How can nurse help prevent loss of strength & contractures after stroke?
Active ROM to unaffected extremities Passive ROM to affected extremities
What are some elimination issues for stroke patient?
- Urine loss of sensation leading to: Urinary frequency
- Urinary urgency
- *Can cause depression
Which side should you approach post-stroke pt. with visual changes?
Approach on side of intact perception (duh!)
Blindness in one half of the visual field of one or both eyes
Multiple Sclerosis (MS)
A chronic, immune-mediated degenerative disease of CNS characterized my demyelization in brain & spinal cord and formation of plaques
Primary CT finding of MS patient in chronic phase of illness
Multiple, multifocal white-matter lesions known as plaques MRI main way to diagnose MS
Assessment findings in pt. with MS
- *Intention tremors (tremor when they try to use arms/legs)
- Urinary hesitancy
- Difficulty in coordination
- Blurred vision
What exacerbates fatigue in MS patients?
Rx treatment for MS Decreases muscle spasms of lower extremities
Patient teaching for MS patients
- Space activities throughout day
- Get enough rest and sleep
- Rest in air conditioned room (do better in cooler environment)
- Diagnostic test for Myasthenia Gravis (MG)
- After 30 seconds of injection, facial muscle weakness & ptosis begin to resolve (within 5 min)
- Have Atrophine available for SE (bradycardia, sweat, cramping)
Clinical manifestation of Myasthenia Gravis (MG)
- Generalized weakness of muscles in extremities and intercostal muscles Motor disease only
- *Do not have sensory or coordination deficits
- *Very high risk for aspiration
- Main medication used for Myasthenia Gravis (MG)
- Start with this Rx first as others have more side effects
- Must be taken on time or weakness sets in quickly
Intervention for pt. with Tic Douloureux- trigeminal neuralgia
- *Effects 5th cranial nerve
- Trigger area on face may initiate pain Avoid washing face, chew on unaffected side, food at room temp., rinse instead of brush teeth.
- Antiseizure agent
- *S/E: bone marrow depression
- *Results in facial paralysis
- *effects the 7th cranial nerve
- Often only effects one side of face
Nursing care for pt. with Bell’s Palsy
- Provide artificial tears
- Provide eye protective eye wear to prevent injury
- Wear eye shield, patch, or tape eye shut at night
- Wear sunglasses
Huntington’s Disease effect on appetite
Despite a ravenous appetite, pt.s are emaciated & exhausted due to chorea (involuntary movements)
Signs of Amyotrophic Lateral Sclerosis (ALS)
Difficulty in verbal communication related to throat muscle weakness Risk for aspiration (needs frequent lung assessment due to swallowing problems).
Medical management for muscular dystrophy
- Stay active
- -use it or lose it
- Orthopedic jacket
- -Improves sitting stability
- -Reduces trunk deformity
Nursing management for post-polio patient:
Plan activities in AM as they have most energy in AM
Risk associated with peripheral neuropathies
- Risk for falls
- -remove trip hazards
- -use hand rails & assistive devices
- -wear good fitting shoes
What should be remembered about a pt. undergoing EEG?
They cannot take medications that affect brain waves for at least 24hrs Stimulants, anti-seizure, depressants
Paralysis of one side of the body
Weakness of one side of the body
The loss of full control of bodily movements
- Communication disorder
- Difficulty in comprehending or producing spoken/written language.
- Expressive, Receptive, or Global (mixed)
Double double vision
Dysphagia vs Dysphasia
- G-gastric (swallow difficulty)
- S- speech (impairment)
Transient Ischemic Attack (TIA)
- *Warning sign*
- No changes on MRI/CT scan
- No brain tissue death
- Same symptoms of CVA
- Death in 6-24 months
- Caused by prions (very small proteins) that cannot be sterilized in food
- Tx for MG Exchange plasma for healthy plasma (removes antibodies)
- Can take up to 3 yrs to see improvement
Amyotrophic Lateral Sclerosis (ALS)
- “Lou Gehrig’s Disease”
- *Monitor for aspiration pneumonia
- *They can understand but can’t speak (expressive dysphasia)
- Let them use non-verbal techniques to communicate
What is the #1 medication to reduce immunity strength?
Nursing intervention for AIDS?
- Pt. teaching (Prevention)*
- Abstain from sharing sexual fluids Reduce number of partners
- Always use condoms
What is the most common respiratory infection w/ AIDS & HIV?
Pneumocystis Pneumonia (PCP)
Pneumocystis Pneumonia (PCP)
- The most common respiratory infection w/ AIDS & HIV
- Initial symptoms may be nonspecific (unproductive cough, fever, chills) Untreated progresses to pulmonary impairment and respiratory failure
- Tx: TMP/SMZ or Pentamidine
When you’ve got HIV and it’s progressing into AIDS…
Diarrhea, Diarrhea Tx: Sandostatin
Rx for HIV/AIDS associated diarrhea
- Sandostatin (Ocreotide)
- Increases absorption of fluid & electrolytes
- Increases transit time of “stuff” through GI tract
Treatment for wasting syndrome associated with AIDS
- Megestrol Acetate (Megace)
- Appetite stimulant
- Progressive cognitive, behavioral, or motor decline
- Probably directly related to HIV infection
Goals for treatment of pt. with HIV/AIDS
- Absence from infection
- Improved airway clearance
- Improved nutritional status
- Increase in the number of cells of a tissue
- Uterine enlargement during pregnancy
- Conversion of one type of mature cell into another type of cell
- Damaged cells replaced with stronger ones
- Barrett’s esophagus
- Abnormal change in size, shape, appearance, & organization structure of cells
- Caused by persistent injury or irritation
- Cervical dysplasia
- Uncontrolled cell growth that follows physiologic demand
- Fast-growing tumor
Invasion (tumor growth)-
Growth of tumor into the surrounding host tissue
Spread of malignant cells from primary tumor to distant sites
Cancer metastasize through lymph nodes or bloodstream
- Rapid formation of new blood vessels which helps malignant cells obtain nutrients & O2
- Way tumors can grow
Primary prevention of cancer-
Avoid known carcinogens, positive dietary/lifestyle changes
Secondary prevention of cancer-
Screening & early detection
- Chemotherapy used in an attempt to destroy tumors
- Is systemic tx. rather then specific like radiation
Stress’s affect on immunity
- Day to day stress has a larger impact then major life events
- Weakens the immune system’s response
- Associated with infectious disease
How is HIV/AIDS spread?
- Seminal fluid
- Vaginal secretions
- Amniotic fluid
- Breast milk
Effect on GI from radiation therapy
- Impaired nutritional status
- Oral stomatitis (inflammation mouth mucus membranes)
- Xerostomia (dry mouth)
Systemic effects of radiation tx.
- SE result of tx, not deterioration
Most common GI SE from Chemotherapy
Nursing management of chemotherapy
- Modify risk for infection
- Dispose hazardous waste in appropriate receptacle
- Total mastectomy and reconstruction of the breast
- Candidates include strong family hx, cancer phobic, and hx of cancer in one breast
“100 day concern” regarding bone marrow transplant
Before engraphment, pt. high risk for infection, sepsis, & bleeding
What would you like to do?
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