Term
| number of head injuries per year |
|
Definition
|
|
Term
| highest incidence group for head injuries |
|
Definition
|
|
Term
|
Definition
- accidents
- falls
- assaults and violence
- sports and recreational activities |
|
|
Term
| primary injury occurs when? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| secondary injuries include... |
|
Definition
- hypoxia
- hypercapnia
- hypotension
- cerebral edema
- hypertension |
|
|
Term
|
Definition
|
|
Term
|
Definition
- ecchymosis over the mastoid process
- raccoon eyes
- halo sign |
|
|
Term
| with what type of skull fracture does Battle's Sign occur? |
|
Definition
|
|
Term
| what can nurses do for basilar skull fractures? |
|
Definition
- place a piece of sterile cotton loosely against the ear and under the nose
- elevate head of bed no more than 30 degrees (to reduce ICP & promote spontaneous closure of leak)
- monitor temp
- monitor for nucheal rigidity
- assess cranial nerves
- rarely, lumbar catheter for continual CSF drainage (most CSF leaks resolve spontaneously within 7-10 days) |
|
|
Term
|
Definition
| temporary loss of neurologic function with no apparent structural damage |
|
|
Term
| concussion symptoms, Grade 1 |
|
Definition
- vacant stare
- recovery in <1 min. |
|
|
Term
| concussion symptoms, Grade 2 |
|
Definition
- no LOC but retrograde/post-traumatic amnesia
- confusion
- headache |
|
|
Term
| concussion symptoms, Grade 3 |
|
Definition
- LOC
- retrograde/post-traumatic amnesia
- confusion
- headache
- loss of judgment
- loss of reaction time
- loss of information processing |
|
|
Term
| postconcussion syndrome (definition) |
|
Definition
| - residual effects that occur following orientation or within a few days |
|
|
Term
| postconcussion syndrome symptoms |
|
Definition
- headache
- lethargy
- personality/behavior changes
- attention deficits
- difficulty with memory |
|
|
Term
| cerebral contusions (definition) |
|
Definition
| - cerebral bruising associated with blunt/penetrating trauma, depressed skull fracture, or acceleration-deceleration injury |
|
|
Term
| diffuse axonal injury (definition) |
|
Definition
| damaged nerve fibers and torn axons caused by shearing forces associated with acceleration-deceleration or rotational injuries |
|
|
Term
| diffuse axonal injury symptoms |
|
Definition
- immediate period of unconsciousness
- longer period of confusion and amnesia
- prolonged recovery
- graded mild to severe based on degree of symptoms and time spent in coma |
|
|
Term
| intracranial hematoma - most common risk factor? |
|
Definition
| presence of a skull fracture |
|
|
Term
| intracranial hematoma types |
|
Definition
- epidural
- subdural
- intracerebral |
|
|
Term
|
Definition
1. force/blow to head
2. tearing of middle meningeal artery
3. rapid accumulation of blood in epidural space
4. compression of the motor cortex and brain tissue
5. marked neurologic deficit and increase in ICP |
|
|
Term
| epidural hematoma symptoms |
|
Definition
- brief LOC
- lucidity
- progressive deterioration of LOC and hemiparesis on opposite side
- dilated, fixed pupil on same side of EDH
- headache
- vomiting
- seizures
- sleepiness |
|
|
Term
| subdural hematoma (definition) |
|
Definition
| - hemorrhage from small vessels between the dura mater and arachnoid |
|
|
Term
|
Definition
- acceleration/deceleration
- rotational forces |
|
|
Term
|
Definition
- acute
- subacute
- chronic |
|
|
Term
| subdural hematoma, acute (definition) |
|
Definition
| major contusion or laceration that occurs within 48 hours of injury |
|
|
Term
| subdural hematoma, acute (symptoms) |
|
Definition
- gradually worsening headache, confusion, difficulty thinking, agitation, drowsiness
- ipsilateral pupil dilated and fixed
- contralateral hemiparesis
- profound coma |
|
|
Term
| subdural hematoma, subacute (definition) |
|
Definition
| - less severe contusion that occurs within 2 days - 2 weeks of injury |
|
|
Term
| subdural hematoma, chronic (definition) |
|
Definition
| minor head injury in which symptoms persist longer than 2 weeks or more after injury |
|
|
Term
| subdural hematoma, chronic (symptoms) |
|
Definition
- headache
- progressive lethargy
- forgetfulness
- possible seizure
- may look like having a TIA, change in pupils, hemiparesis |
|
|
Term
| subdural hematoma, chronic (risk groups) |
|
Definition
- elderly
- persons who have had long term alcohol abuse with impaired blood clotting resulting from deteriorated liver function
- persons on anticoagulant therapy |
|
|
Term
| What can we do for a subdural hematoma? |
|
Definition
- frequent neuro checks & close monitoring
- watch pupils closely
- monitor motor ability |
|
|
Term
| subdural hematoma medical management |
|
Definition
- craniotomy
- burr hole evacuation
- catheter drainage |
|
|
Term
| intracerebral hematoma (definition) |
|
Definition
| bleeding within cerebral tissue |
|
|
Term
| intracerebral hematoma causes |
|
Definition
- skull fracture
- penetrating injuries
- contusions
- lacerations
- sudden acceleration/deceleration motion |
|
|
Term
| subarachnoid hemorrhage (definition) |
|
Definition
| hemorrhage into the subarachnoid space |
|
|
Term
| subarachnoid hemorrhage cause |
|
Definition
|
|
Term
| subarachnoid hemorrhage symptoms |
|
Definition
- nuchal rigidity
- severe headache
- visual disturbances
- ipsilateral dilated pupil |
|
|
Term
|
Definition
| object penetrates the skull to produce significant focal damage |
|
|
Term
|
Definition
- depressed
- penetrating
- perforating |
|
|
Term
| missile injury, depressed |
|
Definition
| - caused by fractures of the skull, with penetration of bone into cerebral tissue |
|
|
Term
| missile injury, penetrating |
|
Definition
| - object enters the cranial cavity but does not exit |
|
|
Term
| missile injury, perforating |
|
Definition
| - object enters and exits |
|
|
Term
|
Definition
| - related to velocity/weight of object, structures involved, associated contusions, and hemorrhages |
|
|
Term
| what can we do for a missile injury? |
|
Definition
|
|
Term
|
Definition
13-15 mild injury
9-12 moderate injury
3-8 severe injury |
|
|
Term
| traumatic brain injury priority goals |
|
Definition
- restore circulating volume
- keep BP>90 mmHg
- maintain airway
- decrease ICP
- assess neuro status, including motor movements and pupillary response
- monitor fluid and electrolyte status
- nutrition |
|
|
Term
|
Definition
serum Na > 145
serum osmolality > 300
urine osmolality < 300
urine specific gravity < 1.005 |
|
|
Term
| what can we do for diabetes insipidus? |
|
Definition
|
|
Term
| diabetes insipidus diagnoses |
|
Definition
- fluid volume deficit
- decreased cardiac output |
|
|
Term
| traumatic brain injury diagnoses |
|
Definition
- risk for aspiration
- impaired gas exchange
- altered nutrition, less than body requirements
- body image disturbance
- self-care deficit syndrome
- ineffective individual/family coping
- anticipatory grieving |
|
|
Term
| factors affecting behavior and personality |
|
Definition
- site of injury
- severity
- personality before injury
- environment |
|
|
Term
| nurse's role in rehabilitation |
|
Definition
- develop plan of care
- determine family needs
- refer to community resources |
|
|
Term
| potential nursing diagnoses in rehab phase |
|
Definition
- caregiver role strain
- chronic confusion
- ineffective family coping
- altered family processes
- impaired home maintenance management
- risk for injury
- self-concept disturbance |
|
|
Term
| neurological assessment history |
|
Definition
- neurological symptoms
- medical history
- familial history
- social profile
- medication profile |
|
|
Term
| neuro assessment physical exam |
|
Definition
- cerebral function
- motor system
- sensory system
- cranial nerves |
|
|
Term
| level of consciousness is controlled by? |
|
Definition
- reticular activating system in the brain stem
- if reticular activating system (RAS) is still functioning, the patient can open his/her eyes spontaneously to voice or pain |
|
|
Term
| higher cognitive functioning components |
|
Definition
- orientation
- fundamental knowledge
- judgment
- calculation
- abstract reasoning
- memory |
|
|
Term
| receptive aphasia (wernicke's) |
|
Definition
- temporal lobe
- inability to comprehend written or spoken words
- hears but can't understand spoken words
- impaired reading and writing skills
- visual aphasia: can see words, can't read them |
|
|
Term
| expressive aphasia (broca's) |
|
Definition
- frontal lobe
- understands questions and/or directions, but words are difficult to initiate and/or responds inappropriately
- unable to combine speech sounds into words or syllables
- can't speak, can't write, mild impaired reading comprehension |
|
|
Term
|
Definition
|
|
Term
|
Definition
- spontaneous
- localizes the pain
- withdraws from pain
- decorticate
- decerebrate
- flaccid |
|
|
Term
|
Definition
- evaluate for equal/symmetrical movements
- evaluate muscle size and tone
- estimate muscle strength |
|
|
Term
|
Definition
- trapezious squeeze
- supraorbital pressure
- mandibular pressure
- sternal rub |
|
|
Term
|
Definition
|
|
Term
| balance and coordination test |
|
Definition
- touch each of the fingers with the thumb in a consecutive motion; note speed/symmetry
- Romberg test |
|
|
Term
|
Definition
- shuffling gait
- flexed posture
- rigidity of movement |
|
|
Term
|
Definition
- achilles
- quadricepts
- biceps
- triceps |
|
|
Term
| deep tendon reflex grading |
|
Definition
0 absent
1+ present but diminished
2+ normal
3+ increased
4+ hyperactive |
|
|
Term
|
Definition
- corneal
- pharyngeal (gag) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| - assessed by lightly touching a cotton wisp on each side of the body and asking the patient to tell you the location |
|
|
Term
| superficial pain perception |
|
Definition
| - determining patient's sensitivity to a sharp object |
|
|
Term
|
Definition
| - evaluated through use of a tuning fork |
|
|
Term
|
Definition
|
|
Term
|
Definition
1. olfactory
2. optic
3. oculomotor
4. trochlear
5. trigeminal
6. abducens
7. facial
8. vestibulocochlear
9. glossopharyngeal
10. vagus
11. accessory
12. hypoglossal |
|
|
Term
|
Definition
- hold an aromatic substance under the nostril
- problems may mean a tumor on olfactory bulb or basilar skull fracture |
|
|
Term
|
Definition
- optic nerve
- oculomotor nerve |
|
|
Term
|
Definition
- oculomotor
- trochlear
- abducen |
|
|
Term
|
Definition
- estimating pupil size/shape
- evaluating reaction to light
- assessing eye movements
- assessing visual acuity |
|
|
Term
|
Definition
| - opacity of the normally clear lens which may develop as a result of aging, metabolic disorders, trauma, or heredity |
|
|
Term
| V, VII: trigeminal and facial |
|
Definition
V trigeminal - assess face for movement and sensation
VII facial - raise eyebrows, close eyes tight, purse the lips, exaggerated smile, frown |
|
|
Term
| VIII, IX, X: vestibulocochlear, glossopharyngeal, vagus |
|
Definition
VIII vestibulocochlear - whisper, Rinne, & Weber test. For vestibular component, question patient on dizziness, vertigo, balance problems
IX glossopharyngeal - assess mouth for taste
IX glossopharyngeal & X vagus - assess for gag reflex |
|
|
Term
| XI, XII: accessory, hypoglossal |
|
Definition
XI accessory - assessed by ability to shrug shoulders against resistance
XII hypoglossal - assessed by ability to move tongue side to side against resistance and protrude outward midline |
|
|
Term
|
Definition
- to identify fractures, anomalies, or possible tumors
- explain positioning during procedure
- spinal precautions must be maintained until integrity of cervical structures is confirmed |
|
|
Term
|
Definition
- diagnostic study of choice in acute head injury
- if contrast is used, assess renal function and allergy to dye |
|
|
Term
|
Definition
- bone appears white
- blood appears off-white
- brain tissue appears shaded gray
- CSF appears off-black
- air appears black |
|
|
Term
|
Definition
- provides excellent images of brain and spinal cord without radiation exposure
- assess for claustrophobia and premedicate if necessary |
|
|
Term
|
Definition
- to assess cerebral circulation
- involves placement of a catheter normally in the femoral artery under fluoroscopy. catheter is threaded into the origin of the cerebral circulation |
|
|
Term
| what can we do in anticipation of a cerebral angiogram? |
|
Definition
- informed consent
- assess for allergies to contrast dye
- may have a burning sensation when dye is injected
- provide hydration
- monitor vital signs, and puncture site for hematoma (pressure dressing)
- perform frequent neuro checks secondary to risk of vessel occlusion |
|
|
Term
| cerebral blood flow study example |
|
Definition
|
|
Term
|
Definition
- recording of electrical impulses (brain waves)
- often the goal is to elicit a seizure
- informed consent is required with 24 hour videography |
|
|
Term
| what can we do after an EEG? |
|
Definition
- wash hair to remove gel
- resume medications
- test will determine the type of seizure activity
- aids in the diagnosis of brain death criteria |
|
|
Term
|
Definition
- needle is inserted into subarachnoid space to obtain CSF for analysis
- put anesthetics or medicines into the CSF to treat leukemia and other types of cancer of the CNS |
|
|
Term
| lumbar puncture procedure |
|
Definition
- position patient in fetal position of have patient lean over bedside table
- local anesthetic with strict aseptic technique
- needle inserted at L4, L5, or S1
- CSF placed in three separate test tubes and labeled |
|
|
Term
| lumbar puncture post-procedure |
|
Definition
- lie flat 2-6 hours
- observe puncture site
- monitor VS
- encourage fluids
- pain med for headache
- observe for increased temp, stiff neck, difficulty voiding |
|
|
Term
| lumbar puncture contraindications |
|
Definition
- platelet count <50
- INR >1.2
- known bleeding disorder
- evidence of increased intracranial pressure or definite signs of brain tumor |
|
|
Term
|
Definition
- needle electrodes are inserted into the skeletal muscle to measure the electrical potential of the muscles
- useful in the presence of neuromuscular disorders and myopathies
- fairly painful with electrode insertion |
|
|
Term
|
Definition
- needle inserted into the subarachnoid space then contrast medium is injected to provide visualization of spinal column under fluoroscopy
- done to check for the cause of arm or leg numbness, weakness, or pain, narrowing of the spinal canal, tumor, infection, or herniated disc |
|
|
Term
| what can we do in anticipation of a myelogram? |
|
Definition
| - assess for dye allergy and hydration |
|
|
Term
| what can we do after a myelogram? |
|
Definition
- neuro check and VS
- check for back pain, spasms, neck rigidity
- check for sensation in lower extremities |
|
|
Term
| 3 components of intracranial space |
|
Definition
- brain substance 80%
- CSF 10%
- blood 10% |
|
|
Term
|
Definition
| pressure exerted by the total volume within the skull |
|
|
Term
|
Definition
|
|
Term
|
Definition
- if any one of the components increases in volume, another component must decrease to maintain equilibrium
- body adapts to maintain normal ICP |
|
|
Term
| how the body compensates for increase in components |
|
Definition
- displacement/shifting of CSF from ventricles and cerebral subarachnoid space to the spinal subarachnoid space
- increasing absorption of CSF
- decreasing production of CSF
- vasoconstriction of cerebral vasculature
- compressing the low pressure venous system, especially the dural sinuses |
|
|
Term
|
Definition
| Refers to the brain's ability to change the diameter of its blood vessels automatically to maintain a constant cerebral blood flow during alterations in systemic blood pressure |
|
|
Term
|
Definition
| - the brain's adaptive ability to maintain equilibrium in response to physiological and external changes |
|
|
Term
| what happens when a patient's compliance is exhausted? |
|
Definition
| dramatic increase in the pressure/volume curve, leading to a rapid elevation in ICP |
|
|
Term
| cerebral perfusion pressure |
|
Definition
| blood pressure gradient across the brain |
|
|
Term
| equation for cerebral perfusion pressure |
|
Definition
|
|
Term
| cerebral perfusion pressure normal range |
|
Definition
|
|
Term
| when is a CPP of 70-80 recommended? |
|
Definition
| patients with cerebral injury and intracranial hypertension |
|
|
Term
|
Definition
|
|
Term
|
Definition
| regulated to supply the brain with adequate oxygen and substrates to meet its demands |
|
|
Term
| main physiologic influences on cerebral blood flow |
|
Definition
- PaCO2
- arterial oxygenation
- pH
- CPP
- cerebral metabolic rate |
|
|
Term
| how does increased PaCO2 affect cerebral blood flow? |
|
Definition
| - results in vasodilation, which will increase cerebral blood flow and potentially increase ICP |
|
|
Term
| how does acidosis and hypoxemia affect cerebral blood flow? |
|
Definition
| - results in vasodilation, which will increase cerebral blood flow |
|
|
Term
| how do fever and seizures affect cerebral blood flow? |
|
Definition
| - increase cerebral blood flow and cerebral metabolic rate |
|
|
Term
| conditions that increase ICP |
|
Definition
- mass lesions
- head injuries
- brain surgery
- cerebral infections
- vascular insult
- toxic or metabolic encephalopathic conditions |
|
|
Term
| client-related factors that affect ICP |
|
Definition
- restlessness
- straining
- emotional distress
- fever
- hypoxia
- hypercapnia
- seizure activity |
|
|
Term
| environmental factors affecting ICP |
|
Definition
| - upsetting conversations |
|
|
Term
| nursing-related factors affecting ICP |
|
Definition
- clustering of activities
- suctioning
- positioning |
|
|
Term
|
Definition
- deterioration in LOC
- pupillary dysfunction
- deterioration of motor function
- Cushing's triad
- decreased brain stem reflexes
- projectile vomiting
- altered breathing patterns
- headache |
|
|
Term
|
Definition
- increased BP
- decreased pulse
- decreased respirations |
|
|
Term
| types of ICP monitoring devices |
|
Definition
- ventriculostomy
- fiberoptic intraparechymal catheter
- subdural monitor
- subarachnoid screw/bolt
- epidural monitor |
|
|
Term
|
Definition
- pupillary evaluation
- cranial nerve evaluation
- motor function |
|
|
Term
| appropriate positioning for ICP |
|
Definition
- keep HOB at least 30 degrees
- keep neck in midline position
- avoid positions that decrease venous return from the head and increase intrathoracic or intra-abdominal pressure |
|
|
Term
| control ventilation for ICP |
|
Definition
| maintaining PaCO2 levels on the lower side of normal |
|
|
Term
|
Definition
- sedatives and neuromuscular blocking agents
- benzodiazepines
- narcotics |
|
|
Term
| monitoring with neuromuscular blockers |
|
Definition
| - depth of paralysis routinely monitored at bedside using peripheral nerve stimulator and assessment by train of four: pt receives low-voltage electrical stimulation; 1-2 twitches is appropriate |
|
|
Term
| temperature control with ICP |
|
Definition
- with hyperthermia, cerebral metabolic rate increases
- risk of inadequate oxygen supply at the cellular level |
|
|
Term
|
Definition
| desired BP is 140-160 systolic |
|
|
Term
|
Definition
- osmotic diuretics
- loop diuretics |
|
|
Term
|
Definition
- catheter into the lateral ventricle
- document duration, color, and amount of drainage |
|
|
Term
| decompressive craniectomy |
|
Definition
- removal of a variable amount of skull bone to allow a swelling brain room to expand
- a decrease in ICP allows for an increase in cerebral perfusion pressure, aiding blood flow to the ischemic penumbra and optimizing circulation to the damaged area through collateral vessels |
|
|
Term
|
Definition
- monitor fluid/electrolyte balance
- encourage initiation of nutrition
- protect from injury
- provide psychological support for patient and family |
|
|
Term
|
Definition
- displacement of brain tissue can become an irreversible patho process
- ischemia and edema
- compress brain stem and CNs can be fatal |
|
|
Term
| nursing diagnoses for IICP |
|
Definition
- adaptive capacity, decreased: intracranial
- ineffective airway clearance
- ineffective breathing pattern
- alteration in comfort
- impaired verbal communication
- confusion
- altered family processes
- risk for injury
- sensory perceptual alterations
- alterations in thought processes
- self-care deficit syndrome |
|
|
Term
| clinical brain death criteria |
|
Definition
- no spontaneous respirations
- no motor response
- no cranial nerve activity
- no electrical brain activity
- no brainstem reflexes |
|
|
Term
| apnea test for brain death |
|
Definition
- ventilator is removed but O2 continues to be delivered by tracheal cannula, allow the patient's PCO2 to increase to 60+...this should be enough to stimulate respirations if the brainstem is functioning adequately
- these patients must not be influenced by body temp or narcotics or other depressant drugs |
|
|
Term
| oculocephalic reflex (doll's eyes) |
|
Definition
- normal: eye rotates to left as head is turned to right
- abnormal: eyes remain centered as head is turned to right |
|
|
Term
| oculovestibular reflex (cold caloric test) |
|
Definition
| - conjugate eye movement toward stimulation indicate4s brainstem is intact |
|
|
Term
| types of spinal cord injuries |
|
Definition
- concussion
- compression
- contusion or bruising
- laceration
- transection
- hemorrhage
- vascular damage |
|
|
Term
| mechanisms of spinal cord injury |
|
Definition
- acceleration-deceleration
- rotation
- axial loading (falling on head, diving accident) |
|
|
Term
|
Definition
- results from complete injury from T-2 - L-1
- variable innervation to intercostal and abdominal muscles
- patients with injuries in this area may have full use of their arms and may need a wheelchair, although some may have limited ability to ambulate short distances with crutches and orthotic devices |
|
|
Term
|
Definition
|
|
Term
|
Definition
| no motor/pain temp below injury |
|
|
Term
|
Definition
| no pressure/vib below injury |
|
|
Term
| lateral cord (brown-sequard) injury |
|
Definition
- side of injury = loss of motor
- opp side = loss pain/temp/sensation |
|
|
Term
| emergency management of spinal cord injury |
|
Definition
- ABCs
- neuro exam
- stabilize neck
- fluid replacement
- vasopressors |
|
|
Term
|
Definition
- glucocorticosteroids
- directly affects the changes that occur within the spinal cord after injury
- prevents post-traumatic spinal cord ischemia
- improves energy metabolism
- restores extracellular calcium
- improves nerve impulse conduction
- should administer within 8 hours of injury
- bolus followed by cont. infusion |
|
|
Term
|
Definition
- occurs within 60 minutes of injury
- recovery takes 4-6 weeks |
|
|
Term
| spinal shock medical management |
|
Definition
- careful fluid resuscitation
- vasopressors
- atropine
- warming measures |
|
|
Term
| spinal shock assessment findings |
|
Definition
- neurogenic shock: hypotension, bradycardia, decreased cardiac output
- flaccid paralysis
- no spinal reflexes
- no sensation of temperature, proprioception, touch, pressure, and pain
- no somatic/visceral sensations
- lack of perspiration secondary to loss of neurologic innervation of the sweat glands |
|
|
Term
|
Definition
| - used to provide cervical skeletal traction in order to reduce the cervical fracture and align the cervical spine |
|
|
Term
| cervical traction: halo vest |
|
Definition
| - consists of a metal ring secured to the skull with four pins. steel bars anchor screws to the vest to provide cervical immobilization |
|
|
Term
| complications of cervical traction |
|
Definition
- cranial nerve impairment related to pins, screws, traction
- infection related to poor pin site care
- respiratory related to immobility secondary to tong traction |
|
|
Term
| surgical management of spinal cord injury |
|
Definition
- to provide spinal column stability in the presence of disrupted ligaments and tendons, as well as a vertebral column that cannot maintain normal alignment
- particularly important for the patient with minimal neurologic deficit |
|
|
Term
| pulmonary problems with spinal cord injuries |
|
Definition
- respiratory failure
- atelectasis
- pneumonia
- pulmonary embolism |
|
|
Term
| goals for pulmonary issues |
|
Definition
- maintenance of airway and oxygenation
- assess for aspiration
- cough assistance to mobilize secretions |
|
|
Term
| cardiovascular management of SCI |
|
Definition
- hemodynamic invasive monitoring
- hydration
- inotropic or vasopressor support
- monitor/correct temp
- sequential pneumatic compression stockings and/or anticoagulant therapy |
|
|
Term
| bowel/bladder function problems of SCI |
|
Definition
- storing/emptying urine
- spastic or flaccid bowel |
|
|
Term
| goals of bowel/bladder function problems |
|
Definition
- monitor voiding patterns
- indwelling/external urine device
- maintain fluid intake
- assess for bladder distention
- initiate bladder retraining
- monitor for UTI
- digital stimulation/removal of stool
- stool softeners
- suppositories |
|
|
Term
| skin integrity nursing management in SCI |
|
Definition
- reposition Q2h
- lifting devices
- specialty mattresses
- Braden skin scale Q8h
- adequate nutrition
- maximize mobility |
|
|
Term
| pain nursing management in SCI |
|
Definition
| - management of pain with non-pharmacological and pharmacological interventions |
|
|
Term
| sexual function nursing management in SCI |
|
Definition
- women: pregnancy in possible, and most can have normal vaginal deliveries; loss of sensation in pelvic area can prevent knowledge that labor has begun
- men: level, type, time elapsed, and site of SCI injury impact sexuality |
|
|
Term
| psychosocial nursing management with SCI |
|
Definition
- grief
- anxiety
- denial
- fear
- anger
- hopelessness
- powerlessness
- altered body image
- provide psych support
- promote coping mechanisms
- identify support systems
- stimulate patient to participate in rehab
- allow patient to make choices and provide input into his/her plan of care
- multidisciplinary team approach |
|
|
Term
|
Definition
- common in T6 or higher injuries
- occurs when an irritating stimulus is introduced to the body below the level of SCI. the stimulus sends nerve impulses to the spinal cord, travelling upward until they are blocked by the lesion at the level of injury. impulses cannot reach brain, so reflex is activated that increases activity of sympathetic nervous system |
|
|
Term
| causes of autonomic dysreflexia |
|
Definition
- full bladder
- fecal impaction
- pressure ulcer
- fold in bed sheets
- tight clothing
- infected toe nail
- DVT |
|
|
Term
| s/s of autonomic dysreflexia |
|
Definition
- increased BP
- decreased HR
- diaphoresis
- anxiety
- flushing
- spasticity |
|
|
Term
| what can we do for autonomic dysreflexia? |
|
Definition
- sit client upright if supine
- look for causes:
- full bladder? if indwelling catheter, check for kinks. if indwelling catheter not present, catheterize the patient
- check for fecal impaction
- loosen constrictive clothing
- reposition patient and remove folds from linens
- treat BP if >150 mm Hg |
|
|
Term
| diagnoses in acute care setting |
|
Definition
- dysreflexia
- impaired gas exchange
- disuse syndrome
- body image disturbance
- impaired physical mobility
- ineffective individual/family coping |
|
|
Term
| educational needs for SCI |
|
Definition
- prevention of autonomic dysreflexia
- prevention of infections
- skin integrity
- transferring
- bowel/bladder training
- ventilatory support |
|
|
Term
|
Definition
| - a single, finite event resulting in abnormal motor, sensory, autonomic or psychic activity caused by sudden excessive discharge from cerebral neurons |
|
|
Term
| seizure disorder (definition) |
|
Definition
| - chronic disorder of abnormal, recurrent, excessive, and self-terminating discharge from cerebral neurons |
|
|
Term
| risk factors for seizures |
|
Definition
- age
- IICP
- cerebral vascular disease
- drugs/alcohol
- electrolyte/vitamin imbalances
- endocrine disorders |
|
|
Term
| precipitating factors for seizures |
|
Definition
- fatigue
- sleep deprivation
- hypoglycemia
- emotional stress
- febrile illness
- alcohol consumption
- certain drugs
- constipation
- menstruation
- hyperventilation
- photo stimuli
- certain types of music |
|
|
Term
|
Definition
- part of brain
- simple
- complex |
|
|
Term
|
Definition
|
|
Term
|
Definition
| - involves epileptic activity in part of the brain rather than affecting the whole brain |
|
|
Term
|
Definition
| - no loss of consciousness |
|
|
Term
|
Definition
|
|
Term
|
Definition
- tonic-clonic/grand mal
- loss of consciousness and breathing becomes irregular
- person becomes stiff and limbs jerk
- biting of the tongue and inside of cheek may occur
- pale/diaphoretic |
|
|
Term
|
Definition
- onset between 4 and 14 years
- no aura
- sudden vacant facial expression
- no confusion |
|
|
Term
|
Definition
- continuous seizure lasting at least 5 minutes, or 2+ discrete seizures between which there is incomplete recovery of consciousness
- can lead to death because of the interference with respirations |
|
|
Term
| diagnostic tests for seizures |
|
Definition
- H&P
- toxicology screen
- EEG
- CT/MRI
- LP
- sleep study
- continuous videography with EEG |
|
|
Term
| implications with antiseizure drugs |
|
Definition
- monitor therapeutic serum levels
- monitor for signs of toxicity
- monitor protein intake
- decreased bone calcium |
|
|
Term
|
Definition
- visual
- gingival
- hyperplasia |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
- n/v
- increase weight
- hair loss |
|
|
Term
|
Definition
- side rails up/padded
- suction equipment in room
- artificial airway available
- bed in low position |
|
|
Term
| what can we do during a seizure? |
|
Definition
- prevention of injury
- ease to floor/bed if possible
- remove glasses/loosen clothing
- lay on side if possible
- remain with client
- give O2 |
|
|
Term
| what can we do after a seizure? |
|
Definition
- lay on side
- provide adequate ventilation
- allow client to sleep
- reorient as awakens |
|
|
Term
| what can we do for status epilepticus? |
|
Definition
- ABCs
- administer antiseizure drugs
- treat underlying cause
- prevent or treat complications |
|
|
Term
| seizure considerations for women |
|
Definition
- often increase around menses
- antiseizure drugs reduce efficacy of oral contraceptives
- seizure patterns often change during pregnancy
- some antiseizure drugs can cause birth defects |
|
|
Term
| modifiable risk factors for stroke |
|
Definition
- hypertension
- heart disease
- atrial fibrillation
- carotid artery disease
- diabetes
- elevated serum cholesterol/lipids |
|
|
Term
| unmodifiable risk factors for stroke |
|
Definition
- age
- gender
- race
- family history
- personal history of stroke or TIA |
|
|
Term
|
Definition
- sudden numbness/weakness
- sudden confusion/difficulty speaking/understanding what is being said
- sudden visual changes
- sudden difficulty walking
- sudden severe headache with no known cause |
|
|
Term
|
Definition
- blood clot blocks blood vessel/artery, or blood vessel breaks, interrupting blood flow to an area of the brain
- increases ICP
- results in cellular destruction or loss of function |
|
|
Term
|
Definition
- most common type
- a clot/thrombus completely occludes a cerebral artery
- can convert to hemorrhagic CVA |
|
|
Term
|
Definition
- results from a rupture of a cerebral artery
- common in clients with uncontrolled HTN or cerebral aneurysms
- often associated with poorer outcomes
- complains of horrible headache |
|
|
Term
| intracerebral hemorrhagic stroke |
|
Definition
- bleeding within the cerebral tissue caused by a rupture of vessels that lasts from minutes to days
- most often related to poorly controlled HTN
- HTN and atherosclerosis cause degenerative changes in the walls of arteries, resulting in rupture and subsequent hemorrhage |
|
|
Term
| subarachnoid hemorrhagic stroke |
|
Definition
| - most often related to ruptured aneurysm or arteriovenous malformation |
|
|
Term
|
Definition
| - dilation of bulging of the walls of a cerebral artery that develops as a result of weakness in the arterial wall |
|
|
Term
|
Definition
- HTN
- atherosclerosis
- infection
- tumors
- head trauma
- congenital defects |
|
|
Term
|
Definition
| - congenital disorder of blood vessels within the brain, characterized by tangles of veins and arteries that disrupt normal blood flow in the brain |
|
|
Term
| National Institutes of Health Stroke Scale (NIHSS) |
|
Definition
- overall level of consciousness
- visual function
- motor skills
- sensation and inattention
- language
- cerebellar integrity
- score ranges from 0-42. The higher the score, the more neurologically impaired the patient |
|
|
Term
|
Definition
- CT
- MRI
- EEG
- EKG
- cerebral angiogram
- carotid doppler studies
- ECG |
|
|
Term
The nurse is working on a surgical floor. The nurse must logroll a client following a:
A. laminectomy
B. thoracotomy
C. hemorrhoidectomy
D. cystectomy |
|
Definition
A. laminectomy
The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. |
|
|
Term
The nurse is preparing a female client with tonic-clonic seizure disorder for discharge. Which instructions should the nurse include about phenytoin (Dilantin)? Select all that apply.
1. monitor for skin rash
2. maintain adequate amounts of fluid and fiber in the diet
3. perform good oral hygiene, including daily brushing and flossing
4. receive necessary periodic blood work
5. report to the physician any problems with walking, coordination, slurred speech, or nausea
6. feel safe about taking this drug, even during pregnancy |
|
Definition
1, 3, 4, 5
A rash may occur 10 to 14 days after starting phenytoin. If a rash appears, the client should notify the physician and discontinue the medication. Because phenytoin may cause gingival hyperplasia, the client must practice good oral hygiene and see a dentist regularly. Periodic blood work is necessary to monitor complete blood counts, platelet levels, hepatic function, and drug levels. Signs and symptoms of phenytoin toxicity include problems with walking, coordination, slurred speech, and nausea. Other signs of toxicity include lethargy, diplopia, nystagmus, and disturbances in balance. These symptoms must be reported to the physician immediately. |
|
|
Term
The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in ICP?
A. suction the airway every hour and as needed
B. elevate the HOB 15 to 30 degrees
C. turn the client and change his position every 2 hours
D. maintain a well-lit room |
|
Definition
B. elevate the HOB 15 to 30 degrees
To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. |
|
|
Term
The physician prescribes mannitol (Osmitrol) IV stat for a client who develops increased ICP after a head injury. While preparing to administer mannitol, the nurse notices crystals in the solution. What should the nurse do?
A. administer the solution as is
B. warm the solution in hot water to dissolve the crystals
C. send the crystallized solution back to the pharmacy
D. add a filter to the infusion set and administer the solution |
|
Definition
B. warm the solution in hot water to dissolve the crystals
The nurse must dissolve crystallized mannitol before administering it. This is best done by warming it in hot water and shaking the container vigorously, then allowing the solution to return to room temperature before administering it. |
|
|
Term
If a client experienced a stroke that damaged the hypothalamus, the nurse would anticipate that the client has problems with:
A. body temperature control
B. balance and equilibrium
C. visual acuity
D. thinking and reasoning |
|
Definition
A. body temperature control
The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. |
|
|
Term
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
A. administering zolpidem tartrate (Ambien)
B. assessing laboratory test results as ordered
C. placing the client in Trendelenburg's position
D. monitoring the patency of an indwelling urinary catheter |
|
Definition
D. monitoring the patency of an indwelling urinary catheter
Because a full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling catheter to prevent its occlusion, which could result in a full bladder |
|
|
Term
A client with a head injury is being monitored for increased ICP. His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is:
A. 52 mm Hg
B. 88 mm Hg
C. 48 mm Hg
D. 68 mm Hg |
|
Definition
A. 52 mm Hg
CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mm Hg. The MAP is derived using the following formula:
MAP = ([diastolic blood pressure x 2] + systolic blood pressure)/3
MAP = ([60 x 2] + 90)/3
MAP = 70 mm Hg
To find the CPP, subtract the client's ICP from the MAP, in this case, 70 mm Hg - 18 mm Hg = 52 mm Hg |
|
|
Term
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent?
A. succinylcholine (Anectine)
B. vecuronium (norcuron)
C. pancuronium (pavulon)
D. atracurium (tracrium) |
|
Definition
A. succinylcholine (Anectine)
Succinylcholine, a depolarizing blocking agent, is the drug of choice when short-term muscle relaxation is desired - for example, during ECT or intubation. |
|
|
Term
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes highest priority in this client's care plan?
A. disturbed sensory perception (visual)
B. dressing or grooming self-care deficit
C. impaired verbal communication
D. risk for injury |
|
Definition
D. risk for injury
Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. |
|
|
Term
The nurse is performing a mental status exam on a client diagnosed with subdural hematoma. This test assesses which of the following?
A. cerebellar function
B. intellectual function
C. cerebral function
D. sensory function |
|
Definition
C. cerebral function
The mental status exam assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. |
|
|
Term
Damage to which area of the brain results in receptive aphasia?
A. parietal lobe
B. occipital lobe
C. temporal lobe
D. frontal lobe |
|
Definition
C. temporal lobe
The temporal lobe contains the auditory association area. If the area is damaged in the dominant hemisphere, the client hears words but doesn't know their meaning. |
|
|
Term
A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. What does this mean?
A. normal, full muscle strength is present
B. muscles move actively against gravity alone
C. muscle contraction is palpable and visible
D. muscle contraction or movement is undetectable |
|
Definition
C. muscle contraction is palpable and visible
Muscle strength is assessed and rated on a five-point scale in all four extremities, comparing one side to the other. A rating of 1/5 indicates palpable, visible muscle contraction on the affected side and normal, full muscle strength on the unaffected side. Normal, full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on the affected side with normal, full muscle strength on the unaffected side is rated 3/5. Undetectable muscle contraction or movement on the affected side with normal, full muscle strength on the unaffected side is rated 0/5. |
|
|
Term
A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's ICP is increasing, the nurse would expect to observe which sign first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness |
|
Definition
D. declining level of consciousness
With a brain injury such as an epidural hematoma (a diagnosis that is most likely based on this client's symptoms), the initial sign of increasing ICP is a change in the level of consciousness. |
|
|
Term
The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client? Select all that apply.
1. spontaneous eye opening
2. tachypnea, bradycardia, and hypotension
3. unequal pupil size
4. orientation to person, place, and time
5. motor response to pain localized
6. incomprehensible sounds |
|
Definition
1, 4
The Glasgow Coma Scale assesses level of consciousness by testing and scoring three observations: eye opening, motor response, and verbal stimuli response. Clients are scored on their best responses and these scores are totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands, and orientation to time, place, and person. |
|
|
Term
The nurse is monitoring a client for increasing ICP. Early signs of increased ICP include:
A. pupillary changes
B. diminished responsiveness
C. decreasing blood pressure
D. elevated temperature |
|
Definition
B. diminished responsiveness
Usually, diminished responsiveness is the first sign of increasing ICP. |
|
|
Term
A client is diagnosed with a conductive hearing loss. When performing Weber's test, the nurse expects that this client will hear sound:
A. on the affected side by bone conduction
B. on the unaffected side
C. longer through bone than air conduction
D. by neither air nor bone conduction |
|
Definition
A. on the affected side by bone conduction
During Weber's test, which tests bone conduction, a client with a conductive hearing loss hears sound on the affected side by bone conduction. |
|
|
Term
The nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client? Select all that apply.
1. elevating the HOB 90 degrees
2. loosening constrictive clothing
3. using a fan to reduce diaphoresis
4. assessing for bladder distention and bowel impaction
5. administering antihypertensive medication
6. placing the client in a supine position with legs elevated |
|
Definition
1, 2, 4, 5
The client is exhibiting signs and symptoms of autonomic dysreflexia. The condition is a potentially life-threatening emergency caused by an uninhibited response from the sympathetic nervous system, resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the head of the bed to 90 degrees and place the extremities in a dependent position to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction - both of which may trigger autonomic dysreflexia - and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, myocardial infarction, or seizure activity. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia. |
|
|
Term
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
A. raccoon's eyes and Battle's sign
B. nuchal rigidity and Kernig's sign
C. motor loss in the legs that exceeds that in the arms
D. pupillary changes |
|
Definition
A. raccoon's eyes and Battle's sign
A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle's sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. |
|
|
Term
| nuchal rigidity and Kernig's sign are associated with? |
|
Definition
|
|
Term
| motor loss in the legs that exceeds that in the arms suggests? |
|
Definition
|
|
Term
Family members would like to bring in birthday cake for a client with nerve damage. What cranial nerve needs to be functioning so the client can chew?
A. CN II
B. CN V
C. CN IX
D. CN X |
|
Definition
B. CN V
Chewing is a function of cranial nerve V. |
|
|
Term
| swallowing is a motor function of which cranial nerves? |
|
Definition
|
|
Term
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?
A. caucasian race
B. female gender
C. obesity
D. bronchial asthma |
|
Definition
C. obesity
Obesity is a risk factor for stroke. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. |
|
|
Term
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
A. hold the client's arm still to keep him from hitting anything
B. carefully move him to a flat surface and turn him on his side
C. allow him to remain in the chair but move all objects out of his way
D. place an oral airway in his mouth to maintain an open airway |
|
Definition
B. carefully move him to a flat surface and turn him on his side
When caring for a client experiencing a tonic-clonic seizure, the nurse should take steps to ensure that the client can breath and to protect the client from injury. In this situation, the nurse should help the client to a flat nonelevated surface and then position him on his side. These steps help reduce the risk of injury from falling or hitting surrounding objects. They also help establish an open airway. |
|
|
Term
The nurse is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?
A. excessive tearing
B. urine retention
C. muscle weakness
D. slurred speech |
|
Definition
C. muscle weakness
The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. |
|
|
Term
A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?
A. a level below 5 mcg/ml
B. 10 to 20 mcg/ml
C. 25 to 35 mcg/ml
D. 40 to 50 mcg/ml |
|
Definition
B. 10 to 20 mcg/ml
Clients require individualized dosages of phenytoin to achieve a therapeutic blood drug level of 10 to 20 mcg/ml |
|
|
Term
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic exam, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
A. diencephalon
B. medulla
C. midbrain
D. cortex |
|
Definition
C. midbrain
Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. |
|
|
Term
| with damage to the dienchephalon or cortex, which type of posturing occurs when a painful stimulus is applied? |
|
Definition
|
|
Term
| damage to the medulla results in? |
|
Definition
|
|
Term
a client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eyes) response by:
A. introducing ice water into the external auditory canal
B. touching the cornea with a wisp of cotton
C. turning the client's head suddenly while holding the eyelids open
D. shining a bright light into the pupil |
|
Definition
| C. turning the client's head suddenly while holding the eyelids open |
|
|
Term
A client is receiving an IV infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
A. decreased LOC
B. elevated BP
C. increased output
D. decreased HR |
|
Definition
C. increased output
The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. |
|
|
Term
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
A. allow time for the client to respond
B. speak loudly and articulate clearly
C. give the client a writing pad
D. use short, simple sentences |
|
Definition
D. use short, simple sentences
Although receptive aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. |
|
|
Term
| a writing pad would be helpful for clients with what type of aphasia? |
|
Definition
|
|
Term
| true or false: the autonomic nervous system regulates involuntary body functions |
|
Definition
|
|
Term
| functions of the nervous system |
|
Definition
| controls all motor, sensory, autonomic, cognitive, and behavioral activities |
|
|
Term
| structures of central nervous system |
|
Definition
|
|
Term
| structures of peripheral nervous system |
|
Definition
- cranial and spinal nerves
- autonomic and somatic systems |
|
|
Term
| basic functional unit of the neurologic system is the... |
|
Definition
|
|
Term
how many cranial nerves does the nurse have to assess?
A. ten
B. eleven
C. twelve
D. thirteen |
|
Definition
C. twelve
There are twelve pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull |
|
|
Term
| true or false: cerebral angiography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture |
|
Definition
false
myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Cerebral angiography is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery |
|
|
Term
| altered level of consciousness (LOC) |
|
Definition
- level of responsiveness and consciousness is the most important indicator of the patient's condition
- is a continuum from normal alertness and full cognition to coma |
|
|
Term
|
Definition
| unconsciousness, unarousable unresponsiveness |
|
|
Term
|
Definition
| unresponsiveness to the environment, makes no movement or sound but sometimes open eyes |
|
|
Term
| persistent vegetative state |
|
Definition
| devoid of cognitive function but has sleep-wake cycles |
|
|
Term
|
Definition
| inability to move or respond except for eye movements due to a lesion affecting the pons |
|
|
Term
the body temperature of an unconscious patient is never taken by which route?
a. axillary
b. mouth
c. rectal
d. tympanic |
|
Definition
|
|
Term
| potential problems related to altered LOC |
|
Definition
- respiratory distress/failure
- pneumonia
- aspiration
- pressure ulcur
- DVT
- contractures |
|
|
Term
| what can we do for altered LOC? |
|
Definition
- frequent monitoring of respiratory status including auscultation of lung sounds
- positioning to promote accumulation of secretions and prevent obstruction of upper airway - HOB elevated 30 degrees, lateral or semiprone position
- suctioning, oral hygiene |
|
|
Term
The nurse is caring for a client who requires ICP monitoring. The nurse should be alert for what major complication of ICP monitoring?
a. coma
b. infection
c. high blood pressure
d. apnea |
|
Definition
b. infection
the catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. |
|
|
Term
| coma, high blood pressure, and apnea are late signs of? |
|
Definition
|
|
Term
a client recovering from a stroke has right-sided hemiplegia and telegraphic speech and often seems frustrated and agitated, especially when trying to communicate. however, the chart indicates that the client's auditory and reading comprehension are intact. the nurse suspects that the client has:
a. global aphasia
b. nonfluent aphasia
c. fluent aphasia
d. anomic aphasia |
|
Definition
b. nonfluent aphasia
nonfluent aphasia is characterized by telegraphic speech, failure to use conjunctions and pronouns, and impaired repetition and ability to read aloud |
|
|
Term
| type of aphasia where spontaneous speech is absent or limited to a few stereotyped words; comprehension is limited to the client's name or a few words |
|
Definition
|
|
Term
| type of aphasia where auditory comprehension is disturbed, speech lacks meaningful content, is unrelated to questions, and includes paraphasias |
|
Definition
|
|
Term
| type of aphasia in which client can't name objects, has trouble finding words, and may be unable to read or write |
|
Definition
|
|
Term
the nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. which action should the nurse perform?
a. sit with the client for a few minutes
b. administer an analgesic
c. inform the nurse manager
d. call the physician immediately |
|
Definition
d. call the physician immediately
the headache may be an indication that the aneurysm is leaking. the nurse should notify the physician immediately. |
|
|
Term
a client who recently experienced a stroke tells the nurse that he has double vision. which nursing intervention is the most appropriate?
a. encourage the client to close his eyes
b. alternatively patch one eye every 2 hours
c. turn out the lights in the room
d. instill artificial tears |
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Definition
b. alternatively patch one eye every 2 hours
patching one eye at a time relieves diplopia. |
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Term
the nurse is caring for a client with an acute bleeding cerebral aneurysm. the nurse should do all of the following except:
a. position the client to prevent airway obstruction
b. keep the client in one position to decrease the bleeding
c. administer IV fluid as ordered and monitor the client for signs of fluid volume excess
d. maintain the client in a quiet environment |
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Definition
b. keep the client in one position to decrease the bleeding
the nurse shouldn't keep the client in one position but rather carefully reposition the client often (at least every hour). |
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Term
the nurse is assessing a client's extraocular eye movements as part of the neurologic examination. Which cranial nerves are the nurse assessing? select all that apply:
1. II
2. III
3. IV
4. V
5. VI
6. VIII |
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Definition
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Term
| when caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the client's nose. what should the nurse do? |
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Definition
| because CSF contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. |
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