Glossary of Nursing 128 Test 3
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- Name 5 changes related to aging
- Recent memory loss
Decreased touch sensation
Change in perception of pain
Change in sleep patterns
Altered balance or coordination
- Name some neurological problem symptoms.
- dizziness, confusion, parasthesia, unsteady gait, seizures, visual problems, hearing problems
- What is the first sign of a neurological problem?
- Decrease in level of conciousness.
- Name the 6 levels of conciousness
- Alert (awake, responsive)
Lethargic(sleepy, yet arousable)
Arousable (can be woken up)
Stuporous (arousable w/ difficulty)
Obtunded(insensitive to painful stimuli)
Comatose (not arousable)
- Test for remote/long term memory?
- What is your birthdate?
- Test for recent recall memory?
- Who brought you here?
- Test for immediate/new memory?
- Tell the client 3 unrelated words. Have them repeat them 5 minutes later.
- Test for attention span
- Have client count backwards from 100 by 7
- Test for cognition.
- What is the name of the V.P.?
- What are ipsilateral symptoms?
- Symptoms on the same side as a brain injury. (injury on left, symptoms on left)
- What are contralateral symptoms?
- Symptoms are on the opposite side of the injury. (injury on right, symptoms on left)
- Test for sensory function.
- Use the edge of a paperclip on the hand with the client's eyes closed.
- Test for sensory function
- Touch different parts of the body while the client's eyes are closed.
- Some causes of peripheral nervous system involvemenet.
- Diabetes, malnutrition, vascular problems, spinal cord or nerve injury.
- Test for motor function
- Squeeze my two fingers, resist hand, push with legs.
- What is the pronator drift test?
- While standing, client closes eyes, holds hands out w/ palms up & arms extended. If there is a problem, one arm will drift down & the hand will pronate. Indicates a brain lesion.
- Tremors, unintentional movements, changes in gait or posture, weakness or paralysis can all be signs of what?
- Cerebral/brainstem problems
- What are the superficial reflexes?
- Achilles (back of ankle), Babinski (bottom of foot), Abdominal (near umbilicus), cremasteric (upper inner aspect of the thigh)
- Rating scale for reflex activity.
- 0 absent
1 hypoactive/weaker than normal
3 stronger than normal
- Hyperactive reflexes may indicate these 3 problems
- neurological disease, tetanus, hypocalcemia
- Hypoactive reflexes may indicate these 6 problems
- neurological disease, neuromuscular disease, muscular disease, diabetes, hypothyrodism, hypokalemia
- PIH leads to eclampsia, then hyperactive reflexes, and then
- seizure activity
- Glascow coma scale measures these 3 assessments.
- Eyes open, best verbal response, best motor response.
- 4 stages of eye responses
to sound/speech, on request
- 5 stages of verbal response
- 1.oriented to person, place & time
2.engages in conversation, confused in content
3.inappropriate words spoken
- 6 stages of motor response
- 1. obeys verbal commands (raise arm)
2. localizes pain
3. normal flexion to painful stimuli
4. abnormal flexion
5. extension to painful stimuli
6. no response
- early responses to pain
- localize pain
withdraw from pain
- 3 late signs of pain (extensive damage has already occurred)
- decorticate posturing
decerebrate posturing - related to brain stem problem
- What is decorticate posturing?
- arms flex on the chest, hands internally rotated, legs may extend. indicates problem w/ corticospinal pathways.
- What is decerebrate posturing?
- arms stiffly extended, hands externally rotated, legs may extend.
- Pupils that are pinpoint or dilated and do not react are a sign of...
- neurological deterioration.
- Pupil assessment - 5 items
Size estimated in mm
- Types of lab tests for neurologic disorders
- C&S of blood or cerebral spinal fluid
- When is a skull and spine xray used?
- To detect injury that involves fractures or dislocations that may damage the nervous system. ex. vertebrae.
- When is a cerebral angiogram used?
- To show soft tissue. A picture of groups of vessels. May do carotid or vertebral angiograms to see blockages, leakage and aneurisms (ballooms).
- Preop for Angiogram
- NPO for 24 hours, empty bladder
remove dentures, remove metal
vs,neuro checks before test
- Postop for angiogram
- vs, neuro checks, fluid encouraged to flush dye, bedrest w/affected extremity immobilized, pressure dressing on site, sandbag on pressure dressing, ice application
- 2 types of cerebral angiograms
- contrast media method
digital subtraction method
- precaution for contrast media method
- Check allergies for shellfish, eggs, iodine.
- Digital subtraction method (DSA)
- dye is injected IV
images taken w/ computerized digital camera
safer than contrast media method
- Digital subtraction method prep
- Fluids are restricted
- Digital Subtraction Method post op.
- drink fluids
assess insertion site & extremity
no activity restrictions
- What does a myelography show?1
- Abnormalities of the spinal cord.
- What does an Electroencephalography (EEG) do?
- Measure the electrical activity of the brain w/ an electrode. Can be used to diagnose sleep disorders and pinpoint the site of seizure activity.
- Preop for EEG
- Outpatient. Shampoo hair, no cream, oil, spray. Avoid stimulants, depressants.
- Contrast method of Angiogram
- dye injected into brachial or femoral artery
may rarely use carotid artery
client will feel heat when dye is injected.
- Risks of the contrast method of angiogram.
- allergic reaction.
spasms of the blood vessels
(artery constricts - decreases blood supply)
- What are MRI's used for?
- to detect neuro disorders.
- How is a brain scan done?
- A radioactive isotope is injected and absorbed by the brain. Provides information about the structure of an organ. 2 hours after dye is injected, films are taken.
- How is a PET scan done?
- Radioactive substances are used to provide information about both the structure and the function of an organ.
- What are some reasons for doing a lumbar puncture/spinal tap?
- CSF examination
measurement of pressure
inject medication or anesthesia
to inject dye or air
contraindicated w/ inc. ICP
- Assessment of CSF
appearance - clear and colorless
cell count - RBC's indicate bleeding, WBC's indicate infection.
- Why is a C&S of the CSF done?
- To identify bacteria, microorganisms.
- Why is a glucose and protein gest done on CSF?
- To diagnose neuromuscular disease and bacterial meningitis.
- What does it indicate when LDH is found in CSF?
- It is associated with bacterial meningitis.
- Why is a cytology test of the CSF done?
- To test cells to diagnose CNS tumors
- What are the preop nursing implications for lumbar puncture?
- empty bladder
lateral recumbent position (fetal)
label samples sequentially
needle is inserted between 3&4 vertebrae of the lumbar spine.
- What are the postop considerations for lumbar puncture?
- lie flat 4-8 hours-prevent CSF leakage
force fluids 24-48 hours to replace CSF
vs & neuro checks
assess for spinal headache (from excessive loss of CSF)
- What are causes of increased ICP?
- increased intracranial bulk (brain tissue, blood, CSF)due to trauma, hemorrhage, tumors, abscesses, edema, inflammation.
- What happens with increased ICP?
- impedes cerebral circulation, absorption of csf, function of nerve cells.
- What is a fatal consequence of increased ICP?
- The brain herniates downward toward the brainstem causing irreversible brain damage or death.
- What is the most common cause of death with head trauma?
- Increased ICP.
- What is normal ICP?
- 10-15 mm Hg
80-180 mm H2O
- How is ICP measured?
- A catheter is inserted into the spinal column or into the ventricles of the brain.
- Factors that increase ICP?
- increased PCO2, Decreased PO2, valsalva maneuver, isometric muscle contraction, coughing/sneezing/vomiting, emotional upset, supine or trendelenburg position (head down, suctioning.
- What is the most sensitive indicator of increased ICP?
- Assess LOC!
- 4 Assessments for increased ICP
- LOC, headache, projective vomiting
pupillary changes, assess motor function, assess vital signs, diagnostic tests.
- Motor functions that indicate increase ICP.
- weakness, hemiplegia, positive Babinski, decorticate or decerebrate posturing, seizure activity.
- Vital signs that indicate increased ICP.
- widening pulse pressure (large gap between sys & dias.), bradycardia, abnormalities in respirations, especially periods of apnea, elevated temperature.
- Diagnostic tests for increased ICP
- MRI, CT scan, EEG
No lumbar puncture!
- Management of increased ICP
- decrease ICP & prevent damage to brain cells by maintaining adequate blood flow w/ sufficient O2 & glucose & to reduce the buildup of CO2.
- Medications used for increased ICP
- steroids - to decrease edema (antiflammatory effects)
diuretics to decrease edema by excreting large volumes of water.
- What is a potential complication of using diuretics to decrease ICP?
- Fluid and electrolyte imbalance, especially sodium and potassium.
- Nursing interventions to decrease ICP
- normalize body temperature
maintain fluid balance
elevate hop 30 degrees
administer O2, decrease stimuli
prevent straining, medications
pulmonary clearance, patent airway
- Comparison of ICP and shock
- Increased ICP - inc. temp, inc. BP, pulse pressure widens, dec. pulse, irreg. respirations, apnea.
Shock - no temp change, dec. BP, inc. pulse, inc. resp.
- When treating increased ICP with medications, what is contraindicated?
- morphine and other narcotics that alter neuro status.
- Some assessments of the comatose client.
- neurological status
bowel and bladder
- Nursing interventions of the comatose client.
- pulmonary clearance
I&O and bowel elimination
maintain skin integrity
- Nursing interventions of the comatose client
- protect eyes
provide uninterrupted rest
provide auditory, visual and tacile stimuli
profide family support
- Some causes of confusion in a client
alcohol - chronic
metabolic disorders (diabetes)
medication side effects
- Nursing diagnosis of a confused client.
- alteration in thought processes related to decreased memory/lack of orientation...
- Interventions for the confused client with decreased memory.
- repetition of instructions
written memory aids
appeal to several senses
small steps; simple to complex
- Interventions for the confused client with lack of orientation.
- window view, social interaction, clock, calendar, photographs, television, structure environment, face to face contact, short sentences, simple commands.
- Interventions for the confused client with aggressive behavior.
- maintain calm, firm attitude.
rotate care among staff
provide a structured environment
set limits on behavior
reinforce appropriate behaviors.
- Nursing diagnosis of the aphasic (inability to communicate) client.
- alterations in communication related to expressive or receptive aphasia or dysarthia.
- Expressive aphasia is...
- The client understands people, but can't form the words to respond.
- Receptive aphasia is...
- The client can talk, but can't understand what is being said.
- Interventions for the client with aphasia.
- Use alphabet or picture board
Treat the client as as adult
Present one thought at a time
Ask simple questions/one word answers
Keep familiar routine for client.
- Nursing diagnosis of a client with dysphagia
- Alteration in nutrition related to dysphagia...
- Assessment of a client with dysphagia.
- Gag reflex
ability to chew
condition of mouth
deviation of uvula
ability to suck
- Interventions for a client with dysphagia
- Feed from good side
offer thickened liquids only
offer semisolid foods
offer small amounts frequently
- Examples of food for dysphagic client.
- custard, jello, mashed potatos, ice cream, canned fruits.
- Nursing diagnosis of the immobile client.
- Alteration in mobility related to ...
- Complications of the immobile client.
- Pneumonia, Thrombosis
Urinary tract infection
- Examples of acidic fruit juices to prevent UTI's.
- Cranberry, prune
(Orange is not acidic)
- Nursing diagnosis of the incontinent client.
- Altered urinary elimination or bowel incontinence...
- Interventions for bowel incontinence
- establish schedule for evacuation
administer stool softeners
- Interventions for bladder incontinence.
- Schedule use of bathroom
Foley clamping routine
Crede method (pressure to pubic area)
Intermittent self catheterization
- What medication is given for a bladder with poor muscle tone?
- What medications are given for spastic bladder?
- Ditropan, Pro-banthine
- Two types of neurological problems of the CNS-Brain
- Seizure disorders, epilepsy
- What is a seizure disorder?
- A physical manifestation of rapid paroxymal and abnormal electrical firing of neurons
- What is epilepsy?
- A chronic disorder characterized by recurrent unprovoked seizure activity.
- Who has the highest incidence of epilepsy?
- Older adults.
- Can epilepsy be inherited?
- What are the causes of epilepsy?
- Primary (idiopathic)- cause unknown
Secondary - underlying lesion d/t brain tumor, trauma, metabolic, electrolyte disturbance, infection, drug/alcohol withdrawal, hyperthermia.
- What is the diagnostic test for epilepsy?
- Name four types of seizures
- Tonic-clonic (grand mal)
Atonic (without muscle tone)
- Name the stages of a tonic-clonic (grand mal) seizure.
Tonic - body stiffens
Clonic - rhythmic jerking
- What are some types of auras in a tonic/clonic seizure?
- smell, sound, taste, hallucination, weakness, numbness.
- What types of things happen during the clonic stage of a grand mal seizure?
- loss of consciousness
respirations may stop (apnea)
- What happens during the postictal stage of a tonic-clonic seizure?
no memory of the seizure (may last hours, days)
- Nursing management for seizures
Protection from injury
Support respiratory function
- Assessments for seizure management
- time of onset, type of motor movement, incontinence, pupil reaction and eye movement, respiratory status, skin color, moisture, pre and postictal state.
- Ways to protect the seizure patient from injury.
- Clear environment
pad side rails
loosen restrictive clothing
protect clients head (pillows)
stay with client throughout seizure
- Ways to support respiratory function for the seizure client.
- Place client on side
suction as needed
- Post seizure care
- quiet environment, decrease stimuli
side rails up
vs and neuro checks
check mouth for injuries
check for incontinence
administer meds as ordered
maintain seizure precautions
- What are seizure precautions?
- Prevent injury
O2 and suction equipment
padded side rails
bed in low position
no padded tongue blade!
- Describe absence seizures
- Brief loss of consciousness
common in children
easy to miss
- Describe myoclonic seizures
- brief jerking or stiffening of extremities - singly or in groups
last a few seconds
- Describe atonic/akinetic seizures
- sudden loss of muscle tone causing the person to drop to the floor
may be followed by confusion
- What are 2 types of partial seizures?
- Complex partial (with loss of consciousness)
Simple partial (no loss of consciousness)
- 50% of seizures are ...
- unclassified - not in any category
- What is status epilepticus?
- Continuous seizure activity lasting longer than 10 minutes or repeated seizures over the course of 30 minutes.
- What are the usual causes of seizures?
- Sudden withdrawal from anticonvulsant medication, infections, head trauma, cerebral edema, metabolic disturbances.
- Interventions for the management of seizures.
Vagal nerve stimulation
Client and family education
- Risk factors for stroke.
- Heredity, gender (males), >65, race (African American), HTN, coronary artery disease, diabetes, hyperlipidemia, obesity, sickle cell anema, phenylpropanolamine (PPA), smoking, alcohol, cocaine, IV drug use.
- Cranial nerve involvement in stroke patients
- CN V - chewing
CN VII - facial paralysis, drooping
CN IX & X - swallowing, gag reflex
CN X11 - tongue movement
- Test for cranial nerve V for stoke patient.
- Trigeminal. Clench teeth, lightly touch anterior skull, paranasal sinus area, jaw area. (both sides)
- Test for cranial nerve VII for stroke patients.
- Facial paralysis. 6 facial movements - raise eyebrows, smile, puff out cheeks, purse lips and blow out, show teeth, squeeze eyes shut while you try to pry them open.
- Test for cranial nerve IX and X for stroke patients.
- swallowing and gag reflex. IX movement of posterior pharynx when client says AHhh. X gag reflex (touch tongue blade to posterior pharynx.
- Test for cranial nerve XII for stroke patients.
- Tongue movement - stick tongue out.
- Nursing management for patient with meningeal irritation.
- vs, neuro checks, assess for signs of ICP, cranial nerve testing 3,4,6,7,8; seizure precautions, IV antibiotics, isolation precautions, people in close contact are tested.
- Nutrition for a stroke patient.
- Count calories, weigh patient, give supplements, foods high in fiber, adequate fluids.
- Neuro checks for ICP
- assess LOC, headache, motor function, vital signs, projectile vomiting, pupilary changes
- Pupilary changes in ICP
- unilateral pupil dilation
bilaterally dilated and fixed pupils
slow pupil reaciton to light
papilledema with opthalmoscopic exam
- Difference between bacterial and viral meningitis.
- Bacterial - fall & winter, s. pneumonia,common in dorms, most common
Viral - after virus (measles, mumps, herpes simplex, herpes zoster), complete recovery
- Signs of meningeal irritation
- Nuchal rigidity
- Alzheimer's Disease warning signs
- Recent memory loss, difficulty performing familiar tasks, problems with language, disorientation to time and place, impaired judgment, wandering.
- Risk factors of Alzheimers Disease.
- Genetic disposition, chemical imbalance, environment, immunologic causes.
- Nursing responsibilities for treating MS with prednisone.
- Monitor fluids, electrolytes, glucose levels, K, GI Bleeding, personality changes and protect from exposure to infections.
- Antiepileptic drug that causes impaired liver function.
- Antiepileptic drug that causes body hair increase and slurred speech.
- Why are antihistamines given for Parkinson's disease?
- To enhance anticolinergic drying action
- Post op care for spinal nerve root decompression.
- Deep breathing w/o coughing, rest the back, narcotic analgesics, assess for resp distress w/ cervical fusion, assess donor site, back brace or collar, logrolling day of surgery, support head, assess dressing, assess voiding, nv checks of extremities
- Clinical management of multiple sclerosis.
- PT, OT, Corticosteroids, immunosuppressive therapy, adjunctive therapy, bee sting therapy, nutritional supplements.
- Two types of Autonomic Nervous System Syndromes
- Neurogenic/Spinal shock
- What is neurogenic/spinal shock
- Sudden depression of sympathetic reflex activity below the level of injury.
- What is autonomic dysreflexia?
- a later complication of spinal injury.
- Symptoms of neurogenic/spinal shock
- hypotension, bradycardia, flaccid paralysis, paralytic ileus, loss of reflexes. Symptoms appear 30-60 min. after injury, last several months. Tx-medication.
- Symptoms of Autonomic Disreflexia
- sever hypertension, bradycardia, flushing and sweating, blurred vision, nausea, cool mottled skin below injury.
- Cause of autonomic disreflexia
- overstimulation of the autonomic nervous system, i.e, distended bladder or color - emptying will reverse the problem.
- Assessment for spinal nerve root decompression
- Assess for pain, posture/gait, paresthesia, deep tendon reflexes.
- Nonsurgical management for spinal nerve root decompression
- assess pain, motion & sensation in extremities, Williams position(HOB elevated, knees flexed), firm mattress, exercise, medications for pain and inflammation, heat/ice, weight control.
- Mechanisms of spinal cord injury
- hyperflexion of neck, hyperextension of neck, axial loading (jump off roof), penetrating injuries (stab, gunshot)
- Degrees of spinal cord injury
- cord concussion (blow)
laceration (Tear in spinal cord)
transection (complete severing of cord)
- Effect of high cervical damage to the spine (C2-3)
- Respiratory failure - often immediate death.
- Effect of low spinal damage
- loss of motor function, sensation, reflex activity, bowel & bladder function
- What is the priority assessment in spinal cord injury?
- Assess Airway!
- What is the next nursing priority after assessing airway in spinal cord injury?
- Immobilization of the head, neck and back; maintain proper alignment of the spine at all times.
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