question

the most common causes of prolonged unconsciousness includes these four

answer

CVA Heady Injury Brain Tumor Drug Overdose

question

Important Nursing Considerations to always take into account

answer

(1) Always assume that the patient can hear, even though they make no response. (2) Always address the patient by name and tell him what you are going to do. (3) Refrain from any conversation about the patient's condition while in the patient's presence.

question

What to regularly observe and record

answer

Vital Signs and Level of consciousness!

question

What to Do in regards to changes in vitals or consciousness

answer

report changes to charge nurse, Doctor, ARNP or PA

question

Types of changes to be very aware of

answer

temperature consciousness response to stimuli protective reflexes (corneal gag)

question

Normothermic interventions

answer

Take temperature regularly Feel the patient's skin with back of hand Adjust room temperature accordingly

question

airway and breathing interventions

answer

-chin extended and lateral recumbent is the safest position. -suction secretions to prevent aspiration -reposition side to side to prevent pooling of secretions in lungs -administer oxygen as ordered -always have suction available to prevent aspiration of vomitus

question

this is often referred to as the coma position

answer

lateral recumberant

question

nutritional needs interventions

answer

observe patient carefully when administering savage feedings. Best position is the sitting position to reduce aspiration Fluids are maintained by IVF MUST keep accurate records of intake and output(urine) -Observe for signs of dehydration or fluid overload.

question

skin care interventions

answer

-the unconscious patient should be given a complete bed bath every other day. -moisturize skin with lotion after bathing -keep nails short so that the patient does not scratch themselves

question

skin care nursing interventions continued

answer

provide oral hygiene at least twice per shift (tongue, tooth surfaces, and soft tissue areas) unconscious patients are mouth breathers so pay attention area! Put petroleum on lips from drying.

question

skin care interventions continued

answer

-keep nostrils free of crusted secretions with water soluble lubricant -put eye drops or corneal ointment to prevent abrasions -watch perineal area throughly after each incident

question

bowel elimination interventions

answer

BM should be regular to prevent impaction keep ACCURATE record of BM. Note amount, color, consistency assess for signs of impaction administer laxatives and enemas Probiotics?

question

sings of impaction

answer

-no incontinence however complete evacuation is not observed. Small frequent loos stools may be the first sign of impaction.

question

urine interventions

answer

the bladder should be emptied regularly to prevent infection or stone formation adequate hydration is important. monitor urine output CAREFULLY. This should be reported provide catheter care at least once per shift and whenever to patient soils linens

question

When positioning the unconscious patient, pay particular attention to maintaining proper body alignment. The unconscious patient cannot tell you that he is __________ or is experiencing pressure on a body part.

answer

uncomfortable

question

Limbs must be supported in a position of _________. Do not allow flaccid limbs to rest unsupported

answer

function

question

When turning the patient, maintain _____________ and do not allow the arms to be caught under the torso.

answer

alignment

question

Utilize a foot board or boots at the end of the bed to ________ the possibility of foot drop

answer

decrease

question

When joints are not exercised in their full range of motion each day, the muscles will gradually shrink, forming what is known as a contracture. -___________ exercises must be provided for the unconscious patient to prevent contractures.

answer

Passive (thank you PT)

question

Exercises with a range of motion (ROM) are performed under the direction of the ________ __________

answer

physical therapist.

question

Precautions must be taken to prevent the development of __________ __________.

answer

pressure sores

question

Utilize a ___________ mattress such as a flotation mattress, alternating pressure mattress, or eggcrate mattress.

answer

protective

question

get the patient _____ and int o the chair

answer

OOB

question

Definition. inflammation of the meninges. The severity of the disease is dependent upon the specific microorganism involved, the presence of other neurological disorders, the general health of the patient, the speed of diagnosis, and the initiation of treatment

answer

meningitis

question

causes of meningitis

answer

Travel of infectious microorganisms to the meninges via the bloodstream or through direct extension from an infected area (such as the middle ear or paranasal sinuses).

question

Common meningitis microorganisms include

answer

(a) Meningococcus. (b) Streptococcus. (c) Staphylococcus. (d) Pneumococcus. (2) Contaminated head injury. (3) Infected shunt. (4) Contaminated lumbar puncture.

question

diagnostic procedure for meningitis

answer

Lumbar puncture blood cultures Physical examination

question

signs and symptoms of meningitis

answer

Hyperthermia chills Headache nausea and vomiting nuchal rigidity photophobia opisthotonos altered LOC Multiple petechiae over the body

question

nursing management for meningitis

answer

administer IVF and meds as ordered Antibiotics should be started immediately corticosteroids should be used for the critically ill patient. drug therapy may be continued after the acute phase of illness.

question

nursing interventions for meningitis

answer

record intake and output carefully to observe the patient for signs of dehydration due to insensible fluid losses. monitor vital signs and neurological status. monitor temperature every 4 hours and if there is any cooling or warming device, this will be every hour.

question

nursing management for meningitis part 2

answer

if isolation is required, educate family and staff maintain dim lighting in the room

question

is a disorder of the nervous system that affects peripheral nerves and spinal nerve roots. It is also called infectious polyneuritis.

answer

Guillain Barre syndrome

question

the exact cause is unknown. Many patients give a history of a recent infection, especially of the upper respiratory tract. There is also evidence of a connection with the Swine flu vaccination.

answer

Guillain Barre syndrome

question

diagnosis is made on history and symptoms. lumbar puncture will reveal increased protein in the cerebral spinal fluid

answer

Guillain Barre syndrome

question

signs and symptoms of Guillain Barre syndrome

answer

motor weakness especially in the extremities. weakness usually ascends over period of hours to weeks. sensory disturbances, numbness, and tingling. cranial nerve involvement resulting in difficulty chewing and talking diminished deep tendon reflexes and low grade fever

question

nursing management of patients with Guillain Barre syndrome

answer

treatment in nonspecific and symptomatic observed for adequacy of respiratory effort EKG monitoring after several weeks the paralysis will begin to disappear. This will usually start from the head down.

question

chronic, progressive disease of the central nervous system characterized by the destruction of myelin. Myelin is the fatty and protein material that covers certain nerve fibers in the brain and spinal cord.

answer

multiple sclerosis.

question

Multiple Sclerosis primarily affects adults between __________- years of age.

answer

20 and 40

question

signs and symptoms of MS

answer

weakness visual disturbance nystagmus slurred speech intention tremor abnormal reflexes ataxia paraplegia urinary and bowel incontinence emotional labile

question

nursing management of MS

answer

keep patient active and as functional as possible provide support to receive symptoms encourage exercises to strengthen and prevent contractures encourage frequent rest periods to prevent muscle fatigue administer muscle relaxants as ordered.

question

nursing management of MS 2

answer

-avoid skin pressure and immobility -give special attention to sacral and perineal hygiene -support bladder -observe for retention -teach self catheterization -give urinary antiseptics -establish bowel regulation.

question

nursing management of MS continued

answer

admin corticosteroids to reduce edema and swelling encourage bedrest with active stage effects of disease increase with each exacerbation support eye and speech defects use speech therapist assist patient and family to cope

question

the patient with MS will experience behavioral changes such as

answer

euphoria, depression, denial, forgetfulness

question

a progressive neurological disorder affecting the brain centers that are responsible for control of movement.

answer

Parkinsons

question

signs and symptoms of parkinson's

answer

bradykinesia, tremor, rigidity, shuffling gait, muscle weakness, mask like face, depression, dementia

question

nursing management of parkinson's

answer

drug therapy, physical therapy, encoring patient to be an active participant,

question

an autoimmune disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body.

answer

myasthenia gravis

question

There may be too much cholinesterase present, and acetylcholine is destroyed too quickly. or there my be too little released from the nerve or the motor end is not sensitive to ach.

answer

myasthenia gravis

question

signs and symptoms of myasthenia gravis.

answer

anti cholinesterase drugs must be given at exact times. Teach symptoms of overdose. Have therapy coincide with mealtimes so that swallowing is at its best.

question

Myasthenic crisis may result from

answer

natural deterioration of the disease, emotional upset, upper respiratory infection, surgery, or steroid therapy.

question

______ _______ may occur due to overmedication with anticholinergic drugs

answer

cholinergic crisis

question

signs and symptoms of cholinergic crisis

answer

the muscles stop responding to the bombardment of ACh, leading to flaccid paralysis, respiratory failure, and other signs and symptoms reminiscent of organophosphate poisoning. Other symptoms include increased sweating, salivation, bronchial secretions along with miosis.

question

with this acetylcholine disease the patient may require ventilation, intubation

answer

myasthenia gravis

question

is a cranial nerve disorder characterized by facial paralysis. Peripheral involvement of the 7th cranial nerve (facial nerve) produces weakness or paralysis of the facial muscles.

answer

bell's palsy

question

The cause of this condition is unknown, but the majority of patient's have experienced a viral upper respiratory infection 1 to 3 weeks prior to the onset of symptoms.

answer

bells palsy

question

Complications associated with Bell's palsy include

answer

facial weakness, facial spasm with contracture, corneal ulceration, and blindness.

question

nursing interventions for bell's palsy

answer

protect involved eye, install articicial tears, increase environmental humidity, tell patient to wear eye patch at night. wear protective glasses in the day time. facial massage to maintain tone, surgical decompression of facial nerve may be necessary

question

also known as Tic Douloureux, is a disorder of the 5th cranial nerve (trigeminal nerve). It is characterized by sudden paroxysms of burning pain along one or more of the branches of the trigeminal nerve.

answer

trigeminal neuralgia

question

signs and symptoms of trigeminal neuralgia

answer

(1) Sudden, severe pain appearing without warning. (Along one or more branches of trigeminal nerve.) (2) Numerous individual flashes of pain, ending abruptly and usually on one side of the face only.

question

trigeminal neuralgia attacks can be provoked by

answer

shaving talking yawning chewing gum cold wind

question

nursing interventions for trigeminal neuralgia

answer

avoid cold things give tegretol and dilantin to relieve pain serum drug levels will be needed eat easily chewed foods

question

the disruption of the blood supply to the brain, resulting in neurological dysfunction.

answer

CVA

question

causes of CVA

answer

thrombosis cerebral embolism cerebral artery stenosisi cerebral hemorrhage

question

risk factors associated with CVA

answer

hypertension previous history of TIAs Cardiac disease advanced age diabetes mellitus

question

signs and symptoms of CVA

answer

depends on lesions size and site hemiplegia (paralysis) hemiparesis (weakness) communication loss receptive or expressive aphasia vision loss bladder impairment LOC changes

question

signs and symptoms of CVA continued

answer

BP may be elevated due to increased ICP sudden headache with nausea and vomiting patient may be comatose for hours or weeks

question

the longer the coma the

answer

poorer to prognosis

question

____ is a frequent complication resulting from hemorrhage or ischemia and subsequent cerebral edema.

answer

ICP

question

nursing management for CVA acute phase

answer

keep patient alive ensure adequate oxygenation to the brain support airway frequently assess LOC, pupils, response to commands, movement and strength, patient's vital signs

question

Be aware of changes in any of the above. _________- could indicate progression of the CVA.

answer

Deterioration

question

nursing management for CVA acute phase continued

answer

continually reorient patient maintain proper alignment prevent complication of bedrest HOB at 30 degrees

question

________ may be a result of simply regaining consciousness, or may be due to a neurological deficit.

answer

Confusion

question

nursing management of CVA

answer

ensure adequate fluid and electrolytes fluids may be restricted to decrease ICP IVF are maintain until patient stabilizes and NG insertion can begin

question

medication therapy for CVA

answer

antihypertensives antibiotics seizure control anticoagulants

question

these drugs are not given to a patient with a CVA because they depress the respiratory center and obscure neurological observations

answer

sedatives and tranquilizers

question

medical and nursing management of CVA

answer

maintain adequate elimination foley catheter stool softners include family in plan of care keep them informed

question

is an abnormal electrical disturbance in one or more areas of the brain. An estimated 2 to 4 million persons in the United States are afflicted with epilepsy and more that half of those are under 20 years of age

answer

epilepsy

question

The underlying disorder may be structural, chemical, physiological, or a combination of all three.

answer

epilepsy

question

factors that predispose a patient to epilepsy

answer

(a) Trauma to the head/brain. (b) Brain tumor. (c) Circulatory disorder, stroke. (d) Metabolic disorder (such as hypoglycemia, hypocalcemia, or cerebral anoxia). (e) Drug/alcohol toxicity. (f) Infection (meningitis/brain abscess).

question

this phase of grand mal seizure consists of vague emotional changes (depression, anxiety, nervousness). Lasts for minutes to hours. Followed by an "aura." Aura is usually a sensory "cue" (odor or sound) or sensation "cue" (weakness, numbness). It is related to the anatomical origin of the seizure, and warns the patient that a seizure is imminent. this phase may not be present in all patients

answer

preictal phase

question

this phase of granola includes: loss of consciousness, skin is cyanotic and breathing is spasmodic, jaws are clenched tight, tongue may be bitten, urinary and equal incontinende usually occur. may last minutes

answer

tonic-clonic phase

question

______activity is characterized by rigid contraction of the muscles.

answer

tonic

question

__________ activity is characterized by alternate contraction and relaxation of muscles, causing jerking movements of the arms and legs.

answer

Clonic

question

this phase of grand mal seizures will vary in symptoms. Some patients will fall into a deep sleep. patients may experience headache, fatigue, confusion and nausea

answer

post ictal phase

question

Characterized by brief loss of consciousness, or "blank spells." (2) Individual stares blankly, eyelids may flutter, and there is slight movement of head and extremities. (3) More common in children. (4) May occur dozens of times per day.

answer

petit mal seizures

question

Different forms of seizure activity often appearing as irrational or odd behavior, such as removing one's clothing or purposeless behaviors such as smacking one's lips. (2) Last only a few moments and individual has no recall of behavior. (3) Auditory, visual, or olfactory hallucinations may also occur.

answer

psychomotor seizure

question

Seizures may start in one part of the body and move to another. Consciousness may not be lost. (2) May be followed by a grand mal seizure. Status Epilipticus. this is a extreme neurological emergency.

answer

Jacksonian seizure or also call focal/ marching seizure

question

nursing management of epilepsy

answer

prevent cause and recurrence reinforce importance of drugs to control not cure

question

nursing management of seizure

answer

place oral airway by bed set up suction equipment

question

essential steps to protect a patient during a seizure.

answer

turn the patient on their side to provide drainage for oral secretions do not restrain patient during seizure remove objects that may obstruct breathing or cause injury. protect the patient's head from injury.

question

nursing managment of epilepsy

answer

keep bed flat, turn patient on side, dim room lighting and noise kept to a minimum. loosen restrictive clothing, check vital signs, check lips and tongue for injury

question

a localized intracranial lesion which occupies space with the skull and tends to cause a rise in intracranial pressure.

answer

brain tumor

question

The most common brain tumors are _______, which begin in the glial (supportive) tissue. There are several types , including the following: Astrocytomas arise from small, star-shaped cells called astrocytes. They may grow anywhere in the brain or spinal cord.

answer

gliomas

question

signs and symptoms of brain tumor

answer

depend on location decreased LOC or confusion. Headache, lethargy, vomiting, papilledema, alterations in mentation, aphasia, hemiparesis, visual field defects, sensory defects, seizures

question

nursing management of brain tumors

answer

diagnostic test to determine location and size of lesion monitor and record vital signs use measure to decrease ICP initiate sz precautions

question

medications for brain tumors

answer

steroids and anti-eleptic agents

question

withholding a patients steroids can result in

answer

adrenal crisis

question

withholding antiepileptic agents frequently precipitates ____

answer

seizures

question

post op nursing care

answer

goal is to prevent complications accurately monitor and record vitals and neurological signs

question

post operative cerebral edema peaks between

answer

48 to 60 hours following surgery. Patient may be lucid during first 24 hours, then experience a decrease in level of consciousness during this time.

question

post operative nursing interventions

answer

do not turn patient on operative side of brain. this can cause irreversible damage in the first 72 hours. normothermic goal seizure precautions monitor I & Os cough and deep breath continually reorient patient

question

increased body temperature in a neuro patient may be due to swelling around the

answer

hypothalamus.

question

head injuries are categorized into these 2 categories

answer

direct and indirect

question

This phenomenon is a combination of direct and indirect injury. A direct blow to one side of the skull causes the brain to be jarred inside the skull, causing an indirect injury on the side opposite the direct blow.

answer

Coup-contrecoup

question

Brain damage resulting from a head injury is dependent upon these 3 things

answer

(1) The force of impact. (2) The type of impact. (3) The location of impact.

question

________- skull fractures are potentially serious injuries due to the proximity of the brain stem.

answer

Basilar

question

__________ skull fractures may be open or closed. In either case, the underlying brain tissue may be damaged.

answer

Depressed

question

________ skull fractures are "cracks." They may be dangerous if they overlie vascular structures.

answer

Linear

question

are a result of bleeding within the closed compartment of the skull. They may cause compression of brain tissue.

answer

hematomas

question

_______ hematoma is caused by bleeding between the skull and the dura.

answer

epidural

question

________ hematoma is caused by bleeding between the dura and the arachnoid membrane.

answer

subdural

question

______hemorrhage/hematoma is caused by bleeding into the subarachnoid space.

answer

subarachnoid

question

results from violent jarring of the brain against the interior of the skull. The patient experiences a brief loss of consciousness followed by confusion, headache, and irritability. Complete recovery is usual

answer

concussion

question

This injury is more serious than a concussion. The severe jarring of the brain causes bruising of the brain. (This bruising is the result of blood vessel rupture.) Permanent damage may result.

answer

contusion

question

causes of increased ICP

answer

edema, bleeding, trauma, or space-occupying lesions.

question

signs and symptoms of increased ICP

answer

change in LOC may occur over minutes, hours, days diminished response to stimuli confusion, restlessness, disorientation, and drowsiness, headache vomiting

question

ways that ICP is increased

answer

coughing, sneezing, straining

question

clinical signs and symptoms of increased ICP

answer

papilledema pupils may be non reactive, dilated, pinpoint, non reactive, elevation of BP with a widened pulse pressure increased pulse initially and then brady out bradypnea

question

Edema and pressure of both the optic nerve and the oculomotor nerve at the point at which they enter the globe is caused by venous congestion resulting from increased intracranial pressure.

answer

papilledema

question

Pupil on the affected side may be ___________.

answer

nonreactive

question

nursing managment for increased ICP

answer

monitor vital signs closely accurately assess and document neuro status maintain airway intubation and hyperventilation place patient on side do not simulate coughing... elevate HOB, promote venous return, seizure precautions

question

evaluation of _____ is crucial in the neuro ICU since symptoms progress rapidly!

answer

consciousness

question

_________ may be indicated to provide adequate cerebral perfusion of oxygenated blood and decrease carbon dioxide induced vascular spasm.

answer

Intubation and hyperventilation

question

If patient is not intubated, position the patient on his ______ to decrease the possibility of airway occlusion use oral or nasopharyngeal airway, prn.

answer

side

question

Be aware that stimulation of coughing when suctioning increases intracranial pressure and may precipitate _____ activity.

answer

seizure

question

medication for increased ICP

answer

mannital, corticosteroids, dilantin, antibiotics, hypertonic IVF ,

question

_______ fluids such as Dextrose in water crosses the blood-brain barrier and increase cerebral edema and intracranial pressure.

answer

hypotonic

question

______ will be restricted to reduce intracranial pressure.

answer

Fluids. so accurate I and O must be kept

question

seizure precaution for ICP

answer

pad side rails, secure tongue blade to head of bed, maintain normal body temperature, monitor rectal temperature frequently, place hypothermia blanket as ordered for temperature over 102.

question

Flexion-extension injuries are commonly located at ________ ("whiplash").

answer

C4 - C7

question

_____________- are frequent sites of spinal cord injury resulting rom falls.

answer

T11, T12, and L1

question

signs and symptoms of spinal cord injury,

answer

total sensory, motor loss below the level of ijury

question

______ spinal cord injuries will produce quadriplegia--loss of function of all four extremities.

answer

Cervical

question

Injuries to the thoracic spinal cord below the level of ______ will produce paraplegia--paralysis of the lower extremities.

answer

T1

question

The diaphragm is innervated by the phrenic nerves which arise from cervical nerve roots______

answer

C3 to C5

question

nursing management of spinal cord injury

answer

reduce fracture and obtain immobilization of spine to prevent further damage. continuously assess breathing pattern

question

patient with ___ will have some form of skeletal traction.

answer

cervical

question

Continuously observe patient for motor and sensory changes due to ______ edema or hemorrhage, which may further compromise cord function.

answer

cord

question

Test patient's motor ability by asking him/her to

answer

spread fingers, grip your hands, shrug shoulders, etc.

question

Test sensory level by

answer

gently pinching the skin at shoulders and progressing down sides ascertain level at which patient can no longer feel pinch.

question

Carefully record findings in patient's clinical record report changes in patient's motor/sensory level immediately to

answer

HCP

question

Be on high alert for signs of

answer

spinal shock

question

signs and symptoms of spinal shock

answer

complete loss of motor, sensory, reflex, and autonomic activity below the level of injury. this is temporary but may last for several weeks

question

with spinal cord injury If turning is allowed and patient is not on a turning frame or turning bed, the patient must be carefully________ with the spine maintained in alignment.

answer

log-rolled

question

(1) Sensory nerve. (2) Transmits smell impulses from receptors in the nasal mucosa to the brain.

answer

CN 1 olfactory

question

(1) Sensory nerve. (2) Transmits visual impulses from the eye to the brain.

answer

CN 2 optic

question

Motor nerve. (2) Contracts the eyeball muscles.

answer

CN 3 oculomotor nerve

question

(1) Motor nerve. (2) Contracts the eyeball muscles.

answer

CN 4 trochlear nerve

question

(1) Mixed nerve. (2) Transmits pain, touch, and temperature impulses from the face and head to the brain (sensory function). (3) Contracts the muscles of chewing (motor function).

answer

CN 5 Trigeminal nerve

question

(1) Motor nerve. (2) Contracts eyeball muscles.

answer

CN 6. abducens nerve

question

Mixed nerve. (2) Transmits taste impulses from the tongue to the brain (sensory function). (3) Contracts the muscles of facial expression and stimulates secretion of salivary and lacrimal glands (motor function).

answer

CN 7 Facial

question

(1) Sensory nerve. (2) Transmits hearing and balance impulses from the inner ear to the brain.

answer

CN 8 Vestibulocochlear Nerve (VIII).

question

(1) Mixed nerve. (2) Transmits taste impulses and general sensations from the tongue and pharynx (sensory function) to the brain. (3) Contracts the swallowing muscles in the pharynx and stimulates secretions of the salivary glands.

answer

CN 9 Glossopharyngeal Nerve (IX).

question

(1) Mixed nerve. (2) Transmits sensory impulses from the viscera (heart, smooth muscles, abdominal organs), pharynx, and larynx to the brain. (3) Secrets digestive juices, contracts the swallowing muscles of the pharynx and larynx, slows down the heart rate, and modifies muscular contraction of smooth muscles.

answer

CN 10 vagus

question

(1) Mixed nerve. (2) Transmits sensory impulses from the pharynx and larynx to the brain. (3) Contracts the muscles of the pharynx, larynx, and the neck.

answer

CN 11 spinal accessory nerve

question

(1) Motor nerve. (2) Contracts the muscles of the tongue.

answer

CN 12 Hypoglossal nerve

question

this scale is used to assess subarachnoid hemorrhages or aneurysms

answer

Hunt hess scale

question

what is worse, grade 1 or grade 5?

answer

grade 5

question

asymptomatic or mild headache with minimal nuchal rigidity is this grade on the hunt hess scale

answer

grade 1

question

moderate to severe headache with nuchal rigidity and non neurological deficit is this grade on the hunt hess scale

answer

grade 2

question

drowsiness or confusion with mild focal neurological deficit is this grade on the hunt hess scale

answer

grade 3

question

stupor with moderate to severe hemiparesis is this grade on the hunt hess scale

answer

grade 4

question

coma with decerebrate posturing is this grade on the hunt hess scale

answer

grade 5

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