Rasmussen College :NUR MISCMDC4 exam 1 review 1_LATEST 2021/2022
• What is the most common type of dementia?
- Alzheimer's disease
• Is
... [Show More] Alzheimer's reversible?
- No
• What is the etiology of Alzheimer's?
- Unknown
• Alzheimer's is the result of?
- changes in personality, memory, and/or judgement
• What are risk factors for Alzheimer's?
- 65+ years
* female
* head injury
* APOE gene
• what is the patho of Alzheimer's
- plaques, tangles, degeneration of neurons
• How is Alzheimer's diagnosed?
- biopsy at autopsy is the only definitive way but dementia can be ruled out with CT, labs, UA, and MRI
• Early s/s of Alzheimer's Disease
- decreased short term memory
- decreased sense of smell
- misplaced items
• Middle s/s of Alzheimer's Disease
- wander
- agitated
- incontinent
- money issues
• late s/s of Alzheimer's disease
- bed ridden
- agnosia (inability to recognize objects, people, or sounds)
• Medications used for Alzheimer's
- Cholinesterase inhibitors
- slow breakdown of Ach
- Donepezil and Rivastigimine
- NMDA receptor antagonists
- block excess amounts of glutamate
- Memantine
• Nursing care for Alzheimer's
- safe environment (#1) good lighting, no clutter
- stick with a routine
- offer walks, exercise
- reduce distractions
- avoid use of restraints
• What is Parkinson's Disease
- Movement disorder caused by the death of cells that generate dopamine in the basal ganglia and substantial nigra.
Low levels of dopamine and high levels of Ach
• How does Parkinson's progress?
- slowly, but will eventually lead to disability
• How is parkinson's diagnosed
- history and s/s
• s/s of parkinsons
- tremors
- muscle rigidity
- mak like facial expression
- bradykinesia
- shuffling gait
- cogwheel rigidity in limbs
- propulsive gait (head and neck forward, back is slouched)
• nursing care for parkinson's
- safe environment
- sit up when eating, thick liquids
- encourage ROM and exercise
• Medication for Parkinson's
- Sinemet
- Levodopa (increases dopamine levels in CNS) and Carbidopa (prevents levodpa breakdown)
- take at same time every day
- know that increased protein can alter effectiveness
- Benztropine
- decreases Ach levels
• What are headaches?
- vasodilation of blood vessels in the brain
• What causes headaches
- genetics, stress, hormones
• What can trigger a headache?
- coffee, yogurt, alcohol, MSG, marinated foods
• s/s of headache
- head pain for 4-72 hours, N/V, unilateral pain, may come with aura
• what are cluster headaches?
- happen at night, stuffy nose
• treatment of headache
- Prophylactic = propranolol
▪ Mild = NSAID
▪ Severe = sumatriptan
- ergotamine tartrate
- 6 tabs in 1 day
- take as soon as pain starts
- MOA = constricts cerebral blood vessels
• What is increased ICP made of?
- CSF, blood, brain
• what causes increased ICP
- infection, trauma, increased CSF, hemorrhage, tumors
• s/s of increased ICP
- MIND CRUSH
M: mental status change (early sign) = decreased LOC, irritable, confusion I: irregular breathing (late sighn) = Cheyene Stokes
N: nerve damage to eye = pupil changes
D: decerebrate (limbs out) and decorticate (limbs to core) posturing C: cushing's triad (late) = HTN + brady + wide pule pressure
R: reflux - N/V U: unconscious S: seizures
H: headaches
• Nursing care for Increased ICP
- PRESS
P: position HOB @ 30 degrees and make sure body's midline (no flexion of neck or hips)
R: respiratory we want to prevent hypercapnia by hyperventilating (limit suctioning)
E: elevated temp - prevent it!
S: system checks = neuro checks
S: straining things - avoid it (no lifting, blowing nose, cough/sneeze)
• Additional Nursing care measures for ICP
- turn down the lights
- no TV or noise
- put sign on door telling visitors to see nurse first
• What do you NOT do when someone has increased ICP?
- Lumbar Puncture
• What is the Glasgow Coma Scale?
- A brain injury severity scale that assesses depth and duration of impaired consciousness and coma.
• what 3 areas make up the Glasgow coma scale?
- eyes score 1-4
- verbal score 1-5
- motor score 1-6
Total score 3-15 **lower the score = more severe injury/status
• Eyes for Glasgow Coma Scale
- ESPN
E - eyes open spontaneously (4) S - sound (3)
P - pain (2)
N - not open (1)
• Verbal for Glasgow coma scale
- Our Country WIN
O: oriented (5)
C: confusion (4)
W: words are inappropriate (3) I: incomprehensible sounds (2) N: nothing (1)
• Motor for Glasgow coma scale
- Can't Live Without FANs
C: commands followed (6) L: localize to pain (5)
W: withdrawal from pain (4)
F: flexion - decorticate posturing (3)
A: abnormal extension-decerebrate (2) N: nothing (1)
• what are seizure
- abnormal and increase in firing of neurons
• what is epilepsy
- chronic seizures
• what triggers seizures
- stress, fatigue, coffee
• what are risk factors for seizures
- infection, trauma, fever, withdrawal, imbalances
• How do you diagnose siezures
- EEG (wash hair prior)
• Seizure Precautions
- padded bed rails
- O2 and suction at bedside
- IV access
- lowest bed setting
• Types of siezures
- absence, atonic, tonic clonic, status epilepticus
• Absence Seizures
- day dreaming
- LOC for a few seconds
- s/s = pick at clothes, lip smack, blank stare
• Atonic Seizures
- loss of muscle tone - fall
• Tonic Clonic seizure
- tonic = stiffening
- clonic = rhythmic jerking
- postictal phase = coming back to - confused/sleepy
• Status Epilepticus
- medical emergency!
- 1 seizure that lasts > 5 mins
- repeat of seizure w/in 30 min
• nursing care during siezure
- turn patient on left side (#1)
- loosen restrictive clothing
- note onset and duration
- do NOT insert anything by mouth
• Nursing care after seizure
- take vitals
- perform neuro checks
- determine what trigger was
- maintain left lying position
• Treatment of seizures
- Phenytoin
- narrow range (10-20), s/s= gingival hyperplasia
Valproic acid
- s/s = hepatotoxic
Carbamazepine
- can cause a rash (Steven Johnson syndrome)
• Education for Seizures and Seizure treatment
- medication compliance (abrupt withdrawal = rebound seizures)
- do not drive
- wear medical alert bracelet
• surgical treatment of seizure
- vagal nerve stimulator
- craniotomy
• What is encephalitis?
- infection & inflammation of the brain tissue
***life threatening
• How is encephalitis diagnosed?
- CSF analysis or EEG
• What are the s/s of encephalitis?
- stiff neck, n/v, fever
• What can encephalitis increase risk of?
- increased ICP
• Nursing care for encephalitis
- turn down lights and noise
- keep midline and HOB @ 30 degrees
- avoid straining activities
• What is meningitis
- inflammation of meninges (around brain and spinal cord)
• what are the two main types of meningitis
- viral - more common
- bacterial - cause is step
• Prevention of meningitis
- vaccination
- Hib for baby
- MCV4 for teens
• Diagnosis of meningitis
- CSF analysis
• What does CSF analysis look like for viral meningitis?
- clear, increased wbc and protein
• what does CSF analysis look like for bacterial meningitis
- cloudy, decreased glucose, increased wbc, and protein
• s/s of meningitis
- nuchal rigidity, n/v, photophobia, Brudzinski's sign, Kernig's sign
• What is Brudzinski's sign?
- After forced flexion of the neck there is a reflex flexion of the hip and knee and abduction of the leg.
• What is Kernig's sign?
- After flexing the hip and knee at 90 degree angles, pain and resistance are noted.
• Nursing care for Meningitis
- bacterial = antibiotics
- viral = acyclovir
- steroids (decrease inflammation, increased infection)
- prophylaxis treatment for anyone in contact/exposed
- implement droplet precautions for first 24 hours of treatment
- Decrease ICP risk by elevating HOB, keep body midline, avoid straining activities, turn everything down
• What is MS?
- Autoimmune disease with chronic inflammation and no cure; just periods of relapse and remition
• what is patho of MS
- body attacking its own myelin sheath
• what causes MS
- genetic, autoimmune, infection
• what are risk factors of MS
- female, white, 20-50 y/o
• diagnosis of MS
- no 100% way
- MRI
- CSF analysis (increased WBC, proteins, IgG)
• S/S of MS
- muscle weakness
- intention tremors
- tinnitus
- vision (diplopia, nystagmus)
• Nursing care for MS
- protect from injury
- allow for periods of rest
- help manage stress b/c this can lead to relapse/remit
• Meds for MS
Immunomodulators, immunosuppressants (decreased inflammation, increase infection)
- muscle relaxant = baclofen
• what is Autonomic dysreflexia
- Firing of SNS with no PNS response
• what injury causes autonomic dysreflexia?
- injury above T6
• what causes autonomic dysreflexia?
- bowel, bladder, breakdown of skin
• s/s of autonomic dysreflexia
- severe htn
- bradycardia
- headache
- diaphoresis
- blurry vision
- facial flush above injury
- pale below injury
• nursing care for autonomic dysreflexia
- Prevent:
- bladder distention (empy it, check tubing for kinks, use bladder scanner)
- bowel - check for impactation
- skin breakdown - remove tight clothing
Detect: at risk above T6 injury, report of headache, check BP
Action: elevate HOB, Remove restrictive clothing, schedule bowel and bladder maintenance
• What is true for spinal cord injury
- the higher the injury, the more system affected and shorter the lifespan
• diagnosis of spinal cord injury
- X-ray, CT scan, MRI
• prevention of spinal cord injury
- stop drugs and alcohol
• causes of spinal cord injury
- traumatic: falls, MVA, violence Non-traumatic: tumors, RA
Direct: fracture, hyperflexion (diving), hyperextension, penetration (GSW), axial load
• types of spinal cord injuries
- Complete: complete severed spinal cord, complete loss of function below injury
Incomplete: spinal cord is partially severed, partial loss of function Quadriplegia
- at C6
- Unable to move all 4 extremeties
- MVA, fall
Paraplegia
- below T1, paralysis of lower extremities, can be result of GSW
• what is the main cause of death for people with spinal cord injuries
- sepsis, pneumonia, PE
• Acute management of spinal cord injury
- airway and breathing
- immobilize head and neck (c-collar)
- determine LOC by using GCS
• Medications for spinal cord injuries
- corticosteroid = methylprednisolone
- first given as IV bolus - then IV continuous drip for 24 hours
- needs to be given w/in 8 hrs of injury
-s/s hyperglycemia, poor wound healing, infection
- education: increae Ca intake, ROM, deep breathing
• what is the number 1 thing to keep in mind with a spinal cord injury?
- AIRWAY and BREATHING
• Complications of Spinal cord injury
- autonomic dysreflexia
- neurogenic shock (hypo, bready, edema, temp)
• what is a stroke?
- alteration in blood flow to the brain
• TIA
- transient ischemic attack = mini stroke, warning sign
• diagnosis of stroke
- CT without contrast
• Etiology of stroke
- nonmodifiable = age, sex, history
- modifiable = HTN, BC user, high cholesterol, smoker
• s/s of stroke
- FAST
facial droop, arm drift, speech is slurred, time how much as passed
• General Left vs Right side stroke
- Left = language
Right = impulse & judgement
• Left-sided stroke s/s
- receptive aphasia (unable to verbally communicate back)
- right sided hemiparesis (weakness)
- agraphia (unable to right)
- Aware of their deficits - anxiety and depression
• Right-sided stroke s/s
- poor impulse control and judgement
- 1 sided neglect syndrome (unaware of deficits on left side of body, big safety concern)
- short attention span
- proprioception (depth) issues
• Broca's area
- expressive aphasia: unable to communicate/express back in speech
• Wernikies aphasia
- receptive aphasia: unable to receive/understand what is being said
• nursing care for both broca's and wernikies
- be patient
- use short phrases
- use gestures/point
- limit distractions around
• Treatment of stroke
- General - anticoagulants, stool softeners, benzo's
Ischemic stroke aka clot - tPa = thrombolytics (must be w/in 3 hours, BP needs to be in range, neuro checks every 15 mins. NOT for bleeding, htn,
>3hrs
Hemorrhagic stroke - only treatment is surgery (BP must be in range, NOT for someone on blood thinners (coumadin), if blood is too thin, admin fresh plasma or Vit K)
• Nursing care for stroke
- safe environment (teach patient to scan before ambulating)
- lots of eating concerns:
- sit up
- tuck chin
- thick liquids
- use dentures
- no straws
- take small bites
- use mechanical soft diet
Complications of stroke: increased ICP, seizures, HTN, headach
• Who is at risk for TBI
- infants, teens, older adults
• how does TBI occur
- falls, mva, gsw, sports
• levels of tbi
- mild - concussion moderate - decreased loc severe - prolonged LOC
• types of TBI
- subdural hematoma - bleeding below dura and above arachnoid
- primary: open (directly to brain) closed (fracture)
- secondary - result of primary
• Nursing care for TBI
- #1 determine what caused injury
- monitor LOC by GCS
- watch for CSF - clear drainage, shows halo with test
- wiping = ok
- blowing/inserting = NO
- prevent increased ICP
• Complications of ICP
- hydrocephalus, infection, stroke, increased ICP
• meds for icp
- antiseizure, mannitol, corticosteroids [Show Less]