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Exam 4 Review- Neuro, Oncology, Vision
Medical-Surgical Nursing II (NSG 223)
Herzing University
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Med Surg2 Exam 4 Review
Meningitis (3 ques) - Diagnosed by a positive Kernig sign - The client experienced pain while lying in a supine position with the thigh flexed on the abdomen, and the legs cannot be completely extended - Manifestations - Fever - Increases cerebral metabolism which further increases ICP - Headache, Changes in LOC, Nuchal rigidity, Positive bruzdzinksi sign, photophobia - Management - Prevention by meningococcal vaccine - Early administration of high doses of appropriate IV antibiotics for bacterial - Dexamethasone - Decreases inflammation - Most effective if given 15-20 min prior to the first dose of antibiotic and then every 6 hours for a total of 4 days - Viral meningitis - Antibiotics are ineffective - Treatment for dehydration, shock, and seizures ALOC - Level of responsiveness and consciousness is the most important indicator of the patient's condition - Must document LOC on every patient for every shift - Interventions for Patients ALOC - A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care - Maintaining an airway - Frequent monitoring of respiratory status, including auscultation of lung sounds - Positioning to promote accumulation of secretions and prevent obstruction of upper airway —head of bed (HOB) elevated 30 degrees; lateral or semiprone position - Suctioning, oral hygiene, and CPT - Assess and Maintain fluid status - Maintaining body temp - Adjust environment, measure to prevent shivering - Maintain Tissue Integrity - Assess skin frequently
Frequent turning
Careful positioning
Passive ROM
Splints
Artificial tears
Protect eyes
Frequent, scrupulous oral care
Sensory Stimulation and Communication
Talk to and touch patient
Orient patient frequently Increased Intracranial pressure
Monro-kellie hypothesis
Normal ICP of 10-20 mmHg
ICP may increase with disease or injurt
Increased ICP causes decreases cerebral perfusion
Brain tissues may shift
Autoregulation
Decreased CO2 results in vasoconstriction, and increased CO2 results in vasodilation
Early Symptoms of Increased ICP
Changes in LOC
Any change in condition
Pupillary changes
Weakness
Headache
Late signs of Increased ICP
Respiratory and vasomotor changes
VS: increase in systolic pressure, widened pulse pressure, slow heart rate, rapid fluctuation from brady to tachycardia, temperature increase
Projectile vomiting
Cheyne-stokes breathing
Loss of brainstem reflexes
Assessment of Patients with ICP
Evaluate mental status, LOC
Assessment of selected cranial nerves
Assess cerebellar function, reflexes, motor and sensory function
Glasgow Coma Scale, pupil checks
Interventions patient with increased ICP
maintain a patent airway
Position with head in neutral position and elevation of HOB 0 to 60 degrees
Maintain a calm, quiet atmosphere
Monitor fluid status
Use strict aseptic technique
Intracranial Surgery
Craniotomy
Craniectomy
Cranioplasty
Types of stroke: refer to Table 67-1 (next slide)
- Ischemic (87%) (2 ques)
- Symptoms depend on the location and size of the affected area
- Numbness or weakness of face, arm, or leg, especially on one side
- Confusion or change in mental status
- Trouble speaking or understanding speech
- Difficulty in walking, dizziness, or loss of balance or coordination
- Sudden, severe headache
- Perceptual disturbances
- Goal is to administer TPA (IV) WITHIN 45-60 minutes of patient arriving to the ED. Criteria to administer: - Age > 18 year - Clinical diagnosis of stroke - Time of onset of stroke known and is < 3 hours before treatment - Systolic pressure BP185 mm Hg; Diastolic pressure110 mm Hg - PT <15 seconds, INR ratio <1. - Not received heparin during the past 48 hours - Platelet count >100,000/mm - No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm
- Hemorrhagic (13%) (3 ques)
- 1 question: what order would you question?
- Subarachnoid hemorrhage caused by a ruptured aneurysm;
- Intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants
- Manifestations
- Similar to ischemic stroke
- Severe headache—caused by increased intracranial pressure
- Early and sudden changes in LOC
- Vomiting
- Bleeding
- Ischemic (87%) (2 ques)
Complications
- Cerebral vasospasm
- Often heralded by a worsening headache, decrease LOC, or new focal neurologic deficit (aphasia, hemiparesis)
- Seizures, Hydrocephalus, rebleeding
- Hyponatremia
- Associated with vasospasm
- Evaluate patient for SIADH
- Kidneys are unable to conserve sodium and volume depletion results
- IV hypertonic 3% saline Aneurysm
- Cerebral vasospasm
Absolute bed rest with HOB 30 degrees
Avoid all activity that may increase ICP or BP; Valsalva maneuver, acute flexion or rotation of neck or head Getting out of bed (increase ICP or BP)---keep on bedrest Cancer
2 ques: Risk Factors for Cancer
Malignant tumors spread by way of blood and lymph channels to other areas of the body
Prevention (2 ques) Primary prevention: reducing the risks of disease through health promotion and risk reduction strategies. Secondary prevention: screening and early detection activities that seek to identify precancerous lesions and early-stage cancer in individuals who lack signs and symptoms of cancer. Tertiary prevention: efforts focus on monitoring for and preventing recurrence of the primary cancer as well as screening for development of secondary malignancies in cancer survivors.
Diagnosis Closed awareness – client is unaware of the prognosis Suspected awareness - client suspects the diagnosis but is not sure Mutual pretense awareness – client and family know the prognosis but refuse to discuss it
Radiation Therapy (3 ques) Replicating cells are most vulnerable to the disruptive effects of radiation (Radiation works best on tissues with frequent cell division) o Bone marrow o Lymphatic tissue o Epithelium of GI tract
First line treatment of cancer primary focus is to perform toxicity assessment and management
Cancer Surgery Diagnostic surgery, Prophylactic surgery, reconstructive surgery Palliative Surgery - is performed in an attempt to relieve complications of surgery.
Kubler-Ross Stages of Grief (2 ques) Not sequential Attitude towards death, grief, bereavement
Know difference between hospice and Palliative
Palliative Care Does not mean the end of medical treatments
Hospice Care Care for patients who want to die at home Provide appropriate home care
End of Life Care Focus on keeping the client comfortable Avoid: blood draws, tube feedings, suctioning, and invasive monitoring
Participation in assisted suicide is prohibited by the ANA code of ethics even though it is legal in a few states Role of the nurse is to be non-judgmental and support the client, while following the code of ethics (do no harm)
Nursing Care Maintain tissue integrity, relieving pain, decreasing fatigue, improving body self image Promoting nutrition o Keeping room clean and free of odors o Providing frequent oral care o Managing nausea, pain, constipation o Offering favorite foods with high nutrition values o Mealtimes should be stress free o Don’t want to force or push client into eating
Pain management & Opioid (1 ques)
Educate the patient on the following: o Stool softeners o Adequate water intake o Scheduled pain medication should be given if the client is not reporting pain o Addiction is not an issue Eye & Vision
- Steps for Instilling Eye drops (3 ques) Wash hands Tilt head back Pull lower lid down Place dropper over eye Look up, apply drop, then look down Release eye lid, close eyes and press inside the corner of the eye for 3-5 minutes o Glaucoma In glaucoma, aqueous production and drainage are not in balance When aqueous outflow is blocked, pressure builds up in the eye Increased IOP causes irreversible mechanical or ischemic damage Risk Factors: (1 ques) Afro-Americans Cardiovascular disease Family history of glaucoma Migraine Thin cornea Manifestations AKA “silent thief” (1 ques) 1. significant vision loss 2. peripheral vision loss 3. Blurred vision 4. Halos of light 5. Difficulty focusing 6. Difficulty adjusting eyes to low lighting 7. Aching discomfort around the eyes 8. Headaches Meds Beta Blockers – decrease aqueous humor production (timolol) (1 ques) o Systemic side effects such as bradycardia, exacerbation of pulmonary disease and hypotension o Assess for other comorbidities such as asthma, bradycardia, heart failure, heart block and chronic obstructive pulmonary disease (BB are contraindicated for these patients)
5. Use of thyroid hormones and hydrochlorothiazide 6. Arthritis Wet vs Dry AMD “Wet” exudative or neovascular AMD o May have abrupt onset o Proliferation of abnormal blood vessels growing under the retina–choroidal revascularization Amsler Grid Test Used for patients with macular problems This test is performed at home several times a week for early detection and worsening symptoms o Teaching Points to Patients to Reduce Risk of Eye Disorders Never used anyone else optic medications No driving right after administration of eye drops Blurred vision OTC eye drops – taken no longer than 3 days; if sx are not improving seek medical provide for examination o
Exam 4 Review- Neuro, Oncology, Vision
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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