Final Breakdown.docx

Final Breakdown 12 math 45 Cristy 35 Leesa Neuro 20 Neuro assessment—need to do neuro assessment Need to do—head injury, stroke like symptoms, decreased LOC. Neuro exam can establish LOC, level of functioning, cranial nerve testing, rectal tone Expressive aphasia A deficit in language output or speech production. Inability to express oneself CVA—assessment, first priority Initial assessment focuses on airway patency, which may be compromised by loss of gag or cough reflexes and altered respiratory pattern Cardiovascular status—BP, cardiac rhythm, and rate Neurologic assessment—LOC, monitor symptoms, speech, eye symptoms Monitor for potential complications—musculoskeletal problems, swallowing difficulty, respiratory problems, s/s of increased ICP, meningeal irritation

Guillain Barr—ABG, causes that exacerbate Viral infection, cytomegalovirus, Epstein-Barr, mycoplasma pneumoniae, H influenzae, HIV are the associated infections associated with the development of GBS Respiratory acidosis Halo vest Halo ring that is fixed to the skull by 4 pins that are inserted into the outer table of the skull. The ring is attached to a removable halo vest, which is a device that suspends the weight of the unit circumferentially around the chest. A frame connects the ring to the chest. Provides immobilization of the cervical spine while allowing early ambulation for patients with adequate function IICP—mannitol, assessment of IICP Normal pressure = 0-15 Mannitol: given for IICP, osmotic diuretic—pulls fluid from the brain Assessment: decreased LOC, restlessness, nausea, vomiting, headache, pupillary changes, late sign—Cushing’s triad: increased pulse pressure, decreased heart rate, change in respiratory pattern Parkinson’s S/S : Tremor, rigidity, bradykinesia, postural instability, depression, dementia, autonomic symptoms, sleep disturbances

Pathophys: decreased dopamine levels, unknown cause, movements start to slow and the disease progresses Assessment: fall risk, gross motor skills—assess while they are doing something. Resting is the best time to assess for tremors—purposeful activities = tremor can stop Planning: maintain independence, improving mobility. Need a rigorous routine program with activity and rest periods Interventions: encourage socialization, recreation, and independence, use of assistive devices—plate guard/silverware TIA with a fib, discharge medication Anticoagulants—Apixaban (Eliquis), Warfarin Autonomic dysreflexia Massive sympathetic response to a noxious stimulus (full bladder, fecal impaction) S/S: extreme hypertension, bradycardia, facial flushing, headache Tx: Sit patient up; frequent vital signs q5 minutes; loosen clothing and restrictive devices; foley; fecal impaction—digital rectal exam, remove stool, laxative may be needed; antihypertensives; call for help if needed C7-C8 injury Tetraplegia—quadriplegic Lower cervical injury Monitor respiratory status, bowel/bladder control, sexual dysfunction

Hypothalamus—what it does Major respiratory center, appetite, sex drive, temperature, heart rate, blood pressure, sleep, anterior and posterior pituitary gland regulation, coordination of autonomic nervous system, stress response, emotional status Homeostasis Hormones: serotonin, norepinephrine, endorphin Spinal cord injury—why we perform rectal exam To determine rectal tone—bowel control/function Frontal lobe lesion May produce hemiparesis and partial seizures on the opposite side of the body, or generalized seizures. Changes in emotional state and behavior—impulsive, inappropriate in speech, gestures, and behavior. Functions of frontal lobe: voluntary motor function; cognitive function—orientation, memory, insight, judgement, arithmetic, abstraction; expressive language—written and verbal Next gen—head injury—anticipated vs contraindicated C collar, neuro assessment, serial neuro assessments, hemodynamic monitoring, CT scan, surgery may be needed, management of ICP and adequate CPP, ensure adequate oxygenation, ICP monitoring, IV fluid therapy, management of body temperature, control environment, suctioning may be needed.

Cardiac 11 AAA—surgical ileus—how to prevent Start nutrition early Peptic ulcer prophylaxis Ambulate early Anterior wall MI—nursing diagnosis Goal is to restore oxygen to tissues— impaired tissue perfusion Decreased cardiac output Acute pain Chest pain—priority action 12 lead EKG, telemetry, vitals, labs—troponin elevation, patient history Aspirin, Nitro CHF—labs to report BNP over 100—key diagnostic finding in HF, CBC DCM—CVP Increased CVP related to jugular vein distention Right sided heart failure—late sign Echo—ejection fraction less than 40%

Mitral regurgitation—s/s Dyspnea, weakness, fatigue, palpitations, SOB on exertion, cough Murmur during systole—high pitched/blowing Low cardiac output, pulmonary edema Manifests as severe congestive heart failure Telemetry reading—PR interval Normal: 0.12-0.20 Represents time between atrial depolarization and ventricular depolarization Cardiac diet Low cholesterol, low fat, low sodium Small, frequent snacks versus large meals Fish, lean meats, eggs, fruits, vegetables, whole grains, legumes, nuts PTCA—discharge instructions Increase fluid intake to flush dye Stop smoking Diet restrictions, weight loss Maintain bed rest for 24 hours, no hip flexion, no sitting up in bed Keep extremity extended for 4-6 hours post op

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