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TL - Neurologic
Nursing of the Client with Neurologic Disorder
| Question | Answer |
|---|---|
| What are the variables in the Glasgow Coma Scale? | Eye opening, Verbal Response, Motor response |
| What would a score of 15 on the GCS indicate? | Maximum score - unimpaired |
| What would a score of 7 or less on the GCS? | Indicates coma |
| What would a score of 8 indicate? | good prognosis for recovery |
| What would a GCS score of 3 or 4 indicate? | poor prognosis for recovery |
| What are the possible responses and their scores for eye opening on the GCS? | Spontaneous-4, To verbal command – 3, To pain – 2, No response – 1 |
| What are the possible responses and scoring for verbal response on the GCS? | Oriented and converses – 5, Disoriented and converses – 4, Inappropiate words – 3, Incomprehensible sounds – 2, No response – 1 |
| What are the possible responses and scores for motor response on the GCS? | To verbal command – 6, Pain response: Localizes pain – 5, flexes/withdraws – 4, Flexor Decorticate – 3, Extensor Decerebrate - 2, No response – 1 |
| Name all the components that should be included in the neurologic assessment of a client in an altered state of consciousness. | GCS, Pupils, Limb movement, BP, Temp, Pulse, Respirations, Skin integrity, Corneal integrity, Bladder for fullness, Lung sounds, Cardiac Status |
| What assessments are pertinent to the family members of a neurologic client? | knowledge of client status, coping, need for support, ability to assist and provide care at discharge |
| Explain why almost any NANDA diagnosis could be applicable to the severely neurologically impaired client? | Because severely neurologically impaired persons require total care |
| List 13 applicable nursing diagnoses for the severely neurologically impaired client. | Ineffective: breathing pattern, airway clearance; Impaired: gas exchange, mobility, elimination; Decreased cardiac output, Anxiety, Imbalanced Nutrition, Self-Care deficit; Risk for: imbalanced body temp, injury, impaired skin integrity, constipation |
| What is the rationale for feeding severely neurologically impaired clients enterally (via feeding tube) vs. by mouth? | high risk for aspiration pneumonia |
| What would 100mL of residual from previous feeding indicate? | poor gastric emptying – hold feeding |
| Explain the rationale for a gastric tube in comatose clients. | Paralytic ileus is a common complication for the comatose client. A gastric tube aids in gastric decompression |
| What care is required in reqards to position and mobility when the client is immobilized? | ROM exercise and frequent position changes @ least q 2hrs; Avoid positions that decrease venous return or dependent extremities |
| What can be done to help the severely neurologically impaired client with oxygenation? | monitor respirations, Po2 & Pco2, doc & report changes; position ¾ or semiprone for maximum ventilation, provide frequent suctioning – hyperventilate with 100% o2 before & after, Chest physiotherapy per rx, prepare for emergency airway |
| What nursing responsibilities address the neurologically impaired client’s need for fluid/electrolyte balance and nutrition? | NPO till responsive, mouth care q 4hrs, count calories, feeding per rx, I&O, daily weight |
| What nursing interventions address risk for impaired skin integrity? | assess skin integrity, turn q 2hrs, assess boney prominences, special mattresses, minimal linens/underpads |
| What nursing interventions address the clients increased risk for thrombus formation? | Passive ROM to lower extremities Q4 hrs, SCDs remove and reapply q 8 hrs, position to encourage venous return, keep extremities nondependent, no pillows or gatch under knees |
| What nursing interventions decrease the risks for developing urinary calculi? | ensure adequate hydration, balance I&O, assess urine for high specific gravity |
| What nursing interventions prevent contracture? | passive ROM q 4 hrs, sit client up in bed or chair if possible, reposition q 2hrs, proper body alignment, use assistive devices to prevent foot/wrist drop |
| Why are pulse changes important to monitor in the neurologically impaired client? | pulses <60 or >100 can indicate ICP. >100 can indicate infection, thrombus formation, or dehydration |
| What BP changes would indicate increased ICP? | rising BP and widening pulse pressure |
| What is widening pulse pressure? | the difference between the systolic and diastolic BP. The normal value is around 40mmHg |
| What is the Cushing’s triad? | widening pulse pressure, bradycardia, irregular breathing pattern – notify physician immediately – indicates increasing ICP |
| Why is it important to monitor temperature for the neurologically impaired client? | elevation can indicate worsening condition, infection, or damage to the temperature controlling area of the brain |
| Why is it important to quickly take measures to decrease elevating temperature in the neurologically impaired client? | fever increases cerebral metabolism and can increase cerebral edema |
| What is the most important indicator of increased ICP? | change in level of consciousness |
| What should the nurse suspect as a possible cause of irritability, restlessness, or confusion in a client with a closed head injury? | increased ICP |
| Give all the signs and symptoms associated with increased intracranial pressure. | changes in LOC, slowed or irregular respirations, increased/decreased pulse, rising BP, widening pulse pressure, temperature elevation, HA, projectile vomit, changed pupil size, unequal pupils, non-conjugate movement, papilledema |
| What signs indicate CSF leakage? | Runny nose or liquid from ear |
| What are the dangers with CSF leakage? | indicate deteriorating condition, could lead to meningitis, usuals signs of increased ICP may be masked |
| What can CT scans and MRIs tell us about head injuries? | They can detect lesions such as epidural or subdural hematoma that may require surgery |
| What can be detected by an Electroencephalograph? | seizure activity |
| We know that increased temperature causes increased blood flow to the brain resulting in cerebral edema. What measures should be taken to reduce temperature and thus reduce risks? | ASA, acetaminophen, cooling blanket |
| Disucss intracranial pressure monitoring. | a catheter is inserted into the lateral ventricle, a sensor on the dura, or a screw into the subarachnoid space attached to a pressure transducer. Pressure is monitored. Elevations above 20mmHg are reported STAT |
| What kinds of medications may be prescribed to decrease ICP? | Diuretics/hyperosmotics like urea and mannitol, steroids like Dexamethasone (Decadron), Solu-medrol, or barbiturates to reduce brain metabolism and systemic BP |
| How does passive hyperventilation on the ventilator assist with lowering ICP? | leads to respiratory acidosis which constricts cerebral blood vessels thus reducing blood flow and pressure in the brain |
| What is the therapeutic use of phenytoin (Dilantin) in head injury? | Sometimes orders for seizure prophylaxis |
| We should educate the head injury client of possible aftereffects of head injury at discharge. What should be included in this education? | Possible to develop post traumatic stress syndrome, posttraumatic epilepsy or posttraumatic neuroses or psychoses |
| Describe the action of mannitol (Osmitrol). | acts on renal tubules to prevent water reabsorption and pulls fluid from the extra cellular spaces into the plasma in the blood stream |
| What are the adverse reactions of mannitol? | disorientation, confusion, headache, N&V, convulsions and anaphylactic reactions |
| How long would you expect your client to receive mannitol? | used for short term therapy only |
| How is mannitol usually administered and dosed? | Usually given by IV and adjusted to urine output |
| What does the nurse monitor for in urine while the patient is receiving mannitol? | crystals |
| When is mannitol contraindicated? | cerebral hemorrhage, anuria or <30mL/hour |
| What can happen if a patient’s output is impaired and they receive mannitol? | it can accumulate and cause pulmonary edema and water intoxication |
| List the most common sites for spinal cord injuries to occur? | C-5, C-6, and C-7; T-12 and L-1 |
| Why can’t we tell what kind of permanent damage has been sustained until about a week after an injury to the spinal cord? | It takes that long for spinal cord edema to subside |
| Which assessment is especially pertinent to client’s with injury at C-3 to C-5? Why? | respiratory status because the cervical plexus innervates the diaphragm |
| Discuss assessments pertinent to the client with a spinal cord injury. | breathing pattern, lung sounds, neurologic vitals esp sensory and motor function, cardiovascular status, abdominal girth, bowels sounds, bladder distention, temperature esp for hyperthermia, psychosocial status, BP |
| What symptoms are common with an injury above T-6? Why? | hypotension and bradycardia because sympathetic outflow is affected |
| What are some potential nursing diagnoses for the client with a spinal cord injury? | ineffective breathing pattern, tissue perfusion, coping; Impaired skin integrity, Self-care deficit, Urinary retention |
| Differentiate between the symptoms related to language when the damage is in the right vs. the left hemisphere. | Left – aphasia and agraphia; Right – may be alert and oriented |
| Define Aphasia | loss of ability to speak |
| Define agraphia | loss of the ability to write |
| How would memory be affected differently by damage to the left hemisphere vs the right? | no deficit in memory – left hemisphere; disorientation and inability to recognize faces – right hemisphere |
| What visual symptoms would be indicative of damage to the left hemisphere? | unable to discern words/letters; reading problems; deficits in the right visual field |
| What visual symptoms would be indicative of damage to the right hemisphere? | visual/spatial deficits, neglect of the left visual field, loss of depth perception |
| What behavioral changes are linked to damage in the left hemisphere? | behavior may become slow, cautious; anxiety with new task, depression, sense of quilt, feelings of worthlessness, worry over future, quick anger and frustration |
| What behavioral changes are linked to damage in the right hemisphere? | Impulsiveness, not aware of neurologic deficits, confabulation, euphoric, constant smile, denies illness, poor judgement, overestimates abilities, impaired sense of humor |
| Differentiate between left and right hemispheric damage as it affects hearing. | left- no deficit, right – lost ability to hear tonal variances |
| Define apraxia | inability to perform purposeful movements |
| Define dysarthia | difficulty with pronunciation |
| Define dysphasia | difficulty with speech and verbal comprehension |
| Define alexia | loss of ability to read |
| Define dysphagia | dysfunctional swallowing |
| What diagnostic tests could be used to confirm the diagnosis of stroke? | CT scan, MRI, Doppler flow studies, Ultrasound imaging |
| What symptoms would you expect to see in the patient who has suffered from stroke? | motor loss such as hemiplegia/hemiplasia, communication loss, perceptual disturbance, impaired mental acuity or psychological changes, bladder dysfunction (incontinence or retention) |
| When does rehab need to start for the stroke patient? | as soon as the client is able |
| What assessments are pertinent to the client with stroke? | LOC, language impairments, parethesias, paralysis, memory impairment, vision impairment, bladder/bowel function, behavioral changes, functional abilities (mobility, ADLs, elimination, communication, ability to eat w/o risk of aspiration) |
| What nursing diagnoses are applicable to the client with stroke? | impaired physical mobility, verbal communication, urinary elimination; ineffective coping, family coping; Self-Care deficit, Disturbed body image |
| Why is control of HTN an important intervention for the client with stroke? | To prevent future stroke |
| Discuss positioning and mobility as it relates to the client with stroke. | maintain proper alignment and functional position with splints or pillows, prevent contracture and edema, maintain skin integrity and mobility with ROM |
| Discuss nursing interventions related to Self-care and the client with stroke. | Encourage client participation, set realistic goals with new tasks daily, encourage client to assist with dressing and wear street clothes during waking hours. |
| Discuss nursing interventions regarding bladder elimination and the patient with stroke. | offer bedpan or urinal as appropriate, reassure client bladder control tends to be regained quickly |
| What is the therapeutic value of steroids after stroke? | to decrease cerebral edema and retard permanent disability |
| What is the therapeutic value of H2 inhibitors after a stroke? | prevention of peptic ulcers |
Created by:
Perseverandovercome
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