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NR341 Complex Adult Health Care
Study Guide Questions and Answers
What are symptoms of a stroke, brain attack, and CVA? -Correct Answer= *Headache *Confusion *Seizures *Incontinence *Vomiting *Disorientation *Diplopia *Ptosis *Hypertension *Apraxia *Decreased Neuromuscular control *Memory Impairment *Aphasia (L Hemisphere for CVA) *Decreased cough/Swallow Reflex *Agnosia (Decr. Sensory interpretation) *Hemiparesis/hemiplegia *Emotional Liability *Loss of corneal reflex *Homonymous *Hemianopsia *Spatial-Perceptual Defects What are symptoms of Transient Ischemic Attacks (TIA)? -Correct Answer= *Confusion *Vertigo *Dysarthria
*Transient Hemiparesis *Temporary Vision Changes *Typically lasts less than 1 hours What are Focal Neurological symptoms? -Correct Answer= *Paralysis *Sensory Loss *Language Disorder *Reflex Changes What are the 3 steps to stroke recognition? -Correct Answer= 1. Ask person to smile and stick out tongue
- Ask person to make a complete sentence
- Ask person to raise both arms What are symptoms of CVA? -Correct Answer= *Hypo/Hypertonia *Perceptual Defects *Apraxia *Loss of voluntary movement on one side *Decreased Neuromuscular Control *Communication Issues *Emotional Lability *Impaired judgement and memory
*Impaired comprehension What are diagnostics for CVA? -Correct Answer= *Neuro Exam *Lumbar Puncture *CT of the brain *MRI What are pupillary abnormalities associated with CVA? -Correct Answer= *Pupil on opposite side of lesion usually larger *Conjugate Deviation (looks toward lesion) *Homonymous Hemianopsia What are reversible risk factors for CVA? -Correct Answer= *Smoking *Obesity *Increased salt intake *Sedentary life *Increased stress *Oral Birth Control What are partially reversible risk factors of CVA? -Correct Answer= *Increased BP *Cardiac Valve Disease *Dysrhythmias *Diabetic Mellitus *Increased Cholesteral
What are the non-reversible risk factors for CVA? -Correct Answer= *Sex *Age *Race *Heredity What are the nursing goals related to CVA care? -Correct Answer= 1) Airway and oxygenation
- Decreased ICP
- Nutrition
- Preserve function
- Safety
- Rehabilitation
- Education What are causes of cerebral edema? -Correct Answer= *Cerebral Hemorrhage *Cellular Toxins *Ischemic Cells What are causes of dilated cerebral arteries? -Correct Answer= *Increased PCO *Acidotic State What are risk factors/Etiology of increased ICP? -Correct Answer= *Secondary to initial damage *Brain tumor *Closed head injury *Ruptured blood vessels *Embolism
*Maintain hydration *SZ precautions *Monitor I&O's *Avoid coughing, sneezing, and valsalva maneuver *Prevent Aspiration *Calm/Quite environment *Early mobility *Change positions Q2 hours What are complications of increased ICP? -Correct Answer= *Herniation *Inadequate Cerebral Perfusion *SIADH *Diabetes Insipidus *Infection What are treatments for increased ICP? -Correct Answer= *ICP Monitoring (Ventriculostomy, GCS) *Cerebral oxygenation Monitoring (LICOX) *Hypertonic Saline IVs *Medications
-Osmotic Diuretics -Corticosteriods -Anti-seizure Drugs What are diagnostics for increased ICP? -Correct Answer= *CT Scan *MRI *PET *EEG *Angiography *Brain tissue oxygenation Catheter- LICOX *Transcranial Doppler Studies *Evoked Potential Studies Management of increased ICP includes? -Correct Answer= *Identification of patients risks *Initiation of ICP monitoring if indicated *Airway maintenance and ventilation *Oxygenation and low normal PaCO *Fluid balance to maintain cerebral perfusion
(brain) *Oxygen *BP meds (Labetalol & Nicardipine) *IV fluids (NS/Hypertonic) *Diuretics (Mannitol, Furosemide) What is Cushing's triad? -Correct Answer= *HTN with widened pulse pressure *Bradycardia *Irregular breathing (Cheyene) What is Cerebral Perfusion Pressure -Correct Answer= *CPP = MAP - ICP *60-100mg HH *Determines Cerebral blood flow (CBF) *Less than 50 = ischemia & neuronal death *Raising MAP increases CPP *Raising ICP decreases CPP
What is Decorticate Posturing? -Correct Answer= Decorticate Posturing *Flexor Posturing *Damage to the cervical spinal tract/cerebral hemisphere *Suggests cerebral cortex involvement *To the core *Hands turned inward *Arms folded in *Feet and legs extended out What is Decerebrate Posturing? -Correct Answer= Decerebrate Posturing -Extensor Posturing -Damage to brain stem -Arms extended -Wrist rotated -Legs extended -Feet internally rotated What is Flaccid Posturing? -Correct Answer= *No motor response display in any extremity
What is the Glasgow Coma Scale scoring for motor response? -Correct Answer= *Obeys commands for movement = 6 points *Purposeful movement to pain = 5 points *Withdraws from pain = 4 points *Decorticate posture = 3 points *Decerbrate posture = 2 points *No motor response = 1 point Summarize total scoring for Glasgow Coma Scale -Correct Answer= *13-15 = Minor brain injury *9-12 = Moderate brain injury *3-8 = Severe brain injury What are warning signs after a head injury? -Correct Answer= *Changes in LOC (drowsiness, confusion) *Seizures *Bleeding or Water Drainage from nose or ears *Blurred vision
*Pupils slow to react or unequal *Loss of sensation to extremity *Projectile vomiting *Slurred speech. What is Autonomic Dysreflexia? -Correct Answer= *Disregulation of nervous system *Triggered by pain *Occurs after shock resolved *Spinal cord injury at T-6 or higher *Triggered by sustained stimuli at T-6 or below -Restrictive Clothing -Full bladder/UTI -Pressure area -Fecal Impaction What are signs and symptoms of Autonomic Dysreflexia? -Correct Answer= ~Above Injury (due to vasodilation)~ *Increased BP (Severe & Rapid) *Flushed face *Headache
*End-of-life/comfort care measures are being discussed ~Call within 1 Hour~ *GCS score below 5 and ventilated *Cardiac Death Indications your patient is a donor candidate? -Correct Answer= *Brain Dead *Circulatory Death *Living Donor What is brain death? -Correct Answer= *Absent cerebral & brain stem function associated with non- survivable head injury *Verified with -Apnea test -EEG -Cerebral angiography -Radionuclide cerebral perfusion scan What happens with circulatory death? -Correct Answer= Once criteria met, life support is withdrawn, and organs are harvested Management of donor patients include? -Correct Answer= *Maintain BP *Monitor glucose, temperature, ABGs, fluids, & electrolytes
*Treat anemia, coagulopathy, & thrombocytopenia *Provide appropriate mechanical ventilation (based on acid-base balance) Discuss catecholamine issues with organ donation -Correct Answer= Initial catecholamine release is followed by depletion resulting in vasodilation causing distributive shock. *Increase support when catecholamines decreased *Optimize Oxygenation What are neurohormonal regulations? -Correct Answer= *Thyroid hormones lead to cardiac issues *Pancreas hormones (insulin) lead to metabolic issue *Pituitary hormones lead to Diabetes Insipidus (increased UO) What are complications of organ transplant? -Correct Answer= *Rejection -Hyperacute = Immediate -Acute = Common, Can transfuse donor blood into recipient, symptoms mimic infection. *Infection -Anti-Rejection meds decrease immune Nurse
What are major complications of transplant medications? -Correct Answer= *Nephrotoxicity *Hypertension *Hyperlipidemia *Diabetes *Infection ~ Patient must be treated for any of these complications, they cannot stop transplant medications. What is considered a trauma? -Correct Answer= *Injury or wound caused by an external force or violence *Minor trauma: single system that does not pose a threat to life/limb *Major trauma: serious multiple system injuries that does pose threat to life/limb What is the mechanism of a blunt injury? -Correct Answer= *MVA *Motorcycle accident *Sports injury *Liver injury (most common) What is the mechanism of penetrating injury? -Correct Answer= *Knifes *Bullets *Debris *Liver most common organ injured What is the mechanism of blast injury? -Correct Answer= *Explosion (blast causes tissue/organ damage)
*Usually involves blunt/penetrating trauma What is Primary Survey? -Correct Answer= *ABCDEFG - Done in 1-2 minutes A-Airway with cervical spine immobilization (Collar) B-Breathing & Ventilation C-Circulation with hemorrhage control D-Disabiilty or neurological status E-Exposure F-Full set of vital signs & family presence G-Get resuscitation adjuncts (Tests/support) What is secondary survey? -Correct Answer= *HI = Initiated after all actual/potential life-threatening injuries have been identified & addressed & resuscitation efforts initiated H-History and head-to-toe assessment I-Inspect posterior surfaces *Assessment = Inspection, palpation, percussion, & auscultation to identify injuries
