-
A&Ox4 must have what
- LOC= alert
- Orentation= Person, Place, TIme, Situation
-
Data Collection-cranial check
I olfactory
smell common odors and identify
-
Data Collection-cranial check
II Optic
cover one eye and read eye chart
-
Data Collection-cranial check
III Oculomotor
follow/track pen with eyes. Both eyes should be going same direction.
-
Data Collection-cranial check
IV Trochlear
eye movement, follow pen with eyes
-
Data Collection-cranial check
V Trigeminal
bite down, sensation on face, corneal reflex
-
Data Collection-cranial check
VI Abducens
eye movement
-
Data Collection-cranial check
VII Facial
face moves in symmetry, tasting(salt and sugar)
-
Data Collection-cranial check
VIII Acoustic
hearing, balance
-
Data Collection-cranial check
IX Glossopharyngeal
taste
-
Data Collection-cranial check
X Vagus
gag reflex, swallow
-
Data Collection-cranial check
XI Spinal accessory
shrug shoulders, move head around
-
Data Collection-cranial check
XII Hypoglossal
tongue movement
-
when to do data collection
- -upon admission
- - " assessing each time enter a room
- - "condition change
- - " pt complaint
- - as needed= ongoing
- - uopn discharge
-
Data collection- History
- Sx now
- Hx of headaches
- clumsiness or change in motor skills
- change in vision
- seizures
- memory/personality changes
- pain/numbness
-
II Verbal response
5
4
3
2
1
- 5 alert and oriented
- 4 confused, yet coherent speech
- 3 inappropriate words and jumbled phrases
- 2 incomprehensive sounds
- 1 no sounds
-
III Eye opening
4
3
2
1
- 4 spontaneous eye opening
- 3 eyes open to speech
- 2 eyes open to pain
- 1 no eye opening
-
NSG Dx with neuro
- impaired nutrition
- risk for imbalanced body temp
- autonomic dysreflexiave
- constipation
- impaired elemination
- innefective tissue perfusion
- " airway clearance
-
NSG Dx
- impaired spontaneous ventilation
- sexual dysfunction
- impaired thought process
- unalateral neglect
- impaired mobility
- self care deficit
-
Goals and planning
- pt will:
- no bowel obstruction
- maintain/ improve mobility
- " foley catheter
- " effective airway
- " adequte weight
- will not choke
- dress with assistance
-
hip fractures-care
- pillow or wedge betreen legs to keep in abduction
- don't cross legs
- use raised toilet seat
- turn from uneffected side to back at first
- pain control
-
data collection- orientation
person
place
time
memory
calcualtion/situation
- -who they are
- -where they are
- -year, month, president, next holiday
- -
-
neuro assessment
- -pupil size and responce
- -alert and oriented
- -motor responses
- -memory/calculation
- -check cranial nerve responses
- -sensations
- -blance, gait
-
Lack of O2 to certain parts of the brain, large vessel in brain pops. Hard to
treat.SX numbness, headache, speech problem,
drooping face, pain.if use a clot buster = Pt death
Hemorrhagic
-
Blockage of 1 or both carotid arteries/ vessels within brain itself are blocked.3hrs. of
initial SX= No adverse reactions.Use clot buster medication.SX
numbness, headache, speech problem, drooping face, pain.
Occlusive Stroke
-
What are some warning signs following splint or cast application?
- -Elevate injured arm or leg for 24- 72 hours
- -Increased pain and swelling = cast is too tight
- -Numbness and tingling = too much pressure in the nerves
- -Burning and stinging = too much pressure on the skin
- -Excessive swelling under cast = cast is slowing blood circulation
- -Loss of active movement of toes or fingers = urgent eval. by doc.
-
Tends to happen with spinal (above C3) injury. Gives noxious stimuli, tries to
send stimuli to brain but is blocked by innjury, it comes back on
itself and body gets extreme: bradycardia, hypertension, diaphoresis,
flushed.Find the stimuliCan be fatalGive
Antihypertensives
Autonomic Dysreflexia
-
Types of musculoskeletal abnormalities (fractures)
Traction
Casts
Surgery
Complications
- -Pt complains of increased pain - make sure they are straight.
- -Signs of infection = pus, purolent drainage, redness, swelling.
- -Do not file. Petal with tape, pad it.
- -Treat fractures and all S/S of surgery
- -Compartment syndrome fat embolism
-
-Trauma
-Psychological illness
-Increased ICP
-Medication
-Seizures
-Dimentia
-Electrolyte
imbalances
-Overdose
-Alcohol
-Infection
-Mental illness
Causes of alteration in LOC, orientation
-
Levels of Consciousness (LOC)
-Alert
-Lethogic/ disoriented
-Obtunded/ stupor
-Semicomatose
-Comatose
- -Someone is awake and aware of you.
- -Weak, tired/ having trouble
following simple commands, inattentive.- -Resond to verbal commands
but not with words.- -Responds only to painfull stimuli.
- -No
response to anything, even pain.
-
Which of the following is not one of the 5 p's assessed with a dislocation injury? Pallor, pain, paresthesia, pinprick.
Pinprick
-
A child has a disease that weakens her bones. She sustains a fracture. This is called what kind of fracture?
Pathologic
-
After a fracture, the most important pharmacologic intervention focuses on what?
Pain relief
-
Most common type of skin traction is called what?
Bucks
-
A pt with a femur fx develops a petechial rash on the chest and neuro dysfunction, what complication is suspected?
Fat embolism
-
During pt teaching, the nurse tells the client that the best treatment for a DVT is what?
Prevention then heparin drip (if they have one already)
-
A common complication of rib fractures is a flail chest. The treatment for this is aimed at what?
Stabilizing the segment.
-
The priority goal of hip surgery is to do what?
- 1. reduce the fracture
- 2. increase mobility
-
Something pressing against tissue, cutting off blood supply, damaging tissue and nerves from pressure.
Compartment syndrome
-
WHat is the function of a cervical collar after an MVA? When can it be safely removed?
- -To stabilize the neck to prevent injury to CNS and spine.
- -Docs orders
-
A client with a C2 spinal injuryand a foley suddenly has a B/P of 230/125. What are your priority interventions?
- -Sit them up, call for help, try to find cause, anti-hypertensive.
- -called autonomicdisreflexia
-
How could a nurse determine if there is an infected sore under a cast when are cannot be seen?
Feel for a hot spot on the cast
-
What tests or procedures help us to identify musculoskeletal disorders?
CT, MRI, X-Ray
-
The rationale for immobilization of a sprain is that motion increases.
Overstretching of muscles
-
-Breaking long bones
-Fat in bone marrow congeals in lung, heart, brain.
-Almost always fatal.
- Fat embolism
- -Petechial flushing on head and chest, change in LOC, SOB
-
What positions to avoid when positioning a client with ICP? Why?
- Flat or trendelenburg
- Gravity to take fluid out
- Neutral midline
-
Uses pins inserted through skin into bone, attached to a metal frame.
Traction
-
The 5 p's used to assess musculoskeletal trauma.
- -Pain
- -Pallor
- -Parastesia
- -Pulses
- -Puffiness
-
Are of muscles, ligaments or tendons.
-wrenching or hyperextending a joint ___ the ligaments.
- -Sprains and strains
- -Tears
-
Sx of sprain/ strain
- -Pain (worse when mmoving)
- -Swelling
- -Edema
- -Redness
- -Heat
-
R
I
C
E
- Rest
- Ice
- Compression
- Elevate
-
Musculoskeletal assessment
ROM, strength, physical capacity, may need mobility aids
-
Kind of test to find out what kind of stroke...
Can start out as ___ and turn into ___. Can be both
- CT Scan
- Occlusive
- Hemorrhagic
-
Neuro problem
-A smell, feeling, hallucination, taste that lets the pt know when they will have this.
-
Destroys mylin sheath
Makes nerve pathway slower
Multiple sclerosis
-
Why
Neuro
NSG Dx
Impaired nutrition
My not be able to swallow, percieve it as something else
-
Why
Risk for imbalanced body temp
Could affect hypothalamus
-
Why impaired elimination
Can stop peristalsis
-
Why
Inactive tissue perfusion
Loss of blood and O2 to brain
-
Why ineffective airway clearance
No gag reflex or cough reflex
-
Causes dimentia and change in LOC
Alzheimers
-
-
Toes curl in normal/ negative result
Babinski
-
CNS =
Brain and spinal chord
-
Peripheral nervous system
All nerves outside the CNS
-
Autonomic nervous system
Controls all smooth muscle, cardiac muscle, and all glands
-
Glascow coma scale
- -Used if pt in extended care falls
- -Motor, verbal and eye response
- -The higher the # the better neuro stasis is.
-
ROM, restate, redirect, reorient, sit upright, reposition, I&O
Interventions
-
Musculoskeletal
___ bones
muscle, ligament, tendons help ___ body.
___ where bones connect and move
-
___ and ___ frequently cause musculoskeletal injuries.
___, ___, ___ can cause abnormalities.
___ injury to a bone continuity of bone is broken.
Acute care unless
- -Accidents and trauma
- -Inherited, age-related, illness
- -Fracture
- -Age, illness, or born with it
-
Stabilization - put in place and keep it there
Surgery
-
Holds where we want
Removable
Used for fractures and Scoliosis
Splints
-
Fractures
Immobilize
Move bone where we want it over time
Use plaster of paris
Casts
-
Bucks - hip fractures
Skin traction
-
Skeletal traction
Neck and head injuries
Halo traction
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