1. A&Ox4 must have what
    • LOC= alert
    • Orentation= Person, Place, TIme, Situation
  2. Data Collection-cranial check
    I olfactory
    smell common odors and identify
  3. Data Collection-cranial check
    II Optic
    cover one eye and read eye chart
  4. Data Collection-cranial check
    III Oculomotor
    follow/track pen with eyes. Both eyes should be going same direction.
  5. Data Collection-cranial check
    IV Trochlear
    eye movement, follow pen with eyes
  6. Data Collection-cranial check
    V Trigeminal
    bite down, sensation on face, corneal reflex
  7. Data Collection-cranial check
    VI Abducens
    eye movement
  8. Data Collection-cranial check
    VII Facial
    face moves in symmetry, tasting(salt and sugar)
  9. Data Collection-cranial check
    VIII Acoustic
    hearing, balance
  10. Data Collection-cranial check
    IX Glossopharyngeal
  11. Data Collection-cranial check
    X Vagus
    gag reflex, swallow
  12. Data Collection-cranial check
    XI Spinal accessory
    shrug shoulders, move head around
  13. Data Collection-cranial check
    XII Hypoglossal
    tongue movement
  14. when to do data collection
    • -upon admission
    • - " assessing each time enter a room
    • - "condition change
    • - " pt complaint
    • - as needed= ongoing
    • - uopn discharge
  15. Data collection- History
    • Sx now
    • Hx of headaches
    • clumsiness or change in motor skills
    • change in vision
    • seizures
    • memory/personality changes
    • pain/numbness
  16. II Verbal response
    • 5 alert and oriented
    • 4 confused, yet coherent speech
    • 3 inappropriate words and jumbled phrases
    • 2 incomprehensive sounds
    • 1 no sounds
  17. III Eye opening
    • 4 spontaneous eye opening
    • 3 eyes open to speech
    • 2 eyes open to pain
    • 1 no eye opening
  18. NSG Dx with neuro
    • impaired nutrition
    • risk for imbalanced body temp
    • autonomic dysreflexiave
    • constipation
    • impaired elemination
    • innefective tissue perfusion
    • " airway clearance
  19. NSG Dx
    • impaired spontaneous ventilation
    • sexual dysfunction
    • impaired thought process
    • unalateral neglect
    • impaired mobility
    • self care deficit
  20. Goals and planning
    • pt will:
    • no bowel obstruction
    • maintain/ improve mobility
    • " foley catheter
    • " effective airway
    • " adequte weight
    • will not choke
    • dress with assistance
  21. 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
  22. data collection- orientation
    • -who they are
    • -where they are
    • -year, month, president, next holiday
    • -
  23. neuro assessment
    • -pupil size and responce
    • -alert and oriented
    • -motor responses
    • -memory/calculation
    • -check cranial nerve responses
    • -sensations
    • -blance, gait
  24. 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
  25. 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
  26. 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.
  27. 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
    Autonomic Dysreflexia
  28. Types of musculoskeletal abnormalities (fractures)
    • -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
  29. -Trauma
    -Psychological illness
    -Increased ICP
    -Mental illness
    Causes of alteration in LOC, orientation
  30. Levels of Consciousness (LOC)
    -Lethogic/ disoriented
    -Obtunded/ stupor
    • -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.
  31. Which of the following is not one of the 5 p's assessed with a dislocation injury? Pallor, pain, paresthesia, pinprick.
  32. A child has a disease that weakens her bones. She sustains a fracture. This is called what kind of fracture?
  33. After a fracture, the most important pharmacologic intervention focuses on what?
    Pain relief
  34. Most common type of skin traction is called what?
  35. A pt with a femur fx develops a petechial rash on the chest and neuro dysfunction, what complication is suspected?
    Fat embolism
  36. 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)
  37. A common complication of rib fractures is a flail chest. The treatment for this is aimed at what?
    Stabilizing the segment.
  38. The priority goal of hip surgery is to do what?
    • 1. reduce the fracture
    • 2. increase mobility
  39. Something pressing against tissue, cutting off blood supply, damaging tissue and nerves from pressure.
    Compartment syndrome
  40. 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
  41. 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
  42. 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
  43. What tests or procedures help us to identify musculoskeletal disorders?
    CT, MRI, X-Ray
  44. The rationale for immobilization of a sprain is that motion increases.
    Overstretching of muscles
  45. -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
  46. What positions to avoid when positioning a client with ICP? Why?
    • Flat or trendelenburg
    • Gravity to take fluid out
    • Neutral midline
  47. Uses pins inserted through skin into bone, attached to a metal frame.
  48. The 5 p's used to assess musculoskeletal trauma.
    • -Pain
    • -Pallor
    • -Parastesia
    • -Pulses
    • -Puffiness
  49. Are of muscles, ligaments or tendons.
    -wrenching or hyperextending a joint ___ the ligaments.
    • -Sprains and strains
    • -Tears
  50. Sx of sprain/ strain
    • -Pain (worse when mmoving)
    • -Swelling
    • -Edema
    • -Redness
    • -Heat
  51. R
    • Rest
    • Ice
    • Compression
    • Elevate
  52. Musculoskeletal assessment
    ROM, strength, physical capacity, may need mobility aids
  53. Kind of test to find out what kind of stroke...
    Can start out as ___ and turn into ___. Can be both
    • CT Scan
    • Occlusive
    • Hemorrhagic
  54. Neuro problem
    -A smell, feeling, hallucination, taste that lets the pt know when they will have this.
    • Seizures
    • Aura
  55. Destroys mylin sheath
    Makes nerve pathway slower
    Multiple sclerosis
  56. Why
    NSG Dx
    Impaired nutrition
    My not be able to swallow, percieve it as something else
  57. Why
    Risk for imbalanced body temp
    Could affect hypothalamus
  58. Why impaired elimination
    Can stop peristalsis
  59. Why
    Inactive tissue perfusion
    Loss of blood and O2 to brain
  60. Why ineffective airway clearance
    No gag reflex or cough reflex
  61. Causes dimentia and change in LOC
  62. 2 types of strokes
    • Occlusive
    • Hemorrhagic
  63. Toes curl in normal/ negative result
  64. CNS =
    Brain and spinal chord
  65. Peripheral nervous system
    All nerves outside the CNS
  66. Autonomic nervous system
    Controls all smooth muscle, cardiac muscle, and all glands
  67. Glascow coma scale
    • -Used if pt in extended care falls
    • -Motor, verbal and eye response
    • -The higher the # the better neuro stasis is.
  68. ROM, restate, redirect, reorient, sit upright, reposition, I&O
  69. Musculoskeletal
    ___ bones
    muscle, ligament, tendons help ___ body.
    ___ where bones connect and move
    • ZOG
    • Support
    • Joints
  70. ___ 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
  71. Stabilization - put in place and keep it there
  72. Holds where we want
    Used for fractures and Scoliosis
  73. Fractures
    Move bone where we want it over time
    Use plaster of paris
  74. Bucks - hip fractures
    Skin traction
  75. Skeletal traction
    Neck and head injuries
    Halo traction
Card Set
lecture notes