Trauma to the skull resulting in mild to extensive damage to the brain. Complications can include cerebral bleeding, hematomas, uncontrolled increased ICP, infections & seizures.
- Assess orientation q 1 hr (early signs of Increased ICP is alterations in orientation).
- Check VS (rise in BP with widening pulse pressure and slow HR can indicate increase ICP)
- Check PERLA (pupil changes)
- Check nose and ears of CSF Leakage. Complete Neuro Assessment.
- Assess for HA, N/V (could be a sign)
- -->Increased ICP can impede circulation to the brain, impede absorption of CSF, affect function of nerve
- cells, and lead to brainstem compression & death.
Seizure Precautions, prophylactic anticonvulsants may be administered.
Narcotic analgesic contraindicated b/c it masks signs of ICP
Instruct client to avoid coughing b/c may increase ICP
Maintain HOB elevated to reduce venous pressure
Monitor for signs of infection.
- Craniotomy incision through cranium to removed accumulated blood or a tumor. Complications include Diabetes Insipidus and SIADH (measure urine specific gravity)
- Hyposecretion of ADH: can be caused by CVA, Trauma or may be Idiopathic. Kidney tubules do not reabsorb H2O
- Muscle Pain
- Low Urine Specific Gravity, Increased Urine Output
- DDAVP (Lifelong SQ injections)
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Excess AHD is released, but not in response to bodily need for it. Caused by trauma, CVA, Malignancies (often in lungs or pancreas), medications and stress.
- Changes in LOC & mental status changes
- Weight Gain
- Anorexia, N/V
- Restrict Fluid Intake
- Administer diuretics and IV fluids
- Administer demeclocycline (Declomycin) - inhibits ADH- induced water reabsorption and produces water diuresis.
- Monitor I & O, daily weights
Catecholamine producing tumor usually found in adrenal medulla, may also be found in chest, bladder, abdomen, and brain. Excessive amounts of norepinephrine and epinephrine released. Typically benign, but can be malignant.
Avoid palpating abdomen
- Paroxysmal or sustained HTN
- Severe HA
- Profuse diaphoresis
- Pain in chest or abdomen with N/V
- Weight loss
- Heat intolerance
--> can cause sudden release of catacholamines and cause HTNsive CRISIS.
Surgical Excision is typical treatment. Adrenalectomy (lifelong glucocorticoid tx required with bilateral adrenalectomy)
- Administer phenoxybenzamine (Dibenzyline) as prescibed to control BP
- Promote rest and a nonstressful environment
- Instruct the client not to smoke, drink caffeine containing beverages or change positions suddenly.
Superior Vena Cava Syndrome
Occurs when the vein is compressed or obstructed by tumor growth. Results from blockage of blood flow in the venous system of the head, neck and upper trunk.
- Edema of face
- Tightness of the shirt collar (Stoke's sign)
- Neck Distention
Prepare client for radiation therapy.
Elevate HOB 30-45 degrees, reduce stress of suture line.
Position client on R side-lying, in low to semi-fowler's to promote comfort.
Apply icepacks to abdomen for 20-30 min q 1 hr as prescribed.
Avoid application of heat to abdomen.
Avoid laxatives or enemas.
Advance diet slowly as BS return.
Expect drainage form Penrose drain to be profuse for the first 12 hrs.
Maintain NG suction
Administer analgesics and antibiotics as prescribed.
Collapse of lung d/t air in pleural space caused by surgery, disease or trauma.
Open- caused by penetrating chest wound causing the intrapleural space to be open to atmospheric pressure resulting in lung collapse.
- Spontaneous (without known cause)
- Tension (pressure builds up)
- Hemothroax (blood in pleural space)
- Flail Chest (affected side goes down with inspiration & up during expiration)
- Apply sterile drsg loosely to allow air to escape but not reenter.
- Chest Tube
Caused by infection, fractures, otitis media, mastoiditis
- Nuchal Rigidity
- Change in LOC
- Kernig's Sign (when hip flexed 90 degrees, complete extention of the knee is restricted & painful)
- Brudzinski's Sign (attempts to flex the neck will produce flexion at knee and thigh)
- Opisthotonic position (extensor rigidity with legs hyper exteded and forming an arc with the trunk)
- IV antibiotic therapy (PCN, Cephalosporin, Vanco)
- Droplet PrecautionsHib Vaccine for infants
- Monitor ABG, arterial pressures, body weight, serum electrolytes, urine volume, specific gravity, osmolality
Deficiency of acetylcholamine at myoneural junction. Caused unknown. Chronic and progressive, with intellect intact.
- Muscular weakness produced by repeated movements soon disappears following rest.
- Diplopia (double vision)
- Ptosis (drooping of eyelid)
- Impaired Speech
- Respiratory Distress
- Periods of remissions/exacerbations
- Administer medications before eating!! Anticholinesterases, Corticosteroids, Immunosuppressants.
- Good eye care (artificial tears or eye patch for diplopia)
- Provide environment that is restful and free of stress
- Teach client to avoid infections, emotional upsets, use of streptomycin or neomycin and surgery
Be alert for myasthenia crisis
- sudden inability to swallow, speak or maintain patent airway.
Multiple Sclerosis (MS)
Demyelination of white matter throughout brain and spinal cord. Cause unknown. Chronic and progressive. Intellect intact, leads to paraplegia or complete paralysis.
- Early: visin, motor sensation changes
- Late: cognitive and bowel changes.
- Muscular incoordination
- Intention Tremors
- Chewing & Swallowing Difficulties
- Impaired Speech
- Emotional Instability
- Sexual Dysfunction
- Teach relaxation and coordination exercises, ROM
- Adminsiter immunosuppressants, corticosteroids, antispasmodics
- Wide base walk, use of cane/walker
- Use weight bracelets and cuffs to stabalize upper extremities
- Avoid over exposure to heat/cold
- Bladder & Bowel Training (catheter may be necessary)
- Self-help devices
- No tetracycline or neomycin
- OT, PT and emotional support
- Refer to National MS Society
separation of retina from choroid caused by trauma, aging, Diabetes, Tumors
- Flashes of light
- Blurred or "sooty" vision with "floaters"
- sensation or particles moving in line of vision
- Delineated areas of vision blank
- A feeling of curtain going up and down
- Loss of vision, client may c/o portion of visual field is dark
- Confusion, apprehension
- BR, do not allow client to bend forward, avoid excessive movements
- Affected eye or both eyes may be patched to decrease movement of eye
- Avoid bumping head, moving eyes rapidly, or rapidly jerking head.
Surgery to reattach retina to choroid. No hair washing for 1 week. Avoid strenuous activity for 3 months. Administer sedatives and tranquilizers and antiemetics. Avoid straining during BM, sneezing, coughing, bending down.
Abnormal increase in IOP leading to visual disability and blindness; obstruction of outflow of aqueous humor.
- Cloudy, blurry vision or loss of vision
- Artificial lights have a halo around them
- Decreased peripheral vision
- Pain, HA
- 5 SIGNS:
- Brow Arching, Halos around Lights, Blurry Vision, Diminished Peripheral Vision, HA/Eye Pain
- Open--> primary glaucoma: blockage of aqeuous humor. Associated with trauma, tumor, hemorrhage, aging
- Closed--> sudden onset, emergency. Associated with allergy or emotional disturbances.
- Surgery- laser
- Avoid tight clothing (collars)
- Reduce external stimuli
- Avoid heaving lifing, straining stool
- Avoid use of mydriatics (Atropine)
Levin-Single Lumen NG TUBE
Used to removed stomach contents or provide tube feeding.
Measure distance from tip of nose to earlobe to bottom of xiphoid process. Mark distance with tape and lubricate end with water-soluble jelly. Insert tube through nose into stomach. Offer sips of water and advance tube gently; bend the head forward.
Observe for respiratory distress, an indication that the tube is misplaced in the lungs. Verify with xray prior to use. Aspirate gastric contents. pH usually < or equal to 4. (respiratory >5.5)
- Check residual before intermittent feeding and q 4 hrs whith continuous feeding. Hold feeding if >100mL.
- Instill 15-30mL before and after each med and feeding.
Administer feeding at room temp. Change bag q 24-72hrs. Elevated HOB 30 degress while feeding adn 30 min after.
Check patency q 4 hrs.
Double lumen stomach tube; most frequently used for decompression with suction.
A small vent tube within the large suction tube prevents mucosal suction damage by maintaing the pressure in open eyes at the distal end of the tube at less than 25mm Hg.
Air vent is not to be clamped and is to be kept above level of stomach. If leakage occurs through air vent, instill 30mL of air into the air vent & irrigate the main lumen with NS.
Hissing sound is indicative that air is freely exiting airway, purpose is to provide steady continuous suction without pulling gastric mucosa.
Nursing care the same as with Levin NG tube.
Triple Lumen Gastric Tube with inflatable esophagus ballon, stomach balloon, gastric suction lumen used for treatment of esophageal varices.
Keep scissors at bedside if dislodgement with respiratory distress occurs, cut balloon ports and remove tube.
Soft silicone rubber, medium length tube used for long-term feedings. Takes 24 hours to pass from stomach to intestines; lay on right side to facilitate passage.
Acute infectious neuronitis of the cranial and peripheral nerves, Immune system overreacts to the infection & destroys myelin sheath. Usually preceded by a mild upper respiratory infection or gastroenteritis. Recovery is a slow process and may take years. Major concern is difficulty breathing.
- Paresthesias (abnormal prickling sensation)
- Weakness of lower extremities
- Gradual, progressive weakness of upper extremities and facial muscles
- Possible progression to respiratory failure
- Cardiac Dsyrhythmias
- CSF that reveals an elevated protein level
- Abnormal electroencephalogram
- Monitor cardiac and respiratory status
- Asses for complications with immbolitiy
Sex Linked ---> Mother transmits to Son (transmitted to male by female carrier)
Tx= Plasma/Factor VIII, Cryoprecipitate
Avoid IM injections, Contact Sports, & ASA