NUR 122 test 4

Maintain airway

• Chest pain.
• Can cause cardiac disorder
• *Do not give to pt.s with heart disorders

It’s a vasodilator

• Last stage of seizure
• Lasts 5-30 minutes or more
• s/s Drowsiness, confusion, nausea, HTN, headache, migraine
• *Nurse assess for signs of injury, paralysis, difficulty awakening from sleep

• -Prodromal- mood change, irritability, insomnia
• -Aura- sensation warning pt. of impending seizure
• -Loss of motor activity of bladder/bowel control, Loss of consciousness
• -Postictal- lasts 5-30 min.drowsiness/ confusion/ nausea/ HTN/ headache

• Gingival hyperplasia
• Provide really good oral care

• Over 55 yrs old
• Male

Hypertension is primary risk factor

• Thrombolytic
• Continuous monitoring of cardiac after admission of tPA
• Must be given within 3 hrs of stroke
• Not for hemorrhagic strokes!

• Bleeding
• Contraindicated of already on anticoagulants

Raise HOB to reduce intracranial pressure

• Increasing age (non-modifiable)
• HTN (modifiable)

• Stroke
• Bells-palsy

Cardiac and respiratory function

Decrease intracranial pressure in subarachnoid space

CT scan

Active ROM to unaffected extremities Passive ROM to affected extremities

• Urine loss of sensation leading to: Urinary frequency
• Urinary urgency
• *Can cause depression

Approach on side of intact perception (duh!)

Blindness in one half of the visual field of one or both eyes

A chronic, immune-mediated degenerative disease of CNS characterized my demyelization in brain & spinal cord and formation of plaques

Multiple, multifocal white-matter lesions known as plaques MRI main way to diagnose MS

• *Intention tremors (tremor when they try to use arms/legs)
• *Fatigue*
• Urinary hesitancy
• Difficulty in coordination
• Blurred vision

• *Heat*
• Anemia
• Depression

Rx treatment for MS Decreases muscle spasms of lower extremities

• Space activities throughout day
• Get enough rest and sleep
• Rest in air conditioned room (do better in cooler environment)

• Diagnostic test for Myasthenia Gravis (MG)
• After 30 seconds of injection, facial muscle weakness & ptosis begin to resolve (within 5 min)
• Have Atrophine available for SE (bradycardia, sweat, cramping)

• Generalized weakness of muscles in extremities and intercostal muscles Motor disease only
• *Do not have sensory or coordination deficits
• *Very high risk for aspiration

• Main medication used for Myasthenia Gravis (MG)
• Start with this Rx first as others have more side effects
• Must be taken on time or weakness sets in quickly

• *Effects 5th cranial nerve
• Trigger area on face may initiate pain Avoid washing face, chew on unaffected side, food at room temp., rinse instead of brush teeth.

• Antiseizure agent
• *S/E: bone marrow depression

• *Results in facial paralysis
• *effects the 7th cranial nerve
• Often only effects one side of face

• Provide artificial tears
• Provide eye protective eye wear to prevent injury
• Wear eye shield, patch, or tape eye shut at night
• Wear sunglasses

Despite a ravenous appetite, pt.s are emaciated & exhausted due to chorea (involuntary movements)

Difficulty in verbal communication related to throat muscle weakness Risk for aspiration (needs frequent lung assessment due to swallowing problems).

• Stay active
• -use it or lose it
• Orthopedic jacket
• -Improves sitting stability
• -Reduces trunk deformity

Plan activities in AM as they have most energy in AM

• Risk for falls
• -remove trip hazards
• -use hand rails & assistive devices
• -wear good fitting shoes

They cannot take medications that affect brain waves for at least 24hrs Stimulants, anti-seizure, depressants

Paralysis of one side of the body

Weakness of one side of the body

The loss of full control of bodily movements

• Communication disorder
• Difficulty in comprehending or producing spoken/written language.
• Expressive, Receptive, or Global (mixed)

Double double vision

Difficulty swallowing

• G-gastric (swallow difficulty)
• S- speech (impairment)

• *Warning sign*
• No changes on MRI/CT scan
• No brain tissue death
• Same symptoms of CVA

• Death in 6-24 months
• Caused by prions (very small proteins) that cannot be sterilized in food

• Tx for MG Exchange plasma for healthy plasma (removes antibodies)
• Can take up to 3 yrs to see improvement

• “Lou Gehrig’s Disease”
• *Monitor for aspiration pneumonia
• *They can understand but can’t speak (expressive dysphasia)
• Let them use non-verbal techniques to communicate

Corticosteroids Prednisone

Intravenous Immunoglobulin

• Pt. teaching (Prevention)*
• Abstain from sharing sexual fluids Reduce number of partners
• Always use condoms

Pneumocystis Pneumonia (PCP)

• The most common respiratory infection w/ AIDS & HIV
• Initial symptoms may be nonspecific (unproductive cough, fever, chills) Untreated progresses to pulmonary impairment and respiratory failure
• Tx: TMP/SMZ or Pentamidine

Diarrhea, Diarrhea Tx: Sandostatin

• Sandostatin (Ocreotide)
• Increases absorption of fluid & electrolytes
• Increases transit time of “stuff” through GI tract

• Megestrol Acetate (Megace)
• Appetite stimulant

• Progressive cognitive, behavioral, or motor decline
• Probably directly related to HIV infection

• Absence from infection
• Improved airway clearance
• Improved nutritional status

• Increase in the number of cells of a tissue
• Uterine enlargement during pregnancy

• Conversion of one type of mature cell into another type of cell
• Damaged cells replaced with stronger ones
• Barrett’s esophagus

• Abnormal change in size, shape, appearance, & organization structure of cells
• Caused by persistent injury or irritation
• Cervical dysplasia

• Uncontrolled cell growth that follows physiologic demand
• Fast-growing tumor

Growth of tumor into the surrounding host tissue

Spread of malignant cells from primary tumor to distant sites

Cancer metastasize through lymph nodes or bloodstream

• Rapid formation of new blood vessels which helps malignant cells obtain nutrients & O2
• Way tumors can grow

Avoid known carcinogens, positive dietary/lifestyle changes

Screening & early detection

• Chemotherapy used in an attempt to destroy tumors
• Is systemic tx. rather then specific like radiation

• Day to day stress has a larger impact then major life events
• Weakens the immune system’s response
• Associated with infectious disease

• Blood
• Seminal fluid
• Vaginal secretions
• Amniotic fluid
• Breast milk

• Impaired nutritional status
• Oral stomatitis (inflammation mouth mucus membranes)
• Xerostomia (dry mouth)

• Weakness
• Fatigue
• SE result of tx, not deterioration

N/V

• Modify risk for infection
• Dispose hazardous waste in appropriate receptacle

• Total mastectomy and reconstruction of the breast
• Candidates include strong family hx, cancer phobic, and hx of cancer in one breast

Before engraphment, pt. high risk for infection, sepsis, & bleeding