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Who are the high risk pateints for a stroke?
Male, african american, HTN, smoker, advanced age
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What is your primary assessment on a stroke pt?
- Cardiac and respiratory* airway patency
- facial droop
- neurological deficit
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Numbness
weakness (especially one sided)
confusion or change in mental status
difficulty speaking or swallowing
visual distrubances
severe headaches
>>>>> are all signs/symptoms of a possible ??
STROKE or Brain attack
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What are nursing interventions for a stroke patient?
maintaining an airway**
- •Assess neurovascular, cardiac and respiratory status
- •Assist as needed (safety issues)
- •Assist as needed in meeting nutritional needs thickened liquids if dysphagia present
- •Maintain patent airway and oxygenation
- •Place objects where patient can see them
- •Place objects within reach if hemiparesis or paralysis is present
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What is a complication from a stroke?
Intracrainial pressure. (ICP)
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What is an intervention you can do for ICP?
elevate the head of the bed
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What causes ICP?
increased pressure due to blood in the subarachnoid space
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What is an intervention you should do for an unconscious patient?
Maintain airway
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What should your postictal assessment findings may include?
- *Postictal is after the seizure, last 5-30 min. or >
- Usually characterized by: drowsiness, confusion, nausea, HTN, HA, migraine
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What is the patho Multiple Sclerosis?
it is a chronic progressive, non-contagious, degenerative, disease of the CNS characterized by demylinization.
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What are the clinical manifestations of MS?
- •Primary finding on CT will be:
- –Multifocal multiple white matter lesions known plaques when in chronic phase of illness
- •Intention tremors (shaking movement)
- •Urinary hesitancy
- •Difficulty in coordination
- •Blurred vision
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What are some interventions for a pt with MS?
- •Instruct in spacing activities through out the day, get enough rest and sleep
- •Rest in air conditioned room
- •Instruct to get enough rest and sleep to prevent exacerbation
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What is the Assessment data for a pt with Myasthenia Gravis?
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•Weakness of face and throat muscles
- •Bland facial expression
- •Dysphonia (voice impairment)
- •Generalized weakness of extremities and intercostal muscles
- •No sensation or coordination loss
- •Only a motor disorder
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What is the test to r/o Myasthenia Gravis?
•Tensilon test: fast-acting antiacetylcholinesterase inhibitor –30 seconds after injection facial muscle weakness and ptosis resolve in 5 minutes –Atropine should be available for side effects: bradycardia, sweating, cramping
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What precipitates an attack of Trigeminal Neuralgia?
•Trigger area on the face may initiate the pain try to avoid washing the face, teach to chew on the unaffected side, eat food at room temperature, and rinse mouth instead of brushing the teeth
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Facial paryalyisis
inability to wrinkle eye brows
no muscle tone in face
are all clinical manifestations of ?
Bells Palsy
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What are some nursing interventions you can use when caring for a pt with bells palsy?
- Use artificial tears
- provide protective eye wear
- prevent injury
- provide an eye shield
- patch or tape eye shut at night
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What is Amyotrophic Lateral Sclerosis (ALS)?
•Progressive degenerative neurological disease involving the motor system
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What is some managment for ALS?
frequent lung assessment due to risk for aspiration from swallowing problems, difficulty communicating d/t muscle weakness
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What are clinical manifestations of huntingtons disease?
- ravenouse appetite d/t increase in rate of calorie burn
- exhaustion
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What is managment for a pt suffering from post polio disease?
plan daily activities in the morning d/t fatigue later on in the day
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What is the affect of alcohol on a migraine?
Vasodilation
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WHat is medical managment for Muscular Dystrophy?
orthopedic jacket to improve sitting stability and reduce trunk deformity
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How is stress related to infectious diseases?
- •Decreases the immune system
- •Daily hassles have greater impact on health than major life events
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HOw is HIV/AIDS transmitted?
–Blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk
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what are the clinical manifestations of encephalopathy ?
- –Progressive cognitive, behavioral, and motor decline
- –Probably directly related to the HIV infection
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What is the most commom infection related to HIV/AIDS?
- –Most common infection is
- Pneumocystic carini pneumonia (PCP
- – symptoms may be nonspecific and may include nonproductive cough, fever chills, dyspnea, and chest pain
- –If untreated, progresses to pulmonary impairment and respiratory failure
- –Treatment: TMP-SMZ or pentamidine, prophylactic TMP-SMZ
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What is common treatment related to HIV/AIDs induced chronic diarrhea?
- •Diarrhea related to HIV infection or enteric pathogens
- –Octretide acetate (sandostatin)for severe chronic diarrhea
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What is the nutritional goal for the pt with AIDS/HIV?
- Improve nutritional status
- possibly asminister megestrol acetate (Megace) for appetite stimulant
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What is some preventions for not getting aids/HIV?
- •Safer sex practices and safer behaviors
- –Abstain from sharing sexual fluids
- –Reduce the number of sexual partners to one
- –Always use latex condoms; if allergic to latex, use non-latex condoms
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What is the primary prevention for cancer?
concerned with reducing cancer risk in healthy people
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What is secondary prevention in cancer?
•Secondary prevention: involves detection, screening to achieve early diagnosis, intervention
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What are some common side effects of radiation?
- •Effect on GI system
- –Impaired nutritional statusOral – stomatitis, xerostomia (dryness of mouth
- •Systemic effects
- –Weakness, fatigue (result of tx, it is not deterioration)
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What are the common side effects of chemo?
- •Gastrointestinal
- –N/V most common
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What is the proper way to dispose meds in connection with chemo?
- •Dispose wastes in
- hazardous receptacle
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What is the 100 day concern in regards to a bone marrow transplant?
•Graft vs. host disease: donor cells recognize malignant cells to eliminate them
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What is the prevention stratagy for breast cnacer and when would it be used?
Phophylactic mastectomy; on pts who have a strong hx of breast cancer, cancer phobia, or previous cancer in one breast
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What is a side effects of carbamazepine(Tergretol)?
bone marrow suppression
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What is the purpose of Lioresel(Baclofen)?
decrease muscle spasms in lower extremities
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What are side effects of phenytoin(dilantin)?
cause gingival hyperplasia, provide oral care
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Who should imitrex NOT be given to?
Cardiac pts because it causes chest pain.
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What is the time frame for a thrombolytic to be given?
Within 3 hours or ir is not effective
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