Cephalgia
Pad the side rails of the bed to prevent injury during a seizure, having full resuscitation equipment (oxygen and suction equipment) at the bedside, confirming a patent IV line, limit the number of pillows used, lower bed as close to the ground as possible with side rails up, showers rather than baths.
What are some safety measures for patients at risk for seizures?
Falls, vehicle related collisions, sports injuries and violent assaults. Also common in military personal due to explosive blasts and combat-related injuries.
What are common causes of traumatic brain injury?
A clinical scale used to reliably measure a client's level of consciousness after brain injury (measures ocular, verbal and motor response). A score of 8 or less indicates severe brain injury.
BP 220/120 with a severe headache, dizziness, double vision and confusion (risk for stroke).
What is hypertensive emergency?
Automobile accidents.
What is the leading cause of spinal cord injuries?
An emergency situation in which cortisol levels are too low and therefore must be treated with fluids and an IV hydrocortisone injection.
What is adrenal crisis?
In a patient with multiple sclerosis, cerebrospinal fluid analysis would reveal these two findings.
What is an elevated protein level and a slight increase in WBCs?
(MS is an autoimmune disorder that has been linked to an abundance of myelin basic protein found in CNS myelin)
This neurotransmitter helps to control smooth muscle movement and coordination.
What is dopamine?
This plan is mandated by The Joint Commision and describes how a facility will respond to and recover from all hazards.
What is an Emergency Operations Plan (EOP)?
(what are the components of an EOP?)
Seizure that occurs continuously for much longer than usual, or seizures that occur in quick succession with no time between the seizures for the person to recover (medical emergency). Treat with benzodiazepine and anti-seizure medication.
What is status epilepticus?
This is a very important assessment question to ask any client with suspected head trauma to establish their risk factors for head trauma complications, such as uncontrolled bleeding.
What is "can you tell me about your past medical history and current home medication regimen?"
Stimulation of the lateral plantar aspect of the foot leads to extension (dorsiflexion) of the big toe and fanning of the other toes, indicating a neurological problem or damage.
What is a positive Babinski sign?
BP 210/120 without signs of end-organ damage. Treat with oral antihypertensives.
What is hypertensive urgency?
Autonomic dysreflexia develops in 48 to 70% of clients with injuries that involve the thoracic nerves at or above this level of the spine.
What is T6?
This medication acts primarily in the nephrons to decrease urine volume and an increase urine osmolality. Used to treat diabetes insipidus.
What is desmopressin?
(IV, subcutaneous injection, intranasal spray, and dissolvable sublingual strip)
Alternating an eye patch from one eye to the other can help to block out the double image for this common complication of ocular myasthenia gravis.
What is diplopia (double vision)?
True or false: Parkinson's can start as a simple tremor in the hand.
What is true?
A health care system's ability to quickly expand beyond normal services to meet the increased demand for medical care in the event of bioterrorism or other large-scale public emergencies.
What is surge capacity?
Avoid bright/flickering lights; avoid food triggers (MSG, chocolate, red wine, cheese, processed meats), eat and sleep on a regular basis.
What are ways to avoid a migraine headache?
A mild traumatic brain injury that affects brain function. Effects are often short term and can include headaches and trouble with concentration, confusion and loss of memory, tinnitus, nausea/vomiting, fatigue or drowsiness, blurry vision and dizziness.
The primary recommended treatment is pain control, regular neuro checks, seizure precautions, rest in a quiet, low-stimulus environment. Monitor for fluid from the ear or nose (basilar skull fracture).
What is a concussion?
BEFAST (balance, eyes, face, arms, speech, time).
What is the algorithm used to identify an acute stroke?
IV sodium nitroprusside.
What is the treatment of choice for hypertensive emergency?
Dangerous spike in BP (20 to 40 mmHg above baseline), tachycardia, diaphoresis above injury level, headache, anxiety, piloerection, cold/clammy skin below level of injury.
What are signs and symptoms of autonomic dysreflexia?
Approximately 30 to 50% of clients with Cushing's syndrome (hypercortisolism) are at risk for brittle bones/fractures (particularly at the spinal level) due to this bone disorder.
What is osteoporosis?
Medical treatment that improves muscle strength in patients with myasthenia gravis by inhibiting the breakdown of acetylcholine in the neuromuscular junction.
What is pyridostigmine (Mestinon)?
Pill rolling tremor, shuffling gait, stooped posture, drooling, difficulty chewing, lack of facial expression and visual disorders, freezing of gait and falls.
What are clinical manifestations of Parkinson's disease?
Natural/Environmental, Chemical, Biological, Radiological/Nuclear, Explosive Incidents
What are types of disasters?
- Facilitate prompt medical evaluation and initiation of appropriate treatment.
- Elevate HOB minimum 30 degrees (or greater as tolerated) to reduce ICP and maintain CPP.
- Perform position changes slowly to avoid increase in ICP.
- Monitor VS and neuro status regularly.
- Pain relief, fluid management, and maintain normothermia.
What are nursing priorities for a patient with meningitis?
A physiological response/reflex characterized by widening pulse pressure, bradycardia, irregular respirations that is indicative of increased intracranial pressure and is considered a significant predictor of the need for immediate neurosurgical intervention in adult traumatic brain injury.
What is Cushing's Triad?
This is the single most important modifiable risk factor for stroke and is the leading cause for strokes.
What is arterial hypertension?
The primary goal of this blood pressure disorder is to gradually lower blood pressure using short-acting, titratable intravenous (IV) medications. Rapid and abrupt reduction can be harmful, so a gradual approach is preferred.
What is hypertensive emergency?
The nurse is providing care for a client in Halo traction. This finding would warrant an immediate call to the physician.
What is loosening of the Halo pins or swelling/redness at the pin sites?
Characterized by muscle weakness, hyperpigmentation, hyponatremia, hypotension, dehydration, reduced appetite/weight loss.
What is Addison's disease?
This treatment for Parkinson's disease uses electrodes placed deep into the brain that deliver electrical impulses that regulate and reset faulty electrical communication between brain cells that leads to PD symptoms such as tremor and dyskinesia.
What is deep brain stimulation?
Bradykinesia can be seen in a patient with Parkinson's Disease through these clinical manifestations.
What are lack of arm swing while walking and shuffling gait?
Mitigation, preparedness, response and recovery.
What are four phases of a disaster occurrence cycle?
Take at the first onset of a migraine attack or cluster headache (for treatment, not prevention - not effective if taken during the aura phase). May cause rapid increase in blood pressure or dizziness due to its vasoconstrictive properties. Can also lead to serotonin syndrome - take cautiously with antidepressants or MAOIs.
At what point during a migraine headache attack should sumatriptan (Imitrex) be taken?
You receive a report that your patient sustained a witnessed fall at home with a brief loss of consciousness. Your patient presents with what he calls "the worst headache of his life," nausea and vomiting. On assessment you observe left temporal lobe bruising and a fixed and dilated pupil on that same side. Based on your findings, what neurological condition to you suspect is developing and what treatment do you anticipate.
What is a subdural hematoma? Patient may need surgery to evacuate the hematoma and relieve pressure on the brain.
Within 4.5 hours of onset of ischemic stroke?
How long after onset of ischemic stroke can alteplase be administered?
Encephalopathy, nephropathy, intracranial hemorrhage, aortic dissection, pulmonary edema, myocardial infarction, unstable angina.
What are signs of end-organ damage in hypertensive emergency?
Inability to breathe, paraplegia loss of bowel, bladder, and sexual function, chronic pain, hypotension, impaired temperature control.
What are clinical manifestations of spinal cord injury?
(depend on the level of injury)
These are the mainstays of treatment for adrenal crisis.
What are IV fluids and glucocorticoid therapy (hydrocortisone or dexamethasone)?
Assess BP and perform orthostasis. Client may need vasopressors to maintain a MAP above 65. Monitor glucose levels and electrolytes.
This nervous system disorder affects nerve cells in the brain and spinal cord but does not affect intelligence, thinking, vision, or hearing. It causes muscle weakness/wasting, difficulty with speaking/swallowing and leads to respiratory challenges as the disease progresses.
What is amyotrophic lateral sclerosis (ALS)?
The main cause of Parkinson's disease is the loss of these cells in the brain.
What are dopamine-producing cells?
Based on the need for emergency treatment; goal is to maximize the number of survivors; "Do the most good for the most people!"
What is triage based on, and what is the goal in a disaster situation?
What precautions should be started for patients presenting with severe headache and neck stiffness (nuchal rigidity) and possible diagnosis of meningitis?
Droplet precautions for the first 24 hours of antimicrobial therapy or until meningitis is ruled out.
The onset of dry mouth, excessive thirst and urination following a significant neurological issue, such as traumatic brain injury or stroke, may be an indication of this condition of ADH insufficiency that causes fluids in the body to become out of balance.
What is diabetes insipidus?
Headache, increasing drowsiness, decreased LOC, slurred speech, weakness/paralysis, seizures, vision changes, poor response to commands, vomiting.
What are signs and symptoms of worsening intracerebral hemorrhage?
Blood pressure (both arms/supine and standing), EKG, UA, BUN/CR, ophthalmic exam.
What are methods for diagnosing hypertensive emergency?
This is a primary treatment approach for spinal cord injury to avoid contractures due to immobility.
What is stretching and passive range of motion exercises at least 2-3 times per day?
Patients with Addison's disease often experience this electrolyte imbalance.
What is hyponatremia?
Clients undergoing testing for myasthenia gravis should be given this medication prior to undergoing a Tensilon (edrophonium chloride) test due to the risk of a potential decrease in heart rate or abnormal heart rhythms.
What is atropine sulfate?
This medication is the most effective treatment for Parkinson's Disease.
What is Carbidopa-Levodopa?
Respirations, perfusion, mental status (RPM).
What is evaluated in the START triaging system?
Pulsing/throbbing head pain that is unilateral (could be bilateral) in the frontotemporal distribution with nausea/vomiting, sensitivity to light/sound/odors and difficulty concentrating.
What is a migraine headache?
An intracranial pressure (ICP) greater than 20 mmHg that results in decreased perfusion of blood to the brain. Symptoms include headache or blurred vision - can cause secondary brain injury and death.
What is intracranial hypertension (high intracranial pressure (HICP))?
Optic nerve edema resulting from raised intracranial pressure. Its presence confirms diagnosis of malignant hypertension.
What is papilledema?
The primary goal of this blood pressure disorder is to slowly lower BP over a period of 24 hours using oral antihypertensive medications. A reduction of no more than 25% within the first 24 hours is recommended.
What is hypertensive urgency?
This item should be placed on a client suspected of a head or spinal cord injury to prevent further injury and/or permanent disability.
With Addison's disease, glucocorticoid secretion does not increase during stress; therefore, in the presence of fever, infection, or other illnesses, a client should do this to compensate for a possible stress response.
What is increase dose of hydrocortisone to compensate for a possible stress response (generally 2-3 times the daily maintenance dose)?
An immune-mediated disorder characterized by ascending, symmetric muscle paralysis and absence of reflexes. Initial signs include weakness and tingling sensations in hands and feet that can quickly spread leading to respiratory distress and paralysis.
What is Guillain-Barré syndrome?
This class of medications can be used to reduce the amount of saliva that is produced, and therefore can decrease drooling often seen in younger clients with Parkinson's disease.
What are anticholinergics?
(block the action of acetylcholine)
This tag is used for patients who are capable of ambulating and understanding directions and have adequate perfusion to follow commands and stay upright.
What is a GREEN tag?
Sharp, stabbing, unilateral pain with pain/swelling/tearing around affected eye. Pain can last for 1-3 hours and can occur multiples times per day for weeks or months followed by remission.
What is a cluster headache?
Bruising around the eyes (racoon’s eyes) or bruising behind the mastoid process (ear) that indicates a fracture at the base of the skull.
What are late signs of a basilar skull fracture and possible underlying brain injury?
TPAIN IS 45
What is an acronym used to identify contraindications to rtPA therapy.
Clonidine (Catapres), Beta-blockers (labetalol), CCB (amlodipine, nicardipine), ACE inhibitors (Captopril), thiazide diuretics (HCTZ), direct-acting vasodilator (hydralazine).
What medications are more appropriate for chronic management of severe asymptomatic hypertension (hypertensive urgencies)?
Spinal shock, neurogenic shock, autonomic dysreflexia.
What are 3 complications of spinal cord injury?
Exogenous glucocorticoids.
What is the most common cause of Cushing's syndrome?
Clients with multiple sclerosis who are sensitive to temperature should avoid these, which may trigger a phenomenon known as an MS pseudoexacerbation and worsen of their MS symptoms.
What are sources of heat, such as increased activity, hot weather, hot baths and showers, saunas, and hot tubs?
A neurodegenerative progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement. Symptoms progress to rigid muscles, difficulty walking, slowing of movements, stooped posture, and a mask-like expression.
What is Parkinson's Disease?
This color tag is used for clients who need immediate attention for a life-threatening injury; cannot survive without immediate treatment but have a chance for survival (compromised airway).
What is a RED tag?
Constant, dull/aching head pressure that feels like a tight band around the head. Scalp, neck and shoulder muscles may also become tender or sensitive. Treatment involves relaxation, adequate sleep, hydration, and limiting alcohol, caffeine and sugar intake.
What is a tension headache?
Cushing's triad, projectile vomiting, lethargy, unilateral or bilateral dilated pupils, sunset eyes (lids are at half-mast) seizures and coma and death.
What are late signs of intracranial pressure?
What are nursing interventions for stroke patients?
What are some causes for hypertensive emergency?
Bladder/bowel distension (kinked catheter), tight/restrictive clothing, pressure sores, discomfort from shoes, lying or siting on a hard object, DVT/PE, infection.
What are common causes/triggers of autonomic dysreflexia?
(Remember: stop the trigger - sit patient upright; get them naked)
Hyperpigmentation in Addison's disease is a result of an overproduction of this hormone and a sign of primary adrenal insufficiency.
An autoimmune neuromuscular disease characterized by fluctuating muscle weakness, ocular symptoms, difficulty chewing, and fatigue that worsens as the day progresses.
What is Myasthenia Gravis?
Education, Support services, Exercise and Nutrition.
What are four categories of nonpharmacological treatments for clients with Parkinson's disease?
This color tag is used for deceased or mortally wounded clients who are beyond help and therefore a lower priority. Patients with no spontaneous respirations (or agonal respirations) who remain apneic.
What is a BLACK tag?
When giving this medication intravenously, use an in-line IV filter, give through a large vein or central line, place on cardiac monitor and monitor BP, flush with NS before and after infusion. Classically used as the drug of second choice (after benzodiazepines) to end an active seizure.
What do you need to remember with giving phenytoin intravenously?
What are some nursing interventions for a patient with head trauma?
Two crystalloid intravenous fluids that are indicated to decrease brain water content and reduce intracranial pressure.
What are hypertonic saline and mannitol?
(Hypotonic solutions (D5W; 0.45% NS) should be avoided as they decrease plasma osmolality, drive water across the blood brain barrier and increase cerebral water content and ICP.
What is the goal of hypertensive emergency treatment?
A complication of spinal cord injury that causes temporary loss of all function below level of injury, loss of bladder/bowel function - can last for days/weeks.
What is spinal shock?
These tears in the dermis are associated with Cushing's syndrome and appear as purple stretch marks.
What are purple striae?
Muscle flaccidity, stiffness or spasms; fatigue; vision problems; numbness and tingling; difficulty swallowing.
What are clinical manifestations of multiple sclerosis?
Neurological examination, family history and assessment of physical symptoms, such as changes in gait, handwriting and facial expressions, difficulty in getting up from a chair and walking, etc.
How is Parkinson's disease diagnosed?
This color tag is used for clients whose condition is stable for the moment, and they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances; however, their treatment is delayed.
What is a YELLOW tag?