Neuro now
The most important question to ask when a stroke is suspected.
Why?
When did your symptoms start?
CT determine nature of stroke
Ischemic (Embolic/thombotic) vs Hemorrhagic
If an Ischemic stroke: Treatment options are geared to last normal, window of time determines if candidate for IV tPA- tissue plasminogen activator(clot buster) therapy.
Lewis p 1348
The inability to maintain body temperature.
What is poikilothermia?
I just ate strawberries and my airway is tight, I feel like I can't breath and am getting dizzy...
What is happening and what is priority intervention
What is an allergic reaction vs anaphylactic reaction
Epinephrine
Relaxes the muscles around the airways in the lungs assisting the airways to open up
Powerful vasoconstriction
Increases BP and HR
Name a common long acting Insulin used in practice.
Glargine (Lantus) = long acting usually give once a day.
Please remember that Glargine keeps blood glucose levels even over 24 hours.
These comorbidities contribute to Renal disease. Name 2.
These annual assessments should be done to prevent/assess risk for each of the comorbidities.
DOUBLE JEOPARDY
What is Diabetes & Cardiovascular disease
What is Diabetes (check for Hgb A1C >6.5%, fasting blood glucose >126 , 2hr glucose test...
What is Cardio vascular disease high BP, Echocardiagram, HLD, Cholesterol panel
Renal: BP, Cr, Bun, GFR for renal,
As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, “If my heart or breathing stops, I do not want to be resuscitated.” Which action should the nurse take first?
What is ask the patient if they have discussed with the provider?
A health care provider’s order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient’s request but does not have the authority to place the DNR order in the care plan.
Your patient’s head is arching backward, and his toes are pointing downward.
What is Decerebrate Posturing (extensor)?
(may indicate more serious issue lesion or injury in the midbrain and brainstem)
Decorticate posturing (flexor) patient is stiff with bent arms clenched fist and arms bent in toward the body and chest (core) (cerebral brain injury)
A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this is consistent with what type of seizure?
What is a Focal Seizure.
Rationale: The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain.
A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?
A. The patient’s heart rate is 58 beats/min. B. The patient’s extremities are warm and dry. C. The patient’s IV infusion site is cool and pale. D. The patient’s urine output is 28 mL over the past hour.
C. The patient’s IV infusion site is cool and pale.
The nurse has a DM Type II COVID pneumonia patient on high dose steroids who is critically ill. What would you expect the Blood Glucose levels to demonstrate? Why?
What is BGruns high.
Rationale: Counter-regulatory hormones such as cortisol and epinephrine, and stress will drive the BG high!!!
COVID PNA patients are on very high dose insulins, Aspart/Lispro SS q 4, Glargine q day, and NPH daily.
In CKD, this combination of electrolyte values, when one goes high the other goes low.
What is Phosphorus and calcium levels.
Phosphorus has an inverse relationship with Calcium in the body. When phosphorus levels rise, calcium falls, and vice versa.
CKD: Fluid restriction and dietary restrictions of protein, potassium and phosphate (Tbl 52-9, London et al., 2017. p1386)
A patient in hospice is manifesting a decrease in all body system functions except for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min.
How would you describe to the family the patient's status.
"These vital signs are an expected response now but will slow down later.”
An increase in heart and respiratory rate may occur before the slowing of these functions in a dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement or compensation, and it would be inappropriate for the nurse to indicate this to the family.
The most common patient complaint of this type of stroke is the sudden onset of “the worst headache ever.”
What is Hemorrhagic Stroke?
A female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first?
what is ask about the usual urinary pattern and any measures used for bladder control.
Rationale: Before planning any interventions, the nurse should complete the assessment and determine the patient’s normal bladder pattern and the usual measures used by the patient at home.
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which interventions may be ordered by the health care provider and which one should the nurse implement first?
What is 100% oxygen-non-rebreather mask!!!!!!
Initiate continuous electrocardiogram (ECG) monitoring.
Insert two large-bore IV catheters.
Draw blood to type and crossmatch for transfusion (rainbow of lab tubes to check Chemistry, coag, drug screen panelts & more)
IV Fluids
What priority information does the nurse include in the teaching plan for a patient scheduled for a Roux-en-Y gastric bypass? Why is this the priority?
What is coughing, deep breathing, and incentive spirometry; the reason is to avoid respiratory complications after surgery such as atelectasis.
You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected and patient receives an nasal gastric tube to low intermittent suction. Which acid-base imbalance do you anticipate in this patient may have or develop?
What is Metabolic Alkalosis?
Because gastric secretions are rich in HCl acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.
The hospice nurse is caring for a patient with end stage heart disease in a home hospice program. Which action by the nurse is appropriate and why?
a. Discuss risk factors and appropriate lifestyle modifications.
b. Teach the patient about the purpose of taking daily vitamins and daily weights.
c. Encourage the patient to discuss past life events and their meanings.
d. Accomplish a thorough head-to-toe assessment several times a week.
c. Encourage the patient to discuss past life events and their meanings.
The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patient’s life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments. Taking medications like vitamins or non essential meds like statins. Discussion of risk factors and therapies is not appropriate.
"Safety Alert" recommendations for acute stroke patients regarding oral feeding and drinking.
What is determining gag reflex present!
Yes gag present: Have patient sit in high Fowlers Position or ideally sit in a chair position.
Have patient take a few ice chips and then sips of water, move forward with bedside swallow test per hospital/unit protocol.
Swallow evaluation may (most likely) initially involve a Speech therapist who specializes in evaluating both speech and swallow capabilities when patient has had a stroke.
No gag present, do not give anything to patient at all orally; wait, keep patient NPO and notify provider and/or speech therapy.
Shuffling gait, tremor at rest, and cogwheel rigidity are the hallmark signs.
What is Parkinson's Disease?
This process defines the movement of molecules against the concentration gradient.
What is Active Transport; adenosine triphosphate (ATP)?
External energy is required for the process.
Na+ & K+ pump is a great example. The concentrations of Na+ and K+ differ greatly intracellularly and extracellularly. To maintain the concentration difference the cell uses active transport (adenosine triphosphate) to move sodium out of the cell and potassium into the cell. For every 3 Na ions exit out of cell, 2 K+ ions move into the cell.
DAILY DOUBLE
The nurse is caring for a terminally ill patient who is experiencing continuous and severe pain. How should the nurse adjust the administration of opioid pain medications (analgesics)?
Plan around-the-clock routine administration of analgesics and as needed dosing for breakthrough pain.
Rationale: Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs, so round-the-clock administration needs to be ordered with extra dosing for breakthrough pain.
You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 57 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results?
What is Partially compensated respiratory acidosis
A low pH (normal, 7.35-7.45) indicates acidosis. In a patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal, 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 (normal 22-26 mEq/L) indicates a partial compensation for the elevated CO2 as the pH is not yet in the normal range.
O2 sats adequate at 92%
The son of a dying patient tells the nurse, “Mother doesn’t really respond any more when I visit. I don’t think she knows or cares that I am here.” How should the nurse respond?
“Withdrawal can be a normal response in the process of dying.”
Rationale: Withdrawal is a normal psychosocial response to approaching death. Visitors are encouraged to be “present” with the patient, talking softly, and making physical contact in a way that does not demand a response from the patient.
The ominous sign of Cushing’s Triad appears when what is occurring?
Name the elements of Cushing's Triad.
DOUBLE JEOPARDY
What is Increased Intracranial Pressure and brain-stem compression?
What is bradycardia, widening pulse pressure, and irregular respiration?
Symptoms of this condition are often worse during postpartum.
What is Multiple Sclerosis (MS)?
Double Jeopardy!!!!!!!!
A patient receives 3% NaCl solution for correction of hyponatremia.
The assessment findings that are most important for the nurse to monitor?
What is Neuro assessment and Lung sounds
Neuro assessment & careful frequent analysis of serum Na levels determine titratration of 3% solution & maintain gradual increase of serum Na levels (8-12 over 24 hrs) to avoid osmotic demyelination syndrome with permanent damage to nerve cells in the brain) and shift of fluid in cerebral compartment.
Lung sounds especially in the patient with heart failure.
Ch 16 F & E ppt
This time of day is most appropriate time for administration for the medicine Levothyroxine (Synthroid).
What is one hour before breakfast?
Rationale: Take 30-60 minutes before food to avoid erratic absorption and effectiveness of levothyroxine (Davis).
The patient has chronic respiratory alkalosis. The nurse understands which statement describes how the kidneys respond to alkalosis?
What is increase the secretion of bicarbonate (HCO3) in the urine
Rationale: The kidneys control pH by adjusting the amount of HCO3 that is reabsorbed into the bloodstream or excreted into the urine. Since this patient's pH is alkalotic, the body would want to eliminate HCO3 (a base) and hold onto.absorb more hydrogen ions in order to make the pH more acidic. Harding et al., Ch 16 p 288-291, lecture, ppt and ABG link.
How should the nurse provide appropriate cultural and spiritual care for the hospice patient?
Assess the beliefs and preferences of the patient and family. Use cultural sensitivity and meet the needs of both patient and family wishes.
Differences among spiritual and culture beliefs and values related to death and dying are innumerable. The individual patient and family must be assessed to avoid stereotyping individuals with different spiritual and cultural belief systems.