LOC/Assessment
Neuromuscular checks
Reflex, muscular strength, response to stimuli
Ability to move legs and arms
Phenytoin (Dilantin)
Therapeutic levels (blood tests), gingival hyperplasia (mouth care), Warfarin is contraindicated.
Bacterial Meningitis
Isolate the client (droplet precautions), decrease environmental stimuli, monitor to increased intracranial precautions, and seizure precautions.
Myasthenia gravis
Aspiration precautions maintained, fall precautions maintained, medical bracelet, infection risk precautions. Eye care/moisture. Risk for respiratory distress - CPR
Epidural hematoma with closed head injury
Periorbital ecchymosis, Battle's sign (rash behind ear), conjugate deviation (eyes moving in direction of brain injury/trauma)
Agnosia
Inability to recognize sensory information
Unfamiliar with familiar things. Loss of ability to recognize objects, persons, sounds, shapes
Coumadin (Warfarin) actions
Does not dissolve but prevents formation of new clots by inhibiting vitamin K activity in clotting.
Give vitamin K and antidote
Labs to determine therapeutic levels: PT/PTT and INR
Multiple Sclerosis: Decrease the effects of fatigue
Offer frequent rest periods, balanced diet with increased protein, use of Ritalin for increased energy.
Multiple Sclerosis diagnosis based on
MRI - Plaques in brain occurring over time and pt complaints.
Elevated protein in CSF
T lymphocytes elevated
Autonomic dysreflexia triggers
Constipation, urinary retention, insertion pf rectal supps, wrinkles in linen and abrupt environmental changes.
Haldol side effects
Dystonia (painful muscle spasms), parkinsonian tremors (pill rolling), bradykinesia, akathesia (restlessness).
Torticollis abnormal twisting or tilting of head and neck.
Impaired physical mobility r/t stroke (CVA) interventions
Assist w/ standing, assess unilateral vs bilateral deficits, safety awareness (call light), assistive devices (walker/cane) and encourage active ROM.
Carbidopa- Levodopa side effects
Orthostatic hypotension
Dyskinesia
Hallucinations/confusion
Dark urine is a normal finding
Scaly erythematous rash
Urinary retention
Depression
Characteristics of tremors in Parkinson's
Worst at rest (decreased with intentional movement).