Intracranial Regulation
Asymptomatic until the rupture occurs. When rupture occurs the patient can have a severe headache, stiff neck, blurred/double vision, and vomit.
What is a cerebral aneurysm?
Absence of insulin production from the beta cells in the pancreas.
What is Type I Diabetes?
Venous stasis
Endothelial damage
Altered coagulation
What is Virchow's Triad?
Chest pain that only occurs during exercise, anxiety, or other stress and lasts less than 15 minutes.
What is stable angina?
Decreases blood sugar in 30 min to 1 hour. Peaks in 1-5 hours. Lasts for 6-10 hours.
What is short acting insulin like Regular Insulin?
Frequent neuro checks, seizure precautions, fluid restrictions, vomiting prevention, bedrest, DVT/PE prevention, administration of anticonvulsant, osmotic diuretic, and possible corticosteroids, and maintaining head of bed between 15-30 degrees.
What are nursing interventions for epidural, subdural, and intracerebral hematoma's?
Shaky, sweaty, clammy, cool, confused, light headed, dizzy, and double vision.
What are signs and symptoms of hypoglycemia?
Edema, warmth, tenderness, calf/foot/ankle pain, hardness over the vessel.
What are manifestations of a DVT?
Chest pain not relieved by nitro, nausea/vomiting, high heart rate, sweating, pale, shortness of breath, dizziness.
What are signs and symptoms of an MI?
Weight gain, feelings of being cold, tired and fatigued, slow heart rate, thinning hair, depression, constipation, memory loss, dry skin, menstrual problems.
What are signs and symptoms of hypothyroidism?
Too much CSF in the brain. Fluid builds up in the brain and causes head to enlarge in infants.
What is hydrocephalus?
Experiences paresthesia's usually occurring in the legs, feet, and hands. Causes increased risk of injury due to lack of sensation awareness.
What is peripheral neuropathy?
Administer oxygen therapy, assess respiratory status, place client in high fowlers position, EKG to determine cardiac involvement, pain/anxiety management.
What are nursing interventions for a PE?
Oxygen, nitroglycerin, supine position, morphine, emotional support, bleeding precautions, education.
What are some nursing interventions for an MI?
PT/INR
What is the lab used to measure warfarin dosing?
Drowsiness/confusion, restlessness, GCS 13-15, unequal pupils, weakness in extremities, slow speech, dull headache.
What are early signs and symptoms of increased intracranial pressure?
Acronym STRESSEDD. Skin fragile, Truncal obesity, Round or moon face, Ecchymosis, Striae on the extremities and abdomen, Sugar extremely high, Excessive body hair, Dorsocervical fat pad, Depression.
What are signs and symptoms of Cushing's disease?
Not smoking, maintaining health diet and weight, exercise, managing BP.
What are modifiable risk factors for stroke prevention?
Cool/dusky feeling limbs, decreased perfusion to limbs, hairless/dry/scaly limbs, thick toenails, numbness in affected leg, pale and slow healing skin lesions, discomfort relieved with rest.
What are manifestations of peripheral arterial disease?
Sitting patient upright for meals at 90 degrees or high fowlers. Putting food on the unaffected side. Sitting upright for 30 minutes after meals. Using thickener with fluids. Avoiding the use of straws. Tucking the chin while swallowing.
What are nursing interventions to manage dysphagia?
Period of time after the seizure that allows time for the brain to recover. May take hours to days and some hardly see this at all.
What is the post ictus phase of a seizure?
Tremors, itchy skin, jaundice, loss of appetite, varices, edema in legs and abdomen, ascites, increased breast tissue for males, infection, and bleeding.
What are signs and symptoms of cirrhosis?
paralysis or weakness on the left side of the body, left visual field deficit, spatial-perceptual deficits, increased distractibility, impulsive behavior.
What are manifestations of a right hemispheric stroke?
Weight management, compression stockings, leg elevation, exercise, shoes with laces, and assess legs for skin integrity and edema.
What are nursing interventions for peripheral vascular disease?
Pain/cramping in the thigh, calf or buttock muscles during activity such as walking or climbing the stairs.
What is intermittent claudication?