WSU BEACON; Dr. Keister NUR 441 Test 3

assess LOC, verbal and motor ability; scale 3-15; higher the better, <8 = coma

brain tissue, blood, CSF

5-15 mmHg

sneezing, straining, defecation, coughing, blowing nose

vision; diplopia, blurred, lower acuity

personality change, thought process change, h/a, N

compliance and accommodation fails with increasing volume in intracranial space

IICP-> dec. cerebral perfusion -> tissue hypoxia, lower pH, inc. CO2

CT(cause), MRI

craniotomy, craniectomy, tumor removal, drain ventricles, drain hematoma, intubation

osmotic diuretics, loop diuretics, corticosteroids, antipyretics, anticonvulsants, histamine antagonists, barbiturates

lowers ICP by inc. blood osmolality, draws blood from edemitus brain tissue into vascular circulation

controls hyperthermia (which increases metabolic rate in brain)

lowers risk of stress ulcers

barbiturate-induced coma; lowers metabolic demand of tissue

elevate HOB 30 degrees, avoid valsalva's, quiet environment (lower stress), cluster activity (provide rest periods), restrict fluids, avoid freq. suctioning, O2, hypothermia blanket

excessive and abnormal transient electrical activity within the brain usually resulting in involuntary body movements

idiopathic, hypoglycemic, electrolyte imbalance (hyperkalemia), trauma, infection, IICP, toxins

idiopathic

do not always involve loss of conciousness, may develop into generalized seizures

1 hemisphere, uncontrolled movement, Pt has memory of incident and can interact during seizure

inappropriate behaviors, effects LOC, often includes feeling an "aura" prior, common to have amnesia about event

usually affects LOC

type of generalized seizure; 5-30 sec., can have >100/day, no movement, unresponsive, "daydreaming", can be commonly found in kids

type of generalized seizure; periods of rhythmic jerking and relaxation

15-60 sec.; may see cyanosis, cease to breath, urinary/bowel incontinence

60-90 sec.; jerking, eyes roll back in head, hyperventilation

quiet, relaxed, no movement, not concious, eventually wakes confused

type of generalized seizure; sudden loss of tone in muscle, collapse/fall or dropping object, may have brief loss of conciousness, no postictal phase

emergency; prolonged seizure or several seizures right after eachother lasting >30min.

dilantin, valium, depakene, neurontin, tegrital

low bed position, padded side rails, side rails up, IV access, O2 and suction equipment ready

lower Pt to floor, pillow under head, do not restrain, no tongue blade, prevent aspiration by turning on side, loosen clothing around neck, document

AI disease effecting the myelin sheath, causing slow/loss of nerve conduction expressed through exacerbations/remissions

wide range depending on loc. or myelin damage- shaking, weakness, numb, tinnitus, visual s/s, difficult chewing and walking, incontinent, impotent

ataxia, behavior change, nystagmus, spasticity, tremors, dysphagia, palsy, impaired speech, incontinence, impaired judgement

CSF (inc. protein, WBC, and IgG), MRI (plaques), CT (plaques), visual/auditory/brainstem evoked potential, electromyography

corticosteroids, muscle relaxers, immunosupressants, immunomodulators

reduce edema and inflammatory response during exacerbations

ACTH, Solu Medrol, Prednisone

reduces muscle spasticity

Baclofen, Dantrolene, Valium

stability disease (MS) process

Imuran, Cytoxan

slows disease (MS) progression

Avonex, Betaseron, Copaxone

inc. energy in morning, rest/relaxation periods, maintain constant temp., set priorities, pace activities, adaptive devices

a chronic degenerative disease of neurons of the basal ganglia, causing a deficiency in dopamine

fatigue, problems w/dexterity, minor tremors

muscle rigidity, "pill rolling", uncoordination, stooped posture, shuffling gait, mask-like face, dysphagia, drooling, monotone, dementia, akinesia/bradykinesia

no test; based on symptoms and response to med

dopaminergics, dopamine agonists, monoamine oxidase inhibitors, anticholinergics

inc. mobility by red. tremors and rigidity, increases dopamine release

levodopa, sinemet, symmetrel

activates dopamine receptors (used in conj. w/dopaminergics)

parlodel, permax, mirapex, requip

used early in Parkinson's, blocks dopamine metabolism

eldepryl

eases drooling, tremors, rigidity

artane, cogentin, parsidol, akineton

ROM, ambulate 4xday, assistive devices, speech pathologist, OT, food consistencies, sleep-wake cycle, strategies to promote sleep

AI disease affecting ACh receptors at the neuromuscular junction

ptosis, diplopia

weakness, dysarthria, dysphagia, difficulty sitting, resp. distress

+ tensilon test, EMG, ACh receptor Ab serum levels

Anticholinesterases, immunosuppressives, procedures

allows ACh to collect @ neuromuscular junction @ ACh receptor sites; promotes muscle contraction

mestinon, prostigmin, mytelase

improves strength, reduces inflammation

prednisone, imuran (lowers ACh Ab in months)

plasmaphoresis, thymectomy (40% remmission w/ Pt<40 y/o)

assist w/turning, coughing, incentive spir., semi-fowler's, hydrate (<2500), food consistencies, meal/med sched., small bites, know heimlich

caused by low ACh, stress, or infection, exacerbation of MG s/s, respiratory arrest

toxic rxn to percription, too much ACh, causing sudden extreme weakness, respiratory arrest

Myasthenic crisis = + tensilon test

lou gehrig's disease; chronic, rapidly progressing degenerative disease of motor neurons, causing eventual paralysis of resp. muscles

weakness, fasciculations, uncoordinated, spasticity, paresis, hyperreflexia, atrophy

dysarthria, dyspnea, difficulty coughing and chewing, dysphagia, emotional, loss of control

50% die in 2-5 yrs following Dx due to resp. failure or aspiration pn.

EMG, muscle biopsy, mostly process of elimination

ROM q2hr, + N balance, hydrate, monitor infection, assist turning, coughing, incentive spir., turn q2hr, elevate HOB >30, suction, oxygen

genetically dominant inherited degenerative disease of the nervous system; ex. woody guthrie

restless, fidgety, gait and posture changes, protruding tongue, slurred speech

chorea, grimacing, dysphagia, unintelligible speech, impaired diaphragmatic movement, resp. problems

irritability, outbursts, dperession, risk for suicide

decreased memory, loss of cognition, dementia, total dependence

genetic tests

antipsychotics (block dopamine rec.) and antidepressants

upright positioning, heimlich, thickened food consistency, calm env., continue feeding when turns head away, high cal snacks/food, avoid milk, adaptive tools, oral hygeine, alternative/therapeutic communication

progressive, degenerative form of dementia causing a deterioration of general intellect

still alert, memory lapses, subtle personality changes, dec. attention span, restless, forgetful, congitive deficits

more memory problems, disoriented to time/place, language deficits (paraphasia, eccolalia, scanning speech), sensorimotor deficits (apraxia, astereognosis, agraphia), wandering, periods of lucidity

unable to do purposeful movements or use objects properly

inability to identify objects by touch

inability to write

using the wrong word

repition of same words/phrases

searching for the words

total disorientation, inability to communicate, incontinent, loss of cognition

pneumonia, dehydration, falls, paranoia

no test; EEG pattern, MRI/CT (hippocampus shrink), PET, folstein's mini-mental status exam, fam Hx, autopsy

7 yrs from Dx

cholinesterase inhibitors, tranquilizers, supplements, complementary therapies

for mild-mod dementia; cognex, aricept, exelon

for aggitation; mellaril, haldol

vit c & e, folic acid, vitamin B12

massage, herbs (gingko), coenzyme Q10, art/music/dance therapy

calenders, lists, alarms, med boxes, safety in kitchen, program emergency phone #s, life-line, labels, remove toxins/hazards, min. stimuli, ID self every time and orient, repeat, boundaries, continuity [caregiver role strain]

AI disorder causing muscle weakness and paralysis

flaccid paresthesias, symmetric LE weakness, progressive weakness to UE and face, possible resp. arrest

physical exam, Hx, CSF (inc. protein, norm cell count), EMG studies

analgesics, antibiotics, anticoagulents, vasopressors (if HTN)

tracheostomy, plasmaphoresis

brief attack of localized cerebral ischemia lasting <24 hrs, considered a warning sign for CVA

dec. blood flow to brain by ischemia or hemorrhage

opposite side effects, balance, coordination, gait, proprioception

aphasia, agnosia, apraxia, neglect syndrome, visual difficulty

denial, impaired memory/judgement, unable to concentrate, disoriented, slow and cautious, depressed and anxious, angers quickly

CT w/o contrast, MRI, cerebral angiogram

thrombolytics (w/in 3 hrs), antiplatelets/anticoagulants (contraindicated for hemorrhagic), corticosteroids, anticonvulsants, carotid endarterectomy, aneurysm repair

AA, NA, hispanic/LA

leading cause of heart disease, stroke, adult blindness, end stage renal failure, non-traumatic LE amputation

produced by alpha cells in pancreas, stimulates glycogenolysis, increasing BG levels

produced by delta cells of pancreas, inhibits glucagon and insulin secretion, maintaining current BG levels

AI disease where beta cells are destroyed, absolute insulin deficient; 5-10% of cases, usually <25 y/o, "juvenile onset" or "insulin dep."

no beta cell destruction, insufficient insulin prod. or cell resistence to insulin; 90% of cases, usually >40 y/o, "adult onset" or "non- insulin dependent"

transitory glucose intolerance; 2-5% of pregnancies

genetic predisposition + environmental trigger, AI, more common in the young and men

polyuria, polydipsia, polyphagia, glycosuria, weight loss, malaise, fatigue, blurred vision

genetic predisposition, advancing age, obesity, inactivity, race/ethnicity, more common in women than men, pregnancy, baby >9lbs, polycystic ovary syndrome

usually asymptomatic, hyperglycemia, polyuria, polydipsia, blurred vision, fatigue, paresthesias, prolonged healing, recurrent skin/vaginal infection

casual BG taken any time of day w/out regard to last meal, activity, etc.; >200

fasting (>8 hr) glucose level >126

glucose bolus of 75 g, in 2 hrs, BG>200

positive one of 3 tests + a positive result of different test on different day

<7%= good control, 7-9%= fair control, >9%=poor control

glucose permanently attaches to Hgb, the more glucose in blood, the more glycosylated Hgb, not effected by meals, time of day, drugs, stress, activity; shows diabetic control for last 100 days

when renal glucose threshold exceeded; 180-200 BG level

when fatty acids are being metabolized for energy

indicates pending ketoacidosis

diabetic is ill, stressed, any s/s, or BG level >300

diet, exercise, medications, self-monitoring of BG, and education

60-70%

15-20%

<10%

20-35 g/day

1000-3000 mg/day MAX

men: <2 drinks/day
women: <1 drink/day
alcohol potentiates the hypoglycemic effect of insulin or other diabetic meds

lowers BG levels by inc. uptake of glucose in muscles, dec. risk for insulin resistance, reduces CV risks, improves muscle tone and circulation, dec. total cholesterol and triglycerides, assists in weight loss

20-40 min.; 4-7 days/wk

30 min. aerobic; 3 days/week

no exercise if ketones found in urine; no prolonged exercise; if long period of activity, check BG before, during and after; no exercise w/in 1 hr of insulin or peak insulin action; eat 15g carb snack before; add additional 15-30 g carb snack for every additional 30-60 min.

subcu, IV

fastest absorption in abdomen, then thigh & butt; on regular schedule, sliding scale, or continuous infusion

IV push or continuous drip

sulfonylureas, biguanides, meglitinides, alpha-glucosidase inhibitors, TZDs

glyperide, glypizide, dolputamide

stimulates pancreas to release more insulin AND increases sensitivity of tissue to insulin (non-obese T2)

metformin

prevents liver from releasing more glucose AND increasing muscle cell insulin sensitivity

starlex

stimulates pancreatic cells to release more insulin

slows intestinal digestion allowing increased time for carbohydrate absorption

avandia and actos

increased muscle cell insulin sensitivity

normal met., diabetes & met., diet, exercise, s/s of hyper-/hypo- glycemia, self administering, self-monitoring, foot care, sick days, community

abnormal pressure distribution or trauma s/t neuropathy, vascular disease w/diminished blood flow

wash and inspect daily, file nails w/round corners, never go barefoot, test water temp w/hand, wear leather shoes w/cotton socks

prevent dehydration, provide nutrition for recovery

monitor BG q3 or q4hr, continue insulin/meds, sip 8-12 oz. glucose fluid every hr., soft foods, rest- no exercise

s/s of infection, illness >2 days, unable to eat >24 hr, vomiting/diarrhea >6 hrs, BG >400 two tests, urine + for glucose, ketones in urine >200

postop infection, delayed wound healing, fluid/electrolyte imbalance, hypoglycemia, DKA

best met. state, regular insulin given w/IV glucose solution, 1/2 dose short-acting insulin preop, 1/2 dose PACU, oral hypoglycemics held 1-2 days preop, T2 may need perioperative insulin, early morning surgery, if NPO postop IV dextrose admin. on sliding scale

hyper-/hypo-glycemia, dawn phenom., somogyi phenom., DKA, HHNK

BG<70; caused by mismatch of insulin or oral hypoglycemic, too much exercise, too little food

40-60 BGL; sweating, tremor, tachycardia, palpitations, nervousness, hunger

20-40 BGL; h/a, lightheaded, double vision, drowsy, confused, numb lips/tongue, slurred speech

BGL<20; disoriented, difficulty arousing from sleep, loss of consciousness, seizure

15 g CHO; 8 oz. milk, 4 oz. juice/soda, 5 hard candy, 3 marshmallows, 2-3 tsp sugar, 3-4 dextrose tabs; recheck 15 min., another snack if s/s persist

conscious; 15 g CHO fast-acting, simple; then d50% 10ml/min IV followed by D5W 10 g/hr
unconscious; glucagon 0.5-1 mg IM or subcu

BGL>200; caused by too little insulin or oral hypoglycemics, too much food, too little exercise, illness/stress

extreme thirst, hunger, freq. urination, blurred vision, drowsiness, nausea

fasting hyperglycemia; normal or high BGL @ bedtime, decreased BGL @ 2-3 am, followed by hyperglycemia caused by counter-reg. hormones

decrease evening dose of insulin or increase bedtime snack

fasting hyperglycemia; norm BGL, rise in BGL @ 3-4am, then glucose levels rise along w/ GH; differentiated from somogyi by taking BGL @ 3 (SE=hypo, DP=norm)

change time of evening insulin from dinnertime to bedtime

severe insulin deficiency in T1 DM clients; develops over several hrs/days

1. hyperglycemia, 2. dehydration, 3. acidosis

altered consciousness, kussmaul's resp., fruity breath, N/V, increased urine prod.

BSL = 300-800, inc. plasma ketones, urine ketones & glucose, ABGs= met. acidosis

fluid therapy, insulin drip, monitor/admin. electrolytes, EKG, hourly BG checks, assess vs, lungs, I/O, ketones

slow onset of extreme hyperglycemia w/o ketosis/acidosis, found in T2 DM clients

BSL= 600-2000, hypotension, tachycardia, extreme thirst; all r/t profound dehydration; altered LOC, neuro deficits, seizure, dry skin/mucous membranes

stress, INFECTION, trauma, surgery, dehydration, TPN, drugs (thiazides, glucocorticoids, phenytoin)

atherosclerosis, PVD, inc. risk for CAD, CVD, PVD, retinopathy, nephropathy, neuropathy

after 20 yrs of DM, almost all T1 DM, and 60% T2 DM

chronic progressive non-inflammatory impairment of retinal circulation, eventually causing hemorrhage, causing perm. vision changes to blindness

control HTN & BSL, photocoagulation, vitrectomy, cataract removal/lens implant

20-40% DM Pts; leading cause of morbidity and mortality in DM

microalbuminuria

thirst, fatigue, anemia, weight loss, freq. UTIs

control HTN & BSL, monitor vs, I/O, BUN, creatinine, restrict protein, Na, K, dialysis, kidney transplant

polyneuropathy, mononeuropathy

bilateral sensory disorder; most common; begins in foot/toes

effects a single nerve, unilateral

involves the ANS (GI, sexual performance, sweating, etc.)

distal parasthesias, pain, aching, burning, feelings of cold, altered/impaired sensation

absent reflexes, pain in LE, poor peripheral pulses, N/V, diarrhea, incontinence, skin breakdown, skin infection, parasthesias

control HTN & BSL, foot care, pain meds, bladder training program

systolic <120
diastolic <80

systolic 120-139 OR
diastolic 80-89

systolic 140-159 OR
diastolic 90-99

systolic >160 OR
diastolic >100

aging, fam Hx, African American or Native American, obesity, smoking, stress

renal disorder, cardiovascular disorders, endocrine disorders (cushings), neurogenic disorders (tumor), meds (glucocorticoids, estrogen)

asymptomatic, h/a, edema, pattern of consistently high BP

UA, BUN, creatinine, electrolytes, glucose, corticoids, ketosteroids, cholesterol, triglycerides, CXR, EKG

DASH diet, Na restriction, weight reduction, moderate alcohol intake, exercise, relaxation tech., avoid caffeine/smoking

diuretics, b-blockers, Ca channel blockers, ACE inhibitors, Angio II antagonists, aldosterone receptor antagonists

>240/120; uncontrolled HTN, requires immediate reduction in BP, life-threatening; quick organ damage to kidneys, heart, and vasculature

systolic >240, diastolic >120, h/a, drowsy, confused, tachycardia, tachypnea, cyanosis, numbness, tingling, seizure, motor impairment

semi-Fowler's, admin. O2, IV vasodilators (nitroprusside, nicardipine, labetalol), monitor BP q5-q15min until diastolic 75-90, then q30min, neuro assessments

caused by arterial thromobosis or embolism, abrupt onset, usually in younger adults

peripheral atherosclerosis, insidious, usually older adults

inc. coagulation, clot on vessel wall, infection/inflammation, pooling of blood

colt floats through circulation, usually originating in the heart and lodged in smaller vessel

sudden or insidious pain (distal to obstruction), numbness in extremity, pallor/mottling of extremity, cool/cold skin, pulselessness, paralysis, line of demarcation

arteriography (gold standard)

meds: anticoagulants, thrombolytics; surgery: thrombectomy, emolectomy, thromboendarterectomy

IV fluids, no hot/cold on extremities, bed cradle, extremity on same plane or lower than heart, no knee raising in bed, no 90-degree hip flexion, monitor pulses, color, pain, temp.

caused by atherosclerosis in ab. and iliac aorta, femoral or popliteal arteries or distal arteries, usually men in 60s, 70s, or 80s

intermittent claudication, pain w/rest (burning), parasthesias, diminished peripheral pulses, pallor w/elevation, rubor w/dependency, thin, shiny hairless skin, thickened toenails, skin discoloration or breakdown

gangrene, amputation, rupture of AAA, infection, sepsis

doppler, transcutaneous oximetry, angiography

no smoking, limit caffeine, foot cradle, socks, slippers, position changes, avoid leg crossing and restrictive clothing, adapt exercise, pain meds, pain relief tech., keep feet warm and dependent position, inspect feet daily, foot care

peripheral angioplasty, athrectomy, bypass grafting

assess 6 p's of ischemia, no hip/knee bends, 24 hr bedrest, hydrate/IV fluids

aspirin, plavix, ticlid, trental, pletal

thrombangitis obliterans; inflammation of medium and small arteries and veins of hands and feet

young, male smokers 20-40 y/o

intermittent claudication in arch of foot, sensitivity to cold, numbness, diminished pulses, red/cyanotic extremities when dependent, ulcerations

stop smoking, prevent vasoconstriction, improve peripheral pulses, prevent complications

vasospasms of small arteries of UE or LE, mostly in hands; white-blue-red

numbness, tingling, stiffness, decreased sensation, aching, pallor then cyanosis then rubor

avoid triggers (cold), wear warm clothing, avoid injuries to fingers/hands, Ca channel blockers, muscle relaxants, vasodilators

localized dilation or outpouching or an artery

atherosclerosis

control BP w/antihypertensives to prevent rupture

@ circle of willis

CXR, ab. ultrasound, TEE, tomography, MRI, angiography

ripping/tearing pain, pallor, sweating, tachycardia, diff. BP in each arm, LE paralysis, SHOCK

bedrest, legs flat/avoid crossing, calm environment, avoid valsalva's (stool softeners, avoid reaching, lift team), antihypertensives, monitor EKG, vs, I/O

thoracic: >6cm
abdominal: >5cm

open procedure (graft), endovascular stent graft

renal failure, graft occlusion, resp. distress, arrhythmia, paralytic ileus, sepsis

colloids, IV fluids, monitor vs, perfusion distal to graft, resp., NG tube, DVT prophylaxis, avoid valsalva's

venous occlusion, ineffective venous bloodflow (stasis, clotting, congestion)

immobile, surgery, cancer, trauma, pregnancy, hormone therapy, coagulation disorder

dull aching pain in extremity, cyanosis, elevated temp., malaise

venogram, MRI, doppler

anticoagulants, antiplatelets, thrombolytics, analgesics

pain relief, decrease edema, prevent ulceration (bed cradle), bedrest, no massage, monitor meds, hr, resp.

venous thrombectomy, vena cava filter, ligation, plication

135-148

3.4-5.3

3-29

3.8-10.8