Capstone ATI
ICP monitoring HIGH R/O infection
Used for GCS 8 or below; coma;
Glasgow Coma Scale Score 3-15
8 or less = coma
S/S increased ICP Irritability (EARLY)
Restlessness
Headache
Decreased LOC
Pupil changes
Abnormal breathing (Cheyenne stokes)
Abnormal posturing (decorticate or deceribrate)
Cushing's Triad
ICP range 10-15 mmHg
Over 15 = head injury/abnormal
Lumbar Puncture Spinal fluid sample to diagnose MS, syphilis, meningitis, cerebrospinal fluid infection
Lumbar Puncture Pre-procedure *have pt void first
Position pt in cannonball position on side OR stretch over table w/ rounded back
Lumbar Puncture Post-procedure Pt lay flat for several hours
If dura Puncture site does not heal properly, CSF may leak = SEVERE headache
Sooo admin pain meds & encourage pt to increase FL intake
Epidural blood patch may be used to seal hole if needed
MRI precautions Shellfish or iodine (w contrast only)
Assess pt for claustrophobia, might give sedative
MRI pre-procedure Remove jewelry
No metal implants (pacemaker; ortho joint; artificial heart valve; IUD; aneurism clip)
May give pt earplugs
Meningitis inflammation of the meninges of the brain and spinal cord
Viral Meningitis MOST COMMON
No vaccine
Usually resolves on own
(Risk factors: mumps, measles, arbovirus (West Nile), herpes)
Bacterial Meningitis Requires antibiotics
Highly contagious
High mortality rate
(Risk factors otitis media, sinusitis, pneumonia)
, Capstone ATI
Meningitis Prevention HIB (hemophil. influ. type B) vaccine for kids
MCV4 (meningitis) vaccine before college (bc dorms/close quarters - risk factor)
PPS vaccine
Meningitis s/s Headache
Nuchal (neck) Rigidity
Fever & chills
Photophobia
N/V
Positive Kernig's sign
Positive Brudzinski's sign
Hyperactive DTRs
Seizures
Tachycardia
Restlessness & irritability
Altered LOC (confusion; lethargy; difficulty arousing; coma)
Kernig's sign Positive = indicative of meningitis
Pt lays supine, bring in knees & try to straighten leg, very painful
Kernig's=Knee!!!
Brudzinski's sign Positive = indicative of meningitis
Pt lays supine, lift neck, causes pain, bring in/flex knees
Meningitis Diagnosis Lumbar Puncture for CSF
Cloudy & decreased glucose = bacterial meningitis
Clear = viral meningitis
*elevated protein & WBC
Meningitis nursing care DROPLET PRECAUTIONS (until ABX for 24 hours)
Provide quiet, room; low light
HOB 30 degrees
Monitor for increased ICP (*irritability)
Instruct pt to avoid coughing & sneezing (increases ICP)
Implement sz precautions
Meningitis treatment Antibiotics (for bacterial meningitis)
Anticonvulsants (phenytoin)
Seizures Uncontrolled electrical impulses in brain
Seizures risk factors Fevers
Cerebral edema
Infection
Toxin exposure
Brain tumor
Hypoxia
Alcohol/drug withdrawal
Fluid/electrolyte imbalances
Seizure triggers Stress
Fatigue
Caffeine
Flashing lights
, Capstone ATI
Tonic-clonic seizure May be preceded by aura (may not be)
3 phases:
Tonic episode (stiffening of muscles & LOC)
Conic episode (1-2 mins rhythmic jerking)
Post-ictal phase (pt confused & sleepy)
Absence Seizures Loss of consciousness for just a few seconds
Blank staring
Eye fluttering
Lip smacking
Picking at clothes
*resembles day dreaming
Myoclonic Seizues Brief stiffening of extrememties
Atonic Seizures Loss of muscle tone
Usually results in falling
Status Epilepticus Repeated seizure activity within 30 mins
OR
Single seizure that lasts more than 5 minutes
Seizure diagnosis EEG - help identify origin
EEG Wash hair
Don't have to be NPO
Sleep deprived preferred
What should you do when a patient is having a seizure? Turn pt to side
Loosen restrictive clothing
NEVER insert airway/put anything in mouth
NEVER restrain pt
Clear airway
*document onset & duration
POST SZ:
-check vital signs
-check neuro status
-re-orient pt
-implement sz precautions (pad bed rails, etc)
-find trigger
Seizure treatment Anti-seizure meds - **PHENYTOIN
Surgery:
-vagal nerve stimulator
-craniotomy to remove affected part of brain (chronic sz)
Parkinson's dz Caused by degeneration of substantia Nigra = DECREASED DOPAMINE &
INCREASED ACETYLCHOLINE
ICP monitoring HIGH R/O infection
Used for GCS 8 or below; coma;
Glasgow Coma Scale Score 3-15
8 or less = coma
S/S increased ICP Irritability (EARLY)
Restlessness
Headache
Decreased LOC
Pupil changes
Abnormal breathing (Cheyenne stokes)
Abnormal posturing (decorticate or deceribrate)
Cushing's Triad
ICP range 10-15 mmHg
Over 15 = head injury/abnormal
Lumbar Puncture Spinal fluid sample to diagnose MS, syphilis, meningitis, cerebrospinal fluid infection
Lumbar Puncture Pre-procedure *have pt void first
Position pt in cannonball position on side OR stretch over table w/ rounded back
Lumbar Puncture Post-procedure Pt lay flat for several hours
If dura Puncture site does not heal properly, CSF may leak = SEVERE headache
Sooo admin pain meds & encourage pt to increase FL intake
Epidural blood patch may be used to seal hole if needed
MRI precautions Shellfish or iodine (w contrast only)
Assess pt for claustrophobia, might give sedative
MRI pre-procedure Remove jewelry
No metal implants (pacemaker; ortho joint; artificial heart valve; IUD; aneurism clip)
May give pt earplugs
Meningitis inflammation of the meninges of the brain and spinal cord
Viral Meningitis MOST COMMON
No vaccine
Usually resolves on own
(Risk factors: mumps, measles, arbovirus (West Nile), herpes)
Bacterial Meningitis Requires antibiotics
Highly contagious
High mortality rate
(Risk factors otitis media, sinusitis, pneumonia)
, Capstone ATI
Meningitis Prevention HIB (hemophil. influ. type B) vaccine for kids
MCV4 (meningitis) vaccine before college (bc dorms/close quarters - risk factor)
PPS vaccine
Meningitis s/s Headache
Nuchal (neck) Rigidity
Fever & chills
Photophobia
N/V
Positive Kernig's sign
Positive Brudzinski's sign
Hyperactive DTRs
Seizures
Tachycardia
Restlessness & irritability
Altered LOC (confusion; lethargy; difficulty arousing; coma)
Kernig's sign Positive = indicative of meningitis
Pt lays supine, bring in knees & try to straighten leg, very painful
Kernig's=Knee!!!
Brudzinski's sign Positive = indicative of meningitis
Pt lays supine, lift neck, causes pain, bring in/flex knees
Meningitis Diagnosis Lumbar Puncture for CSF
Cloudy & decreased glucose = bacterial meningitis
Clear = viral meningitis
*elevated protein & WBC
Meningitis nursing care DROPLET PRECAUTIONS (until ABX for 24 hours)
Provide quiet, room; low light
HOB 30 degrees
Monitor for increased ICP (*irritability)
Instruct pt to avoid coughing & sneezing (increases ICP)
Implement sz precautions
Meningitis treatment Antibiotics (for bacterial meningitis)
Anticonvulsants (phenytoin)
Seizures Uncontrolled electrical impulses in brain
Seizures risk factors Fevers
Cerebral edema
Infection
Toxin exposure
Brain tumor
Hypoxia
Alcohol/drug withdrawal
Fluid/electrolyte imbalances
Seizure triggers Stress
Fatigue
Caffeine
Flashing lights
, Capstone ATI
Tonic-clonic seizure May be preceded by aura (may not be)
3 phases:
Tonic episode (stiffening of muscles & LOC)
Conic episode (1-2 mins rhythmic jerking)
Post-ictal phase (pt confused & sleepy)
Absence Seizures Loss of consciousness for just a few seconds
Blank staring
Eye fluttering
Lip smacking
Picking at clothes
*resembles day dreaming
Myoclonic Seizues Brief stiffening of extrememties
Atonic Seizures Loss of muscle tone
Usually results in falling
Status Epilepticus Repeated seizure activity within 30 mins
OR
Single seizure that lasts more than 5 minutes
Seizure diagnosis EEG - help identify origin
EEG Wash hair
Don't have to be NPO
Sleep deprived preferred
What should you do when a patient is having a seizure? Turn pt to side
Loosen restrictive clothing
NEVER insert airway/put anything in mouth
NEVER restrain pt
Clear airway
*document onset & duration
POST SZ:
-check vital signs
-check neuro status
-re-orient pt
-implement sz precautions (pad bed rails, etc)
-find trigger
Seizure treatment Anti-seizure meds - **PHENYTOIN
Surgery:
-vagal nerve stimulator
-craniotomy to remove affected part of brain (chronic sz)
Parkinson's dz Caused by degeneration of substantia Nigra = DECREASED DOPAMINE &
INCREASED ACETYLCHOLINE
